Spontaneous bacterial peritonitis: prevention and therapy

Comparison of clinical characteristics and outcomes of spontaneous bacterial peritonitis and culture negative neutrocytic ascites

OBJECTIVE

Ascitic fluid infections (AFI) in cirrhotic patients can be classified into two groups: spontaneous bacterial peritonitis (SBP) and culture-negative neutrocytic ascites (CNNA). The aim of this study was to compare the clinical characteristics and outcomes of the two groups of patients with AFI.

METHODS

We retrospectively reviewed the medical records of cirrhotic patients with AFI. We evaluated demographic data, clinical presentations of AFI, laboratory findings, liver function, and mortality rates.

RESULTS

Between January 2005 and December 2014, 533 patients with AFI were evaluated; 259 (48.6%) had SBP and 274 (51.4%) CNNA. Ascites neutrophil count (4410/mm³ versus 1046/mm³, p < .001) and the blood culture positive rate (38.1% versus 20.1%, p < .001) were higher in the SBP group, which also had a higher MELD score (24.29 versus 22.05, p = .004). Seven-day mortality was higher in the SBP group (9.4% versus 4.5%, p = .027) but there was no significant difference in 30-day (22.1% versus 17.5%) or 90-day mortality rate (36.1% versus 36.4%).

CONCLUSIONS

Patients in the SBP group had a higher MELD score, ascites neutrophil count, and positive blood culture rate. Although seven-day mortality rate was higher in the SBP group, the 30-day and 90-day mortality rates were similar in the two groups.

Impairment of innate immune responses in cirrhotic patients and treatment by branched-chain amino acids

It has been reported that host defense responses, such as phagocytic function of neutrophils and natural killer (NK) cell activity of lymphocytes, are impaired in cirrhotic patients. This review will concentrate on the impairment of innate immune responses in decompensated cirrhotic patients and the effect of the treatment by branched-chain amino acids (BCAA) on innate immune responses. We already reported that phagocytic function of neutrophils was significantly improved by 3-mo BCAA supplementation. In addition, the changes of NK activity were also significant at 3 mo of supplementation compared with before supplementation. Also, Fisher’s ratios were reported to be significantly increased at 3 mo of BCAA supplementation compared with those before oral supplementation. Therefore, administration of BCAA could reduce the risk of bacterial and viral infection in patients with decompensated cirrhosis by restoring impaired innate immune responses of the host. In addition, it was also revealed that BCAA oral supplementation could reduce the risk of development of hepatocellular carcinoma in cirrhotic patients. The mechanisms of the effects will also be discussed in this review article.

Haemophilus paraphrophilus peritonitis followed by tuberculous peritonitis and Pott's disease

Patients with alcoholic cirrhosis who have ascites have a high risk of developing spontaneous bacterial peritonitis (SBP). The authors report a case of SBP caused by Haemophilus paraphrophilus, the first-reported SBP in literature with this pathogen. Later on, the patient also developed tuberculous (TB) peritonitis associated with thoracic Pott's disease, a combination never reported before. The diagnoses were confirmed by positive mycobacterium cultures of both omental tissues and vertebral tissues. This report also illustrates prominent computed tomography findings of TB peritonitis and magnetic resonance imaging of spinal cord compression of Pott's disease. Tuberculosis is a treatable and curable disease and should be considered as a potential offending pathogen on differential diagnosis in SBP of alcoholic cirrhotic patients. Timely biopsy and surgical intervention with these kinds of TB are needed to lead early diagnosis and result in an excellent outcome.

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.

Restoration of innate host defense responses by oral supplementation of branched-chain amino acids in decompensated cirrhotic patients

AIM

It has been reported that host defense responses, such as phagocytic function of neutrophils and natural killer (NK) cell activity of lymphocytes, are impaired in cirrhotic patients. The aim of the present study was to examine the effects of oral supplementation of branched-chain amino acids (BCAA) on host defense mechanisms in peripheral blood of patients with decompensated cirrhosis.

METHODS

Ten patients with decompensated cirrhosis received 12 g BCAA daily for 3 months. Phagocytic function of neutrophils and NK activity of lymphocytes as well as serum albumin levels and Fisher's ratios were determined before and at 1 and 3 months of BCAA supplementation. For quantification of phagocytic function, fluorescent intensities of cells in the neutrophil region in the cytogram were determined by flow cytometry after incubation of whole blood with fluorescent microspheres. NK activity was estimated by (51)Cr release assay using K-562 cell line as target cells.

