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Fortuny M, Sarrias MR, Torner M, Iborra I, Clos A, Ardèvol A, Bartolí R, Morillas RM, Domènech E, Masnou H. Systematic review of the role of calprotectin in cirrhosis. Eur J Clin Invest 2024; 54:e14111. [PMID: 37849372 DOI: 10.1111/eci.14111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 09/16/2023] [Accepted: 09/23/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND Calprotectin is a calcium-binding-S100-protein synthetized mainly in neutrophils which has been demonstrated to be an accurate biomarker of the presence of these cells. Gut barrier dysfunction in patients with advanced chronic liver disease (ACLD), in addition to the lack of noninvasive tools for diagnosis and prognosis of cirrhosis decompensations, has raised interest in this biomarker. AIMS Our aim is to summarize the current evidence regarding the role of calprotectin in terms of its diagnostic and prognostic utility in ACLD. METHODS We performed a systematic search (PROSPERO registration no. CRD42023389069) of original articles published without any restrictions on the publication date until January 2023 providing information about calprotectin for the prognosis or diagnosis of ACLD and its decompensations in adult patients. RESULTS A total 227 articles were identified, and 26 observational studies finally met the inclusion criteria. In 14 studies, calprotectin was measured in ascitic fluid, all of which reported higher calprotectin values in spontaneous bacterial peritonitis, while cut-off points for its diagnosis were proposed in nine studies. Three studies reported higher faecal calprotectin levels in patients with hepatic encephalopathy and portal hypertension. Four studies evaluated faecal calprotectin and one plasma calprotectin as biomarkers for gut barrier integrity and bacterial translocation. CONCLUSIONS Calprotectin is emerging as a promising biomarker in ACLD, particularly for the management of bacterial infections and alcohol-related liver disease. Further research with better study designs should help to determine the feasibility of calprotectin measurement in routine clinical practice.
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Affiliation(s)
- Marta Fortuny
- Hepatology Unit, Hospital Germans Trias i Pujol, Badalona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Maria-Rosa Sarrias
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
- Germans Trias i Pujol Research Institute (IGTP), Badalona, Spain
| | - Maria Torner
- Hepatology Unit, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Ignacio Iborra
- Hepatology Unit, Hospital Germans Trias i Pujol, Badalona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ariadna Clos
- Hepatology Unit, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Alba Ardèvol
- Hepatology Unit, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Ramon Bartolí
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
- Germans Trias i Pujol Research Institute (IGTP), Badalona, Spain
| | - Rosa M Morillas
- Hepatology Unit, Hospital Germans Trias i Pujol, Badalona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Eugeni Domènech
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
- IBD Unit, Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Helena Masnou
- Hepatology Unit, Hospital Germans Trias i Pujol, Badalona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
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2
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Song S, Yang Y, Geng C, Tang Z, Wang C, Li X. Norfloxacin versus alternative antibiotics for prophylaxis of spontaneous bacteria peritonitis in cirrhosis: a systematic review and meta-analysis. BMC Infect Dis 2023; 23:557. [PMID: 37641014 PMCID: PMC10463656 DOI: 10.1186/s12879-023-08557-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/22/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Spontaneous bacterial peritonitis (SBP) is a life-threatening complication in patients with advanced cirrhosis. Prophylactic Norfloxacin used to be considered effective in SBP prevention, but in recent years its efficacy has been partially compromised by increasing quinolone-resistant bacteria. However, whether the effects of alternative prophylactic regimens are superior to norfloxacin remains controversial. The goal of this study is to compare the effects of norfloxacin with other antibiotics in SBP prophylaxis for cirrhotic patients. METHODS We systematically searched Pubmed, Embase, and Cochrane Library Databases. Two reviewers independently identified relevant random control trials (RCTs) comparing the role of norfloxacin and other antibiotics in SBP prevention. RESULTS Eight studies comprising 1043 cirrhotic patients were included in this study. Norfloxacin and alternative antibiotics displayed comparable effects in SBP prophylaxis, survival benefit, overall infection prevention, and safety. Subgroup analyses revealed that rifaximin prophylaxis could reduce the recurrence of SBP with fewer adverse events but failed to improve overall survival compared with norfloxacin. CONCLUSIONS Other antibiotics are a reasonable alternative to norfloxacin in the prophylaxis of SBP. Rifaximin prophylaxis could be an alternative choose of antibiotic for SBP prevention because of its better protective effect and safety.
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Affiliation(s)
- Shuailing Song
- Department of Gastroenterology, West China Hospital of Sichuan University, NO.37 GuoXue Street, Chengdu, 610041, Sichuan, China
| | - Yi Yang
- Department of Laboratory Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Chong Geng
- Department of Gastroenterology, West China Hospital of Sichuan University, NO.37 GuoXue Street, Chengdu, 610041, Sichuan, China
- Laboratory of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zeya Tang
- Department of Outpatient, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Chunhui Wang
- Department of Gastroenterology, West China Hospital of Sichuan University, NO.37 GuoXue Street, Chengdu, 610041, Sichuan, China
| | - Xiao Li
- Department of Gastroenterology, West China Hospital of Sichuan University, NO.37 GuoXue Street, Chengdu, 610041, Sichuan, China.
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3
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Singh V, De A, Mehtani R, Angeli P, Maiwall R, Satapathy S, Singal AK, Saraya A, Sharma BC, Eapen CE, Rao PN, Shukla A, Shalimar, Choudhary NS, Alcantara-Payawal D, Arora V, Aithal G, Kulkarni A, Roy A, Shrestha A, Mamun Al Mahtab, Niriella MA, Siam TS, Zhang CQ, Huei LG, Yu ML, Roberts SK, Peng CY, Chen T, George J, Wong V, Yilmaz Y, Treeprasertsuk S, Kurniawan J, Kim SU, Younossi ZM, Sarin SK. Asia-Pacific association for study of liver guidelines on management of ascites in liver disease. Hepatol Int 2023; 17:792-826. [PMID: 37237088 DOI: 10.1007/s12072-023-10536-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 04/08/2023] [Indexed: 05/28/2023]
Affiliation(s)
- Virendra Singh
- Punjab Institute of Liver and Biliary Sciences, Mohali, Punjab, India.
