What is the management for spontaneous bacterial peritonitis (SBP) with 11,000 white blood cells (WBC) in paracentesis fluid?

Management of Spontaneous Bacterial Peritonitis with 11,000 WBC in Paracentesis Fluid

For spontaneous bacterial peritonitis (SBP) with 11,000 white blood cells (WBC) in paracentesis fluid, immediate treatment with third-generation cephalosporins such as cefotaxime 2g IV every 8 hours for 5 days plus intravenous albumin (1.5 g/kg at diagnosis and 1 g/kg on day 3) is strongly recommended. 1

Diagnosis Confirmation

• A neutrophil count >250/mm³ in ascitic fluid confirms SBP diagnosis, with 11,000 WBC representing a severe infection requiring prompt treatment 1
• Although ascitic fluid culture is not necessary for diagnosis, it should be performed to guide antibiotic therapy 1
• Blood cultures should be obtained before starting antibiotics to identify potential bacteremia 1

Antibiotic Treatment

First-line Treatment:

• Initiate empirical antibiotics immediately upon diagnosis without waiting for culture results 1
• Third-generation cephalosporins are the first-line treatment:
  • Cefotaxime 2g IV every 6-8 hours for 5 days 1
  • A 5-day therapy is as effective as a 10-day treatment 1

Alternative Options:

• Amoxicillin/clavulanic acid (1/0.2g IV every 8 hours, then 0.5/0.125g PO every 8 hours) 1
• Ciprofloxacin (IV for 2 days, then oral for 5 days) for uncomplicated SBP 1
• For nosocomial SBP with high risk of resistant organisms, broader-spectrum antibiotics like meropenem (1g every 8 hours) may be considered 2, 3

Important Considerations:

• Avoid nephrotoxic antibiotics such as aminoglycosides 1
• Do not use quinolones in patients already on quinolone prophylaxis or in areas with high quinolone resistance 1
• For patients with renal impairment, adjust antibiotic dosing accordingly 2

Adjunctive Therapy

• Intravenous albumin (1.5 g/kg at diagnosis, followed by 1 g/kg on day 3) significantly reduces the risk of hepatorenal syndrome and mortality 1
• Albumin is particularly important for patients with:
  • Serum bilirubin ≥4 mg/dL (68 μmol/L) or
  • Serum creatinine ≥1 mg/dL (88 μmol/L) 1

Monitoring Response to Treatment

• Perform a repeat paracentesis after 48 hours of treatment to assess response 1, 4
• Treatment failure is defined as:
  • Failure of ascitic neutrophil count to decrease by at least 25% of the pre-treatment value 1, 4
  • Worsening of clinical signs and symptoms 1
• Treatment failure occurs in approximately 22% of cases and doubles 30-day mortality risk 4

Management of Treatment Failure

• If treatment fails, consider:
  • Resistant bacteria requiring antibiotic change based on culture results 1
  • Secondary bacterial peritonitis requiring surgical evaluation 1
• For suspected resistant organisms, modify antibiotics according to culture results or switch to broader-spectrum agents 1, 3
• Secondary peritonitis should be suspected with:
  • Multiple organisms on culture
  • Very high ascitic neutrophil count (as in this case with 11,000 WBC)
  • Inadequate response to therapy 1
• Obtain CT scan if secondary peritonitis is suspected 1

Common Pitfalls to Avoid

• Delaying antibiotic treatment while waiting for culture results 1
• Failing to administer albumin in high-risk patients 1
• Not performing follow-up paracentesis to confirm treatment response 1, 4
• Overlooking the possibility of resistant organisms or secondary peritonitis in cases with very high neutrophil counts 1
• Using quinolones empirically in patients already receiving quinolone prophylaxis 1

Prognosis

• SBP has approximately 20% hospital mortality rate despite infection resolution 1
• Early appropriate antibiotic treatment combined with albumin therapy significantly improves survival 1
• Treatment failure doubles the 30-day mortality risk 4