Spontaneous bacterial peritonitis medical therapy: Difference between revisions

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{{Spontaneous bacterial peritonitis}}
{{Spontaneous bacterial peritonitis}}
{{CMG}}; {{AE}} {{ADI}}
{{CMG}}; {{AE}} {{ADI}}, {{chetan}}, {{GRN}}, {{AL}} {{SCh}}{{AY}}


==Overview==
==Overview==
After confirmation of SBP, patients need hospital admission for intravenous antibiotics (most often [[cefotaxime]] given as 1gm/12hours for 5 days or [[ceftriaxone]]). They will often also receive intravenous albumin. A repeat paracentesis in 48 hours is sometimes performed to ensure control of infection. Once patients have recovered from SBP, they require regular prophylactic antibiotics (e.g. Septra DS, Cipro, norfloxicin) as long as they still have [[ascites]].


==Recommendations for the treatment of Spontaneous Bacterial Peritonitis (DO NOT EDIT)==
Empiric broad-spectrum [[intravenous]] [[antibiotic]], preferably a third generation [[cephalosporin]] such as [[cefotaxime]], is warranted for suspected or established [[spontaneous bacterial peritonitis|spontaneous bacterial peritonitis (SBP)]] to cover the most common isolates including ''[[Escherichia coli]]'', ''[[Klebsiella pneumoniae]]'', and ''[[Streptococcus pneumoniae]]''.<ref name="pmid11786457">{{cite journal| author=Soares-Weiser K, Paul M, Brezis M, Leibovici L| title=Evidence based case report. Antibiotic treatment for spontaneous bacterial peritonitis. | journal=BMJ | year= 2002 | volume= 324 | issue= 7329 | pages= 100-2 | pmid=11786457 | doi= | pmc=1121993 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11786457  }} </ref> Oral [[ofloxacin]] may be considered in selected cases. [[Albumin]] infusion should be reserved for patients with [[ascites|ascitic fluid]] [[PMN]] counts greater than or equal to 250 cells/mm<sup>3</sup> 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. The use of non-selective [[beta blockers]] in [[cirrhosis|cirrhotic]] patients with SBP should be discouraged since it is associated with an increased risk for [[hemodynamic compromise]], prolonged [[hospitalization]], [[hepatorenal syndrome]], and [[acute kidney injury]].<ref name="pmid24631577">{{cite journal| author=Mandorfer M, Bota S, Schwabl P, Bucsics T, Pfisterer N, Kruzik M et al.| title=Nonselective β blockers increase risk for hepatorenal syndrome and death in patients with cirrhosis and spontaneous bacterial peritonitis. | journal=Gastroenterology | year= 2014 | volume= 146 | issue= 7 | pages= 1680-90.e1 | pmid=24631577 | doi=10.1053/j.gastro.2014.03.005 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24631577  }} </ref>


