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Cortese F, Fransvea P, Saputelli A, Ballardini M, Baldini D, Gioffre A, Marcello R, Sganga G. Streptococcus pneumoniae primary peritonitis mimicking acute appendicitis in an immunocompetent patient: a case report and review of the literature. J Med Case Rep 2019; 13:126. [PMID: 31029142 PMCID: PMC6486957 DOI: 10.1186/s13256-019-2038-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 02/28/2019] [Indexed: 12/31/2022] Open
Abstract
Introduction Primary peritonitis without an identifiable intra-abdominal source is extremely rare in healthy individuals; it is commonly seen in cases of nephrotic syndrome, cirrhosis and end-stage liver disease, ascites, immunosuppression, and inflamed peritoneum due to pre-existing autoimmune and oncological conditions. Case presentation We present the case of a 68-year-old Caucasian woman operated on due to acute abdomen with a provisional diagnosis of acute appendicitis. During the operation a small amount of free intra-abdominal fluid was found. Her uterus, ovaries, and fallopian tubes were macroscopically normal. Therefore, with the suspicion of appendicitis, appendectomy was performed. Her blood cultures were negative while peritoneal fluid was positive for capsulated form of Streptococcus pneumoniae. A 30-day follow-up was performed and she was asymptomatic without any sign of infection. Discussion Streptococcus pneumoniae commonly causes upper respiratory tract infection and cutaneous infections. It very rarely causes gastrointestinal infection and it is very rarely responsible for primary peritonitis and septic shock syndrome. Conclusion Pneumococcal peritonitis has a rare occurrence and represents a clinical challenge because of its subtle and non-specific clinical findings. The interest in our case lays in the relatively rare diagnosis of primary peritonitis mimicking acute appendicitis.
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Affiliation(s)
- Francesco Cortese
- Emergency Surgery and Trauma Care Unit - St Filippo Neri Hospital, Rome, Italy
| | - Pietro Fransvea
- Faculty of Medicine and Psychology, University of Rome "La Sapienza", St. Andrea's Hospital, Via Di Grottarossa, 1035-39, 00189, Rome, Italy.
| | - Alessandra Saputelli
- Faculty of Medicine and Psychology, University of Rome "La Sapienza", St. Andrea's Hospital, Via Di Grottarossa, 1035-39, 00189, Rome, Italy.,Emergency Surgery and Trauma Care Unit - St Filippo Neri Hospital, Rome, Italy
| | | | - Daniela Baldini
- Anatomical Pathology - St Filippo Neri Hospital, Rome, Italy
| | - Aldo Gioffre
- Emergency Surgery and Trauma Care Unit - St Filippo Neri Hospital, Rome, Italy
| | - Roberto Marcello
- Diagnostic and Interventional Radiology Unit - St Filippo Neri Hospital, Rome, Italy
| | - Gabriele Sganga
- UOC Chirurgia d'Urgenza, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
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2
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Araiz JJ, Serrano MT, García-Gil FA, Lacruz EM, Lorente S, Sánchez JI, Suarez MA. Intention-to-treat survival analysis of hepatitis C virus/human immunodeficiency virus coinfected liver transplant: Is it the waiting list? Liver Transpl 2016; 22:1186-96. [PMID: 27114030 DOI: 10.1002/lt.24474] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Accepted: 04/08/2016] [Indexed: 01/13/2023]
Abstract
In human immunodeficiency virus (HIV)/hepatitis C virus (HCV) coinfected patients, the accelerated severity of liver disease, associated comorbidities, and mortality on the waiting list could change the possibility and results of liver transplantation (LT). Intention-to-treat survival analysis (ITTA) can accurately estimate the applicability and efficacy of LT. The primary objective of this study was to compare the survival of patients with HCV with and without HIV infection. We analyzed a cohort of 199 patients with HCV infection enrolled for LT between 1998 and 2015; 17 were also infected with HIV. The patients with HCV/HIV coinfection had higher mortality on the waiting list than those with HCV monoinfection (35.3% versus 4.6%; P < 0.001). ITTA at 1, 3, and 4 years was 75%, 64%, and 57% for HCV monoinfection and 52%, 47%, and 39% for HCV/HIV coinfection, respectively (Wilcoxon test P < 0.05). The ITTA at 1, 3, 6, and 12 months was 96%, 91%, 87%, and 75% for HCV monoinfection and 76%, 70%, 64%, and 52% for HCV/HIV coinfection, respectively (log-rank P < 0.05; Wilcoxon test P < 0.01). A Cox regression analysis was carried out including all variables with predictive value in the univariate analysis, showing that only donor age > 70 years (hazard ratio [HR] = 3.12; P < 0.05), United Network for Organ Sharing status 1 (HR = 10.1; P < 0.01), Model for End-Stage Liver Disease (HR = 1.13; P < 0.001), and HIV coinfection (HR = 2.65; P < 0.05) had independent negative predictive value for survival. In conclusion, our study indicates that HIV coinfection is a factor in mortality prior to transplantation and associated with higher mortality on the waiting list. Liver Transplantation 22 1186-1196 2016 AASLD.
