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The need for antibiotic stewardship and treatment standardization in the care of cirrhotic patients with spontaneous bacterial peritonitis - a retrospective cohort study examining the effect of ceftriaxone dosing.

BACKGROUND: Spontaneous bacterial peritonitis (SBP) is a common, often fatal affliction for cirrhotic patients. Despite all clinical trials of ceftriaxone for SBP using 2g daily, it is often given at 1g daily.

AIM: We evaluated survival after SBP as a function of ceftriaxone dosage.

METHODS:   A retrospective cohort of all patients who received ceftriaxone for SBP (greater than 250 neutrophils in the ascites).

RESULTS: As opposed to 1 gram, median survival is longer for patients receiving 2 grams (228 days vs. 102 days (p = 0.26) and one year survival is significantly higher (p = 0.0034).  After adjusting for baseline Model for End Stage Liver Disease (MELD) score, however, this difference was no longer significant.  Similarly, there was a significantly shorter length of intensive care for patients receiving 2 g (0.59 ± 1.78 days vs. 3.26 ± 6.9, p = 0.034), odds ratio 0.11 (95% CI 0.02 - 0.65). This difference, too, was no longer significant after controlling for the MELD score - odds ratio 0.21 (95% CI 0.04 - 1.07). Additionally, 70% of patients received at least one additional antibiotic; over 25 different medications were used in various combinations.

CONCLUSIONS:   Patients receiving 2 g of ceftriaxone may require fewer intensive care days and may enjoy an improved survival compared to those receiving 1 g daily. The complexity of antibiotic regimens to which cirrhotic patients are exposed must be studied further and rationalized.  We recommend fastidious antibiotic stewardship for patients with cirrhosis. Efforts should be made to craft local standards for the treatment of SBP that include appropriate antibiotic selection and dose.

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