{{cquote|
==Medical Therapy <SMALL><SMALL><SMALL><SMALL><SMALL>Adapted from ''AASLD Practice Guidelines: Management of Adult Patients with Ascites Due to Cirrhosis''.<ref name=AASLD2013>{{cite web
# 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).
| title = AASLD Practice Guidelines: Management of Adult Patients with Ascites Due to Cirrhosis
# 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).
| url = http://www.aasld.org/practiceguidelines/Documents/ascitesupdate2013.pdf
# 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.
}}</ref></SMALL></SMALL></SMALL></SMALL></SMALL>==
# 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.}}
* The diagnosis of spontaneous bacterial peritonitis (SBP) is made in the presence of an elevated [[ascites|ascitic fluid]] absolute [[PMN|polymorphonuclear leukocyte (PMN)]] count (i.e., ≥250 cells/ mm<sup>3</sup> without an evident intra-abdominal, surgically treatable source of infection.
-->
{| style="float: right; cellpadding=0; cellspacing= 0; width: 425px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Empiric Therapy}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Cefotaxime]] 2 g IV q8h (or 2 g IV q4h if life-threatening) x 5–10 days<ref name="pmid11871762">{{cite journal| author=França A, Giordano HM, Sevá-Pereira T, Soares EC| title=Five days of ceftriaxone to treat spontaneous bacterial peritonitis in cirrhotic patients. | journal=J Gastroenterol | year= 2002 | volume= 37 | issue= 2 | pages= 119-22 | pmid=11871762 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11871762  }} </ref>'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Alternative Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left |  ▸ '''''[[Ofloxacin]] 400 mg PO bid x 5–10 days'''''<sup>†</sup><BR> OR <BR> ▸ '''''[[Ciprofloxacin]] 200 mg IV q12h x 7 days'''''<sup>†</sup><BR> OR <BR> ▸ '''''[[Ciprofloxacin]] 200 mg IV q12h x 2 days, then 500 mg PO bid x 5 days'''''<sup>†</sup><ref name="pmid11059861">{{cite journal| author=Terg R, Cobas S, Fassio E, Landeira G, Ríos B, Vasen W et al.| title=Oral ciprofloxacin after a short course of intravenous ciprofloxacin in the treatment of spontaneous bacterial peritonitis: results of a multicenter, randomized study. | journal=J Hepatol | year= 2000 | volume= 33 | issue= 4 | pages= 564-9 | pmid=11059861 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11059861  }} </ref>
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | <sup>†</sup> <SMALL>Should <u>not</u> be used in a patient who had been receiving a quinolone for prophylaxis.</SMALL><ref name="pmid8831596">{{cite journal| author=Navasa M, Follo A, Llovet JM, Clemente G, Vargas V, Rimola A et al.| title=Randomized, comparative study of oral ofloxacin versus intravenous cefotaxime in spontaneous bacterial peritonitis. | journal=Gastroenterology | year= 1996 | volume= 111 | issue= 4 | pages= 1011-7 | pmid=8831596 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8831596  }} </ref><ref name="pmid11059861">{{cite journal| author=Terg R, Cobas S, Fassio E, Landeira G, Ríos B, Vasen W et al.| title=Oral ciprofloxacin after a short course of intravenous ciprofloxacin in the treatment of spontaneous bacterial peritonitis: results of a multicenter, randomized study. | journal=J Hepatol | year= 2000 | volume= 33 | issue= 4 | pages= 564-9 | pmid=11059861 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11059861  }} </ref>
|-
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|ESBL–producing ''Enterobacteriaceae''<sup>†</sup>}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Doripenem]] 500 mg IV q8h (1–hr infusion)'''''<BR> OR <BR> ▸ '''''[[Ertapenem]] 1 g IV q24h'''''<BR> OR <BR> ▸ '''''[[Imipenem cilastatin|Imipenem–Cilastatin]] 0.5–1 g IV q6–8h'''''<BR> OR <BR> ▸ '''''[[Meropenem]] 1 g IV q8h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Alternative Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Ciprofloxacin]] 400 mg IV q12h'''''<BR> OR <BR> ▸ '''''[[Levofloxacin]] 750 mg IV q24h'''''<BR> OR <BR> ▸ '''''[[Moxifloxacin]] 400 mg IV q24h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | <sup>†</sup> <SMALL>Check ''in vitro'' susceptibility.</SMALL><ref name="pmid22147550">{{cite journal| author=Wiest R, Krag A, Gerbes A| title=Spontaneous bacterial peritonitis: recent guidelines and beyond. | journal=Gut | year= 2012 | volume= 61 | issue= 2 | pages= 297-310 | pmid=22147550 | doi=10.1136/gutjnl-2011-300779 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22147550  }} </ref><ref name="pmid20457818">{{cite journal| author=Hoban DJ, Bouchillon SK, Hawser SP, Badal RE, Labombardi VJ, DiPersio J| title=Susceptibility of gram-negative pathogens isolated from patients with complicated intra-abdominal infections in the United States, 2007-2008: results of the Study for Monitoring Antimicrobial Resistance Trends (SMART). | journal=Antimicrob Agents Chemother | year= 2010 | volume= 54 | issue= 7 | pages= 3031-4 | pmid=20457818 | doi=10.1128/AAC.01808-09 | pmc=2897303 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20457818  }} </ref>
|}
 