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Arka De
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rohit Mehtani
- Department of Hepatology, Amrita Institute of Medical Sciences and Research, Faridabad, India
| | - Paolo Angeli
- Department of Internal Medicine and Hepatology, University of Padova, Padua, Italy
| | - Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Sanjaya Satapathy
- Division of Hepatology, Sandra Atlas Bass Center for Liver Diseases and Transplantation, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Manhasset, NY, USA
| | - Ashwini K Singal
- University of South Dakota Sanford School of Medicine, Sioux Falls, USA
| | - Anoop Saraya
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - B C Sharma
- Department of Gastroenterology, G.B. Pant Hospital, New Delhi, Delhi, India
| | - C E Eapen
- Department of Hepatology, Christian Medical College, Vellore, India
| | - P N Rao
- Department of Hepatology, AIG Hospitals, Hyderabad, India
| | - Akash Shukla
- Department of Gastroenterology, Lokmanya Tilak Municipal General Hospital and Lokmanya Tilak Municipal Medical College, Sion, Mumbai, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | | | | | - Vinod Arora
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Guru Aithal
- Biomedical Research Unit, NIHR Nottingham Digestive Diseases, Nottingham, UK
| | - Anand Kulkarni
- Department of Hepatology, AIG Hospitals, Hyderabad, India
| | - Akash Roy
- Institute of Gastrosciences and Liver Transplantation, Apollo Multispeciality Hospitals, Kolkata, India
| | - Ananta Shrestha
- Department of Hepatology, The Liver Clinic, Liver Foundation, Kathmandu, Nepal
| | - Mamun Al Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Madunil A Niriella
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Tan Soek Siam
- Department of Hepatology, Hospital Selayang, Selangor Darul Ehsan, Malaysia
| | - Chun-Qing Zhang
- Department of Gastroenterology, Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Lee Guan Huei
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Ming-Lung Yu
- School of Medicine, College of Medicine and Center of Excellence for Metabolic Associated Fatty Liver Disease, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | | | - Cheng-Yuan Peng
- Centre for Digestive Medicine, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Tao Chen
- Department of Infectious Diseases, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jacob George
- University of Sydney School of Medicine, Sydney, Australia
| | - Vincent Wong
- Mok Hing Yiu Professor of Medicine, Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China
| | - Yusuf Yilmaz
- Liver Research Unit, Institute of Gastroenterology, Marmara University, Istanbul, Turkey
- Department of Gastroenterology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey
| | | | - Juferdy Kurniawan
- Hepatobiliary Division, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital Jakarta, Jakarta, Indonesia
| | - Seung Up Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | | | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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4
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Crocombe D, Ahmed N, Balakrishnan I, Bordea E, Chau M, China L, Corless L, Danquah V, Dehbi HM, Dillon JF, Forrest EH, Freemantle N, Gear DP, Hollywood C, Hunter R, Jeyapalan T, Kallis Y, McPherson S, Munteanu I, Portal J, Richardson P, Ryder SD, Virk A, Wright G, O'Brien A. ASEPTIC: primary antibiotic prophylaxis using co-trimoxazole to prevent SpontanEous bacterial PeritoniTIs in Cirrhosis-study protocol for an interventional randomised controlled trial. Trials 2022; 23:812. [PMID: 36167573 PMCID: PMC9513307 DOI: 10.1186/s13063-022-06727-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 09/08/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Bacterial infection is a major cause of mortality in patients with cirrhosis. Spontaneous bacterial peritonitis (SBP) is a serious and common infection in patients with cirrhosis and ascites. Secondary prophylactic antibiotic therapy has been shown to improve outcomes after an episode of SBP but primary prophylaxis to prevent the first episode of SBP remains contentious. The aim of this trial is to assess whether primary antibiotic prophylaxis with co-trimoxazole improves overall survival compared to placebo in adults with cirrhosis and ascites. METHODS The ASEPTIC trial is a multicentre, placebo-controlled, double-blinded, randomised controlled trial (RCT) in England, Scotland, and Wales. Patients aged 18 years and older with cirrhosis and ascites requiring diuretic treatment or paracentesis, and no current or previous episodes of SBP, are eligible, subject to exclusion criteria. The trial aims to recruit 432 patients from at least 30 sites. Patients will be randomised in a 1:1 ratio to receive either oral co-trimoxazole 960 mg or an identical placebo once daily for 18 months, with 6 monthly follow-up visits thereafter (with a maximum possible follow-up period of 48 months, and a minimum of 18 months). The primary outcome is overall survival. Secondary outcomes include the time to the first incidence of SBP, hospital admission rates, incidence of other infections (including Clostridium difficile) and antimicrobial resistance, patients' health-related quality of life, health and social care resource use, incidence of cirrhosis-related decompensation events, liver transplantation, and treatment-related serious adverse events. DISCUSSION This trial will investigate the efficacy, safety, and cost-effectiveness of co-trimoxazole for patients with liver cirrhosis and ascites to determine whether this strategy improves clinical outcomes. Given there are no treatments that improve survival in decompensated cirrhosis outside of liver transplant, if the trial has a positive outcome, we anticipate widespread adoption of primary antibiotic prophylaxis. TRIAL REGISTRATION ClinicalTrials.gov NCT043955365 . Registered on 18 April 2020. Research ethical approval was granted by the Research Ethics Committee (South Central - Oxford B; REC 19/SC/0311) and the Medicines and Healthcare products Regulatory Agency (MHRA).
