Utility of an algorithm in differentiating spontaneous from secondary bacterial peritonitis

Management of end-stage liver disease

Patients with cirrhosis who experience hepatic decompensation, such as the development of ascites, SBP, variceal hemorrhage, or hepatic encephalopathy, or who develop HCC, are at a higher risk of mortality. Management should be focused on the prevention of recurrence of complications, and these patients should be referred for consideration of liver transplantation.

Spontaneous bacterial peritonitis in patients with hepatitis B virus-related liver cirrhosis: community-acquired versus nosocomial

PURPOSE

Spontaneous bacterial peritonitis (SBP) frequently develops in patients with liver cirrhosis; however, there is little data to suggest whether the acquisition site of infection influences the prognosis. This study compared the bacteriology, clinical characteristics and treatment outcomes of community-acquired SBP (CA-SBP) and nosocomial SBP (N-SBP).

MATERIALS AND METHODS

The medical records of 130 patients with hepatitis B virus (HBV)-related liver cirrhosis, who had experienced a first episode of SBP between January 1999 and December 2008, were reviewed.

RESULTS

The study population included 111 (85.4%) patients with CA-SBP and 19 (14.6%) patients with N-SBP. Baseline and microbiological characteristics as well as clinical course, including in-hospital mortality, did not differ between patients with CA-SBP and those with N-SBP (all p>0.05). The median survival time was 6.5 months, and 117 (90.0%) patients died during the follow-up period. Patients with CA-SBP and N-SBP survived for median periods of 6.6 and 6.2 months, respectively, without significant difference (p=0.569). Time to recurrence did not differ between patients with CA-SBP and N-SBP (4.7 vs. 3.6 months, p=0.925).

CONCLUSION

The acquisition site of infection did not affect clinical outcomes for patients with HBV-related liver cirrhosis who had experienced their first episode of SBP. Third-generation cephalosporins may be effective in empirically treating these patients, regardless of the acquisition site of the infection.

Development of a new in situ hybridization method for the detection of global bacterial DNA to provide early evidence of a bacterial infection in spontaneous bacterial peritonitis

BACKGROUND & AIMS

Despite the importance of identifying the causative pathogen(s), ascitic fluid cultures are occasionally negative in patients with spontaneous bacterial peritonitis (SBP). A novel strategy using the in situ hybridization (ISH) method was introduced to detect the bacterial genomic DNA phagocytized in the blood of patients with sepsis. In the present study, we developed a new ISH probe to detect global bacterial DNA (named as GB probe) and evaluated its utility for detecting the phagocytized bacterial DNA in SBP ascites.

METHODS

Hybridization of bacterial DNA with the GB probe was examined by dot-blot and ISH tests. In addition, the utility of the ISH method to detect the bacterial DNA in the leukocytes of SBP ascites was evaluated.

RESULTS

The GB probe hybridized with the genomic DNA of all 59 bacterial strains tested (59 species of 36 genus). Eleven of 51 patients with ascites (out of total 542 cirrhotic inpatients) were categorized as SBP. The ISH tests showed positive results in 10 of 11 SBP cases. However, the ISH tests all showed negative results in the 40 non-SBP ascitic samples. Therefore, the ISH tests yielded highly sensitive and specific results for detecting the phagocytized bacterial DNA in the leukocytes of SBP ascites. Moreover, all of the ISH test results were obtained within only one day.

CONCLUSIONS

Our newly established ISH method was found to provide both a rapid and sensitive detection of bacterial DNA in SBP ascites, thus suggesting its utility for providing early and direct evidence of bacterial infection in SBP ascites.

Immune dysfunction and infections in patients with cirrhosis

Patients with cirrhosis are immunocompromised and susceptible to infections. Although detection and treatment of spontaneous bacterial peritonitis (SBP) have improved, overall survival rates have not increased greatly in recent decades-infection still increases mortality 4-fold among patients with cirrhosis. Hospitalized patients with cirrhosis have the highest risk of developing infections, especially patients with gastrointestinal (GI) hemorrhage. Bacterial infections occur in 32% to 34% of patients with cirrhosis who are admitted to the hospital and 45% of patients with GI hemorrhage. These rates are much higher than the overall rate of infection in hospitalized patients (5%-7%). The most common are SBP (25% of infections), urinary tract infection (20%), and pneumonia (15%). Bacterial overgrowth and translocation from the GI tract are important steps in the pathogenesis of SBP and bacteremia-these processes increase levels of endotoxins and cytokines that induce the inflammatory response and can lead to septic shock, multiorgan dysfunction, and death. A number of other bacterial and fungal pathogens are more common and virulent in patients with cirrhosis than in the overall population. We review the pathogenesis of infections in these patients, along with diagnostic and management strategies.

