A 55-year-old man is evaluated in the hospital for new-onset ascites. He has a history of cirrhosis due to hepatitis C viral infection. His only medication is propranolol.
On physical examination, pulse rate is 58/min; other vital signs are normal. The abdomen is soft and distended consistent with ascites.
Laboratory studies show a serum albumin level of 2.5 g/dL (25 g/L), serum total bilirubin level of 3.6 mg/dL (61.6 µmol/L), and serum creatinine level of 1.4 mg/dL (123.8 µmol/L).
Paracentesis with analysis of ascitic fluid shows a leukocyte count of 200/µL with 30% neutrophils, albumin level of 0.4 g/dL (4 g/L), and total protein level of 0.9 g/dL (9 g/L).
Which of the following is the most appropriate next step in management?
A. Increase propranolol therapy
B. Initiate albumin infusion
C. Initiate ciprofloxacin therapy
D. Initiate lisinopril therapy
MKSAP Answer and Critique
The correct answer is C. Initiate ciprofloxacin therapy. This item is available to MKSAP 18 subscribers as item 27 in the Gastroenterology & Hepatology section. More information about MKSAP is available online.
Initiation of indefinite primary prophylaxis with ciprofloxacin is the most appropriate next step in the management of this patient with ascites. Patients with ascites are at risk for developing spontaneous bacterial peritonitis (SBP), a common infection in patients with cirrhosis. SBP has a mortality rate of 20%. Long-term primary antibiotic prophylaxis may reduce mortality in patients at high risk for SBP. Criteria for patients at high risk include an ascitic-fluid total protein level less than 1.5 g/dL (15 g/L) in conjunction with any of the following: serum sodium level less than or equal to 130 mEq/L (130 mmol/L), serum creatinine level greater than or equal to 1.2 mg/dL (106.1 µmol/L), blood urea nitrogen level greater than or equal to 25 mg/dL (8.9 mmol/L), serum bilirubin level greater than or equal to 3 mg/dL (51.3 µmol/L), or Child-Turcotte-Pugh class B or C cirrhosis. Patients who have had a bout of SBP should also receive lifelong antibiotic prophylaxis to reduce the risk for recurrence. In the setting of variceal hemorrhage, a limited 7-day course of antibiotics initiated at the time of bleeding is indicated to prevent infectious complications from intestinal bacterial translocation.
Increasing this patient's propranolol is not indicated because, although beta-blocker therapy can reduce the risk for variceal bleeding, the patient already has a pulse rate of less than 60/min. Nonselective beta-blockers such as propranolol may be associated with higher transplant-free survival in patients with cirrhosis overall but may decrease transplant-free survival in the first 6 months after SBP or in patients with refractory ascites, and discontinuation should be considered at that time.
Albumin infusion may decrease the frequency of hepatorenal syndrome and improves survival in patients with SBP, but its role in primary prevention of SBP is undefined and its use for primary prevention not recommended.
Systemic blood pressure decreases in patients with decompensated cirrhosis resulting in reductions in renal perfusion and glomerular filtration rate. This leads to elevated levels of vasopressin, angiotensin, and aldosterone. ACE inhibitors, such as lisinopril, and angiotensin receptor blockers impair these compensatory efforts to maintain blood pressure and can worsen kidney perfusion in the setting of ascites due to portal hypertension; therefore, initiating lisinopril is inappropriate in this patient.
- Primary prophylactic antibiotic therapy is indicated for patients at high risk for the development of spontaneous bacterial peritonitis, including patients with very low ascitic-fluid protein levels and those with advanced liver failure.