* Empiric [[antibiotic therapy]] should be administered to patients with [[ascites|ascitic fluid]] [[PMN]] counts greater than or equal to 250 cells/mm<sup>3</sup> in a clinical setting compatible with [[ascites|ascitic fluid]] [[infection]] or those who have convincing signs or symptoms of infection ([[fever]], [[abdominal pain]], or unexplained [[encephalopathy]]) regardless of the [[PMN]] count in the [[ascites|ascitic fluid]].<ref name="pmid23463403">{{cite journal| author=Runyon BA, AASLD| title=Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis 2012. | journal=Hepatology | year= 2013 | volume= 57 | issue= 4 | pages= 1651-3 | pmid=23463403 | doi=10.1002/hep.26359 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23463403  }} </ref><ref name="pmid7095741">{{cite journal| author=Hoefs JC, Canawati HN, Sapico FL, Hopkins RR, Weiner J, Montgomerie JZ| title=Spontaneous bacterial peritonitis. | journal=Hepatology | year= 1982 | volume= 2 | issue= 4 | pages= 399-407 | pmid=7095741 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7095741  }} </ref>
 
* Bacterascites is defined as an [[ascites|ascitic]] [[neutrophil]] count less than 250/mm<sup>3</sup> but with a positive [[ascites|ascitic fluid]] culture. If the patient exhibits signs of systemic [[inflammation]] or [[infection]], the patient should be treated with [[antibiotics]]. Otherwise, the patient should undergo a second [[paracentesis]] when [[Culture medium|culture]] results turns positive. Patients in whom the repeat [[ascites|ascitic]] [[neutrophil]] count is >250/mm<sup>3</sup> should be treated for SBP, and the remaining patients (i.e., [[neutrophil]]s <250/mm<sup>3</sup>) should be followed up.<ref name="pmid20633946">{{cite journal| author=European Association for the Study of the Liver| title=EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. | journal=J Hepatol | year= 2010 | volume= 53 | issue= 3 | pages= 397-417 | pmid=20633946 | doi=10.1016/j.jhep.2010.05.004 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20633946  }} </ref>
 
* The most common isolates from the [[ascites|ascitic fluid]] are ''[[Escherichia coli]]'', ''[[Klebsiella pneumoniae]]'', and ''[[Streptococcus pneumoniae]]''.
 
* Relatively [[Broad-spectrum antibiotic|broad-spectrum]] therapy, preferably with [[cefotaxime]], is warranted until the results of susceptibility testing are available.


==Medical Therapy==
* Infection with [[MDR|multiresistant]] organism including [[ESBL|Extended-spectrum β-lactamase (ESBL)]]-producing ''[[Enterobacteriaceae]]'', ''[[Pseudomonas aeruginosa]]'', [[MRSA|methicillin-resistant ''Staphylococcus aureus'' (MRSA)]], and ''[[Enterococcus faecium]]'' is associated with an increased [[mortality]]. [[Risk factor]]s for [[MDR|multiresistant]] infections include:<ref name="pmid22183941">{{cite journal| author=Fernández J, Acevedo J, Castro M, Garcia O, de Lope CR, Roca D et al.| title=Prevalence and risk factors of infections by multiresistant bacteria in cirrhosis: a prospective study. | journal=Hepatology | year= 2012 | volume= 55 | issue= 5 | pages= 1551-61 | pmid=22183941 | doi=10.1002/hep.25532 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22183941  }} </ref><ref name="pmid23463403">{{cite journal| author=Runyon BA, AASLD| title=Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis 2012. | journal=Hepatology | year= 2013 | volume= 57 | issue= 4 | pages= 1651-3 | pmid=23463403 | doi=10.1002/hep.26359 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23463403  }} </ref>
:* [[Nosocomial]] origin of infection
:* Long-term [[norfloxacin]] prophylaxis
:* Recent infection with [[MDR|multiresistant]] bacteria
:* Recent use of [[beta-lactam]]s