A Rare Case of Secondary Bacterial Peritonitis from Clostridium perfringens in an Adult Patient with Noncirrhotic Ascites and a Krukenberg Tumor: Report of a Case

Secondary bacterial peritonitis, in comparison to spontaneous, presents with a surgically treatable intraabdominal source for infection such as a gastrointestinal perforation or abscess and is nearly always polymicrobial. We present a rare case of secondary bacterial peritonitis from Clostridium perfringens in an adult patient with noncirrhotic ascites and a Krukenberg tumor.

Diagnosis and therapy of ascites in liver cirrhosis

Ascites is one of the major complications of liver cirrhosis and is associated with a poor prognosis. It is important to distinguish noncirrhotic from cirrhotic causes of ascites to guide therapy in patients with noncirrhotic ascites. Mild to moderate ascites is treated by salt restriction and diuretic therapy. The diuretic of choice is spironolactone. A combination treatment with furosemide might be necessary in patients who do not respond to spironolactone alone. Tense ascites is treated by paracentesis, followed by albumin infusion and diuretic therapy. Treatment options for refractory ascites include repeated paracentesis and transjugular intrahepatic portosystemic shunt placement in patients with a preserved liver function. Potential complications of ascites are spontaneous bacterial peritonitis (SBP) and hepatorenal syndrome (HRS). SBP is diagnosed by an ascitic neutrophil count > 250 cells/mm³ and is treated with antibiotics. Patients who survive a first episode of SBP or with a low protein concentration in the ascitic fluid require an antibiotic prophylaxis. The prognosis of untreated HRS type 1 is grave. Treatment consists of a combination of terlipressin and albumin. Hemodialysis might serve in selected patients as a bridging therapy to liver transplantation. Liver transplantation should be considered in all patients with ascites and liver cirrhosis.

Characteristics of ascitic fluid from patients with suspected spontaneous bacterial peritonitis in emergency units at a tertiary hospital

CONTEXT AND OBJECTIVE

Spontaneous bacterial peritonitis (SBP) is a complication of ascites, especially in cirrhosis. Ascitic fluid with 250 or more neutrophils/mm³ is an acceptable criterion for diagnosis, even when bacterial fluid cultures are negative. The aims here were to estimate SBP frequency among emergency room patients based on cellular criteria and evaluate the biochemical profile of these fluids.

DESIGN AND SETTING

Retrospective study at a public tertiary hospital.

METHODS

Laboratory records of patients with ascites attended in emergency rooms between November 2001 and November 2006, from whom ascitic fluid samples were sent to the laboratory due to suspected SBP, were evaluated. The 691 samples included were divided into group A (presumed SBP: ≥ 250 neutrophils/mm³; n = 219; 31.7%) and group B (no presumed SBP: < 250 neutrophils/mm³; n = 472; 68.3%). Patients' sex and age; ascitic fluid characteristics (numbers of neutrophils, leukocytes and nucleated cells); bacteriological characteristics; and protein, lactate dehydrogenase, adenosine deaminase and glucose concentrations were evaluated.

RESULTS

Among group A cultured samples, 63 (33.8%) had positive bacterial cultures with growth of pathogens commonly associated with SBP. In total, the group A samples showed higher lactate dehydrogenase levels than seen in the group B samples. The latter presented predominance of lymphocytes and macrophages.

CONCLUSION

Among the ascitic fluid samples with clinically suspected SBP, 31.7% fulfilled the cellular diagnostic criteria. Positive bacterial isolation was found in 33.8% of the cultured samples from the presumed SBP group.

[Ascites, hepatorenal syndrome and spontaneous bacterial peritonitis in patients with portal hypertension]

Ascites, hepatic encephalopathy and variceal hemorrhage are three major complications of portal hypertension. The diagnostic evaluation of ascites involves an assessment of its etiology by determining the serum-ascites albumin gradient and the exclusion of spontaneous bacterial peritonitis. Ascites is primarily related to an inability to excrete an adequate amount of sodium into urine, leading to a positive sodium balance. Sodium restriction and diuretic therapy are keys of ascites control. But, with the case of refractory ascites, large volume paracentesis and transjugular portosystemic shunts are required. In hepatorenal syndrome, splanchnic vasodilatation with reduction in effective arterial volume causes intense renal vasoconstriction. Splanchnic and/or peripheral vasoconstrictors with albumin infusion, and renal replacement therapy are only bridging therapy. Liver transplantation is the only definitive modality of improving the long term prognosis.

Biochemical analysis of ascitic (peritoneal) fluid: what should we measure?

Ascitic fluid samples are frequently sent to the laboratory for analysis. Although the underlying cause of the ascites is often thought to be clinically obvious, it is important to establish a definitive diagnosis. The value of a cell count and bacterial culture of the ascitic fluid is not disputed, but the role of biochemical testing is less clear. The use of ascitic fluid total protein to try to classify ascitic fluids as either an exudate or a transudate has contributed to this. The use of the physiologically based serum ascites albumin gradient to differentiate ascites caused by portal hypertension from other causes provides a better diagnostic approach. We recommend that the serum ascites albumin gradient is performed by laboratories as the first-line test and that interpretative reports are provided. Additional testing should be restricted to specific diagnostic queries and requires close collaboration between the laboratory and the clinician.

