Spontaneous Bacterial Peritonitis Treatment & Management
- Author: Thomas E Green, DO, MPH, FACOEP, FACEP; Chief Editor: Rick Kulkarni, MD more...
Approach Considerations
A 2009 guideline from the American Association for the Study of Liver Diseases recommends that adult cirrhotic patients with ascitic fluid polymorphonuclear neutrophil (PMN) counts greater than 250 cells/ µL receive empiric antibiotic therapy (eg, an intravenous third-generation cephalosporin, preferably cefotaxime 2 g every 8 hours).[4] As an alternative to intravenous cefotaxime, inpatients with cirrhosis can be treated with oral ofloxacin (400 mg twice per day), if none of the following contraindications are present[4] :
- Prior exposure to quinolones
- Vomiting
- Shock
- Grade II (or higher) hepatic encephalopathy
- Serum creatinine greater than 3 mg/dL
Patients with a peritoneal fluid PMN count greater than 500 cells/µL should universally be admitted and treated for spontaneous bacterial peritonitis, regardless of peritoneal fluid Gram stain result. Antibiotics should be initiated as soon as possible. The regimen can be chosen empirically, unless microbiologic studies further guide treatment.
For patients with a peritoneal fluid PMN count below 250 cells/µL, management depends upon the results of ascitic fluid cultures. All symptomatic patients should be admitted. Patients whose culture results are positive should be treated for spontaneous bacterial peritonitis. A select subset of patients who are completely asymptomatic yet have positive culture results may be managed without treatment but must undergo a follow-up paracentesis within 24-48 hours.
All symptomatic patients with a peritoneal fluid PMN count of 250-500 cells/µL should be admitted and treated for spontaneous bacterial peritonitis.
Inpatient Care
For spontaneous bacterial peritonitis (SBP), a 10- to 14-day course of antibiotics is recommended. Although not required, a repeat peritoneal fluid analysis is recommended to verify declining PMN counts and sterilization of ascitic fluid.
If improvement in ascitic fluid or clinical condition does not occur within 48 hours, further evaluation is required to rule out bowel perforation or intra-abdominal abscess. Evaluation may include a combination of radiography, CT scanning, intraluminal contrast studies, or surgical exploration.
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