RESULTS

Phagocytic function of neutrophils was significantly improved by 3-month BCAA supplementation (P < 0.01). Thechanges of NK activity were also significant at 3 months of supplementation compared with before supplementation (P < 0.01). Fisher's ratios were significantly increased at 3 months of BCAA supplementation compared with those before oral supplementation (P < 0.05), although the changes of serum albumin level were not statistically significant.

CONCLUSIONS

BCAA oral supplementation improved phagocytic function of neutrophils and NK activity of lymphocytes in cirrhotic patients. BCAA supplementation may reduce the risk of bacterial and viral infection in patients with decompensated cirrhosis.

Dental management of patients with end-stage liver disease

This article presents a review of end-stage chronic liver disease (cirrhosis) with emphasis on the clinical presentation, diagnosis, and complications of cirrhosis, along with their medical and surgical management and prognosis. This article also discusses the evaluation and management of the dental patients with cirrhosis, including the implications decreased hepatic function has on drugs commonly used in dental treatment.

Diagnostic usefulness of carbohydrate antigen-125 in cancerous and noncancerous peritoneal effusions

Carbohydrate antigen-125 (CA-125) is a tumor marker that has been used for differential diagnosis of peritoneal malignancies. The aim of the present study was to evaluate the diagnostic usefulness of simultaneous quantification of CA-125 in peritoneal fluid and serum for abdominal cancer cases and noncancer diseases. Noncancer disease group included cirrhotic patients (n=28) and spontaneous bacterial peritonitis (SBP) patients (n=11). Abdominal cancer group was composed of histologically diagnosed various malignancies (n=10), such as gastric cancer. CA-125 levels were quantified by chemiluminescent enzyme immuno-assay. Diagnostic usefulness tests and receiver operating characteristics (ROC) curve analysis were performed for the levels of peritoneal fluid CA-125 (pCA-125) and serum CA-125 (sCA-125), and the ratio of pCA-125 to sCA-125 (p/sCA-125). The sCA-125 levels were significantly higher in noncancer patients than those in the cancer patients, while the pCA-125 levels showed no significant difference between the two groups. Notably, the p/sCA-125 ratio was significantly lower in the noncancer patients than that in the cancer patients. Area under the ROC curve was 0.267 for sCA-125, 0.542 for pCA-125 and 0.831 for p/sCA-125. The accepted cutoff values were the combination of values that gave the greatest diagnostic sensitivity plus specificity. Either sCA-125 or pCA-125 value gave lower diagnostic accuracy, whereas p/sCA-125 value demonstrated a significantly higher diagnostic accuracy (sensitivity-specificity pairs: 0.40-0.33 for sCA-125, 0.60-0.54 for pCA-125, and 0.80-0.72 for p/sCA-125, respectively). Hence, determination of p/sCA-125 improves the biochemical discrimination of abdominal cancerous cases from noncancerous diseases.

Bacterial translocation and its consequences in patients with cirrhosis

Bacterial translocation is the passage of viable bacteria from the intestinal lumen to mesenteric lymph nodes and other extraintestinal sites. Spontaneous bacterial peritonitis is the main clinical consequence of bacterial translocation in cirrhosis. Translocation of bacterial products of viable or non-viable bacteria, such as endotoxin and/or bacterial DNA, through the intestinal wall could stimulate the immune system and the hyperdynamic circulatory state in cirrhosis with clinical consequences that are under evaluation. Bacterial translocation is currently considered the passage of viable gut flora across the intestinal barrier to extraluminal sites. Aerobic Gram-negative bacilli are the most common translocating bacteria. Intestinal bacterial overgrowth, impairment in permeability of the intestinal mucosal barrier, and deficiencies in local host immune defences are the major mechanisms postulated to favour bacterial translocation in cirrhosis. Bacterial translocation is a key step in the pathogenesis of spontaneous bacteraemia and spontaneous bacterial peritonitis in cirrhosis. Translocation of intestinal bacterial products from viable or non-viable bacteria, such as endotoxin and bacterial DNA, has recently been associated with pathophysiological events, such as activation of the immune system and derangement of the hyperdynamic circulatory status in cirrhosis. Clinical consequences of these effects of bacterial products are presently under investigation.