===Antibiotics===
* Oral [[ofloxacin]] may be used alternatively in selected cases such as patients without [[vomiting]], [[shock]], grade II (or higher) [[hepatic encephalopathy]], or serum [[creatinine]] greater than 3 mg/dL.<ref>{{Cite journal
Antibiotic therapy is administered empirically. Therapy can be initiated if
| issn = 0016-5085
* temperature is more than 100 degree Fahrenheit.
| volume = 111
* alteration of [[mental status]]
| issue = 4
* ascitic fluid neutrophil count >250 cells/mm<sup>3<sup>
| pages = 1011–1017
* [[abdominal tenderness]]
| last = Navasa
| first = M
| coauthors = A Follo, J M Llovet, G Clemente, V Vargas, A Rimola, F Marco, C Guarner, M Forné, R Planas, R Bañares, L Castells, M T Jimenez De Anta, V Arroyo, J Rodés
| title = Randomized, comparative study of oral ofloxacin versus intravenous cefotaxime in spontaneous bacterial peritonitis
| journal = Gastroenterology
| date = 1996-10
| pmid = 8831596
}}</ref>


Broad spectrum antibiotics are used to cover the intestinal bacteria which are gram negative, aerobic bacteria.
* The optimal duration of therapy remains unclear, although most patients respond to a treatment course of five days. Infection-related [[mortality]], bacteriologic cure, and recurrence of [[ascites|ascitic fluid]] infection were not significantly different between the 5- and 10-day treatment groups in a randomized trial.<ref name="pmid2019378">{{cite journal| author=Runyon BA, McHutchison JG, Antillon MR, Akriviadis EA, Montano AA| title=Short-course versus long-course antibiotic treatment of spontaneous bacterial peritonitis. A randomized controlled study of 100 patients. | journal=Gastroenterology | year= 1991 | volume= 100 | issue= 6 | pages= 1737-42 | pmid=2019378 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2019378  }} </ref>
* [[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.<ref name="pmid17854593">{{cite journal |author=Fernández J, Navasa M, Planas R, ''et al'' |title=Primary prophylaxis of spontaneous bacterial peritonitis delays hepatorenal syndrome and improves survival in cirrhosis |journal=Gastroenterology |volume=133 |issue=3 |pages=818–24 |year=2007 |pmid=17854593 |doi=10.1053/j.gastro.2007.06.065}}</ref>


===Intravenous albumin===
===Adjunctive IV Albumin===
A [[randomized controlled trial]] found that intravenous [[albumin]] on the day of admission and on hospital day 3 can reduce  renal impairment.<ref name="pmid10432325">{{cite journal |author=Sort P, Navasa M, Arroyo V, ''et al'' |title=Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis |journal=N. Engl. J. Med. |volume=341 |issue=6 |pages=403-9 |year=1999 |pmid=10432325 |doi=}}</ref>
* In a randomized controlled study involving cirrhotic patients with SBP, the use of [[Albumin|IV albumin]] (1.5 g/kg given within 6 hours of enrollment and repeated as a 1.0 g/kg dose on day 3) as an adjunctive to [[cefotaxime]] was shown to decrease [[Mortality rate|in-hospital mortality]] when compared with use of [[cefotaxime]] alone (29% versus 10%). <ref name="pmid10432325">{{cite journal| author=Sort P, Navasa M, Arroyo V, Aldeguer X, Planas R, Ruiz-del-Arbol L et al.| title=Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. | journal=N Engl J Med | year= 1999 | volume= 341 | issue= 6 | pages= 403-9 | pmid=10432325 | doi=10.1056/NEJM199908053410603 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10432325  }} </ref>


===Guidelines ===
* In addition, those treated with [[albumin]] had a reduction in the development of [[renal impairment]] (10% versus 33%).  
* 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.<ref name="urlNational Guideline Clearinghouse | Management of adult patients with ascites due to cirrhosis: an update.">{{cite web |url=http://guideline.gov/content.aspx?id=14887&search=ascitis |title=National Guideline Clearinghouse &#124; Management of adult patients with ascites due to cirrhosis: an update. |format= |work= |accessdate=}}</ref>
* Use of [[Albumin|IV albumin]] should be reserved for patients with a:
** Serum [[creatinine]] greater than 1 mg/dL,
** [[Blood urea nitrogen]] greater than 30 mg/dL, or  
** Total [[bilirubin]] greater than 4 mg/dL.<ref name="pmid17369392">{{cite journal| author=Sigal SH, Stanca CM, Fernandez J, Arroyo V, Navasa M| title=Restricted use of albumin for spontaneous bacterial peritonitis. | journal=Gut | year= 2007 | volume= 56 | issue= 4 | pages= 597-9 | pmid=17369392 | doi=10.1136/gut.2006.113050 | pmc=1856861 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17369392  }} </ref>


