Mortality from Spontaneous Bacterial Peritonitis Among Hospitalized Patients in the USA

Early Diagnostic Paracentesis Improves Outcomes of Hospitalized Patients With Cirrhosis and Ascites: A Systematic Review and Meta-Analysis

INTRODUCTION

Diagnostic paracentesis is recommended for patients with cirrhosis admitted to the hospital, but adherence is suboptimal with unclear impact on clinical outcomes. The aim of this meta-analysis was to assess the outcomes of early vs delayed diagnostic paracentesis among hospitalized patients with cirrhosis and ascites.

METHODS

We searched multiple databases for studies comparing early vs delayed diagnostic paracentesis among hospitalized patients with cirrhosis and ascites. The pooled odds ratio (OR) and mean difference with confidence intervals (CIs) for proportional and continuous variables were calculated using the random-effects model. Early diagnostic paracentesis was defined as receiving diagnostic paracentesis within 12-24 hours of admission. The primary outcome was in-hospital mortality. Secondary outcomes were length of hospital stay, acute kidney injury, and 30-day readmission.

RESULTS

Seven studies (n = 78,744) (n = 45,533 early vs n = 33,211 delayed diagnostic paracentesis) were included. Early diagnostic paracentesis was associated with lower in-hospital mortality (OR 0.61, 95% CI 0.46-0.82, P = 0.001), length of hospital stay (mean difference -4.85 days; 95% CI -6.45 to -3.20; P < 0.001), and acute kidney injury (OR 0.62, 95% CI 0.42-0.92, P = 0.02) compared with delayed diagnostic paracentesis, with similar 30-day readmission (OR 1.11, 95% CI 0.52-2.39, P = 0.79). Subgroup analysis revealed consistent results for in-hospital mortality whether early diagnostic paracentesis performed within 12 hours (OR 0.51, 95% CI 0.32-0.79, P = 0.003, I2 = 0%) or within 24 hours of admission (OR 0.67, 95% CI 0.45-0.98, P = 0.04, I2 = 82%). Notably, the mortality OR was numerically lower when diagnostic paracentesis was performed within 12 hours, and the results were precise and homogenous ( I2 = 0%).

DISCUSSION

Findings from this meta-analysis suggest that early diagnostic paracentesis is associated with better patient outcomes. Early diagnostic paracentesis within 12 hours of admission may be associated with the greatest mortality benefit. Data from large-scale randomized trials are needed to validate our findings, especially if there is a greater mortality benefit for early diagnostic paracentesis within 12 hours.

Role of Continuous Drainage of Tense Ascites in Peritoneal Dialysis: Mehandru/Masud Technique

Insertion of a peritoneal dialysis (PD) catheter in end-stage renal disease (ESRD) patients with cirrhosis and tense ascites remains a challenge for nephrologists. Ascitic fluid leak at the surgical site, a common postoperative occurrence, leads to the disqualification of many patients who could be otherwise great candidates for PD. The ascitic fluid leak has been described to occur during or immediately after surgery even after the entire volume of ascitic fluid has been drained. In this study, we report a case study of three patients with ESRD, liver cirrhosis, and tense ascites on hemodialysis. The patients required super large volume paracentesis (SLVP), draining 9,000 - 15,000 cc of ascitic fluid twice weekly in an interventional radiology setup. Besides ascitic fluid drainage, the patients needed in-center hemodialysis (ICHD) 3 days a week, leading to their engagement in procedures 5 days a week. In addition, intradialytic symptomatic hypotension, hypoalbuminemia, and other adverse effects of hemodialysis lead to their poor lifestyle. To improve their lifestyle, all patients desired to switch to PD from ICHD. Upon the PD catheter insertion and drainage of the entire ascitic fluid, leaks developed at the insertion site within a few hours. To overcome these leaks, PD catheters of all three patients were attached via a transfer set to a bag for continuous drainage of ascitic fluid for about 2 weeks. No leak or complication was noted, leading to complete healing of insertion site. We recommend, for the patients with tense ascites requiring SLVP, approximately 2 weeks of healing period continuously be performed till initiation of PD training,.

LINAS-Score: prognostic model for mortality assessment in patients with cirrhotic liver and infected ascites

BACKGROUND AND AIM

Patients with liver cirrhosis often face a grave threat from infected ascites (IA). However, a well-established prognostic model for this complication has not been established in routine clinical practice. Therefore, we aimed to assess mortality risk in patients with liver cirrhosis and IA.

METHODS

We conducted a retrospective study across three tertiary hospitals, enrolling 534 adult patients with cirrhotic liver and IA, comprising 465 with spontaneous bacterial peritonitis (SBP), 34 with bacterascites (BA), and 35 with secondary peritonitis (SP). To determine the attributable mortality risk linked to IA, these patients were matched with 122 patients with hydropic decompensated liver cirrhosis but without IA. Clinical, laboratory, and microbiological parameters were assessed for their relation to mortality using univariable analyses and a multivariable random forest model (RFM). Least absolute shrinkage and selection operator (Lasso) regression model was used to establish an easy-to-use mortality prediction score.

RESULTS

The in-hospital mortality risk was highest for SP (39.0%), followed by SBP (26.0%) and BA (25.0%). Besides illness severity markers, microbiological parameters, such as Candida spp., were identified as the most significant indicators for mortality. The Lasso model determined 15 parameters with corresponding scores, yielding good discriminatory power (area under the receiver operating characteristics curve = 0.89). Counting from 0 to 83, scores of 20, 40, 60, and 80 corresponded to in-hospital mortalities of 3.3%, 30.8%, 85.2%, and 98.7%, respectively.

CONCLUSION

We developed a promising mortality prediction score for IA, highlighting the importance of microbiological parameters in conjunction with illness severity for assessing patient outcomes.

Use of Bacterial DNA Concentration in Ascites as a Marker for Spontaneous Bacterial Peritonitis

Background and aims

Spontaneous bacterial peritonitis (SBP) is a common and serious complication in patients with decompensated cirrhosis. Precise quantification of bacterial DNA (bactDNA) and the related inflammatory response might add further information on the course of disease. The aim of the study was to evaluate the association between bactDNA, cytokine levels and clinical outcome.

Methods

Ascites and serum samples of 98 patients with decompensated liver cirrhosis (42 with SBP and 56 without SBP) as well as serum samples of 21 healthy controls were collected. BactDNA in ascites and serum was detected and quantified by 16S rRNA PCR. Concentrations of IL-1β, TNF-α, IL-6, IL-8 and IL-10 were measured by a LEGENDplexTM multi-analyte flow assay. Clinical data were collected and analyzed retrospectively.

Results

BactDNA was detected more frequently in ascites of patients with SBP (n = 24/42; 57.1%) than in ascites of patients without SBP (n = 5/56; 8.9%; P < 0.001). Additionally, IL-6 levels in both ascites and serum were significantly higher in patients with SBP (ascites P < 0.001, serum P = 0.036). The quantity of bactDNA in ascites was strongly correlated with polymorphonuclear neutrophil count in ascites (r = 0.755; P < 0.001) as well as ascites IL-6 levels (r = 0.399; P < 0.001). Receiver operating characteristic (ROC) curve analysis to diagnose SBP provided an AUC of 0.764 (95% CI: 0.661-0.867) for serum IL-6 levels, an AUC of 0.810 (95% CI: 0.714-0.905) for ascites IL-6 levels, and an AUC of 0.755 (95% CI: 0.651-0.858) for bactDNA levels in ascites.

Conclusions

The correlation between the amount of bactDNA and IL-6 confirms the pathophysiological relevance of bactDNA and IL-6 as potential biomarkers for the diagnosis of SBP.

Timely Albumin Infusion May Improve Resource Utilization in Patients with Cirrhosis and Spontaneous Bacterial Peritonitis

Spontaneous bacterial peritonitis is a life-threatening complication of cirrhosis that can increase healthcare utilization. The impact of albumin administration timing on hospital resource utilization and its optimal timing is unclear, despite its efficacy in improving survival for cirrhosis patients with spontaneous bacterial peritonitis. A retrospective study was conducted to evaluate the influence of the timing of albumin administration on the length of stay and total hospital cost for patients with cirrhosis and spontaneous bacterial peritonitis who require fluid resuscitation. The study utilized de-identified data from Cerner Health Facts® data. Adult inpatients with a diagnosis of cirrhosis and SBP receiving ≥1 antibiotic and fluid resuscitation between January 1, 2009, and April 30, 2018, were included and stratified by albumin administration timing: ≤24 hours from hospital admission ("timely albumin") or >24 hours of admission or no albumin ("non-timely albumin"). We used a Kaplan-Meier curve with log-rank test to evaluate the association between timing of albumin administration and time to hospital discharge and a generalized linear model to examine the association between albumin timing and total hospital costs. We identified 1,308 hospitalizations, of which 301 contained valid cost data. The timely albumin group had a median time to discharge of 6.95 days compared to 7.78 days in the non-timely group (p = 0.02). Cost model showed that receiving timely albumin incurred 16% lower costs (p = 0.027) than patients in the non-timely albumin group. Timely albumin administration with an antibiotic regimen may shorten the length of stay and lower costs, thereby reducing hospital resource utilization in patients with cirrhosis and spontaneous bacterial peritonitis requiring fluid resuscitation.

