⏰
Challenge: Can you get this right on your first read?
Clinical Vignette
A 45-year-old man presents with worsening abdominal pain and distension for 2 days. He has a history of cirrhosis from hepatitis C and alcohol use. He was recently hospitalized for ascites requiring paracentesis.
Current medications: spironolactone, furosemide, and propranolol.
On exam: temperature 38.6°C (101.5°F), BP 100/64 mmHg, HR 110/min. Abdomen is distended with shifting dullness and diffuse tenderness without rebound.
Ascitic fluid analysis:
Current medications: spironolactone, furosemide, and propranolol.
On exam: temperature 38.6°C (101.5°F), BP 100/64 mmHg, HR 110/min. Abdomen is distended with shifting dullness and diffuse tenderness without rebound.
Ascitic fluid analysis:
| WBC | 650/mm³ with 78% neutrophils |
| Protein | 0.8 g/dL |
| Albumin | 0.5 g/dL |
Which of the following is the most appropriate next step in management?
- A IV cefotaxime
- B IV metronidazole
- C IV vancomycin
- D Oral ciprofloxacin
- E Repeat paracentesis
Full explanation with high-yield teaching points
Explanation
This patient with cirrhosis has spontaneous bacterial peritonitis (SBP), diagnosed by an ascitic fluid neutrophil count ≥250/mm³. The standard empiric treatment is a third-generation cephalosporin such as cefotaxime.
Metronidazole and vancomycin do not provide adequate coverage against the enteric gram-negative organisms that typically cause SBP. Oral ciprofloxacin is used for SBP prophylaxis, not acute treatment. Repeat paracentesis is a diagnostic tool, not a therapeutic intervention.
Metronidazole and vancomycin do not provide adequate coverage against the enteric gram-negative organisms that typically cause SBP. Oral ciprofloxacin is used for SBP prophylaxis, not acute treatment. Repeat paracentesis is a diagnostic tool, not a therapeutic intervention.
💡 Further Insight
- Mortality from SBP is significant — early empiric antibiotics improve survival outcomes.
- Long-term antibiotic prophylaxis may be indicated to prevent recurrence in high-risk patients.
From MedBoardEducation
Want 790+ more questions like this?
Our Step 2 CK practice exams cover every high-yield topic with detailed explanations and performance tracking.
Explore Practice Exams →
Need help raising your score?
Talk with an experienced USMLE tutor for personalized guidance. We'll review your situation, identify what's holding you back, and give you a clear plan.
Schedule a Free Consultation →