A 62-year-old man with decompensated cirrhosis due to alcohol use disorder and recurrent ascites is admitted to the ICU for acute variceal bleeding. He is intubated for airway protection and on a norepinephrine infusion to maintain his mean arterial pressure. He undergoes successful endoscopic variceal ligation. On hospital day 4, he develops a fever (38.5 °C), diffuse abdominal pain, and worsening encephalopathy. His white blood cell count is 16,000/mm3. A diagnostic paracentesis yields ascitic fluid with a polymorphonuclear leukocyte count of 450 cells/mm3. Which of the following is the MOST appropriate initial empiric antibiotic regimen?

A 62-year-old man with decompensated cirrhosis and refractory ascites presents with acute fever (38.8°C) and diffuse abdominal pain. Diagnostic paracentesis reveals ascitic fluid with a polymorphonuclear (PMN) count of 550 cells/mm³, consistent with spontaneous bacterial peritonitis (SBP). Which of the following pathophysiological mechanisms best explains the development of SBP in this patient?

A 62-year-old man with decompensated alcoholic cirrhosis is admitted to the medical ICU on a norepinephrine infusion for hypotension and requires mechanical ventilation. He develops new-onset fever (38.5 °C), diffuse abdominal pain, and increasing abdominal distension. Paracentesis performed in the emergency department reveals an ascitic fluid polymorphonuclear (PMN) leukocyte count of 350 cells/mm³. Which of the following is the most appropriate initial empirical antibiotic regimen?

A 62-year-old man with alcohol-related cirrhosis and recurrent ascites has been hospitalized in the medical ICU for 5 days for worsening hepatic encephalopathy. He is intubated on mechanical ventilation and has a central venous catheter. He has a history of spontaneous bacterial peritonitis (SBP) 3 weeks ago treated with ceftriaxone and is receiving secondary prophylaxis with oral norfloxacin. Today he develops a fever of 38.8°C and diffuse abdominal tenderness. Laboratory studies show a WBC count of 16,000/mm³. Diagnostic paracentesis reveals an ascitic fluid PMN count of 650 cells/mm³. Which of the following is the most appropriate initial empirical antibiotic regimen?

A 62-year-old man with alcohol-induced cirrhosis presents with tense, large-volume ascites, fever, and abdominal pain. Diagnostic paracentesis reveals an ascitic fluid polymorphonuclear (PMN) count of 1200 cells/mm³. His body weight is 70 kg, baseline serum creatinine is 1.0 mg/dL, and serum sodium is 128 mmol/L. According to current AASLD practice guidance, what is the most appropriate initial management strategy?

A 62-year-old man with decompensated cirrhosis and refractory ascites is admitted for fever and hypotension. He has a temperature of 38.5 °C, blood pressure of 90/55 mm Hg on norepinephrine 0.1 mcg/kg/min, heart rate of 110 beats/min, and diffuse abdominal tenderness. Laboratory values show serum creatinine 1.8 mg/dL (baseline 0.9 mg/dL), BUN 45 mg/dL, sodium 130 mEq/L, and albumin 2.1 g/dL. A diagnostic paracentesis reveals ascitic fluid polymorphonuclear leukocyte count of 450 cells/mm³. He has no recent healthcare exposure or antibiotic use. Which of the following is the most appropriate initial antibiotic regimen for this patient’s condition?

A 62-year-old man with decompensated cirrhosis and refractory ascites presents with new-onset fever (38.8°C), diffuse abdominal pain, and worsening encephalopathy. Diagnostic paracentesis reveals an ascitic fluid polymorphonuclear leukocyte count of 450 cells/mm³. His serum creatinine is 1.8 mg/dL (baseline 1.0 mg/dL) and total bilirubin is 4.5 mg/dL. Which of the following initial pharmacotherapy regimens is most appropriate for this patient?

A 62-year-old man with decompensated cirrhosis is admitted to the ICU for management of spontaneous bacterial peritonitis (SBP) and refractory ascites. On admission, his blood pressure is 100/60 mm Hg, heart rate 88 bpm, respiratory rate 18/min, temperature 38.1 °C. Over the past 8 hours, urine output has averaged 25 mL/hr. He is receiving IV cefotaxime, spironolactone 100 mg daily, and furosemide 40 mg daily. Baseline serum creatinine is 1.0 mg/dL and sodium 132 mmol/L. The initial diagnostic paracentesis showed 550 cells/mm³ polymorphonuclear leukocytes (PMNs). Which of the following monitoring plans should be prioritized over the next 48 hours to assess antibiotic efficacy and detect diuretic-related toxicities?

A 62-year-old man with decompensated cirrhosis and refractory ascites presents with fever and diffuse abdominal pain. He has no known drug allergies. A diagnostic paracentesis shows an ascitic fluid PMN leukocyte count of 450 cells/mm³, confirming spontaneous bacterial peritonitis (SBP). His serum creatinine is 1.8 mg/dL (baseline 0.9 mg/dL), BUN 35 mg/dL, and sodium 132 mEq/L. Which of the following antibiotic classes is the least appropriate choice for empirical treatment of SBP in this patient?

A 62-year-old man with a history of alcoholic cirrhosis and known ascites is admitted to the ICU. He is intubated and on mechanical ventilation for worsening hepatic encephalopathy. A low-dose norepinephrine infusion is running via a central venous catheter to maintain mean arterial pressure. A diagnostic paracentesis performed in the emergency department revealed an ascitic fluid polymorphonuclear (PMN) count of 450 cells/mm³. His current labs are sodium 132 mmol/L, potassium 4.1 mmol/L, and creatinine 1.2 mg/dL (baseline 0.9 mg/dL). Which of the following interventions is the highest priority?