Spontaneous bacterial peritonitis

• Blood cultures prior to administering antibiotics.
• Paracentesis should be carried out without delay. Diagnosis confirmed by:

• WCC > 500 X 10⁶/L
• Positive ascitic fluid culture with clinical signs of infection

Piperacillin-tazobactam 4.5g every 8 hours IV

Known MRSA carriage:

Piperacillin-tazobactam 4.5g every 8 hours IV

PLUS

Vancomycin IV (use NHS Lothian Calculator located on AMT intranet page)- target trough level 15-20mg/L

Penicillin allergy:

Vancomycin IV (use NHS Lothian Calculator located on AMT intranet page) - target trough level 15-20mg/L

PLUS

Ciprofloxacin 500mg every 12 hours orally (or 400mg every 12 hours IV)

See MHRA fluoroquinolone guidance here.

Piperacillin-tazobactam and ciprofloxacin are associated with C.diff infection. See here for risk factors for C.diff infection.

Recommended total duration: 5 days (total duration = IV + oral)

• Review patient in 48 hours. If clinically improving, consider IV to oral switch
• This should be based on culture results when available. Otherwise empirical cover as below:

Preferred:

Co-trimoxazole 960mg every 12 hours orally (suitable in penicillin allergy)

Alternative:

Co-amoxiclav 625mg every 8 hours orally

Suitable for those ≤ 65 years old. See prevention of Cdiff infection.

• Likely organisms: Gram positive cocci and/or Gram negative coliforms.
• Culture results may be negative in patients taking prophylactic antibiotics