* 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.
==Recommendations for the Management of Spontaneous Bacterial Peritonitis (2013 AASLD Practice Guideline)==


* 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.    
{{cquote|
# 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 [[ascites|ascitic fluid]] [[PMN]] counts greater than or equal to 250 cells/mm<sup>3</sup> in a community-acquired setting in the absence of recent [[beta-lactam]] [[antibiotic]] exposure should receive empiric antibiotic therapy, e.g., an [[intravenous]] third-generation [[cephalosporin]], preferably [[cefotaxime]] 2 g every 8 hours.
# Patients with [[ascites|ascitic fluid]] [[PMN]] counts greater than or equal to 250 cells/mm<sup>3</sup> in a nosocomial setting and/or in the presence of recent [[beta-lactam]] antibiotic exposure should receive empiric antibiotic therapy based on local susceptibility testing of bacteria in patients with [[cirrhosis]].
# 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 [[ascites|ascitic fluid]] [[PMN]] counts less than 250 cells/mm<sup>3</sup> and signs or symptoms of [[infection]] (temperature >100ºF 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 [[ascites|ascitic fluid]] of a patient with [[cirrhosis]] is found to have a [[PMN]] count greater than or equal to 250 cells/mm<sup>3</sup> and there is high suspicion of secondary [[peritonitis]], it should also be tested for [[protein]], [[lactic dehydrogenase]], [[glucose]], [[Gram’s stain]], [[carcinoembryonic antigen]], and [[alkaline phosphatase]] to assist with the distinction of SBP from secondary [[peritonitis]]. [[Computed tomography|Computed tomographic]] scanning should also be performed.
# Patients with [[ascites|ascitic fluid]] [[PMN]] counts greater than or equal to 250 cells/mm<sup>3</sup> in a nosocomial setting and/or in the presence of recent [[beta-lactam]] antibiotic exposure and/or culture an atypical organism(s) or have an atypical clinical response to treatment, should undergo a follow-up [[paracentesis]] after 48 hours of treatment to assess the response in [[PMN]] count and culture.
# Patients with [[ascites|ascitic fluid]] [[PMN]] counts greater than or equal to 250 cells/mm<sup>3</sup> 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 should receive 1.5 g [[albumin]] per kg body weight within 6 hours of detection and 1.0 g/kg on day 3.
}}


* 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.
===Followup Diagnostic Paracentesis===


* 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.
* Follow-up ascitic fluid analysis is usually not necessary following treatment of SBP unless there is no clinical improvement in the patient’s symptoms, abnormal fluid analysis, suspected infection with multi-drug resistant organisms, or altered clinical course is noted.
* If the ascitic fluid [[PMNs|PMN]] count has not declined by at least 25% after two days of [[antibiotic therapy]], then the [[Antibiotic|antibiotic coverage]] needs to be broadened to cover resistant organisms and [[Secondary peritonitis|secondary bacterial peritonitis]] needs to be considered. 
* Patients with [[Secondary peritonitis|secondary bacterial peritonitis]] should undergo surgical intervention of the [[Bowel perforation|perforated viscus]] or drainage of the [[abscess]] and should be treated with [[Broad-spectrum antibiotic|broad-spectrum antibiotics]], such as [[Cephalosporins|third-generation cephalosporins]], with the addition of an [[antimicrobial agent]] that has good [[Anaerobic organism|anaerobic coverage]], such as [[metronidazole]]
** Consider repeat [[paracentesis]] after 48 hours of therapy
** Consider changing [[antibiotics]] if [[Ascites|ascitic fluid]] PMN has not dropped by 25% after 48 hours and/or patient is not responding clinically.


