Spontaneous bacterial peritonitis prophylaxis including acute variceal bleeding - Guideline for antimicrobial prevention of

Publication: 03/12/2012  
Last review: 18/09/2017  
Next review: 01/09/2020  
Clinical Guideline
CURRENT 
ID: 3177 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2017  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Update on aztreonam injection shortage - now only restricted outside of CF and UTI (protected antibiotic codes no longer required for these indications). See alternatives - 22 August 2018

Guideline for antimicrobial prevention of spontaneous bacterial peritonitis (SBP) including acute variceal bleeding

  1. Summary table of routine prophylaxis recommendations
  2. Background information
  3. Special antimicrobial prophylaxis recommendations
    1. Cirrhotic patients with gastrointestinal bleeding
    2. Primary prevention of SBP
    3. Secondary prevention of SBP

1. Summary table of routine prophylaxis recommendations

Situation

Prophylaxis recommended

Evidence level

Prophylaxis aims to prevent

NNT

Antimicrobial dose/route

Routine

true allergy to routine agent

MRSA risk

VARICEAL BLEEDING
Acute-setting
(NOT applicable to upper GI bleeding from other causes)

YES

B

Bacterial peritonitis

NK

Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam 4.5g 8-hourly - stop at 48 hours.

Teicoplanin electronic Medicines Compendium information on 

Teicoplanin # IV 400mg STAT

AND Aztreonam electronic Medicines Compendium information on Aztreonam IV 1g 8-hourly stop at 48 hours.

Teicoplanin electronic Medicines Compendium information on 

Teicoplanin IV # 400mg STAT

AND Aztreonam electronic Medicines Compendium information on Aztreonam IV 1 g 8-hourly stop at 48 hours.

Primary Prophylaxis of Spontaneous bacterial peritonitis (SBP)

YES: Patients with ascitic fluid protein ≤ 10g/L AND bilirubin ≥ 50μmol/L who are potential liver transplant candidates

B

Bacterial peritonitis

NK

Oral Trimethoprim -sulfamethoxazole 960mg daily, long term

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 500mg orally daily, long term

Oral Trimethoprim -sulfamethoxazole 960mg daily, long term

Secondary prophylaxis: Post first episode of SBP

YES

B

Bacterial peritonitis

NK

Oral Trimethoprim -sulfamethoxazole (Co-trimoxazole electronic Medicines Compendium information on Co-trimoxazole ) 960mg daily, long term

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 500mg orally daily, long term

Oral Trimethoprim -sulfamethoxazole 960mg daily, long term

NNT = number needed to treat; NK = not known
#Use of teicoplanin in for this indication is off-label and the patient should be informed of this

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2. Background information

Current practice in the antimicrobial prevention of SBP in LTHT has been reviewed in light of recommendations from the British Society for Gastroenterology (Jalan et al., 2000) and because of on-going problems with Clostridium difficile infection and meticillin-resistant Staphylococcus aureus (MRSA) infection in LTHT. It is noteworthy that increases in mortality, length of stay and cost have recently been identified in cirrhotic patients who become infected with Clostridium difficile (Bajaj et al., 2010). Reducing the risk of acquisition of these pathogens by avoiding unnecessary antimicrobial exposure is a pressing concern.

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3. Special antimicrobial prophylaxis recommendations

1. Cirrhotic patients with gastrointestinal bleeding.

Recommendation: The initial decision to prevent ascitic fluid infection in variceal haemorrhage is based on the clinical setting. A high index of suspicion is essential.

Recommendation: Ascitic paracentesis should be performed prior to starting antibiotics according to Standard operating procedure.
[Evidence level D]

Recommendation: Empirical regimen for the prevention of ascitic fluid infection in variceal haemorrhage is Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam  4.5g 8-hourly IV.
[Evidence level D]  

If genuine penicillin allergy –Teicoplanin electronic Medicines Compendium information on 

Teicoplanin# IV 400mg STAT plus Aztreonam electronic Medicines Compendium information on Aztreonam IV 1g 8-hourly OR monotherapy with Tigecycline electronic Medicines Compendium information on Tigecycline * 100mg IV loading followed by 50mg 12-hourly IV*.
[Evidence level D]

*Only use Tigecycline electronic Medicines Compendium information on Tigecycline if Aztreonam electronic Medicines Compendium information on Aztreonam is not available because of supply problems. Tigecycline electronic Medicines Compendium information on Tigecycline requires dosage adjustment in Child Pugh C liver disease to 25mg 12-hourly IV.