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Affiliation(s)
- Dominic Crocombe
- UCL Institute of Liver and Digestive Health, Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, London, UK
| | - Norin Ahmed
- University College London Comprehensive Clinical Trials Unit, London, UK
| | - Indran Balakrishnan
- Royal Free London NHS Foundation Trust, University College London, London, UK
| | - Ekaterina Bordea
- University College London Comprehensive Clinical Trials Unit, London, UK
| | - Marisa Chau
- University College London Comprehensive Clinical Trials Unit, London, UK
| | - Louise China
- UCL Institute of Liver and Digestive Health, Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, London, UK
| | | | - Victoria Danquah
- University College London Comprehensive Clinical Trials Unit, London, UK
| | - Hakim-Moulay Dehbi
- University College London Comprehensive Clinical Trials Unit, London, UK
| | - John F Dillon
- Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee, UK
| | - Ewan H Forrest
- Gastroenterology Unit, Glasgow Royal Infirmary, University of Glasgow, Glasgow, UK
| | - Nick Freemantle
- University College London Comprehensive Clinical Trials Unit, London, UK
| | | | - Coral Hollywood
- Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - Rachael Hunter
- University College London Comprehensive Clinical Trials Unit, London, UK
| | - Tasheeka Jeyapalan
- University College London Comprehensive Clinical Trials Unit, London, UK
| | - Yiannis Kallis
- The Blizard Institute, Queen Mary University of London, London, UK
| | - Stuart McPherson
- Liver Unit, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, The Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Iulia Munteanu
- University College London Comprehensive Clinical Trials Unit, London, UK
| | - Jim Portal
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Paul Richardson
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Stephen D Ryder
- NIHR Nottingham Biomedical Research Centre at Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, UK
| | - Amandeep Virk
- University College London Comprehensive Clinical Trials Unit, London, UK
| | - Gavin Wright
- Mid & South Essex NHS Foundation Trust, Basildon, UK
| | - Alastair O'Brien
- UCL Institute of Liver and Digestive Health, Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, London, UK. a.o'.,University College London Comprehensive Clinical Trials Unit, London, UK. a.o'.,University College London Hospitals NHS Foundation Trust, London, UK. a.o'
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5
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Aithal GP, Palaniyappan N, China L, Härmälä S, Macken L, Ryan JM, Wilkes EA, Moore K, Leithead JA, Hayes PC, O'Brien AJ, Verma S. Guidelines on the management of ascites in cirrhosis. Gut 2021; 70:9-29. [PMID: 33067334 PMCID: PMC7788190 DOI: 10.1136/gutjnl-2020-321790] [Citation(s) in RCA: 154] [Impact Index Per Article: 51.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 08/27/2020] [Accepted: 09/04/2020] [Indexed: 12/15/2022]
Abstract
The British Society of Gastroenterology in collaboration with British Association for the Study of the Liver has prepared this document. The aim of this guideline is to review and summarise the evidence that guides clinical diagnosis and management of ascites in patients with cirrhosis. Substantial advances have been made in this area since the publication of the last guideline in 2007. These guidelines are based on a comprehensive literature search and comprise systematic reviews in the key areas, including the diagnostic tests, diuretic use, therapeutic paracentesis, use of albumin, transjugular intrahepatic portosystemic stent shunt, spontaneous bacterial peritonitis and beta-blockers in patients with ascites. Where recent systematic reviews and meta-analysis are available, these have been updated with additional studies. In addition, the results of prospective and retrospective studies, evidence obtained from expert committee reports and, in some instances, reports from case series have been included. Where possible, judgement has been made on the quality of information used to generate the guidelines and the specific recommendations have been made according to the 'Grading of Recommendations Assessment, Development and Evaluation (GRADE)' system. These guidelines are intended to inform practising clinicians, and it is expected that these guidelines will be revised in 3 years' time.
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Affiliation(s)
- Guruprasad P Aithal
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
- Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Naaventhan Palaniyappan
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
- Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Louise China
- Institute of Liver Disease and Digestive Health, University College London, London, UK
| | - Suvi Härmälä
- Institute of Health Informatics, University College London, London, UK
| | - Lucia Macken
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Jennifer M Ryan
- Institute of Liver Disease and Digestive Health, University College London, London, UK
- Royal Free London NHS Foundation Trust, London, UK
| | - Emilie A Wilkes
- Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Kevin Moore
- Institute of Liver Disease and Digestive Health, University College London, London, UK
| | - Joanna A Leithead
- Liver Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Peter C Hayes
- Hepatology Department, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Alastair J O'Brien
- Institute of Liver Disease and Digestive Health, University College London, London, UK
| | - Sumita Verma
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
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6
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Santoiemma PP, Dakwar O, Angarone MP. A retrospective analysis of cases of Spontaneous Bacterial Peritonitis in cirrhosis patients. PLoS One 2020; 15:e0239470. [PMID: 32986728 PMCID: PMC7521743 DOI: 10.1371/journal.pone.0239470] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 09/04/2020] [Indexed: 12/18/2022] Open
Abstract
Background & aims Spontaneous Bacterial Peritonitis (SBP) is an infection in patients with cirrhosis and carries significant mortality. The management of SBP is evolving with the rise of multidrug resistant organisms. Our aim was to perform a retrospective analysis to determine if identification of bacteria in culture could aid in prognosis and provide information regarding optimal treatment. Methods We analyzed our 10-year experience of SBP in a single academic center (Northwestern Memorial Hospital). We obtained information regarding SBP prophylaxis, culture data and resistance patterns of bacteria, choice/duration of inpatient antibiotics, and key laboratory measurements and determined outcomes including mortality, hospital duration, and ICU stay. Results Patients with SBP had a 17.8% mortality and had culture positive SBP 34.4% of the time. Antimicrobial resistance was seen in 21.3% of cases and trended towards worsening mortality, with worsened mortality associated with first line use of piperacillin-tazobactam (p = 0.0001). Patients on SBP prophylaxis who developed SBP had improved mortality (p<0.0001) unless there was a positive culture, in which case patients had worsened mortality (p = 0.019). Patient with a higher PMN counts after repeat paracentesis had higher mortality (p = 0.02). Conclusions Our results show that SBP continues to be a morbid and deadly condition and identification of an organism is key in treatment. The standard initial antibiotic for SBP may need to be modified to reflect emerging resistant pathogens and gram-positive organisms. Further, antibiotic prophylaxis should be utilized only in select cases to prevent development of resistance.