Pharmacokinetics of fluoroquinolones in uncompensated cirrhosis: the significance of penetration in the ascitic fluid

In order to study the penetration of routinely used fluoroquinolones in the ascitic fluid of patients with uncompensated cirrhosis the following doses were given. Three patients received three consecutive iv doses of 200 mg of ciprofloxacin, six patients, three consecutive iv doses of 300 mg of ciprofloxacin, seven others, three consecutive iv doses of 400 mg of pefloxacin and six, three consecutive iv doses of 400 mg of ofloxacin. Drug levels in serum and the ascitic fluid were monitored at regular time intervals. Peak levels of the 200 mg dose of ciprofloxacin, of the 300 mg dose of ciprofloxacin, of pefloxacin and of ofloxacin in serum were 2.11,2.45,9.21 and 8.86 microg/ml, respectively and in the ascitic fluid 0.67, 0.45, 6.09 and 5.83 microg/ml, respectively T(1/2) was 3.19+/-0.73, 3.55+/-1.68, 15.60+/-12.40 and 9.45+/-3.14 h, respectively with AUC of 3.62+/-4.02, 7.39+/-4.70, 137.85+/-63.96 and 119.8+/-16.83 mg/l h. Urinary excretion of ciprofloxacin and of ofloxacin was similar to healthy individuals but pefloxacin showed a mean urinary excretion of 30.11%. It is concluded that pefloxacin and ofloxacin at the administered iv doses result in serum and ascitic fluid levels above the MICs of the common pathogens causing spontaneous bacterial peritonitis and that they should be administered to cirrhotic patients in dosing regimens similar to those in patients with normal hepatic function. The use of ciprofloxacin requires further studies to define the appropriate dose.

[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.

Changes in nature and antibiotic resistance of bacteria causing peritonitis in cirrhotic patients over a 20 year period

AIM

To assess all clinically and bacteriologically documented episodes of spontaneous bacterial peritonitis diagnosed in a single unit over a 20 year period, to identify changes in the nature and antibiotic resistance of the causative bacteria.

SETTING

A specialist liver disease unit in a tertiary care centre.

MATERIAL

Cultured ascitic fluid obtained in the course of 240 consecutive episodes of clinically and bacteriologically proven spontaneous bacterial peritonitis. Patient recruitment remained stable during the 20 year period in terms of the number of cirrhotic patients admitted and the severity of their condition.

RESULTS

78.7% of isolates were Enterobacteriaceae (Escherichia coli in 51%) and 19% were Gram positive cocci. Until 1979 all the Enterobacteriaceae had the wild phenotype, compared with only 50% at the end of the study period. Since 1993, 22% of Enterobacteriaceae have been resistant to third generation cephalosporins. Methicillin resistant staphylococci were only isolated after 1989.

CONCLUSIONS

Changes in the epidemiology and antibiotic resistance of bacteria causing spontaneous bacterial peritonitis must be monitored for optimal treatment.

Oral management of the patient with end-stage liver disease and the liver transplant patient

The patient with end-stage liver disease who is in need of a liver transplant should have a pretransplant dental evaluation. Such a patient faces lifelong immunosuppression with an increased risk of infection. This article discusses both the need for control of oral diseases before liver transplantation and guidelines for oral care in the immediately postoperative and long-term transplant patient. Specific indications for antibiotic prophylaxis and antibiotic regimens are presented; in addition, adverse reactions and side effects of immunosuppressant drugs are discussed. Pertinent drug interactions salient to the dental management of patients with end-stage liver disease are reviewed, and specific management recommendations for these patients are presented.

Rapid emergence of quinolone resistance in cirrhotic patients treated with norfloxacin to prevent spontaneous bacterial peritonitis

We carried out quantitative culturing of stools from 31 hospitalized alcoholic patients with cirrhosis and ascites, before treatment with 400 mg of norfloxacin per day, weekly for the first month, and then every 2 weeks thereafter for 15 to 229 days (median, 54 days). Members of the family Enterobacteriaceae virtually disappeared from the stools (< 10(2)/g), but treatment had little effect on enterococci. No selection of resistant organisms occurred in 15 patients, but the remaining 16 patients developed fecal organisms resistant to fluoroquinolones between days 14 and 43 of treatment (median, 25 days). Staphylococcus aureus was isolated four times, coagulase-negative Staphylococcus spp. were isolated six times, Citrobacter freundii was isolated four times, Enterobacter cloacae was isolated three times, Klebsiella oxytoca was isolated twice, Proteus rettgeri was isolated once, and untypeable streptococci were isolated six times. Some isolates persisted, while others were transient (one to seven consecutively positive cultures). The MICs of four quinolones (nalidixic acid, norfloxacin, ofloxacin, and ciprofloxacin) were determined by use of experimental microwell strips (ATB CMI; Biomerieux S.A.). All the strains isolated before treatment were susceptible to the four quinolones, with low MICs, whereas those isolated during norfloxacin treatment were highly resistant. Long-term norfloxacin administration thus carries a risk of disturbing the bacterial ecology in these patients, suggesting that digestive decontamination should no longer be prescribed routinely to cirrhotic patients with ascites.

