This protocol addresses liver cirrhosis complicated by healthcare-associated or nosocomial spontaneous bacterial peritonitis, defined by an ascitic fluid neutrophil count above 250 cells/mm³. This presentation is more likely to involve organisms resistant to standard antibiotics, which directly shapes the empirical treatment strategy.
Management centres on empirical antibiotic therapy, with the choice of agent determined by local antimicrobial resistance patterns, combined with a supportive intervention. The full selection criteria, combination strategy, and complete regimen are detailed in the structured protocol.
The primary target is a marked reduction in ascitic fluid neutrophil count — at least 25% within 48 hours of starting treatment — and a count below 250/mm³ by day seven. Efficacy is reassessed at 48 hours to guide any necessary escalation.
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 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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