#Use of Teicoplanin electronic Medicines Compendium information on 

Teicoplanin in for this indication is off-label and the patient should be informed of this

Recommendation: To reduce adverse events including selection for resistant bacteria, 48 hours should be the standard duration.
[Evidence level D]

Recommendation: If ascitic fluid culture results are positive and a diagnosis of SBP confirmed then patient should be managed according to LTHT guidelines for management of SBP. Antimicrobials should be changed to optimise effectiveness and reduce adverse effects - this will usually be the most narrow spectrum effective agent available.

Existing guidance
BSG guidelines recommend Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 500mg 12-hourly for 7 days.

Evidence
There is a Cochrane review from 2002. Eight trials evaluated the effects of antibiotic prophylaxis compared with placebo or no antibiotic prophylaxis in 864 patients. A significant beneficial effect on decreasing mortality (RR 0.73, 95% CI 0.55 to 0.95) and the incidence of bacterial infections (RR 0.40, 95% CI 0.32 to 0.51) was observed. No trials were double blind, only 1 was placebo controlled.

Quinolones were the most commonly studied agent, tested in 7/11 trials. The dosage used varied from 400 mg ofloxacin, 400-800 mg Norfloxacin electronic Medicines Compendium information on Norfloxacin , and 400-1000 mg Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin . Quinolones were prescribed together with Amoxicillin electronic Medicines Compendium information on Amoxicillin /clavulanic acid (one to three grams) in two trials. Four other trials used: cephalosporins in a single dose (Cefotaxime electronic Medicines Compendium information on Cefotaxime , one gram; Ceftriaxone electronic Medicines Compendium information on Ceftriaxone , one to two grams), non-absorbable antibiotics up to two days after haemorrhage cessation (Gentamicin , Vancomycin electronic Medicines Compendium information on Vancomycin , and nystatin or Neomycin electronic Medicines Compendium information on Neomycin , colistin, and nystatin), or imipenem/cilastin (500 mg) up to three days after cessation of the haemorrhage. The treatment durations varied from one single dose up to ten days.

Three trials also evaluated one antibiotic regimen versus another antibiotic regimen none showed significant advantages of one regime over the other. This may be due to type II errors as at least two trials examined very small patient numbers.

Quinolones were initiated intravenously and switched to oral therapy in three trials and given orally in four other trials. Median course length was 7 days. Antibiotics were initiated just before (6 trials) or just after (5 trials) the endoscopic procedure

Literature since the Cochrane review:

One trial found Ceftriaxone electronic Medicines Compendium information on Ceftriaxone to be superior to Norfloxacin electronic Medicines Compendium information on Norfloxacin . 111patients with advanced cirrhosis and gastrointestinal bleeding were given either oral Norfloxacin electronic Medicines Compendium information on Norfloxacin 400mg twice daily or IV Ceftriaxone electronic Medicines Compendium information on Ceftriaxone 1g daily for 7 days. Nineteen patients (33%) in the Norfloxacin electronic Medicines Compendium information on Norfloxacin group and 6 (11%) in the Ceftriaxone electronic Medicines Compendium information on Ceftriaxone group developed proved or possible infections within the first 10 days after the initiation of the hemorrhage (p=0.01) (primary outcome for which the study was powered). The corresponding figures for proved infections were 15 cases (26%) and 6 cases (11%), respectively (p=0.07).

In a chinese trial, in 97 patients, cefazolin 1g 8-hourly for 3 days was started pre-endoscopy followed by Cefalexin electronic Medicines Compendium information on Cefalexin 500mg 6-hourly for 4 days, vs no treatment. Proven infection was found in 0% vs 12.0% of patients during hospitalisation (p=0.027).

