第一选择
环丙沙星
:
500 mg 口服，每日 1 次
或
甲氧苄啶/磺胺甲基异恶唑
:
160/800 mg，口服，每日一次，每周 5 天
-- 和 --
普萘洛尔
:
咨询专家以获取剂量上的指导
或
环丙沙星
:
500 mg 口服，每日 1 次
或
甲氧苄啶/磺胺甲基异恶唑
:
160/800 mg，口服，每日一次，每周 5 天
-- 和 --
纳多洛尔
:
咨询专家以获取剂量上的指导
-- 和 --
单硝酸异山梨酯
:
咨询专家以指导剂量
腹水蛋白浓度低（<15 g/L[<1.5 g/dL]）是导致 SBP 一个危险因素。多项研究发现，在这个患者亚组中，口服抗生素预防疗法可降低首次 SBP 降低腹水低蛋白患者的初次自发性细菌性腹膜炎 (SBP) 发生率：有高质量的研究证据表明预防性口服抗生素可减少腹水低蛋白浓度（<15 g/L[<1.5 g/dL]）患者的初次 SBP 发生率。[6]Blaise M, Pateron D, Trinchet JC, et al. Systemic antibiotic therapy prevents bacterial infections in cirrhotic patients presenting with gastrointestinal hemorrhage. Hepatology. 1994;20:34-38.http://www.ncbi.nlm.nih.gov/pubmed/8020902?tool=bestpractice.com[52]Loomba R, Wesley R, Bain A, et al. Role of fluoroquinolones in the primary prophylaxis of spontaneous bacterial peritonitis: meta-analysis. Clin Gastroenterol Hepatol. 2009;7:487-493.http://www.ncbi.nlm.nih.gov/pubmed/19250986?tool=bestpractice.com[53]Fernandez J, Navasa M, Planas R, et al. Primary prophylaxis of spontaneous bacterial peritonitis delays hepatorenal syndrome and improves survival in cirrhosis. Gastroenterology. 2007;133:818-824.http://www.ncbi.nlm.nih.gov/pubmed/17854593?tool=bestpractice.com[54]Pauwels A, Mostefa-Kara N, Debenes B, et al. Systemic antibiotic prophylaxis after gastrointestinal hemorrhage in cirrhotic patients with a high risk of infection. Hepatology. 1996;24:802-806.http://www.ncbi.nlm.nih.gov/pubmed/8855179?tool=bestpractice.com[55]Hsieh WJ, Lin HC, Hwang SJ, et al. The effect of ciprofloxacin in the prevention of bacterial infection in patients with cirrhosis after upper gastrointestinal bleeding. Am J Gastroenterol. 1998;93:962-966.http://www.ncbi.nlm.nih.gov/pubmed/9647029?tool=bestpractice.com[56]Saab S, Hernandez JC, Chi AC, et al. Oral antibiotic prophylaxis reduces spontaneous bacterial peritonitis occurrence and improves short-term survival in cirrhosis: a meta-analysis. Am J Gastroenterol. 2009;104:993-1001.http://www.ncbi.nlm.nih.gov/pubmed/19277033?tool=bestpractice.com一个 meta 分析发现其可降低 8%SBP 风险，这意味着 13 个治疗患者可防止 1 个患者出现 SBP。系统评价或者受试者＞200名的随机对照临床试验（RCT）。和其他细菌性感染的发生率，从而降低死亡率。降低低腹水蛋白患者的病死率：有高质量的研究证据表明预防性口服抗生素可提高 1 年生存率（60%，未治疗的患者为 48%）。[52]Loomba R, Wesley R, Bain A, et al. Role of fluoroquinolones in the primary prophylaxis of spontaneous bacterial peritonitis: meta-analysis. Clin Gastroenterol Hepatol. 2009;7:487-493.http://www.ncbi.nlm.nih.gov/pubmed/19250986?tool=bestpractice.com[53]Fernandez J, Navasa M, Planas R, et al. Primary prophylaxis of spontaneous bacterial peritonitis delays hepatorenal syndrome and improves survival in cirrhosis. Gastroenterology. 2007;133:818-824.http://www.ncbi.nlm.nih.gov/pubmed/17854593?tool=bestpractice.commeta 分析发现一个明显的短期效果（证据来自一个关于一级预防和二级预防 2 组患者的高质量研究），治疗的患者 3 个月病死率为 6%，未经治疗的患者为 22%。[56]Saab S, Hernandez JC, Chi AC, et al. Oral antibiotic prophylaxis reduces spontaneous bacterial peritonitis occurrence and improves short-term survival in cirrhosis: a meta-analysis. Am J Gastroenterol. 2009;104:993-1001.http://www.ncbi.nlm.nih.gov/pubmed/19277033?tool=bestpractice.com系统评价或者受试者＞200名的随机对照临床试验（RCT）。已经发生过 SBP 的患者，复发风险高。在这些患者中，应当采取长期抗生素预防疗法。[126]Runyon BA; AASLD Practice Guidelines Committee. Management of adult patients with ascites due to cirrhosis: update 2012. February 2013. http://www.aasld.org (last accessed 1 September 2016).http://www.aasld.org/sites/default/files/guideline_documents/adultascitesenhanced.pdf[52]Loomba R, Wesley R, Bain A, et al. Role of fluoroquinolones in the primary prophylaxis of spontaneous bacterial peritonitis: meta-analysis. Clin Gastroenterol Hepatol. 