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Affiliation(s)
- Juan J Araiz
- Transplant Procurement Management, University Hospital Lozano Blesa, Zaragoza, Spain.,Intensive Care Unit, University Hospital Lozano Blesa, Zaragoza, Spain.,Department of Medicine, University Hospital Lozano Blesa, Zaragoza, Spain
| | - M Trinidad Serrano
- Department of Medicine, University Hospital Lozano Blesa, Zaragoza, Spain.,Liver Unit, Department of Gastroenterology, University Hospital Lozano Blesa, Zaragoza, Spain.,Instituto de Investigación Sanitaria Aragón, Zaragoza, Spain
| | - Francisco A García-Gil
- Instituto de Investigación Sanitaria Aragón, Zaragoza, Spain.,Hepatic Surgery Unit, Department of Surgery, University Hospital Lozano Blesa, Zaragoza, Spain.,Department of Surgery, University of Zaragoza, Zaragoza, Spain
| | - Elena M Lacruz
- Intensive Care Unit, University Hospital Lozano Blesa, Zaragoza, Spain
| | - Sara Lorente
- Liver Unit, Department of Gastroenterology, University Hospital Lozano Blesa, Zaragoza, Spain.,Instituto de Investigación Sanitaria Aragón, Zaragoza, Spain
| | - José I Sánchez
- Intensive Care Unit, University Hospital Lozano Blesa, Zaragoza, Spain
| | - Miguel A Suarez
- Intensive Care Unit, University Hospital Lozano Blesa, Zaragoza, Spain.,Department of Medicine, University Hospital Lozano Blesa, Zaragoza, Spain
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3
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Merli M, Messina E, Salpietro S, Lazzarin A, Uberti-Foppa C, Hasson H. Marked Decrease in Lymphocyte Count in HIV/Hepatitis C Virus (HCV)-Coinfected Patients With Advanced Liver Disease During Anti-HCV Treatment With Direct-Acting Antiviral Regimens Including Ribavirin. Clin Infect Dis 2016; 62:527-8. [PMID: 26508514 DOI: 10.1093/cid/civ902] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Marco Merli
- Infectious Diseases Clinic, San Raffaele Hospital Vita-Salute San Raffaele University, Milano, Italy
| | - Emanuela Messina
- Infectious Diseases Clinic, San Raffaele Hospital Vita-Salute San Raffaele University, Milano, Italy
| | | | - Adriano Lazzarin
- Infectious Diseases Clinic, San Raffaele Hospital Vita-Salute San Raffaele University, Milano, Italy
| | | | - Hamid Hasson
- Infectious Diseases Clinic, San Raffaele Hospital
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4
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Pérez-Cameo C, Vargas V, Castells L, Bilbao I, Campos-Varela I, Gavaldà J, Pahissa A, Len O. Etiology and mortality of spontaneous bacterial peritonitis in liver transplant recipients: a cohort study. Liver Transpl 2014; 20:856-63. [PMID: 24723503 DOI: 10.1002/lt.23889] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 03/17/2014] [Accepted: 04/03/2014] [Indexed: 02/07/2023]
Abstract