Local perspective
The choice of antibiotic should have activity against coliforms such as Escherichia coli and Klebsiella species, and Gram positives such as Enterococcus faecalis and streptococci. Nephrotoxic antimicrobials should be avoided if at all possible. The choice of antimicrobial therapy must take into consideration the increasing frequency of hospital acquired infections, for example, a recent audit at Leeds Teaching Hospitals NHS Trust has identified that patients with liver failure are at increased risk of Clostridium difficile infection.

The use of antibiotics for SBP in patients with cirrhosis has been described in the Cochrane Database of Systematic Reviews (2009). Thirteen studies were included in this review. No meta-analysis was performed since each trial compared different antibiotics in their experimental and control groups. These trials looked at the following antibiotics: intravenous (iv)/oral (po) Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin , iv Ceftazidime electronic Medicines Compendium information on Ceftazidime , iv Cefotaxime electronic Medicines Compendium information on Cefotaxime , iv amikacin, iv Cefotaxime electronic Medicines Compendium information on Cefotaxime , iv ampicillin-tobramycin, iv/po moxifloxacin, iv/po Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav , oral cefixime and oral Ofloxacin electronic Medicines Compendium information on Ofloxacin . The most commonly used antibiotics were 3rd generation cephalosporins although these did not demonstrate superior efficacy over other antibiotics.

Up to 10% of infections are caused by Gram-positive cocci (particularly Enterococcus species). Ampicillin-tobramycin and Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav have been used with the assumption that they would provide adequate Gram-positive cover.

The Cochrane review made no firm conclusions from the randomised controlled trials. Although third generation cephalosporins have been established as the standard treatment of SBP in many centres, current concerns about Clostridium difficile infection, selection of extended-spectrum beta-lactamase (ESBL) producing coliforms and adequacy of spectrum have raised questions about the wisdom of this approach.

The final recommendation was influenced by local epidemiology and resistance patterns which are shown in Figure 1.

Table 1 - Resistance profile of patients 2006-2008 & 2008-2014

Figure 1

Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam was chosen in order to provide appropriate antimicrobial cover (including enterococci, streptococci, and resistant gram-negative including Pseudomonas species) and to avoid the use of cephalosporins, quinolones (whose activity can no longer be relied upon for empirical treatment) and Gentamicin (to reduce the risk of toxicity).Teicoplanin electronic Medicines Compendium information on 

Teicoplanin and Aztreonam electronic Medicines Compendium information on Aztreonam in combination provides a similar spectrum of activity. Tigecycline electronic Medicines Compendium information on Tigecycline has an appropriate spectrum of activity (active against Staphylococus aureus, enterococci and many Gram negatives but not Pseudomonas). Tigecycline electronic Medicines Compendium information on Tigecycline is licensed for use in intra-abdominal infections but data specific for spontaneous bacterial peritonitis are lacking.

N.B. Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav susceptibility has not been routinely tested in the laboratory during the review period so data are not available. Cefuroxime electronic Medicines Compendium information on Cefuroxime can be used as a reasonable marker of Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav susceptibility. This antimicrobial is less broad spectrum than Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam against Gram-negatives and lacks antipseudomonal activity.

Conclusion
Quinolones have been most extensively studied with a median course length of 7 days, though shorter courses or single doses have not really been studied. The data include studies that commence antimicrobials both pre and post endoscopy. No superiority of any particular regimen has been identified. There are significant concerns about the selection pressure for MRSA/C. difficile and anincreased incidence of gram positive SBP if quinolones are used (see next section). Recommended regimens have appropriate spectrum of activity with a more favourable side effect profile.

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2. Primary prevention of SBP

Recommendation: The prophylaxis regimen for the primary prevention of SBP is oral Trimethoprim-sulfamethoxazole 960mg od.
[Evidence level D]

Recommendation: Primary prophylaxis of SBP should be considered in all high risk individuals. These are patients with ascitic fluid protein ≤ 10g/L AND bilirubin ≥ 50μmol/L who are potential liver transplant candidates.
[Evidence level B]

Existing Guidelines

Various gastroenterology and hepatology societies have existing guidelines regarding primary prophylaxis of spontaneous bacterial peritonitis (SBP):

British Society of Gastroenterology (Moore et al., 2006)
“For patients who have never had SBP and in whom ascitic fluid protein concentration is low (<10g/L), there is no consensus among experts regarding primary prophylaxis.”

