What is the treatment for a potential complication (pme) in an adult patient with acute hepatitis?

Treatment of Polymorphonuclear (PMN) Elevation in Ascitic Fluid (Spontaneous Bacterial Peritonitis)

Initiate empiric antibiotic therapy immediately with a third-generation cephalosporin (cefotaxime 2 g IV every 8 hours) when ascitic fluid PMN count is ≥250 cells/mm³ in patients with cirrhosis and ascites, without waiting for culture results. 1

Diagnostic Threshold and Treatment Initiation

• The diagnostic threshold for spontaneous bacterial peritonitis (SBP) is an ascitic fluid PMN count ≥250 cells/mm³ (0.25 × 10⁹/L), revised from the previous threshold of 500 cells/mm³ 1
• The ascitic fluid PMN count is more rapidly available than culture results and accurately determines who requires empiric antibiotic treatment 1
• Delaying treatment until ascitic fluid cultures grow bacteria may result in death from overwhelming infection 1

Specific Clinical Scenarios Requiring Immediate Treatment

Treat empirically regardless of PMN count if the patient has:

• Fever 1
• Abdominal pain 1
• Unexplained clinical deterioration 1
• Unexplained encephalopathy 1

These symptoms indicate infection even before neutrophil response develops, and waiting for PMN elevation could be fatal 1

First-Line Antibiotic Regimen

Cefotaxime is the treatment of choice:

• Dose: 2 g intravenously every 8 hours 1
• Covers 95% of causative organisms including Escherichia coli, Klebsiella pneumoniae, and pneumococci 1
• Achieves excellent ascitic fluid levels (20-fold killing power after one dose) 1
• Superior to ampicillin plus tobramycin in controlled trials 1

Duration of treatment:

• 5 days of treatment is as efficacious as 10 days in carefully characterized SBP patients 1
• After sensitivities are known, narrow the spectrum of coverage 1

Alternative Antibiotic Options

Oral therapy (for selected patients only):

• Ofloxacin 400 mg orally twice daily for 8 days is as effective as parenteral cefotaxime 1
• Only appropriate for patients WITHOUT: 1
  • Vomiting
  • Shock
  • Grade II or higher hepatic encephalopathy
  • Serum creatinine ≥3 mg/dL
• Only 61% of SBP patients meet these inclusion criteria 1
• All treatment must be given in hospitalized patients 1

Ceftriaxone:

• 1 g intravenously twice daily for 5 days is effective for culture-negative neutrocytic ascites 1
• Note: Ceftriaxone is highly protein-bound, which may limit penetration into low-protein ascitic fluid 1

Important Clinical Considerations

Alcoholic hepatitis patients require special attention:

• These patients may have fever, leukocytosis, and abdominal pain that can masquerade as SBP 1
• They do NOT develop false-positive elevated ascitic fluid PMN counts due to peripheral leukocytosis 1
• An elevated PMN count must be presumed to represent SBP 1
• Empiric antibiotics can be discontinued after 48 hours if ascitic fluid, blood, and urine cultures show no bacterial growth 1

Changing bacterial flora:

• Widespread quinolone use for SBP prophylaxis has led to more gram-positive organisms and quinolone-resistant bacteria in recent years 1
• This makes third-generation cephalosporins even more important as first-line therapy 1

Bacterascites (Positive Culture, PMN <250 cells/mm³)

• 62% of patients with monomicrobial non-neutrocytic bacterascites resolve colonization spontaneously without antibiotics 1
• Treat patients with bacterascites who have signs or symptoms of infection (fever, abdominal pain, unexplained deterioration) regardless of PMN count 1
• Patients with bacterascites who progress to SBP have signs or symptoms of infection at the time of initial paracentesis 1

Common Pitfalls to Avoid

• Never delay antibiotic treatment while waiting for culture results - this can be fatal 1
• Do not use quinolones as first-line therapy given increasing resistance patterns 1
• Do not assume peripheral leukocytosis causes false-positive ascitic PMN elevation - it does not 1
• Do not withhold treatment in symptomatic patients with low PMN counts - they may have early infection 1