2009;7:487-493.http://www.ncbi.nlm.nih.gov/pubmed/19250986?tool=bestpractice.com治疗应持续到腹水消退、患者病危或肝移植时。[45]Strauss E, Caly WR. Spontaneous bacterial peritonitis: a therapeutic update. Expert Rev Anti Infect Ther. 2006;4:249-260.http://www.ncbi.nlm.nih.gov/pubmed/16597206?tool=bestpractice.com抗生素预防性治疗已被证明可降低肝硬化消化道出血患者的感染率（包括 SBP）和病死率。[126]Runyon BA; AASLD Practice Guidelines Committee. Management of adult patients with ascites due to cirrhosis: update 2012. February 2013. http://www.aasld.org (last accessed 1 September 2016).http://www.aasld.org/sites/default/files/guideline_documents/adultascitesenhanced.pdf[127]Chavez-Tapia NC, Barrientos-Gutierrez T, Tellez-Avila FI, et al. Antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding. Cochrane Database Syst Rev. 2010;(9):CD002907.http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002907.pub2/pdfhttp://www.ncbi.nlm.nih.gov/pubmed/20824832?tool=bestpractice.com
抗生素预防性治疗益处必须权衡长期应用抗生素的风险。研究发现，没有全面评估长期应用抗生素的风险可出现一些危害，如患者和社区患者尿道或腹水出现耐氟喹诺酮类病原体，出现氟喹诺酮类药物的肌肉骨骼副作用和难辨梭菌感染。[57]Cohen MJ, Sahar T, Benenson S, et al. Antibiotic prophylaxis for spontaneous bacterial peritonitis in cirrhotic patients with ascites, without gastro-intestinal bleeding. Cochrane Database Syst Rev. 2009;(2):CD004791.http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004791.pub2/fullhttp://www.ncbi.nlm.nih.gov/pubmed/19370611?tool=bestpractice.com[58]Segarra-Newnham M, Henneman A. Antibiotic prophylaxis for prevention of spontaneous bacterial peritonitis in patients without gastrointestinal bleeding. Ann Pharmacother. 2010;44:1946-1954.http://www.ncbi.nlm.nih.gov/pubmed/21098755?tool=bestpractice.com
3 项随机对照试验的 meta 分析表明，β受体阻滞剂可预防肝硬化和腹水患者 SBP 的发生。这 3 项研究使用了普萘洛尔和纳多洛尔（2 项试验用于二级预防、1 项试验用于一级预防）。[60]Senzolo M, Cholongitas E, Burra P, et al. beta-Blockers protect against spontaneous bacterial peritonitis in cirrhotic patients: a meta-analysis. Liver Int. 2009;29:1189-1193.http://www.ncbi.nlm.nih.gov/pubmed/19508620?tool=bestpractice.com
质子泵抑制剂 (PPIs) 可促进肠道细菌定植、过度生长并易位至腹腔，可能增加 SBP 的风险。一个 4 项临床相关研究的 meta 分析显示，使用 PPI 和 SBP 的发生有显著重要关联。[62]Trikudanathan G, Israel J, Cappa J, et al. Association between proton-pump inhibitors and spontaneous bacterial peritonitis in cirrhotic patients - a systematic review and meta-analysis. Int J Clin Pract. 2011;65:674-678.http://www.ncbi.nlm.nih.gov/pubmed/21564440?tool=bestpractice.com但其他研究没有发现 PPI 的使用与 SBP 存在正相关。[63]Campbell MS, Obstein K, Reddy KR, et al. Association between proton pump inhibitor use and spontaneous bacterial peritonitis. Dig Dis Sci. 2008;53:394-398.http://rd.springer.com/article/10.1007/s10620-007-9899-9/fulltext.htmlhttp://www.ncbi.nlm.nih.gov/pubmed/17616817?tool=bestpractice.com[64]Terg R, Casciato P, Garbe C, et al; Study Group of Cirrhosis Complications of the Argentine Association for the Study of Liver Disease. Proton pump inhibitor therapy does not increase the incidence of spontaneous bacterial peritonitis in cirrhosis: a multicenter prospective study. J Hepatol. 2015;62:1056-1060.http://www.ncbi.nlm.nih.gov/pubmed/25481567?tool=bestpractice.com鉴于这些有矛盾的数据，在决定对肝硬化患者处方 PPI 时，应当谨慎。
一个随机对照试验显示加用益生菌并没有预防作用。[61]Pande C, Kumar A, Sarin SK. Addition of probiotics to norfloxacin does not improve efficacy in the prevention of spontaneous bacterial peritonitis: a double-blind placebo-controlled randomized-controlled trial. Eur J Gastroenterol Hepatol. 2012;24:831-839.http://www.ncbi.nlm.nih.gov/pubmed/22522141?tool=bestpractice.com
