Effect of alternative antibiotics in treatment of cefotaxime resistant spontaneous bacterial peritonitis

AIM:To evaluate effective alternative antibiotics in treatment of cefotaxime-resistant spontaneous bacterial peritonitis.METHODS:One hundred cirrhotic patients with spontaneous bacterial peritonitis [ascitic fluid polymorphonuclear cell count(PMNLs) ≥ 250 cells/mm 3 at admission] were empirically treated with cefotaxime sodium 2 g/12 h and volume expansion by intravenous human albumin.All patients were subjected to history taking,complete examination,laboratory tests(including a complete blood cell count,prothrombin time,biochemical tests of liver and kidney function,and fresh urine sediment),chest X-ray,a diagnostic abdominal paracentesis,and the sample subjected to total and differential cell count,chemical examination,aerobic and anaerobic cultures.Patients were divided after 2 d by a second ascitic PMNL count into group Ⅰ;patients sensitive to cefotaxime(n = 81),group Ⅱ(n = 19);cases resistant to cefotaxime(less than 25% decrease in ascitic PMNL count).Patients of group Ⅱ were randomly assigned into meropenem(n = 11) or levofloxacin(n = 8) subgroups.All patients performed an end of treatment ascitic PMNL count.Patients were considered improved when:PMNLs decreased to < 250 cells/mm 3,no growth in previously positive culture cases,and improved clinical manifestations with at least 5 d of antibiotic therapy.RESULTS:Age,sex,and Child classes showed no significant difference between group Ⅰ and group Ⅱ.Fever and abdominal pain were the most frequent manifestations and were reported in 82.7% and 80.2% of patients in group Ⅰ and in 94.7% and 84.2% of patients in group Ⅱ,respectively.Patients in group Ⅱ had a more severe ascitic inflammatory response than group Ⅰ and this was demonstrated by more ascitic lactate dehydrogenase(LDH) [median:540 IU/L(range:150-1200 IU/L) vs median:240 IU/L(range:180-500 IU/L),P = 0.000] and PMNL [median:15 000 cell/mm 3(range:957-23 822 cell/mm 3) vs 3400 cell/mm 3(range:695-26 400 cell/mm 3),P = 0.000] counts.Ascitic fluid culture was positive in 32% of cases.Cefotaxime failed in 19% of patients;of these patients,11(100%) responded to meropenem and 6(75%) responded to levofloxacin.Two patients with failed levofloxacin therapy were treated according to the in vitro culture and sensitivity(one case was treated with vancomycin and one case was treated with ampicillin/sulbactam).In group Ⅱ the meropenem subgroup had higher LDH(range:108-860 IU/L vs 120-491 IU/L,P = 0.042) and PMNL counts(range:957-23 822 cell/mm 3 vs 957-15 222 cell/mm 3,P = 0.000) at initiation of the alternative antibiotic therapy;there was no significant difference in the studied parameters between patients responsive to meropenem and patients responsive to levofloxacin at the end of therapy(mean ± SD:316.01 ± 104.03PMNLs/mm 3 vs 265.63 ± 69.61 PMNLs/mm 3,P = 0.307).The isolated organisms found in group Ⅱ were;enterococci,acinetobacter,expanded-spectrum β-lactamase producing Escherichia coli,β-lactamase producing Enterobacter and Staphylococcus aureus.CONCLUSION:Empirical treatment with cefotaxime is effective in 81% of cases;meropenem is effective in cefotaxime-resistant cases.