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Spontaneous Bacterial Peritonitis Empiric Therapy 

  • Author: Bruce M Lo, MD, CPE, RDMS, FACEP, FAAEM, FACHE; Chief Editor: Thomas E Herchline, MD  more...
Updated: Aug 18, 2015

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]

General recommendations

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.[1]

Clinical judgement does not rule out SBP.[2]

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.[3]

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.

Special considerations

Probiotics have not been shown to improve outcomes in conjunction with antibiotics.[8]

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.[4]

Patients on a prophylactic fluoroquinolone who develop SBP should be placed on alternative agents.[1]

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,[6] 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.[1]

Contributor Information and Disclosures

Bruce M Lo, MD, CPE, RDMS, FACEP, FAAEM, FACHE Medical Director, Department of Emergency Medicine, Sentara Norfolk General Hospital; Associate Professor, Assistant Program Director, Core Academic Faculty, Department of Emergency Medicine, Eastern Virginia Medical School

Bruce M Lo, MD, CPE, RDMS, FACEP, FAAEM, FACHE is a member of the following medical societies: American Academy of Emergency Medicine, American Association for Physician Leadership, American College of Emergency Physicians, American College of Healthcare Executives, American Institute of Ultrasound in Medicine, Emergency Nurses Association, Medical Society of Virginia, Norfolk Academy of Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Jasmeet Anand, PharmD, RPh Adjunct Instructor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Thomas E Herchline, MD Professor of Medicine, Wright State University, Boonshoft School of Medicine; Medical Director, Public Health, Dayton and Montgomery County, Ohio

Thomas E Herchline, MD is a member of the following medical societies: Alpha Omega Alpha, Infectious Diseases Society of Ohio, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

  1. Runyon BA. Management of adult patients with ascites due to cirrhosis: an update. Hepatology. 2009 Jun. 49(6):2087-107. [Medline].

  2. 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].

  3. 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].

  4. 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].

  5. 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].

  6. 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].

  7. Spontaneous Bacterial Peritonitis. Available at Accessed: May 12, 2013.

  8. 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].

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