Guidelines for the Management of Adult Patients with Spontaneous Bacterial

Peritonitis or Liver Cirrhosis with Upper Gastrointestinal Bleed

Full Title of Guideline: Guidelines for the Management of Adult Patients with
Spontaneous Bacterial Peritonitis or Liver Cirrhosis with Upper
Gastrointestinal Bleed.
Author (include email and role): Dr Richard Ingram – Gastroenterology Registrar
Dr Emilie Wilkes – Consultant Hepatologist
Mr Tim Hills – Lead Pharmacist Antimicrobials and Infection
Control
Dr Vivienne Weston – Consultant Microbiologist.
Division & Speciality: Surgery division, Gastroenterology,

Scope (Target audience, state if Trust Doctors, nurses, pharmacists

wide):
Review date (when this version goes out
of date):
Explicit definition of patient group
to which it applies (e.g. inclusion and
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:
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.
Nottingham Antibiotic Guidelines Committee
January 2021
Either patients diagnosed with Spontaneous Bacterial
Peritonitis or has liver cirrhosis and an upper GI bleed
Cut-off WCC for diagnosis for SBP changed to ascitic fluid ≥0.5
9
x 10 /L, and updated guidance to ensure correct sample(s) are
received in safe and timely manner
1st line treatment for SBP amended to piperacillin/ tazobactam
1st line antibiotic prophylaxis for GI bleed amended to
piperacillin/ tazobactam
SBP treatment in severe penicillin allergy: metronidazole
amended from PO to IV
Liver cirrhosis with upper GI bleed penicillin allergy advice
changed from cefuroxime to ciprofloxacin.
st
SBP prophylaxis 1 line changed to ciprofloxacin
SBP severe penicillin allergic regimen changed from IV
ciprofloxacin + vancomycin to IV levofloxacin.
Agreement from laboratory to incorporate comment on ascitic
fluid WCC reports – “For advice on the diagnosis and
management of Spontaneous Bacterial Peritonitis, please see
the Antibiotics Website > infection by site > gastrointestinal”
Medline literature search 2012-2017
British Society of Gastroenterology Guidelines
Recommended best practice based on clinical experience of
guideline developers.
The Sanford Guide To Antimicrobial Therapy Web edition
accessed 07/2017
John Hopkins Guides: Peritonitis, Spontaneous Bacterial &
Secondary: Accessed 07/2017
EASL clinical guidelines on spontaneous bacterial peritonitis
available at http://www.easl.eu/research/our-
contributions/clinical-practice-guidelines/detail/management-of-
ascites-spontaneous-bacterial-peritonitis-and-hepatorenal-
syndrome-in-cirrhosis/report/4 accessed 22/12/2017
NICE guideline 50 Cirrhosis in over 16s Assessment and
management July 2016.
Page 1 of 4 Written January 2018
Review January 2021
 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, and it occurs in 15% of all
those with ascites admitted to hospital irrespective of their symptoms. The 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 ascitic tap is mandatory in all cirrhotic patients with ascites requiring hospital
admission. This should be performed within the first 24 hours of admission. Screening for SBP
is also recommended for all patients undergoing a therapeutic large volume paracentesis,
including as a day case procedure.
• Inject ascitic fluid into a FBC bottle (lavender EDTA bottle) and send to CLINICAL
PATHOLOGY. Request total white cell count (WCC). This should be an urgent request
and results should be followed up. SBP is confirmed by: an ascitic fluid WCC of ≥0.50 ×
109/L
• Note this is equivalent to an ascitic fluid total WCC of ≥ 500 cells/mm3 OR an ascitic fluid
neutrophil count of ≥0.25 × 109/L (≥250 cells/mm3), which are used at some other centres.
Ascitic fluid should also be inoculated into a STERILE UNIVERSAL CONTAINER and into
BLOOD CULTURE BOTTLES at the bedside and sent to MICROBIOLOGY for
microscopy, culture and sensitivities (MC&S).
• To improve bacterial diagnosis, the diagnostic ascitic tap should ideally be performed prior
to starting antibiotics. However, in patients meeting high-risk-red sepsis criteria,
appropriate antibiotics are required within one hour and should not be delayed if the
samples cannot be obtained immediately.
• The frequency of bleeding complications in patients with coagulopathy after paracentesis
are reported to be low and do not support a relationship between risk of bleeding and
degree of coagulopathy. Ascertain the bleeding risk based on history of spontaneous
bleeding (nose/gums) and previous platelet count and Prothrombin time (PT) (within the
last 3 months). Patients not at high-risk of bleeding, as described above, should not
routinely have the procedure delayed to check FBC and coagulation. If platelets <50 ×
109/L or PT >25 sec then, unless the results are within the previous 7 days, it is
reasonable to repeat these prior to the procedure. Consider platelet cover if count is <50 ×
109/L. It is acceptable to proceed if PT ≤25 sec; if PT >25 sec then seek the advice of the
acute gastroenterology team.
• For a first diagnostic ascitic tap, it is routine practice to send, in addition to the samples
described above: (1) a STERILE UNIVERSAL CONTAINER to CLINICAL PATHOLOGY
for ascitic fluid ALBUMIN, (2) paired blood sample for LFTs in order to calculate the serum-
albumin ascites gradient (SAAG), and (3) a STERILE UNIVERSAL CONTAINER to
CYTOPATHOLOGY for ascitic fluid CYTOLOGY.
• For a diagnostic tap to check for SBP in a patient with known ascites due to portal
hypertension, only the samples described above are routinely required. Be explicit in
request if mycobacterial or fungal pathogens are suspected. DO NOT request glucose,
LDH and lactate estimation in ascitic fluid routinely. If blood-stained then send for cytology.
If chylous send for triglycerides and lipid profile. If pancreatic ascites if suspected, send for
amylase.
Nottingham Antibiotic Guidelines Committee Page 2 of 4 Written January 2018
Review January 2021
Antibiotic Treatment
Initial treatment in severe disease:
Total duration for severe disease: 5-7 days

