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] |
- Empiric antibiotic therapy should be administered to patients with ascitic fluid PMN counts greater than or equal to 250 cells/mm3 in a clinical setting compatible with 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 ascitic fluid.[6][7]
- Bacterascites is defined as an ascitic neutrophil count less than 250/mm3 but with a positive 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 results turns positive. Patients in whom the repeat ascitic neutrophil count is >250/mm3 should be treated for SBP, and the remaining patients (i.e., neutrophils <250/mm3) should be followed up.[8]
- The most common isolates from the ascitic fluid are Escherichia coli, Klebsiella pneumoniae, and Streptococcus pneumoniae.
- Relatively broad-spectrum therapy, preferably with cefotaxime, is warranted until the results of susceptibility testing are available.
- Infection with multiresistant organism including Extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae, Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus (MRSA), and Enterococcus faecium is associated with an increased mortality. Risk factors for multiresistant infections include:[9]
- Nosocomial origin of infection
- Long-term norfloxacin prophylaxis
- Recent infection with multiresistant bacteria
- Recent use of beta-lactams
- 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.[10]
- 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]
- Albumin infusion should be administered to cirrhotic patients with spontaneous bacterial peritonitis in the following conditions:[12]
- Serum creatinine >1 mg/dL
- Blood urea nitrogen >30 mg/dL
- Total bilirubin >4 mg/dL
- Adjunctive intravenous albumin at a dose of 1.5 g/kg at the time of diagnosis, followed by 1 g/kg on day 3 is associated with a reduced incidence of renal impairment and death in comparison with treatment with an antibiotic alone.[13]
- 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.[14]
Recommendations for the Management of Spontaneous Bacterial Peritonitis (2013 AASLD Practice Guideline)
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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
- ↑ "AASLD Practice Guidelines: Management of Adult Patients with Ascites Due to Cirrhosis" (PDF).
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Hoefs JC, Canawati HN, Sapico FL, Hopkins RR, Weiner J, Montgomerie JZ (1982). "Spontaneous bacterial peritonitis". Hepatology. 2 (4): 399–407. PMID 7095741.
- ↑ 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.
- ↑ 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.
- ↑ 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
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(help) - ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.