Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 45-year-old man is admitted to the hospital for a 2-day history of fever and abdominal pain. His medical history is notable for cirrhosis due to chronic hepatitis C, esophageal varices, ascites, and minimal hepatic encephalopathy. His medications are furosemide, spironolactone, nadolol, lactulose, zinc, vitamin A, and vitamin D.

On physical examination, temperature is 36.5 °C (97.7 °F), blood pressure is 100/50 mm Hg, pulse rate is 84/min, and respiration rate is 20/min. BMI is 28. Abdominal examination discloses distention consistent with ascites. The abdomen is nontender to palpation.

Laboratory studies

Hemoglobin	10 g/dL (100 g/L)
Leukocyte count	3500/µL (3.5 × 109/L)
Platelet count	70,000/µL (70 × 109/L)
INR	1.5 (normal range, 0.8-1.2)
Albumin	2.5 g/dL (25 g/L)
Alkaline phosphatase	220 units/L
Alanine aminotransferase	30 units/L
Aspartate aminotransferase	40 units/L
Total bilirubin	4 mg/dL (68.4 µmol/L)
Creatinine	1.8 mg/dL (159 µmol/L)
Urinalysis	Normal

Abdominal ultrasound discloses cirrhosis, splenomegaly, and ascites. The portal and hepatic veins are patent, and there is no hydronephrosis. Diagnostic paracentesis discloses a cell count of 2000/µL with 20% neutrophils, a total protein level of 1 g/dL (10 g/L), and an albumin level of 0.7 g/dL (7 g/L), consistent with spontaneous bacterial peritonitis.

Which of the following is the most appropriate treatment?

A: Cefotaxime
B: Cefotaxime and albumin
C: Furosemide and spironolactone
D: Large-volume paracentesis

MKSAP Answer and Critique

The correct answer is B: Cefotaxime and albumin.

The most appropriate treatment is cefotaxime and albumin. The diagnosis of spontaneous bacterial peritonitis (SBP) is made in the setting of a positive ascitic fluid bacterial culture and/or an elevated ascitic fluid absolute polymorphonuclear (PMN) cell count (≥250/microliter) without evidence of secondary causes of peritonitis. Patients with negative cultures have the same clinical presentation and outcomes compared with those with positive cultures. Intravenous cefotaxime or a similar third-generation cephalosporin is the treatment of choice for SBP. Three of the most common isolates are Escherichia coli, Klebsiella pneumoniae, and pneumococci. Oral fluoroquinolone treatment may be indicated in ambulatory patients with stable hepatic and kidney function and ascitic fluid absolute PMN cell count of 250/microliter or greater. While a significant number of hospitalized patients with SBP recover, it has been shown that kidney failure associated with SBP increases the risk for mortality. The use of cefotaxime plus intravenous albumin at 1.5 g/kg on admission and 1 g/kg on day 3 has been shown to decrease in-hospital mortality by 20% in patients with serum creatinine values of 1.5 mg/dL (133 micromoles/L) or greater, as in this patient. Patients with advanced liver disease, including those with a serum total bilirubin of 4 mg/dL (68.4 micromoles/L) or greater, as seen in this patient, also benefit from intravenous albumin to prevent kidney failure associated with SBP.

The use of cefotaxime alone in this patient is not appropriate, because the risk for progressive kidney dysfunction could still exist in the absence of intravenous albumin.

Oral diuretics such as furosemide and spironolactone should be withheld in patients with ascites and SBP to minimize the risk of worsening kidney function.

There is no evidence that large-volume paracentesis improves outcomes in patients with SBP; in fact, it may worsen kidney function owing to excessive fluid shifts.

Key Point

• In patients with spontaneous bacterial peritonitis, the concomitant use of intravenous albumin with antibiotic therapy is associated with a survival benefit compared with antibiotic therapy alone.

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