What is the appropriate management for a patient with Spontaneous Bacterial Peritonitis (SBP) and an elevated Absolute Neutrophil Count (ANC), likely with a history of liver disease or cirrhosis, and ascites?

Management of Spontaneous Bacterial Peritonitis with Elevated ANC

Diagnose SBP when ascitic fluid absolute neutrophil count (ANC) exceeds 250 cells/mm³ and immediately initiate treatment with cefotaxime 2g IV every 8 hours for 5 days plus intravenous albumin 1.5 g/kg within 6 hours, followed by 1 g/kg on day 3. 1, 2

Diagnostic Threshold and Immediate Actions

• The diagnostic threshold of >250 cells/mm³ for ascitic fluid neutrophils confirms SBP regardless of culture results, and this lower threshold is deliberately chosen because the greater clinical risk lies with underdiagnosing SBP rather than overdiagnosing it. 1, 2

• An ANC ≥250 cells/mm³ is sufficient to diagnose SBP—do not wait for culture results to initiate treatment, as each hour of delay increases in-hospital mortality by 3.3%. 1, 3

• Before starting antibiotics, inoculate at least 10 mL of ascitic fluid into blood culture bottles at bedside (increases culture sensitivity to >90%) and simultaneously obtain blood cultures. 1, 2

First-Line Treatment Protocol

Antibiotic therapy:

• Cefotaxime 2g IV every 8-12 hours for 5 days is the most extensively studied regimen with 77-98% resolution rates. 1, 2
• A 5-day course is as effective as 10 days of treatment. 1, 4
• Alternative for uncomplicated cases: oral ofloxacin 400mg twice daily. 1

Critical caveat: Do not use quinolones in patients already taking them for prophylaxis, in areas with high quinolone resistance, or in nosocomial SBP. 1

Albumin Therapy is Essential

• Administer IV albumin 1.5 g/kg body weight within 6 hours of diagnosis, followed by 1.0 g/kg on day 3—this reduces mortality from 29% to 10% and decreases type 1 hepatorenal syndrome from 30% to 10%. 1, 2, 4

• This albumin regimen significantly reduces the risk of hepatorenal syndrome and mortality, making it a non-negotiable component of SBP management. 1, 4

Monitoring Treatment Response

• Perform repeat paracentesis at 48 hours to assess treatment efficacy. 1, 2, 4

• Treatment success is defined as:

  • Ascitic PMN count decrease to <25% of pre-treatment value 1, 2
  • Clinical improvement accompanying the laboratory response 1

• Treatment failure is defined as failure of ascitic neutrophil count to decrease by at least 25% of pre-treatment value or worsening of clinical signs and symptoms. 1, 4

Management of Treatment Failure

If PMN count fails to decrease by at least 25% at 48 hours:

• Consider resistant bacteria requiring antibiotic modification based on culture sensitivities or empiric escalation to broader-spectrum agents (carbapenem or piperacillin-tazobactam). 1, 3

• Obtain CT imaging and surgical consultation to rule out secondary bacterial peritonitis (perforated viscus). 1, 4

• For patients who developed SBP while on quinolone prophylaxis, use cefotaxime or amoxicillin-clavulanic acid as alternatives. 1

Special Considerations

Culture-negative neutrocytic ascites (PMN >250/mm³ with negative culture) should be treated identically to culture-positive SBP, as both have similar morbidity and mortality. 1

Bacterascites (positive culture but PMN <250/mm³) requires clinical judgment:

• If symptomatic: treat as SBP 1
• If asymptomatic: repeat paracentesis, as 38% will progress to frank SBP 1

Prognosis

• SBP carries approximately 20% hospital mortality despite infection resolution. 1, 2, 4
• Early appropriate antibiotic treatment combined with albumin therapy significantly improves survival. 1, 2, 4
• Delaying antibiotic therapy increases mortality by 10% for every hour's delay in cirrhotic patients with septic shock. 1