Diuretics vs. paracentesis followed by diuretics in cirrhosis: effect on ascites opsonic activity and immunoglobulin and complement concentrations

Ascitic fluid opsonic activity and ascitic fluid C3 concentrations are important protective factors against spontaneous bacterial peritonitis. This randomized controlled study was performed to compare the effect of diuretic administration alone vs. single large-volume therapeutic paracentesis followed by administration of diuretics on ascitic fluid opsonic activity and on ascites and serum immunoglobulin and complement concentrations in patients with alcoholic cirrhosis and tense ascites. Twenty-one patients were randomly allocated to two groups: group 1 included 11 patients who were treated with diuretics alone, and group 2 included 10 patients who were treated with single large-volume therapeutic paracentesis (5 to 6 L of ascites removed) followed by diuretics. Ascitic fluid opsonic activity and serum and ascites immunoglobulin and complement concentrations were measured at the beginning and at the end of treatment. The ascitic fluid opsonic activity increased significantly in patients treated with diuretics alone (p < 0.05), whereas in the group of patients treated with therapeutic paracentesis followed by diuretics, the ascites opsonic activity remained stable. Although ascitic fluid IgG, IgA and C3 concentrations increased significantly in patients treated with diuretics alone (p < 0.05), ascitic fluid C3 concentration significantly decreased in patients from group 2 (p < 0.05), whereas IgG and IgA concentrations remained unchanged. However, in both groups of patients serum immunoglobulin and complement concentrations remained unchanged. This study suggests that in cirrhotic patients with tense ascites, treatment with diuretics alone may have the potential advantage over single large-volume therapeutic paracentesis followed by the administration of diuretics of providing better protection from spontaneous bacterial peritonitis.(ABSTRACT TRUNCATED AT 250 WORDS)

Randomized trial comparing ceftriaxone with cefonicid for treatment of spontaneous bacterial peritonitis in cirrhotic patients

We compared cefonicid (2 g every 12 h) and ceftriaxone (2 g every 24 h) for their efficacy and safety in treating spontaneous bacterial peritonitis in cirrhotic patients in an open randomized clinical trial (30 patients in each group). Clinical, laboratory, and bacteriologic characteristics were similar in both groups. Ceftriaxone-susceptible strains were isolated on 44 occasions (94%), and cefonicid-susceptible strains were isolated on 43 occasions (91.5%). The antibiotic concentration in ascitic fluid/MIC ratio for ceftriaxone was > 100 throughout the dose interval (24 h), while it was lower for cefonicid (between 1 and 18). A total of 100% of patients treated with ceftriaxone, and 94% of those treated with cefonicid were cured of their infections (P was not significant). Hospitalization mortality was 37% in the cefonicid group and 30% in the ceftriaxone group (P was not significant). The time that elapsed between the initiation of treatment and the patient's death was shorter in the cefonicid group patients (5.3 +/- 3.90 days) than in the ceftriaxone group patients (11.8 +/- 9.15 days) (P < 0.05). None of the patients presented with superinfections, and only two patients treated with cefonicid and three patients treated with ceftriaxone developed colonizations with Enterococcus faecalis or Candida albicans. Ceftriaxone and cefonicid are safe and useful agents for treating cirrhotic spontaneous bacterial peritonitis, although the pharmacokinetic characteristics of ceftriaxone seem to be more advantageous than those of cefonicid.

Antimicrobial therapy and prevention of spontaneous bacterial peritonitis

Spontaneous bacterial peritonitis is a frequent and serious infection in cirrhotic patients with ascites. A high index of suspicion is required for early diagnosis and rapid institution of treatment. The common micro-organisms involved in SBP are the aerobic Gram-negative bacilli and Gram-positive cocci that inhabit the intestine. Empiric antibiotic therapy active against these organisms should be instituted as soon as possible to improve survival. Third generation cephalosporins are very effective and safe as the initial empiric antibiotic regimen. Alternatives include beta-lactam-clavulanic acid combinations and other broad-spectrum antibiotics, although cost benefit considerations are important in selection. If cultures and susceptibility tests allow, antibiotic therapy should be altered to provide optimum narrow-spectrum and cost-effective treatment. Recent evidence suggests that (at least in the case of cefotaxime), 5-day treatment is equally effective as 10-day treatment. Except in patients awaiting liver transplantation, antibiotic prophylaxis of SBP is not recommended at present, as the few trials performed have not been able to demonstrate superior results for survival, hospital admissions or cost-effectiveness, over prompt diagnosis and therapy of individual episodes of SBP.

