A 45-year old Caucasian male follows-up in your clinic and is under evaluation for liver transplantation for NASH associated cirrhosis. He comes in with his wife who reports that the patient is more confused over the last few days.
Vitals signs are: HR 74, BP 106/70 mm Hg, RR of 16 and SpO2 of 95% on room air. He cooperates during the physical examination, however he is very drowsy and it is hard to keep him fully awake. Lungs are clear to auscultation bilaterally, S1 S2 is normal and no murmurs, gallops or rubs are heard. Abdomen is soft and distended with no organomegaly, fluid thrill is palpable. 2+ pitting edema is noted bilaterally. Flapping tremors are noticed on outstretched hands.
Initial labs are as follows :
WBC count – 3.0 X 109/L Hemoglobin – 9.0 g/dL Platelet count – 90 X 109/L
Na – 128 Cl – 94 K – 4.0 CO2 – 26 BUN – 32 and Cr – 1.30
AST – 50 ALT – 36 INR – 2.1 S. bilirubin – 4.2 S. albumin – 2.0 Venous Lactate – 1.0.
Venous Ammonia – 110 umol/L . Blood cultures are drawn.
You decide to admit the patient. This is patient’s first hospitalization since being diagnosed with Cirrhosis. He had an EGD, a month ago that showed grade I varices. A paracentesis is performed after admission. The results of fluid analysis show:
Color : Yellow Clarity : Hazy Gram Stain : Negative
Total Nucleated Cells : 300/uL Neutrophils : 20% Lymphocytes : 60% Monocytes : 20%
Gram Stain : Negative Total Protein : 1.0 g/dl Albumin : < 0.5 g/dL
You initiate the patient on Lactulose and titrate it to 3-4 bowel movements a day. In addition, IV Ceftriaxone is started.
By day 2 the patient is more awake and alert and is oriented to time, place and person. Blood cultures come back negative and peritoneal fluid culture is negative. You decide to start working on discharge of the patient.
In addition to stressing upon compliance with Lactulose, which of the following would you consider at this point?
- Discontinue IV Ceftriaxone and no further antibiotics is necessary
- Discontinue IV Ceftriaxone and switch to oral Cephalosporin at discharge
- Discontinue IV Ceftriaxone and switch to Trimethoprim-Sulfamethoxazole at discharge
- Discontinue IV Ceftriaxone and switch to Amoxicillin-Clavulanate
- Continue IV Ceftriaxone for 7 days total
Answer: DC IV Ceftriaxone and start Bactrim PO
Antibiotic prophylaxis is recommended for patients at high risk for developing SBP rather than waiting for it to develop (Grade 1A).
In those that are high risk, antibiotic prophylaxis is associated with a decreased risk of bacterial infection and mortality.
Those that are high risk include:
– Cirrhosis and GI bleeding
– Patients with one more more episodes of SBP
– Patients with cirrhosis and ascites if the fluid protein is less than 1.5 g/dL along with either impaired kidney function or liver failure (crt≥1.2 mg/dL (106 micromol/L), a blood urea nitrogen level ≥25 mg/dL (8.9 mmol/L), or a serum sodium ≤130 mEq/L (130 mmol/L]).
– Liver failure is defined as a Child-Pugh score ≥9 and a bilirubin ≥3 mg/dL (51 micromol/L).