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

As 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, long-term antibiotic prophylaxis should be reserved for high-risk patients only.[1]

Primary prevention

Because of high risk of resistance and alteration of gut flora, long-term antibiotic prophylaxis should be reserved for high-risk patients with:[2]

  • Cirrhotic patients with 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.

The AASLD guidelines suggest using long-term antibiotic prophylaxis for SBP in patients who have the following risk factors:[3][4]

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).[3][4]

Specific measures for high-risk cases

Cirrhotic patients with gastrointestinal hemorrhage Non-bleeding cirrhotic patients with ascites
  • 25%-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, re-bleeding, and all cause 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.
  • 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.[7][8][9]
  • 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.[10]

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.[11]

References

  1. ↑ Alaniz C, Regal RE (2009). "Spontaneous bacterial peritonitis: a review of treatment options". P T. 34 (4): 204–10. PMC 2697093. PMID 19561863.
  2. ↑ 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.
  3. ↑ 3.0 3.1 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.
  4. ↑ 4.0 4.1 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.
  5. ↑ Bernard, Brigitte; Grangé, Jean-Didier; Khac, Eric Nguyen; Amiot, Xavier; Opolon, Pierre; Poynard, Thierry (1999). "Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: A meta-analysis". Hepatology. 29 (6): 1655–1661. doi:10.1002/hep.510290608. ISSN 0270-9139.
  6. ↑ Singh N, Gayowski T, Yu VL, Wagener MM (1995). "Trimethoprim-sulfamethoxazole for the prevention of spontaneous bacterial peritonitis in cirrhosis: a randomized trial". Ann Intern Med. 122 (8): 595–8. PMID 7887554.
  7. ↑ Fernández, J (2002). "Bacterial infections in cirrhosis: Epidemiological changes with invasive procedures and norfloxacin prophylaxis". Hepatology. 35 (1): 140–148. doi:10.1053/jhep.2002.30082. ISSN 0270-9139.
  8. ↑ "National Guideline Clearinghouse | Management of adult patients with ascites due to cirrhosis: an update".
  9. ↑ Novella, M; Sola, R; Soriano, G; Andreu, M; Gana, J; Ortiz, J; Coll, S; Sabat, M; Vila, M C; Guarner, C; Vilardell, F (1997). "Continuous versus inpatient prophylaxis of the first episode of spontaneous bacterial peritonitis with norfloxacin". Hepatology. 25 (3): 532–536. doi:10.1002/hep.510250306. ISSN 0270-9139.
  10. ↑ Fernández, Javier; Navasa, Miquel; Planas, Ramón; Montoliu, Silvia; Monfort, David; Soriano, German; Vila, Carmen; Pardo, Alberto; Quintero, Enrique; Vargas, Victor; Such, Jose; Ginès, Pere; Arroyo, Vicente (2007). "Primary Prophylaxis of Spontaneous Bacterial Peritonitis Delays Hepatorenal Syndrome and Improves Survival in Cirrhosis". Gastroenterology. 133 (3): 818–824. doi:10.1053/j.gastro.2007.06.065. ISSN 0016-5085.
  11. ↑ Such J, Runyon BA (1998). "Spontaneous bacterial peritonitis". Clin Infect Dis. 27 (4): 669–74, quiz 675-6. PMID 9798013.

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