Spontaneous bacterial peritonitis medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. ; Associate Editor(s)-in-Chief: Aditya Govindavarjhulla, M.B.B.S. , Chetan Lokhande, M.B.B.S , Guillermo Rodriguez Nava, M.D. , Alejandro Lemor, M.D.  Shivani Chaparala M.B.B.S Ahmed Younes M.B.B.CH 
Empiric broad-spectrum intravenous antibiotic, preferably a third generation cephalosporin such as cefotaxime, is warranted for suspected or established spontaneous bacterial peritonitis (SBP) to cover the most common isolates including Escherichia coli, Klebsiella pneumoniae, and Streptococcus pneumoniae. Oral ofloxacin may be considered in selected cases. Albumin infusion should be reserved for patients with ascitic fluid PMN counts greater than or equal to 250 cells/mm3 and clinical suspicion of SBP, who also have a serum creatinine >1 mg/dL, blood urea nitrogen >30 mg/dL, or total bilirubin >4 mg/dL. The use of non-selective beta blockers in cirrhotic patients with SBP should be discouraged since it is associated with an increased risk for hemodynamic compromise, prolonged hospitalization, hepatorenal syndrome, and acute kidney injury.
Medical Therapy Adapted from AASLD Practice Guidelines: Management of Adult Patients with Ascites Due to Cirrhosis.
|▸ Cefotaxime 2 g IV q8h (or 2 g IV q4h if life-threatening) x 5–10 days|
|▸ Ofloxacin 400 mg PO bid x 5–10 days†|
▸ Ciprofloxacin 200 mg IV q12h x 7 days†
▸ Ciprofloxacin 200 mg IV q12h x 2 days, then 500 mg PO bid x 5 days†
|† Should not be used in a patient who had been receiving a quinolone for prophylaxis.|
|▸ Doripenem 500 mg IV q8h (1–hr infusion)|
▸ Ertapenem 1 g IV q24h
▸ Imipenem–Cilastatin 0.5–1 g IV q6–8h
▸ Meropenem 1 g IV q8h
|▸ Ciprofloxacin 400 mg IV q12h|
▸ Levofloxacin 750 mg IV q24h
▸ Moxifloxacin 400 mg IV q24h
|† Check in vitro susceptibility.|
- Empiric antibiotic therapy should be administered to patients with ascitic fluid PMN counts greater than or equal to 250 cells/mm3 in a clinical setting compatible with ascitic fluid infection or those who have convincing signs or symptoms of infection (fever, abdominal pain, or unexplained encephalopathy) regardless of the PMN count in the ascitic fluid.
- Bacterascites is defined as an ascitic neutrophil count less than 250/mm3 but with a positive ascitic fluid culture. If the patient exhibits signs of systemic inflammation or infection, the patient should be treated with antibiotics. Otherwise, the patient should undergo a second paracentesis when culture results turns positive. Patients in whom the repeat ascitic neutrophil count is >250/mm3 should be treated for SBP, and the remaining patients (i.e., neutrophils <250/mm3) should be followed up.
- The most common isolates from the ascitic fluid are Escherichia coli, Klebsiella pneumoniae, and Streptococcus pneumoniae.
- Relatively broad-spectrum therapy, preferably with cefotaxime, is warranted until the results of susceptibility testing are available.
- Infection with multiresistant organism including Extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae, Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus (MRSA), and Enterococcus faecium is associated with an increased mortality. Risk factors for multiresistant infections include:
- Nosocomial origin of infection
- Long-term norfloxacin prophylaxis
- Recent infection with multiresistant bacteria
- Recent use of beta-lactams
- Oral ofloxacin may be used alternatively in selected cases such as patients without vomiting, shock, grade II (or higher) hepatic encephalopathy, or serum creatinine greater than 3 mg/dL.
- The optimal duration of therapy remains unclear, although most patients respond to a treatment course of five days. Infection-related mortality, bacteriologic cure, and recurrence of ascitic fluid infection were not significantly different between the 5- and 10-day treatment groups in a randomized trial.
Adjunctive IV Albumin
- In a randomized controlled study involving cirrhotic patients with SBP, the use of IV albumin (1.5 g/kg given within 6 hours of enrollment and repeated as a 1.0 g/kg dose on day 3) as an adjunctive to cefotaxime was shown to decrease in-hospital mortality when compared with use of cefotaxime alone (29% versus 10%). 
- In addition, those treated with albumin had a reduction in the development of renal impairment (10% versus 33%).
- Use of IV albumin should be reserved for patients with a:
- Serum creatinine greater than 1 mg/dL,
- Blood urea nitrogen greater than 30 mg/dL, or
- Total bilirubin greater than 4 mg/dL.
Recommendations for the Management of Spontaneous Bacterial Peritonitis (2013 AASLD Practice Guideline)
Followup Diagnostic Paracentesis
- Follow-up ascitic fluid analysis is usually not necessary following treatment of SBP unless there is no clinical improvement in the patient’s symptoms, abnormal fluid analysis, suspected infection with multi-drug resistant organisms, or altered clinical course is noted.