==References==
==References==
{{reflist|2}}
{{reflist|2}}


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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] Shivani Chaparala M.B.B.S [6]Ahmed Younes M.B.B.CH [7]

Overview

Empiric broad-spectrum intravenous antibiotic, preferably 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.[1] Oral ofloxacin may be considered in selected cases. Albumin infusion 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. The use of non-selective beta blockers in cirrhotic patients with SBP should be discouraged since it is associated with an increased risk for hemodynamic compromise, prolonged hospitalization, hepatorenal syndrome, and acute kidney injury.[2]

Medical Therapy Adapted from AASLD Practice Guidelines: Management of Adult Patients with Ascites Due to Cirrhosis.[3]

Empiric Therapy
Preferred Regimen
Cefotaxime 2 g IV q8h (or 2 g IV q4h if life-threatening) x 5–10 days[4]
Alternative Regimen
Ofloxacin 400 mg PO bid x 5–10 days
OR
Ciprofloxacin 200 mg IV q12h x 7 days
OR
Ciprofloxacin 200 mg IV q12h x 2 days, then 500 mg PO bid x 5 days[5]
Should not be used in a patient who had been receiving a quinolone for prophylaxis.[6][5]
ESBL–producing Enterobacteriaceae
Preferred Regimen
Doripenem 500 mg IV q8h (1–hr infusion)
OR
Ertapenem 1 g IV q24h
OR
Imipenem–Cilastatin 0.5–1 g IV q6–8h
OR
Meropenem 1 g IV q8h
Alternative Regimen
Ciprofloxacin 400 mg IV q12h
OR
Levofloxacin 750 mg IV q24h
OR
Moxifloxacin 400 mg IV q24h
Check in vitro susceptibility.[7][8]
  • Relatively broad-spectrum therapy, preferably with cefotaxime, is warranted until the results of susceptibility testing are available.
  • The optimal duration of therapy remains unclear, although most patients respond to a treatment course of five days. Infection-related mortality, bacteriologic cure, and recurrence of ascitic fluid infection were not significantly different between the 5- and 10-day treatment groups in a randomized trial.[14]

Adjunctive IV Albumin

  • In a randomized controlled study involving cirrhotic patients with SBP, the use of IV albumin (1.5 g/kg given within 6 hours of enrollment and repeated as a 1.0 g/kg dose on day 3) as an adjunctive to cefotaxime was shown to decrease in-hospital mortality when compared with use of cefotaxime alone (29% versus 10%). [15]

Recommendations for the Management of Spontaneous Bacterial Peritonitis (2013 AASLD Practice Guideline)

  1. 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).
  2. Patients with ascitic fluid PMN counts greater than or equal to 250 cells/mm3 in a community-acquired setting in the absence of recent beta-lactam antibiotic exposure should receive empiric antibiotic therapy, e.g., an intravenous third-generation cephalosporin, preferably cefotaxime 2 g every 8 hours.
  3. Patients with ascitic fluid PMN counts greater than or equal to 250 cells/mm3 in a nosocomial setting and/or in the presence of recent beta-lactam antibiotic exposure should receive empiric antibiotic therapy based on local susceptibility testing of bacteria in patients with cirrhosis.
  4. 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.
  5. Patients with ascitic fluid PMN counts less than 250 cells/mm3 and signs or symptoms of infection (temperature >100ºF 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.
  6. When the ascitic fluid of a patient with cirrhosis is found to have a PMN count greater than or equal to 250 cells/mm3 and there is high suspicion of secondary peritonitis, it should also be tested for protein, lactic dehydrogenase, glucose, Gram’s stain, carcinoembryonic antigen, and alkaline phosphatase to assist with the distinction of SBP from secondary peritonitis. Computed tomographic scanning should also be performed.
  7. Patients with ascitic fluid PMN counts greater than or equal to 250 cells/mm3 in a nosocomial setting and/or in the presence of recent beta-lactam antibiotic exposure and/or culture an atypical organism(s) or have an atypical clinical response to treatment, should undergo a follow-up paracentesis after 48 hours of treatment to assess the response in PMN count and culture.
  8. 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 should receive 1.5 g albumin per kg body weight within 6 hours of detection and 1.0 g/kg on day 3.

