Terlipressin and albumin combination treatment in hepatorenal syndrome

OBJECTIVES

Hepatorenal syndrome (HRS) is a severe complication of cirrhosis, leading to death in nearly all of cases in the absence of liver transplantation. Several treatments have been attempted as a bridge to liver transplantation. Promising results have been shown with terlipressin and albumin treatment. The aim of this retrospective study was to evaluate our patients with HRS and the effects of combined therapy of terlipressin and albumin on survival.

PATIENTS AND METHODS

Twenty two patients (15 with type 1 HRS and 7 with type 2 HRS) who were admitted to our clinic between 1996 and 2001, were enrolled. All 7 pts with type 1 HRS were given terlipressin 2-4 mg/day and albumin 2 x 20 g/day for 6 days (range: 3-14).

RESULTS

Rate of mortality in hospital was 64% in total group, 80% in type 1 and 29% in type 2. Additionally rate of death was 57% in type 1 patients that received terlipressin+albumin and 100% in unreceived ones (p<0.05).

CONCLUSION

In this retrospective study, survival following improvement in renal function was noted in nearly half (43%) of type 1 patients that received terlipressin+albumin. Parameters associated with response to terlipressin+albumin and increased survival should be defined better in a large cohort of cirrhotic patients with HRS.

Cyclosporin for severe ulcerative colitis attacks

BACKGROUND/AIMS

Cyclosporin-A is used as alternative medical therapy in steroid refractory ulcerative colitis with severe activity. In spite of known effectivity, the long term results of cyclosporin-A therapy is not clear for today.

METHODS

The results of 13 steroid refractory patients that treated with cyclosporin-A were retrospectively assessed. Cyclosporin-A was started as orally, 8 mg/kg/day in 4 patients and intravenously, 4 mg/kg/day in 9 patients. Intravenous therapy changed to oral therapy one week after beginning. Patients also received 5-ASA and azathioprine. Steroid was tapered.

RESULTS

Ten patients responded to treatment in a mean of 9 days (range: 2-30 days). Three unresponded patients underwent total colectomy on 7, 11 and 19th day of therapy. Ten initially responded patients received the drug for average 4.9 months. Of these, four relapsed during and one relapsed soon after therapy. Four of 5 relapser patients underwent colectomy. One patient that not accepted surgical intervention is still receiving medical therapy. Remaining 5 patients, 38% of total group; 50% of patients that initially responded, maintain the remission at the end of average 17 months of follow up period.

CONCLUSION

Cyclosporin-A therapy in severe ulcerative colitis that is refractory to steroids, provides initial remission in 80% of patients and allows 40% to retain their colon for 1 year.

Crohn's disease; analysis of 105 patients

In this paper, 105 patients with Crohn's disease, (47 M, 58 F), mean age 37.4 +/- 42 years were evaluated clinically, demographically and epidemiologically. Mean age of patients at the time of diagnosis was 26.5 +/- 10.9 years. Follow-up period was 2.7 +/- 2.1 years on average. On admission, symptoms or signs were as follows: right lower quadrant pain 90.5%, abdominal mass 18.1%, enterocutaneous fistula 11.4% and subileus 9.5%. Diagnosis of Crohn's disease was established during appendectomy in 14 patients (13.3%). Family history of inflammatory bowel disease was determined only in six patients (5.7%). Intestinal localization were as follows: ileo colonic 52%, ileal 38%, colonic 10%. Clinical forms were inflammatory (68%), fistulous (23%) and obstructive (9%). Sacroiliitis (7.6%), ankylosing spondylitis (4.7%), erythema nodosum (2.9%), pyoderma gangrenosum (1%) were detected as extraintestinal manifestations. Of the patients, 12.4% underwent surgical intervention due to abscess drainage in 6.6%, fistulectomy in 3.8%, stricture resection in 1.9%. Medical therapy alone was sufficient in 75.3% of patients. As a result, our cases mentioned in this paper reflect the general characteristics of Crohn's disease and prominence of regular visits and treatment.

Adrenomedullin in cirrhotic and non-cirrhotic portal hypertension

AIM: Adrenomedullin (ADM) is a potent vasodilator peptide. ADM and nitric oxide (NO) are produced in vascular endothelial cells. Increased ADM level has been linked to hyperdynamic circulation and arterial vasodilatation in cirrhotic portal hypertension (CPH). The role of ADM in non-cirrhotic portal hypertension (NCPH) is unknown. plasma ADM levels were studied in patients with NCPH, compensated and decompensated cirrhosis in order to determine its contribution to portal hypertension (PH) in these groups.

