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Spontaneous Bacterial Peritonitis Organism-Specific Therapy

Specific Organisms and Therapeutic Regimens

Common organisms in spontaneous bacterial peritonitis (SBP) and treatment recommendations for these organisms are provided below, as well as special considerations.

Common organisms in spontaneous bacterial peritonitis

Escherichia coli

Klebsiella pneumoniae

Streptococcus pneumoniae

Enterococcus species

Treatment recommendations for E coli, K pneumoniae, and S pneumoniae

Cefotaxime 2 g IV q8h for 5 d or

Ofloxacin 400 mg PO q12h for 5 d

Treatment recommendations for resistant E coli or Klebsiella spp

Doripenem 500 mg IV q8h or

Ertapenem 1 g IV q24h or

Imipenem 0.5-1 g IV q6h or

Meropenem 1 g IV q8h or

Ciprofloxacin 400 mg IV q12h or

Moxifloxacin 400 mg IV q24h

Duration of therapy is unclear; however, treatment for 5 day has shown success; 2 weeks is recommended if blood cultures are positive.

Treatment recommendations for Enterococcus spp

Ampicillin 1-2 g IV q4-6h for 5 d or

Vancomycin 15 mg/kg IV q12h for 5 d or

Linezolid 600 mg IV q12h or

Daptomycin 4-6 mg/kg IV q24h

Special considerations

Probiotics have not been shown to improve outcomes in conjunction with antibiotics.

Paracentesis should be performed in any patient suspected of SBP; to increase the sensitivity, culture bottles should be inoculated at the bedside rather than in the laboratory.

Repeat paracentesis is required only if the patient is not improving.

Albumin 1.5 g/kg IV within 6 hours of diagnosis followed by 1 g/kg IV on day 3 has been reported to decrease mortality
from 29% to 10% when used with appropriate antibiotics versus antibiotics and no albumin.

Patients on a prophylactic fluoroquinolone who develop SBP should be placed on alternative agents.

Prophylaxis is indicated after the initial episode of SBP or in patients with cirrhosis and active upper gastrointestinal bleeding.
Routine prophylaxis for patients with ascites without gastrointestinal bleeding may also be beneficial,
especially if the patient has high-risk features, which include ascitic fluid protein less than 1.5 g/dL and at least 1 of the following: serum creatinine greater than or equal to 1.2 mg/dL, blood urea nitrogen greater than 25 mg/dL, serum sodium less than or equal to 130 mEq/L, or Child-Pugh score greater than or equal to 9 with bilirubin greater than or equal to 3 mg/dL.

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