Development of Spontaneous Bacterial Peritonitis after Extended Hepatic Resection in a Patient without Evidence of Liver Cirrhosis

Hilar cholangiocarcinomas are often treated with liver resections. Hepatic dysfunction and infection are common postoperative complications. Although secondary bacterial peritonitis due to abdominal abscess or perforation is common, we report herein the first case of spontaneous bacterial peritonitis after hepatic resection. A 61-year-old male patient without underlying liver disease was diagnosed as having a Klatskin tumor, and a right trisectionectomy with caudate lobectomy was performed. From postoperative days 18-28, the patient gained 4.1 kg as ascites developed, and showed evidence of hepatic insufficiency with prolonged prothrombin time and jaundice. Computed tomography, performed at postoperative day 28 when fever had developed, showed only ascites without bowel perforation or abscess. When paracentesis was performed, the serum-ascites albumin gradient was 2.3 g/dL, indicating portal hypertension, and the ascites' polymorphonuclear cell count was 1,156/mm(3). Since the clinical, laboratory, and image findings were compatible with spontaneous bacterial peritonitis, we started empirical antibiotics without additional intervention. Follow-up analysis of the ascites after 48 hours revealed that the polymorphonuclear cell count had decreased markedly to 108/mm(3); the fever and leukocytosis had also improved. After 2 weeks of antibiotic treatment, the patient recovered well, and was discharged without any problem.

A recent evaluation of empirical cephalosporin treatment and antibiotic resistance of changing bacterial profiles in spontaneous bacterial peritonitis

The aim of this research is to evaluate the recent changes in microorganisms causing spontaneous bacterial peritonitis in cirrhotic patients, antibiotic resistance, and response to empirical cephalosporin therapy. A total of 218 patients with ascites secondary to cirrhosis were enrolled. Parenteral cefotaxime or cefepime was given to patients who had a neutrophil count of 250/mm(3) or more or a positive bacterial culture of ascitic fluid. Antibiotic failure was defined by an absence of clinical improvement and an insufficient decrease in neutrophil count of ascites (<25% of initial value) by the third day of therapy. Of all the patients, 44.6% had culture-negative neutrocytic ascites, 24.8% had spontaneous bacterial peritonitis, and 10.1% had monomicrobial nonneutrocytic bacterascites. Growth in culture was observed in 76 patients (34.9%). The two most common isolated bacteria were Escherichia coli (33.8%) and coagulase-negative Staphylococcus (CoNS; 19.7%). The two cephalosporins were effective against E. coli (82%) and but not against CoNS (44%), while levofloxacin showed reasonable activity against both E. coli (71%) and CoNS (90%) in vitro. We confirmed a recent increased incidence of spontaneous bacterial peritonitis caused by Gram-positive bacteria. Levofloxacin seems to be a good alternative treatment for patients with uncomplicated spontaneous ascites infections.

Secondary bacterial peritonitis in cirrhosis: a retrospective study of clinical and analytical characteristics, diagnosis and management

BACKGROUND & AIMS

Secondary bacterial peritonitis in cirrhotic patients is an uncommon entity that has been little reported. Our aim is to analyse the frequency, clinical characteristics, treatment and prognosis of patients with secondary peritonitis in comparison to those of patients with spontaneous bacterial peritonitis (SBP).

METHODS

Retrospective analysis of 24 cirrhotic patients with secondary peritonitis compared with 106 SBP episodes.

RESULTS

Secondary peritonitis represented 4.5% of all peritonitis in cirrhotic patients. Patients with secondary peritonitis showed a significantly more severe local inflammatory response than patients with SBP. Considering diagnosis of secondary peritonitis, the sensitivity of Runyon's criteria was 66.6% and specificity 89.7%, Runyon's criteria and/or polymicrobial ascitic fluid culture were present in 95.6%, and abdominal computed tomography was diagnostic in 85% of patients in whom diagnosis was confirmed by surgery or autopsy. Mortality during hospitalization was higher in patients with secondary peritonitis than in those with SBP (16/24, 66.6% vs. 28/106, 26.4%) (p<0.001). There was a trend to lower mortality in secondary peritonitis patients who underwent surgery (7/13, 53.8%) than in those who received medical treatment only (9/11, 81.8%) (p=0.21). Considering surgically treated patients, the time between diagnostic paracentesis and surgery was shorter in survivors than in non-survivors (3.2+/-2.4 vs. 7.2+/-6.1 days, p=0.31).

CONCLUSIONS

Secondary peritonitis is an infrequent complication in cirrhotic patients but mortality is high. A low threshold of suspicion on the basis of Runyon's criteria and microbiological data, together with an aggressive approach that includes prompt abdominal computed tomography and early surgical evaluation, could improve prognosis in these patients.

