Spontaneous bacterial peritonitis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aditya Govindavarjhulla, M.B.B.S. [2], Chetan Lokhande, M.B.B.S [3], Guillermo Rodriguez Nava, M.D. [4], Alejandro Lemor, M.D. [5]

Overview

Empiric broad-spectrum intravenous antibiotic, preferably with 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 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.

Recommendations for the treatment of Spontaneous Bacterial Peritonitis (DO NOT EDIT)

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Patients with ascites admitted to the hospital should undergo abdominal paracentesis. Paracentesis should be repeated in patients (whether in the hospital or not) who develop signs or symptoms or laboratory abnormalities suggestive of infection (e.g., abdominal pain or tenderness, fever, encephalopathy, renal failure, acidosis, or peripheral leukocytosis). Patients with ascitic fluid polymorphonuclear leukocyte (PMN) counts greater than or equal to 250 cells/mm3 (0.25 X 109/L) should receive empiric antibiotic therapy (e.g., an intravenous third-generation cephalosporin, preferably cefotaxime 2 g every 8 hours). Oral ofloxacin (400 mg twice per day) 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 PMN counts less than 250 cells/mm3 (0.25 X 109/L) and signs and symptoms of infection (temperature >100 degrees F or abdominal pain or tenderness) should also receive empiric antibiotic therapy (e.g., intravenous cefotaxime 2 g every 8 hours) while awaiting results of cultures. When the ascitic fluid of a patient with cirrhosis is found to have a PMN count greater than or equal to 250 cells/mm3 (0.25 X 109/L), 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 PMN counts greater than or equal to 250 cells/mm3 (0.25 X 109/L) 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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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 or quinolones can be used.

Primary Spontaneous Bacterial
Preferred Regimen
▸ Cefotaxime 2 gm IV q8h (q4h, if life-threatening infection) OR ▸Ticaricillin-clavulanate 3.1 gm IV q6h OR ▸Piperacillin-tazobactam 3.375 gm IV q6h (or 4-hour infusion of 3.375 gm q8h) OR ▸Ceftriaxone 2 gm IV q24h OR ▸Ertapenem 1 gm IV q24h
If resistant E. coli or Klebsiella species
▸ Imipenem 500 mg IV q6h OR ▸Meropenem 1000 mg IV q8h OR ▸Doripenem 500 mg IV q8h (1 hr infusion)
If checking sensitivities, then start
▸ Ciprofloxacin 400 mg IV q12h OR ▸Levofloxacin 750 mg IV once daily OR ▸Moxifloxacin 400 mg IV once daily
In addition to antibiotic, to decrease frequency of renal impairment start
▸IV Albumin 1.5 gm/kg at diagnosis and 1 gm/kg on day 3
Preventive regimen for chronic ascites
▸TMP-SMX 1 DS tab po 5 days/week OR ▸Ciprofloxacin 750 mg po once/week

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.

References

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