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Affiliation(s)
- Phillip Pasquale Santoiemma
- Department of Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Omar Dakwar
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Michael Peter Angarone
- Department of Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
- * E-mail:
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7
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Komolafe O, Roberts D, Freeman SC, Wilson P, Sutton AJ, Cooper NJ, Pavlov CS, Milne EJ, Hawkins N, Cowlin M, Thorburn D, Davidson BR, Tsochatzis E, Gurusamy KS. Antibiotic prophylaxis to prevent spontaneous bacterial peritonitis in people with liver cirrhosis: a network meta-analysis. Cochrane Database Syst Rev 2020; 1:CD013125. [PMID: 31978256 PMCID: PMC6984637 DOI: 10.1002/14651858.cd013125.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Approximately 2.5% of all hospitalisations in people with liver cirrhosis are for spontaneous bacterial peritonitis. Spontaneous bacterial peritonitis is associated with significant short-term mortality; therefore, it is important to prevent spontaneous bacterial peritonitis in people at high risk of developing it. Antibiotic prophylaxis forms the mainstay preventive method, but this has to be balanced against the development of drug-resistant spontaneous bacterial peritonitis, which is difficult to treat, and other adverse events. Several different prophylactic antibiotic treatments are available; however, there is uncertainty surrounding their relative efficacy and optimal combination. OBJECTIVES To compare the benefits and harms of different prophylactic antibiotic treatments for prevention of spontaneous bacterial peritonitis in people with liver cirrhosis using a network meta-analysis and to generate rankings of the different prophylactic antibiotic treatments according to their safety and efficacy. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trials registers to November 2018 to identify randomised clinical trials in people with cirrhosis at risk of developing spontaneous bacterial peritonitis. SELECTION CRITERIA We included only randomised clinical trials (irrespective of language, blinding, or status) in adults with cirrhosis undergoing prophylactic treatment to prevent spontaneous bacterial peritonitis. We excluded randomised clinical trials in which participants had previously undergone liver transplantation, or were receiving antibiotics for treatment of spontaneous bacterial peritonitis or other purposes. DATA COLLECTION AND ANALYSIS We performed a network meta-analysis with OpenBUGS using Bayesian methods and calculated the odds ratio, rate ratio, and hazard ratio (HR) with 95% credible intervals (CrI) based on an available-case analysis, according to National Institute of Health and Care Excellence Decision Support Unit guidance. MAIN RESULTS We included 29 randomised clinical trials (3896 participants; nine antibiotic regimens (ciprofloxacin, neomycin, norfloxacin, norfloxacin plus neomycin, norfloxacin plus rifaximin, rifaximin, rufloxacin, sparfloxacin, sulfamethoxazole plus trimethoprim), and 'no active intervention' in the review. Twenty-three trials (2587 participants) were included in one or more outcomes in the review. The trials that provided the information included people with cirrhosis due to varied aetiologies, with or without other features of decompensation, having ascites with low protein or previous history of spontaneous bacterial peritonitis. The follow-up in the trials ranged from 1 to 12 months. Many of the trials were at high risk of bias, and the overall certainty of evidence was low or very low. Overall, approximately 10% of trial participants developed spontaneous bacterial peritonitis and 15% of trial participants died. There was no evidence of differences between any of the antibiotics and no intervention in terms of mortality (very low certainty) or number of serious adverse events (very low certainty). However, because of the wide CrIs, clinically important differences in these outcomes cannot be ruled out. None of the trials reported health-related quality of life or the proportion of people with serious adverse events. There was no evidence of differences between any of the antibiotics and no intervention in terms of proportion of people with 'any adverse events' (very low certainty), liver transplantation (very low certainty), or the proportion of people who developed spontaneous bacterial peritonitis (very low certainty). The number of 'any' adverse events per participant was fewer with norfloxacin (rate ratio 0.74, 95% CrI 0.59 to 0.94; 4 trials, 546 participants; low certainty) and sulfamethoxazole plus trimethoprim (rate ratio 0.19, 95% CrI 0.02 to 0.81; 1 trial, 60 participants; low certainty) versus no active intervention. There was no evidence of differences between the other antibiotics and no intervention in the number of 'any' adverse events per participant (very low certainty). There were fewer other decompensation events with rifaximin versus no active intervention (rate ratio 0.61, 65% CrI 0.46 to 0.80; 3 trials, 575 participants; low certainty) and norfloxacin plus neomycin (rate ratio 0.06, 95% CrI 0.00 to 0.33; 1 trial, 22 participants; low certainty). There was no evidence of differences between the other antibiotics and no intervention in the number of decompensations events per participant (very low certainty). None of the trials reported health-related quality of life or development of symptomatic spontaneous bacterial peritonitis. One would expect some correlation between the above outcomes, with interventions demonstrating effectiveness across several outcomes. This was not the case. The possible reasons for this include sparse data and selective reporting bias, which makes the results unreliable. Therefore, one cannot draw any conclusions from these inconsistent differences based on sparse data. There was no evidence of any differences in the subgroup analyses (performed when possible) based on whether the prophylaxis was primary or secondary. FUNDING the source of funding for five trials were organisations who would benefit from the results of the study; six trials received no additional funding or were funded by neutral organisations; and the source of funding for the remaining 18 trials was unclear. AUTHORS' CONCLUSIONS Based on very low-certainty evidence, there is considerable uncertainty about whether antibiotic prophylaxis is beneficial, and if beneficial, which antibiotic prophylaxis is most beneficial in people with cirrhosis and ascites with low protein or history of spontaneous bacterial peritonitis. Future randomised clinical trials should be adequately powered, employ blinding, avoid postrandomisation dropouts (or perform intention-to-treat analysis), and use clinically important outcomes such as mortality, health-related quality of life, and decompensation events.