Bacterial profile, drug resistance pattern, clinical and laboratory predictors of ascites infection in cirrhosis patients

Ascites is a pathological collection of free fluid in the peritoneal cavity, which is a common complication in patients with cirrhosis, an advanced liver disease. Bacterial infection increases the mortality rate of hospitalized patients with cirrhosis, irrespective of the severity of the liver disease. Around 60% of patients with compensated cirrhosis developed ascites within 10 years during the course of their disease. The in-hospital mortality rate due to spontaneous bacterial peritonitis (SBP) could exceed 90%, but with early diagnosis and prompt antibiotic therapy, this rate has been shown to decrease to 20%. Here, we enrolled adult (age ≥ 18) patients with liver disease with evidence of cirrhosis who developed ascites and assessed the presence of spontaneous ascites fluid infection (SAFI) in these patients. Of the total 218 patients, 22.9% (50/218) develop ascites infection. The liver organ function tests like alanine aminotransferase, aspartate aminotransferase, total bilirubin, and direct bilirubin were found to be significantly (P < 0.05) higher in patients with ascites fluid infection compared to patients with non-ascites fluid infection. Of the gram-negative bacteria, K. pneumonia and E. coli were isolated and found to be 100% resistant to amoxicillin and clavulanate. From the gram-positive bacterial isolates, S. aureus was only resistant to penicillin, whereas Str. viridans was resistant to ceftriaxone, cefotaxime, cefepime, and penicillin. On the other hand, clinical features such as a history of jaundice, low arterial blood pressure, and ultrasound results such as a shrunken liver and enlarged spleen were also independent predictors of spontaneous bacterial peritonitis. In conclusion, given the high probability of death following SAFI, early detection, and treatment, as well as knowledge of the microbial agent, resistance profile, and predictive markers in various contexts, are essential for the timely diagnosis and management of SAFI in these patients.

Epidemiological Study of Pathogens in Spontaneous Bacterial Peritonitis in 2017-2024-A Preliminary Report of the University Hospital in South-Eastern Poland

Spontaneous Bacterial Peritonitis (SBP) is a serious complication and a common cause of death in patients with liver cirrhosis. Between January 2017 and March 2024, a retrospective study was conducted involving 302 patients (>18 years old) with ascites treated at a tertiary referral center in south-eastern Poland. Microbiological analysis of the ascitic fluids was performed in all patients. The presence of microorganisms was found in samples from 17 patients, and 21 pathogens were isolated, including 15 Gram-positive bacteria and 6 Gram-negative bacteria. Staphylococcus epidermidis, MRCNS (methicillin-resistant coagulase-negative staphylococci, resistant to all beta-lactam antibiotics: penicillins, penicillins with beta-lactamase inhibitor, cephalosporins and carbapenems) was the main pathogen detected (19.05%, 4/21), followed by Enterococcus faecalis (9.52%, 2/21), Enterococcus faecium (9.52%, 2/21), Staphylococcus haemolyticus, MRCNS (4.76%, 1/21), Streptococcus mitis (9.52%, 2/21), Streptococcus parasanguinis (9.52%, 2/21), Micrococcus luteus (4.76%, 1/21) and Bacillus spp. (4.76%, 1/21). The following Gram-negative bacteria were also found in the specimens examined: Escherichia coli, ESBL (extended-spectrum β-lactamase producing E. coli) (4.76%, 1/21), Escherichia coli (4.76%, 1/21), Pseudomonas aeruginosa (4.76%, 1/21), Klebsiella oxytoca (9.52%, 2/21) and Sphingomonas paucimobilis (4.76%, 1/21). Gram-positive bacteria caused nosocomial infections in nine patients with SBP, Gram-negative bacteria caused nosocomial infections in two patients. In six patients with SBP, community-acquired infections caused by Gram-negative bacteria were found in three cases, Gram-positive bacteria in two cases, and in one case, community-acquired infection was caused by mixed Gram-positive and Gram-negative. Bacteria isolated from patients with hospital-acquired SBP showed higher drug resistance than those found in patients with non-hospital SBP. Bacterial infections in cirrhotic patients with complications may be responsible for their deteriorating health. Prompt intervention is critical to reducing mortality.

Inflammatory liver diseases and susceptibility to sepsis

Patients with inflammatory liver diseases, particularly alcohol-associated liver disease and metabolic dysfunction-associated fatty liver disease (MAFLD), have higher incidence of infections and mortality rate due to sepsis. The current focus in the development of drugs for MAFLD is the resolution of non-alcoholic steatohepatitis and prevention of progression to cirrhosis. In patients with cirrhosis or alcoholic hepatitis, sepsis is a major cause of death. As the metabolic center and a key immune tissue, liver is the guardian, modifier, and target of sepsis. Septic patients with liver dysfunction have the highest mortality rate compared with other organ dysfunctions. In addition to maintaining metabolic homeostasis, the liver produces and secretes hepatokines and acute phase proteins (APPs) essential in tissue protection, immunomodulation, and coagulation. Inflammatory liver diseases cause profound metabolic disorder and impairment of energy metabolism, liver regeneration, and production/secretion of APPs and hepatokines. Herein, the author reviews the roles of (1) disorders in the metabolism of glucose, fatty acids, ketone bodies, and amino acids as well as the clearance of ammonia and lactate in the pathogenesis of inflammatory liver diseases and sepsis; (2) cytokines/chemokines in inflammatory liver diseases and sepsis; (3) APPs and hepatokines in the protection against tissue injury and infections; and (4) major nuclear receptors/signaling pathways underlying the metabolic disorders and tissue injuries as well as the major drug targets for inflammatory liver diseases and sepsis. Approaches that focus on the liver dysfunction and regeneration will not only treat inflammatory liver diseases but also prevent the development of severe infections and sepsis.

Diagnostic Paracentesis Within 1 Day Is Associated With Reduced Mortality and Length of Hospital Stay in Patients with Cirrhosis and Ascites

Spontaneous bacterial peritonitis (SBP) is the most common infection in patients with cirrhosis and is associated with high mortality. Although recent literature reports mortality benefits to early diagnostic paracentesis, current guidelines do not offer specific recommendations for how quickly diagnostic paracentesis should be performed in patients with cirrhosis and ascites who are admitted to the hospital. Therefore, we conducted a systematic review and meta-analysis to evaluate outcomes among patients admitted to the hospital with cirrhosis and ascites receiving paracentesis within ≤ 12, ≤ 1 day, and > 1 day. Eight studies with 116,174 patients were included in the final meta-analysis. The pooled risk of in-hospital mortality was significantly lower in patients who underwent early (≤ 12 h or ≤ 1 day) compared to delayed (> 12 h or > 1 day) paracentesis (RR: 0.69, p < 0.00001), and in patients who underwent paracentesis compared to no paracentesis (RR: 0.74, p < 0.00001). On subgroup analysis, in-hospital mortality was significantly lower in both paracentesis within ≤ 12 h (RR: 0.61, p = 0.02) vs. > 12 h, and within ≤ 1 day (RR: 0.70, p < 0.00001) vs. > 1 day. While there was a trend towards decreased mortality in those undergoing paracentesis within ≤ 12 h compared to ≤ 1 day, the difference did not reach statistical significance. The length of hospital stay was significantly shorter by 5.38 days in patients who underwent early (≤ 12 h) compared to delayed (> 12 h) paracentesis (95% CI 4.24-6.52, p < 0.00001). Early paracentesis is associated with reduced mortality and length of hospital stay. We encourage providers to perform diagnostic paracentesis in a timely manner, at least within 1 day of hospital admission, for all patients with cirrhosis and ascites.

Quality improvement project demonstrating a sustained increase in the assessment and sampling of ascites for hospitalised patients with cirrhosis

Objective

Using quality improvement techniques, we aimed to improve the rate of assessment and sampling of ascitic fluid for the purpose of diagnosing spontaneous bacterial peritonitis in patients with cirrhosis admitted to the hospitalist service of our institution.

Design/methods

Based on stakeholder needs assessment, we implemented interventions targeting provider knowledge, procedure workflows and clinical decision support. We analysed key metrics during preintervention (September-December 2020), intervention roll-out (January-April 2021), postintervention (May-September 2021) and sustainability (September-December 2022) periods for admissions of patients with cirrhosis to our hospitalist service at Maine Medical Center, a 700-bed tertiary-care academic hospital in Portland, Maine, USA.

Results

Among patients with cirrhosis admitted to our service, documentation of assessment for paracentesis increased from a preintervention baseline of 60.1% to 93.5% (p<0.005) postintervention. For patients with ascites potentially amenable to paracentesis, diagnostic paracentesis rate increased from 59.7% to 93% (p<0.005), with the rate of paracentesis within 24 hours increasing from 52.6% to 77.2% (p=0.01). These improvements persisted during our sustainability period. Complication rate was low (1.2%) across all study periods.

Conclusion

Our quality improvement project led to a sustained improvement in the identification of patients with cirrhosis needing diagnostic paracentesis and an increased procedure completion rate. This improvement strategy serves as a model for needed work toward closing a national performance gap for patients with cirrhosis.