Spontaneous bacterial peritonitis (SBP) in liver transplantation (LT) recipients who progress to cirrhosis has received little attention. We investigated the adequacy of empirical treatment with third-generation cephalosporins for SBP in this population and the impact of transplantation on the evolution of the infection. We performed a cohort study with 138 SBP episodes: 19 in LT patients and 119 in non-LT patients. The etiology of SBP was identified for 73.7% of the episodes in LT patients and for 38.7% of the episodes in non-LT patients (P = 0.004). The main microorganisms in recipients were Escherichia coli (35.7%) and Streptococcus pneumoniae (21.4%). The etiologies did not differ in non-LT patients. The cephalosporin sensitivity was similar in the 2 groups (85.7% versus 78.4%, P = 0.7). LT recipients developed renal failure (57.9% versus 25.2%, P = 0.004) and encephalopathy (42.1% versus 22%, P = 0.08) more often than non-LT patients, and the mortality rates during episodes (52.6% versus 13.4%, P < 0.001) and at 6 months (70.6% versus 34.7%, P = 0.005) were higher. According to a multivariate analysis, the mortality-associated risk factors at diagnosis were a Model for End-Stage Liver Disease (MELD) score > 18 odds ratio (OR) = 6.1 and being an LT recipient (OR = 4.45). At 6 months, the risk factors for mortality were a MELD score > 18 (OR = 3.08), being an LT recipient (OR = 3.47), a known etiology (OR = 2.08), and the presence of hepatocellular carcinoma (OR = 3.73).
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Affiliation(s)
- Cristina Pérez-Cameo
- Liver Unit, Department of Internal Medicine, Vall d'Hebron Hospital, Barcelona, Spain
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5
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Huang HJ, Yang J, Huang YC, Pan HY, Wang H, Ren ZC. Diagnostic feature of tuberculous peritonitis in patients with cirrhosis: A matched case-control study. Exp Ther Med 2014; 7:1028-1032. [PMID: 24669272 PMCID: PMC3964927 DOI: 10.3892/etm.2014.1538] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Accepted: 01/30/2014] [Indexed: 12/26/2022] Open
Abstract
The aim of the present study was to compare the clinical characteristics of tuberculous peritonitis (TBP) and spontaneous bacterial peritonitis (SBP) in patients with cirrhosis. A retrospective, matched case-control study was conducted consisting of 12 patients with cirrhosis diagnosed with TBP between 2008 and 2011. Control subjects were patients with SBP. Clinical features and laboratory data were analyzed. Compared with SBP, TBP in patients with cirrhosis was frequently associated with extraperitoneal tuberculosis (25 vs. 0%), a more insidious onset (39.67±30.00 vs. 21.60±21.50 days; P<0.05), Child-Pugh classification B at onset (67 vs. 32%; P<0.05) and lymphopenia (0.67±0.22 vs. 1.19±0.41×109/l; P<0.01). Patients with TBP tended to have lymphocytic predominance in the peritoneal fluid (92%), while patients with SBP tended to have neutrophil predominance (68%). Compared with the SBP group, the TBP group had significantly higher ascitic protein, adenosine deaminase (ADA) and lactate dehydrogenase (LDH) levels. Ascitic protein levels were >25 g/l in 9 patients (75%) in the TBP group and in 2 patients (8%) in the SBP group; ascitic ADA activity levels were >27 U/l in 8 patients (67%) in the TBP group, but were not >27 U/l in any of the patients in the SBP group; ascitic LDH levels were >90 U/l in 10 patients (83%) in the TBP group and 5 patients (20%) in the SBP group. Therefore, the results of the present study indicate that TBP should be considered in cirrhotic patients with relevant clinical manifestations and characteristics of laboratory observations.