METHODS: There were 4 groups of subjects. Group 1 consisted of 27 patients (F/M: 12/15) with NCPH due to portal and/or splenic vein thrombosis (mean age: 41 ± 12 years), group 2 consisted of 14 patients (F/M: 6/8) with compensated (Child-Pugh A) cirrhosis (mean age: 46 ± 4), group 3 consisted of 16 patients (F/M: 6/10) with decompensated (Child-Pugh C) cirrhosis (mean age: 47 ± 12). Fourteen healthy subjects (F/M: 6/8) (mean age: 44 ± 8) were used as controls in Group 4. ADM level was measured by ELISA. NO was determined as nitrite/nitrate level by chemoluminescence.

RESULTS: ADM level in Group 1 (236 ± 61.4 pg/mL) was significantly higher than that in group 2 (108.4 ± 28.3 pg/mL) and group 4 (84.1 ± 31.5 pg/mL) (both P < 0.0001) but was lower than that in Group3 (324 ± 93.7 pg/mL) (P = 0.002). NO level in group 1 (27 ± 1.4 μmol/L) was significantly higher than that in group 2 (19.8 ± 2.8 μmol/L) and group 4 (16.9 ± 1.6 μmol/L) but was lower than that in Group 3 (39 ± 3.6 μmol/L) (for all three P < 0.0001). A strong correlation was observed between ADM and NO levels (r = 0.827, P < 0.0001).

CONCLUSION: Adrenomedullin and NO levels were high in both non-cirrhotic and cirrhotic portal hypertension and were closely correlated, Adrenomedullin and NO levels increased proportionally with the severity of cirrhosis, and were significantly higher than those in patients with NCPH. Portal hypertension plays an important role in the increase of ADM and NO. Parenchymal damage in cirrhosis may contribute to the increase in these parameters.

Clinical outcome of Crohn's disease treated with infliximab

BACKGROUND/AIMS

Controlled studies in humans have shown the role of antibodies to tumor necrosis factor-alpha in the treatment of both fistulizing and inflammatory Crohn's disease. The aim of this study is to report the results of a multicenter clinical trial to evaluate efficacy of infliximab in Crohn's disease patients who are refractory to conservative drugs or fistulizing Crohn's disease.

METHODOLOGY

This trial was carried out at 5 university and community hospitals, in Turkey. A total of 25 patients with Crohn's disease that were unresponsive to conventional medical therapy, participated; 17 of the 25 were in the fistulizing disease group and 8 were in the inflammatory disease group. Clinical response was classified according to fistula drainage, diarrhea as positive response or no response.

RESULTS

Overall response rate was 92% (23/25), regardless of the disease group, after first infusion of infliximab. Sixteen out of 17 patients in the fistulizing disease group had a positive response. Fourteen of the 16 positive responders later relapsed. Median duration of response was 8 weeks (range, 2-35 wk). Active inflammatory disease patients had a positive response rate of 75% (6/8) and two of the patients were nonresponders. A further two patients relapsed at week 14. Two patients in both arms of the study were still in remission at the end of the study. Major adverse events were: pneumonia in one patient, skin infections in two patients, pulmonary thromboembolism and death in one patient.

CONCLUSIONS

Infliximab treatment seems to be more effective in Crohn's disease patients especially in those with fistulizing disease than those with non-fistulizing, inflammatory disease. It is evident that maintenance of remission might be achieved with ongoing maintenance therapy. We suggest maintenance of infliximab therapy.

Occult HBV infection and YMDD variants in hemodialysis patients with chronic HCV infection

BACKGROUND/AIMS

End-stage renal disease patients on chronic hemodialysis are at risk for both hepatitis B virus (HBV) and hepatitis C virus (HCV) infection. Although the prevalence is unknown in hemodialysis patients, occult HBV infection is frequent in subjects with chronic HCV infection. We aimed to investigate (1) the prevalence and clinical impact of occult HBV infection in hemodialysis patients with chronic HCV infection, and (2) the frequency of YMDD variants (tyrosine-methionine-aspartate-aspartate amino acid motif of HBV polymerase) in this setting.