Prognosis of spontaneous bacterial peritonitis in patients with hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is the fourth leading cause of death from cancer worldwide. Spontaneous bacterial peritonitis (SBP) is associated with poor prognosis. This study aimed to evaluate risk factors, differences in clinical characteristics and prognosis of SBP in patients with HCC in comparison with non-HCC patients.

METHODS

This study was conducted on patients with cirrhosis who were admitted to hospital with SBP. The patients were divided into two groups: SBP group with HCC (n = 150) and SBP group without HCC (n = 250).

RESULTS

Men and women accounted for 72% and 28% (n = 108 and 42, respectively) of the population in SBP group with HCC with mean age 55.8 ± 13.1 years. They accounted for 68.4% and 31.6% (n = 171 and 79, respectively) in the SBP group without HCC with mean age 56.8 ± 10.5 years. In-hospital mortality was 25.3% in the SBP group with HCC and 18.8% in SBP group without HCC. Gastrointestinal bleeding was the most common cause of death in both groups. No significant difference was observed in patient outcomes between the two studied groups. The deceased patients had significantly higher levels of leukocytes and neutrophils in ascitic fluid as well as a higher frequency of positive culture results than in patients who survived (p < 0.001). However, there was no significant difference in protein level in ascitic fluid or causative organism between patients who survived and those who died (p = 0.63 and 0.19, respectively).

CONCLUSIONS

Prognosis of SBP in patients with HCC seemed similar to that in patients without HCC.

Ascitic Fluid Lactate Level as a Predictor of Mortality in Cirrhotic Patients Having Spontaneous Bacterial Peritonitis (SBP)

Introduction Limited studies are available for predicting mortality in patients with spontaneous bacterial peritonitis (SBP) based on ascitic fluid analysis. Recently, a proposition has been made regarding the role of ascitic fluid lactate as a better prognostic indicator of mortality in cirrhotic patients with SBP. Therefore, we aimed to evaluate the utility of ascitic fluid lactate in predicting mortality in cirrhotic patients with SBP. Methods This was a prospective, observational study that was conducted in the Hepato-Gastroenterology Department of Sindh Institute of Urology and Transplantation (SIUT), Karachi from 1 January 2022 to 31 December 2022. All the patients having liver cirrhosis with ascites, aged between 18 and 65 years, and presenting with fever and/or abdominal pain were recruited in the study in the first six months (i.e., from 1 January 2022 to 30 June 2022) and were followed for six more months for the outcome. However, those patients on dialysis or those with hepatocellular carcinoma, any other malignancy as per a history of solid organ transplant, a history of HIV infection, or those underlying systemic sepsis or infections other than SBP were excluded from the study. The presence or absence of SBP was confirmed by doing the ascitic fluid analysis. Ascitic fluid lactate levels were also requested in each patient. Mortality was assessed at one, two, three, and six months, respectively. All the data were analyzed using SPSS version 23.0. The area under the receiver operating curve (AUROC) was obtained for ascitic fluid lactate for predicting mortality in SBP. At an optimal cutoff, the diagnostic accuracy of ascitic fluid lactate was obtained. Results The total number of cirrhotic patients included in the study was 123. The majority of the patients belong to Child Turcotte Pugh (CTP) class C (n = 88; 71%). Two third of the patients (65.8%; n = 81) had viral hepatitis i.e., hepatitis B, D, and/or C, as the cause of cirrhosis. Overall mortality was observed in 51(41.5%) patients. Ascitic fluid lactate was significantly raised in patients with SBP than in patients with non-SBP (p = 0.004). The AUROC of ascitic fluid lactate was highest at three months (AUROC = 0.88) followed by six months (AUROC = 0.84), two months (AUROC = 0.804), and one month (AUROC=0.773). At an optimal cut-off of more than or equal to 22.4 mg/dl, ascitic fluid lactate had a sensitivity of 84.9%, specificity of 85.7%, positive predictive value (PPV) of 97.3%, negative predictive value of 42.8% with diagnostic accuracy of 85% in predicting overall mortality in patients with SBP. On sub-analysis, the diagnostic accuracy of ascitic fluid lactate was highest at six months followed by at three, two, and one month, respectively. Conclusion Ascitic fluid lactate showed a good diagnostic utility in predicting the overall mortality in patients with SBP with the best diagnostic accuracy in predicting long-term (six months) mortality. However, further studies are required to validate our results.

Clinical features, microbial spectrum, and antibiotic susceptibility patterns of spontaneous bacterial peritonitis in cirrhotic patients

BACKGROUND AND AIMS

The microbial spectrum and antimicrobial resistance patterns change over time and vary across regions in patients with spontaneous bacterial peritonitis (SBP). There is an urgent need to clarify the factors associated with in-hospital mortality in these patients.

METHODS

In this study, 377 patients with SBP and 794 patients with bacterascites were analyzed for the microbial spectrum, antimicrobial resistance profiles, and laboratory findings.

RESULTS

The most common pathogens were Escherichia coli (96, 25.5%), Staphylococcus epidermidis (55, 14.6%), and Enterococcus faecium (42, 11.1%). Multidrug-resistant (MDR) bacteria comprised 49.7% of gram-positive bacteria (GPB) and 48.8% of gram-negative bacteria (GNB). The most sensitive antibiotics were amikacin (91.5%), meropenem (89.8%) and piperacillin/tazobactam (87.6%). Extensively drug-resistant (XDR) (OR=51.457, p < 0.001), neutrophil count (OR=1.088, p < 0.001), and the model for end-stage liver disease (MELD) score (OR=1.124, p < 0.001) were independent predictive factors of in-hospital mortality in patients with SBP.

CONCLUSION

MDR represented nearly half of the bacteria isolated from patients with SBP, of which the high prevalence of extended-spectrum β-lactamase-producing and Carbapenem-resistant bacteria is concerning. The presence of XDR, higher MELD score, and neutrophil count were independent predictive factors associated with higher in-hospital mortality in patients with SBP, indicating that intensive care should be provided to these patients.

Clinical Significance of Ascitic Fluid Polymorphonuclear Leukocyte Percentage in Patients With Cirrhosis Without Spontaneous Bacterial Peritonitis

INTRODUCTION

Absolute polymorphonuclear leukocyte (PMN) count (PMN-C) ≥250 cells/mm 3 in ascites is the diagnostic hallmark of spontaneous bacterial peritonitis (SBP) and is associated with high morbidity and mortality. However, the clinical significance of ascitic PMN percentage (PMN-%) and PMN-C in the absence of SBP as additional biomarkers for mortality and future incidence of SBP has not been determined.

METHODS

This retrospective cohort included adults with cirrhosis undergoing first-recorded paracentesis with initial PMN-C < 250 cells/mm 3 at 2 tertiary medical centers between 2015 and 2020. Patients with prior SBP were excluded. Outcomes were death and SBP development. Cox regression estimated hazard ratios (HRs) for risk of death and SBP development and Akaike information criterion to compare model fit.

RESULTS

Three hundred eighty-four adults (73% male, median age 58 years, 67% with alcohol-associated cirrhosis, median PMN-C 14 cells/mm 3 [interquartile range 5-34], and median PMN-% 10% [interquartile range 4-20]) were included in this study. Univariate risk of death increased 10% per 25-unit increase in PMN-C (95% confidence interval 1.01-1.21, P = 0.03) and 19% per 10-unit increase in PMN-% (95% confidence interval 1.06-1.33, P = 0.003) with PMN-% demonstrating better model fit in assessing mortality risk (Akaike information criterion: 1,044 vs 1,048, respectively). In models adjusted for age, chronic hepatitis C virus infection, and Model for End-Stage Liver Disease-Sodium, PMN-% was associated with risk of death (PMN-% 10%-29%, HR 1.17, P = 0.50; PMN-% ≥ 30% group, HR 1.94, P = 0.03; vs PMN-% < 10%) and SBP development (PMN-% 10%-29%, HR 1.68, P = 0.07; PMN-% ≥ 30%, HR 3.48, P < 0.001; vs PMN-% < 10%).

DISCUSSION

Our results suggest PMN-% at first paracentesis represents a better biomarker compared with PMN-C for assessing risk of death and future SBP development in patients with PMN-C < 250 cells/mm 3 .

Differences in Bacterial Translocation and Liver Injury in Ethanol Versus Diet-Induced Liver Disease

BACKGROUND

Alcohol-associated liver disease (ALD) and non-alcoholic fatty liver disease (NAFLD)/non-alcoholic steatohepatitis (NASH) are two of the most common etiologies of chronic liver disease worldwide. Changes in intestinal permeability and increased gut microbial translocation have been posited as important contributors to inflammation in both ALD and NAFLD. However, gut microbial translocation has not been compared between the two etiologies and can lead to better understanding of the differences in their pathogenesis to liver disease.