European Association for the Study of the Liver (P Gines et al., 2010)
“…patients with severe liver disease…with ascitic fluid protein lower than 15g/L and without prior SBP…should be considered for long-term prophylaxis with Norfloxacin electronic Medicines Compendium information on Norfloxacin .”

American Association for the Study of Liver Diseases (Runyon et al., 2009)
“In patients with cirrhosis and ascites…long-term use of Norfloxacin electronic Medicines Compendium information on Norfloxacin (or Trimethoprim/sulfamethoxazole) can be justified if the ascitic fluid protein <1.5g/dL and at least one of the following is present: serum creatinine≥1.2mg/dL, blood urea nitrogen ≥25mg/dL, serum sodium ≤130mEq/L or Child-Pugh ≥9 points with bilirubin ≥3mg/dL.”

Mortality from SBP

Patients with cirrhosis who develop infections or SBP have a significant mortality. In a study of almost 12,000 cirrhotic patients, there was a high mortality following any infection, with rates of 30% at 1 month and 63% at 12 months (Arvaniti et al., 2010). The same study also identified over 7,000 patients with SBP; the mortality rate was 32% and 66% at 1 and 12 months respectively.

A second study showed that the median short-term (30 day or in-hospital) mortality following SBP was 29%, with significantly higher rates (67%) if renal impairment was also present (Tandon et al., 2011).

Risk of SBP

It has been shown that patients with a low ascitic fluid protein level (≤10g/L) are at significantly higher risk of a first episode of SBP than patients with an ascitic fluid protein level >10g/L, with rates of 15-24% compared with 1.5-4% (Runyon 1986, Llachj et al., 1992).

Studies have also shown that high bilirubin levels are predictive of developing SBP and that survival of patients with SBP is lower than those who do not develop the infection (38 vs. 66%) (Andreu et al., 1993, Guarner et al., 1999).

Evidence

Several trials have examined fluoroquinolones as primary prophylaxis of SBP.

The first trial compared long-term Norfloxacin electronic Medicines Compendium information on Norfloxacin (400mg daily) with in-patient only prophylaxis in patients with low ascitic fluid protein (≤10g/L) or high bilirubin levels (>2.5mg/dL) (Novella et al., 1997). The rates of SBP were lower in the long-term prophylaxis group (2 vs. 17%) but the rate of Norfloxacin electronic Medicines Compendium information on Norfloxacin -resistant E.coli was significantly higher (90 vs. 36%). There was no difference in survival.

A second study compared Norfloxacin electronic Medicines Compendium information on Norfloxacin prophylaxis with placebo in 107 patients with low ascitic fluid protein levels (<15g/L) (Grange et al., 1998). The rate of severe infections (SBP or bacteraemia) was lower in the Norfloxacin electronic Medicines Compendium information on Norfloxacin group (2 vs. 17%) but again there was no difference in survival.

A third trial (double-blind,randomised, placebo-controlled) compared Norfloxacin electronic Medicines Compendium information on Norfloxacin prophylaxis with placebo in 68 patients with a low ascitic fluid protein level (<15g/L) and either advanced liver failure (Child-Pugh score ≥9 points with bilirubin ≥3mg/dL) or impaired renal function (creatinine≥1.2mg/dL, blood urea nitrogen ≥25mg/dL or serum sodium ≤130mEq/L) (Fernandez et al., 2007).

The rates of SBP and hepatorenal syndrome at 1 year were significantly lower in the Norfloxacin electronic Medicines Compendium information on Norfloxacin group (7 vs. 61% and 28 vs. 41% respectively). Importantly, survival at 3 and 12 months was also significantly higher with Norfloxacin electronic Medicines Compendium information on Norfloxacin prophylaxis (94 vs. 62% and 60 vs. 48% respectively).

