A 57-year-old man with cirrhosis due to hepatitis C presents to the emergency department with fever, abdominal discomfort, and worsening confusion for 1 day. Medications include spironolactone and furosemide. Temperature is 38.4°C (101.1°F), blood pressure is 102/64 mm Hg, pulse is 108/min, and respiratory rate is 18/min. Physical examination reveals ascites and diffuse abdominal tenderness without rebound or guarding. Diagnostic paracentesis demonstrates an ascitic fluid neutrophil count of 420 cells/mm³.
Which of the following is the most appropriate treatment?
The correct answer is:
A: Cefotaxime.
This patient has spontaneous bacterial peritonitis, a common and potentially life-threatening complication of cirrhosis with ascites. An ascitic fluid neutrophil count of at least 250 cells/mm³ is diagnostic. Third-generation cephalosporins such as cefotaxime are first-line treatment.
Answer choice B: Immediate exploratory laparotomy, is incorrect.
Patients with secondary peritonitis due to bowel perforation often require surgery. However, this patient has SBP, which is treated medically with antibiotics.
Answer choice C: Lactulose, is incorrect.
The patient’s confusion may suggest hepatic encephalopathy, making this answer attractive. However, the diagnostic paracentesis confirms SBP, which requires prompt antibiotic therapy.
Answer choice D: Oral metronidazole, is incorrect.
Metronidazole is useful for anaerobic infections but is not standard monotherapy for SBP. Third-generation cephalosporins are preferred.
Answer choice E: Proton pump inhibitor therapy, is incorrect.
PPIs treat acid-related disorders and do not address peritoneal infection.
Key Learning Point
An ascitic fluid neutrophil count of at least 250 cells/mm³ is diagnostic of spontaneous bacterial peritonitis and requires prompt antibiotic treatment.
