What is the appropriate management for a patient presenting with ascites, elevated LDH, hypoalbuminemia, and a high neutrophil count in the ascitic fluid, with cytology indicating a chronic inflammatory pattern and reactive mesothelial cells?

Management of Ascites with High Neutrophils and Chronic Inflammatory Pattern

Immediate Antibiotic Therapy Required

This patient requires empiric antibiotic therapy immediately with intravenous cefotaxime 2 g every 8 hours, as the ascitic fluid neutrophil count of 95% (approximately 19,950 cells/mm³ based on 21,000 RBCs) far exceeds the diagnostic threshold of 250 cells/mm³ for spontaneous bacterial peritonitis (SBP), regardless of negative culture results. 1

Diagnostic Interpretation

Ascitic Fluid Analysis Findings

• Neutrophil count >250 cells/mm³: The 95% neutrophil predominance in this patient's ascitic fluid definitively indicates SBP or culture-negative neutrocytic ascites, both requiring identical treatment approaches 1
• LDH 180 U/L: This relatively modest elevation (typically <400 U/L suggests uncomplicated cirrhotic ascites rather than secondary peritonitis or malignancy) 2
• Albumin 2.4 g/dL: Calculate the serum-ascites albumin gradient (SAAG) by obtaining simultaneous serum albumin to determine if portal hypertension is present (SAAG ≥1.1 g/dL indicates portal hypertension) 1
• RBC 21,000 cells/mm³: Mildly bloody ascites occurs in approximately 2% of cirrhotic patients and may suggest hepatocellular carcinoma in 30% of cases 1
• Chronic inflammatory pattern with reactive mesothelial cells: This cytology finding excludes malignancy but does not rule out infection 1

Critical Distinction: SBP vs Secondary Peritonitis

You must exclude secondary bacterial peritonitis, which requires surgical intervention and has similar mortality to SBP when treated appropriately 1. Consider secondary peritonitis if:

• Multiple organisms on culture (not yet available in this case)
• Ascitic fluid LDH >400 U/L (this patient has 180 U/L, making secondary peritonitis less likely) 2
• Ascitic fluid glucose <50 mg/dL 1
• Ascitic fluid total protein >1 g/dL 1
• Localized abdominal symptoms or inadequate response to antibiotics 1

If secondary peritonitis is suspected, obtain CT imaging immediately and add anaerobic antibiotic coverage 1

Treatment Algorithm

Step 1: Immediate Antibiotic Therapy (Within Hours)

• Intravenous cefotaxime 2 g every 8 hours is the gold standard empiric therapy 1
• Alternative: Oral ofloxacin 400 mg twice daily may be considered only if the patient has no prior quinolone exposure, no vomiting, no shock, and no grade II or higher hepatic encephalopathy 1
• Do not wait for culture results to initiate treatment 1

Step 2: Albumin Administration for Renal Protection

Administer albumin 1.5 g/kg within the first 6 hours, followed by 1 g/kg on day 3 if the patient shows any signs of renal impairment or has baseline creatinine elevation 1. This intervention significantly reduces mortality in SBP by preventing hepatorenal syndrome 1

Step 3: Ascitic Fluid Culture Management

• Ensure ascitic fluid was inoculated into blood culture bottles at bedside (at least 10 ml into each bottle) 1
• Culture-negative neutrocytic ascites (PMN >250 cells/mm³ with negative cultures) has similar morbidity and mortality to culture-positive SBP and requires identical treatment 1

Step 4: Clinical Monitoring

• Follow-up paracentesis is NOT routinely necessary if the patient has typical SBP presentation with dramatic clinical response 1
• Repeat paracentesis only if: atypical setting, atypical organisms, poor clinical response, or suspicion of secondary peritonitis 1
• Monitor for clinical improvement within 48 hours (decreased fever, abdominal pain, improved mental status) 1

Long-Term Management After Infection Resolution

Secondary Prophylaxis (Mandatory)

All patients recovering from one episode of SBP require lifelong prophylaxis with norfloxacin 400 mg daily or trimethoprim-sulfamethoxazole to prevent recurrence 1. The recurrence rate without prophylaxis is 61% at one year versus 7% with prophylaxis 1

Liver Transplantation Evaluation

Refer this patient for liver transplantation evaluation immediately, as SBP is an absolute indication for transplant assessment 1. The development of SBP indicates advanced cirrhosis with poor prognosis (3-month mortality 38% without transplant) 1

Ascites Management

Once infection resolves:

• Dietary sodium restriction to 90 mmol/day (5.2 g salt/day) with no-added-salt diet 1, 3
• Spironolactone 100 mg/day initially, increasing to 400 mg/day if needed 1, 3
• Add furosemide 40-160 mg/day if spironolactone alone is inadequate, maintaining 100:40 mg ratio 1, 3
• Avoid bed rest as it promotes muscle atrophy without proven benefit 1, 3

Common Pitfalls to Avoid

• Never delay antibiotics waiting for culture results in patients with ascitic neutrophils >250 cells/mm³ 1
• Do not assume negative cytology excludes infection—this patient has clear SBP based on neutrophil count alone 1
• Do not attribute elevated neutrophils to "chronic inflammation"—this represents active bacterial peritonitis requiring immediate treatment 1
• Avoid missing secondary peritonitis by obtaining CT if LDH is very high (>400 U/L), multiple organisms are cultured, or clinical response is poor 1
• Do not forget albumin administration in patients with renal impairment or elevated creatinine, as this significantly reduces mortality 1