What is the recommended treatment for an adult patient with a history of ascites and liver cirrhosis who develops peritonitis associated with paracentesis?

Treatment of Peritonitis Associated with Paracentesis

Initiate immediate empiric antibiotic therapy with intravenous cefotaxime 2 g every 8 hours when ascitic fluid PMN count is ≥250 cells/mm³, which is the standard treatment for spontaneous bacterial peritonitis (SBP) in cirrhotic patients with ascites. 1

Initial Diagnostic Approach

When peritonitis develops after paracentesis in a cirrhotic patient with ascites, perform immediate diagnostic paracentesis to obtain ascitic fluid for analysis. 1 The critical distinction is whether this represents:

• Spontaneous bacterial peritonitis (SBP): Most common scenario in cirrhotic patients
• Secondary peritonitis: From bowel perforation or other surgical source requiring different management

Key ascitic fluid tests to order immediately: 1

• PMN count (diagnostic threshold ≥250 cells/mm³)
• Bacterial culture (inoculate blood culture bottles at bedside)
• Total protein, LDH, and glucose to distinguish SBP from secondary peritonitis
• Gram stain

Empiric Antibiotic Treatment

Start antibiotics immediately without waiting for culture results if PMN count ≥250 cells/mm³. 1

First-Line Therapy

• Cefotaxime 2 g IV every 8 hours is the most extensively studied and recommended regimen 1, 2
• Alternative: Third-generation cephalosporin based on local resistance patterns 1
• Duration: Typically 5 days for uncomplicated SBP 2

Special Considerations for Antibiotic Selection

• Community-acquired infection: Third-generation cephalosporin (cefotaxime or ceftriaxone) 1, 3
• Healthcare-associated infection: Consider carbapenem or piperacillin-tazobactam based on local susceptibility 3
• If quinolone-resistant organisms suspected (patient on prophylactic norfloxacin): Cefotaxime remains effective 1

Distinguishing SBP from Secondary Peritonitis

This distinction is critical because secondary peritonitis requires surgical intervention and anaerobic antibiotic coverage. 1

Features Suggesting Secondary Peritonitis (Requiring Surgery):

• Ascitic fluid characteristics: 1, 4
  • Total protein >1 g/dL
  • LDH > upper limit of normal for serum
  • Glucose <50 mg/dL
  • Multiple organisms on Gram stain or culture
• Additional markers: 5, 4
  • CEA >5 ng/mL (92% sensitivity, 88% specificity for gut perforation)
  • Alkaline phosphatase >240 U/L
• Clinical response: 1, 5
  • PMN count rises despite appropriate antibiotic therapy (versus decreasing in SBP)
  • Lack of clinical improvement after 48 hours

Important caveat: The classic criteria (protein, LDH, glucose) have 100% sensitivity but only 45% specificity for perforation, and only 50% sensitivity for non-perforation secondary peritonitis. 5 The 48-hour PMN count response is more valuable for distinguishing these conditions. 5

Management Algorithm for Secondary Peritonitis

If secondary peritonitis is suspected or confirmed: 1, 6

1. Add anaerobic coverage to the third-generation cephalosporin immediately
2. Arrange urgent surgical consultation for laparotomy
3. Continue broad-spectrum antibiotics plus anaerobic coverage perioperatively

The mortality of secondary peritonitis treated with antibiotics and surgery is similar to SBP treated with antibiotics alone, but only if surgical intervention is not delayed. 1

Follow-Up Monitoring

When Follow-Up Paracentesis is NOT Needed:

Routine follow-up paracentesis is unnecessary in patients with: 1, 5

• Typical clinical setting (advanced cirrhosis)
• Typical symptoms and ascitic fluid analysis
• Single organism on culture
• Dramatic clinical response to antibiotics

When Follow-Up Paracentesis IS Indicated:

Perform repeat paracentesis at 48 hours if: 1, 5

• Atypical clinical presentation or setting
• Atypical ascitic fluid analysis results
• Multiple organisms on culture
• Poor or inadequate clinical response to appropriate antibiotics
• Suspicion of secondary peritonitis

At 48 hours, the PMN count should decrease substantially from baseline in SBP with appropriate therapy. 5 A rising PMN count despite treatment indicates secondary peritonitis requiring surgical evaluation. 1, 5

Adjunctive Therapy: Albumin Administration

Administer intravenous albumin concurrently with antibiotics to reduce mortality and prevent renal dysfunction. 2 This simultaneous administration has been shown to decrease the development of azotemia and hospitalization-related mortality in SBP. 2

Common Pitfalls to Avoid

• Delaying paracentesis due to coagulopathy concerns: Paracentesis is NOT contraindicated in patients with abnormal coagulation profiles. 4, 3 Fresh frozen plasma is not routinely needed. 4
• Platelet threshold: Consider platelet transfusion only if count <40,000-50,000/μL. 4, 3
• Waiting too long for follow-up paracentesis: In patients with poor clinical response, delayed repeat paracentesis can miss secondary peritonitis requiring urgent surgery. 5
• Assuming all peritonitis in cirrhotic patients is SBP: Always consider secondary peritonitis, especially with atypical features, as it requires surgical intervention. 1, 5
• Using prophylactic antibiotics routinely: Prophylactic antibiotics are NOT indicated for routine diagnostic or therapeutic paracentesis in patients without signs of infection. 4

Prevention of Recurrent SBP

After recovery from an episode of SBP, initiate secondary prophylaxis: 1

• Norfloxacin 400 mg once daily, OR
• Ciprofloxacin 500 mg once daily, OR
• Co-trimoxazole (800 mg sulfamethoxazole/160 mg trimethoprim) daily

Continue until liver transplantation or resolution of ascites. 1, 2