Do you start antibiotics (abx) for ascites?

From the Guidelines

Antibiotics should be started for ascites only when spontaneous bacterial peritonitis (SBP) is suspected or confirmed, based on symptoms or an elevated polymorphonuclear leukocyte count ≥250 cells/mm³ in the ascitic fluid. The decision to start antibiotics should be guided by the results of diagnostic paracentesis, which should be performed without delay in all cirrhotic patients with ascites on hospital admission, as well as in patients with GI bleeding, shock, fever, or other signs of systemic inflammation 1.

When SBP is suspected, empirical antibiotic therapy should be initiated immediately, taking into account the context of SBP (community-acquired or healthcare-associated), severity of infection, and local bacterial resistance profile 1. The first-line treatment is typically a third-generation cephalosporin, such as cefotaxime or ceftriaxone, although the choice of antibiotic should be guided by local resistance patterns and protocol 1.

Some key points to consider when managing ascites and SBP include:

• Diagnostic paracentesis should be performed to rule out SBP in all cirrhotic patients with ascites on hospital admission 1
• Empirical antibiotic therapy should be initiated immediately when SBP is suspected, based on symptoms or an elevated polymorphonuclear leukocyte count ≥250 cells/mm³ in the ascitic fluid 1
• The choice of antibiotic should be guided by local resistance patterns and protocol, and should take into account the context of SBP (community-acquired or healthcare-associated) and the severity of infection 1
• A second diagnostic paracentesis at 48 hours from the start of treatment may be considered to check the efficacy of antibiotic therapy in patients who have an apparently inadequate response 1

Overall, the management of ascites and SBP requires a careful and individualized approach, taking into account the latest evidence and guidelines, as well as the specific needs and circumstances of each patient 1.

From the Research

Treatment of Ascites with Antibiotics

• The use of antibiotics in the treatment of ascites is primarily focused on preventing or managing spontaneous bacterial peritonitis (SBP), a severe infection that can occur in patients with advanced liver disease and ascites 2, 3.
• Studies have shown that the use of non-nephrotoxic broad-spectrum antibiotics, such as cefotaxime, ceftriaxone, or ciprofloxacin, can be effective in treating SBP 2, 3, 4.
• The choice of antibiotic regimen may depend on various factors, including the severity of the infection, the presence of underlying liver disease, and the risk of antibiotic resistance 3, 4.

Initiation of Antibiotic Prophylaxis

• The initiation of antibiotic prophylaxis in patients with ascites is a topic of ongoing debate, with some studies suggesting that it may be beneficial in preventing SBP in high-risk patients 2, 5.
• Selective intestinal decontamination (SID) with oral fluoroquinolones, such as norfloxacin, has been shown to be effective in preventing SBP in patients with low-protein ascites or those who are at high risk of developing SBP 2.
• However, the use of antibiotic prophylaxis should be carefully considered, taking into account the potential risks of antibiotic resistance and other adverse effects 3, 6.

Risk Factors for SBP Development

• Several risk factors have been identified for the development of SBP, including Child-Pugh stage C, ascitic fluid polymorphonuclear cell count, and low serum sodium levels 5.
• Patients with these risk factors may benefit from closer monitoring and early intervention with antibiotics to prevent SBP 5.
• The use of scoring systems, such as the MELD score, can also help identify patients who are at high risk of developing SBP and may benefit from antibiotic prophylaxis 5.