Spontaneous Bacterial Peritonitis (SBP) Empiric Therapy

Updated: Jul 02, 2019
Author: Bruce M Lo, MD, MBA, CPE, RDMS, FACEP, FAAEM, FACHE; 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]

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]