Spontaneous Bacterial Peritonitis Treatment & Management

  • Author: Thomas E Green, DO, MPH, FACOEP, FACEP; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
 
Updated: Jun 15, 2016
 

Approach Considerations

The American Association for the Study of Liver Diseases (AASLD) has issued updated guidelines for adult patients with ascites due to cirrhosis.[15]

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 of 250 cells/µL or greater in a community-acquired setting (in the absence of recent beta-lactam antibiotic exposure) should receive empiric antibiotic therapy (eg, an intravenous third-generation cephalosporin, preferably cefotaxime 2 g every 8 hours). Patients with cirrhosis who have PMN counts of 250 cells/µL or more in a nosocomial setting or patients who have recently received beta-lactam antibiotics should receive empiric antibiotic therapy based on local susceptibility testing of bacteria.[4, 15] 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.

Probiotic therapy in conjunction with antimicrobial treatment does not improve efficacy in the treatment of spontaneous bacterial peritonitis, as was found in a double-blind, placebo-controlled, randomized-controlled trial.[16] In this study, Pande et al found over a 28-month period that 110 patients who were randomized to either norfloxacin 400 mg with probiotics or placebo did not have improved efficacy in primary or secondary prophylaxis or in reducing mortality in cirrhotic patients with ascites.

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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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Deterrence/Prevention

Outpatient prophylaxis, although not recommended routinely, has been shown to prevent spontaneous bacterial peritonitis in the following high-risk groups:

  • Patients with ascites admitted with acute GI bleeding
  • Patients with ascitic fluid protein levels of less than 1 g/dL
  • Patients with a prior episode of spontaneous bacterial peritonitis

Suggested outpatient prophylactic regimens include the following:

  • Norfloxacin - 400 mg daily
  • Ciprofloxacin - 750 mg weekly
  • Five doses of double-strength trimethoprim-sulfamethoxazole per week (Monday through Friday)

A 2012 guideline from the American Association for the Study of Liver Diseases recommends that adult cirrhotic patients who have survived an episode of SBP should receive long-term prophylaxis with norfloxacin or trimethoprim-sulfamethoxazole.[15]

However, mounting evidence shows that use of PPIs and selective-intestinal decontamination leads to development of increased pathogenic and drug-resistant flora.[17] In addition, despite evidence suggesting that primary prophylaxis of spontaneous bacterial peritonitis delays the development of hepatorenal syndrome and improves survival, a prospective study showed that patients with spontaneous bacterial peritonitis on long-term norfloxacin subsequently developed quinolone-resistant spontaneous bacterial peritonitis.[18]

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Contributor Information and Disclosures
Author

Thomas E Green, DO, MPH, FACOEP, FACEP Associate Dean for Clinical Affairs, Des Moines University College of Osteopathic Medicine; Attending Physician, Emergency Department, Emergency Practice Associates; Associate Professor of Emergency Medicine, Midwestern University, Chicago College of Osteopathic Medicine

Thomas E Green, DO, MPH, FACOEP, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American Association for Physician Leadership, American Osteopathic Association

Disclosure: Nothing to disclose.

Coauthor(s)

Steven M Bandy, MD, FACEP Staff Physician, Department of Emergency Medicine, Johnston Memorial Hospital; Adjunct Clinical Professor of Emergency Medicine, Virginia College of Osteopathic Medicine

Steven M Bandy, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Chief Editor

Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor, Department of Surgery, University of South Carolina School of Medicine; Attending Physician, Clinical Instructor, Compliance Officer, Department of Emergency Medicine, Palmetto Richland Hospital

Jeter (Jay) Pritchard Taylor, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Columbia Medical Society, Society for Academic Emergency Medicine, South Carolina College of Emergency Physicians, South Carolina Medical Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Employed contractor - Chief Editor for Medscape.

References
  1. Lata J, Stiburek O, Kopacova M. Spontaneous bacterial peritonitis: a severe complication of liver cirrhosis. World J Gastroenterol. 2009 Nov 28. 15 (44):5505-10. [Medline].

