This protocol applies to patients with liver cirrhosis complicated by ascites who develop spontaneous bacterial peritonitis (SBP) in a healthcare or hospital setting — classified as healthcare-associated or nosocomial SBP.
A diagnostic criterion for this pathway is an ascitic fluid neutrophil count above 250 cells/mm³.
Healthcare-associated and nosocomial SBP is more likely to harbour resistance to antibiotics. This resistance profile directly determines the selection of empirical antibiotic therapy in this setting.
Management centres on empirical intravenous antibiotic therapy, with the specific agent chosen according to local antimicrobial resistance patterns. Antibiotic treatment is combined with intravenous albumin.
Response is evaluated by a second paracentesis at 48 hours from the start of treatment. A successful response requires at least a 25% reduction in ascitic fluid leucocyte (neutrophil) count at that time point.
Healthcare associated and nosocomial SBP is more likely to harbour resistance to antibiotics.
Piperacillin/tazobactam should be given in areas with low prevalence of multi-drug resistance while carbapenem should be used in areas with high prevalence of ESBL producing Enterobacteriaceae. Carbapenem should be combined with glycopeptides or daptomycin or linezolid in areas with high prevalence of gram positive MDR bacteria (I;1).
The duration of treatment should be at least 5–7 days (III;1).
The administration of albumin (1.5 g/kg at diagnosis and 1 g/kg on day 3) is recommended in patients with SBP (I;1).
The efficacy of antibiotic therapy should be checked with a second paracentesis at 48 h from starting treatment. Failure of first-line antibiotic therapy should be suspected if there is worsening of clinical signs and symptoms and/or increase or no marked reduction in leucocyte count (at least 25%) in 48 h (II-2;1).
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