When to intubate in GCS?

GCS ≤ 8 requires intubation for airway protection. The patient cannot protect their own airway at this level of consciousness. Motor score is the most prognostically important component.

What is the best initial fluid for sepsis resuscitation?

Lactated Ringer's (LR) is the preferred resuscitation fluid. The SMART trial (2018) showed balanced crystalloids reduced death, new renal failure, and persistent renal dysfunction compared to normal saline.

When to start vasopressors in septic shock?

Start norepinephrine (first-line vasopressor) if MAP remains < 65 mmHg after initial 30 mL/kg crystalloid resuscitation, or earlier if patient is profoundly hypotensive. Do not delay pressors to complete full fluid resuscitation.

Why can serum uric acid be normal during acute gout?

During acute inflammation, IL-6 increases renal urate excretion and redistributes urate from plasma to tissues. Up to 40% of acute gout flares have normal serum uric acid. Joint aspiration with polarized microscopy is needed for definitive diagnosis.

How do you distinguish lupus flare from infection in SLE?

Key clues: CRP is low/normal in flare but elevated in infection. Complement (C3/C4) drops in flare but is normal/elevated in infection. Procalcitonin is elevated in bacterial infection but normal in flare. Anti-dsDNA rises in flare, stable in infection.

What is the difference between DKA and HHS?

DKA features acidosis (pH 600), hyperosmolality (> 320), and minimal ketosis -typically in Type 2 DM. DKA requires insulin drip; HHS requires aggressive fluid resuscitation first.

When to give tPA in acute ischemic stroke?

IV alteplase (tPA) can be given within 4.5 hours of last known well time in eligible patients. CT head must rule out hemorrhage first. For large vessel occlusion, mechanical thrombectomy can be performed up to 24 hours with favorable imaging.

What antibiotics for community-acquired pneumonia?

Inpatient non-ICU: ceftriaxone + azithromycin. ICU: ceftriaxone + azithromycin (add vancomycin if MRSA risk). Outpatient healthy: amoxicillin. Outpatient with comorbidities: augmentin + azithromycin or respiratory fluoroquinolone. Duration: 5 days if clinically stable for 48 hours.

How to interpret iron studies?

Iron deficiency: low ferritin (< 30), high TIBC, low iron, low transferrin saturation (< 20%). Anemia of chronic disease: normal/high ferritin (acute phase reactant), low TIBC, low iron. A ferritin of 50-100 in an inflamed patient may still represent iron deficiency.

What is the correction rate for hyponatremia?

Correct sodium no more than 8 mEq/L in 24 hours to avoid osmotic demyelination syndrome (ODS). For symptomatic severe hyponatremia with seizures, give 3% hypertonic saline 100-150 mL bolus over 10-20 minutes. If overcorrected, use D5W + DDAVP rescue protocol.

When to start antibiotics in meningitis?

Within 30-60 minutes. Do NOT delay antibiotics for LP or CT. Draw blood cultures, start empiric antibiotics (vancomycin + ceftriaxone ± ampicillin if > 50 or immunocompromised), then perform LP when possible. Dexamethasone should be given before or with the first antibiotic dose.

DOACs vs warfarin in antiphospholipid syndrome?

DOACs are contraindicated in APS. The TRAPS trial (2018) showed rivaroxaban was inferior to warfarin with more thrombotic events in triple-positive APS patients. Warfarin with INR target 2-3 is the standard for APS, indefinitely.

How to manage scleroderma renal crisis?

ACE inhibitors (captopril) are life-saving -start immediately and titrate aggressively. Do NOT hold for rising creatinine. Steroids > 15 mg prednisone per day precipitate scleroderma renal crisis. ARBs are NOT a substitute -evidence is only for ACEi.

What are the 4 pillars of heart failure treatment?

Guideline-directed medical therapy (GDMT) for HFrEF: (1) ARNI or ACEi/ARB, (2) beta-blocker (carvedilol, metoprolol succinate, or bisoprolol), (3) MRA (spironolactone or eplerenone), (4) SGLT2 inhibitor (dapagliflozin or empagliflozin). All four should be initiated and titrated to target doses.