Followup Diagnostic Paracentesis

References

  1. Soares-Weiser K, Paul M, Brezis M, Leibovici L (2002). "Evidence based case report. Antibiotic treatment for spontaneous bacterial peritonitis". BMJ. 324 (7329): 100–2. PMC 1121993. PMID 11786457.
  2. Mandorfer M, Bota S, Schwabl P, Bucsics T, Pfisterer N, Kruzik M; et al. (2014). "Nonselective β blockers increase risk for hepatorenal syndrome and death in patients with cirrhosis and spontaneous bacterial peritonitis". Gastroenterology. 146 (7): 1680–90.e1. doi:10.1053/j.gastro.2014.03.005. PMID 24631577.
  3. "AASLD Practice Guidelines: Management of Adult Patients with Ascites Due to Cirrhosis" (PDF).
  4. França A, Giordano HM, Sevá-Pereira T, Soares EC (2002). "Five days of ceftriaxone to treat spontaneous bacterial peritonitis in cirrhotic patients". J Gastroenterol. 37 (2): 119–22. PMID 11871762.
  5. 5.0 5.1 Terg R, Cobas S, Fassio E, Landeira G, Ríos B, Vasen W; et al. (2000). "Oral ciprofloxacin after a short course of intravenous ciprofloxacin in the treatment of spontaneous bacterial peritonitis: results of a multicenter, randomized study". J Hepatol. 33 (4): 564–9. PMID 11059861.
  6. Navasa M, Follo A, Llovet JM, Clemente G, Vargas V, Rimola A; et al. (1996). "Randomized, comparative study of oral ofloxacin versus intravenous cefotaxime in spontaneous bacterial peritonitis". Gastroenterology. 111 (4): 1011–7. PMID 8831596.
  7. Wiest R, Krag A, Gerbes A (2012). "Spontaneous bacterial peritonitis: recent guidelines and beyond". Gut. 61 (2): 297–310. doi:10.1136/gutjnl-2011-300779. PMID 22147550.
  8. Hoban DJ, Bouchillon SK, Hawser SP, Badal RE, Labombardi VJ, DiPersio J (2010). "Susceptibility of gram-negative pathogens isolated from patients with complicated intra-abdominal infections in the United States, 2007-2008: results of the Study for Monitoring Antimicrobial Resistance Trends (SMART)". Antimicrob Agents Chemother. 54 (7): 3031–4. doi:10.1128/AAC.01808-09. PMC 2897303. PMID 20457818.
  9. 9.0 9.1 Runyon BA, AASLD (2013). "Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis 2012". Hepatology. 57 (4): 1651–3. doi:10.1002/hep.26359. PMID 23463403.
  10. Hoefs JC, Canawati HN, Sapico FL, Hopkins RR, Weiner J, Montgomerie JZ (1982). "Spontaneous bacterial peritonitis". Hepatology. 2 (4): 399–407. PMID 7095741.
  11. European Association for the Study of the Liver (2010). "EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis". J Hepatol. 53 (3): 397–417. doi:10.1016/j.jhep.2010.05.004. PMID 20633946.
  12. Fernández J, Acevedo J, Castro M, Garcia O, de Lope CR, Roca D; et al. (2012). "Prevalence and risk factors of infections by multiresistant bacteria in cirrhosis: a prospective study". Hepatology. 55 (5): 1551–61. doi:10.1002/hep.25532. PMID 22183941.
  13. Navasa, M (1996-10). "Randomized, comparative study of oral ofloxacin versus intravenous cefotaxime in spontaneous bacterial peritonitis". Gastroenterology. 111 (4): 1011–1017. ISSN 0016-5085. PMID 8831596. Unknown parameter |coauthors= ignored (help); Check date values in: |date= (help)
  14. Runyon BA, McHutchison JG, Antillon MR, Akriviadis EA, Montano AA (1991). "Short-course versus long-course antibiotic treatment of spontaneous bacterial peritonitis. A randomized controlled study of 100 patients". Gastroenterology. 100 (6): 1737–42. PMID 2019378.
  15. Sort P, Navasa M, Arroyo V, Aldeguer X, Planas R, Ruiz-del-Arbol L; et al. (1999). "Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis". N Engl J Med. 341 (6): 403–9. doi:10.1056/NEJM199908053410603. PMID 10432325.
  16. Sigal SH, Stanca CM, Fernandez J, Arroyo V, Navasa M (2007). "Restricted use of albumin for spontaneous bacterial peritonitis". Gut. 56 (4): 597–9. doi:10.1136/gut.2006.113050. PMC 1856861. PMID 17369392.

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