Current and emerging pharmacotherapy for the treatment of bacterial peritonitis

ABSTRACT

Introduction: Spontaneous bacterial peritonitis (SBP) is the quintessential model of bacterial infection in cirrhotic patients. In these particularly frail subjects, infections clearly worsen prognosis increasing substantially mortality. Furthermore, treatment of SBP has become more challenging because of the growing impact of multidrug-resistant (MDR) bacteria.

Areas covered: This review addresses the reasons behind the change in therapeutic recommendations for SBP that have occurred in the past few years, by focusing on the following aspects: the importance of an early appropriate empirical treatment, the difference between nosocomial and non-nosocomial forms and the overall microbiological shift (rise of Gram-positive bacteria and MDR strains) that have affected SBP.

Expert opinion: Until recently, third-generation cephalosporins have represented the cornerstone of SBP treatment, a safe choice covering the most important causative agents, namely Enterobacteriaceae. Unfortunately, massive exposure to health systems makes cirrhotic patients prone to MDR infections, which poses significant challenges, all the while not forgetting to strike a balance between effective antimicrobial activity and the risk of toxicity in these fragile subjects. Moreover, there is sparse information about new antibiotics in cirrhotic patients and about drugs levels in ascitic fluid. Therefore, further research is needed to optimize the treatment of SBP.

KEYWORDS:

• Spontaneous bacterial peritonitis
• cirrhosis
• infection
• multidrug-resistant bacteria
• guidelines
• advanced liver disease
• community-acquired

Article highlights

• Spontaneous bacterial peritonitis (SBP) is the most important, as to frequency and clinical impact, among bacterial infections in cirrhotic patients.

• SBP is a relevant cause of morbidity and mortality if not properly and timely treated.

• Third-generation cephalosporins no longer represent the empiric choice applicable to all patients because of the microbiologic change that involved the etiological agents of SBP.

• Broad-spectrum antimicrobial regimens are preferable when there is high risk of infections due to multidrug-resistant (MDR) bacteria, namely nosocomial and healthcare-associated forms.

• The knowledge of local epidemiology is always crucial to drive therapy, to avoid antibiotic overuse when possible or to extend broad-spectrum regimens to community-acquired infections when the risk of MDR is very high also in this setting.

• More data is needed to optimize the treatment of SBP, possibly from the use of novel drugs in cirrhotic patients and from a better knowledge of antibiotic pharmacokinetics in these subjects.

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Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This manuscript was not funded.