From the Guidelines
Spontaneous bacterial peritonitis (SBP) should be treated immediately with empirical antibiotic therapy, preferably cefotaxime 4 g/day for 5 days, as it has been shown to be effective in resolving the infection in 77-98% of patients. The choice of antibiotic is crucial in managing SBP, and cefotaxime is recommended due to its broad coverage of causative organisms and high ascitic fluid concentrations during therapy 1. Alternative options include amoxicillin/clavulanic acid, which has similar results to cefotaxime in terms of SBP resolution and mortality, but with a lower cost 1.
Key Considerations
- Empirical antibiotic therapy should be initiated immediately after diagnosis, without waiting for ascitic fluid culture results 1.
- Potentially nephrotoxic antibiotics, such as aminoglycosides, should be avoided as empirical therapy 1.
- The duration of therapy can be as short as 5 days, as it has been shown to be as effective as a 10-day treatment 1.
- If the ascitic fluid neutrophil count fails to decrease to less than 25% of the pre-treatment value after 2 days of antibiotic treatment, there is a high likelihood of failure to respond to therapy 1.
Treatment Options
- Cefotaxime 4 g/day for 5 days is the recommended first-line therapy 1.
- Amoxicillin/clavulanic acid is an alternative option, with similar results to cefotaxime in terms of SBP resolution and mortality 1.
- Ciprofloxacin can be used as an alternative, but it has a higher cost compared to cefotaxime 1.
- Oral ofloxacin can be used in uncomplicated SBP, without renal failure, hepatic encephalopathy, gastrointestinal bleeding, ileus, or shock 1.
From the Research
Definition and Diagnosis of Spontaneous Bacterial Peritonitis
- Spontaneous bacterial peritonitis (SBP) is a common infection in patients with cirrhosis and ascites, associated with significant risk of mortality 2.
- The typical presentation of SBP includes abdominal pain, worsening ascites, fever, or altered mental status in a patient with known liver disease 2.
- Paracentesis is the diagnostic modality of choice and should be performed in any patient with ascites and concern for SBP or upper gastrointestinal bleeding, or in those being admitted for a complication of cirrhosis 2.
- An ascites absolute neutrophil count (ANC) ≥ 250 cells/mm3 is diagnostic of SBP 2.
Treatment and Management of SBP
- Management traditionally includes a third-generation cephalosporin, but specific patient populations may require more broad-spectrum coverage with a carbapenem or piperacillin-tazobactam 2, 3.
- Albumin infusion is associated with reduced risk of renal impairment and mortality 2, 4.
- Empirical antibiotic therapy should be selected based on analysis of the spectrum of pathogens and their resistance to antibiotics 5.
- Therapeutic response should be defined as a decrease in neutrophil count to 25% of the baseline value after 48-72 hours 5.
Risk Factors and Prevention
- Acid suppressive and beta-adrenergic antagonist therapies are strongly associated with SBP in at-risk individuals 3.
- Withholding acid suppressive medication deserves strong consideration, and discontinuing beta-adrenergic antagonist therapy in patients with end-stage liver disease and resistant ascites is standard care 3.
- Liver transplant evaluation should be undertaken for patients who develop SBP barring contraindications 3.
- Selective intestinal decontamination (SID) with the oral fluoroquinolone norfloxacin may be beneficial in preventing SBP in certain patient populations 4.