prolonged treatment using ceftriaxone or with a change to another antibiotic according to
susceptibility, SBP resolved in seven of the nine patients who had not responded by day 5 of
therapy. Study patients had an overall hospital mortality of only 12%. The authors concluded
that antibiotic therapy for SBP can be discontinued if the polymorphonuclear differential count
in ascitic fluid is less than 250 cells/mm^3 on day five of treatment (32).
Other parenteral antibiotics that have been reported effective for the treatment of SBP
include aztreonam (500 mg every 8 hours) (33), cefonicid (2 g every 12 hours) (34), and
amoxicillin–clavulanic acid (35). Several small trials have involved the use of oral antibiotics.
These included intravenous followed by oral therapy with amoxicillin–clavulanic acid (36) or
ciprofloxacin (37) and oral ofloxacin (38). While some experts recommend that patients with
moderate symptoms and a positive response to a short course of intravenous antibiotics could
benefit from therapy with oral fluoroquinolones (39), others have found the supporting
evidence to be inconclusive (40).
Deterioration of renal function is the most sensitive predictor of in-hospital mortality in
patients with SBP (41). In a randomized, multicenter comparative study, patients with SBP
who received intravenous albumin for plasma volume expansion plus cefotaxime had less
renal impairment and significantly lower mortality (22%) than those receiving cefotaxime
alone (41%) (42). The dose of albumin used in this study was 1.5 g/kg of body weight at the
time of diagnosis followed by 1 g/kg on day 3.
Prophylaxis
The use of prophylactic antibiotics decreases the incidence and mortality of bacterial infections,
including SBP, in patients who are hospitalized with cirrhosis and ascites (7). Cirrhotic patients
who recover from SBP also are at increased risk of subsequent episodes. The one-year
probability of recurrence of SBP in this population has been estimated to approach 70% (43).
Antibiotics reported effective in preventing SBP have included trimethoprim/sulfamethoxazole
(44) and, more commonly, fluoroquinolones such as norfloxacin, ofloxacin and ciprofloxacin
(7,45–47). A major concern regarding repeated or prolonged courses of antibiotic prophylaxis is
selection for resistant bacterial pathogens. There are a growing number of reports of the
development of SBP or other infections caused by fluoroquinolone-resistant organisms,
includingE. coli,Pseudomonasspecies, and methicillin-resistantS. aureus, in cirrhotic patients on
fluoroquinolone prophylaxis (7,48,49). Thus the use of prophylactic antibiotics should be
restricted to patients at greatest risk of SBP, weighing the increased risk of inducing resistant
bacteria against the benefits of preventing infection.
URINARY TRACT INFECTIONS
Urinary tract infections account for 25% to 40% of infections in hospitalized cirrhotic patients
(21,23,50). The majority of these patients have asymptomatic bacteriuria, but approximately
one-third have symptomatic infections (23). The incidence of significant bacteriuria
(> 105 colony-forming units/mL) is higher in women than in men and does not correlate
with the severity of the underlying liver disease or with the age of the patient (50). The
presence of an indwelling urinary catheter increases the risk of infection. The most common
pathogens areE. coliand other aerobic gram-negative coliforms. Asymptomatic bacteriuria
does not require treatment, particularly in patients with an indwelling urinary catheter. A
urine culture should be obtained on any cirrhotic patient suspected to have a urinary tract
infection. Antibiotic therapy, when indicated, should be guided by microbiologic susceptibility
testing of the urinary isolate. Antibiotic options for empiric therapy of symptomatic infections
include fluoroquinolones or expanded-spectrum penicillins or cephalosporins. Indwelling
urinary catheters should be removed as soon as possible to reduce the risk of infection.
BACTEREMIA AND SEPSIS
Cirrhosis predisposes patients to systemic bloodstream infections due to intrahepatic blood
shunting and impaired bacterial clearance from the portal blood. Bacteremia has been reported
to occur in approximately 9% of hospitalized cirrhotic patients (51) and accounts for 20% of the
infections diagnosed during their hospital stay (23). The incidence of bacteremia increases with
344 Preheim