Indications for SBP Prophylaxis

1.  Active GI bleed in a cirrhotic patient – treat with abxs (good choices are Ceftriaxone,  Cipro, or Norfloxacin) for a 7 day course.

2. Prior episode of SBP – treat with long-term prophylaxis.  Good choices are PO norfloxacin, Cipro (weekly or daily), and Bactrim.

3.  Ascites protein < 1  - treat with abx prophylaxis with discontinuation upon hospital discharge.  I.e., patient comes in with some problem like encephalopathy, gets tapped and negative for SBP, but protein < 1 à should give abxs during hospitalization only, and stop on discharge (assuming the patient hasn’t had a prior episode of SBP, in which case he meets indication for long-term ppx as in #2 above).

4.  Ascites protein < 1 AND either advanced decompensated cirrhosis (Childs-pugh score of 9 or more and bilirubin >3, or renal dysfunction (BUN >25, Cr >1.2, or Na <130) - treat with long-term abxs.
The evidence for this last indication comes from an RCT published in Gastroenterology 2007 comparing norfloxacin vs placebo in patients who met the above criteria, and showed significant decreases in development of SBP, hepatorenal syndrome, and mortality at 3 months and 1 year (see attached article). 

(Chanu Rhee MD, 4/14/11)