Spontaneous bacterial peritonitis primary prevention
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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] Guillermo Rodriguez Nava, M.D. [3]
Overview
A variety of randomized controlled trials of prophylactic antibiotics in patients with ascites have shown a benefit for the prevention of development of SBP. Patients with ascitic fluid protein concentration <1.0 g/dL, variceal hemorrhage, and prior episode of SBP should receive antibiotic prophylaxis.[1]
Primary prevention
- Cirrhotic patients with gastrointestinal hemorrhage
- Ciprofloxacin 500mg PO BID X 7days
- If the patients is NPO Ceftriaxone 1 g IV Q24H can be used
- Switch to Ciprofloxacin 500 mg PO BID once bleeding is controlled
- Non-bleeding cirrhotic patients with ascites
- TMP/SMX 1 DS PO once daily or
- Ciprofloxacin 500mg PO daily if sulfa allergic
- All patients with Cirrhosis and upper GI bleeding should receive prophylaxis x 7 days since 50% of the patients develop ascites after the bleed.
- Prophylaxis should be considered for those with low protein concentration in ascites (< 10 g/L) or immunosuppression while the patient is at hospital.
- General measures to improve the patient’s overall medical condition such as abstinence from alcohol and improvement in nutritional status should be attempted.
- Reduction in the volume of ascites using diuretic therapy has been demonstrated to increase the ascitic fluid total protein level and should theoretically decrease the risk of infection by way of higher opsonic activity.[2]
- Screening for and prophylaxis of esophageal varices to reduce the risk of gastrointestinal hemorrhage are also recommended
- Prevention of ascites in cirrhosis, heart failure and renal failure.
- Prevention of peritonitis in cases of ascites.
- Intravenous ceftriaxone for 7 days or twice-daily norfloxacin for 7 days should be given to prevent bacterial infections in patients with cirrhosis and gastrointestinal hemorrhage. [3]
- Patients with cirrhosis and ascites but no gastrointestinal hemorrhage, long-term use of norfloxacin can be considered if the ascitic fluid protein <1.5 g/dL and one or more of the following are present: serum creatinine >1.2 mg/dL, blood urea nitrogen >25 mg/dL, serum sodium <130 mEq/L or Child-Pugh >9 points with bilirubin >3 mg/dL.[4][5]
- Intermittent dosing of antibiotics to prevent bacterial infections may be inferior to daily dosing (due to the development of bacterial resistance) and thus daily dosing should preferentially be used. [6]
References
- ↑ Runyon BA, AASLD Practice Guidelines Committee (2009). "Management of adult patients with ascites due to cirrhosis: an update". Hepatology. 49 (6): 2087–107. doi:10.1002/hep.22853. PMID 19475696.
- ↑ Sheer TA, Runyon BA (2005). "Spontaneous bacterial peritonitis". Dig Dis. 23 (1): 39–46. doi:10.1159/000084724. PMID 15920324.
- ↑ Soares-Weiser K, Brezis M, Tur-Kaspa R, Leibovici L (2002). "Antibiotic prophylaxis for cirrhotic patients with gastrointestinal bleeding". Cochrane database of systematic reviews (Online) (2): CD002907. PMID 12076458.
- ↑ Fernández J, Navasa M, Planas R, Montoliu S, Monfort D, Soriano G; et al. (2007). "Primary prophylaxis of spontaneous bacterial peritonitis delays hepatorenal syndrome and improves survival in cirrhosis". Gastroenterology. 133 (3): 818–24. doi:10.1053/j.gastro.2007.06.065. PMID 17854593.
- ↑ Novella M, Solà R, Soriano G, Andreu M, Gana J, Ortiz J; et al. (1997). "Continuous versus inpatient prophylaxis of the first episode of spontaneous bacterial peritonitis with norfloxacin". Hepatology. 25 (3): 532–6. doi:10.1002/hep.510250306. PMID 9049193.
- ↑ "National Guideline Clearinghouse | Management of adult patients with ascites due to cirrhosis: an update".