Approach Considerations
In a guideline, 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). [25] 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, 25] 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] :
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Prior exposure to quinolones
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Vomiting
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Shock
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Grade II (or higher) hepatic encephalopathy
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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. Evidence supports early antibiotic administration (combined with early diagnostic paracentesis) to help reduce ICU and hospital length of stay, in-hospital mortality, and 3-month mortality. [11, 12]
A retrospective study by Mazer et al showed that patients who received ceftriaxone 2 grams daily (as opposed to 1 gram daily) had fewer ICU days and may have improved survival. [26]
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. [27] 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.
A 2013 meta-analysis by Salerno et al showed that albumin infusion in patients with spontaneous bacterial peritonitis reduced the incidence of renal impairment and mortality. [28]
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.
Deterrence/Prevention
Outpatient prophylaxis, although not recommended routinely, has been shown to prevent spontaneous bacterial peritonitis in the following high-risk groups:
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Patients with ascites admitted with acute GI bleeding
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Patients with ascitic fluid protein levels of less than 1 g/dL
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Patients with a prior episode of spontaneous bacterial peritonitis
Suggested outpatient prophylactic regimens include the following:
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Norfloxacin - 400 mg daily
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Ciprofloxacin - 750 mg weekly
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Five doses of double-strength trimethoprim-sulfamethoxazole per week (Monday through Friday)
A 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 [25] ; however, long-term prophylaxis with norfloxacin is a risk factor for infection with a multi-resistant organism. [29]
Mounting evidence shows that use of PPIs and selective-intestinal decontamination leads to development of increased pathogenic and drug-resistant flora. [30] 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. [31]
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Gram-negative Escherichia coli.