One study has compared Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin prophylaxis (500mg daily) with placebo in 100 patients with low ascitic fluid protein levels (<15g/L) (Terg et al., 2008). The rates of SBP were not significantly different between the two groups but mortality was lower with Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin prophylaxis. However, the deaths in the Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin group were mainly due to gastrointestinal bleeding while those in the placebo group were due to SBP and sepsis.

A meta-analysis of the above studies concluded that the rates of SBP and mortality were significantly lower with fluoroquinoline prophylaxis, with odds ratios of 0.18 and 0.60 respectively (Loomba et al., 2009).

Other agents and regimes (Trimethoprim-sulfamethoxazole 960mg 5x/week and Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 750mg 1x/week) have also been examined and again show reduced rates of SBP (Singh et al., 1995, Rolachon et al., 1995). However, these results are difficult to interpret as mixed populations (patients with and without prior SBP) were included.

Antibiotic Resistance

The major problem with primary prophylaxis of SBP, particularly with fluoroquinolones, is the development of antibiotic resistance.

One study of 405 patients showed that Norfloxacin electronic Medicines Compendium information on Norfloxacin prophylaxis significantly increased the rates of SBP caused by fluoroquinolone resistant gram negative bacilli compared with no prophylaxis (50 vs. 16%) (Fernandez et al., 2002). The rates of SBP caused by Gram negative bacilli resistant to Trimethoprim-sulfamethoxazole were also higher with Norfloxacin electronic Medicines Compendium information on Norfloxacin prophylaxis (44 vs. 18%) but this was not statistically significant.
Another study showed that patients on long-term Norfloxacin electronic Medicines Compendium information on Norfloxacin prophylaxis were more likely to develop infection with Staphylococci (71 vs. 44%) and in particular, methicillin-resistant S. aureus (77 vs. 54%) (Campillo et al., 1998).

Cost Effectiveness

Modelling studies have shown that primary prophylaxis of SBP is cost effective in high-risk groups (patients with low ascitic fluid protein and high bilirubin levels).

Norfloxacin electronic Medicines Compendium information on Norfloxacin saves US$2216 to 8545 per patient per year while Trimethoprim-sulfamethoxazole saves $2934 to 9251 (Inadomi et al., 1997). Norfloxacin electronic Medicines Compendium information on Norfloxacin given to high-risk patients only is more cost effective than when prophylaxis is given to all patients with ascites and when given to no one (Das 1998).

Summary
Primary prophylaxis of SBP:

  • does reduce the rate of SBP;
  • probably improves survival;
  • may be cost effective; but results in antibiotic resistant bacteria.

Primary prophylaxis of SBP should be considered in all high risk individuals. These are patients with ascitic fluid protein ≤ 10g/L AND bilirubin ≥ 50μmol/L who are potential liver transplant candidates. The recommended regimen is Trimethoprim-sulfamethoxazole 960mg daily orally. Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 500mg oral daily should be considered as an alternative if genuine allergy to Trimethoprim-sulfamethoxazole. Prophylaxis should be ceased if SBP caused by a Trimethoprim-sulfamethoxazole-resistant organism occurs. However, this decision should be made on a case-by-case basis after a discussion of the risks and benefits with each patient.

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3. Secondary prevention of SBP

Recommendation: The prophylaxis regimen for the secondary prevention of SBP is oral Trimethoprim-sulfamethoxazole 960mg od.
[Evidence level B]

Existing guidance.
BSG guidance recommends Norfloxacin electronic Medicines Compendium information on Norfloxacin 400mg 24-hourly or Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 500mg 24-hourly.

What are the risk factors for SBP?

  • Prior episode of SBP – two-thirds develop a recurrence within a year
  • GI bleeding (variceal haemorrhage)
  • Ascitic total protein < 1.0 g/dL
  • Child-Pugh score (Arroyo et al., 2000)

The local Leeds audit of SBP looked at all cases of culture positive SBP between 2006 & 2008. The 30 day mortality was 50%.

Evidence
Only 1 placebo controlled trial of 80 patients specifically looked at the secondary prevention of SBP. Norfloxacin electronic Medicines Compendium information on Norfloxacin 400mg once daily started 1 week after resolution of SBP reduced the probability of SBP at 1 year from 68% to 20% (p=0.0063).

