Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

community-acquired infection with low risk for resistant species

1st line – empirical intravenous antibiotics

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ACUTE
|
community-acquired infection with low risk for resistant species
1st line – 

empirical intravenous antibiotics

First-line empirical antibiotic therapy for community-acquired SBP is an intravenous third-generation cephalosporin (e.g., cefotaxime, ceftriaxone).[61] Alternative options include a fluoroquinolone (e.g., ciprofloxacin) or ampicillin/sulbactam.[64][117]​​[118][119][120]​​​​ Do not use fluoroquinolones if patient is already on fluoroquinolone prophylaxis or in areas where there is a high prevalence of fluoroquinolone-resistant bacteria.​[80]

If continued 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.​

Emerging patterns of resistance must be examined closely at each institution to determine if more broad-spectrum empirical coverage is warranted from the outset.

Treatment course: 5-7 days.

Primary options

cefotaxime: 2 g intravenously every 12 hours

OR

ceftriaxone: 1-2 g intravenously every 12-24 hours

Secondary options

ciprofloxacin: 400 mg intravenously every 12 hours

OR

ampicillin/sulbactam: 1.5 to 3 g intravenously every 6 hours

More

Consider – albumin

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ACUTE
|
community-acquired infection with low risk for resistant species
Consider – 

albumin

Additional treatment recommended for SOME patients in selected patient group

Intravenous albumin treatment has been shown to reduce mortality and decrease kidney dysfunction in patients with SBP.[130]​ Albumin decreases renal insufficiency, probably by increasing the circulatory volume and by binding pro-inflammatory molecules.[106][132]

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]

Consider – large-volume paracentesis (LVP)

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ACUTE
|
community-acquired infection with low risk for resistant species
Consider – 

large-volume paracentesis (LVP)

Additional treatment recommended for SOME patients in selected patient group

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, gastrointestinal 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.

nosocomial infection, septic shock, high risk for MDR organisms

1st line – empirical intravenous antibiotics

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ACUTE
|
nosocomial infection, septic shock, high risk for MDR organisms
1st line – 

empirical intravenous antibiotics

Patients should be started on empirical broad-spectrum intravenous antibiotics that cover the most likely MDR organism.[61]

Antibiotic 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 a carbapenem regimen is recommended by the EASL.[64][125][126]

The choice of of broad-spectrum antibiotics should be tailored to the local prevalence and type of multidrug resistant organisms, and antibiotic coverage should be narrowed as soon as culture results are available.[61]

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 also be treated more aggressively.[105]​​

Patients who are responding and clinically improving after 48 hours may be considered for a switch to oral antibiotics.[50][117]​​[128][129]​​

Treatment course: 5-7 days.

Primary options

piperacillin/tazobactam: 3.375 g intravenously every 6 hours

More

OR

imipenem/cilastatin: 0.5 to 1 g intravenously every 6 hours, or 1 g every 8 hours

More

OR

meropenem: 1-2 g intravenously every 8 hours

Consider – vancomycin or daptomycin

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ACUTE
|
nosocomial infection, septic shock, high risk for MDR organisms
Consider – 

vancomycin or daptomycin

Additional treatment recommended for SOME patients in selected patient group

Vancomycin can be added when better coverage of gram-positive cocci is needed (e.g., patients with sepsis or a history of fluoroquinolone prophylaxis, or in areas with a high prevalence of gram-positive multidrug resistant 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 antibiotic should be tailored to local MDR prevalence and narrowed once culture results are available.[61]

Primary options

vancomycin: 15-20 mg/kg intravenously every 8-12 hours

More

OR

daptomycin: 4-6 mg/kg intravenously every 24 hours

Consider – albumin

Back
ACUTE
|
nosocomial infection, septic shock, high risk for MDR organisms
Consider – 

albumin

Additional treatment recommended for SOME patients in selected patient group

Intravenous albumin treatment has been shown to reduce mortality and decrease kidney dysfunction in patients with SBP.[132]

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 pro-inflammatory molecules.[106][132]

Consider – broaden empirical regimen and assess further or switch to oral regimen

Back
ACUTE
|
nosocomial infection, septic shock, high risk for MDR organisms
Consider – 

broaden empirical regimen and assess further or switch to oral regimen

Additional treatment recommended for SOME patients in selected patient group

Consider broadening the antibiotic coverage and assess further (including repeat diagnostic paracentesis) if the patient does not demonstrate significant improvement after 48 hours. Change in antibiotic therapy can be made according to the blood or ascitic fluid culture results. If no growth has occurred, consider addition of, or change to, vancomycin to cover MRSA and group D enterococci, and consider antibiotics that cover resistant Enterobacteriaceae if the patient is not already on antibiotics that cover these organisms. Failure to demonstrate significant improvement should also increase concern for secondary peritonitis, and imaging tests or surgical consultation may be needed.

If the patient responds to treatment after 48 hours, consider switching to a suitable oral antibiotic regimen.[117]

Consider – large-volume paracentesis (LVP)

Back
ACUTE
|
nosocomial infection, septic shock, high risk for MDR organisms
Consider – 

large-volume paracentesis (LVP)

Additional treatment recommended for SOME patients in selected patient group

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, gastrointestinal 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.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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