The prevalence and prognostic significance of spontaneous bacterial peritonitis in severe acute hepatitis with ascites

Epidemiology of extended-spectrum β-lactamases in Enterobacterales in Taiwan for over two decades

The emergence of antimicrobial resistance among microorganisms is a serious public health concern, and extended-spectrum β-lactamases (ESBL)-producing Enterobacterales is one of the major concerns among antibiotic-resistant bacteria. Although the prevalence of ESBL in Enterobacterales has been increasing with time, the prevalence of ESBL could differ according to the species, hospital allocation, sources of infections, nosocomial or community acquisitions, and geographic regions. Therefore, we conducted a comprehensive review of the epidemiology of ESBL-producing Enterobacterales in Taiwan. Overall, the rates of ESBL producers are higher in northern regions than in other parts of Taiwan. In addition, the genotypes of ESBL vary according to different Enterobacterales. SHV-type ESBLs (SHV-5 and SHV-12) were the major types of Enterobacter cloacae complex, but Serratia marcescens, Proteus mirabilis, Escherichia coli, and Klebsiella pneumoniae were more likely to possess CTX-M-type ESBLs (CTX-M-3 and CTX-M-14). Moreover, a clonal sequence type of O25b-ST131 has been emerging among urinary or bloodstream E. coli isolates in the community in Taiwan, and this clone was potentially associated with virulence, ESBL (CTX-M-15) production, ciprofloxacin resistance, and mortality. Finally, the evolution of the genetic traits of the ESBL-producing Enterobacterales isolates helps us confirm the interhospital and intrahospital clonal dissemination in several regions of Taiwan. In conclusion, continuous surveillance in the investigation of ESBL production among Enterobacterales is needed to establish its long-term epidemiology.

Monomicrobial non-neutrocytic bacterascites caused by aeromonas hydrophila in a patient with liver cirrhosis

Aeromonas peritonitis is a rare, but serious infection, as associated with spontaneous bacterial peritonitis, peritonitis in chronic ambulatory peritoneal dialysis, and intestinal perforation. Here, we reported a case of monomicrobial non-neutrocytic bacterascites caused by Aeromonas hydrophila (A. hydrophila). The patient, a 57-year-old man who had a history of alcoholic liver disease and chronic hepatitis C-related Child- Pugh class C liver cirrhosis, was admitted to our hospital with fever, dyspnea and a localized wound pain over left ankle. Ascitic fluid analysis demonstrated that ascitic polymorphonuclear cell count was 30 cells/ mm³. Empirical antimicrobial treatment with a combination of ceftriaxone and clindamycin were administered. However, the patient died due to fatal septic shock on Day 3. His blood and ascites cultures were positive for A. hydrophila. The case report presents the diagnosis, management, and literature review of Aeromonas monomicrobial non-neutrocytic bacterascites.

Prevalence, Clinical Profile, and Outcome of Ascitic Fluid Infection in Children With Liver Disease

OBJECTIVES

Pediatric literature on spontaneous bacterial peritonitis (SBP) is limited. We evaluated the prevalence, subtypes, clinical profile, and effect on outcome of ascitic fluid infection (AFI) in children with liver disease.

METHODS

Children with liver disease-related ascites and subjected to paracentesis were classified as no-AFI and AFI (SBP, culture-negative neutrocytic ascites [CNNA], and monomicrobial non-neutrocytic bacterascites). Clinical and laboratory parameters, in-hospital mortality, and outcome in follow-up were noted.

RESULTS

Two hundred sixty-two children (163 boys; age 84 [1-240] months, chronic liver disease [CLD, n = 173], non-CLD [n = 89]) were enrolled. A total of 28.6% (n = 75) had SBP/CNNA, more common in CLD than non-CLD (55/173 [31.7%] vs 20/89 [22.4%]; P = 0.1). A total of 50.6% SBP/CNNA cases were symptomatic for AFI. Gram-negative bacilli were isolated from 70% SBP cases. Twenty-five percent (18/72) CLD children with AFI had a poor hospital outcome, with INR, Child-Pugh score and gastrointestinal bleeding predicting outcome on multivariate analysis. Patients with CLD with SBP had higher in-hospital mortality (10/20 vs 5/35; P = 0.01) than those with CNNA, but similar Child-Pugh score (12[7-15] vs 11[7-14]; P = 0.1), recurrence of AFI (3/9 vs 6/24; P = 0.6) and mortality in follow-up (22.2% vs 25%; P = 0.1). Patients with CLD with SBP/CNNA had higher mortality over 1 year follow-up than no-AFI (24.2% [8/33] vs 12.2% [7/57]; P = 0.1) but the difference was not significant.

CONCLUSIONS

A total of 28.6% children with liver disease-related ascites have SBP/CNNA; 50% are symptomatic. Patients with CLD with SBP/CNNA have a mortality of 24% over 1year follow-up. CLD with SBP is similar to CNNA except for higher in-hospital mortality.