METHODS

Thirty-three anti-HCV and HCV-RNA-positive, HBsAg-negative hemodialysis patients (mean age 36.9+/-10.4 years, 22 male) were admitted to this study. HBV-DNA (Innogenetics kit) and HCV-RNA (Cobas Amplicor HCV kit) were investigated by polymerase chain reaction technique (PCR). YMDD mutation was studied in all HBV-DNA-positive patients by the BOOM method.

RESULTS

HBV-DNA was detected in 12 of 33 patients (36.4%) by PCR. Their mean age was 33.0+/-9.0 years. Age, dialysis period (years) and biochemical parameters were not significantly different in patients with and without occult HBV infection. YMDD variants were identified in six of 12 (50%) patients with occult HBV infection.

CONCLUSIONS

Occult HBV infection is frequent in hemodialysis patients with chronic HCV infection. YMDD variants are common in this setting.

Hepatopulmonary syndrome in noncirrhotic portal hypertensive patients

Hepatopulmonary syndrome has yet not been sufficiently assessed in noncirrhotic portal hypertension. The prevalence of hepatopulmonary syndrome was determined in 31 consecutive patients with noncirrhotic portal hypertension (19 idiopathic portal hypertension, 7 portal vein thrombosis, 5 congenital hepatic fibrosis) and 46 patients with liver cirrhosis. Contrast echocardiography was carried out in all patients. Macroaggregated albumin lung perfusion scans were performed in patients with positive contrast echocardiogram. Hepatopulmonary syndrome was detected in 5 (10.8%) cirrhotic and 3 (9.7%) noncirrhotic portal hypertensive patients (2 idiopathic portal hypertension, 1 portal vein thrombosis). All patients with hepatopulmonary syndrome had an increased shunt fraction (13-62%) and a decreased diffusion capacity of carbon monoxide (40-79%), and 7 of them were hypoxemic (PaO2, 31.6-69.8 mm Hg). These findings show that hepatopulmonary syndrome may occur in both liver cirrhosis and noncirrhotic portal hypertension and that portal hypertension is the predominant etiopathogenic factor related to hepatopulmonary syndrome.

Intestinal metaplasia of the gastric cardia: a study from Turkey

BACKGROUND/AIMS

We aimed to investigate the prevalence of intestinal metaplasia in the cardia of a patient group with high incidence of Helicobacter pylori infection presenting for elective upper endoscopy. We also re-evaluated the relation between intestinal metaplasia in the cardia and gastroesophageal reflux disease, smoking, alcohol history, H. pylori infection, Barrett's esophagus and intestinal metaplasia elsewhere in the stomach.

METHODOLOGY

Sixty patients presenting for elective upper endoscopy were included in this study. Prior to undergoing endoscopy each patient was questioned with regard to the clinical indication and symptoms including heartburn, regurgitation, and dysphagia. In addition, a smoking and alcohol history were recorded. Endoscopic biopsies: 1) one from the midantrum on the lesser curvature, 2) one from the incisura angularis, 3) one from the mid-corpus on the lesser curvature, 4) one from the columnar side of the squamocolumnar junction, 5) one from the squamous side of the squamocolumnar junction, 6) one from 2 cm distal to the esophagogastric junction, 7) one from across the squamocolumnar junction. Slides were stained using a combination of hematoxylin-eosin with Alcian blue at pH 2.5 for intestinal metaplasia. Each specimen was examined for the presence of H. pylori.

RESULTS

The prevalence of H. pylori infection was 63%. Prevalence of the H. pylori infection was significantly lower in the patients with intestinal metaplasia of the cardia than in the patients without intestinal metaplasia of the cardia (P = 0.025). There was a positive correlation between the age of the patients and having intestinal metaplasia of the cardia (r = 0.286, P = 0.008). There was no relationship between intestinal metaplasia of the cardia and pyrozis, regurgitation, dysphagia, history of alcohol and smoking esophagitis determined by endoscopy or histopathology, sex, intestinal metaplasia elsewhere in the stomach (P > 0.05).

CONCLUSIONS

The incidence of the intestinal metaplasia of the gastric cardia in Turkey is less than that of western countries. Intestinal metaplasia of the gastric cardia negatively correlates with H. pylori infection. And there was no relationship between gastric cardia intestinal metaplasia and reflux disease. Further investigations are needed for determining the premalign lesion and etiologic factors for cancer of the gastric cardia.