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EMERGENTGI

Spontaneous Bacterial Peritonitis

Ascitic fluid infection in cirrhosis. PMN ≥ 250/mm³ = SBP. Start antibiotics immediately -do not wait for cultures. Albumin on day 1 and day 3 prevents hepatorenal syndrome.

🚨 Management

Diagnostic Criteria

Ascitic fluid PMN ≥ 250 cells/mm³ = SBP. Start antibiotics immediately. Do NOT wait for culture results.

PMN ≥ 250/mm³ with positive culture = SBP
PMN ≥ 250/mm³ with negative culture = culture-negative neutrocytic ascites (CNNA) -treat the same as SBP
PMN < 250/mm³ with positive culture = bacterascites -repeat paracentesis in 48h. Treat if symptomatic or PMN rises.

SBP vs Secondary Peritonitis

Feature	SBP	Secondary Peritonitis (perforation)
Organisms	Monomicrobial (single enteric organism -E. coli, Klebsiella, strep)	Polymicrobial (multiple organisms including anaerobes)
Glucose	> 50 mg/dL	< 50 mg/dL
LDH	< serum LDH	> serum LDH
Protein	Low (< 1 g/dL)	Higher
Treatment	Antibiotics alone	Antibiotics + surgical source control (CT abdomen → OR)

Runyon's criteria for secondary peritonitis: if ascitic fluid shows ≥ 2 of (glucose < 50, LDH > ULN serum, protein > 1 g/dL) + polymicrobial gram stain → get CT abdomen to rule out perforation. This patient needs surgery, not just antibiotics.

Common Organisms

E. coli (~40%) -most common
Klebsiella pneumoniae (~10–15%)
Streptococcus pneumoniae (~10%)
Enterococcus (~5–10%)
Mechanism: bacterial translocation from gut lumen → mesenteric lymph nodes → bloodstream → ascitic fluid (which has impaired opsonization due to low complement/protein)

Treatment

Component	Regimen	Notes
Antibiotics IMMEDIATE	Ceftriaxone 2g IV daily × 5 days	Covers E. coli, Klebsiella, strep. If nosocomial SBP or recent FQ prophylaxis failure → broaden to piperacillin-tazobactam or meropenem (resistance is higher). Narrow based on culture + sensitivity.
Albumin CRITICAL	1.5 g/kg on day 1, then 1 g/kg on day 3	SBP Albumin Trial, 1999: albumin with antibiotics in SBP reduced HRS from 33% to 10% and mortality from 29% to 10%. One of the most impactful interventions in hepatology. Do not skip this.

Follow-Up & Response

Repeat paracentesis at 48h if no clinical improvement. PMN should decrease by ≥ 25%. If not → suspect resistant organism, secondary peritonitis, or wrong diagnosis.
Total duration: 5 days if culture-guided. 5–7 days empiric if culture-negative.
After first SBP episode → lifelong prophylaxis (see below)
Transplant evaluation -1-year survival after SBP is ~30–70%. SBP marks a critical inflection point.

SBP Prophylaxis

Indication	Regimen
Prior SBP episode (secondary prophylaxis)	Norfloxacin 400 mg daily (or ciprofloxacin 500 mg daily or TMP-SMX DS daily) -lifelong
Ascitic protein < 1.5 g/dL + advanced liver disease (Child-Pugh ≥ 9 with bilirubin ≥ 3 OR Cr ≥ 1.2 or Na ≤ 130 or BUN ≥ 25)	Norfloxacin 400 mg daily (or alternatives as above). Fernández, 2007: primary prophylaxis in high-risk patients reduced SBP incidence and improved survival.
Acute GI hemorrhage (all cirrhotics)	Ceftriaxone 1g IV daily × 7 days -reduces SBP, bacteremia, and mortality in acute variceal bleed Fernández, 2006.

🔄 Updated Practice: Old teaching: all cirrhotic patients with ascites need fluoroquinolone prophylaxis for SBP. Current practice: SBP prophylaxis is only recommended for (1) prior SBP episode (secondary prophylaxis -norfloxacin or TMP-SMX), (2) GI bleed in cirrhosis (ceftriaxone 1g IV × 7 days), or (3) ascitic fluid protein <1.5 g/dL with either Child-Pugh ≥9 or renal dysfunction. Indiscriminate FQ use drives resistance. Also: rifaximin (Xifaxan) may be an alternative for SBP prophylaxis -emerging evidence but not yet guideline-recommended.

