A 52-year-old man with Child-Pugh B cirrhosis (alcohol) develops increasing ascites. Diagnostic paracentesis shows: serum-ascites albumin gradient (SAAG) 1.4 g/dL, protein 15 g/dL, WBC 350 cells/mm³ with 320 PMN/mm³. Temperature is 38.4°C. Cultures pending. MOST appropriate management is:
- A IV cefotaxime 2g 8-hourly plus IV albumin 1.5 g/kg on day 1 and 1.0 g/kg on day 3 ✓
- B Oral norfloxacin 400 mg twice daily for 5 days
- C Large-volume therapeutic paracentesis before starting antibiotics
- D IV piperacillin-tazobactam for broad-spectrum cover; albumin not required
Explanation
Spontaneous bacterial peritonitis (SBP) is diagnosed when ascitic PMN ≥250 cells/mm³ with clinical signs of infection. IV cefotaxime 2g every 8 hours for 5 days is the standard antibiotic treatment. Critically, IV albumin infusion (1.5 g/kg on day 1, 1.0 g/kg on day 3) significantly reduces the incidence of hepatorenal syndrome and mortality (Sort et al., NEJM 1999) by maintaining renal perfusion. Oral norfloxacin is used for secondary prophylaxis (after SBP) or primary prophylaxis, not acute treatment. Therapeutic paracentesis should not be the primary management of infected ascites — it can be done in addition to antibiotics. Piperacillin-tazobactam lacks the evidence base and albumin co-administration must not be omitted.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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