Ceftriaxone versus cefotaxime in the treatment of spontaneous bacterial peritonitis

Introduction and Objectives

Infections in cirrhotic patients occur in one-third of hospitalized patients. Spontaneous infections (spontaneous bacteremia, spontaneous bacterial peritonitis (SBP), and spontaneous empyema) are the most common and their management with third-generation cephalosporins (cefotaxime or ceftriaxone) is recommended. The effect of albumin on in vitro antimicrobial activity is greater for cefotaxime.

Materials and Patients

This is a retrospective, observational, and analytical study. We included clinical records of patients admitted to the Gastroenterology service of the Hospital General de México “Dr. Eduardo Liceaga” from March 2021 to February 2024 with a diagnosis of SBP ≥ 250 polymorphonuclears (PMN), comparing two different treatments (cefotaxime 2gr c/12 hours vs ceftrixone 1 or 2gr/day) and follow-up one year after the event. We evaluated the response to treatment with a second paracentesis with 48 hours of antibiotic therapy. We determined the recurrence at 12 months and the relationship with serum albumin levels in treated patients. We excluded patients with secondary bacterial peritonitis, tuberculosis or carcinomatosis, and previous antibiotic use (except rifaximin). Qualitative variables were expressed as frequencies and percentages; numerical variables as means and standard deviation. We used X2, Student's t-test, and Mann-Whitney U to compare the variables. To compare the percentages of deaths per treatment, response rate, and recurrences at one year, we used the Z test for contingency tables. The log-rank test and the Kaplan-Meier survival curve were used to evaluate survival per treatment at 30 days. A value of P < 0.05 was considered statistically significant.

Results

Out of 950 hospitalized cirrhotic, 6.42% (61) presented SBP. 63.9% were male and aged 52±11.9 years. Etiology of cirrhosis, 39.3% alcohol, 26.2% unfiliated, 14.8% MASLD, and 8.2% autoimmune hepatitis. Comparing groups, 29 patients with cefotaxime and 32 with ceftriaxone, with no differences concerning Child-Pugh, MELD score (23 vs 31, p=0.07), acute on chronic liver failure (ACLF) (56.5% vs 43. 5%, p=0.79), ACFL points (55 vs 53, p=0.52), leukocytes, PMN and DHL levels in ascites fluid (p=0.55, p=0.45 and p=0.52), and serum albumin (2.32g/dl vs 2.26gr/dl, p=0.71). An equal response rate was observed at 28/32 (87.5%) for cefotaxime and 26/29(89.7%) for ceftriaxone with no statistical differences between groups. The recurrence rate was similar with 3 cases for each group with no differences between them. The mortality rate was 14/61(23%); 4/32(12.5%) for cefotaxime and 10/29(34.5%) for ceftriaxone with statistical differences between groups. At 30 days total mortality was 9/61(14.8%) with 2/32(6.2%) for cefotaxime and 7/29 (24.13%) for ceftriaxone with no difference between groups Log-Rank(1) = 3.75 p=0.053.

Conclusions

The ceftriaxone or cefotaxime is equally effective in patients with SBP, with no difference in ACLF, serum albumin level, or ceftriaxone dose(1-2gr/day). The recurrence rate was similar between both treatments, with a tendency towards higher mortality for ceftriaxone without differences in terms of etiology, ACLF, or the severity of cirrhosis.

Ethical Statement: Retrospective study, the identity of the patients was kept secret at all times.

Declaration of interests: None.

Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Figure 1. Bars expressing patients who survived or died with respect to type of antibiotic.

Source: Data extracted from records of the Gastroenterology service of the Hospital General de México “Dr. Eduardo Liceaga”.

Figure 2. Kaplan Meyer survival curve with respect to type of antibiotic.

Source: Data extracted from records of the Gastroenterology Service of the Hospital General de México “Dr. Eduardo Liceaga”.