📋 On Rounds

Why is albumin so important in SBP treatment?

SBP Albumin Trial, 1999: in the landmark RCT, adding albumin (1.5 g/kg day 1, 1 g/kg day 3) to ceftriaxone in SBP reduced renal impairment (HRS) from 33% to 10% and in-hospital mortality from 29% to 10%. The mechanism: SBP causes an inflammatory cascade → splanchnic vasodilation → effective hypovolemia → RAAS activation → renal vasoconstriction → HRS.

Why do you give albumin with antibiotics in SBP, and what's the dosing?

Albumin prevents hepatorenal syndrome (HRS), which is the leading cause of death in SBP -not the infection itself. The Sort trial SBP Albumin Trial, 1999 showed albumin 1.5 g/kg on day 1 + 1 g/kg on day 3 reduced renal failure from 33% to 10% and mortality from 29% to 10%. The mechanism: SBP causes massive cytokine release → splanchnic vasodilation → effective hypovolemia → renal hypoperfusion.

What are the criteria for SBP prophylaxis and what do you prescribe?

Primary prophylaxis (never had SBP): indicated if ascitic fluid protein < 1.5 g/dL + either (1) renal dysfunction (Cr > 1.2, BUN > 25, or Na < 130) or (2) liver failure (Child-Pugh ≥ 9 + bilirubin ≥ 3). Drug: norfloxacin 400 mg daily or TMP-SMX DS daily. Secondary prophylaxis (after first SBP episode): LIFELONG -norfloxacin 400 mg daily or TMP-SMX DS daily. Recurrence rate without prophylaxis is ~70% at 1 year.

Why is ceftriaxone preferred over fluoroquinolones for SBP treatment?

Rising fluoroquinolone resistance (many cirrhotic patients are on norfloxacin/cipro prophylaxis → resistant organisms). Ceftriaxone 2g IV daily has excellent activity against the common SBP pathogens (E. coli, Klebsiella, Strep) and is well-tolerated in liver disease. If the patient develops SBP while already on FQ prophylaxis, the organism is likely FQ-resistant → ceftriaxone or pip-tazo.

Clinical Examples

📋 Case 1, Classic SBP with Albumin Protocol

Patient: 56M with alcoholic cirrhosis (Child-Pugh C), large-volume ascites. Presents with fever 38.9°C, diffuse abdominal tenderness, worsening hepatic encephalopathy.

Key findings: Paracentesis: PMN 520/mm³ (≥ 250 = SBP). Gram stain: GNR. Ascitic fluid protein 0.8 g/dL. Cr 1.1 (baseline 0.9).

Management:

Ceftriaxone 2g IV daily × 5 days, start immediately once PMN ≥ 250
Albumin 1.5 g/kg on day 1 + 1 g/kg on day 3 SBP Albumin Trial, 1999
Repeat paracentesis at 48h, PMN should drop > 25%
Start norfloxacin 400 mg PO daily at discharge (lifelong secondary prophylaxis)

Teaching point: Albumin reduces HRS from 33% to 10% and mortality from 29% to 10%. This is one of the highest-impact interventions in hepatology, never skip the albumin.

📋 Case 2, Nosocomial SBP on FQ Prophylaxis

Patient: 63F with NASH cirrhosis, admitted for variceal bleed 5 days ago. On norfloxacin prophylaxis. New fever 38.4°C, increasing abdominal distension.

Key findings: Paracentesis: PMN 380. Gram stain: GPC in clusters. Already on FQ prophylaxis, likely resistant organism.

Management:

Piperacillin-tazobactam 4.5g IV q8h (broader coverage for nosocomial SBP)
Albumin protocol: 1.5 g/kg day 1, 1 g/kg day 3
If gram-positive organism confirmed, consider vancomycin
Repeat paracentesis at 48h to confirm response

Teaching point: Nosocomial SBP and SBP in patients on FQ prophylaxis have higher rates of resistant organisms (including MRSA and ESBL). Broaden empiric coverage to piperacillin-tazobactam or meropenem.