Spontaneous bacterial peritonitis: Few additional points

Spontaneous bacterial peritonitis (SBP) is a treatable complication of decompensated cirrhosis. Coagulopathy with evidence of hyperfibrinolysis or clinically evident disseminated intravascular coagulation precludes paracentesis. Alcoholic hepatitis with fever, leucocytosis and abdominal pain should be evaluated for SBP. Oral ofloxacin is as effective as parenteral cefotaxime in treatment of SBP except for inpatients with vomiting, encephalopathy, or renal failure. Albumin is superior to hydroxyethyl starch in treatment of SBP.

Clinical features and prognosis of spontaneous bacterial peritonitis in korean patients with liver cirrhosis: a multicenter retrospective study

Background/Aims

Although early recognition and treatment with effective antibiotics have lead to improvements in the prognosis of patients with spontaneous bacterial peritonitis (SBP), it remains to be a serious complication in cirrhotic patients. This study was designed to evaluate the clinical manifestations and prognosis of patients with liver cirrhosis and SBP in Korea.

Methods

This was a multicenter retrospective study examining 157 episodes of SBP in 145 patients with cirrhosis. SBP was diagnosed based on a polymorphonuclear cell count in ascitic fluid of >250 cells/mm³ in the absence of data compatible with secondary peritonitis.

Results

The mean age of the cohort was 56 years, and 121 (77%) of the 157 episodes of SBP occurred in men. Microorganisms were isolated in 66 episodes (42%): Gram-negative bacteria in 54 (81.8%), Gram-positive in 11 (16.7%), and Candida in 1. Isolated Gram-negative organisms were resistant to third-generation cephalosporin in 6 cases (17%), to ciprofloxacin in 11 (20.8%), and to penicillin in 33 (62.3%). The treatment failure and in-hospital mortality rates were 12.1% and 21%, respectively. A high Model of End-Stage Liver Disease (MELD) score, SBP caused by extended-spectrum β-lactamase-producing organisms, and hepatocellular carcinoma were independent prognostic factors of high in-hospital mortality.

Conclusions

SBP remains to be a serious complication with high in-hospital mortality, especially in patients with a high MELD score.

Ascites: diagnosis and management

Ascites is the pathologic accumulation of fluid in the peritoneal cavity and is a common manifestation of liver failure, being one of the cardinal signs of portal hypertension. The diagnostic evaluation of ascites involves an assessment of its cause by determining the serum-ascites albumin gradient and the exclusion of complications eg, spontaneous bacterial peritonitis. Although sodium restriction and diuretics remain the cornerstone of ascites management, many patients require additional therapy when they become refractory to such medical treatment. These include repeated large volume paracentesis and transjugular intrahepatic portosystemic shunts. This review article summarizes diagnostic tools and provides an evidence-based approach to the management of ascites.

Gas-forming bacterial peritonitis mimics hollow organ perforation

Acute abdomen is an emergent condition in the emergency department, and it is mandatory to evaluate it immediately and treat it without delay. Pneumoperitoneum is usually attributed to perforation of the gastrointestinal tract. However, intra-abdominal, gynecologic, urologic, and miscellaneous pathogenesis not related to a perforated gastrointestinal tract had never been described in the past. Approximately 10% of pneumoperitoneum is not associated with hollow organ perforation. There are many imitators of pneumoperitoneum including subphrenic abscess, colon volvulus, Chilaiditi syndrome, and so on. In our case, the gas-forming bacterial peritonitis accounted for the pneumoperitoneum. We presented an 85-year-old man who received laparotomy due to peritonitis, and radiographic subphrenic free air was seen. However, a large amount of ascites was found rather than perforated bowels during the surgical exploration, and the culture of ascites was positive for Pseudomonas aeruginosa.

An evidence-based manual for abdominal paracentesis

The purpose of this study was to provide evidence-based approaches to detect ascites, perform paracentesis, order tests, and interpret the results. A Medline search was performed to identify relevant articles. Of 731 identified articles, 50 articles were used. The most sensitive findings for ascites detection are ankle edema (93%), increased abdominal girth (87%), flank dullness (84%), and bulging flanks (81%). Paracentesis is safe, with bleeding rates and leakage of <1%. An ascitic fluid polymorphonuclear cell count >or=250 cells/mm(3) is the most sensitive test (86%-100%) to diagnose spontaneous bacterial peritonitis. The serum-ascites albumin gradient is the most useful test in identifying portal hypertension-related ascites. Large-volume paracentesis is effective in the treatment of refractory ascites. We conclude that paracentesis is a safe and vital procedure in patients with new-onset ascites. Once detected, an algorithmic approach to ordering tests and their interpretation is useful to determine etiology and direct further management.

