Internal Medicine

0521779407-19 CUNY1086/Karliner 0 521 77940 7 June 6, 2007 17:50

Spontaneous Bacterial Peritonitis 1367

Treatment of Secondary Ascitic Fluid Infections

■treatment of secondary bacterial peritonitis

➣intravenous cefotaxime and metronidazole initiated immedi-

ately for broad-spectrum coverage

➣studies to localize site of perforation

➣emergent surgical laparotomy

Treatment of Polymicrobial Bacterascites

■intravenous cefotaxime and metronidazole, with duration of therapy

dictated by clinical response and serial ascitic fluid PMN levels and

cultures

Side Effects and Contraindications

■antibiotics

➣side effects: hypersensitivity reactions, thrombophlebitis, and

Clostridium difficile infection for cefotaxime

follow-up

During Treatment

■spectrum of antibiotic coverage narrowed once culture and sensi-

tivity become available

■may repeat diagnostic paracentesis 48 hours after initiation of ther-

apy to monitor therapeutic response

Routine

■long-term antibiotic prophylaxis after initial SBP episode

■antibiotic choices include oral norfloxacin 400 mg daily, ciproflo-

xacin 750 mg weekly, and trimethoprim-sulfamethoxazole double-

strength 5 times per week

■short-term inpatient antibiotic prophylaxis for cirrhotic patients

with ascitic fluid total protein <1 gm/dL or variceal hemorrhage

complications and prognosis

Complications

■renal impairment in 33% of patients with SBP treated with cefo-

taxime alone; intravenous albumin reduces renal impairment and

mortality

Prognosis

■spontaneous ascitic fluid infection

➣one-year survival as low as 20% after treatment

➣established indication for OLT