📋 Case 3, SBP vs Secondary Bacterial Peritonitis

Patient: 48M with cirrhosis, abdominal pain, fever. Paracentesis: PMN 1200, glucose 28 mg/dL, LDH 450 (above serum ULN), total protein 2.8 g/dL. Gram stain shows polymicrobial organisms.

Key findings: Runyon criteria for secondary peritonitis met: glucose < 50, LDH > ULN, protein > 1 g/dL, polymicrobial. This is NOT SBP, suspect bowel perforation.

Management:

Urgent CT abdomen with contrast to identify source (perforation, abscess)
Broad-spectrum antibiotics: meropenem + vancomycin
Surgical consultation for possible intervention
Continue albumin protocol while workup proceeds

Teaching point: Always check ascitic fluid glucose, LDH, and protein to differentiate SBP from secondary peritonitis. Polymicrobial gram stain, glucose < 50, LDH > ULN, and protein > 1 g/dL suggest secondary peritonitis requiring CT and surgical evaluation.

📣 Sample Presentation

One-Liner

"Mr. DeSilva is a 52-year-old with cirrhosis and ascites presenting with fever 38.6°C, diffuse abdominal pain, and worsening confusion. Paracentesis: PMN 680. Consistent with SBP."

Key Points to Cover on Rounds

PMN 680 (>250 = SBP). Gram stain: GNR (likely E. coli). Culture pending. Antibiotics: ceftriaxone 2g IV daily started within 1 hour. Albumin protocol: 1.5 g/kg (112g) on day 1, 1 g/kg (75g) on day 3 to prevent HRS SBP Albumin Trial, 1999. Repeat paracentesis at 48h planned (PMN should drop >25%). Mental status improving with lactulose (SBP was the precipitant for HE). Plan: 5-day antibiotic course, start norfloxacin prophylaxis at discharge.

Monitoring Parameters -Spontaneous Bacterial Peritonitis

Parameter	Frequency	Target / Action
Repeat paracentesis	At 48 hours	PMN should drop > 25% from baseline. If not improving → suspect resistant organism, secondary peritonitis, or wrong diagnosis. Broaden antibiotics and get CT abdomen.
BMP / Creatinine	Daily	HRS surveillance. Rising Cr despite albumin = hepatorenal syndrome → urgent nephrology + hepatology consult. Cr is the most important lab to trend.
Urine output	Strict I&Os	UOP < 0.5 mL/kg/hr or declining → early sign of HRS. Correlate with Cr trend.
Mental status	q4–8h	HE surveillance -SBP is the most common precipitant of hepatic encephalopathy. Worsening confusion → start/escalate lactulose.
Blood cultures	At diagnosis, repeat if persistent fever	Guide antibiotic narrowing once sensitivity data available.
Vitals	q4h	Fever curve, hemodynamics. Persistent fever > 72h on appropriate antibiotics → reconsider diagnosis.

The 48-hour paracentesis is critical. If PMN count is not dropping > 25%, you need to reconsider: resistant organism (broaden coverage), secondary peritonitis (get CT), or bacterascites that resolved on its own.

🧪 Workup

Diagnostic Evaluation -Spontaneous Bacterial Peritonitis

Diagnostic paracentesis is mandatory in any cirrhotic with ascites presenting with fever, abdominal pain, AMS, or worsening clinical status. Tap first, then start antibiotics.

Diagnostic paracentesis: Cell count with differential (PMN ≥ 250/mm³ = SBP), gram stain, culture (inoculate blood culture bottles at bedside), albumin, total protein
Ascitic fluid glucose, LDH, protein: If secondary peritonitis suspected (polymicrobial, glucose < 50, LDH > ULN, protein > 1 g/dL → CT abdomen)
Blood cultures: Before antibiotics -bacteremia common in SBP
BMP/Cr: Baseline renal function -HRS surveillance
CBC, LFTs, INR, lactate: Assess severity, liver function, sepsis