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Affiliation(s)
- Hai-Jun Huang
- Department of Infectious Disease, Zhejiang Provincial People's Hospital, Hangzhou, Zheijiang 310014, P.R. China
| | - Jin Yang
- Department of Medicine, Blood Center of Zhejiang Province, Hangzhou, Zheijiang 310061, P.R. China ; Transform Medicine Center, Affiliated Hospital of Hangzhou Normal University, Hangzhou, Zheijiang 310015, P.R. China
| | - Yi-Cheng Huang
- Department of Infectious Disease, Zhejiang Provincial People's Hospital, Hangzhou, Zheijiang 310014, P.R. China
| | - Hong-Ying Pan
- Department of Infectious Disease, Zhejiang Provincial People's Hospital, Hangzhou, Zheijiang 310014, P.R. China
| | - Hong Wang
- Department of Infectious Disease, Zhejiang Provincial People's Hospital, Hangzhou, Zheijiang 310014, P.R. China
| | - Zhuo-Chao Ren
- Department of Respiratory Medicine, Zhejiang Provincial People's Hospital, Hangzhou, Zheijiang 310014, P.R. China
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6
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Alexopoulou A, Papadopoulos N, Eliopoulos DG, Alexaki A, Tsiriga A, Toutouza M, Pectasides D. Increasing frequency of gram-positive cocci and gram-negative multidrug-resistant bacteria in spontaneous bacterial peritonitis. Liver Int 2013; 33:975-81. [PMID: 23522099 DOI: 10.1111/liv.12152] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Accepted: 02/22/2013] [Indexed: 02/13/2023]
Abstract
BACKGROUND Spontaneous bacterial peritonitis (SBP) is historically caused by Gram-negative bacteria (GNB) almost exclusively Enterobacteriaceae. Recently, an increasing rate of infections with Gram-positive cocci (GPC) and multidrug-resistant (MDR) microorganisms was demonstrated. AIMS To assess possible recent changes of the bacteria causing SBP in cirrhotic patients. METHODS We retrospectively recorded 47 cases (66% males) during a 4-year-period (2008-2011). RESULTS Twenty-eight (60%) patients had healthcare-associated infections while 15 (32%) received prophylactic quinolone treatment. GPC were found to be the most frequent cause (55%). The most prevalent organisms in a descending order were Streptococcus spp (n = 10), Enterococcus spp (n = 9), Escherichia coli (n = 8), Klebsiella pneumonia (n = 5), methicillin-sensitive Staphylococcus aureus (n = 4) and coagulase-negative Staphylococcus spp (n = 3). Nine of the isolated bacteria (19%) were MDR, including carbapenemase-producing K. pneumonia (n = 4), followed by extended-spectrum beta-lactamase-producing E. coli (n = 3) and Pseudomonas aeruginosa (n = 2). MDR bacteria were more frequently isolated in healthcare-associated than in community-acquired infections (100% vs 50%, P = 0.006), in patients receiving long-term quinolone prophylaxis (67% vs 24%, P = 0.013) and in those with advanced liver disease as suggested by higher MELD score (28 vs 19, P = 0.012). More infections with GNB than GPC were healthcare-associated (81% vs 42%, P = 0.007). Third-generation cephalosporin resistance was observed in 49% and quinolone resistance in 47%. CONCLUSIONS GPC were the most frequent bacteria in culture-positive SBP and a variety of drug-resistant microorganisms have emerged. As a result of high rates of resistance in currently recommended therapy and prophylaxis, the choice of optimal antibiotic therapy is vital in the individual patient.