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Affiliation(s)
| | - Danielle Roberts
- University College LondonDivision of Surgery and Interventional ScienceLondonUKNW3 2PF
| | - Suzanne C Freeman
- University of LeicesterDepartment of Health SciencesUniversity RoadLeicesterUKLE1 7RH
| | - Peter Wilson
- University College London Hospitals NHS Foundation TrustClinical Microbiology and Virology5th Floor Central250 Euston RoadLondonUKNW1 2PG
| | - Alex J Sutton
- University of LeicesterDepartment of Health SciencesUniversity RoadLeicesterUKLE1 7RH
| | - Nicola J Cooper
- University of LeicesterDepartment of Health SciencesUniversity RoadLeicesterUKLE1 7RH
| | - Chavdar S Pavlov
- 'Sechenov' First Moscow State Medical UniversityCenter for Evidence‐Based MedicinePogodinskja st. 1\1MoscowRussian Federation119881
| | | | - Neil Hawkins
- University of GlasgowHEHTAUniversity Ave Glasgow G12 8QQGlasgowUK
| | | | - Douglas Thorburn
- Royal Free Hospital and the UCL Institute of Liver and Digestive HealthSheila Sherlock Liver CentrePond StreetLondonUKNW3 2QG
| | - Brian R Davidson
- University College LondonDivision of Surgery and Interventional ScienceLondonUKNW3 2PF
| | - Emmanuel Tsochatzis
- Royal Free Hospital and the UCL Institute of Liver and Digestive HealthSheila Sherlock Liver CentrePond StreetLondonUKNW3 2QG
| | - Kurinchi Selvan Gurusamy
- University College LondonDivision of Surgery and Interventional ScienceLondonUKNW3 2PF
- 'Sechenov' First Moscow State Medical UniversityCenter for Evidence‐Based MedicinePogodinskja st. 1\1MoscowRussian Federation119881
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8
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Gurusamy KS, Wilson P, Tsochatzis E. Antibiotic prophylaxis to prevent spontaneous bacterial peritonitis in people with liver cirrhosis: a network meta-analysis. Hippokratia 2018. [DOI: 10.1002/14651858.cd013125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Kurinchi Selvan Gurusamy
- Royal Free Campus, UCL Medical School; Department of Surgery; Royal Free Hospital Rowland Hill Street London UK NW3 2PF
| | - Peter Wilson
- University College London Hospitals NHS Foundation Trust; Clinical Microbiology and Virology; 60 Whitfield Street London UK W1T 4EU
| | - Emmanuel Tsochatzis
- Royal Free Hospital and the UCL Institute of Liver and Digestive Health; Sheila Sherlock Liver Centre; Pond Street London UK NW3 2QG
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9
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Melcarne L, Sopeña J, Martínez-Cerezo FJ, Vergara M, Miquel M, Sánchez-Delgado J, Dalmau B, Machlab S, Portilla D, González-Padrón Y, Real Álvarez M, Carpintero C, Casas M. Prognostic factors of liver cirrhosis mortality after a first episode of spontaneous bacterial peritonitis. A multicenter study. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2018; 110:94-101. [PMID: 29313695 DOI: 10.17235/reed.2017.4517/2016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Spontaneous bacterial peritonitis is an infectious complication with a negative impact on survival of patients with cirrhosis. OBJECTIVE To analyze the short- and long-term survival after a first episode of bacterial peritonitis and the associated prognostic factors. PATIENTS AND METHODS This was a retrospective, multicenter study of patients admitted to hospital for spontaneous bacterial peritonitis between 2008 and 2013. Independent variables related to mortality were analyzed by logistic regression. The prognostic power of the Child Pugh Score, the Model for End-Stage Liver Disease (MELD) and the Charlson index was analyzed by ROC curve. RESULTS A total of 159 patients were enrolled, 72% were males with a mean age of 63.5 years and a mean MELD score of 19 (SD ± 9.5). Mortality at 30 and 90 days and one and two years was 21%, 31%, 55% and 69%, respectively. Hepatic encephalopathy (p = 0.008, OR 3.5, 95% CI 1.4-8.8) and kidney function (p = 0.026, OR 2.7, 95% CI 1.13-16.7) were independent factors for short- and long-term mortality. MELD was a good marker of short- and long-term survival (area under the curve [AUC] 0.7: 95% CI 1.02-1.4). The Charlson index was related to long-term mortality (AUC 0.68: 95% CI 0.6-0.77). CONCLUSIONS Short- and long-term mortality of spontaneous bacterial peritonitis is still high. The main prognostic factors for mortality are impairment of liver and kidney function. MELD and the Charlson index are good markers of survival.
