Spontaneous Bacterial Peritonitis (SBP)
Approximately 1/3 of cirrhotic patients have bacterial infections. Spontaneous bacterial peritonitis (SBP) is a common infection in this setting which occurs in the absence of an obvious source of infection. Presence of fever or hypothermia, chills, and localizing symptoms should raise suspicion for bacterial infection. Signs/symptoms specific to SBP are abdominal pain, tenderness on palpation +/- rebound tenderness, and ileus. However, typical symptoms may be absent in cirrhotic patients. Common pathogens include gut bacteria (E. coli, Klebsiella spp.) and Streptococci spp.
Diagnosis
- Diagnostic abdominal paracentesis for cell count and bacterial culture, even in absence of signs/symptoms of infection.
- Culture ascitic fluid before initiating antibiotics.
- Polymorphonuclear (PMN) leukocyte count >250/mm3 indicates SBP à Start empiric antibiotics.
SBP Empiric Treatment
Expected duration 5-7 days
|
SBP Infection |
Empiric Therapy |
|
Community Acquired+ |
Ceftriaxone 1 gm IV q24h |
|
Nosocomial++ |
Piperacillin/tazobactam^* 4.5 gm IV q6h |
|
Septic shock; History of ampicillin-resistant enterococcus infection; IV antibiotic use and hospitalization within prior 90 days; Positive MRSA nasal swab or prior MRSA infection |
Piperacillin/tazobactam^* 4.5 gm IV q6h PLUS Vancomycin IV (see pages 36-37 for dosing) |
|
History of Vancomycin-Resistant Enterococcus spp. (VRE) |
Piperacillin/tazobactam^* 4.5 gm IV q6h PLUS Daptomycin* 10 mg/kg IV q24h |
+ Present at or acquired within the first 48 hours of admission
++ Acquisition of infection >48 hours after admission
^ If patient received > 48 hours of piperacillin/tazobactam within the prior 60 days, consider empiric meropenem*
* Contact ID for approval (EXCEPTION: piperacillin/tazobactam may be initiated in ICU without ID prior approval)
SBP Prophylaxis
|
Prophylaxis Criteria |
Antibiotic Therapy |
Duration |
|
Primary Prophylaxis
Advanced cirrhosis without prior episode of SBP and Acute upper gastrointestinal hemorrhage
|
Preferred: Ceftriaxone 1 gm IV Q24H
Alterative initial agent/ PO step down: Ciprofloxacin* 500 mg PO q12h Sulfamethoxazole-trimethoprim 1 DS PO tab q12h |
7 days |
|
Primary Prophylaxis Low ascitic protein (<1.5 g/dL) AND
|
Preferred: Ciprofloxacin* 500 mg PO Q24H
Alternative: Sulfamethoxazole-trimethoprim 1 DS PO tab daily Rifaximin# 400 mg PO TID (preferred) or 550 mg PO BID
|
Long term |
|
Secondary Prophylaxis
Prior episode of SBP |
Preferred: Ciprofloxacin* 500 mg PO Q24H
Alternatives: Sulfamethoxazole-trimethoprim 1 DS PO tab daily Rifaximin# 400 mg PO TID (preferred) or 550 mg PO BID |
Long term |
# Place pharmacy NFDR consult *Contact ID for inpatient use
References:
1. Biggins, Scott W., et al. "Diagnosis, evaluation, and management of ascites, spontaneous bacterial peritonitis and hepatorenal syndrome: 2021 practice guidance by the American Association for the Study of Liver Diseases." Hepatology 74.2 (2021): 1014-1048.
2. Praharaj, Dibya L., et al. "Rifaximin vs. norfloxacin for spontaneous bacterial peritonitis prophylaxis: a randomized controlled trial." Journal of Clinical and Experimental Hepatology 12.2 (2022): 336-342