METHODS

We compared serum and liver markers in the following five models of liver disease to understand the differences in the role of gut microbial translocation on liver disease progression caused by ethanol versus Western diet: (1) 8-week chronic ethanol feeding model. (2) 2-week chronic-plus-binge (National Institute on Alcohol Abuse and Alcoholism (NIAAA)) ethanol feeding model. (3) 2-week chronic-plus-binge (NIAAA) ethanol feeding model in microbiota-humanized gnotobiotic mice colonized with stool from patients with alcohol-associated hepatitis. (4) 20-week Western-diet-feeding model of NASH. (5) 20-week Western-diet-feeding model in microbiota-humanized gnotobiotic mice colonized with stool from NASH patients.

RESULTS

Translocation of bacterial lipopolysaccharide to the peripheral circulation was seen in both ethanol-induced and diet-induced liver disease, but translocation of bacteria itself was restricted to only ethanol-induced liver disease. Moreover, the diet-induced steatohepatitis models developed more significant liver injury, inflammation, and fibrosis compared with ethanol-induced liver disease models, and this positively correlated with the level of lipopolysaccharide translocation.

CONCLUSIONS

More significant liver injury, inflammation, and fibrosis are seen in diet-induced steatohepatitis, which positively correlates with translocation of bacterial components, but not intact bacteria.

Emergency medicine updates: Spontaneous bacterial peritonitis

INTRODUCTION

Spontaneous bacterial peritonitis (SBP) is a common infection in patients with cirrhosis and ascites and is associated with significant risk of mortality. Therefore, it is important for emergency medicine clinicians to be aware of the current evidence regarding the diagnosis and management of this condition.

OBJECTIVE

This paper evaluates key evidence-based updates concerning SBP for the emergency clinician.

DISCUSSION

SBP is commonly due to Gram-negative bacteria, but infections due to Gram-positive bacteria and multidrug resistant bacteria are increasing. The typical presentation of SBP includes abdominal pain, worsening ascites, fever, or altered mental status in a patient with known liver disease; however, some patients may be asymptomatic or present with only mild symptoms. Paracentesis is the diagnostic modality of choice and should be performed in any patient with ascites and concern for SBP or upper gastrointestinal bleeding, or in those being admitted for a complication of cirrhosis. Ultrasound should be used to optimize the procedure. An ascites absolute neutrophil count (ANC) ≥ 250 cells/mm³ is diagnostic of SBP. Ascitic fluid should be placed in blood culture bottles to improve the culture yield. Leukocyte esterase reagent strips can be used for rapid diagnosis if available. While many patients will demonstrate coagulation panel abnormalities, routine transfusion is not recommended. Management traditionally includes a third-generation cephalosporin, but specific patient populations may require more broad-spectrum coverage with a carbapenem or piperacillin-tazobactam. Albumin infusion is associated with reduced risk of renal impairment and mortality.

CONCLUSIONS

An understanding of literature updates can improve the care of patients with suspected SBP.

Cirrhotic patients on proton pump inhibitors are at a twofold risk of spontaneous bacterial peritonitis independently of gastrointestinal bleeding: a population-based retrospective study

Background

Recent findings suggest that cirrhotic patients on proton pump inhibitors (PPIs) are at a higher risk for developing spontaneous bacterial peritonitis (SBP) than non-PPI users. We aimed to identify whether PPI use is an independent risk factor for the development of SBP among cirrhotic patients in the United States (US).

Methods

We enrolled a retrospective cohort using a validated multicenter database. Patients with a SNOMED-CT diagnosis of "cirrhosis" between 1999 and 2022 were identified. All patients below 18 years of age were excluded. We calculated the prevalence of individuals using PPIs in the total US population and in cirrhotic patients from 1999 to date, and the incidence of SBP in the past year. Finally, we constructed a multivariate regression model, controlling for multiple covariates.

Results

The final analysis included 377,420 patients. The 20-year-period prevalence of SBP in patients with cirrhosis was 3.54% and the prevalence of patients using PPIs in the US population was 12,000 per 100,000 people (12.00%). The 1-year incidence of SBP in cirrhotic patients using PPIs was 2500 per 100,000 people. After accounting for confounders, the risk of SBP was higher among males, patients with a diagnosis of gastrointestinal bleeding, and those using β-blockers and PPIs.

Conclusions

To date, this is the largest cohort used to examine the prevalence of SBP among cirrhotic patients in the US. PPI use and hepatic encephalopathy offered the highest risk for the development of SBP, independently of gastrointestinal bleeding. Focusing on judicious PPI use should be encouraged among cirrhotic patients.

Outcomes after hospitalisation with spontaneous bacterial peritonitis over a 13-year period: a retrospective cohort study

GOALS

Assess outcomes in patients with an index presentation of spontaneous bacterial peritonitis (SBP) over a 13-year period.

BACKGROUND

SBP, a bacterial infection of ascites, has a poor prognosis.

STUDY

Retrospective cohort study assessing mortality (standardised to 32 months) and prognostic factors in patients with SBP during two periods: period 1 (June 2006-November 2012) and period 2 (December 2012-May 2019).

RESULTS

The study included 178 patients who were followed up for 11.6 (29.2) months. Mortality was high, with 12-, 24- and 32-month survival being 32%, 26% and 24%, respectively. Inpatient mortality was 36% with mortality in those surviving hospitalisation being 62%. Serum creatinine at the time of SBP diagnosis was an independent predictor of mortality at 32 months [hazard ratio (HR) 1.002, P = 0.023] and inpatient mortality (HR 1.003, P = 0.035). Positive ascitic fluid culture and ascitic fluid neutrophil count were independent predictors of 32-month (HR 1.679, P = 0.008) and inpatient mortality (HR 1.0001, P = 0.005), respectively. Patients in period 2 had lower ascitic fluid albumin (5.9 ± 3.3 g/L vs. 10.8 ± 5.4 g/L, P < 0.001), higher ascitic fluid neutrophil count (815.0 cells/mm3 vs. 345.0 cells/mm3, P < 0.001) and higher rates of hepatorenal syndrome-acute kidney injury (58 vs. 35%, P = 0.002). Mortality at 32 months and mortality in those surviving hospitalisation were similar at 78 vs. 73%, P = 0.392 and 66 vs. 58%, P = 0.355, for periods 1 and 2, respectively.

CONCLUSIONS

Despite more advanced initial presentations, mortality rates have remained similar over the last 13 years. Serum creatinine at the time of SBP diagnosis is an independent predictor of mortality.

Early readmissions of spontaneous bacterial peritonitis in the USA: Insights into an emerging challenge

BACKGROUND AND AIM

Early readmissions of spontaneous bacterial peritonitis (SBP) are often associated with poor outcomes. We compared characteristics and outcomes for index and 30-day readmissions of SBP in the USA.

METHODS

We analyzed the Nationwide Readmissions Database for 2018 to identify all adult (≥ 18 years) 30-day readmissions of SBP in the USA. Hospitalization characteristics and outcomes for index and 30-day readmissions of SBP were compared. Independent predictors of 30-day readmissions were also identified.

RESULTS

In 2018, of the 5,797 index admissions for SBP, 30% (1726) were readmitted within 30 day. At the time of readmission, the most common admitting diagnosis was alcoholic cirrhosis of the liver with ascites (11.8%) followed by sepsis due to an unspecified organism (9.2%). SBP as an admitting diagnosis was identified for only 8.3% of these 30-day readmissions. Compared with index admissions, 30-day readmissions of SBP had a lower mean age (56.1 vs 58.6 years, P < 0.001) without a statistically significant difference for gender. Furthermore, 30-day readmissions of SBP were associated with significantly higher odds of inpatient mortality (10% vs 4.9%, OR: 2.15, 95% CI: 1.66-2.79, P < 0.001), and mean total hospital charge ($85,031 vs $56,000, mean difference: 29,032, 95% CI: 12,867-45,197, P < 0.001) compared with index admissions. The presence of chronic pulmonary disease, liver failure, inpatient dialysis, and discharge against medical advice were identified as independent predictors for increased 30-day readmissions of SBP.

CONCLUSION

The 30-day readmission rate of SBP was 30% and these readmissions were associated with higher odds of inpatient mortality compared with index admissions.

Efficacy predictors of third-generation cephalosporins in treating spontaneous bacterial peritonitis

OBJECTIVE

Third-generation cephalosporins (3rd GCs) have recently become controversial as the first-line strategy for empirical spontaneous bacterial peritonitis (SBP) treatment. This study aimed to identify SBP treatment efficacy predictors of 3rd GCs.

METHODS

In this retrospective cohort study, 279 cirrhosis patients with SBP who received 3rd GC monotherapy for initial empirical treatment from 2013 to 2019 were included. Nonresponse was defined as a decreased ascites polymorphonuclear (PMN) count < 25% from baseline after 48 hours of antibacterial treatment. Multivariate regression analysis was used to identify efficacy predictors of 3rd GCs in treating SBP. Kaplan-Meier analysis was used to evaluate survival data.