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Affiliation(s)
- Luigi Melcarne
- Unidad de Hepatología. Servicio Aparato Digestivo, Hospital Universitari Parc Taulí - Sabadell
| | - Julia Sopeña
- Servicio Aparato Digestivo, Hospital Universitari Joan XXIII - Tarragona
| | | | - Mercedes Vergara
- Unidad de Hepatología. Servicio Aparato Digestivo, Hospital Universitari Parc Taulí - Sabadell
| | - Mireia Miquel
- Unidad de Hepatología. Servicio Aparato Digestivo, Hospital Universitari Parc Taulí - Sabadell
| | - Jordi Sánchez-Delgado
- Unidad de Hepatología. Servicio Aparato Digestivo, Hospital Universitari Parc Taulí - Sabadell
| | - Blai Dalmau
- Unidad de Hepatología. Servicio Aparato Digestivo, Hospital Universitari Parc Taulí - Sabadell
| | - Salvador Machlab
- Unidad de Hepatología. Servicio Aparato Digestivo, Hospital Universitari Parc Taulí - Sabadell
| | - Dustin Portilla
- Servicio Aparato Digestivo, Hospital Universitari Joan XXIII - Tarragona
| | | | | | | | - Meritxell Casas
- Unidad de Hepatología. Servicio Aparato Digestivo, Hospital Universitari Parc Taulí - Sabadell
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10
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Casper M, Mengel M, Fuhrmann C, Herrmann E, Appenrodt B, Schiedermaier P, Reichert M, Bruns T, Engelmann C, Grünhage F, Lammert F. The INCA trial (Impact of NOD2 genotype-guided antibiotic prevention on survival in patients with liver Cirrhosis and Ascites): study protocol for a randomized controlled trial. Trials 2015; 16:83. [PMID: 25887140 PMCID: PMC4359533 DOI: 10.1186/s13063-015-0594-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 02/09/2015] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Patients with liver cirrhosis have a highly elevated risk of developing bacterial infections that significantly decrease survival rates. One of the most relevant infections is spontaneous bacterial peritonitis (SBP). Recently, NOD2 germline variants were found to be potential predictors of the development of infectious complications and mortality in patients with cirrhosis. The aim of the INCA (Impact of NOD2 genotype-guided antibiotic prevention on survival in patients with liver Cirrhosis and Ascites) trial is to investigate whether survival of this genetically defined high-risk group of patients with cirrhosis defined by the presence of NOD2 variants is improved by primary antibiotic prophylaxis of SBP. METHODS/DESIGN The INCA trial is a double-blind, placebo-controlled clinical trial with two parallel treatment arms (arm 1: norfloxacin 400 mg once daily; arm 2: placebo once daily; 12-month treatment and observational period). Balanced randomization of 186 eligible patients with stratification for the protein content of the ascites (<15 versus ≥ 15 g/L) and the study site is planned. In this multicenter national study, patients are recruited in at least 13 centers throughout Germany. The key inclusion criterion is the presence of a NOD2 risk variant in patients with decompensated liver cirrhosis. The most important exclusion criteria are current SBP or previous history of SBP and any long-term antibiotic prophylaxis. The primary endpoint is overall survival after 12 months of treatment. Secondary objectives are to evaluate whether the frequencies of SBP and other clinically relevant infections necessitating antibiotic treatment, as well as the total duration of unplanned hospitalization due to cirrhosis, differ in both study arms. Recruitment started in February 2014. DISCUSSION Preventive strategies are required to avoid life-threatening infections in patients with liver cirrhosis, but unselected use of antibiotics can trigger resistant bacteria and worsen outcome. Thus, individualized approaches that direct intervention only to patients with the highest risk are urgently needed. This trial meets this need by suggesting stratified prevention based on genetic risk assessment. To our knowledge, the INCA trial is first in the field of hepatology aimed at rapidly transferring and validating information on individual genetic risk into clinical decision algorithms. TRIAL REGISTRATIONS German Clinical Trials Register DRKS00005616 . Registered 22 January 2014. EU Clinical Trials Register EudraCT 2013-001626-26 . Registered 26 January 2015.
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Affiliation(s)
- Markus Casper
- Department of Medicine II, Saarland University Medical Center, Kirrberger Straße 100, 66421, Homburg, Germany.
| | - Martin Mengel
- Study Center Bonn, Institute of Clinical Chemistry and Clinical Pharmacology, University Hospital Bonn, Sigmund-Freud-Straße 25, 53125, Bonn, Germany.
| | - Christine Fuhrmann
- Study Center Bonn, Institute of Clinical Chemistry and Clinical Pharmacology, University Hospital Bonn, Sigmund-Freud-Straße 25, 53125, Bonn, Germany.
| | - Eva Herrmann
- Institute for Biostatistics and Mathematical Modelling, Goethe University Hospital, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.
| | - Beate Appenrodt
- Department of Medicine II, Saarland University Medical Center, Kirrberger Straße 100, 66421, Homburg, Germany.
| | - Peter Schiedermaier
- Department of Medicine, Nardini Hospital, Kaiserstraße 14, 66482, Zweibrücken, Germany.
| | - Matthias Reichert
- Department of Medicine II, Saarland University Medical Center, Kirrberger Straße 100, 66421, Homburg, Germany.
| | - Tony Bruns
- Department of Medicine IV, University Hospital Jena, Bachstraße 18, 07743, Jena, Germany.
| | - Cornelius Engelmann
- Department of Medicine II, University Hospital Leipzig, Liebigstraße 18, 04103, Leipzig, Germany.
| | - Frank Grünhage
- Department of Medicine II, Saarland University Medical Center, Kirrberger Straße 100, 66421, Homburg, Germany.
| | - Frank Lammert
- Department of Medicine II, Saarland University Medical Center, Kirrberger Straße 100, 66421, Homburg, Germany.
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11
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O'Brien AJ, Fullerton JN, Massey KA, Auld G, Sewell G, James S, Newson J, Karra E, Winstanley A, Alazawi W, Garcia-Martinez R, Cordoba J, Nicolaou A, Gilroy DW. Immunosuppression in acutely decompensated cirrhosis is mediated by prostaglandin E2. Nat Med 2014; 20:518-23. [PMID: 24728410 DOI: 10.1038/nm.3516] [Citation(s) in RCA: 209] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 02/28/2014] [Indexed: 12/14/2022]
Abstract
Liver disease is one of the leading causes of death worldwide. Patients with cirrhosis display an increased predisposition to and mortality from infection due to multimodal defects in the innate immune system; however, the causative mechanism has remained elusive. We present evidence that the cyclooxygenase (COX)-derived eicosanoid prostaglandin E2 (PGE2) drives cirrhosis-associated immunosuppression. We observed elevated circulating concentrations (more than seven times as high as in healthy volunteers) of PGE2 in patients with acute decompensation of cirrhosis. Plasma from these and patients with end-stage liver disease (ESLD) suppressed macrophage proinflammatory cytokine secretion and bacterial killing in vitro in a PGE2-dependent manner via the prostanoid type E receptor-2 (EP2), effects not seen with plasma from patients with stable cirrhosis (Child-Pugh score grade A). Albumin, which reduces PGE2 bioavailability, was decreased in the serum of patients with acute decompensation or ESLD (<30 mg/dl) and appears to have a role in modulating PGE2-mediated immune dysfunction. In vivo administration of human albumin solution to these patients significantly improved the plasma-induced impairment of macrophage proinflammatory cytokine production in vitro. Two mouse models of liver injury (bile duct ligation and carbon tetrachloride) also exhibited elevated PGE2, reduced circulating albumin concentrations and EP2-mediated immunosuppression. Treatment with COX inhibitors or albumin restored immune competence and survival following infection with group B Streptococcus. Taken together, human albumin solution infusions may be used to reduce circulating PGE2 levels, attenuating immune suppression and reducing the risk of infection in patients with acutely decompensated cirrhosis or ESLD.