Helicobacter pylori eradication lowers esophageal sphincter pressures in functional dyspepsia patients

BACKGROUND/AIMS

Helicobacter pylori infection is the most common cause of gastroduodenal diseases. The role H. pylori eradication in functional dyspepsia patients is contradictory. We performed this study to determine the effects of H. pylori eradication in functional dyspepsia patients with respect to physiological and histological parameters including esophageal sphincter functions.

METHODOLOGY

We studied 20 functional dyspepsia patients, whose H. pylori infection was confirmed by histology and urease test. We also confirmed eradication using the same methods after three months. We performed 24-hour esophageal pH monitoring, esophageal manometry, meal stimulated gastrin release test and measured dyspepsia severity score and gastric emptying time before and three months after eradication. Eradication regimen consisted of omeprazol 20 mg b.i.d., clarithromycin 500 mg b.i.d. and metranidazol 500 mg b.i.d., for two weeks. Gastric inflammation and H. pylori density within biopsy samples from the antrum (n = 4), corpus (n = 4), cardia (n = 2), fundus (n = 2), duodenum (n = 2) and distal esophagus (n = 1) were assessed.

RESULTS

Dyspepsia severity score (P < 0.001), meal stimulated gastrin levels, upper (P = 0.01) and lower (P = 0.06) sphincter pressures were decreased after eradication irrespective of gastric histology; but gastric emptying times (P = 0.87) and pH < 4.5% reflux (P = 0.91) were not changed significantly.

CONCLUSIONS

H. pylori eradication results in decreased esophageal sphincter pressures irrespective of gastric histology in functional dyspepsia patients. These decreases are not associated with increased objective reflux or reflux symptomatology. The clinical significance of these finding deserves further evaluations.

Persistently normal alanine transaminase levels in chronic C hepatitis: what does it tell us?

BACKGROUND/AIMS

We evaluated the demographic, clinical, histological and serological characteristics of chronic hepatitis C infection with persistently normal serum alanine transaminase levels and compared the results with those obtained in a group of chronic hepatitis C infection with serum alanine transaminase levels above normal.

METHODOLOGY

Twenty-one patients who had chronic hepatitis C infection with normal alanine transaminase during the follow-up period and 34 patients who had chronic C infection with serum alanine transaminase levels above normal were included in this study. Demographic, clinical, histological and serological parameters of these two groups were evaluated.

RESULTS

There were no significant differences in age, gender, known route of infection, viral load and genotype distribution between the two groups (P > 0.05). The gamma-glutamyltransferase and gamma-globulin levels were significantly higher in the serum alanine transaminase levels above normal group (P < 0.01 and P < 0.05). Among the patients with normal alanine transaminase, liver biopsy findings were normal in eight patients (38%). None of the patients with serum alanine transaminase levels above normal had normal liver biopsy findings. Histologic activity index was significantly higher in serum alanine transaminase levels above normal group (9.7 +/- 2.2 vs. 6.4 +/- 1.9; P < 0.001). Histologic activity index and alanine transaminase levels correlate with the stage of the disease (P < 0.05).

CONCLUSIONS

For a definite diagnosis in patients with HCV-RNA+ and normal alanine transaminase liver biopsy is necessary and significant liver disease may be present in such patients irrespective of viral load, genotype and alanine transaminase levels.

Solitary pancreatic tuberculosis in immunocompetent patients mimicking pancreatic carcinoma

In this study, two cases of biopsy-proven pancreatic tuberculosis are reported. The patients presented with fever, anorexia, fatigue, abdominal pain and weight loss. A differential diagnosis of fever of unknown origin was conducted. Computed tomography (CT) revealed a cystic mass image in the pancreatic head in one patient, and a hypodense lesion in the pancreatic head in the other. The first patient was diagnosed by a wedge biopsy specimen obtained in the exploratory laparotomy. The other patient was diagnosed by percutaneous fine-needle aspiration biopsy. Both patients were successfully treated with quadruple antituberculous therapy for 12 months. We concluded that especially in young patients who present with a mass in the pancreas, pancreatic tuberculosis should be considered among the differential diagnoses, particularly in developing countries and immunosuppressed individuals.

