Critical Care Medicine-Gastrointestinal, Nutrition and Genitourinary Disorders>>>>>Liver
Question 3#

A 63-year-old female with history of cirrhosis complicated by ascites requiring previous paracentesis presents with fever, abdominal pain, and hypotension. Diagnostic paracentesis shows gramnegative bacteria on Gram stain and neutrophil count of 400 cells/mm3 . 

Which of the following is the BEST next step in management?

A. Abdominal CT scan
B. Initiate therapy with cefotaxime
C. Right upper quadrant ultrasound
D. Initiate therapy with vancomycin
E. Large volume paracentesis

Correct Answer is B

Comment:

Correct Answer: B

This presentation of fever, abdominal pain, and ascitic fluid neutrophils >250 cells/mm3 in a patient with history of cirrhosis and ascites is highly suggestive of spontaneous bacterial peritonitis (SBP). Depending on other aspects of the patient’s history and presentation other workup could be warranted for secondary peritonitis, but this presentation is suspicious enough for SBP that treatment should be initiated regardless of additional ongoing workup. Empiric treatment is generally a third-generation cephalosporin, but cefotaxime has especially good penetration into the ascitic fluid so is preferred except when high rates of local resistance is present. A large volume paracentesis could put the patient at increased risk of hypotension in the setting of a current infection.

References:

  1. Dever JB, Sheikh MY. Review article: spontaneous bacterial peritonitis – bacteriology, diagnosis, treatment, risk factors and prevention. Aliment Pharmacol Ther. 2015;41(11):1116-1131.
  2. Chavez-Tapia NC, Soares-Weiser K, Brezis M, Leibovici L. Antibiotics for spontaneous bacterial peritonitis in cirrhotic patients. Cochrane Database Syst Rev. 2009;21(1).
  3. Runyon BA, Akriviadis EA, Sattler FR, Cohen J. Ascitic fluid and serum cefotaxime and desacetyl cefotaxime levels in patients treated for bacterial peritonitis. Dig Dis Sci. 1991;36(12):1782.