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7
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Mesenterial, omental, and peritoneal disorders in antiretroviral-treated HIV/AIDS patients: spectrum of cross-sectional imaging findings. Clin Imaging 2012; 37:427-39. [PMID: 23068054 DOI: 10.1016/j.clinimag.2012.08.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2012] [Accepted: 08/23/2012] [Indexed: 12/13/2022]
Abstract
In the era of highly active antiretroviral therapy, radiologists are increasingly confronted with a progressively aging HIV-infected population with improved immune function and survival, in whom a wide spectrum of infectious and neoplastic opportunistic disorders may be encountered. Furthermore, HIV / AIDS patients commonly have unspecific symptoms and physical signs, multicentric or coexisting diseases, so that diagnostic imaging studies are crucial to correctly identify and stage HIV-related abnormalities. Currently, volumetric multidetector CT (MDCT) provides comprehensive assessment and confident post-treatment follow-up of opportunistic abnormalities involving the mesentery, omentum, and peritoneum. In this pictorial essay, the cross-sectional imaging appearances of opportunistic disorders involving the mesentery, peritoneum, or both compartments in HIV / AIDS patients are reviewed, with emphasis on those MDCT findings that may be helpful for differential diagnosis along with knowledge of the degree of immune suppression as measured by the CD4 lymphocyte count. Familiarity with the varied spectrum of HIV-related opportunistic disorders encountered in antiretroviral - treated patients and their imaging appearances should allow radiologists to improve their confidence in the characterization of abnormal findings observed on abdominal cross-sectional imaging studies.
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8
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Desai AP, Reau N, Reddy KG, Te HS, Mohanty S, Satoskar R, DeVoss A, Jensen D. Persistent spontaneous bacterial peritonitis: a common complication in patients with spontaneous bacterial peritonitis and a high score in the model for end-stage liver disease. Therap Adv Gastroenterol 2012; 5:275-83. [PMID: 22973414 PMCID: PMC3437533 DOI: 10.1177/1756283x11417037] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES Spontaneous bacterial peritonitis (SBP) is associated with a high mortality rate. After antibiotic therapy, improvement in fluid polymorphonuclear (PMN) cell count is expected within 2 days. However, our institution recognized cases unresponsive to standard treatment. METHODS To study these recalcitrant cases, we completed a retrospective chart review of patients admitted for SBP to the University of Chicago from 2002 to 2007. SBP was defined by an ascitic PMN cell count ≥250/ml. RESULTS Of 55 patients with SBP, 15 did not show improvement in fluid PMN cell count to below 250/ml with standard treatment, leading to a prevalence of 27%. The patients with persistent SBP were younger than those with nonpersistent SBP [mean (SD) 51.80 (9.84) compared with 58.13 (8.79); p = 0.0253]. Persistent SBP had a higher serum ascites albumin gradient (SAAG) [median (Q1, Q3) 1.85 (1.50, 2.41) compared with 1.10 (0.60, 1.60)] and a higher score in the model for end-stage liver disease (MELD) [mean (SD) 27.98 (8.09) compared with 22.22 (8.10)] than nonpersistent SBP patients; p = 0.027 and p = 0.023, respectively. In addition, persistent SBP patients were more likely to have a positive ascitic fluid culture than nonpersistent SBP patients [odds ratio (OR) (95% CI) 4.33 (1.21, 15.47); p = 0.024]. Importantly, in-hospital mortality in the persistent SBP group was 40%, compared with 22.5% in the nonpersistent SBP group [OR = 2.30 (0.64, 8.19); p = 0.20]. CONCLUSIONS The risk of persistent SBP is nearly 40% in patients with MELD score >25, SAAG >1.5 or positive ascitic fluid culture. Furthermore, patients who develop persistent SBP tend to experience a higher mortality rate. This study underscores the importance of further examination of this vulnerable population.