Reduction of the amount of intestinal secretory IgA in fulminant hepatic failure

Intestinal barrier dysfunction plays an important role in spontaneous bacterial peritonitis. In the present study, changes in the intestinal barrier with regard to levels of secretory immunoglobulin A (SIgA) and its components were studied in fulminant hepatic failure (FHF). Immunohistochemistry and double immunofluorescent staining were used to detect intestinal IgA, the secretory component (SC) and SIgA in patients with FHF (20 patients) and in an animal model with FHF (120 mice). Real-time PCR was used to detect intestinal SC mRNA in the animal model with FHF. Intestinal SIgA, IgA, and SC staining in patients with FHF was significantly weaker than in the normal control group (30 patients). Intestinal IgA and SC staining was significantly weaker in the animal model with FHF than in the control groups (normal saline: 30 mice; lipopolysaccharide: 50 mice; D-galactosamine: 50 mice; FHF: 120 mice). SC mRNA of the animal model with FHF at 2, 6, and 9 h after injection was 0.4 ± 0.02, 0.3 ± 0.01, 0.09 ± 0.01, respectively. SC mRNA of the animal model with FHF was significantly decreased compared to the normal saline group (1.0 ± 0.02) and lipopolysaccharide group (0.89 ± 0.01). The decrease in intestinal SIgA and SC induced failure of the intestinal immunologic barrier and the attenuation of gut immunity in the presence of FHF.

Aeromonas spontaneous bacterial peritonitis: a highly fatal infectious disease in patients with advanced liver cirrhosis

BACKGROUND/PURPOSE

Aeromonas infections, rarely reported in Western countries, are not uncommon infectious diseases in Taiwan. The clinical manifestations and prognostic factors of Aeromonas spontaneous bacterial peritonitis (SBP) in patients with liver cirrhosis were investigated.

METHODS

We reviewed the medical charts and microbiological records of liver cirrhosis patients with Aeromonas SBP between January 1990 and December 2005, in a medical center in southern Taiwan.

RESULTS

Thirty-one liver cirrhosis patients developed Aeromonas SBP within a 16-year period. The majority (26, 84%) had concurrent Aeromonas bacteremia. A. sobria (55%) and A. hydrophila (45%) were the causative species. The predominant clinical manifestations included fever (84%), abdominal pain (74%), hypotension on admission (48%), altered mental status (45%), and acute renal failure (42%). Gram-negative bacilli were found in Gram staining of ascitic fluids in 27% of 26 patients, while aeromonads were isolated from ascitic fluids in 55% of 31 patients. The yield rate of ascitic fluid cultures decreased greatly, if paracentesis was performed at > 3 hours after the administration of antimicrobial therapy. All but one patient received in-vitro-active antimicrobial agents within 48 hours, but the all-cause mortality rate was 56%. Initial high Pitt's bacteremia score was independently associated with a fatal outcome in multivariate analysis.

CONCLUSION

Aeromonas SBP is a fatal disease, and must be included in the differential diagnosis of SBP in patients with advanced liver cirrhosis in endemic areas.

Natural history and risk factors in fulminant hepatic failure

BACKGROUND

The natural history of fulminant hepatic failure (FHF) without liver transplantation is not well known.

AIMS

To study the natural history and prognostic factors, especially the presence of ascites and spontaneous bacterial peritonitis (SBP), in children with FHF.

METHODS

FHF was defined by the onset of encephalopathy within 12 weeks of onset of jaundice. From August 1997 to December 2000, 67 children (< or =12 years) were diagnosed with FHF. Their clinical features, investigations and outcome were noted. Viral markers A to E (IgM, anti-HAV; IgM, anti-HEV, HBsAg, and anti-HCV) were determined by ELISA. SBP was defined by the presence of > or =250 neutrophils with or without a positive culture in ascitic fluid.

RESULTS

Mean age of the children was 5.8 years with an almost equal sex distribution. Viral markers were positive in 63 (94%) cases: hepatitis A in 34 (54%), E in 17 (27%), A+E in seven (11%), and B in five (8%). Thirty one children presented with grade I or II encephalopathy and all recovered, whereas 17 of 36 children who had grade III or IV encephalopathy died. Ascites was detected (both clinically and ultrasonically) in 34 (51%) cases, nine (26%) of which had SBP. Overall mortality was 25%. Mortality was higher in those who had ascites than in those who did not (32% v 18%); among those with ascites it was maximum in those who had SBP (78% v 16%). Total serum bilirubin and grade of encephalopathy were significantly higher, serum albumin was significantly lower, and prothrombin time was significantly prolonged in those who died than in those who recovered.

CONCLUSION

The natural history of FHF in Indian children depends on age, grade of encephalopathy, ascites, and SBP. SBP depicts worse outcome. In all cases of FHF with ascites, the presence of SBP should be investigated.

