Spontaneous Bacterial Peritonitis (SBP) Empiric Therapy

Updated: Jan 20, 2023
Author: Bruce M Lo, MD, MBA, RDMS, FACEP, FAAEM, FACHE, FAAPL, CPE; Chief Editor: Thomas E Herchline, MD 

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, 8]

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.[1]

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, 2]

Clinical judgement does not rule out SBP.[3]

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. In areas where there is prevelance of multi-drug resistant organisms (MDRO), broader spectrum antibiotics such as piperacillin/tazobactam should be considered. Antibiotic selection should ideally be based on local MDRO types and resistence patterns.[1, 4, 9]

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.[10]

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.[5]

Patients on a prophylactic fluoroquinolone who develop SBP should be placed on alternative agents.[2]

Prophylaxis is indicated after the initial episode of SBP or in patients with cirrhosis and active upper gastrointestinal bleeding.[2, 6] Routine prophylaxis for patients with ascites without gastrointestinal bleeding also may be beneficial,[7] 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.[2]