Spontaneous bacterial peritonitis (SBP)

Total course duration (IV and oral) up to 10 days

Amoxicillin IV 1g 8 hourly

and 

Temocillin IV 2g 8 hourly

If true penicillin / beta-lactam allergy:

Ciprofloxacin oral 500mg 12 hourly or IV 400mg 12 hourly

and

Vancomycin IV (dosing info here)

N.B. If the patient has received SBP prophylaxis with norfloxacin or another quinolone agent, please discuss antimicrobial therapy with an Infection Specialist.

Long term SBP prophylaxis: Co-trimoxazole oral 960mg once daily

When performing an ascitic tap, always send fluid in a universal (white top) container, as the laboratory is unable to perform cell counts on ascitic fluid injected into blood culture bottles, and gram staining is only done once the culture flags positive.

Amoxicillin provides cover for streptococci of the group formerly known as "Strep milleri", which are always amoxicillin susceptible and for enterococci (amoxicillin resistance rates <10%). It provides no reliable cover for E.coli (70% of bloodstream isolates are resistant). Klebsiella species are always amoxicillin resistant.

Gentamicin is contra-indicated in decompensated alcoholic liver disease as it is thought to increase the risk of hepato-renal syndrome. Temocillin resistance in enterobacteriaceae from abdominal samples is low at around 9%. Please note this is a low risk off-label use of this agent.

Ciprofloxacin resistance in the same isolates is higher (20%), and patient on long-term quinolone SBP prophylaxis are at particular risk.