What is the most appropriate step in treatment for a patient with liver cirrhosis and ascites presenting with abdominal pain, vomiting, generalized abdominal tenderness, hypotension, and elevated White Blood Cell (WBC) count?

Immediate Empiric Antibiotic Therapy is the Most Appropriate Treatment

This patient requires immediate empiric intravenous antibiotics for presumed spontaneous bacterial peritonitis (SBP), specifically cefotaxime 2g IV every 8 hours, without delay for diagnostic paracentesis. 1

Clinical Presentation Strongly Suggests SBP

This patient presents with the classic triad indicating infected ascites:

• Progressive abdominal pain and tenderness (peritoneal signs) 1
• Systemic signs of infection (markedly elevated WBC 23.3 × 10⁹/L, hypotension 100/55 mmHg) 1
• Gastrointestinal symptoms (vomiting) 1

The combination of cirrhotic ascites with these clinical features mandates immediate empiric antibiotic therapy even before paracentesis results are available. 1

Why Antibiotics Are the Correct Answer

Guideline-Directed Immediate Treatment

All major hepatology guidelines unanimously recommend starting empiric antibiotics immediately when SBP is clinically suspected, before awaiting ascitic fluid analysis or culture results. 1

• Patients with signs of infection (fever, abdominal pain/tenderness, vomiting, peripheral leukocytosis) should receive empiric antibiotics even if ascitic fluid PMN count is unavailable or <250 cells/mm³. 1
• The mortality of untreated SBP approaches 90%, but drops to approximately 20% with early antibiotic therapy. 1, 2
• Delaying antibiotics while pursuing observation or diagnostic procedures significantly increases mortality. 2, 3

First-Line Antibiotic Choice

Intravenous cefotaxime 2g every 8 hours is the gold-standard empiric therapy for community-acquired SBP. 1, 4

• Third-generation cephalosporins cover 95% of causative organisms (predominantly E. coli and other Gram-negative enteric bacteria, plus Streptococcus species). 1, 2, 5
• Cefotaxime achieves high ascitic fluid concentrations and has been extensively validated in clinical trials with approximately 90% efficacy. 2, 5
• Alternative antibiotics should be considered based on local resistance patterns and whether infection is healthcare-associated (nosocomial). 1

Why Other Options Are Incorrect

Observation is Contraindicated

• Observation without antibiotics in a patient with clinical signs of peritonitis and systemic infection is medically inappropriate and dangerous. 1
• The hypotension (100/55 mmHg) suggests early septic shock, requiring immediate intervention. 1
• Even if ascitic PMN count were <250 cells/mm³, this patient's clinical presentation mandates empiric treatment. 1

Diagnostic Laparoscopy is Unnecessary

• Laparoscopy has no role in the diagnosis or treatment of SBP. 1
• Diagnostic paracentesis (bedside needle aspiration) is the appropriate diagnostic procedure, not laparoscopy. 1
• Laparoscopy would only be considered if secondary bacterial peritonitis (perforation, abscess) is suspected after failed antibiotic response. 1

Exploratory Laparotomy is Premature

Surgery is reserved for secondary bacterial peritonitis (gut perforation or loculated abscess), not primary SBP. 1

Indications for considering laparotomy include:

• Ascitic fluid showing multiple organisms on Gram stain/culture (versus single organism in SBP) 1
• Ascitic fluid with total protein >1 g/dL, LDH greater than upper limit of normal for serum, AND glucose <50 mg/dL 1
• Very high PMN counts (usually thousands, not hundreds) 1
• Failure to respond to appropriate antibiotics with rising PMN count on repeat paracentesis at 48 hours 1
• CT findings of free air, abscess, or bowel wall thickening 1

This patient has none of these features documented and should receive antibiotics first. 1

Critical Management Algorithm

1. Start IV cefotaxime 2g every 8 hours immediately (or alternative based on local resistance patterns) 1, 4

2. Perform diagnostic paracentesis urgently (if not already done) to obtain:

   • Cell count with differential (PMN count) 1
   • Gram stain and culture (inoculate blood culture bottles at bedside) 1
   • Total protein, LDH, and glucose (to exclude secondary peritonitis) 1

3. Administer IV albumin 1.5 g/kg within 6 hours, then 1 g/kg on day 3 to prevent hepatorenal syndrome 1

4. Resuscitate hypotension with IV fluids and albumin; avoid nephrotoxic agents 1

5. Consider repeat paracentesis at 48 hours if inadequate clinical response to verify decreasing PMN count and guide further management 1

Common Pitfalls to Avoid

• Never delay antibiotics waiting for paracentesis results or imaging. Clinical suspicion alone warrants immediate treatment. 1
• Do not assume surgical pathology without evidence. Most cirrhotic patients with peritonitis have SBP (medical condition), not secondary peritonitis (surgical condition). 1, 6
• Avoid nephrotoxic medications (NSAIDs, aminoglycosides) as these patients are at high risk for hepatorenal syndrome. 1
• Monitor for multidrug-resistant organisms if healthcare-associated infection or prior antibiotic exposure; adjust therapy based on culture results. 1, 3, 5