A 48-year-old man with alcohol-related cirrhosis presents with sudden-onset fever, abdominal pain, and altered mental status. Paracentesis shows ascitic fluid PMN count 320/mm³, ascitic fluid culture negative. Serum-ascites albumin gradient (SAAG) is 1.8 g/dL. What is the diagnosis and treatment?
- A Secondary peritonitis; surgical exploration
- B Spontaneous bacterial peritonitis (SBP); cefotaxime IV + IV albumin ✓
- C Culture-negative SBP (CNNA); observation only
- D Tuberculous peritonitis; anti-TB therapy
Explanation
The diagnosis of SBP requires ascitic fluid PMN count ≥250 cells/mm³, regardless of culture result. Culture-negative SBP (CNNA) is treated identically to culture-positive SBP. Cefotaxime (2g q8h IV) covers the typical pathogens (E. coli, Klebsiella, Streptococcus pneumoniae). IV albumin (1.5 g/kg on day 1, 1 g/kg on day 3) is recommended to prevent hepatorenal syndrome — the SORT trial demonstrated significant reduction in HRS and mortality with albumin. SAAG >1.1 confirms portal hypertension. Secondary peritonitis is suggested by multiple organisms or very high PMN counts with LDH > serum LDH.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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