RESULTS

The nonresponder group included 120 patients with no response, and the responder group included 159 patients with responses. The response rate to 3rd GCs was 57.0% among all patients. The common pathogens were Escherichia coli (40.6%), Staphylococcus (15.6%), Klebsiella pneumonia (12.5%), and Streptococcus (12.5%) in 32 ascites culture isolates. Nosocomial SBP (NSBP) (odds ratio [OR]: 2.371, 95% confidence interval [CI]: 1.323-4.249, P = .004), pneumonia (OR: 11.561, 95% CI: 1.876-71.257, P = .008), recurrent SBP (OR: 3.386, 95% CI: 1.804-6.357, P < .001), platelet count (≥113.5 × 109/L) (OR: 3.515, 95% CI: 1.973-6.263, P < .001), and ascites PMN count (≤0.760 × 109/L) (OR: 4.967, 95% CI: 2.553-9.663, P < .001) were independent predictors of nonresponse to 3rd GCs against SBP. Survival plot analysis at 30 days showed worse survival for the nonresponders (P = .003).

CONCLUSION

NSBP, pneumonia, recurrent SBP, increased platelet count, and lower ascites PMN count were independent predictors of nonresponse to 3rd GC in treating SBP. Nonresponse to initial antibiotic treatment was associated with worse survival.

Cirrhosis Due to Alcohol-Related Liver Disease Hospitalizations in Belgrade, Serbia: A 10-Year Retrospective

BACKGROUND

Cirrhosis due to alcohol-related liver disease (ALD cirrhosis) is a significant burden to health systems worldwide. We aimed to determine the trends in hospitalization frequency due to ALD cirrhosis and to analyze their characteristics.

METHODS

This cross-sectional study used data from the Institute of Public Health of Belgrade database, and included all hospitalization reports which contained code K70.3 (Cirrhosis hepatis alcoholica) as the primary diagnosis, including re-hospitalizations, on the territory of Belgrade, between January 2009 and December 2018.

RESULTS

A total of 4644 patients with ALD cirrhosis were hospitalized (male: 4154, 89.45%), with a mean age of 58.83±10.02 years. During the 2009-2018 decade, no difference in the number of ALD cirrhosis hospitalizations in subsequent years was observed. Men more commonly developed esophageal and gastric varices with bleeding compared to women (P=0.037), while women developed acute-on-chronic liver failure (ACLF) almost two-times more often compared to men (P<0.001). Patients with hepatocellular carcinoma were significantly older (P<0.001), while those who developed ascites and splenomegaly were significantly younger compared to those who did not (P<0.001 and P=0.04, respectively). Altogether, complications of portal hypertension were registered and reported with very low frequency, and therefore do not represent actual frequencies of these conditions. The median duration of hospital stay was 9 days (range 0-243). Patients in whom lethal outcome occurred during the hospitalization were significantly older, and more commonly developed chronic renal failure.

CONCLUSION

These data offer an important insight into the ALD cirrhosis-related hospitalizations while drawing attention to inadequate coding as an important public health issue at the same time.

Neutrophil to Lymphocyte Ratio and Spontaneous Bacterial Peritonitis among Cirrhotic Patients: A Systematic Review and Meta-analysis

BACKGROUND

The goal of this systematic review and meta-analysis was analyzing published studies on the role of neutrophil to lymphocyte ratio (NLR) in infection and spatially spontaneous bacterial peritonitis (SBP) among cirrhotic patients.

METHODS

PubMed, Web of Science, and Scopus were searched until May 24, 2022. The Newcastle-Ottawa scale was used for quality assessment.

RESULTS

Of 14 studies included in our study, six studies were on infection with 2786 hospitalized cirrhotic patients, of whom 934 developed an infection. Other studies were on SBP with 1573 cirrhotic patients with ascites, of whom 557 developed SBP. The pooled results showed that there was no difference in NLR levels between hospitalized cirrhotic patients who developed infection compared to those who did not (random-effects model: SMD = 0.63, 95% CI = -0.01-1.27, p=0.054). However, cirrhotic patients with ascites who developed SBP had elevated levels of NLR compared to those who did not (random-effects model: SMD = 1.05, 95% CI = 0.52-1.57,p < 0.001). This difference remained significant in prospective studies (SMD = 0.94, 95% CI = 0.51-1.38,p < 0.001) but not in retrospective studies (SMD = 1.37, 95% CI = -0.56-3.29,p=0.165), in the subgroup analysis according to the study design. The pooled sensitivity of NLR was 92.07% (95% CI = 74.85%-97.84%) and the pooled specificity was 72.58% (95% CI = 57.72%-83.69%). The pooled positive likelihood ratio, negative likelihood ratio, DOR of NLR were 3.35(95%CI = 2.06-5.46), 0.10 (95%CI = 0.03-0.38), and 30.78 (95%CI = 7.01-135.04), respectively.

CONCLUSION

Our results support NLR to be a valid biomarker that can be readily integrated into clinical settings to help in the prevention and prediction of SBP among cirrhotic patients.

Narrative Review: Glucocorticoids in Alcoholic Hepatitis—Benefits, Side Effects, and Mechanisms

Alcoholic hepatitis is a major health and economic burden worldwide. Glucocorticoids (GCs) are the only first-line drugs recommended to treat severe alcoholic hepatitis (sAH), with limited short-term efficacy and significant side effects. In this review, I summarize the major benefits and side effects of GC therapy in sAH and the potential underlying mechanisms. The review of the literature and data mining clearly indicate that the hepatic signaling of glucocorticoid receptor (GR) is markedly impaired in sAH patients. The impaired GR signaling causes hepatic down-regulation of genes essential for gluconeogenesis, lipid catabolism, cytoprotection, and anti-inflammation in sAH patients. The efficacy of GCs in sAH may be compromised by GC resistance and/or GC’s extrahepatic side effects, particularly the side effects of intestinal epithelial GR on gut permeability and inflammation in AH. Prednisolone, a major GC used for sAH, activates both the GR and mineralocorticoid receptor (MR). When GC non-responsiveness occurs in sAH patients, the activation of MR by prednisolone might increase the risk of alcohol abuse, liver fibrosis, and acute kidney injury. To improve the GC therapy of sAH, the effort should be focused on developing the biomarker(s) for GC responsiveness, liver-targeting GR agonists, and strategies to overcome GC non-responsiveness and prevent alcohol relapse in sAH patients.

Chi-square automatic interaction detector decision tree analysis model: Predicting cefmetazole response in intra-abdominal infection

BACKGROUND

Cefmetazole is used as the first-line treatment for intra-abdominal infections. However, only a few studies have investigated the risk factors for cefmetazole treatment failure.

AIMS

This study aimed to develop a decision tree-based predictive model to assess the effectiveness of cefmetazole in initial intra-abdominal infection treatment to improve the clinical treatment strategies.

METHODS

This retrospective cohort study included adult patients who were unexpectedly hospitalized due to intra-abdominal infections between 2003 and 2020 and initially treated with cefmetazole. The primary outcome was clinical intra-abdominal infection improvement. The chi-square automatic interaction detector decision tree analysis was used to create a predictive model for clinical improvement after cefmetazole treatment.

RESULTS

Among 2,194 patients, 1,807 (82.4%) showed clinical improvement post-treatment; their mean age was 48.7 (standard deviation: 18.8) years, and 1,213 (55.3%) patients were men. The intra-abdomせinal infections were appendicitis (n = 1,186, 54.1%), diverticulitis (n = 334, 15.2%), and pancreatitis (n = 285, 13.0%). The chi-square automatic interaction detector decision tree analysis identified the intra-abdominal infection type, C-reactive protein level, heart rate, and body temperature as predictive factors by categorizing patients into seven groups. The area under the receiver operating characteristic curve was 0.71 (95% confidence interval: 0.68-0.73).

CONCLUSION

This predictive model is easily understandable visually and may be applied in clinical practice.

Patient age affects sex-based differences in post-traumatic mortality: a national trauma registry study in Japan

PURPOSE

Sex-based differences in post-traumatic mortality have been widely discussed for quite some time. We hypothesized that age-related pathophysiologic changes would affect sex-based differences in post-traumatic mortality and aimed to verify the hypothesis using a nationwide trauma registry in Japan.

METHODS

This was a retrospective analysis of trauma patients registered in The Japanese Trauma Data Bank. We stratified the study population into the following three subsets based on age: (1) pediatric subset (age ≤ 14), (2) adult subset (age 15-50) and (3) senior adult subset (age ≥ 51). We evaluated both sex-based differences in mortality in each subset separately using multivariate logistic regression analysis and the two-way interaction effect for predicted survival between the continuous increase of age and the sexes using a nonlinear multivariate regression model.

RESULTS

We included 122,819 trauma patients who fulfilled the inclusion criteria and classified them into the 3 subsets according to age. Male patients were more likely to die compared to female patients only in the senior adult subset (adjusted odds ratio: 1.26; 95% confidence interval: 1.18-1.36), whereas there were no statistically significant differences in the other two subsets. Furthermore, non-linear logistic regression analysis revealed that predicted survival probability in male patients decreased more sharply in accordance with the increase of age compared to that in female patients (p for interaction: 0.051).

CONCLUSION

Age-related change in post-traumatic mortality was significantly different between males and females, and male patients had a relatively higher risk of death in the older population.

