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] Shivani Chaparala M.B.B.S [4]

Overview

• Most episodes of spontaneous bacterial peritonitis (SBP) are thought to result from bacterial translocation from the gut.
• Given the risk of resistance and alteration of gut flora, this long-term antibiotic prophylaxis should be reserved for high-risk patients only.
• Identified risk factors for the development of SBP include:
  • Ascitic fluid total protein less than 1.0 g/dL,
  • Variceal hemorrhage, and a
  • Prior episode of SBP.
• A variety of randomized controlled trials of prophylactic antibiotics in patients with ascites have shown a benefit for the prevention of development of SBP.

Primary prevention

• Cirrhotic patients with low protein ascites (less than 1.0 g/dL) and
• Either impaired renal or liver function and immunosuppression while the patient is at hospital are at increased risk of developing SBP.
• Although some controversy exists regarding the use of prophylactic antibiotics in patients who have never had SBP (primary prophylaxis), in one randomized trial, daily oral norfloxacin in patients with more advanced liver disease prevented the development of spontaneous bacterial peritonitis and hepatorenal syndrome and improved survival at 3 months when compared with those who received placebo.
• The AASLD guidelines suggest using long-term antibiotic prophylaxis in patients who have:
  • Ascitic fluid total protein less than 1.5 g/dL and at least one of the following:
  • Serum creatinine greater than or equal to 1.2 mg/dL,
  • Blood urea nitrogen greater than or equal to 25 mg/dL,
  • Serum sodium less than or equal to 130 mEq/L, or
  • Child-Turcotte-Pugh greater than or equal to 9 points (with bilirubin greater than or equal to 3 mg/dL).

Specific measures for high-risk cases

Cirrhotic patients with gastrointestinal hemorrhage

Non-bleeding cirrhotic patients with ascites

Between 25% and 65% of cirrhotic patients with gastrointestinal bleeding develop bacterial infection, including spontaneous bacterial peritonitis. Antibiotic prophylaxis in this setting has been shown to decrease the risk of bacterial infections, the risk of re-bleeding, and overall mortality. In one meta-analysis of five trials, antibiotic prophylaxis in cirrhotics with gastrointestinal bleeding demonstrated a 9% increase in survival. Indeed, the use of prophylactic antibiotics in this setting is thought to have contributed significantly to the reduced mortality in patients with variceal bleeding (from 43% to 15% over the past two decades). In this situation, the AASLD guidelines recommend using a 7-day course of intravenous ceftriaxone or twice daily oral norfloxacin. Ciprofloxacin 500mg PO BID X 7days If the patient is NPO Ceftriaxone 1 g IV Q24H can be used Switch to Ciprofloxacin 500 mg PO BID once bleeding is controlled

TMP/SMX 1 DS PO once daily or Ciprofloxacin 500mg PO daily if sulfa allergic. 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. Primary prophylaxis with norfloxacin has a great impact in the clinical course of patients with advanced cirrhosis. It reduces the incidence of spontaneous bacterial peritonitis, delays the development of hepatorenal syndrome, and improves survival.

General long-term measures

• Abstinence from alcohol.
• Improvement in nutrition and general status of the patient.
• Aggressive treatment and eradication of localized infections before dissemination.
• Measures directed at reducing the risk of gastrointestinal bleeding or the development of ascites, like surgical portacaval shunts or trans-jugular intrahepatic portasystemic stent-shunts, may help prevent SBP.
• Diuretic therapy decreases the AF volume and has been shown to significantly increase the AF opsonic activity, theoretically helping to prevent the development of SBP.