Bacteremia is a prognostic factor for poor outcome in spontaneous bacterial peritonitis

We performed a retrospective study to determine the influence of bacteremia on the mortality of patients with spontaneous bacterial peritonitis (SBP), a major complication of liver cirrhosis. Patients with SBP with identified pathogens from ascites and/or blood were analyzed by retrospective review of clinical and laboratory records in a university hospital in Korea for 3 y and classified into the bacteremic and non-bacteremic groups. The underlying liver function was determined by model for end-stage liver disease (MELD) score. Microbiological response rate, ascites polymorphonuclear leukocyte (PML) count reduction rate, and SBP-related mortality were compared between the 2 groups. To identify the independent risk factors of mortality, a multiple logistic regression model was used to control for the confounders. A total of 189 patients was enrolled in the study. Among 189 patients, 110 (58.2%) were bacteremic, and 79 (41.8%) non-bacteremic. Escherichia coli was the most common etiologic organism, followed by Klebsiella pneumoniae. MELD scores, microbiological response rate (82.6% vs 88.6%, p=0.295), and ascites PML count reduction rate (33.2% vs 44.8%, p=0.479) were not different between the bacteremic and non-bacteremic group. However, the SBP-related mortality rate of the bacteremic group was significantly higher than that of the non-bacteremic group (37.3% vs 12.7%, p<0.001). Bacteremia (OR=2.86: 95% CI 1.06-7.74, p=0.038), APACHE II score (OR=1.20: 95% CI 1.10-1.31, p<0.001), MELD score (OR=1.07: 95% CI 1.01-1.31, p=0.016) and microbiological no response (OR=5.51: 95% CI 1.82-16.72, p=0.003) were independent risk factors of SBP-related mortality.

Infections in Patients With End-stage Liver Disease

Infections in patients with end-stage liver disease (ESLD) are an important cause of morbidity and mortality in these patients. Abnormalities in their natural defense mechanisms, alterations in the enteric flora and the growing utilization of invasive procedures increase the risk of infections in these patients. Common bacterial infections in ESLD patients include spontaneous bacterial peritonitis, urinary tract infections, community-acquired pneumonia, dermatologic infections, and bacteremia. Viral infections such as influenza can have a devastating course in ESLD patients. Hepatitis B and C are now among the most common causes of ESLD. They also present an important therapeutic challenge. As patients with human immunodeficiency virus are surviving longer, ESLD due to hepatitis C is now emerging as a leading cause of morbidity in these patients. Prompt detection of infections, use of appropriate antibiotics for treatment and prophylactic measures such as vaccinations can help improve survival in these patients.

Changes in the Profiles of Causative Agents and Antibiotic Resistance Rate for Spontaneous Bacterial Peritonitis: an Analysis of Cultured Microorganisms in Recent 12 Years

BACKGROUNDS/AIMS

The causative agents for spontaneous bacterial peritonitis (SBP) and antibiotic resistance rate vary according to the regions and time. This study evaluated the recent changes in the profiles of microorganisms and antibiotic resistance rate for the choice of effective antibiotics in treating SBP.

METHODS

The clinical records of 1,018 episodes of SBP from November, 1994 to December, 2005, were analyzed retrospectively. The profiles of the causative agents for SBP and the rate of antibiotic resistance were compared in every 4-year-term.

RESULTS

The microorganisms were isolated in 394 out of 1018 episodes (38.7%). Gram negative and positive organisms constituted 71.6% and 21.3%, respectively. The five most commonly isolated organisms were E. coli (35.8%), K. pneumoniae (15.5%), viridans Streptococci (10.4%), S. pneumoniae (4.8%) and Aeromonas group (4.6%). The rate of E. coli resistant to cefotaxime (0%, 5.4%, 7.4%) and ciprofloxacin (4.3%, 21.6%, 28.4%) were increased in recent years. In the gram positive organisms, all isolates of viridans Streptococci and Pneumococci were sensitive to cefotaxime and ciprofloxacin. Recently, methicillin-resistant Staphylococcus aureus (MRSA) (28%) and vancomycin-resistant Enterococci (VRE) (31%) have been isolated. In each period, the overall antibiotic resistance rates to cefotaxime were 12.5%, 14.0%, 14.8%, to ciprofloxacin were 3.1%, 16.7%, 18.0%, and to imipenem were 4.7%, 7.0%, 4.2%.

CONCLUSIONS

Cefotaxime may still be the choice of primary empirical antibiotics for the treatment of SBP in Korea because the rate of resistance is acceptable. However, it is important to be aware of the recent increase in ciprofloxacin-resistant E. coli, extended spectrum beta-lactamase (ESBL)-producing gram negative bacilli, MRSA and VRE.