💊 Medications

Key Medications -Spontaneous Bacterial Peritonitis

Drug	Dose	Duration	Notes
Ceftriaxone (Rocephin) 1ST LINE	2g IV daily	5 days	Covers E. coli, Klebsiella, Strep. Start immediately once PMN ≥ 250. If nosocomial SBP or FQ prophylaxis failure → broaden to piperacillin-tazobactam or meropenem.
Albumin CRITICAL	1.5 g/kg on day 1 + 1 g/kg on day 3	2 doses	Reduces HRS from 33% to 10% and mortality from 29% to 10% SBP Albumin Trial, 1999. Do NOT skip this -one of the highest-impact interventions in hepatology.
PROPHYLAXIS (after acute treatment)
Norfloxacin	400 mg PO daily	Lifelong (secondary prophylaxis)	First-line for secondary prophylaxis after first SBP episode. Also for primary prophylaxis if ascitic protein < 1.5 g/dL with renal/liver dysfunction.
TMP-SMX DS	1 DS tablet PO daily	Lifelong	Alternative to norfloxacin for secondary prophylaxis. Equally effective.
Ceftriaxone (Rocephin)	1g IV daily	7 days	Acute GI hemorrhage prophylaxis in all cirrhotics -reduces SBP, bacteremia, and mortality during variceal bleed.

Primary prophylaxis criteria: ascitic fluid protein < 1.5 g/dL PLUS either Child-Pugh ≥ 9 with bilirubin ≥ 3, OR renal dysfunction (Cr ≥ 1.2, Na ≤ 130, BUN ≥ 25).

⚡ Summary

Summary

Diagnosis

Ascitic fluid PMN ≥ 250/mm³. Do NOT wait for culture. Paracentesis is the test -do it in every cirrhotic with AMS, fever, or pain.

Treatment

Ceftriaxone 2g IV daily × 5 days. Albumin: 1.5 g/kg day 1 + 1 g/kg day 3 (prevents hepatorenal syndrome) SBP Albumin Trial, 1999.

Repeat LP

At 48h: PMN should drop > 25%. If not → broaden abx, consider secondary peritonitis (surgical abdomen).

Prophylaxis

Secondary: norfloxacin or TMP-SMX daily (lifelong). Primary: if ascitic protein < 1.5 + renal/liver dysfunction.

Triggers

GI bleed, UTI, line infection, constipation. Often no identifiable source -spontaneous translocation from gut.

Prognosis

1-year mortality ~30-50% after first SBP episode. Start transplant evaluation immediately.

📄 One Pager

Spontaneous Bacterial Peritonitis -Quick Reference Card

Print this page (Ctrl/Cmd + P) for a condensed reference card. All tabs will print on the same page for a complete topic summary.

SPONTANEOUS BACTERIAL PERITONITIS -AT A GLANCE

📋 Diagnose: See Overview tab for criteria
🧪 Workup: Focused labs + imaging → see Workup tab
⚡ Treat: Evidence-based algorithm → see Management tab
💊 Drugs: Key medications with dosing → see Medications tab
📣 Present: One-liner + key points → see Rounds tab

📄 One Pager

GI / Hepatology · One Pager

Spontaneous Bacterial Peritonitis

PMN ≥ 250 on paracentesis. Ceftriaxone + albumin (1.5g/kg day 1 + 1g/kg day 3). Lifelong secondary prophylaxis. Start transplant eval.

🧪 Diagnosis

Ascitic fluid PMN ≥ 250/mm³. Do paracentesis in every cirrhotic with fever, AMS, abdominal pain, or clinical deterioration. Don't wait for culture.

🚨 Treatment

Ceftriaxone 2g IV daily × 5 days. Albumin 1.5g/kg day 1 + 1g/kg day 3 (prevents HRS) SBP Albumin Trial, 1999. Repeat paracentesis at 48h (PMN should drop > 25%).

💊 Prophylaxis

Secondary (after first SBP): norfloxacin 400 mg or TMP-SMX DS daily -LIFELONG. Primary: if ascitic protein < 1.5 + renal/liver dysfunction. GI bleed: ceftriaxone × 7 days.

💊 Key Drugs

Ceftriaxone2g IV daily × 5d

Albumin1.5g/kg D1 + 1g/kg D3

Norfloxacin400 mg daily (prophylaxis)

TMP-SMX DS1 tab daily (alternative)

⚠️ Pitfalls

Not doing paracentesis (the test IS the diagnosis)
Forgetting albumin (prevents HRS -mortality benefit)
Not starting lifelong secondary prophylaxis
Missing secondary peritonitis (surgical abdomen, multiple organisms)