Spontaneous bacterial peritonitis medical therapy

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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]

Overview

Empiric broad-spectrum intravenous antibiotic, preferably with 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. Oral ofloxacin may be considered in selected cases. Albumin 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.

Empiric Therapy Adapted from AASLD Practice Guidelines: Management of Adult Patients with Ascites Due to Cirrhosis.[1]

Spontaneous Bacterial Peritonitis
Preferred Regimen
Cefotaxime 2 g IV q8h (or 2 g IV q4h if life-threatening)
OR
Ticarcillin–Clavulanate 3.1 g IV q4–6h
OR
Piperacillin–Tazobactam 3.375 g IV q6h (or 4.5 g IV q8h)
OR
Ceftriaxone 1–2 g IV q12–24h
OR
Ertapenem 1 g IV q24h
For ESBL–producing Enterobacteriaceae, check susceptibility testing.
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
OR
Ciprofloxacin 400 mg IV q12h
OR
Levofloxacin 750 mg IV q24h
OR
Moxifloxacin 400 mg IV q24h
  • Relatively broad-spectrum therapy, preferably with cefotaxime, is warranted until the results of susceptibility testing are available.

Adjunctive Therapy

AASLD Recommendations for the Management of Spontaneous Bacterial Peritonitis

  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 hrs 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.

References

  1. "Management of Adult Patients with Ascites Due to Cirrhosis: Update 2012" (PDF).
  2. Runyon, Bruce A (2013-04). "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 (Baltimore, Md.). 57 (4): 1651–1653. doi:10.1002/hep.26359. ISSN 1527-3350. PMID 23463403. Unknown parameter |coauthors= ignored (help); Check date values in: |date= (help)
  3. Hoefs, J C (1982-08). "Spontaneous bacterial peritonitis". Hepatology (Baltimore, Md.). 2 (4): 399–407. ISSN 0270-9139. PMID 7095741. Unknown parameter |coauthors= ignored (help); Check date values in: |date= (help)
  4. Fernández, Javier (2012-05). "Prevalence and risk factors of infections by multiresistant bacteria in cirrhosis: a prospective study". Hepatology (Baltimore, Md.). 55 (5): 1551–1561. doi:10.1002/hep.25532. ISSN 1527-3350. PMID 22183941. Unknown parameter |coauthors= ignored (help); Check date values in: |date= (help)
  5. 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)
  6. Sigal, Samuel H (2007-04). "Restricted use of albumin for spontaneous bacterial peritonitis". Gut. 56 (4): 597–599. doi:10.1136/gut.2006.113050. ISSN 0017-5749. PMC 1856861. PMID 17369392. Unknown parameter |coauthors= ignored (help); Check date values in: |date= (help)
  7. Sort, P (1999-08-05). "Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis". The New England journal of medicine. 341 (6): 403–409. doi:10.1056/NEJM199908053410603. ISSN 0028-4793. PMID 10432325. Unknown parameter |coauthors= ignored (help)
  8. Mandorfer, Mattias (2014-06). "Nonselective β Blockers Increase Risk for Hepatorenal Syndrome and Death in Patients With Cirrhosis and Spontaneous Bacterial Peritonitis". Gastroenterology. 146 (7): 1680–1690.e1. doi:10.1053/j.gastro.2014.03.005. ISSN 1528-0012. PMID 24631577. Unknown parameter |coauthors= ignored (help); Check date values in: |date= (help)