Peritonitis after liver transplantation: Incidence, risk factors, microbiology profiles, and outcome

Peritonitis occurring after liver transplantation (PLT) has been poorly characterized to date. The aims of this study were to define the incidence, risk factors, microbiology profiles, and outcome of nonlocalized PLT. This was a retrospective study of 950 cadaveric liver transplantation (LT) procedures in 837 patients, followed for a mean of 1,086 days (range, 104-2,483 days) after LT. PLT was defined as the presence of at least one positive ascitic fluid culture after LT. There were 108 PLT episodes in 91 patients occurring at a median of 14 days (range, 1-102 days) after LT. Significant risk factors associated with the development of PLT by multivariate analysis included pre-LT model for end-stage liver disease score, duration of LT surgery, Roux-en-Y biliary anastomosis, and renal replacement therapy after LT. Biliary complications, intra-abdominal bleeding, and bowel leak/perforation were associated with 34.3%, 26.9%, and 18.5% of episodes, respectively. Multiple organisms, gram-positive cocci, fungus, and multidrug-resistant bacteria were isolated in 61.1%, 92.6%, 25.9%, and 76.9% of ascitic fluid cultures, respectively. The 28 fungal PLT episodes were associated with bowel leak/perforation and polymicrobial peritonitis. Patients who developed PLT after their first LT had a significantly greater risk of graft loss or mortality compared to unaffected patients. Parameters significantly associated with these adverse outcomes by multivariate analysis were recipient age at LT and bowel leak or perforation after LT. In conclusion, PLT is a serious infectious complication of LT, associated with significant intra-abdominal pathology and reduced recipient and graft survival.

Instant diagnosis of spontaneous bacterial peritonitis using leukocyte esterase reagent strips: Nephur-Test vs. MultistixSG

BACKGROUND/AIM

Spontaneous bacterial peritonitis (SBP), defined by an ascites neutrophil count >250/mul, is a severe complication of cirrhosis and demands prompt diagnosis. Leukocyte esterase reagent strips can rapidly detect leukocytes in physiological fluids. We compared the performance of two leukocyte esterase reagent strips in the diagnosis of SBP.

METHODS

Non-selected patients with cirrhosis and ascites were prospectively included in a Community Hospital. Manual ascites cytology, culture and BIOCHEMISTRY were compared with the Nephur-Test (read at 60 s: negative + 1 to + 3) and MultistixSG (read at 120 s: negative, trace, +1 to +3). Multiple investigators performed the tests with repeat readings by one nurse.

RESULTS

Two hundred and forty five ascites fluid samples were obtained in 51 patients: 44% in conditions of SBP antibiotic prophylaxis, 64% in an ambulatory setting. Seventeen samples had an ascites polymorphonuclear count of > or =250/microl, associated with a positive ascites culture in seven, obtained in 12 patients (24%), 53% in an ambulatory setting. Sensitivity, specificity, and positive and negative predictive values were: Nephur-Test (88.2%, 99.6%, 93.8%, 99.1%); MultistixSG (64.7%, 99.6%, 91.7%, 97.4%). There was excellent agreement between the investigators and the nurse.

CONCLUSIONS

Leukocyte esterase reagent strips may provide a rapid bedside diagnosis of SBP and thereby shorten time to appropriate management. The Nephur-Test appeared to out-perform MultistixSG. These tests might be particularly useful in ambulatory settings or whenever ascites fluid analysis is not rapidly available.

Rapid diagnosis of spontaneous bacterial peritonitis with leukocyte esterase reagent strips in a European and in an American center

BACKGROUND

Timely diagnosis and treatment of spontaneous bacterial peritonitis (SBP) are essential to survival. The purpose of the present paper was to evaluate leukocyte esterase reagent strips (Nephur-Test and MultistixSG10) in the bedside diagnosis of SBP.

METHODS

Patients with cirrhotic ascites were prospectively included in France (center 1) and in the USA (center 2). Paracenteses were performed on admission and repeated as indicated. Bedside reagent strip testing was performed on the ascitic fluid and compared to manual cell count with differential and ascitic fluid culture. In center 1, the Nephur-Test was tested in all cases, with dual testing with MultistixSG10 in a subgroup. In center 2, all cases had dual testing. Spontaneous bacterial peritonitis was defined as a polymorphonuclear ascites count > or =250/microL.

RESULTS

A total of 184 samples was obtained in 76 patients. Center 1 included 151 samples from 53 patients. Seven samples had SBP, obtained in six patients. Center 2 included 33 samples from 23 patients. Six samples had SBP, obtained in five patients. The sensitivity, specificity, positive and negative predictive value of the reagent strips were as follows. Center 1/Nephur-Test: 86%, 100%, 100%, 99%; center 1/MultistixSG10: 100%, 100%, 100%, 100%; center 2/Nephur-Test: 100%, 92.5%, 75%, 100%; center 2/MultistixSG10: 83%, 96%, 83%, 96%.

CONCLUSION

Leukocyte esterase reagent strips may provide a rapid bedside diagnosis of SBP.

