TREATMENT OF PRIMARY PERITONITIS
TREATMENT OF PRIMARY PERITONITISInitial treatment of primary peritonitis is often empiric, since the Gram stain is frequently (60% to 80% of the time) negative. Broad antimicrobial coverage should be started until the results of culture and susceptibilities are available. The combination of ampicillin plus an aminoglycoside has generally gone out of favor for patients with cirrhosis, given the potential for nephrotoxicity in this group. Third-generation cephalosporins are often recommended, but many other agents, including carbapenems (particularly, imipenem) and beta-lactam/beta-lactamase-inhibitor combinations (e.g., ampicillin-sulbactam) are alternative options. Anaerobic coverage (metronidazole or clindamycin) should be added, unless a beta-lactam/beta-lactamase inhibitor combination is used. If cultures remain sterile but there is a strong clinical suspicion of primary peritonitis (CNNA), antibiotics should be continued. Treatment is usually continued for 10 to 14 days, although a shorter course of therapy for 5 days has been found to be effective in patients, who are clinically well with a declining ascitic fluid leukocyte count and negative cultures after this period of therapy. Clinical improvement as well as a decline in the ascitic fluid white blood cell count should occur by 48 hours of treatment if the diagnosis is correct; otherwise, further evaluation to rule out other pathologic conditions should be done.While treatment is successful in more than 50% of cirrhotic patients, the overall mortality rate of SBP is high, between 57% and 70%, primarily because of the underlying disease. Patients with the poorest prognosis include patients with renal insufficiency, hypothermia, hyperbilirubinemia, and hypoalbuminemia.*90/348/5*