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Affiliation(s)
- Archita P. Desai
- Section of Gastroenterology, Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Nancy Reau
- Center for Liver Diseases, Department of Medicine, University of Chicago Medical Center, 5841 South Maryland Avenue, MC 7120, Chicago, IL 60637, USA
| | - K. Gautham Reddy
- Section of Gastroenterology, Center for Liver Diseases, Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Helen S. Te
- Section of Gastroenterology, Center for Liver Diseases, Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Smruti Mohanty
- Section of Gastroenterology, Center for Liver Diseases, Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Rohit Satoskar
- Georgetown Transplant Institute, Georgetown University Medical Center, Washington, DC, USA
| | - Amanda DeVoss
- Section of Gastroenterology, Center for Liver Diseases, Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Donald Jensen
- Section of Gastroenterology, Center for Liver Diseases, Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
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9
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TANDON PUNEETA, GARCIA–TSAO GUADALUPE. Renal dysfunction is the most important independent predictor of mortality in cirrhotic patients with spontaneous bacterial peritonitis. Clin Gastroenterol Hepatol 2011; 9:260-5. [PMID: 21145427 PMCID: PMC3713475 DOI: 10.1016/j.cgh.2010.11.038] [Citation(s) in RCA: 121] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2010] [Revised: 11/20/2010] [Accepted: 11/24/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Spontaneous bacterial peritonitis (SBP) is the most common infection among patients with cirrhosis. To improve stratification of patient care, we performed a systematic review to identify the most robust predictors of mortality in cirrhotic patients with SBP. METHODS We reviewed prognostic studies (English language only) of adult patients with SBP, defined as a polymorphonuclear ascitic fluid cell count of 250 cells/mm(3) or more, with or without positive results from culture of ascitic fluid. We reviewed only studies that performed survival and multivariate analyses and reported in-hospital or mortalities within 30 days. RESULTS Of 2008 available references, 18 were included in the study (median, 115 patients per trial). The median age of patients was 56 years (68% male). The most common predictors of death were renal dysfunction, lack of SBP resolution, immunosuppressive factors, and hospital-acquired SBP. Sensitivity analysis using the 12 best-quality studies identified renal dysfunction and levels of blood urea nitrogen and creatinine as the most important variables. The mortality rate among patients with renal dysfunction was 67%, compared with only 11% of patients who maintained normal renal function. CONCLUSIONS Renal dysfunction is the main prognostic factor for cirrhotic patients with SBP, followed by the MELD score. Further studies are needed to determine whether these factors identified retain prognostic value in high-risk patients who receive albumin. Risk stratification might be used to select additional treatments, such as early vasoconstrictor therapy, for the highest-risk group.
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Affiliation(s)
- PUNEETA TANDON
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut,Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - GUADALUPE GARCIA–TSAO
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut
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10
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HIV infection and the liver: the importance of HCV-HIV coinfection and drug-induced liver injury. Clin Liver Dis 2011; 15:131-52. [PMID: 21111997 DOI: 10.1016/j.cld.2010.09.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Hepatitis C virus-Human immunodeficiency virus (HCV-HIV) coinfections are identified in up to 30% of patients infected with HIV and in 8% of patients infected with HCV. Now that progression of HIV and deaths due to AIDS can be prevented by highly active antiretroviral therapy (HAART), it is clear that HCV coinfection is associated with accelerated progression to cirrhosis and increased liver-related morbidity and mortality. Antiviral therapy with pegylated interferon and ribavirin for HCV in HCV-HIV coinfected patients is less successful than in patients with HCV monoinfection, and HAART can cause drug-induced liver injury. Multiple barriers limit the number of HCV-HIV coinfected patients who receive antiviral therapy for HCV, and the role of orthotopic liver transplantation (OLT) in HIV monoinfected and HCV-HIV coinfected patients remains controversial. Clinical trials of HCV-specific protease or polymerase inhibitors combined with pegylated interferon and ribavirin are needed urgently in coinfected patients, both before and after OLT.
