Approach

Treatment for SBP is directed primarily at early administration of appropriate empirical antibiotics.[61][64] Ascitic fluid should ideally be obtained by paracentesis prior to antibiotic administration but antibiotics should be started before culture results are known to avoid delay.[61][64]​​

Aggressive resuscitation is essential if sepsis is present, with fluid resuscitation and pressor support to maintain a mean arterial pressure >65 mmHg.[116] Empirical broad-spectrum antibiotic therapy is required as soon as possible after recognition.[61][64]​ Assess for signs of sepsis, antibiotics should ideally be started within 1 hour once sepsis is suspected. See Sepsis in adults.

Antibiotic selection relies on the following factors:

  • Community-acquired infection versus nosocomial infection

  • Presence of risk factors for multi-drug-resistant (MDR) species

    • Recent ascitic fluid, urine, or blood culture demonstrating MDR

    • Patient not improving on appropriate therapy

    • Patient taking SBP prophylaxis

  • Local bacterial resistance patterns

  • Clinical signs of severe infection

Community-acquired infection with low risk for resistant species

First-line empirical antibiotic therapy for community-acquired SBP is an intravenous third-generation cephalosporin (e.g., cefotaxime, ceftriaxone).[61] Alternative options include an intravenous fluoroquinolone (e.g., ciprofloxacin) or ampicillin/sulbactam.[117]​ Treatment should continue for 5-7 days.[61][64][118][119][120] If the patient shows clinical improvement over 48 hours, it is reasonable to consider switching to an oral antibiotic.[117]​​

Systemic fluoroquinolone antibiotics, such as ciprofloxacin, may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycaemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behaviour.[121]

  • Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability).

  • Consult your local guidelines and drug information source for more information on suitability, contraindications, and precautions.

Despite increasing cephalosporin and fluoroquinolone resistance, a recent randomised, controlled trial comparing cefotaxime, ceftriaxone, and ciprofloxacin demonstrated similar resolution rates and mortality, and at rates similar to prior studies.[122]

Patients at high risk for MDR including nosocomial infection

Nosocomial SBP is associated with higher mortality than community-acquired SBP.[123] Patients with nosocomial infection or with other high risk factor for MDR should be started on empirical broad-spectrum intravenous antibiotics that cover the most likely MDR organism.[61]​ Overall, increased prevalence of infection from gram-positive cocci, such as MRSA and Enterococcus faecalis, and extended spectrum beta-lactamase (ESBL)-producing gram-negative bacilli, along with the emergence of carbapenem-resistant Klebsiella pneumoniae puts these patients at higher risk.[124]

Options include a carbapenem (e.g., imipenem/cilastatin, meropenem) or piperacillin/tazobactam.[61][64]​​​ Due to the concern of cephalosporin resistance in this population, and the higher mortality, primary treatment with carbapenems is recommended by the EASL.[64][125][126]​​​ Vancomycin can be added when better coverage of gram-positive cocci is needed (e.g., for patients with sepsis or a history of fluoroquinolone prophylaxis, or in areas with a high prevalence of gram-positive MDR organisms).[64][127]​​​​​​​​ Daptomycin is recommended for patients with previous vancomycin-resistant enterococcus (VRE) infection or a VRE-positive surveillance swab.[61] The choice of of broad-spectrum antibiotics should be tailored to the local prevalence and type of MDR organisms, and antibiotic coverage should be narrowed as soon as culture results are available.[61] There are no large randomised, controlled trials comparing efficacy of antibiotic regimens in nosocomial/high risk MDR patients. ​

Patients who are responding and clinically improving after 48 hours may be considered for a switch to oral antibiotics.[50][117][128][129]​​​​ Antibiotics should be continued to give a total duration of treatment of 5-7 days.[61]

Patients with high severity of infection

While standard therapy has excellent efficacy in SBP patients, the risk of an MDR pathogen being undertreated in a patient who presents critically ill (e.g., septic) is unacceptably high and antibiotic therapy should be broadened accordingly. This includes patients with nosocomial infection, recent hospitalisation, and patients who are admitted to the intensive care unit.[61]​ In addition, patients with CLIF-SOFA scores ≥7 are at higher risk of short-term mortality and should be treated more aggressively.[105]

Albumin

Intravenous albumin treatment has been shown to reduce mortality and decrease kidney dysfunction in patients with SBP.[130]​

Subgroup analysis of studies examining albumin use for SBP show the greatest mortality and renal dysfunction prevention benefits occur in patients with serum bilirubin >68.42 micromol/L (>4 mg/dL) or serum creatinine >88.4 micromol/L (>1 mg/dL) and serum urea >10.7 mmol/L (>30 mg/dL).[131] Because of this, the AASLD recommends albumin in all patients with SBP, but notes that patients with acute kidney injury and/or jaundice at time of diagnosis of SBP are more likely to benefit.[61]​​ Albumin decreases renal insufficiency, probably by increasing the circulatory volume and by binding proinflammatory molecules.[106][132]

Large-volume paracentesis (LVP)

LVP can improve abdominal discomfort in patients with tense ascites. However, there is little evidence on the safety of LVP in SBP and further research is warranted.[133]

Studies in patients with uncomplicated SBP (no sepsis, hepatic encephalopathy, GI bleeding, or significant renal dysfunction) have demonstrated that LVP with albumin replacement can be safe.[134][135]​ There are no studies that have examined whether LVP is safe in patients with complicated SBP.

Abdominal paracentesis animated demonstration
Abdominal paracentesis animated demonstration

Demonstrates how to perform diagnostic and therapeutic abdominal paracentesis.

Repeat paracentesis and broadened antibiotic coverage in treatment-resistant patients

Patients who have not demonstrated significant clinical improvement, or who are lacking a confirmed antibiotic-susceptible organism from their initial ascitic fluid culture, should undergo repeated diagnostic paracentesis after 48 hours of treatment.[61][136] Treatment failure is believed to occur if the absolute neutrophil count has decreased by <25% on 48-hour repeat paracentesis.[61]

Change in antibiotic therapy can be done according to blood or ascitic fluid culture results. If no growth has occurred, the addition of, or change to, vancomycin to cover MRSA and group D enterococci should be considered. Also, antibiotics that cover resistant Enterobacteriaceae (such as E coli) should be considered.

Failure to demonstrate significant improvement should also increase concern for secondary peritonitis, and imaging tests or surgical consultation may be needed.

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