  2. Bert F, Noussair L, Lambert-Zechovsky N, Valla D. Viridans group streptococci: an underestimated cause of spontaneous bacterial peritonitis in cirrhotic patients with ascites. Eur J Gastroenterol Hepatol. 2005 Sep. 17(9):929-33. [Medline].

  3. Cholongitas E, Papatheodoridis GV, Lahanas A, Xanthaki A, Kontou-Kastellanou C, Archimandritis AJ. Increasing frequency of Gram-positive bacteria in spontaneous bacterial peritonitis. Liver Int. 2005 Feb. 25(1):57-61. [Medline].

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

  5. Greenberger NJ et al. Ascites & Spontaneous Bacterial Peritonitis. Current Diagnosis & Treatment: Gastroenterology, Hepatology & Endoscopy. 2nd ed. 2012. Ch 45.

  6. Siple JF, Morey JM, Gutman TE, Weinberg KL, Collins PD. Proton pump inhibitor use and association with spontaneous bacterial peritonitis in patients with cirrhosis and ascites. Ann Pharmacother. 2012 Oct. 46(10):1413-8. [Medline].

  7. Deshpande A, Pasupuleti V, Thota P, Pant C, Mapara S, Hassan S. Acid-suppressive therapy is associated with spontaneous bacterial peritonitis in cirrhotic patients: a meta-analysis. J Gastroenterol Hepatol. 2013 Feb. 28(2):235-42. [Medline].

  8. Ge PS, Runyon BA. Preventing future infections in cirrhosis: a battle cry for stewardship. Clin Gastroenterol Hepatol. 2015 Apr. 13 (4):760-2. [Medline].

  9. Mandorfer M, Bota S, Schwabl P, Bucsics T, Pfisterer N, Kruzik M. Nonselective ß blockers increase risk for hepatorenal syndrome and death in patients with cirrhosis and spontaneous bacterial peritonitis. Gastroenterology. 2014 Jun. 146(7):1680-90.e1. [Medline].

  10. Riggio O, Angeloni S. Ascitic fluid analysis for diagnosis and monitoring of spontaneous bacterial peritonitis. World J Gastroenterol. 2009 Aug 21. 15(31):3845-50. [Medline]. [Full Text].

  11. Chinnock B, Gomez R, Hendey GW. Peritoneal fluid cultures rarely alter management in patients with ascites. J Emerg Med. 2011 Jan. 40(1):21-4. [Medline].

  12. Gaya DR, David B Lyon T, et al. Bedside leucocyte esterase reagent strips with spectrophotometric analysis to rapidly exclude spontaneous bacterial peritonitis: a pilot study. Eur J Gastroenterol Hepatol. 2007 Apr. 19(4):289-95. [Medline].

  13. Téllez-Ávila FI, Chávez-Tapia NC, Franco-Guzmán AM, Uribe M, Vargas-Vorackova F. Rapid diagnosis of spontaneous bacterial peritonitis using leukocyte esterase reagent strips in emergency department: uri-quick clini-10SG® vs. Multistix 10SG®. Ann Hepatol. 2012 Sep-Oct. 11(5):696-9. [Medline].

  14. Runyon BA. Monomicrobial nonneutrocytic bacterascites: a variant of spontaneous bacterial peritonitis. Hepatology. 1990 Oct. 12(4 Pt 1):710-5. [Medline].

  15. [Guideline] Runyon BA. Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis 2012. Hepatology. 2013 Apr. 57(4):1651-3. [Medline].

  16. 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].

  17. Runyon BA, Borzio M, Young S, Squier SU, Guarner C, Runyon MA. Effect of selective bowel decontamination with norfloxacin on spontaneous bacterial peritonitis, translocation, and survival in an animal model of cirrhosis. Hepatology. 1995 Jun. 21 (6):1719-24. [Medline].

  18. Fernández J, Navasa M, Planas R, Montoliu S, Monfort D, Soriano G, et al. Primary prophylaxis of spontaneous bacterial peritonitis delays hepatorenal syndrome and improves survival in cirrhosis. Gastroenterology. 2007 Sep. 133 (3):818-24. [Medline].

 
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