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Spontaneous bacterial peritonitis — ABIM Board MCQ

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HardGastroenterology/HepatologySpontaneous bacterial peritonitisABIM Board

A 59-year-old man with alcohol-related cirrhosis presents with fever, abdominal pain, and worsening confusion. He has tense ascites and has not been hospitalized or received antibiotics during the preceding 90 days. Diagnostic paracentesis performed before antibiotics shows 840 neutrophils/mm3, albumin 0.7 g/dL, total protein 0.9 g/dL, glucose 92 mg/dL, and lactate dehydrogenase below the serum upper limit of normal. Serum creatinine is 1.8 mg/dL, increased from 0.9 mg/dL, and total bilirubin is 4.2 mg/dL. Which of the following is the most appropriate initial management?

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Correct answer: E — Intravenous ceftriaxone plus intravenous albumin

The correct answer is E. An ascitic neutrophil count of at least 250/mm3 establishes spontaneous bacterial peritonitis when there is no surgically treatable intra-abdominal source. The low ascitic protein, preserved glucose, and low lactate dehydrogenase support SBP rather than secondary bacterial peritonitis. Community-acquired SBP requires prompt empiric antibiotics; intravenous ceftriaxone is an appropriate third-generation cephalosporin. Albumin should accompany antibiotics because the creatinine is greater than 1 mg/dL and bilirubin is greater than 4 mg/dL, identifying high risk for kidney failure and death. TIPS does not treat acute infection and is inappropriate during active sepsis. Paracentesis may relieve tense ascites but cannot replace antibiotics. Ciprofloxacin prophylaxis is used to prevent future SBP, not as sole treatment of established symptomatic infection. Delaying antibiotics for repeat paracentesis is unsafe.

Reference: Tapper EB, Parikh ND. Diagnosis and Management of Cirrhosis and Its Complications: A Review. JAMA. 2023;329(18):1589-1602. https://pubmed.ncbi.nlm.nih.gov/10432325/