MEDizzy - A 63-year-old man with cirrhosis and portal hypertension due

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A 63-year-old man with cirrhosis and portal hypertension due to hemochromatosis presents with altered mental status. He has chronic ascites controlled with diet and spironolactone. He has a history of one esophageal bleed but none since starting propranolol. His family reports that over the last 2 days, he has become more confused, but he has had no melena or hematemesis. He is afebrile with normal vital signs, and physical examination is notable for ascites, asterixis, and being oriented only to the person. His laboratory examination is notable for hemoglobin of 10.1 (baseline, 9.5), creatinine of 1.4 (baseline, 1.4), and blood urea nitrogen of 45 (baseline, 18). A paracentesis is performed that yields reveal clear fluid with 800 WBC (40% neutrophils). Which of the following is the most indicated therapy?

ExplanationSpontaneous bacterial peritonitis (SBP) is a common and severe complication of ascites characterized by spontaneous infection of the ascitic fuid without an intra-abdominal source. In patients with cirrhosis and ascites severe enough for hospitalization, SBP can occur in up to 30% of individuals and can have a 25% in-hospital mortality rate. Bacterial translocation is the presumed mechanism for development of SBP, with gut f ora traversing the intestine into mesenteric lymph nodes, leading to bacteremia and seeding of the ascitic fuid. The most common organisms are E coli and other gut bacteria; however, gram- positive bacteria, including Streptococcus viridans, Staphylococcus aureus, and Enterococcus spp., can also be found. If more than two organisms are identifed, secondary bacterial peritonitis due to a perforated viscus should be considered. The diagnosis of SBP is made when the fuid sample has an absolute neutrophil count >250/μL. In this case, the patient has an absolute neutrophil count of 320/μL (800 × 0.4). Patients with ascites may present with fever, altered mental status, elevated white blood cell count, and abdominal pain or discomfort, or they may present without any of these features. Therefore, it is necessary to have a high degree of clinical suspicion, and peritoneal taps are important for making the diagnosis. Treatment is with a second-generation cephalosporin, with cefotaxime being the most commonly used antibiotic. In patients with variceal hemorrhage, the frequency of SBP is signifcantly increased, and prophylaxis against SBP is recommended when a patient presents with upper GI bleeding. Furthermore, in patients who have had an episode(s) of SBP and recovered, once-weekly administration of antibiotics is used as prophylaxis for recurrent SBP. There is no indication for hemodialysis with the normal serum creatine or EGD with no history of bleeding and a stable hemoglobin. Blood urea nitrogen (BUN) may increase as a result of the infection. Similarly, although the BUN is elevated and the patient has altered mental status, lactulose would not treat the primary disorder causing the altered mental status. Given the likely diagnosis of SBP, empiric therapy for meningitis is not warranted at this time.