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11
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Arvaniti V, D'Amico G, Fede G, Manousou P, Tsochatzis E, Pleguezuelo M, Burroughs AK. Infections in patients with cirrhosis increase mortality four-fold and should be used in determining prognosis. Gastroenterology 2010; 139:1246-56, 1256.e1-5. [PMID: 20558165 DOI: 10.1053/j.gastro.2010.06.019] [Citation(s) in RCA: 762] [Impact Index Per Article: 54.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2010] [Revised: 05/18/2010] [Accepted: 06/08/2010] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS A staged prognostic model of cirrhosis based on varices, ascites, and bleeding has been proposed. We analyzed data on infections in patients with cirrhosis to determine whether it is also a prognostic factor. METHODS Studies were identified by MEDLINE, EMBASE, COCHRANE, and ISI Web of Science searches (1978-2009); search terms included sepsis, infection, mortality, and cirrhosis. Studies (n = 178) reporting more than 10 patients and mortality data were evaluated (225 cohorts, 11,987 patients). Mortality after 1, 3, and 12 months was compared with severity, site, microbial cause of infection, etiology of cirrhosis, and publication year. Pooled odds ratio of death was compared for infected versus noninfected groups (18 cohorts, 2317 patients). RESULTS Overall median mortality of infected patients was 38%: 30.3% at 1 month and 63% at 12 months. Pooled odds ratio for death of infected versus noninfected patients was 3.75 (95% confidence interval, 2.12-4.23). In 101 studies that reported spontaneous bacterial peritonitis (7062 patients), the median mortality was 43.7%: 31.5% at 1 month and 66.2% at 12 months. In 30 studies that reported bacteremia (1437 patients), the median mortality rate was 42.2%. Mortality before 2000 was 47.7% and after 2000 was 32.3% (P = .023); mortality was reduced only at 30 days after spontaneous bacterial peritonitis (49% vs 31.5%; P = .005). CONCLUSIONS In patients with cirrhosis, infections increase mortality 4-fold; 30% of patients die within 1 month after infection and another 30% die by 1 year. Prospective studies with prolonged follow-up evaluation and to evaluate preventative strategies are needed.
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Affiliation(s)
- Vasiliki Arvaniti
- The Sheila Sherlock Liver Centre, and University Department of Surgery, Royal Free Hospital and University College London, London, United Kingdom
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12
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Waisman DC, Tyrrell GJ, Kellner JD, Garg S, Marrie TJ. Pneumococcal peritonitis: Still with us and likely to increase in importance. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2010; 21:e23-7. [PMID: 21358876 PMCID: PMC2852291 DOI: 10.1155/2010/867571] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Pneumococcal peritonitis is uncommon and poorly understood. METHODS As part of a five-year study (2000 to 2004) of invasive pneumococcal disease (IPD) in Alberta, all cases of peritonitis due to Streptococcus pneumoniae were reviewed and compared with all other cases of IPD. RESULTS Twenty-three of 1768 (1.3%) IPD patients were found to have peritonitis. Patients with peritonitis were more likely to have cirrhosis, hepatitis C, alcoholism and HIV/AIDS, than the remainder of the patients with IPD. The all-cause mortality did not differ between the two groups. Peritonitis was classified as primary in nine (39%) patients, secondary in 12 (52%) patients, and genitourinary in females, specifically, in two (9%) patients. Pneumococcal serotypes causing peritonitis were under-represented in current vaccines - 17% among peritonitis patients versus 53% for the remainder of IPD patients for the 7-valent pneumococcal conjugate vaccine, and 56% versus 86% for the 23-valent pneumococcal polysaccharide vaccine. CONCLUSIONS Peritonitis represents a small subset of patients with IPD, but one that is likely to grow in importance given the increase in the number of patients with hepatitis C and HIV, and the reduced coverage of peritonitis serotypes in currently available vaccines.
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Affiliation(s)
- Darcy C Waisman
- University College Dublin, Dublin, Ireland
- Department of Medicine, Faculty of Medicine and Dentistry
| | - Gregory J Tyrrell
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton
| | | | - Sipi Garg
- EPICORE centre, University of Alberta, Edmonton, Alberta
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13
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Al Anazi AR. Gastrointestinal opportunistic infections in human immunodeficiency virus disease. Saudi J Gastroenterol 2009; 15:95-9. [PMID: 19568572 PMCID: PMC2702983 DOI: 10.4103/1319-3767.48965] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2008] [Accepted: 11/18/2008] [Indexed: 12/15/2022] Open
Abstract
Gastrointestinal (GI) opportunistic infections (OIs) are commonly encountered at various stages of human immunodeficiency virus (HIV) disease. In view of the suppressive nature of the virus and the direct contact with the environment, the GI tract is readily accessible and is a common site for clinical expression of HIV. The subject is presented based on information obtained by electronic searches of peer-reviewed articles in medical journals, Cochrane reviews and PubMed sources. The spectrum of GI OIs ranges from oral lesions of Candidiasis, various lesions of viral infections, hepatobiliary lesions, pancreatitis and anorectal lesions. The manifestations of the disease depend on the level of immunosuppression, as determined by the CD4 counts. The advent of highly active antiretroviral therapy has altered the pattern of presentation, resorting mainly to features of antimicrobial-associated colitis and side effects of antiretroviral drugs. The diagnosis of GI OIs in HIV/acquired immunodeficiency syndrome patients is usually straightforward. However, subtle presentations require that the physicians should have a high index of suspicion when given the setting of HIV infection.