Ascites and spontaneous bacterial peritonitis in fulminant hepatic failure

OBJECTIVE

Although presence of ascites has been reported in patients with fulminant hepatic failure (FHF), spontaneous bacterial peritonitis (SBP) has not been studied in a large group of such patients. Hence, the present study was conducted to evaluate the prevalence and prognostic significance of ascites and SBP in FHF patients.

METHODS

Two hundred ninety-eight consecutive patients (mean age 32.9+/-14.8 yr) with FHF were studied. There were 133 (44.6%) men and 165 (55.4%) women. Acute viral hepatitis accounted for 91.6% of the patients and were analyzed in the present study.

RESULTS

Ascites was clinically detected in 79 (28.9%) patients. The patients with ascites were older (p = 0.005), had longer jaundice-encephalopathy interval (p<0.0000001), lesser grade of encephalopathy on admission (p = 0.0000043), and a lower incidence of raised intracranial pressure on admission (p = 0.0007). Patients with ascites had significantly lower serum albumin (p = 0.021), ALT (p = 0.0005), AST (p = 0.00017), and PT (p = 0.002) on admission than in patients without ascites. Multivariate logistic regression analysis showed that jaundice-encephalopathy interval (> or =14 days) and serum albumin (< or =2.5 g/dl) were the only independent predictors of ascites. SBP was detected in 14 (17.7%) patients (neutrocytic culture positive, 4; neutrocytic culture negative, 9; and monomicrobial bacterascites, 1). Escherichia coli was identified in three patients. Survival was no different between patients with and those without ascites and also between patients with and those without SBP.

CONCLUSIONS

Ascites is a frequent accompaniment of FHF and is complicated by SBP. Jaundice-encephalopathy interval of 14 days or more and serum albumin (< or =2.5 g/dl) on admission predicts the development of ascites in these patients.

Short-course ceftriaxone therapy in spontaneous bacterial peritonitis

Forty patients with spontaneous bacterial peritonitis, three of whom had complicating acute hepatitis syndrome, eight late-onset hepatic failure, and 29 with cirrhosis, were treated with ceftriaxone 2 g intravenously once daily for 5 days. Ascitic fluid culture was positive in 28 patients, with Escherichia coli and Klebsiella as common isolates. All the bacteria isolated were sensitive to ceftriaxone except Enterococcus faecalis, which was isolated in a cirrhotic patient. All culture-positive patients sensitive to ceftriaxone showed bacteriological cure and 26 (65%) patients showed cytological cure after 48 hours of treatment. A total of 95% were cured of their infection after 5 days of treatment. Twelve (30%) patients died during hospitalisation after documented cure of their spontaneous bacterial peritonitis (renal failure, gastrointestinal bleed and cerebral oedema were the primary causes of death). Infection-related mortality due to Pseudomonas septicaemia was seen in one cirrhotic patient.

Spontaneous bacterial peritonitis in fulminant hepatic failure

Ascites may be associated with fulminant hepatic failure (FHF), but spontaneous bacterial peritonitis (SBP) is an extremely rare complication. We report on two patients with FHF who developed SBP. One patient died and the other recovered.

Prevalence and prognostic significance of bacterascites in cirrhosis with ascites

The prevalence and prognostic significance of bacterascites (BA) were prospectively studied in 443 predominantly HBsAg-positive cirrhotic patients with ascites. Spontaneous bacterial peritonitis (SBP), culture-negative neutrocytic ascites (CNNA), and BA were identified in 12.4%, 8.4%, and 10.8%, respectively. Of these, 67%, 70%, and 71%, respectively, had peritonitis-related signs or symptoms. Among patients with SBP or CNNA, the clinical and laboratory data showed no significant difference between the symptomatic and asymptomatic groups. In contrast, among the patients with BA, the symptomatic group had significantly higher levels of serum total bilirubin and prolonged prothrombin time and significantly lower levels of ascitic fluid total protein than the asymptomatic group. Furthermore, the clinical and laboratory data were relatively similar between patients with asymptomatic BA and those with sterile ascites. In contrast, patients with SBP, CNNA, or symptomatic BA exhibited significantly more severe degrees of liver disease and significantly lower levels of ascitic fluid total protein than those with sterile ascites. There was no statistically significant difference between SBP and bacterascites regarding flora. All patients with SBP, CNNA, or symptomatic BA received antibiotic treatment immediately after paracentesis, as did six of the 14 patients with asymptomatic BA for concurrent respiratory or urinary tract infection, while the remaining eight patients with asymptomatic BA were followed clinically without treatment. Repeated paracentesis in the latter revealed no evidence of SBP or CNNA. The in-hospital mortality for sterile ascites was 22.8%, significantly lower than the 54.5% for SBP, 43.2% for CNNA, and 50% for symptomatic BA, but similar to the 21.4% for asymptomatic BA.(ABSTRACT TRUNCATED AT 250 WORDS)