Epidemiology of ascites fluid infections in patients with cirrhosis in Queensland, Australia from 2008 to 2017: A population-based study

Spontaneous bacterial peritonitis (SBP), a common infection in patients with cirrhosis and ascites, is associated with high morbidity and mortality. The aim of this study was to investigate changes in the epidemiology of ascites fluid infections over time in an Australian population, including patient demographics, trends in mortality, length of hospital stay and the nature and antibiotic resistance profile of causative organisms.An observational descriptive population-based epidemiological study of patients with cirrhosis admitted to public hospitals in Queensland during 2008-2017 was performed, linking demographic/clinical and microbiology data.Among 103,165 hospital admissions of patients with cirrhosis, ascites was present in 16,550 and in 60% (9977) a sample of ascitic fluid was tested. SBP was diagnosed in 770 admissions (neutrophil count >250/ml) and bacterascites in 552 (neutrophil count <250/ml with positive culture). The number of admissions with an ascites fluid infection increased by 76% from 2008 to 2017, paralleling an 84% increase in cirrhosis admissions over the same timeframe. Patients with SBP had a longer hospital stay (median 15.7 vs 8.3 days for patients without SBP, P < .001) and higher in-hospital mortality, although this decreased from 39.5% in 2008 to 2010 to 24.8% in 2015 to 2017 (P < .001). Common Gram-positive isolates included coagulase negative staphylococci (37.9%), viridans group streptococci (12.1%), and Staphylococcus aureus (7.2%). Common Gram-negative isolates included Escherichia coli (13.0%), Klebsiella pneumoniae (3.1%) and Enterobacter cloacae (2.6%). The prevalence of resistance to any tested antibiotic was <10%.SBP remains associated with high in-hospital mortality and long hospital stay. Typical skin and bowel pathogens were common, therefore, empirical antibiotic therapy should target these pathogens. This study provides valuable evidence informing infection management strategies in this vulnerable patient population.

Predictors of Short-Term Mortality Following First Episode of Spontaneous Bacterial Peritonitis in Hospitalized Cirrhotic Patients

Background and aims

Spontaneous bacterial peritonitis (SBP) is an important cause of morbidity and mortality in patients with cirrhosis. This study aimed to identify the factors impacting morbidity and short-term mortality in a cohort of patients with cirrhosis following an index episode of SBP.

Methods

In a retrospective study of hospitalized cirrhotic cohort, 333 patient records were reviewed. Demographic, clinical, and laboratory, as well as radiological characteristics of the patient population were analyzed on day 1 of admission. The diagnosis of cirrhosis was based on the combination of laboratory, clinical, and radiological features. The diagnosis of SBP was established by abdominal paracentesis in the presence of cellular, biochemical, and microbiological features consistent with SBP. All independent variables were analyzed to generate a predictive model of mortality by using the Cox proportional hazards regression analysis (adjusted for age and gender).

Results

A total of 61 cirrhotic patients with ascites and a first episode of SBP were identified. The overall mortality among hospitalized patients was 19.7% and was associated with longer length of stay (12.6 vs. 7.6 days; p=0.01). Patient cohorts with multiple antibiotic resistant bacteria as a cause of SBP had a significantly higher mortality compared to those with other bacterial phenotypes (p=0.03). Multivariate analyses showed that a model for end-stage liver disease (MELD) score (hazard ratio [HR]=1.29; 95% CI: 1.10 to 1.92; p=0.023), Child-Turcotte-Pugh score (HR=1.23; 95% CI: 1.05 to 1.82; p=0.027), and acute kidney injury (HR=2.09; 95% CI: 1.41 to 3.47; p=0.01) were the predictors of mortality from SBP.

Conclusion

SBP predicts in-hospital mortality in cirrhotic patients. In addition to multiple antibiotic resistant bacteria, thresholds of both hepatic and renal injury independently predict adverse outcomes.

Invasive fungal infections in acute and chronic liver impairment: A systematic review

Patients with acute and chronic liver impairment are susceptible to invasive fungal infections such as candidemia and invasive pulmonary aspergillosis as a result of cirrhosis-associated immune dysfunction, humoral immunodeficiency, cell-mediated dysfunction and systemic inflammation. Besides classical risk factors for invasive fungal infection, acute-on-chronic liver failure, corticosteroid use, gastrointestinal bleeding, and prophylactic use of antibiotics are all additional conditions which are related to the potential development of fungal infections. Therefore, high-risk patients should be carefully followed by microbiological surveillance including cultures but also by imaging and fungal biomarkers for providing early diagnosis. Echinocandins are still the mainstay and first line antifungal therapy in cases of invasive candidiasis. Due to concerns of liver toxicity and in cases of renal impairment liposomal amphotericin B is a suitable alternative to voriconazole in patients with invasive pulmonary aspergillosis. Although, data of isavucoanzole and posaconazole use in those patients are also promising more specific studies in the subgroup of patients with liver impairment are needed. Especially, due to the late diagnosis and multiple organ dysfunction usually present in patients with liver impairment morbidity and mortality rates remain high. Based on the broad spectrum of diverse reports with varying content and quality and in some cases lack of evidence we performed a systematic review on this topic.

A Predictive Model for Avoiding Follow-Up Paracentesis in Spontaneous Bacterial Peritonitis

Background

Recent studies suggest that follow-up paracentesis (FuP) in cases of spontaneous bacterial peritonitis (SBP) should only be performed if there is a clinical and/or analytic worsening. We aimed to evaluate which patients with SBP would benefit from the FuP.

Métodos

This retrospective study included consecutive patients diagnosed with SBP between January 2011 and June 2018 in our tertiary center. Clinical and analytical data were obtained at baseline and on the third day of antibiotic therapy. An adequate response on the third day of treatment was defined by a decrease of ≥25% in the neutrophil count of the ascitic fluid (AF).

Results

Ninety-six episodes of PBE in 75 patients (79% male sex, mean age 61 ± 11 years old) were included. At admission, a higher serum neutrophil count (p = 0.043), a lower level of serum total proteins (p = 0.040), a positive culture in AF (p < 0.001) and a previous diagnosis of diabetes mellitus (p = 0.035) were related to inadequate response (IR). At day 3, acute kidney injury (p = 0.023), C-reactive protein >100 mg/L (p < 0.001), the presence of fever (p = 0.047) and abdominal pain (p < 0.001) were also associated with IR. In multivariate analysis, the presence of respiratory insufficiency (OR = 16.403; 95% CI: 2.315-116.222; p = 0.005) and abdominal pain (OR = 10.381; 95% CI: 1.807-59.626; p = 0.009) at admission, serum white blood cell count >9 × 10⁹ (OR = 5.832; 95% CI: 1.275-26.669; p = 0.023), and CRP >100 mg/L (OR = 5.043; 95% CI: 1.267-20.076; p = 0.022) at day 3 of antibiotic therapy were predictors of IR. The predictive model presented good accuracy [AUROC of 0.893 (p < 0.001)] - a cutoff of 0.090 had a sensitivity, specificity, positive predictive value, and negative predictive value for IR of 97, 46, 83, and 77%, respectively.

Conclusions

The performance of FuP on day 3 after the beginning of empiric therapy should be individualized, according to clinical and analytic variables of this predictive model.

Peritoneal Dialysis Use in Patients With Ascites: A Review

The past few decades have seen steady increase in the prevalence of kidney failure needing kidney replacement therapy. Concomitantly, there has been progressive growth of heart failure and chronic liver disease, and many such patients develop ascites. Therefore, it is not uncommon to encounter patients with kidney failure who concurrently have ascites. The presence of ascites adds many challenges in the management of kidney failure. Poor hemodynamics make volume management difficult. The presence of coagulopathy, malnutrition, and encephalopathy compounds the complexity of the management. Such patients do not tolerate hemodialysis well. However, several concerns have limited the use of peritoneal dialysis (PD), so hemodialysis remains the predominant dialysis modality in these patients. However, observational studies have illustrated that PD provides hemodynamic stability and facilitates better volume management compared with hemodialysis. Moreover, PD obviates the need for therapeutic paracentesis by facilitating continuous drainage of ascites. PD potentially reduces hemorrhagic complications by avoiding routine anticoagulation use. Moreover, small studies have suggested that outcomes such as peritonitis and mechanical complications are comparable to those in PD patients without ascites. PD does not affect transplant candidacy, and these patients can successfully receive combined liver and kidney transplants. Hence, PD should be considered a viable dialysis option in kidney failure patients with ascites.

ACUTE-ON-CHRONIC LIVER FAILURE IS INDEPENDENTLY ASSOCIATED WITH LOWER SURVIVAL IN PATIENTS WITH SPONTANEOUS BACTERIAL PERITONITIS

BACKGROUND

Spontaneous bacterial peritonitis (SBP) is a decompensation of cirrhosis with an in-hospital mortality ranging from 20% to 40%.

OBJECTIVE

The purpose of this study is to analyze if EASL-CLIF definition of acute-on-chronic liver failure (ACLF) is able to predict mortality in cirrhotic patients with SBP.

METHODS

Historical cohort study conducted in a public tertiary care teaching hospital. Data from medical records from January 2009 to July 2016 were obtained by searching the hospital electronic database for samples of ascites collected in the period. Electronic and physical medical records were analyzed and patients were included if they were over 18-years old, with cirrhosis and an ascites fluid compatible with SBP: 69 patients were included. Liver-specific scores were calculated and Kaplan-Meier survival analysis was used for univariate analysis and a stepwise approach to the Cox regression for multivariate analysis.