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Affiliation(s)
- Alastair J O'Brien
- Centre for Clinical Pharmacology and Therapeutics, Division of Medicine, University College London, London, UK
| | - James N Fullerton
- Centre for Clinical Pharmacology and Therapeutics, Division of Medicine, University College London, London, UK
| | - Karen A Massey
- Manchester Pharmacy School, Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
| | - Grace Auld
- Centre for Clinical Pharmacology and Therapeutics, Division of Medicine, University College London, London, UK
| | - Gavin Sewell
- Division of Medicine, University College London, London, UK
| | - Sarah James
- Centre for Clinical Pharmacology and Therapeutics, Division of Medicine, University College London, London, UK
| | - Justine Newson
- Centre for Clinical Pharmacology and Therapeutics, Division of Medicine, University College London, London, UK
| | - Effie Karra
- Centre for Clinical Pharmacology and Therapeutics, Division of Medicine, University College London, London, UK
| | - Alison Winstanley
- Department of Histopathology, University College London Hospitals, London, UK
| | - William Alazawi
- Liver Unit, Centre for Digestive Diseases, Blizard Institute of Cell and Molecular Science, Queen Mary University of London, London, UK
| | - Rita Garcia-Martinez
- Hospital Clínic de Barcelona, Servicio de Hepatología, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Joan Cordoba
- Centro de Investigacion Biomédica en Red de Enfermedades Hepaticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
| | - Anna Nicolaou
- Manchester Pharmacy School, Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
| | - Derek W Gilroy
- Centre for Clinical Pharmacology and Therapeutics, Division of Medicine, University College London, London, UK
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12
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Hemkens LG, Contopoulos-Ioannidis DG, Ioannidis JP. Concordance of effects of medical interventions on hospital admission and readmission rates with effects on mortality. CMAJ 2013; 185:E827-37. [PMID: 24144601 PMCID: PMC3855143 DOI: 10.1503/cmaj.130430] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Many clinical trials examine a composite outcome of admission to hospital and death, or infer a relationship between hospital admission and survival benefit. This assumes concordance of the outcomes "hospital admission" and "death." However, whether the effects of a treatment on hospital admissions and readmissions correlate to its effect on serious outcomes such as death is unknown. We aimed to assess the correlation and concordance of effects of medical interventions on admission rates and mortality. METHODS We searched the Cochrane Database of Systematic Reviews from its inception to January 2012 (issue 1, 2012) for systematic reviews of treatment comparisons that included meta-analyses for both admission and mortality outcomes. For each meta-analysis, we synthesized treatment effects on admissions and death, from respective randomized trials reporting those outcomes, using random-effects models. We then measured the concordance of directions of effect sizes and the correlation of summary estimates for the 2 outcomes. RESULTS We identified 61 meta-analyses including 398 trials reporting mortality and 182 trials reporting admission rates; 125 trials reported both outcomes. In 27.9% of comparisons, the point estimates of treatment effects for the 2 outcomes were in opposite directions; in 8.2% of trials, the 95% confidence intervals did not overlap. We found no significant correlation between effect sizes for admission and death (Pearson r = 0.07, p = 0.6). Our results were similar when we limited our analysis to trials reporting both outcomes. INTERPRETATION In this metaepidemiological study, admission and mortality outcomes did not correlate, and discordances occurred in about one-third of the treatment comparisons included in our analyses. Both outcomes convey useful information and should be reported separately, but extrapolating the benefits of admission to survival is unreliable and should be avoided.
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Affiliation(s)
- Lars G. Hemkens
- Stanford Prevention Research Center (Hemkens, Ioannidis), Department of Medicine, Stanford University School of Medicine, Stanford, Calif.; Basel Institute for Clinical Epidemiology and Biostatistics (Hemkens), University Hospital Basel, Basel, Switzerland; Department of Pediatrics (Contopoulos-Ioannidis), Division of Infectious Diseases, Stanford University School of Medicine, Stanford, Calif.; Health Policy Research (Contopoulos-Ioannidis), Palo Alto Medical Foundation Research Institute, Palo Alto, Calif.; Department of Health Research and Policy (Ioannidis), Stanford University School of Medicine; Department of Statistics (Ioannidis), Stanford University School of Humanities and Sciences, Stanford, Calif
| | - Despina G. Contopoulos-Ioannidis
- Stanford Prevention Research Center (Hemkens, Ioannidis), Department of Medicine, Stanford University School of Medicine, Stanford, Calif.; Basel Institute for Clinical Epidemiology and Biostatistics (Hemkens), University Hospital Basel, Basel, Switzerland; Department of Pediatrics (Contopoulos-Ioannidis), Division of Infectious Diseases, Stanford University School of Medicine, Stanford, Calif.; Health Policy Research (Contopoulos-Ioannidis), Palo Alto Medical Foundation Research Institute, Palo Alto, Calif.; Department of Health Research and Policy (Ioannidis), Stanford University School of Medicine; Department of Statistics (Ioannidis), Stanford University School of Humanities and Sciences, Stanford, Calif
| | - John P.A. Ioannidis
- Stanford Prevention Research Center (Hemkens, Ioannidis), Department of Medicine, Stanford University School of Medicine, Stanford, Calif.; Basel Institute for Clinical Epidemiology and Biostatistics (Hemkens), University Hospital Basel, Basel, Switzerland; Department of Pediatrics (Contopoulos-Ioannidis), Division of Infectious Diseases, Stanford University School of Medicine, Stanford, Calif.; Health Policy Research (Contopoulos-Ioannidis), Palo Alto Medical Foundation Research Institute, Palo Alto, Calif.; Department of Health Research and Policy (Ioannidis), Stanford University School of Medicine; Department of Statistics (Ioannidis), Stanford University School of Humanities and Sciences, Stanford, Calif
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13
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Madsen BS, Havelund T, Krag A. Targeting the gut-liver axis in cirrhosis: antibiotics and non-selective β-blockers. Adv Ther 2013; 30:659-70. [PMID: 23881723 DOI: 10.1007/s12325-013-0044-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Indexed: 02/08/2023]
Abstract
The gut-liver axis in cirrhosis and portal hypertension is gaining increasing attention as a key pathophysiological mechanism responsible for progression of liver failure and development of complications such as spontaneous infections and hepatocellular carcinoma. Antibiotics and non-selective β-blockers (NSBB) intercept this axis and each drug has proven efficacy in clinical trials. A synergistic effect is a hitherto unproven possibility. There is an increasing body of evidence supporting improved outcome with expanded use of NSBB and antibiotic therapy beyond current indications. This review addresses the issue of pharmacological treatment of cirrhosis and portal hypertension with antibiotics and NSBB. We discuss their mechanism of action and suggest that combining the two treatment modalities could potentially reduce the risk of complications.