A prospective study of bacterial infections in patients with cirrhosis

One hundred and seventy hospitalized patients with cirrhosis were included in a prospective and sequential study, to verify the prevalence and most frequent causes of bacterial infection. The differences in clinical and laboratory data between the two groups were analyzed: group I--80 patients who developed bacterial infection and group II--90 patients without bacterial infection. The prevalence or cumulative frequency of the development of bacterial infection during one hospitalization was 47.06%. Among these, the most frequent types of infection were: spontaneous bacterial peritonitis (SBP): 31.07%, urinary tract infection (UTI): 25.24% and pneumonia: 21.37%. Community infections were more frequent (56.25%) than nosocomial infections (32.50%) and they occurred sequentially in 11.25% of the cases. The agents responsible were gram negative bacteria in 72.34% of the cases. Clinical and biochemical parameters in bacterial infection were generally correlated with the severity of liver disease. Child-Pugh classification showed a predominance of class C in infected cirrhotic patients compared to non-infected ones. During hospitalization, the mortality rate of group I was 30% whereas in group II it was 5.55% (P = 0.0001). SBP and pneumonia were the most severe types of infection, with high mortality rates, 31.25% and 40.91%, respectively. These results indicate that bacterial infection is a severe complication in the course of cirrhosis.

Selection of patients for liver transplantation

Liver transplantation is now available world-wide. It plays an important role in the treatment of irreversible acute and chronic liver disease (CLD). Selection of patients for liver transplantation is subject to many factors including economic, cultural, availability of donor organs and degree of illness. This article looks at seven general considerations for recipients of liver transplantation. As well, disease-specific criteria are investigated and include such areas as cirrhosis due to chronic hepatitis B virus (HBV), hepatitis C virus (HCV) positive cirrhosis, fulminant hepatic failure (FHF), malignancy, alcoholic liver disease (ALD), metabolic conditions and Budd-Chiari syndrome. If hepatic transplantation survival rates were to approach 95%, the relative risk ratio between transplantation and conservative therapy would increase. At present an 80% 1-5 year survival rate following transplantation should be expected.

Spontaneous bacterial peritonitis due to Clostridium perfringens in a patient with liver cirrhosis and pure red cell aplasia

A 63-year-old man with decompensated liver cirrhosis and pure red cell aplasia complained of pyrexia, abdominal distention and abdominal pain. A diagnosis of spontaneous bacterial peritonitis (SBP), Conn's syndrome, was made upon the isolation of an anaerobe Clostridium perfringens from both ascitic fluid and peripheral blood. The bacteria were found to be susceptible to piperacillin, and administration of the antimicrobial agent markedly improved his SBP. The anaerobes should be kept in mind as one of the possible pathogens of SBP, although anaerobic infection has been reported to be quite rare in the disease.

High concentrations of soluble tumor necrosis factor receptors in ascites

Ascites and plasma concentrations of soluble tumor necrosis factor receptors p55 and p75 were measured in a prospective study in 34 patients (35 occasions of ascites) with hepatic (5 infected and 21 uninfected) and malignancy-related (9) ascites. All patients had high concentrations of both soluble tumor necrosis factor receptors in ascites and plasma; these were about 500 times higher than the corresponding tumor necrosis factor-alpha concentrations. Ascites levels of soluble tumor necrosis factor receptors p55 and soluble tumor necrosis factor receptors p75 were significantly elevated in patients with malignancy-related (p55: 26.0 +/- 8.6 ng/ml; p75: 20.5 +/- 17.4 ng/ml; mean +/- S.D.) and infected ascites (p55: 25.1 +/- 10.9 ng/ml, p75: 22.6 +/- 11.0 ng/ml) compared with patients with uncomplicated hepatic ascites (p55: 10.1 +/- 4.4 ng/ml; p75: 6.0 +/- 2.6 ng/ml). Patients with infected or malignancy-related ascites also showed higher soluble tumor necrosis factor receptor concentrations in plasma than did patients with plain hepatic ascites. Successful antibiotic treatment of peritonitis reduced soluble tumor necrosis factor receptor p55 and p75 ascites levels in three patients from 24.2 +/- 15.2 ng/ml to 10.7 +/- 1.9 ng/ml and from 20.2 +/- 14.4 ng/ml to 7.5 +/- 1.8 ng/ml, respectively. Soluble tumor necrosis factor receptors p55 and p75 at cutoff levels of 16.5 ng/ml and 9.5 ng/ml, respectively, differentiated between infected or malignant and plain hepatic ascites with diagnostic accuracies of 94% and 89%, respectively. They did not differentiate between infected and malignant ascites. The concentrations of soluble tumor necrosis factor receptor p55 were usually higher in ascites than in plasma in all subgroups of patients.(ABSTRACT TRUNCATED AT 250 WORDS)