Spontaneous bacterial peritonitis secondary 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] Shivani Chaparala M.B.B.S [3]
Overview
Following a first episode of spontaneous bacterial peritonitis, the recurrence rate at one year is ~70%, with a 1-year overall survival rate of 30-50% in patients who do not receive antibiotic prophylaxis.Cirrhotic patients with ascites with a prior history of SBP, on receiving antibiotic prophylaxis there is a reduction in the risk of recurrence from 68% to 20%.Accordingly, most experts recommend daily long-term antimicrobial prophylaxis for patients with a history of one or more episodes of SBP.
Secondary Prevention
- Secondary SBP prophylaxis
| Preferred therapy | Alternative therapy | Duration of treatment |
|---|---|---|
| Norfloxacin 400 mg PO daily | Trimethoprim-sulfamethoxazole one DS tablet daily. Ciprofloxacin 500 mg PO daily. Levofloxacin 250 mg PO daily. Rifaximin | Indefinite, unless ascites resolves. |
Several studies have shown that oral norfloxacin 400 mg daily prevents spontaneous bacterial peritonitis in patients with low-protein ascites and those with previous history of spontaneous bacterial peritonitis (SBP).
- In one study, norfloxacin reduced SBP recurrence rates from 68% to 20%.
- Alternative regimens that have been studied include oral double-strength trimethoprim-sulfamethoxazole 5 doses per week or oral ciprofloxacin 750 mg once a week, but intermittent dosing may lead to resistance.
- In addition, prolonged use of antibiotic prophylaxis has led to the development of gram-negative bacterial resistance (to fluoroquinolones and trimethoprim-sulfamethoxazole), as well as an increased likelihood of developing gram-positive infections.
- Therefore, prophylaxis should be reserved for patients at high risk of developing SBP and daily dosing regimens are preferred.
- Daily long-term dosing with norfloxacin has been proved to be superior to in-hospital administration of norfloxacin.
- All patients who have survived an episode of SBP should receive long-term prophylaxis with daily norfloxacin (or trimethoprim/sulfamethoxazole) because this is the most data-supported indication for long-term outpatient prophylaxis to prevent future episodes ( 40-70% risk of recurrence in 1 year ). [1][2]
- Rifaximin was more effective than norfloxacin in the secondary prevention of SBP as encephalopathy-related mortality and side effects were fewer with rifaximin than norfloxacin.[5][6]
References
- ↑ http://guideline.gov/content.aspx?id=14887&search=ascitis
- ↑ Ginés, Pere; Rimola, Antoni; Planas, Ramón; Vargas, Victor; Marco, Francesc; Almela, Manuel; Forne, Montserrat; Miranda, Maria Luisa; Llach, Josep; Salmerón, Joan Manuel; Esteve, Maria; Marques, Josep Maria; de Anta, Maria Teresa Jiménez; Arroyo, Vicente; Rodés, Joan (1990). "Norfloxacin prevents spontaneous bacterial peritonitis recurrence in cirrhosis: Results of a double-blind, placebo-controlled trial". Hepatology. 12 (4): 716–724. doi:10.1002/hep.1840120416. ISSN 0270-9139.
- ↑ Runyon BA (1986). "Low-protein-concentration ascitic fluid is predisposed to spontaneous bacterial peritonitis". Gastroenterology. 91 (6): 1343–6. PMID 3770358.
- ↑ Grangé JD, Roulot D, Pelletier G; et al. (1998). "Norfloxacin primary prophylaxis of bacterial infections in cirrhotic patients with ascites: a double-blind randomized trial". J. Hepatol. 29 (3): 430–6. PMID 9764990.
- ↑ Elfert, Asem; Abo Ali, Lobna; Soliman, Samah; Ibrahim, Shimaa; Abd-Elsalam, Sherief (2016). "Randomized-controlled trial of rifaximin versus norfloxacin for secondary prophylaxis of spontaneous bacterial peritonitis". European Journal of Gastroenterology & Hepatology. 28 (12): 1450–1454. doi:10.1097/MEG.0000000000000724. ISSN 0954-691X.
- ↑ Dong, Tien; Aronsohn, Andrew; Gautham Reddy, K.; Te, Helen S. (2016). "Rifaximin Decreases the Incidence and Severity of Acute Kidney Injury and Hepatorenal Syndrome in Cirrhosis". Digestive Diseases and Sciences. 61 (12): 3621–3626. doi:10.1007/s10620-016-4313-0. ISSN 0163-2116.