Prevention and treatment of infections in patients with cirrhosis

In-hospital mortality in spontaneous bacterial peritonitis: a new predictive model

INTRODUCTION AND OBJECTIVE

Spontaneous bacterial peritonitis (SBP) is a severe complication in cirrhotics with ascites. Early identification of high-risk patients is crucial for prognostic improvement. Model for end-stage liver disease (MELD) relies on a few objective variables and predicts short-term survival. We aimed to determine the predictive value of MELD score, at admission, in the short-term mortality of SBP patients.

METHODS

We conducted a retrospective study of 73 SBP episodes admitted in our department between January 2002 and April 2006. Diagnosis (neutrophil count in ascitic fluid >or=250/mm3) was established within 24 h and cefotaxime was immediately started. Data collected included age, sex, etiology of liver disease, severity of ascites and hepatic encephalopathy, serum creatinine, total bilirubin and albumin, prothrombin time with international normalized ratio, and ascitic fluid analysis.

STATISTICS

Student's t-test, chi2 test, univariate analysis, logistic regression model, and receiver operating characteristic curves.

RESULTS

In-hospital mortality rate was 37%. In multivariate analysis, MELD score (P<0.001), and advanced age (P<0.05) were independent predictors of mortality. Receiver operating characteristic curve for MELD score revealed an excellent discriminatory ability to predict death, with an area under curve of 0.84. Age increased the predictive ability of MELD score, represented by an increment of area under curve to 0.88.

CONCLUSION

MELD score and older age were independent predictors of mortality. Age increased the discriminatory ability of MELD score to predict death. This new model may be useful for stratifying patients in future therapeutic trials, deserving further validation.

Leucocyte esterase reagent strips for the diagnosis of spontaneous bacterial peritonitis: a systematic review

The reported incidence of spontaneous bacterial peritonitis (SBP) is 7-30% per annum in cirrhotic patients. Timely diagnosis and treatment is crucial to reduce mortality owing to this infection. Recently, leucocyte esterase reagent strips have been tested in the diagnosis of infection in the ascitic fluid. The objective was to evaluate the diagnostic value of leucocyte esterase reagent strips in SBP in cirrhotic patients with ascites, by systematically reviewing the evidence from prospective clinical studies. We performed a comprehensive literature search in Medline up to July 2007 for adult human prospective clinical studies. Two reviewers independently checked all identified studies for fulfillment of predefined inclusion criteria, extracted data and assessed methodological quality of included studies. We had decided a priori to pool the studies via meta-analysis, only if statistical heterogeneity was found to be nonsignificant (P>0.10). Seventeen studies were included. Statistical heterogeneity among studies was found to be highly significant (P<0.001) in all analyses, precluding pooling of data for meta-analysis. Compared with the manual polymorphonuclear count ('gold standard'), leucocyte esterase reagent strips were found to have sensitivity ranging from 45 to 100%, specificity ranging from 81 to 100%, positive predictive value ranging from 42 to 100% and negative predictive value ranging from 87 to 100%. Despite the wide variation in sensitivity and positive predictive value between studies, the consistently high negative predictive value of leucocyte esterase reagent strips in SBP diagnosis should gain it a place in the ascitic tap diagnostic algorithm.

[Medical therapy of complications in liver cirrhosis]

Patients with liver cirrhosis bear a considerable risk of a variety of complications that involve virtually all organ systems. They can be addressed with a wide spectrum of drugs for acute interventions as well as for prophylactic purposes. At the same time treatment of the underlying disease, the identification and treatment of triggering factors and the possibility of liver transplantation should be kept in mind.

Functionality of the immune system in patients with chronic hepatitis C: trial by superinfections and vaccinations

Viral infections, specifically chronic, markedly influence the host response to subsequent infections and vaccinations. Does this apply to chronic hepatitis C (CHC)? The review considers this question with implications for the immune status and functionality of the immune system of a chronically HCV-infected host. The data collected here indicate that CHC may increase the risk of viral superinfections and modify their course by immunocompromising the host. Patients with CHC do not lose the 'memory' of previous infections and vaccinations but, apparently, have problems with building such immunity anew, as illustrated by their impaired response to hepatitis A and B vaccinations. This underlines the necessity of extra protection of CHC patients against blood-borne diseases, hepatitis A, possibly also varicella, influenza, tetanus, and diphtheria - immunity to which, in the Western population, appears to falter. Such immune protection has to be adapted to selective impairments of immune response characteristic to CHC. Some approaches to this are reviewed here and more need to be elaborated. Special attention has to be given to CHC patients who do not respond to common vaccines; further studies in this field are of great interest.