Treating spontaneous bacterial peritonitis with 5 days of antibiotics

Up to 30% of cirrhosis patients will develop spontaneous bacterial peritonitis (SBP) with a mortality rate of about 20%. Consider spontaneous bacterial peritonitis (SBP) in liver patients with ascites and fever, abdominal pain, altered mental status, or other risks such as a variceal bleed. For further information, see topic on Spontaneous bacterial peritonitis (SBP). 

          Try to perform paracentesis and draw blood cultures before starting antibiotics. Send fluid for a neutrophil count and cultures. Don't use cultures alone to diagnose SBP, they're negative in about 50% of infected patients. Consider SBP symptoms and look for an ascitic neutrophil count of 250 cells/mm³ or higher. But don't hold antibiotics if paracentesis will be delayed. 

MANAGEMENT ㅡ Empirically start cefotaxime (Claforan) 2 g IV q8hr × 5 days or ceftriaxone (Rocephin) 2 g IV q24hr × 5 days in most patients. But check your antibiogram to verify that these antibiotics are a good choice for common pathogens (E. coli, Streptococcus, and Klebsiella). In patients with penicillin allergy who are not receiving long‐term fluoroquinolone therapy, levofloxacin (Tavanic) 500 mg IV daily × 5 days is a reasonable and safe alternative treatment for SBP. If there's a risk for resistant organisms, use broader empiric coverage, such as piperacillin/tazobactam (Tazocin) 3.375 g IV q6hr plus vancomycin 1 g IV q12hr × 5 days for "hospital-acquired SBP" occurring more than 48 hours after admission. 

          Treat most patients with antibiotics for 5 days, longer durations don't seem to improve cure rates, recurrence, or hospital mortality. Consider switching to an oral antibiotic in stable patients after 48 hours. Save albumin for SBP patients at a high renal impairment risk (serum creatinine greater than 1 mg/dL, BUN over 30 mg/dL, or total bilirubin above 4 mg/dL). Adding albumin prevents one renal injury AND in-hospital death for every 5 of these patients treated. When indicated, give albumin 1.5 grams/kg on day one, within 6 hours of diagnosis if possible then 1 gram/kg on day three.

PROPHYLAXIS ㅡ Start all SBP patients on chronic SECONDARY antibiotic prophylaxis when acute treatment is complete, since the risk of recurrence is about 70%. Consider using one double-strength TMP/SMX (Septrin DS) daily or Norfloxacin (Epinor) 400 mg daily or ciprofloxacin (Ciprobay) 500 mg daily.

REFERENCES

• Dever, J.B. and Sheikh, M.Y. (2015). Review article: spontaneous bacterial peritonitis - bacteriology, diagnosis, treatment, risk factors and prevention. Alimentary pharmacology & therapeutics, [online] 41(11), pp.1116–31. Available at: https://www.ncbi.nlm.nih.gov/pubmed/25819304

  Long, B. and Koyfman, A. (2018). The emergency medicine evaluation and management of the patient with cirrhosis. The American Journal of Emergency Medicine, [online] 36(4), pp.689–698. Available at: https://pubmed.ncbi.nlm.nih.gov/29290508 

  Runyon, B. Management of adult patients with ascites due to cirrhosis: Update 2012 practice guideline Jump to: Contents recommendations full text references forward management of adult patients with ascites due to cirrhosis: Update 2012 full text references recommendations web site contents contents. [online]. Available at: https://www.aasld.org/sites/default/files/2019-06/141020_Guideline_Ascites_4UFb_2015.pdf