Tuberculous peritonitis--reports of 26 cases, detailing diagnostic and therapeutic problems

OBJECTIVE

To evaluate the clinical presentation, biochemical (ascites and serum) and laparoscopic findings, and to assess the efficacy of triple antituberculous therapy without rifampicin for 6 months in patients with tuberculous peritonitis.

METHODS

Twenty-six tuberculous peritonitis patients (11 male, 15 female) with a mean age of 34.8 +/- 3.4 years (range 14-77) were assessed with regard to diagnostic and therapeutic features.

RESULTS

The most common symptoms and signs were abdominal pain (92.3%) and ascites (96.2%), respectively. Tuberculin skin test (TST) was positive in all patients. An abnormal chest radiography suggestive of previous tuberculosis was present in five patients (19.2%), and two patients (7.7%) had extra-peritoneal (cerebral, pericardial) active tuberculous involvement. In 24 of the 25 patients who underwent laparoscopy with directed biopsy, whitish nodules suggested tuberculous peritonitis; 76% of the biopsy specimens revealed caseating, 20% non-caseating granulomatous inflammation, and 4% non-specific findings. The ascitic fluid of one patient (3.8%) was positive for acid-resistant bacilli, and culture was positive in two patients (7.7%). Twenty-four of the patients were treated for 6 months with isoniazid, streptomycin (total dose 40 g) and pyrazinamide (for the first 2 months and then substituted with ethambutol). Eighteen patients also received methyl prednisolone, initially 20 mg/day, for 1 month. The follow-up period was 19 +/- 1.7 months after the end of therapy (range 6-36). Ascites and abdominal pain abated earlier in patients on steroid therapy. All but two of the 24 patients responded to treatment.

CONCLUSION

Non-invasive tests such as acid-fast stain and culture of the ascitic fluid are usually insufficient, hence invasive laparoscopy and peritoneal biopsy are necessary for the diagnosis of tuberculous peritonitis if non-invasive tests such as ascites adenosine deaminase activity measurement are not easily available. Triple therapy without rifampicin for 6 months is sufficient to treat tuberculous peritonitis.

Genes of major histocompatibility complex class II influence chronic C hepatitis treatment with interferon in hemodialysis patients

The prevalence of anti-HCV among patients on hemodialysis is consistently higher than in the general population, indicating that patients on hemodialysis programs are at risk of acquiring HCV infection. The response to interferon alpha 2b (IFN -alpha 2b) therapy in chronic C hepatitis depends on viral and host factors. We treated 22 chronic C hepatitis uremic patients with IFN -alpha 2b (3 MU three times a week) and compared interferon responsive and unresponsive patients with regard to HLA II genes. HLA II genes were investigated by PCR-SSP low resolution, anti-HCV with ELISA II and HCV-RNA with reverse transcriptase "nested" PCR.

FINDINGS

HLA DRB1*13 is 50% positive in the non-responder group (four women, four men, mean age; 28.8+/-11.9 years) and 7% in the responder group (five women, nine men, mean age; 32.2+/-7.8 years) (p<0.05). There was no difference with respect to HLA genes between controls (six women, eight men, mean age; 29.5+/-12.8 years) and patients (nine women, 13 men, mean age; 31.0+/-9.3 years) (HLA DRB1*13 is 28% and 22% positive, respectively). We conclude that major histocompatibility complex class II genes influence the outcome of chronic C hepatitis treatment with IFN -alpha 2b.

Serial measurements of serum transaminases in renal transplant recipients with chronic hepatitis C: do they reflect disease severity?

Chronic hepatitis C infection is a common problem in renal allograft recipients, this study was designed to investigate the association of serum aminotransferase levels with liver histology, in renal transplant patients with chronic hepatitis C virus (HCV) infection, in the long term.

METHODS

In this study, 82 HCV-infected renal allograft recipients, who were followed up with functioning grafts for at least 6 months, were analyzed. Patients were classified according to their transaminase values as persistently normal, intermittently abnormal, or continuously abnormal liver function tests. Serum transaminase levels exceeding at least 1.5 times the upper limit of normal (40 IU) for periods longer than 1 month were taken as abnormal. Patients with abnormal liver function tests owing to HCV unrelated causes (drugs, alcohol, or other toxic substances, other viruses, etc.) were excluded from the study. Forty-eight of these patients underwent at least one liver biopsy.