- If the ascitic fluid PMN count has not declined by at least 25% after two days of antibiotic therapy, then the antibiotic coverage needs to be broadened to cover resistant organisms and secondary bacterial peritonitis needs to be considered.
- Patients with secondary bacterial peritonitis should undergo surgical intervention of the perforated viscus or drainage of the abscess and should be treated with broad-spectrum antibiotics, such as third-generation cephalosporins, with the addition of an antimicrobial agent that has good anaerobic coverage, such as metronidazole
- Consider repeat paracentesis after 48 hours of therapy
- Consider changing antibiotics if ascitic fluid PMN has not dropped by 25% after 48 hours and/or patient is not responding clinically.
- ↑ Soares-Weiser K, Paul M, Brezis M, Leibovici L (2002). "Evidence based case report. Antibiotic treatment for spontaneous bacterial peritonitis". BMJ. 324 (7329): 100–2. PMC 1121993. PMID 11786457.
- ↑ Mandorfer M, Bota S, Schwabl P, Bucsics T, Pfisterer N, Kruzik M; et al. (2014). "Nonselective β blockers increase risk for hepatorenal syndrome and death in patients with cirrhosis and spontaneous bacterial peritonitis". Gastroenterology. 146 (7): 1680–90.e1. doi:10.1053/j.gastro.2014.03.005. PMID 24631577.
- ↑ "AASLD Practice Guidelines: Management of Adult Patients with Ascites Due to Cirrhosis" (PDF).
- ↑ França A, Giordano HM, Sevá-Pereira T, Soares EC (2002). "Five days of ceftriaxone to treat spontaneous bacterial peritonitis in cirrhotic patients". J Gastroenterol. 37 (2): 119–22. PMID 11871762.
- ↑ 5.0 5.1 Terg R, Cobas S, Fassio E, Landeira G, Ríos B, Vasen W; et al. (2000). "Oral ciprofloxacin after a short course of intravenous ciprofloxacin in the treatment of spontaneous bacterial peritonitis: results of a multicenter, randomized study". J Hepatol. 33 (4): 564–9. PMID 11059861.
- ↑ Navasa M, Follo A, Llovet JM, Clemente G, Vargas V, Rimola A; et al. (1996). "Randomized, comparative study of oral ofloxacin versus intravenous cefotaxime in spontaneous bacterial peritonitis". Gastroenterology. 111 (4): 1011–7. PMID 8831596.
- ↑ Wiest R, Krag A, Gerbes A (2012). "Spontaneous bacterial peritonitis: recent guidelines and beyond". Gut. 61 (2): 297–310. doi:10.1136/gutjnl-2011-300779. PMID 22147550.
- ↑ Hoban DJ, Bouchillon SK, Hawser SP, Badal RE, Labombardi VJ, DiPersio J (2010). "Susceptibility of gram-negative pathogens isolated from patients with complicated intra-abdominal infections in the United States, 2007-2008: results of the Study for Monitoring Antimicrobial Resistance Trends (SMART)". Antimicrob Agents Chemother. 54 (7): 3031–4. doi:10.1128/AAC.01808-09. PMC 2897303. PMID 20457818.
- ↑ 9.0 9.1 Runyon BA, AASLD (2013). "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. 57 (4): 1651–3. doi:10.1002/hep.26359. PMID 23463403.
- ↑ Hoefs JC, Canawati HN, Sapico FL, Hopkins RR, Weiner J, Montgomerie JZ (1982). "Spontaneous bacterial peritonitis". Hepatology. 2 (4): 399–407. PMID 7095741.
- ↑ European Association for the Study of the Liver (2010). "EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis". J Hepatol. 53 (3): 397–417. doi:10.1016/j.jhep.2010.05.004. PMID 20633946.
- ↑ Fernández J, Acevedo J, Castro M, Garcia O, de Lope CR, Roca D; et al. (2012). "Prevalence and risk factors of infections by multiresistant bacteria in cirrhosis: a prospective study". Hepatology. 55 (5): 1551–61. doi:10.1002/hep.25532. PMID 22183941.
- ↑ Navasa, M (1996-10). "Randomized, comparative study of oral ofloxacin versus intravenous cefotaxime in spontaneous bacterial peritonitis". Gastroenterology. 111 (4): 1011–1017. ISSN 0016-5085. PMID 8831596. Unknown parameter
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- ↑ Runyon BA, McHutchison JG, Antillon MR, Akriviadis EA, Montano AA (1991). "Short-course versus long-course antibiotic treatment of spontaneous bacterial peritonitis. A randomized controlled study of 100 patients". Gastroenterology. 100 (6): 1737–42. PMID 2019378.
- ↑ Sort P, Navasa M, Arroyo V, Aldeguer X, Planas R, Ruiz-del-Arbol L; et al. (1999). "Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis". N Engl J Med. 341 (6): 403–9. doi:10.1056/NEJM199908053410603. PMID 10432325.
- ↑ Sigal SH, Stanca CM, Fernandez J, Arroyo V, Navasa M (2007). "Restricted use of albumin for spontaneous bacterial peritonitis". Gut. 56 (4): 597–9. doi:10.1136/gut.2006.113050. PMC 1856861. PMID 17369392.