A 45-year-old man with a history of alcoholic cirrhosis and poor medication compliance is dropped off in the emergency department by a friend. He is:
On examination he is sleepy but rouses to voice. He cannot remember how he got to the hospital and gets irritated with repeated questions. He has asterixis and hyperactive reflexes. His abdomen is moderately distended but not tense or painful. In addition to admitting the patient and starting medical management of his decompensated cirrhosis, what is the best approach to working up and treating a possible infection?
A. No antibiotics needed at this time, and await results of blood and urine culturesCorrect Answer: D
All inpatients with ascites should have a diagnostic paracentesis performed at least once during every admission, and it should be repeated if the patient develops new evidence of infection during their stay. The symptoms of spontaneous bacterial peritonitis (SBP) can be subtle, and sending ascitic fluid for culture is a cost-effective way to detect an unexpected infection. The prevalence of SBP in hospitalized patients with cirrhosis and ascites is ∼10%. Initial laboratory testing should include ascitic fluid cell count and differential, ascitic fluid total protein, serumascites albumin gradient (SAAG), and both aerobic and anaerobic cultures. Cultures should be obtained before the initiation of antibiotics. Other tests may also be indicated based on the clinical scenario. In the presence of cirrhosis a SAAG of >1.1 g/dL nearly always indicates that the ascites is from portal hypertension. Patients with an ascitic protein concentration of <15 g/L have an increased risk of SBP. An ascitic fluid polymorphonuclear (PMN) leukocyte count greater than 250 cells/mm3 suggests the presence of infection, even if cultures are negative, and empiric antibiotics should be started. Patients with an ascitic fluid PMN count less than 250 cells/mm3 , but with signs and symptoms of infection, should also receive empiric antibiotic coverage. Gram stain cannot rule out infection because the concentration of bacteria in the ascitic fluid is often very low (ascitic fluid cultures are positive only ∼40% of the time in patients with other clinical evidence of SBP). The most common organisms cultured are Escherichia coli, Klebsiella pneumoniae, and Streptococcal pneumoniae. The preferred treatment for community-acquired SBP is cefotaxime or a similar thirdgeneration cephalosporin. For patients with nosocomial SBP or recent betalactam antibiotic exposure, empiric antibiotics should be based on local antibiograms.
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