A 48-year-old man with known cirrhosis and previous SBP is on norfloxacin prophylaxis. He presents with fever, abdominal pain, and ascites with neutrophil count of 320 cells/mm³ in diagnostic paracentesis. Blood cultures are negative. Ascitic fluid protein is >1 g/dL. What is the appropriate treatment?

• A Oral norfloxacin alone as he is already on prophylaxis
• B IV cefotaxime 2g every 8 hours for 5 days plus albumin infusion ✓
• C Piperacillin-tazobactam IV for nosocomial SBP coverage
• D Withhold antibiotics and repeat paracentesis in 48 hours

Explanation

Spontaneous bacterial peritonitis (SBP) is diagnosed by ascitic fluid PMN count ≥250 cells/mm³. Treatment is IV cefotaxime (2g every 8 hours for 5 days) plus IV albumin (1.5 g/kg on day 1 and 1 g/kg on day 3), which prevents hepatorenal syndrome and reduces mortality (SORT trial). In patients on norfloxacin prophylaxis, SBP may be caused by gram-positive or quinolone-resistant organisms; cefotaxime remains the standard empirical choice. Secondary prophylaxis with norfloxacin is continued indefinitely after the episode resolves.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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