Review Question - QID 107598

This patient’s clinical presentation is consistent with spontaneous bacterial peritonitis (SBP). The most appropriate treatment is to start cefotaxime.

Decompensated liver cirrhosis may lead to life-threatening complications such as hepatic encephalopathy, variceal hemorrhage, or SBP. SBP is an ascitic fluid infection without a surgically treatable intra-abdominal source. Patients may present with fever, abdominal pain, diarrhea, or altered mental status, though some may be asymptomatic and incidentally are diagnosed by paracentesis.

According to Starr and Raines, the diagnosis of SBP is based on presence of ascitic fluid with polymorphonuclear cell count greater than 250 cells/uL or positive Gram stain and culture. Typical causative organisms include E. coli, Klebsiella, streptococcus, and staphylococcus. First-line treatment is with cefotaxime, a third-generation cephalosporin with activity against many gram-positive and gram-negative bacteria.

After a first episode of SBP, patients should be started on outpatient antibiotic prophylaxis, typically with an oral fluoroquinolone. In a randomized controlled trial by Fernandez et al. comparing norfloxacin to placebo in the primary prophylaxis of SBP, the norfloxacin group demonstrated reduced incidence of SBP, delayed development of hepatorenal syndrome, and improved survival at 3-month and 1-year follow-up.

Incorrect Answers:
Answer 1: Large volume paracentesis with albumin may be used in diuretic-refractory ascites.
Answer 2: Diuretics and salt restriction are used in the maintenance of ascites.
Answer 3: Transjugular intrahepatic portosystemic shunt (TIPS) placement may be considered in patients with diuretic-refractory ascites.
Answer 5: Metronidazole alone should not be used for SBP, but can be added to cefotaxime for broader coverage in suspected secondary bacterial peritonitis and polymicrobial infections.