Antibiotic Guideline for Adult Patients with Spontaneous Bacterial
Peritonitis or Liver Cirrhosis with Upper Gastrointestinal Bleed
Division & Speciality:
Antibiotic Guideline for Adult Patients with Spontaneous
Bacterial Peritonitis or Liver Cirrhosis with Upper
Gastrointestinal Bleed.
Drs Aithal, Ryder and Teli – Consultant Gastroenterologists
Mr Tim Hills – Lead Pharmacist Antimicrobials and Infection
Control
Dr Steve Holden – Consultant Microbiologist.
Riya Savjani – Senior Antimicrobial Pharmacist: (May 2017
update)
Diagnostics and clinical support, microbiology
Scope (Target audience, state if Trust
Doctors, nurses, pharmacists
Full Title of Guideline:
Author (include email and role):
wide):
Review date (when this version goes out
July 2017
of date):
Explicit definition of patient group
to which it applies (e.g. inclusion and
Either patients diagnosed with Spontaneous Bacterial
Peritonitis or has liver cirrhosis and an upper GI bleed
exclusion criteria, diagnosis):
Changes from previous version (not
applicable if this is a new guideline, enter
below if extensive):
Summary of evidence base this
guideline has been created from:
st
1 line treatment for SBP amended from
piperacillin/tazobactam due to shortage.
st
1 line antibiotic prophylaxis for GI bleed in cirrhotic patient
amended from piperacillin/tazobactam due to shortage
SBP treatment in severe penicillin allergy: metronidazole
amended from PO to IV
Medline literature search 2012-2014
British Society of Gastroenterology Guidelines
Recommended best practice based on clinical experience of
guideline developers.
The Sanford Guide To Antimicrobial Therapy 2012.
John Hopkins Guides: Peritonitis, Spontaneous Bacterial &
Secondary: Accessed 10/06/2014
This guideline has been registered with the trust. However, clinical guidelines are
guidelines only. The interpretation and application of clinical guidelines will remain the
responsibility of the individual clinician. If in doubt contact a senior colleague or expert.
Caution is advised when using guidelines after the review date or outside of the Trust.
Antibiotic Treatment and Prophylaxis of Spontaneous bacterial peritonitis
Diagnosis
Spontaneous Bacterial Peritonitis (SBP) is a frequent and serious complication of cirrhotic
patients with ascites. Patients with SBP are frequently asymptomatic, it occurs in 15% of all those
with ascites admitted to hospital irrespective of their symptoms. Diagnosis should also be
suspected in cirrhotic patients with ascites presenting with:
• Acute deterioration
• Hepatic encephalopathy
• Impairment of renal function
• Peripheral leucocytosis without any obvious precipitating factor
Investigations
A diagnostic paracentesis is mandatory in all cirrhotic patients with ascites requiring hospital
admission.
• Inject ascitic fluid into FBC count bottle (lavender EDTA bottle) and send to haematology.
Ask for WCC and neutrophils. This should be an urgent request and results should be
followed up. SBP is confirmed if:
Ascitic fluid WCC of >0.5 x 109/L (> 500 cells/mm3)
or neutrophil count of >0.25 x 109/L ( >250 cells/mm3 )
• Ascitic fluid should be inoculated into a sterile universal container and into blood culture
bottles at the bedside and sent to microbiology for culture.
• DO NOT request glucose and lactate estimation in ascitic fluid routinely.
Antibiotic Treatment
Initial treatment in severe disease:
Total duration for severe disease: 5-7 days
1st Line (including in mild penicillin allergy (e.g. rash only, no anaphylaxis, angioedema or
immediate onset urticaria))
Cefuroxime IV 1.5g TDS +/- Metronidazole IV 500mg TDS
Severe penicillin allergy/allergic to cephalosporins
Ciprofloxacin PO 500mg BD (IV 400mg BD if oral route not available) plus Vancomycin IV
Refer to antibiotic website for dosing, or use vancomycin dosing calculator available on the
website. [monitor levels] +/- Metronidazole IV 500mg TDS
Mild disease/Oral continuation treatment from severe above:
(NB see IV to PO switch guideline on the antibiotic website)
Total duration for mild disease: 5 days
1st Line
Co-trimoxazole PO 960mg BD (Reduce dose to 480mg BD if CrCl <30ml/min - N.B.
contains a sulphonamide and trimethoprim)
Allergic to sulphonamides and/or trimethoprim
Ciprofloxacin PO 500mg BD
Nottingham Antibiotic Guidelines Committee
Page 2 of 7
Written July 2014
Review July 2017
Antibiotic Prophylaxis
Prophylaxis should be given to patients who have recovered from one previous episode of SBP
Continuous Prophylaxis Regimen:
1st Line
Co-trimoxazole PO 960mg OD
(N.B. contains sulphonamide and trimethoprim)
Allergic to sulphonamides and/or trimethoprim
Ciprofloxacin PO 500mg OD
Upper Gastrointestinal Haemorrhage in Patients with Liver Cirrhosis
Introduction
Bacterial infections occur in about 20% of patients with cirrhosis with upper gastrointestinal
bleeding within 48 hours of admission, another 50% will have an infection during their hospital
stay. A Cochrane review of randomised trials indicated that antibiotic prophylaxis reduces the risk
of infection and mortality in this patient group.
