Spontaneous bacterial peritonitis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

After confirmation of SBP, patients need hospital admission for intravenous antibiotics (most often cefotaxime given as 1gm/12hours for 5 days or ceftriaxone). They will often also receive intravenous albumin. A repeat paracentesis in 48 hours is sometimes performed to ensure control of infection. Once patients have recovered from SBP, they require regular prophylactic antibiotics (e.g. Septra DS, Cipro, norfloxicin) as long as they still have ascites.

Medical Therapy

Antibiotics

Antibiotic therapy is administered empirically. Therapy can be initiated if

• temperature is more than 100 degree Fahrenheit.
• alteration of mental status
• ascitic fluid neutrophil count >250 cells/mm³
• abdominal tenderness

Broad spectrum antibiotics are used to cover the intestinal bacteria which are gram negative, aerobic bacteria.

• Cefotaxime is the antibiotic of choice given intravenously. Dosage has to be adjusted in renal failure patients.
• In patients allergic to penicillin, levofloxacin can be used.

Intravenous albumin

A randomized controlled trial found that intravenous albumin on the day of admission and on hospital day 3 can reduce renal impairment.

Guidelines

• Patients with ascites admitted to the hospital should undergo abdominal paracentesis. Paracentesis should be repeated in patients who develop signs or symptoms or laboratory abnormalities suggestive of infection.

• Oral ofloxacin can be considered a substitute for intravenous cefotaxime in inpatients without prior exposure to quinolones, vomiting, shock, grade II (or higher) hepatic encephalopathy, or serum creatinine greater than 3 mg/dL.

• Patients with ascitic fluid neutrophil counts less than 250 cells/mm3 and signs and symptoms of infection should also receive empiric antibiotic therapy while awaiting results of cultures.

• When the ascitic fluid of a patient with cirrhosis is found to have a neutrophil count greater than or equal to 250 cells/mm3, and there is high suspicion of secondary peritonitis, it should also be tested for total protein, lactic dehydrogenase (LDH), glucose, Gram's stain, carcinoembryonic antigen, and alkaline phosphatase to assist with the distinction of SBP from secondary peritonitis.

• Patients with ascitic fluid neutrophil counts greater than or equal to 250 cells/mm3 and clinical suspicion of SBP who also have a serum creatinine greater than 1 mg/dL, blood urea nitrogen greater than 30 mg/dL, or total bilirubin greater than 4 mg/dL should receive 1.5 g albumin per kg body weight within 6 hours of detection and 1.0 g/kg on day 3.

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