Spontaneous Bacterial Peritonitis Empiric Therapy
- Author: Bruce M Lo, MD, CPE, RDMS, FACEP, FAAEM, FACHE; Chief Editor: Thomas E Herchline, MD more...
Empiric Therapy Regimens
General recommendations, empiric treatment recommendations, and special considerations in the treatment of spontaneous bacterial peritonitis (SBP) are provided below.[1, 2, 3, 4, 5, 6, 7]
SBP is defined as ascitic fluid polymorphonuclear leukocyte (PMN) count level greater than or equal to 250 cells/µL without a surgical, intra-abdominal cause of infection. However, SBP can occur with PMN count level of less than 250 cells/µL and either bacterascites or signs and symptoms of SBP.
Empiric therapy of suspected SBP should be initiated as soon as possible to increase the patient's chance of survival. Indications for empiric therapy include the presence of 1 or more of the following findings that are characteristically seen in SBP: fever, abdominal pain, and change in mental status.
Clinical judgement does not rule out SBP.
Intravenous antibiotic with a third-generation cephalosporin is considered first line; however, this class has not been shown to be superior to other classes of antibiotics.
Empiric treatment recommendations
Cefotaxime 2 g IV q8h or
Ceftriaxone 1-2 g IV q24h or
Ticarcillin-clavulanate 3.1 g IV q6h or
Piperacillin-tazobactam 3.375 g IV q6h or 4.5 g IV q8h or
Ampicillin-sulbactam 3 g IV q6h or
Ertapenem 1 g IV q24h or
Levofloxacin 500 mg IV q24h or
Moxifloxacin 400 mg IV q24h
Duration of therapy is unclear; however, treatment for 5 days has shown success; 2 weeks is recommended if blood cultures are positive.
Probiotics have not been shown to improve outcomes in conjunction with antibiotics.
Paracentesis should be performed in any patient suspected of SBP; to increase the sensitivity, culture bottles should be inoculated at the bedside rather than in the laboratory.
Repeat paracentesis is required only if the patient is not improving.
Albumin 1.5 g/kg IV within 6 hours of diagnosis followed by 1 g/kg IV on day 3 has been reported to decrease mortality from 29% to 10% when used with appropriate antibiotics versus antibiotics and no albumin.
Patients on a prophylactic fluoroquinolone who develop SBP should be placed on alternative agents.
Prophylaxis is indicated after the initial episode of SBP or in patients with cirrhosis and active upper gastrointestinal bleeding.[1, 5] Routine prophylaxis for patients with ascites without gastrointestinal bleeding may also be beneficial, especially if the patient has high-risk features, which include ascitic fluid protein less than 1.5 g/dL and at least 1 of the following: serum creatinine greater than or equal to 1.2 mg/dL, blood urea nitrogen greater than 25 mg/dL, serum sodium less than or equal to 130 mEq/L, or Child-Pugh score greater than or equal to 9 with bilirubin greater than or equal to 3 mg/dL.
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Chinnock B, Afarian H, Minnigan H, Butler J, Hendey GW. Physician clinical impression does not rule out spontaneous bacterial peritonitis in patients undergoing emergency department paracentesis. Ann Emerg Med. 2008 Sep. 52(3):268-73. [Medline].
Chavez-Tapia NC, Soares-Weiser K, Brezis M, Leibovici L. Antibiotics for spontaneous bacterial peritonitis in cirrhotic patients. Cochrane Database Syst Rev. 2009 Jan 21. CD002232. [Medline].
Sort P, Navasa M, Arroyo V, et al. Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med. 1999 Aug 5. 341(6):403-9. [Medline].
Chavez-Tapia NC, Barrientos-Gutierrez T, Tellez-Avila FI, Soares-Weiser K, Uribe M. Antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding. Cochrane Database Syst Rev. 2010 Sep 8. CD002907. [Medline].
Cohen MJ, Sahar T, Benenson S, Elinav E, Brezis M, Soares-Weiser K. Antibiotic prophylaxis for spontaneous bacterial peritonitis in cirrhotic patients with ascites, without gastro-intestinal bleeding. Cochrane Database Syst Rev. 2009 Apr 15. CD004791. [Medline].
Spontaneous Bacterial Peritonitis. Available at http://emedicine.medscape.com/article/789105-overview. Accessed: May 12, 2013.
Pande C, Kumar A, Sarin SK. Addition of probiotics to norfloxacin does not improve efficacy in the prevention of spontaneous bacterial peritonitis: a double-blind placebo-controlled randomized-controlled trial. Eur J Gastroenterol Hepatol. 2012 Jul. 24(7):831-9. [Medline].