RESULTS

All cause mortality was 44%, 56.5% and 74% for 28-, 90- and 365-day, respectively. The prevalence of ACLF was 58%. Of these, 65% grade 1, 17.5% grade 2 and 17.5% grade 3. In multivariate analysis, the use of proton-pump inhi-bitors, alanine transaminase lower than 40 U/L, hemoglobin higher than 9 g/dL, absence of ACLF and lower CLIF-SOFA and MELD scores were independently associated with higher survival for both 28- and 90-day interval.

CONCLUSION

The presence of ACLF and higher CLIF-SOFA scores were independently associated with higher 28- and 90-day mortality in cirrhotic patients admitted due to SBP.

Large Pleural Effusion After Transjugular Intrahepatic Portosystemic Shunt, a Rare but Deadly Complication

Cirrhosis affects more than 630,000 adults globally and can lead to development of ascites. Transjugular intrahepatic portosystemic shunt (TIPS) is an alternative option for refractory ascites in patients who are ineligible or are waiting for liver transplants. However, this procedure can have serious complications. We present a case that highlights the development of a complex pleural effusion complicated by hemorrhagic shock and disseminated intravascular coagulation after TIPS in a 54-year-old man. Our case is the first to report such a complication and aims to provide awareness.

An Epidemiological Meta-Analysis on the Worldwide Prevalence, Resistance, and Outcomes of Spontaneous Bacterial Peritonitis in Cirrhosis

Background and Aims: Spontaneous bacterial peritonitis (SBP) is a common and potentially fatal complication of liver cirrhosis. This study aims to analyze the prevalence of SBP among liver cirrhotic patients according to geographical location and income level, and risk factors and outcomes of SBP. Methods: A systematic search for articles describing prevalence, risk factors and outcomes of SBP was conducted. A single-arm meta-analysis was performed using generalized linear mix model (GLMM) with Clopper-Pearson intervals. Results: Ninety-Nine articles, comprising a total of 5,861,142 individuals with cirrhosis were included. Pooled prevalence of SBP was found to be 17.12% globally (CI: 13.63-21.30%), highest in Africa (68.20%; CI: 12.17-97.08%), and lowest in North America (10.81%; CI: 5.32-20.73%). Prevalence of community-acquired SBP was 6.05% (CI: 4.32-8.40%), and 11.11% (CI: 5.84-20.11%,) for healthcare-associated SBP. Antibiotic-resistant microorganisms were found in 11.77% (CI: 7.63-17.73%) of SBP patients. Of which, methicillin-resistant Staphylococcus aureus was most common (6.23%; CI: 3.83-9.97%), followed by extended-spectrum beta-lactamase producing organisms (6.19%; CI: 3.32-11.26%), and lastly vancomycin-resistant enterococci (1.91%; CI: 0.41-8.46%). Subgroup analysis comparing prevalence, antibiotic resistance, and outcomes between income groups was conducted to explore a link between socioeconomic status and SBP, which revealed decreased risk of SBP and negative outcomes in high-income countries. Conclusion: SBP remains a frequent complication of liver cirrhosis worldwide. The drawn link between income level and SBP in liver cirrhosis may enable further insight on actions necessary to tackle the disease on a global scale.

ICD-10-AM codes for cirrhosis and related complications: key performance considerations for population and healthcare studies

Objective

The utility of International Classification of Diseases (ICD) codes relies on the accuracy of clinical reporting and administrative coding, which may be influenced by country-specific codes and coding rules. This study explores the accuracy and limitations of the Australian Modification of the 10th revision of ICD (ICD-10-AM) to detect the presence of cirrhosis and a subset of key complications for the purpose of future large-scale epidemiological research and healthcare studies.

Design/method

ICD-10-AM codes in a random sample of 540 admitted patient encounters at a major Australian tertiary hospital were compared with data abstracted from patients’ medical records by four blinded clinicians. Accuracy of individual codes and grouped combinations was determined by calculating sensitivity, positive predictive value (PPV), negative predictive value and Cohen’s kappa coefficient (κ).

Results

The PPVs for ‘grouped cirrhosis’ codes (0.96), hepatocellular carcinoma (0.97) ascites (0.97) and ‘grouped varices’ (0.95) were good (κ all >0.60). However, codes under-detected the prevalence of cirrhosis, ascites and varices (sensitivity 81.4%, 61.9% and 61.3%, respectively). Overall accuracy was lower for spontaneous bacterial peritonitis (‘grouped’ PPV 0.75; κ 0.73) and the poorest for encephalopathy (‘grouped’ PPV 0.55; κ 0.21). To optimise detection of cirrhosis-related encounters, an ICD-10-AM code algorithm was constructed and validated in an independent cohort of 116 patients with known cirrhosis.

Conclusion

Multiple ICD-10-AM codes should be considered when using administrative databases to study the burden of cirrhosis and its complications in Australia, to avoid underestimation of the prevalence, morbidity, mortality and related resource utilisation from this burgeoning chronic disease.

Mortality and health care burden of Budd Chiari syndrome in the United States: A nationwide analysis (1998-2017)

BACKGROUND

The Budd Chiari syndrome (BCS) is a rare and potentially fatal disease, but there is a paucity of data on the in- hospital mortality as well its economic burden on the health care system.

AIM

To evaluate trends in mortality, length of hospital stays and resource utilization among inpatients with BCS.

METHODS

Data on all adult patients with a diagnosis of BCS were extracted from the National Inpatient Sample (NIS) from 1998 to 2017. To make inferences regarding the national estimates for the total number of BCS discharges across the study period, sample weights were applied to each admission per recommendations from the NIS.

RESULTS

During the study period, there were 3591 (8.73%) in-patient deaths. The overall in-hospital mortality rates among BCS patients decreased from 18% in 1998 to 8% in 2017; the mortality decreased by 4.41% (P < 0.0001) every year. On multivariate analysis, older age, higher comorbidity score, acute liver failure, acute kidney injury, acute respiratory failure, hepatic encephalopathy, hepatorenal syndrome, inferior vena cava thrombosis, intestinal infarct, sepsis/septic shock and cancer were associated increased risk of mortality. The average of length of stay was 8.8 d and it consistently decreased by 2.04% (95%CI: -2.67%, -1.41%, P < 0.001) from 12.7 d in 1998 to 7.6 d in 2017.The average total charges after adjusted for Medical Care Consumers Price Index to 2017 dollars during the time period was $94440 and the annual percentage change increased by 1.15% (95%CI: 0.35%, 1.96%, P = 0.005) from $95515 in 1998 to $103850 in 2017.

CONCLUSION

The in-hospital mortality rate for patients admitted with BCS in the United States has reduced between 1998 and 2017 and this may a reflection of better management of these patients.

Spontaneous bacterial peritonitis mortality trends of cirrhotic patients in the last decade in Constanta County

Spontaneous bacterial peritonitis (SBP) is a complication of liver cirrhosis with an increased in-hospital mortality rate. For this reason, the aim of the present study was to examine the main predictors of mortality in order to be able to identify high-risk patients in time and to guide the optimal treatment for prognosis improvement. We retrospectively collected demographic, clinical, laboratory and treatment data as well as data regarding length of stay and cost of hospitalization from 72 patients diagnosed with SBP between January 2010 and December 2019 in the Emergency Clinical Hospital St. Apostle Andrew, Constanta, Romania. Patients were divided into two groups: Those who survived and those who died. Logistic regression was used to identify a possible association between these factors and the increased risk of mortality. Univariate analysis revealed that clinical factors (fever, chills, and hepatic encephalopathy), biological factors such as serum and ascites leukocyte value, polymorphonuclear percentage (PMN), erythrocyte sedimentation rate (ESR) value, previous SBP episodes, and the presence of complications such as acute kidney injury (AKI), sepsis, and systemic inflammatory response syndrome (SIRS) were significantly associated with in-hospital mortality in patients with SBP. Multivariate analysis revealed that SIRS (P=0.0010) and fever (P=0.0258) were significantly associated with in-hospital mortality in patients with SBP. Findings of the present study suggest that, SIRS and fever were independent predictive factors of mortality in cirrhotic patients with SBP.

Spontaneous bacterial peritonitis due to carbapenemase-producing Enterobacteriaceae: Etiology and antibiotic treatment

Carbapenem antibiotics were first introduced in the 1980s and have long been considered the most active agents for the treatment of multidrug-resistant gram-negative bacteria. Over the last decade, carbapenem-resistant Enterobacteriaceae (CRE) have emerged as organisms causing spontaneous bacterial peritonitis. Infections caused by CRE have shown a higher mortality rate than those caused by bacteria sensitive to carbapenem antibiotics. Current antibiotic guidelines for the treatment of spontaneous bacterial peritonitis are insufficient, and rapid de-escalation of empiric antibiotic treatment is not widely recognized. This review summarizes the molecular characteristics, epidemiology and possible treatment of spontaneous bacterial peritonitis caused by CRE.

Coagulopathy and Hospital Outcomes in Patients With Spontaneous Bacterial Peritonitis: A Call for Action to Improve Care of Inpatients

Objectives

To assess the risk of in-hospital mortality in spontaneous bacterial peritonitis (SBP) with coagulopathy, and to understand the impact of comorbid coagulopathy on length of stay (LOS) and total charges for SBP inpatients.

