Are recommendations of our S3-guidelines for antibiotic treatment in patients with spontaneous bacterial peritonitis up to date?

Background: Current recommendations for empirical antimicrobial therapy in spontaneous bacterial peritonitis (SBP) are based on quite old trials. Since microbial epidemiology and the management of patients have changed, whether these recommendations are still appropriate must be confirmed.

Methods: Patients with their first episode of SBP were analyzed regarding the antimicrobial agents, antibiotic resistances and survival.

Results: There were 219 men and 92 women, most of whom presented severe cirrhosis (51.8% Child C, 42.4% Child B and 5.8% Child A) with a median Child score of 9.5 ± 1.9. Of the 311 cirrhotic patients, we found 138 positive microbial cultures in 114 patients (note: 28 patients with plurimicrobial cases) while 197 patients had a neutrophil count above 250/mm² without positive microbial culture. The most prominent infectious agent were E. coli (25.1%), E. faecium (16.7%), Klebsielle pneumoniae (7.2%), Staph. epidermidis (5.1%), Candida albicans (3.6%), Staph. aureus (3.6%) and Staph. haemolyticus (3.6%). For non-nosocomial acquired SBP, Ciprofloxacin had a antimicrobial susceptibility of 44.4% while Ceftriaxon had a susceptibility of 70.2%. For nosocomial SBP, Ceftriaxon had a antimicrobial susceptibility of only 56.3%. Highest in-vitro susceptiblity rates for non-nosocomial SBP were observed for Meropenem, Piperacillin/Tazobactam (both 85.1%) and Tigecyclin (93.6%). For nosocomial SBP, treatment with Piperacillin/Tazobactam (92.5%) and Tigecyclin (96.3%) had the highest susceptibility rates. Interestingly, patients in which diagnosis of SBP was made by positive ascites culture had significanlty reduced survival (mean: 13.9 months ± 2.9; 95% CI: 8.1 – 19.8) compared to patients without positive ascites culture but neutrophil count > 250/µl (mean: 44.1 months ± 5.4; 95% CI: 33.4 – 54.9; p = 0.000). Along with MELD-Score (OR: 1.05; 95% CI: 1.03 – 1.07), a positive ascites culture remained as an independent risk factor associated with poor survival (OR: 1.49; 95% CI: 1.09 – 2.03) in multivariate analysis.

Discussion:

Ceftriaxon, the current S3-antibiotic recommendation was not efficient in 29.8% of non-nosocomial and 45.7% of nosocomial SBP. Therefore, our current guidelines do not reflect antimicrobial resistances and need to be adjusted.