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] Shivani Chaparala M.B.B.S [6]

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 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.

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

Empiric Therapy
Preferred Regimen
Cefotaxime 2 g IV q8h (or 2 g IV q4h if life-threatening) x 5–10 days
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
Should not be used in a patient who had been receiving a quinolone for prophylaxis.[2][3]
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.[4][5]
  • 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.[11]

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

  • Consider repeat paracentesis after 48hours of therapy
  • Consider changing antibiotics if ascitic fluid PMN has not dropped by 25% after 48 hours and/or patient is not responding clinically.


References

  1. "AASLD Practice Guidelines: Management of Adult Patients with Ascites Due to Cirrhosis" (PDF).
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. Hoefs JC, Canawati HN, Sapico FL, Hopkins RR, Weiner J, Montgomerie JZ (1982). "Spontaneous bacterial peritonitis". Hepatology. 2 (4): 399–407. PMID 7095741.
  8. 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.
  9. 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.
  10. 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)
  11. 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.
  12. 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.
  13. 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.
  14. 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.

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