Review Question - QID 107874

The patient’s history, symptoms, and paracentesis findings is suggestive of spontaneous bacterial peritonitis (SBP). Cefotaxime is used in the treatment for SBP for its exceptional drug level in the blood and ascitic fluid.

SBP is an infection of the ascitic fluid without a clear source of infection. A frequent cause of infection in patients with cirrhosis is due to bacterial translocations (BT) of gram-negative bacteria from the intestinal lumen to areas such as the mesenteric lymph nodes. A possible mechanism for BT may be due to impaired motility of the small bowel allowing for bacterial overgrowth. In patients with cirrhosis, there is an associated impairment of innate and acquired immunity. There may also be a decrease in the complement concentration of ascitic fluid, impairing bacterial destruction due to decreased opsonin activity. These factors contribute to the persistence of bacteremia, and thus increasing the risk of SBP. Other causes of serum ascites albumen gradient (SAAG)> 1.1 g/dL include congestive heart failure, portal hypertension, and so on.

Starr et al. discuss the diagnosis, management, and prevention of patients with cirrhosis. New-onset ascites identified in patients should have a paracentesis to assess cell count, total protein, albumin, and bacterial culture and sensitivity. A serum-ascites albumin gradient is greater than or equal to 1.1 g/dL confirms the diagnosis of cirrhotic portal hypertension ascites or heart failure cirrhosis.

Garcia-Tsao et al. discuss the management and treatment of patients with cirrhosis and portal hypertension. Once SBP has been diagnosed, initiate antibiotic treatment before receiving the results of ascites or blood cultures. The most widely used antibiotic, with great SBP resolution, is cefotaxime. In uncontrolled studies, ceftriaxone has shown to be as effective as cefotaxime.

Incorrect Answers:
Answer 1: Nadolol is a non-selective beta blocker (NSBB). NSBB in patients with SBP have been associated with increased mortality, and increased risk of hepatorenal syndrome.
Answer 3: Penicillin is not the best choice while awaiting ascitic fluid culture results. This is a narrow spectrum penicillinase-sensitive drug mostly used for gram-positive organisms, gram-negative cocci, and spirochetes. SBP is commonly due to gram-negative bacteria, making the broader spectrum third generation cephalosporin a better choice.
Answer 4: Levofloxacin is a fluoroquinolone given to SBP patients who have a penicillin allergy; however, it does not have as great as ascitic fluid penetration as cefotaxime. Do not give fluoroquinolones in patients who have received fluoroquinolone therapy for SBP prophylaxis as resistance is high.
Answer 5: Gentamicin is an aminoglycoside. Patients with cirrhosis are sensitive to aminoglycoside-induced nephrotoxic injury due to kidney underperfusion.