SPONTANEOUS BACTERIAL PERITONITIS (SBP) PROPHYLAXIS IN UCDHS PATIENTS WITH END STAGE LIVER DISEASE (ESLD)

SBP prophylaxis is appropriate in ESLD patients meeting any of the following criteria: 1. Prior history of SBP 2. No history of SBP, but with ascitic fluid protein levels <1.5gm/dL 3. Hospital admission for upper GI bleed

Due to recent unavailability of norfloxacin as a result of discontinuation by the manufacturer, the recommended regimen for long term prophylaxis is TMP/SMX 1 double strength (DS) tablet PO daily.1-2 In patients with a documented history of true sulfa allergy, the recommended agent is levofloxacin 250mg PO daily. For patients to be treated as outpatients and lacking insurance coverage for levofloxacin, ciprofloxacin 500mg PO once daily can be used as an alternative.3

In patients admitted for GI bleeding, the recommended regimen is ceftriaxone 1gm IV q24H for 7 days, after which long term prophylaxis can be considered if patients meet criteria 1 or 2 listed above.1-2

A note on resistance: Intermittent use of prophylactic antibiotics (i.e. once weekly) is associated with increased bacterial resistance. Long term use of prophylactic antibiotics has also led to shifts in gastrointestinal flora and resistance to antibiotics.4-5 The use of intermittent antibiotics for SBP prophylaxis should be avoided if possible and long term prophylactic antibiotics should be reserved for patients at highest risk for infection as outlined above.

The use of other restricted antibiotics for prophylaxis will require ID approval.

References: 1. Runyon, B A. (2013). Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis 2012. Hepatology, 57(4), 1651-1653. 2. (2010). EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. Journal of hepatology, 53(3), 397-417. 3. Terg, R, Fassio, E, Guevara, M, et al. (2008). Ciprofloxacin in primary prophylaxis of spontaneous bacterial peritonitis: a randomized, placebo-controlled study. Journal of hepatology, 48(5), 774-779. 4. Terg, R, Llano, K, Cobas, S M, et al. (1998). Effects of oral ciprofloxacin on aerobic gram-negative fecal flora in patients with cirrhosis: results of short- and long-term administration, with daily and weekly dosages. Journal of hepatology, 29(3), 437-442. 5. Fernández, J, Acevedo, J, Castro, M, et al. (2012). Prevalence and risk factors of infections by multiresistant bacteria in cirrhosis: a prospective study. Hepatology, 55(5), 1551-1561. 6. Lontos, S, Gow, P J, Vaughan, R B, et al. (2008). Norfloxacin and trimethoprim-sulfamethoxazole therapy have similar efficacy in prevention of spontaneous bacterial peritonitis. Journal of gastroenterology and hepatology, 23(2), 252-255. 7. Alvarez, R F, de Mattos, A A, Corrêa, E B, et al. (2005). Trimethoprim-sulfamethoxazole versus norfloxacin in the prophylaxis of spontaneous bacterial peritonitis in cirrhosis. Arquivos de gastroenterologia, 42(4), 256-262.

Approved by UCDH Pharmacy & Therapeutics Committee 6/2017.