Antibiotic Prophylaxis
Prophylaxis should be started on admission for all cirrhotic patients with upper gastrointestinal
haemorrhage.
1st Line whilst NBM (including in mild penicillin allergy (e.g. rash only, no
anaphylaxis, angioedema or immediate onset urticaria))
Cefuroxime IV 1.5g TDS converting once able to
Co-trimoxazole PO 960mg BD
(Reduce dose to 480mg BD if CrCl <30ml/min - N.B. contains a sulphonamide and
trimethoprim)
Total duration of antibiotic prophylaxis (IV+PO) is usually 5 days
Severe penicillin allergy/allergic to cephalosporins
Discuss with medical microbiologist/gastroenterologist
Allergic to sulphonamides and/or trimethoprim
Discuss with medical microbiologist/gastroenterologist
Nottingham Antibiotic Guidelines Committee
Page 3 of 7
Written July 2014
Review July 2017
Appendix - Audit tools
Spontaneous Bacterial Peritonitis
Hospital No.
Date of audit:
Ascitic tap results
WCC >0.5 Y/N
Ascitic culture sent Y/N
Ascitic Culture results:
sensitivity results if positive
Blood culture results:
sensitivity results if positive
Initial SBP antibiotic treatment prescribed:
Prophylaxis in line with guidelines Y/N
In no, clear justification for deviation in the medical notes: Y/N
Changed to PO within 24 hours of patient meeting the IV-PO switch guideline criteria? Y/N
In no, clear justification for deviation in the medical notes: Y/N
Secondary Antibiotic Prophylaxis prescribed:
Prophylaxis in line with guidelines Y/N
In no, where was the deviation?
Was there a clear justification for deviation in the medical notes: Y/N
Subsequent SBP infections whilst on prophylaxis.- Y/N
if yes details –
organism –
resistant to prophylaxis Y/N
no. of days after starting prophylaxis:
Nottingham Antibiotic Guidelines Committee
Page 4 of 7
Written July 2014
Review July 2017
Upper GI bleed.
Hospital No.
Date of audit:
Evidence of cirrhosis Y/N
Antibiotic Prophylaxis prescribed:
Prophylaxis in-line with guidelines: Y/N
In no, clear justification for deviation in the medical notes: Y/N
Switched to oral within 24 hours of oral route becoming available: Y/N
In no, clear justification for deviation in the medical notes: Y/N
Nottingham Antibiotic Guidelines Committee
Page 5 of 7
Written July 2014
Review July 2017
Equality Impact Assessment Report
1.
Name of Policy or Service
Response to external best practice policy
2.
Responsible Manager
Tim Hills Lead pharmacist antimicrobials and Infection control
3.
Name of person Completing EIA
Tim Hills Lead pharmacist antimicrobials and Infection control
4.
Date EIA Completed
17/6/2014
5.
Description and Aims of Policy/Service
This guideline describes the management, treatment and prophylaxis of adult
patients with spontaneous bacterial peritonitis and adult patients with liver
cirrhosis and an upper gastrointestinal haemorrhage.
6.
Brief Summary of Research and Relevant Data
See information within evidence base on front page
7.
Methods and Outcome of Consultation
Consultations have been carried out with the following:
Antibiotic guidelines committee
Comments from the above consultations have been received and
incorporated where appropriate.
Nottingham Antibiotic Guidelines Committee
Page 6 of 7
Written July 2014
Review July 2017
8.
Results of Initial Screening or Full Equality Impact Assessment:
Equality Group
Assessment of Impact
Age
No Impact Identified
Gender
No Impact Identified
Race
No Impact Identified
Sexual Orientation
No Impact Identified
Religion or belief
No Impact Identified
Disability
No Impact Identified
Dignity and Human Rights No Impact Identified
9.
Working Patterns
No Impact Identified
Social Deprivation
No Impact Identified
Decisions and/or Recommendations (including supporting rationale)
From the information contained in the procedure, and following the initial
screening, it is my decision that a full assessment is not required at the
present time.
10.
Equality Action Plan (if required)
N/A
11.
Monitoring and Review Arrangements
Review July 2017
Nottingham Antibiotic Guidelines Committee
Page 7 of 7
Written July 2014
Review July 2017