A 52-year-old woman presents with known history of liver cirrhosis and ascites due to chronic alcoholism and HCV. Her current medications are spironolactone, furosemide, and a vitamin supplement. She presents to ER with worsening abdominal pain that started last night, associated with low-grade fever, but no nausea, vomiting, or changes in the bowel movements. On physical exam, BP 115/70, HR 94 and regular, and temperature is 38.2°C. She has spider angiomas scattered across her upper chest, no asterixis, and no change in mental status. Abdomen is diffusely distended with full flanks, nontender, and no evidence of rigidity or rebound tenderness. Bowel sounds are audible but decreased.
| Laboratory evaluation: |
| Leukocyte count 4,200/μL (normal 4,000-10,000/μL) |
| Platelet count 55,000/μL (normal 150,000-350,000/μL) |
| INR 1.3 |
| Serum albumin 2.7g/dL (normal 3.5-5.5g/dL) |
| Serum creatinine 0.8 mg/dL (normal 0.7-1.3 mg/dL) |
| Serum total bilirubin 1.3 mg/dL (normal 0.3-1.2 mg/dL) |
| Ascitic fluid analysis: |
| Albumin 1.2 g/dl |
| Glucose 112 mg/dl |
| Lactate dehydrogenase 140 mg/dl (less than upper limit for serum level) |
| Neutrophils 850/Ul |
| Culture results are pending. |
A. Surgical evaluation
B. Repeat paracentesis
C. Ceftriaxone plus IV albumin
D. Observation until culture results are available
E. Treatment with oral ofloxacin
Cefotaxime has been the most extensively investigated in patients with SBP
ReplyDeletebecause it covers 95% of the flora isolated from ascitic fluid and achieves high ascitic fluid concentrations during therapy.
Five days of treatment with cefotaxime is as effective as 10 day therapy, and low dose (2 g twice daily) is similar in efficacy to the higher doses (2 g four times daily).Other cephalosporins, such as ceftriaxone and
ceftazidime as well as co-amoxiclav (amoxicillin plus clavulanic acid), have been shown to be as effective as cefotaxime in resolving SBP.
In patients who are ‘‘well’’(asymptomatic), with bowel sounds, SBP can be treated with oral antibiotics. Under these circumstances either oral
ciprofloxacin (750 mg twice daily) or oral co-amoxiclav (1000/200 mg amoxicillin/clavulanic acid three times daily),subject to renal function, is logical.
Resolution of infection in SBP is associated with an improvement in symptoms and signs. However, for those patients who do not improve, treatment failure should be recognised early. A reduction in ascitic fluid neutrophil count of less than 25% of the pretreatment value after two days of antibiotic treatment suggests failure to respond to therapy.
BSG guidelines