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Affiliation(s)
- Awadh R Al Anazi
- Department of Medicine (38), King Khalid University Hospital, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
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Role of host and bacterial virulence factors in Escherichia coli spontaneous bacterial peritonitis. Eur J Gastroenterol Hepatol 2008; 20:924-9. [PMID: 18794608 DOI: 10.1097/meg.0b013e3282fc7390] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Host factors and bacterial virulence determinants may play a role in Escherichia coli (E. coli) spontaneous bacterial peritonitis. We evaluated the importance of these factors in the emergence of fluoroquinolone-resistant strains and outcome in cirrhotic patients with E. coli spontaneous bacterial peritonitis. METHODS E. coli spontaneous bacterial peritonitis was detected in a 2-year period in three tertiary hospitals. Clinical and bacteriological data were obtained. Phylogenetic group and 15 virulence genes of E. coli strains were analyzed by polymerase gene reaction and compared with 50 isolates from pyelonephritis patients. RESULTS Forty-seven E. coli spontaneous bacterial peritonitis patients were identified, 18 (38%) were fluoroquinolone-resistant, a 12% increase compared with our earlier series from 1997 to 2002. Fluoroquinolone resistance was associated with norfloxacin prophylaxis, increased resistance to trimethoprim-sulfamethoxazole and cefotaxime, and less bacterial virulence, as demonstrated by a higher prevalence of 'nonpathogenic' phylogenetic groups A+B1 (56 vs. 28%; P=0.04) and lower virulence scores in fluoroquinolone-resistant E. coli compared with fluoroquinolone-susceptible E. coli. E. coli strains from cirrhotic patients belonged more frequently to 'nonpathogenic' phylogenetic groups A+B1, had fewer virulence factors and higher rates of fluoroquinolone resistance than isolates from pyelonephytis patients. Immunosuppression was independently associated with in-hospital and 3-month mortality. Bacterial virulence factors were unrelated to mortality. CONCLUSION Fluoroquinolone-resistant E. coli spontaneous bacterial peritonitis prevalence is increasing because of norfloxacin prophylaxis. Strains from peritonitis are less virulent than strains from pyelonephritis because of a higher prevalence of A+B1 phylogeny and quinolone resistance. Mortality is related to immunosuppression, but not to bacterial virulence factors.
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Abstract
PURPOSE OF REVIEW Portal hypertension is responsible for most of the complications associated with cirrhosis, specifically variceal hemorrhage, ascites and hepatic encephalopathy. Progress in understanding the pathophysiology of portal hypertension and improvements in the diagnosis and management of its complications that have occurred over the last year are discussed. RECENT FINDINGS Endothelial dysfunction contributes to the pathogenesis of portal hypertension and may represent a novel therapeutic target. Hepatic venous pressure gradient measurements, when properly performed, are useful in the management of patients with cirrhosis. Hyponatremia in cirrhosis has prognostic value and novel aquaretic and other agents may provide alternative approaches to the management of chronic liver disease. The mechanisms for bacterial translocation in cirrhosis that predisposes patients to infectious complications, such as spontaneous bacterial peritionitis, are being explored. Adrenal insufficiency is common in septic patients with advanced cirrhosis and corticosteroids may provide a survival benefit. Pulmonary disease complicates the management of patients with advanced liver disease. SUMMARY Significant advances continue to be made in the diagnosis and management of the complications of portal hypertension in the face of an increasing burden of chronic liver disease.
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Affiliation(s)
- Andres T Blei
- Division of Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA.
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