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Acute Complications of Cirrhosis Masterclass by Sarah Kessler, PharmD, BCPS, BCGP

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  • Bacterial infection of ascitic fluid without an obvious source
  • Mortality rate can be greater than 20%
  • Usually signifies advanced disease
  • Organisms:
    • Enteric – E.coli, K. pneumoniae
    • S. aureus
    • Hospital acquired infections have increased risk of resistance

SBP Specific Symptoms

  • Abdominal pain
  • Tenderness on palpation
  • Ileus
  • BUT
    • Up to 1/3 of patients may be asymptomatic
    • Present with AMS and/or AKI
  • A diagnostic paracentesis should be obtained to evaluate ascitic fluid even in the absence of infectious symptoms

Diagnostic Paracentesis

  • Evaluation of ascitic fluid:
    • Cell count:
      • Polymorphonuclear leukocyte (PMN) count ≥ 250 cells/mm3 indicative of SBP
    • Cultures:
      • Ideally isolate organism to guide antibiotic therapy
      • Difficult, even more so after antibiotics have been given
        • ALWAYS obtain paracentesis prior to initiating therapy
      • Also recommended to obtain blood cultures
      • If PMN count < 250 cells/mm3 with positive cultures but no s/sx of infection à no antibiotics

Antibiotics 3rd Generation cephalosporin for 5 days:

•Cefotaxime 2g q8h

•Ceftriaxone 1g q12h


•Ofloxacin 400mg BID

Albumin Reduce risk of renal failure:

•Day 1: 1.5 mg/kg within 6 hours of presentation

•Day 3: 1 mg/kg

Also give when:

•Scr > 1 mg/dl

•BUN > 30

•Total bilirubin > 4

Monitoring for Improvement

  • Though not routinely done in practice, you can assess for empiric antibiotic response with repeat paracentesis
    • 2 days after antibiotic initiation
    • Expect a 25% decrease in PMN from baseline
  • Lack of PMN decrease may indicate antibiotic failure, and broader antibiotic therapy may be needed

Prevention of Recurrent SBP

  • Once a patient with cirrhosis has developed SBP, they are at increased risk for redevelopment (secondary prevention)
  • Individuals who have had an episode of SBP should be provided prophylactic antibiotics to prevent the development of an additional episode
Antibiotics •Norfloxacin (no longer available in US), Ciprofloxacin, or Bactrim

Bactrim: 1 DS tablet daily

Ciprofloxacin: 500mg daily

Monitoring Bactrim: renal function, hyperkalemia, DDI’s

Ciprofloxacin: renal  dose adjustments, QTc monitoring