For other agents evidence comes from trials that included a mixture of primary and secondary prophylaxis.

Singh et al., (1995) studied Trimethoprim-sulfamethoxazole 960mg daily five times a week for the prevention of SBP in 60 patients in a RCT; 27% of the active group and 17% of the placebo group had prior SBP. At 90 days SBP or bacteraemia developed in 27% of the placebo group vs. 3% of the Trimethoprim-sulfamethoxazole group (p=0.012). Mortality was 20% placebo vs. 7% Trimethoprim-sulfamethoxazole group (p=0.15)

Rolachon et al., (1995) studied Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 750mg orally once weekly in 60 patients, though only 2 patients in the Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin group and 5 patients in the placebo group had prior SBP. At 6 months there was a significant decrease in SBP, 3.6% vs. 22% placebo (p=<0.05)

Resistance
There is evidence that use of quinolones for prophylaxis changes the pattern of recurrent SBP from Gram negative to Gram positive infections including an increased incidence of MRSA and quinolone resistant organisms.

Campillo et al., (1998) in a retrospective study compared the epidemiology of SBP and bacteraemia of hospitalised patients receiving Norfloxacin electronic Medicines Compendium information on Norfloxacin prophylaxis against those not receiving prophylaxis and found that staphylococci was isolated significantly more often in the prophylaxis group, with the proportion of staphylococci that was MRSA higher in the Norfloxacin electronic Medicines Compendium information on Norfloxacin group (77% vs. 53%).

In a prospective study of cirrhotic patients in a liver unit, Fifty percent of culture-positive spontaneous bacterial peritonitis in patients on long-term Norfloxacin electronic Medicines Compendium information on Norfloxacin administration (n= 93) vs. 16% in patients not receiving this therapy (n = 414) were caused by quinolone-resistant Gram negative bacilli, (p=0.01).

The local audit of SBP in Leeds from 2006-2008 showed resistance patterns among Gram negative isolates were 38% Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin , 32% amoxicillin, 29% cefuroxime and 17% Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam .

Conclusion
Quinolones again have the best evidence (Norfloxacin electronic Medicines Compendium information on Norfloxacin ), but evidence of increased quinolone resistant and MRSA SBP in those patients who go on to develop further infection.
Some evidence for Trimethoprim-sulfamethoxazole, but in a mixed primary secondary prevention group.

Justification/Evidence review
The evidence base for secondary prophylaxis of SBP is poor. Unfortunately recurrent SBP is common. Two thirds recur within 12 months. Mortality from a single episode of SBP is high. Local data suggests 50% mortality at 30 days.

The choice of antibiotic must demonstrate low resistance but must not select for hospital acquired infections (MRSA, C difficile.). The local data suggest that 38% of Gram negative isolates are resistant to quinolones. Published literature suggests quinolones confer high risk for Hospital Acquired Infections.

The choice of Trimethoprim-sulfamethoxazole (septrin) is based upon the published literature. Rare severe side effects include rash (Stevens-Johnson syndrome, toxic epidermal necrolysis, photosensitivity and blood disorders (including leucopenia, thrombocytopenia, megaloblastic anaemia, eosinophilia). These necessitate immediate discontinuation. The choice of antibiotic for an individual will be tailored by culture results. All individual can be discussed with a senior microbiologist.
It is expected that local audit will permit further tailoring of the secondary prevention regime.

SBP Outcome

Recommendation: An episode of SBP is a relative indication for transplant assessment. Survivors should be discussed with Gastroenterologists and/or Hepatologists within LTH.
[Evidence level D]

Recommendation: Prophylaxis should be ceased if SBP caused by a Trimethoprim-sulfamethoxazole-resistant organism occurs. However, this decision should be made on a case-by-case basis after a discussion of the risks and benefits with each patient.
[Evidence level D]

Provenance

Record: 3177
Objective:
Clinical condition:

Spontaneous bacterial peritonitis including acute variceal bleeding

Target patient group: Adults
Target professional group(s): Secondary Care Doctors
Pharmacists
Adapted from:

Evidence base

A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. LTHT Consensus (no national guidelines exist, guidelines from different learned bodies contradict each other, or no evidence exists)

References

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