RESULTS

Of the 82 patients, 34 (41.5%) had persistently normal (liver biopsy revealed normal or minimal changes in 77.0%, chronic persistent hepatitis in 15.3%, chronic active hepatitis in 7.7%; no patient had cirrhosis), 29 (35.3%) intermittently abnormal (liver histology was consistent with minimal changes in 50%, chronic persistent hepatitis in 27.8%, chronic active hepatitis in 16.7%, cirrhosis in 5.5%), 19 (23.2%) persistently abnormal (liver biopsy showed minimal changes in 41.1%, chronic persistent hepatitis in 17.6%, chronic active hepatitis in 35.3%, cirrhosis in 5.9%) transaminase values.

CONCLUSION

Although continuously or intermittently elevated transaminases do not always indicate morphologically advanced disease, the normal course of serum transaminases is mostly accompanied by normal, or near-normal, liver histology, in HCV-infected renal transplant patients. Liver biopsy is not indicated in deciding disease severity in these patients unless clinical findings dictate otherwise.

A rare complication of endoscopic injection sclerotherapy: thrombosis of subclavian vein

A 28-year-old man with compensated cirrhosis of the liver (Child B) and after 4 episodes of esophageal variceal bleeding received prophylactic endoscopic variceal sclerotherapy in our Gastroenterology Clinic for 8 consecutive months. Sclerotherapy of the esophageal varices had been performed at monthly intervals until variceal obliteration was achieved. Both the intravariceal and paravariceal injection techniques were used and injections were repeated periodically as necessary. On the 8th month, 1 week after the 4th sclerotherapy procedure, the patient complained of swelling on his right shoulder and on his right arm. There was jugular congestion and swelling of his right arm and right shoulder. The patient was hemodynamically stable. An X-ray of brachial venography revealed an obstruction of the vena subclavia dextra. During follow-up, the jugular congestion and swelling of his right arm gradually subsided spontaneously over a 6-month period without any need for medication. There has been no recurrence of his symptoms during the 1-year follow-up period. Now, he is still well clinically. This experience suggests that endoscopic injection sclerotherapy may cause thrombosis of the subclavian vein which have been never seen before.

Spontaneous ascitic infection in different cirrhotic groups: prevalence, risk factors and the efficacy of cefotaxime therapy

OBJECTIVE

To investigate the prevalence of spontaneous ascitic infection (SAI) in different cirrhotic groups, the risk factors for development of SAI, and the efficacy of cefotaxime therapy.

DESIGN

A prospective study.

SETTING

In-patient clinic of a university hospital.

PATIENTS

Eighty cirrhotic patients with ascites were assigned to four groups: hepatitis B or D virus-related 34, alcoholic 18, hepatitis C virus-related 14, miscellaneous 14.

INTERVENTIONS

Paracentesis was performed on 80 patients during 92 consecutive hospitalizations. Ascitic fluid was cultured by the method of bedside inoculation of blood culture bottles with ascites. The patients with SAI were treated with cefotaxime (2 g, three times daily, intravenously) for 5 days.

MAIN OUTCOME MEASURES

Frequency of SAI in cirrhotic groups; clinical, bacteriological and biochemical findings of SAI; rate of recovery-from infection.

RESULTS

Twenty SAI episodes (22%) were found in 16 patients; 8 episodes were spontaneous bacterial peritonitis, 2 bacterascites, and 10 culture-negative neutrocytic ascites. SAI occurred more frequently in patients with hepatitis B or D virus-related liver cirrhosis (32%) than in the alcoholic (6%, P < 0.05), hepatitis C virus-related (14%) or miscellaneous (14%) cirrhotic groups in multivariate analysis, independent predictive factors associated with the development of SAI are chronic hepatitis B virus infection, ascitic fluid total protein and serum bilirubin. Escherichia coli was obtained in 5 of 10 positive ascitic fluid cultures. Cure of the infection was achieved in 95% of episodes. Hospitalization mortality rate in infected patients was 20%.

CONCLUSION

Spontaneous ascitic infection occurs in approximately 20% of cirrhotic patients hospitalized with ascites. The patients with low ascitic protein concentration, high serum bilirubin level or hepatitis B virus cirrhosis are more predisposed to SAI. Cefotaxime may be an effective first-choice antibiotic for ascitic fluid infection.