Specific Organisms and Therapeutic Regimens
Common organisms in spontaneous bacterial peritonitis (SBP) and treatment recommendations for these organisms are provided below, as well as special considerations. [1, 2, 3, 4, 5, 6, 7, 8, 9, 10]
Common organisms in spontaneous bacterial peritonitis
Escherichia coli
Klebsiella pneumoniae
Streptococcus pneumoniae
Enterococcus species
Treatment recommendations for E coli, K pneumoniae, and S pneumoniae
Cefotaxime 2 g IV q8h for 5 d or
Ofloxacin 400 mg PO q12h for 5 d
Treatment recommendations for resistant E coli or Klebsiella spp
Doripenem 500 mg IV q8h or
Ertapenem 1 g IV q24h or
Imipenem 0.5-1 g IV q6h or
Meropenem 1 g IV q8h or
Ciprofloxacin 400 mg IV q12h 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.
Treatment recommendations for Enterococcus spp
Ampicillin 1-2 g IV q4-6h for 5 d or
Vancomycin 15 mg/kg IV q12h for 5 d or
Linezolid 600 mg IV q12h or
Daptomycin 4-6 mg/kg IV q24h
Special considerations
Probiotics have not been shown to improve outcomes in conjunction with antibiotics. [11]
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 [12] from 29% to 10% when used with appropriate antibiotics versus antibiotics and no albumin. [3]
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, 4, 13] Routine prophylaxis for patients with ascites without gastrointestinal bleeding may also be beneficial, [5] 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]
