# Situation: A 62-year-old woman has cirrhosis caused by chronic hepatitis B. Endoscopy shows large esophageal varices that have never bled. She has moderate ascites and takes spironolactone, furosemide, and lactulose. Carvedilol has just been started. On day 6 she develops new abdominal tenderness, and a diagnostic paracentesis is repeated. Which ascitic fluid neutrophil count is the diagnostic threshold for spontaneous bacterial peritonitis (SBP)?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630395  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 62-year-old woman has cirrhosis caused by chronic hepatitis B. Endoscopy shows large esophageal varices that have never bled. She has moderate ascites and takes spironolactone, furosemide, and lactulose. Carvedilol has just been started.

On day 6 she develops new abdominal tenderness, and a diagnostic paracentesis is repeated. Which ascitic fluid neutrophil count is the diagnostic threshold for spontaneous bacterial peritonitis (SBP)?

## 보기

1. 250 cells/mm³ **✔ 정답**
2. 500 cells/mm³
3. 100 cells/mm³
4. 1,000 cells/mm³

**정답: 1**

## 해설

An ascitic neutrophil (polymorphonuclear) count of 250 cells/mm³ or more is diagnostic of spontaneous bacterial peritonitis, and treatment with an IV third-generation cephalosporin plus albumin starts without waiting for the culture. Fluid is also sent for culture in blood-culture bottles.

## 심화 해설

The diagnostic threshold
New abdominal tenderness in a client with cirrhosis and ascites raises concern for spontaneous bacterial peritonitis (SBP), an infection of ascitic fluid without an obvious surgical source. An ascitic neutrophil (polymorphonuclear) count of 250 cells/mm³ or more is diagnostic of SBP. Once this threshold is reached, treatment with an IV third-generation cephalosporin plus albumin starts without waiting for the culture result.

Why the threshold matters
Ascitic fluid cultures are often negative or slow to grow even when infection is present, so diagnosis relies on the neutrophil count. A threshold of 250 cells/mm³ balances sensitivity and specificity: it identifies most true infections early enough to start treatment, while not labeling too many uninfected clients as having SBP. Because untreated SBP can progress rapidly to sepsis and kidney failure, early empirical treatment is important. Fluid is also sent for culture, ideally inoculated into blood-culture bottles at the bedside, which improves the chance of growing the organism.

| Option | Problem |
| --- | --- |
| 250 cells/mm³ | Correct diagnostic threshold |
| 500 cells/mm³ | Too high; would delay treatment of many infections |
| 100 cells/mm³ | Too low; would label many uninfected clients as infected |
| 1,000 cells/mm³ | Far too high; many infected clients never reach it |

Treatment and nursing care
Treatment combines an IV third-generation cephalosporin with albumin, which reduces the risk of kidney injury in SBP. The nurse gives antibiotics promptly, monitors temperature, mental status, urine output, and kidney function, and watches for signs of sepsis or worsening hepatic encephalopathy. SBP can also present subtly, with only confusion, fever, or worsening kidney function, so the nurse reports any unexplained change in a client with ascites.

Recognizing SBP early
Classic signs include fever, abdominal pain or tenderness, and altered mental status, but some clients have few symptoms. Any client with cirrhosis and ascites who deteriorates without a clear reason should have a diagnostic paracentesis. That is why the procedure was repeated on day 6 in this case.

Exam takeaway
Key point Remember the number 250: an ascitic neutrophil count of 250 cells/mm³ or more diagnoses SBP and triggers immediate antibiotics plus albumin.

## 임상 시나리오

Diagnosing Spontaneous Bacterial PeritonitisThe ascitic neutrophil threshold
Spontaneous bacterial peritonitis is infection of ascitic fluid in cirrhosis. An ascitic neutrophil count of 250 cells/mm³ or more is diagnostic.

Treatment with an IV third-generation cephalosporin plus albumin begins without waiting for the culture. Fluid is sent for culture in blood-culture bottles to improve yield.

CautionSBP can present with only confusion, fever, or worsening kidney function. Report any unexplained deterioration in a client with ascites.

## 핵심 개념

- **Spontaneous bacterial peritonitis** — Infection of ascitic fluid without an evident intra-abdominal surgical source, common in cirrhosis.
- **Polymorphonuclear count** — The number of neutrophils in a fluid sample, used to diagnose infection.
- **Third-generation cephalosporin** — A broad-spectrum beta-lactam antibiotic class, such as cefotaxime or ceftriaxone.
- **Albumin infusion** — IV albumin given in SBP to reduce the risk of kidney injury.

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