A 58-year-old man with a history of decompensated alcoholic cirrhosis is evaluated in the … — USMLE Step 3

A 58-year-old man with a history of decompensated alcoholic cirrhosis is evaluated in the emergency department for worsening abdominal distension, fever, and confusion over the past 24 hours. His current outpatient medications include propranolol, spironolactone, furosemide, and lactulose. His temperature is $38.1^\circ\text{C}$ ( $100.6^\circ\text{F}$ ), blood pressure is $92/58\text{ mmHg}$ , and heart rate is $108/\text{min}$ . Physical examination reveals a lethargic man with a distended, diffusely tender abdomen, shifting dullness, and mild asterixis. Laboratory studies show:

Laboratory Test	Result
Leukocyte count	$12,500/\text{mm}^3$
Total bilirubin	$4.5\text{ mg/dL}$
Blood urea nitrogen	$38\text{ mg/dL}$
Serum creatinine	$1.9\text{ mg/dL}$ (baseline $1.0\text{ mg/dL}$ )

Diagnostic paracentesis yields cloudy fluid with a nucleated cell count of $600/\text{mm}^3$ and $80\%$ polymorphonuclear leukocytes.

Which of the following pharmacologic interventions are appropriate for this patient's acute management? (Select all that apply.)

Initiate intravenous ceftriaxoneAnswer
Administer intravenous albuminAnswer
Discontinue home propranololAnswer
D
Continue home spironolactone and furosemide
E
Initiate intravenous vancomycin

Answer

The appropriate pharmacologic interventions are initiating intravenous ceftriaxone, administering intravenous albumin, and discontinuing home propranolol.

The patient has spontaneous bacterial peritonitis (SBP), diagnosed by an ascitic fluid absolute neutrophil count

\geq 250/\text{mm}^3

(in this case,

600 \times 0.80 = 480/\text{mm}^3

). The standard of care includes empiric coverage with a third-generation cephalosporin, such as intravenous ceftriaxone. Because the patient also has acute kidney injury (creatinine

> 1.0\text{ mg/dL}

) and significant hyperbilirubinemia, intravenous albumin is strongly indicated to prevent hepatorenal syndrome and reduce mortality. Furthermore, nonselective beta-blockers (like propranolol) should be discontinued in patients with cirrhosis who develop SBP, severe sepsis, or acute kidney injury due to the high risk of hemodynamic collapse.

Step-by-Step Solution

Calculate the ascitic fluid absolute neutrophil count (ANC).

The ANC is

480/\text{mm}^3

(

600 \times 0.80

), confirming the diagnosis of spontaneous bacterial peritonitis (SBP).

An ANC

\geq 250/\text{mm}^3

establishes the diagnosis of SBP and warrants immediate empiric treatment.

Identify appropriate empiric antimicrobial therapy.

Intravenous ceftriaxone is selected.

Third-generation cephalosporins provide excellent coverage against the most common enteric pathogens responsible for community-acquired SBP.

Assess indications for adjunctive intravenous albumin.

Intravenous albumin is indicated.

The patient's elevated serum creatinine (

1.9\text{ mg/dL}

) and bilirubin (

4.5\text{ mg/dL}

) meet established criteria for albumin administration to prevent hepatorenal syndrome.

Evaluate current outpatient medications for safety in the setting of acute decompensation.

Home propranolol and diuretics (spironolactone, furosemide) must be discontinued.

In the setting of SBP and acute kidney injury, nonselective beta-blockers and diuretics are contraindicated due to the high risk of exacerbating circulatory dysfunction and worsening renal perfusion.

Key Concept

Patients with spontaneous bacterial peritonitis complicated by acute kidney injury require empiric third-generation cephalosporins, intravenous albumin to prevent hepatorenal syndrome, and the immediate discontinuation of antihypertensive and diuretic therapies (e.g., nonselective beta-blockers, spironolactone).

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