From the Guidelines
A body fluid culture from a paracentesis with a neutrophil count of 68 cells/mm³ does not typically warrant antibiotic treatment by itself, as the diagnosis of Spontaneous Bacterial Peritonitis (SBP) is generally based on a neutrophil count in ascitic fluid of >250/mm³. The decision to start antibiotics should be based on the clinical picture and additional laboratory findings, as recommended by the EASL clinical practice guidelines for the management of patients with decompensated cirrhosis 1. According to these guidelines, a diagnostic paracentesis should be carried out in all patients with cirrhosis and ascites without delay at hospital admission to rule out SBP, and the diagnosis of SBP is based on neutrophil count in ascitic fluid of >250/mm³.
However, if the patient shows clinical signs of infection such as fever, abdominal pain, or altered mental status, or if other laboratory parameters suggest infection, empiric antibiotic therapy might be considered while awaiting culture results. In such cases, the guidelines suggest that patients with bacterascites (neutrophil count less than 250/mm³ but positive bacterial culture) exhibiting signs of systemic inflammation or infection should be treated with antibiotics 1. The choice of antibiotic should be guided by the culture results and the patient's clinical status, with consideration of the potential for antibiotic resistance.
Key considerations in the management of these patients include:
- Clinical signs of infection, such as fever, abdominal pain, or altered mental status
- Laboratory parameters, such as elevated serum white blood cell count or C-reactive protein
- Risk factors for infection, such as a history of SBP or other infections
- The results of the ascitic fluid culture, which can guide antibiotic therapy 1. The final decision to start antibiotics should be based on a comprehensive assessment of the patient's clinical status, rather than relying solely on the paracentesis neutrophil count.
From the Research
Body Fluid Culture Paracentesis and Antibiotic Administration
- The decision to administer antibiotics (abx) in the context of body fluid culture paracentesis, particularly in patients with ascites, depends on various factors including the presence of infection, the type of microorganism involved, and the patient's clinical condition 2, 3.
- Studies have shown that early paracentesis before antibiotic administration can reduce morbidity and mortality in patients with decompensated cirrhosis 2.
- The presence of spontaneous bacterial peritonitis (SBP), a common and serious complication of ascites, is an indication for antibiotic therapy, and paracentesis is crucial for its diagnosis 3.
- Procalcitonin levels have been investigated as a potential marker for infection and sepsis in patients with positive body fluid culture, and may aid in the decision to administer antibiotics 4.
Paracentesis and Antibiotic Prophylaxis
- The guidelines recommend performing diagnostic paracentesis in patients with new-onset ascites or with known ascites and any change in their condition, to characterize the ascitic fluid and detect infection 3.
- Hospitalized patients with low-protein ascites should receive antibiotic prophylaxis, and paracentesis can help identify those at risk 3.
- However, in asymptomatic outpatients with cirrhosis and ascites, the prevalence of spontaneous bacterial peritonitis and culture-negative neutrocytic ascites is low, and routine analysis of ascitic fluid at the time of therapeutic paracentesis may not be necessary 5.
Clinical Considerations
- The timing of paracentesis and antibiotic administration can be influenced by various factors, including the patient's admission time, with increased relative risk for performing paracentesis after antibiotic administration for patients admitted at night 2.
- Increased body mass index has been associated with decreased relative risk for paracentesis not being done, highlighting the importance of individualized patient care 2.