A 48-year-old man with alcohol-related cirrhosis and Child-Pugh B presents with his second episode of spontaneous bacterial peritonitis (SBP). He survives with norfloxacin prophylaxis started. Creatinine is 1.1 mg/dL. What additional agent should be started given the high 1-year mortality risk?
- A Terlipressin to reduce portal pressure
- B IV albumin infusion (long-term) plus evaluation for liver transplantation ✓
- C Rifaximin to reduce gut bacterial translocation
- D Oral propranolol for secondary prophylaxis of SBP
Correct answer: B. IV albumin infusion (long-term) plus evaluation for liver transplantation
Explanation
After a first episode of SBP, long-term secondary prophylaxis with norfloxacin or trimethoprim-sulfamethoxazole reduces recurrence. The PILOT trial and ATTIRE trial data support IV albumin infusions improving survival in cirrhosis by maintaining oncotic pressure and modulating systemic inflammation. More critically, after SBP, 1-year mortality approaches 50–60%, making transplant evaluation imperative. Terlipressin is used for hepatorenal syndrome. Rifaximin primarily reduces hepatic encephalopathy episodes. Propranolol is for variceal prophylaxis, not SBP.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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