The role of likelihood ratio in clinical diagnosis: applicability in the setting of spontaneous bacterial peritonitis

Despite imperfect clinical information and uncertainty about clinical course and outcome, the clinician's main task is to make reasonable decisions about patient care. The clinical history and physical examination typically provide information that is useful for making a diagnosis; however, we still rely on laboratory and radiologic tests to confirm a diagnosis in most cases. Understanding the operative characteristic of a test is of key importance because it can change the probability that a patient has a disease before the result of a test is known. This operative characteristic, better known as the likelihood ratio (LR), is a global assessment of the information provided by a test. The LR allows calculating the odds that a patient has a disease after a test is performed. In this article, we explain the meaning of the LR, how it works, and the applicability of this tool in the setting of a challenging scenario in clinical practice, spontaneous bacterial peritonitis.

Spontaneous bacterial peritonitis

Spontaneous bacterial peritonitis (SBP) is a bacterial infection of ascitic fluid in patients with decompensated cirrhosis. The modifier 'spontaneous' distinguishes this from surgical peritonitis. The infecting organisms are usually enteric gram-negatives which have translocated from the bowel. Symptoms of infection occur in most patients with SBP, including fever, abdominal pain, mental status changes, and ileus. A high index of suspicion should exist for SBP in patients with cirrhosis and ascites. Diagnostic abdominal paracentesis can be undertaken with minimal risk and should be performed in all patients admitted to the hospital, during times of worsening clinical appearance, or when gastrointestinal bleeding occurs. The ascitic fluid polymorphonuclear cell count is the most sensitive test in evaluating for infection. Cultures of the ascitic fluid are helpful in identifying the organism and are best performed by bedside injection of blood culture bottles. Ascites total protein, lactate dehydrogenase, and glucose levels can assist in distinguishing SBP from secondary peritonitis. Empirical therapy is recommended after paracentesis if suspicion for infection exists. Cefotaxime is the best-studied antibiotic for this purpose and has excellent penetration into ascites with no nephrotoxicity. Prophylaxis should be limited to high-risk settings. Mortality rates in SBP have declined dramatically, largely due to earlier detection and improved therapy.

Biochemical analysis of pleural, peritoneal and pericardial effusions

Body fluids other than blood, urine and cerebrospinal fluid are often submitted for biochemical analysis. Of these, pleural, peritoneal and pericardial fluids are the most common. Laboratory tests are a useful tool to assess the aetiology, pathophysiology and subsequent treatment of effusions. A wide range of biochemical tests may be requested. This review critically examines the various analytes that have been used to investigate these body fluids.

Intensive care unit management of intra-abdominal infection

OBJECTIVE

To review the biologic characteristics of, and management approaches to, intra-abdominal infection in the critically ill patient.

DESIGN

Narrative review.

SETTING

Medline review focussed on intra-abdominal infection in the critically ill patient.

PATIENTS AND SUBJECTS

Restricted to studies involving human subjects.

INTERVENTIONS

None.

RESULTS

Intra-abdominal infections are an important cause of morbidity and mortality in the intensive care unit (ICU). Peritonitis can be classified as primary, secondary, or tertiary, the unique pathologic features reflecting the complex nature of the endogenous gut flora and the gut-associated immune system, and the alterations of these that occur in critical illness. Outcome is dependent on timely and accurate diagnosis, vigorous resuscitation and antibiotic support, and decisive implementation of optimal source control measures, specifically the drainage of abscesses and collections of infected fluid, the debridement of necrotic infected tissue, and the use of definitive measures to prevent further contamination and to restore anatomy and function.

CONCLUSIONS

Optimal management of intra-abdominal infection in the critically ill patient is based on the synthesis of evidence, an understanding of biologic principles, and clinical experience. An algorithm outlining a clinical approach to the ICU patient with complex intra-abdominal infection is presented.

A cirrhotic patient with fever and abdominal pain in the presence of ascites

The patient was a 64-year-old woman suffering from diabetes mellitus and Child's grade B hepatitis B virus-related liver cirrhosis. In November 2001, she complained of persistent dull right upper quadrant pain and fever for 2 days. She did not notice any jaundice, tea-coloured urine or pale stool. There was no increase in abdominal distension.

Review article: spontaneous bacterial peritonitis--diagnosis, treatment and prevention

Spontaneous bacterial peritonitis is a serious complication of cirrhotic ascites, arising most frequently in those with advanced liver disease. Its development leads to a further reduction in the effective arterial blood volume, and it has a mortality rate equivalent to that of a variceal bleed. However, problems remain with regard to the identification and optimal treatment of spontaneous bacterial peritonitis. Several important studies and consensus documents on the condition have recently been published which aid in the identification of patients at risk and help to guide therapy. In this review, we discuss these publications and address the issues of diagnosis, treatment and both primary and secondary prophylaxis of spontaneous bacterial peritonitis in the light of recent data.

