Spontaneous bacterial peritonitis (SBP)
- Spontaneous bacterial peritonitis is usually monomicrobial. Polymicrobial infections suggest bowel perforation. See 2° peritonitis.
Diagnosis:
- Ascitic fluid positive for bacteria and PMNs ≥ 0.25 x 109/L.
- Blood/peritoneal fluid cultures recommended.
Management:
- Urinary/intravascular catheterization may increase risk of infection in patients with ascites - avoid if possible.
- Aminoglycosides should be avoided in patients with cirrhosis.
- Increased risk of SBP (and Clostridioides (Clostridium) difficile infection) in cirrhotic patients on proton pump inhibitors (PPIs). Therefore use PPIs judiciously and only when clearly indicated in cirrhotic patients.
Prophylaxis:
- SBP will occur in 10-25% of cirrhotic patients with ascites. Prophylactic antibiotics decrease incidence of initial (primary prophylaxis)/recurrent (secondary prophylaxis) episodes of SBP but have not demonstrated reduction in hospitalization or survival rates.
- Long term prophylaxis with antibiotics increases carriage of multiresistant organisms.
Enterobacterales
S. pneumoniae
Streptococcus spp
Treatment
Community-acquired
| Empiric Therapy | Dose | Duration |
|---|---|---|
| Ceftriaxone | 1-2g IV daily | 5-7 days |
| Ceftriaxone allergy |
||
| Ciprofloxacin |
400mg IV q12h/ 500mg PO bid |
5-7 days |
Healthcare-associated
- hospitalization or antibiotic use within previous 3 months
- from long term care
- on hemodialysis
| Empiric Therapy | Dose | Duration |
|---|---|---|
| Piperacillin-tazobactam |
4.5g IV q8h or | 5-7 days |
| 3.375g IV q6h | ||
| Penicillin allergy | ||
| Ceftriaxone | 1-2g IV daily | 5-7 days |
| + | ||
| Vancomycin | 15mg/kg IV q12h |
Hospital-acquired (≥ 48 hours post-admission)/previous ceftriaxone-resistant Gram negative organism
| Empiric Therapy | Dose | Duration |
|---|---|---|
| Meropenem | 500mg IV q6h | 5-7 days |
| If sepsis/septic shock, add | ||
| Vancomycin | 15mg/kg IV q12h |
5-7 days |
| or |
|
|
| Linezolid | 600mg IV/PO q12h |
5-7 days |
Prophylaxis
- SBP will occur in 10-25% of cirrhotic patients with ascites. Prophylactic antibiotics decrease incidence of initial (primary prophylaxis)/recurrent (secondary prophylaxis) episodes of SBP but have not demonstrated reduction in hospitalization or survival rates. Recent Cochrane review questions the benefit of secondary SBP prophylaxis: Antibiotic prophylaxis to prevent spontaneous bacterial peritonitis in people with liver cirrhosis: a network meta‐analysis
- Long term prophylaxis with antibiotics increases carriage of multiresistant organisms.
Primary prophylaxis in patients with cirrhosis & GI bleed:
| Empiric Therapy | Dose | Duration |
|---|---|---|
| Ceftriaxone | 1g IV daily | while NPO |
| then | ||
| [TMP/SMX | 1 DS tab PO bid | to complete 5 days |
| or | ||
| Norfloxacin | 400mg PO bid | to complete 5 days |
| or | ||
| Ciprofloxacin] | 500mg PO bid | to complete 5 days |
Secondary prophylaxis in high risk patients only:
- recent Cochrane review questions the benefit of secondary SBP prophylaxis: Antibiotic prophylaxis to prevent spontaneous bacterial peritonitis in people with liver cirrhosis: a network meta‐analysis
| Empiric Therapy | Dose | Duration |
|---|---|---|
| TMP/SMX | 1 DS tab PO daily | lifetime |
Alternative
| Empiric Therapy | Dose | Duration |
|---|---|---|
| Norfloxacin | 400mg PO daily | lifetime |
| or | ||
| Ciprofloxacin | 500mg PO daily | lifetime |