1st Line:
Piperacillin/Tazobactam IV 4.5g TDS (N.B. contains a penicillin)

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

IV Levofloxacin 500mg BD +/- 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

Human Albumin Solution

All patients diagnosed with SBP should be treated with albumin (1.5 g/kg at diagnosis and 1g/kg
on day 3), unless contraindicated. This has been shown to reduce mortality and the risk of
hepatorenal syndrome. This is administered in the form of 20% Human Albumin Solution (HAS),
which is typically provided in 100 mL vials and prescribed rounded to the nearest 100 mL. Each
100mL of 20% HAS contains 20 g of albumin. It can be requested from blood bank if required and
is prescribed on the blood product prescription sheet, with each 100 mL typically given over 15-
30 minutes. The total dose must be divided over 24 hours rather than as a single bolus and
caution used in patients with evidence of heart failure as there is risk of pulmonary oedema from
rapid infusion of large volumes of HAS. Please seek the advice of the acute gastroenterology
team if required.

Antibiotic Prophylaxis
Prophylaxis should be given to patients who have recovered from one previous episode of SBP
Continuous Prophylaxis Regimen:
1st Line
Ciprofloxacin PO 500mg OD

Allergic/unable to take quinolones to

Co-trimoxazole PO 960mg OD
(N.B. contains sulphonamide and trimethoprim)

Primary prophylaxis, regimens as above, should also be offered for patients with cirrhosis and
ascites with an ascitic fluid protein of 15g/L or less, until the ascites has resolved.

Nottingham Antibiotic Guidelines Committee Page 3 of 4 Written January 2018

Review January 2021
 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
When NBM
Piperacillin/Tazobactam IV 4.5g TDS (N.B. contains a penicillin)
converting once able to
PO Ciprofloxacin 500mg BD as soon as oral route is available.
Total duration of antibiotic prophylaxis (IV+PO) is usually 5 days

Penicillin allergy
When NBM
Ciprofloxacin IV 400mg BD converting to PO Ciprofloxacin 500mg BD as soon as oral
route is available.
Total duration of antibiotic prophylaxis (IV+PO) is usually 5 days

Allergic to taking ciprofloxacin as prophylaxis

Discuss with medical microbiologist/gastroenterologist

Nottingham Antibiotic Guidelines Committee Page 4 of 4 Written January 2018

Review January 2021