Infectious complications of cirrhosis

Infectious complications in cirrhotic patients can cause severe morbidity and mortality. Bacterial infections are estimated to cause up to 25% of deaths in cirrhotic patients. The most frequent are urinary tract infection, spontaneous bacterial peritonitis, respiratory tract infection, and bacteremia. It has been said that cirrhosis is the most common form of acquired immunodeficiency, exceeding even AIDS. The specific risk factors for infection in cirrhotic patients are low serum albumin, gastrointestinal bleeding, intensive care unit admission for any cause, and therapeutic endoscopy. Certain infectious agents are more virulent and more common in patients with liver disease. These include Vibrio, Campylobacter, Yersinia, Plesiomonas, Enterococcus, Aeromonas, Capnocytophaga, and Listeria species, as well as organisms from other species. Spontaneous bacterial peritonitis is a frequent, severe, life-threatening complication of patients with ascites. Current observations and recommendations regarding treatment and prophylaxis are reviewed. A brief synopsis of miscellaneous infections encountered in cirrhotic patients is also included.

Ascitic fluid analysis: the role of biochemistry and haematology

In specific settings, biochemical and haematological analysis of ascitic fluid may provide answers to important clinical questions. This review seeks to outline the value and limitations of ascitic fluid analysis and the main clinical scenarios in which it may be useful.

Management of ascites

The evaluation of ascites includes a directed history, focused physical examination, and diagnostic paracentesis with ascitic fluid analysis. Dietary sodium restriction and oral diuretics are the mainstay of therapy for the majority of patients with cirrhotic ascites. Transjugular intrahepatic portocaval shunt has emerged as the treatment of choice for selected patients with refractory ascites, although serial large-volume paracenteses should be attempted first. Early diagnosis, broad-spectrum antibiotics, and albumin infusion contribute to the successful management of spontaneous bacterial peritonitis (SBP). Referral for liver transplant evaluation should be considered at the first sign of decompensation and should not be delayed until development of ominous clinical features, such as refractory ascites and SBP.

Ascitic fluid carcinoembryonic antigen and alkaline phosphatase levels for the differentiation of primary from secondary bacterial peritonitis with intestinal perforation

BACKGROUND/AIMS

In cirrhotic patients, spontaneous bacterial peritonitis (SBP) may be difficult to distinguish from secondary peritonitis with occult intestinal perforation; Runyon's criteria (based on ascitic fluid glucose, protein and lactate dehydrogenase levels) are sensitive but not specific. Ascitic fluid carcinoembryonic antigen (CEA) and alkaline phosphatase (AP) are potential markers for secondary peritonitis.

METHODS

Ascitic fluid CEA and AP levels were prospectively compared among three subject groups--cirrhotic patients with sterile ascites, cirrhotic patients with SBP, and patients (cirrhotic and non-cirrhotic) with perforation-related secondary peritonitis.

RESULTS

The secondary peritonitis group (n = 38 including 11 cirrhotic patients) had significantly higher mean CEA and AP levels than the SBP (n = 34) and sterile ascites patients (n = 63). Of secondary peritonitis patients, 92% fulfilled predetermined criteria (either CEA >5 ng/ml or AP >240 units/l) versus only 12% of SBP patients; sensitivity was 92% and specificity 88% for differentiating secondary peritonitis from SBP. Runyon's criteria had a sensitivity of 97% and specificity of 56%. Stratification of secondary peritonitis patients by the presence or absence of cirrhosis did not alter our results.

CONCLUSIONS

Ascitic fluid CEA or AP elevations appear to be sensitive and specific markers for perforation-related secondary peritonitis in cirrhotic as well as non-cirrhotic patients.

Liver transplantation. Selection, listing criteria, and preoperative management

Although only the expansion of the donor pool will have a major impact on the survival of patients with decompensated cirrhosis awaiting OLT, anticipation of complications such as SBP may improve the likelihood of a patient surviving until OLT, and may ameliorate some of the major causes of morbidity of cirrhosis, such as osteoporosis. Close communication between the treating physicians and the transplant center is crucial to ensure that the patients' UNOS status can be appropriately adjusted if additional complications of cirrhosis, such as intractable ascites, have occurred.

[Spontaneous bacterial peritonitis]

BACKGROUND

Since the beginning of the eighties systematic investigations broadened our knowledge about the clinical picture of spontaneous bacterial peritonitis very much. Important insights into epidemiology, pathogenesis, symptomatology, diagnosis and therapy of this disease, which is a frequent complication in patients with cirrhosis of the liver and ascites, could be gained. Actual research work primarily deals with questions of therapy and prophylaxis.

AIM

Aim of this review is a comprehensive presentation of the different aspects of this disease on the basis of the present literature.

CONCLUSIONS

As on the one side the clinical symptoms may be very little and on the other side the prognosis is very bad, it is extremely important to take this entity into the differential considerations to make an early diagnosis and to start an adequate therapy early.