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Pleguezuelo M, Benitez JM, Jurado J, Montero JL, De la Mata M. Diagnosis and management of bacterial infections in decompensated cirrhosis. World J Hepatol 2013; 5:16-25. [PMID: 23383362 PMCID: PMC3562722 DOI: 10.4254/wjh.v5.i1.16] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Revised: 08/29/2012] [Accepted: 11/25/2012] [Indexed: 02/06/2023] Open
Abstract
Bacterial infections are one of the most frequent complications in cirrhosis and result in high mortality rates. Patients with cirrhosis have altered and impaired immunity, which favours bacterial translocation. Episodes of infections are more frequent in patients with decompensated cirrhosis than those with compensated liver disease. The most common and life-threatening infection in cirrhosis is spontaneous bacterial peritonitis followed by urinary tract infections, pneumonia, endocarditis and skin and soft-tissue infections. Patients with decompensated cirrhosis have increased risk of developing sepsis, multiple organ failure and death. Risk factors associated with the development of infections are severe liver failure, variceal bleeding, low ascitic protein level and prior episodes of spontaneous bacterial peritonitis (SBP). The prognosis of these patients is closely related to a prompt and accurate diagnosis. An appropriate treatment decreases the mortality rates. Preventive strategies are the mainstay of the management of these patients. Empirical antibiotics should be started immediately following the diagnosis of SBP and the first-line antibiotic treatment is third-generation cephalosporins. However, the efficacy of currently recommended empirical antibiotic therapy is very low in nosocomial infections including SBP, compared to community-acquired episodes. This may be associated with the emergence of infections caused by Enterococcus faecium and extended-spectrum β-lactamase-producing Enterobacteriaceae, which are resistant to the first line antimicrobial agents used for treatment. The emergence of resistant bacteria, underlines the need to restrict the use of prophylactic antibiotics to patients with the greatest risk of infections. Nosocomial infections should be treated with wide spectrum antibiotics. Further studies of early diagnosis, prevention and treatment are needed to improve the outcomes in patients with decompensated cirrhosis.
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Affiliation(s)
- Maria Pleguezuelo
- Maria Pleguezuelo, Jose Manuel Benitez, Juan Jurado, Jose Luis Montero, Manuel De la Mata, Liver Research Unit, Reina Sofia University Hospital, Avda Menendez Pidal s/n, 14004 Cordoba, Spain
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Abstract
Antimicrobial prophylaxis is commonly used by clinicians for the prevention of numerous infectious diseases, including herpes simplex infection, rheumatic fever, recurrent cellulitis, meningococcal disease, recurrent uncomplicated urinary tract infections in women, spontaneous bacterial peritonitis in patients with cirrhosis, influenza, infective endocarditis, pertussis, and acute necrotizing pancreatitis, as well as infections associated with open fractures, recent prosthetic joint placement, and bite wounds. Perioperative antimicrobial prophylaxis is recommended for various surgical procedures to prevent surgical site infections. Optimal antimicrobial agents for prophylaxis should be bactericidal, nontoxic, inexpensive, and active against the typical pathogens that can cause surgical site infection postoperatively. To maximize its effectiveness, intravenous perioperative prophylaxis should be administered within 30 to 60 minutes before the surgical incision. Antimicrobial prophylaxis should be of short duration to decrease toxicity and antimicrobial resistance and to reduce cost.
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Affiliation(s)
- Mark J Enzler
- Division of Infectious Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
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Lata J, Stiburek O, Kopacova M. Spontaneous bacterial peritonitis: a severe complication of liver cirrhosis. World J Gastroenterol 2010. [PMID: 19938187 DOI: 10.3748/wig.15.5505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
This report presents a survey of current knowledge concerning one of the relatively frequent and severe complications of liver cirrhosis and associated ascites-spontaneous bacterial peritonitis. Epidemiology, aetiology, pathogenesis, clinical manifestation, diagnosis and present possibilities of treatment are discussed.
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Lata J, Stiburek O, Kopacova M. Spontaneous bacterial peritonitis: A severe complication of liver cirrhosis. World J Gastroenterol 2009; 15:5505-10. [PMID: 19938187 PMCID: PMC2785051 DOI: 10.3748/wjg.15.5505] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
This report presents a survey of current knowledge concerning one of the relatively frequent and severe complications of liver cirrhosis and associated ascites-spontaneous bacterial peritonitis. Epidemiology, aetiology, pathogenesis, clinical manifestation, diagnosis and present possibilities of treatment are discussed.
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