Methods

We included adult patients (age, 18-50 years) with a principal diagnosis of SBP using the Nationwide Inpatient Sample (NIS, 2012 to 2014). These patients were further subgrouped by comorbid coagulopathy. The independent sample t-test was used to measure the mean difference in LOS and total charges between subgroups. The logistic regression model was used to measure the odds ratio (OR) of association of coagulopathy and in-hospital mortality after adjusting for demographic confounders and other comorbid risk factors.

Results

SBP with comorbid coagulopathy was prevalent in males (68.7%) and white (58.1%). When compared with the non-coagulopathy cohort, males had 1.6 times (95% CI 1.46-1.84), and hispanics had 1.4 times (95% CI 1.19-1.58) high odds for coagulopathy. In-hospital mortality was statistically significant in SBP inpatients with coagulopathy (6.5% vs. 2.8% in non-coagulopathy), and with two times higher odds of association (95% CI 1.47-2.51) compared with non-coagulopathy cohort. SBP inpatients with comorbid coagulopathy had a statistically significantly higher LOS by 1.1 days and higher total charges by $14,123 per hospitalization compared with the non-coagulopathy cohort.

Conclusions

Coagulopathy is a significant risk factor that increases the risk of in-hospital mortality in SBP inpatients by 92%. Comorbid coagulopathy is also associated with extended LOS and higher hospitalization costs, thereby increasing the healthcare burden. Clinicians need to effectively manage coagulopathy in SBP patients to improve patient outcomes and reduce the healthcare burden with better health-related quality of life.

Chronic Alcoholic Liver Disease and Mortality Risk in Spontaneous Bacterial Peritonitis: Analysis of 6,530 Hospitalizations

Objective

Our study aimed to assess the risk of in-hospital mortality due to chronic alcoholic liver disease (CALD) and other comorbidities in spontaneous bacterial peritonitis (SBP) inpatients.

Methods

We conducted a cross-sectional study using the Nationwide Inpatient Sample (NIS, 2012 to 2014) from the United States and included 6,530 patients (age 18-50 years) with a primary diagnosis of SBP. Logistic regression was used to evaluate the odds ratio (OR) for in-hospital mortality in SBP by comorbidities.

Results

The prevalence of CALD in SBP patients is 43.6%, and a higher proportion were males (68.8%) and whites (67%). Middle-aged adults (OR 2.8, 95% CI 1.74-4.45) had higher odds of in-hospital mortality in SBP patients. Race and sex were non-significant predictors for mortality risk. Patients with comorbid coagulopathy (OR 1.9, 95% CI 1.45-2.48) and heart failure (OR 3.9, 95% CI 2.46-6.36) have increased mortality in SBP inpatients. After controlling confounders, CALD was significantly associated with increased in-hospital mortality (OR 1.5, 95% CI 1.12-1.94) in SBP inpatients.

Conclusion

CALD is an independent factor in increasing the risk of in-hospital mortality in SBP patients by 48%. Alcohol use screening, and alcohol abstinence and supportive therapy need to be implemented at an earlier stage to improve health-related quality of life and reduce in-hospital mortality in SBP patients.

Effect of gender on mortality and causes of death in cirrhotic patients with gastroesophageal varices. A retrospective study in Norway

Background & aims

The prognostic role of gender in patients with liver cirrhosis is not fully understood. Our primary aim was to assess how gender affects cumulative incidence and risk of death without liver transplantation (LT) in cirrhotic patients with gastroesophageal varices. Secondary aims were to assess the relationship between gender and cause specific death, risk of variceal bleeding and incidence rates of gastroesophageal varices in patients with cirrhosis.

Methods

All new patients with gastroesophageal varices due to liver cirrhosis at Oslo University Hospital between 2006 and May 2016 were identified. Clinical data were retrieved retrospectively from hospital files. Causes of death were classified according to a specified protocol in cases of in-hospital-death, otherwise by data from the Norwegian Death Registry. Competing risk analyses were used to calculate cumulative incidences and risks of i) all-cause death, ii) cause-specific death and iii) variceal bleeding or re-bleeding.

Results

Cumulative one- and five years incidence of death without LT in 266 included patients were 28% and 51%, respectively. In univariate analysis, risk of death was positively associated with age, Child Pugh class, alcoholic liver disease and presentation with variceal bleeding, and negatively associated with female sex. In a multivariate model, risk of death without LT was associated with female sex (SHR 0.59 [0.40–0.86]), age (SHR 1.05 [1.04–1.07] per year), Child Pugh class B (SHR 1.54 [1.03–2.32]) and Child Pugh class C (SHR 4.29 [2.57–7.17]). Variceal bleeding caused 27% of deaths. Adjusting for age and Child Pugh score, a trend towards reduced risk of death due to variceal bleeding was seen in women (SHR 0.53; [0.26–1.06]). High alcohol consumption was associated with increased risk of first variceal bleeding, both at univariate analysis (SHR 7.73 [1.71–34.9]) and multivariate analysis (SHR 13.9 [2.51–77.0]).

Conclusions

Reduced mortality due to variceal bleeding may contribute to improved survival without LT in cirrhotic women with gastroesophageal varices.

Early Paracentesis in High-Risk Hospitalized Patients: Time for a New Quality Indicator

INTRODUCTION

Symptomatic ascites is the most common indication for hospitalization in patients with cirrhosis. Although guidelines recommend paracentesis for all inpatients with ascites, the timing of paracentesis is likely to be crucial. Performance of an early paracentesis and its relationship to outcomes are unknown, particularly among patients at high risk of spontaneous bacterial peritonitis (SBP).

METHODS

We included 75,462 discharges of adult patients with cirrhosis presenting with ascites who underwent paracentesis from the State Inpatient Databases of New York, Florida, and Washington from 2009 to 2013. High-risk patients were identified as having concomitant hepatic encephalopathy or acute kidney injury present on admission. The primary outcome was performance of early paracentesis (within 1 hospital day) with secondary outcomes being inpatient mortality, SBP-related mortality, and 30-day readmission. Multivariable logistic regression models included a priori covariates known to impact outcomes.

RESULTS

There were 43,492 (57.6%) patients who underwent early paracentesis. High-risk patients (27,496) had lower rates of early paracentesis (52.8% vs 60.5%, P < 0.001). On multivariable analysis, high-risk patients had significantly decreased odds of undergoing early paracentesis (odds ratio [OR] 0.74, 95% confidence interval [CI] 0.71-0.78, P < 0.001). Early paracentesis was associated with a reduced inpatient all-cause mortality (OR 0.68, 95% CI 0.63-0.73, P < 0.001), SBP-related mortality (OR 0.84, 95% CI 0.73-0.94, P = 0.01), and 30-day readmission (OR 0.87, 95% CI 0.82-0.92, P < 0.001).

DISCUSSION

Early paracentesis is associated with reduced inpatient mortality, SBP-related mortality, and 30-day readmission. Given its impact on outcomes, early paracentesis should be a new quality metric. Further education and interventions are needed to improve both adherence and outcomes.

Short- and long-term predictors of spontaneous bacterial peritonitis in Singapore

INTRODUCTION

Spontaneous bacterial peritonitis (SBP) is the commonest complication of liver cirrhosis. Timely and appropriate treatment of SBP is crucial, particularly with the rising worldwide prevalence of multidrug-resistant organisms (MDROs). We aimed to investigate the clinical outcomes of SBP in Singapore.

METHODS

All cirrhotic patients with SBP diagnosed between January 2014 and December 2017 were included. Nosocomial SBP (N-SBP) was defined as SBP diagnosed more than 48 hours after hospitalisation. Clinical outcomes were analysed as categorical outcomes using univariate and multivariate analysis.

RESULTS

There were 33 patients with 39 episodes of SBP. Their mean age was 64.5 years and 69.7% were male. The commonest aetiology of cirrhosis was hepatitis B (27.3%). The Median Model for End-stage Liver Disease (MELD) score was 17; 33.3% had acute-on-chronic liver failure and 60.6% had septic shock at presentation. N-SBP occurred in 25.6% of SBP cases. N-SBP was more commonly associated with MDROs, previous antibiotic use in the past three months (p = 0.014) and longer length of stay (p = 0.011). The 30-day and 90-day mortality among SBP patients was 30.8% and 51.3%, respectively. MELD score > 20 was a predictor for 30-day mortality. N-SBP and MELD score > 20 were predictors for 90-day mortality.

CONCLUSION

N-SBP was significantly associated with recent antibiotic use, longer hospitalisation, more resistant organisms and poorer survival among patients with SBP. N-SBP and MELD score predict higher mortality in SBP. Judicious use of antibiotics may reduce N-SBP and improve survival among cirrhotic patients.

RS, Lee JI. Quality improvement initiative increases total paracentesis and early paracentesis rates in hospitalised cirrhotics with ascites

OBJECTIVE

Early paracentesis (EP) for rapid diagnosis of spontaneous bacterial peritonitis is considered best practice in the care of admitted patients with cirrhosis and ascites, but inpatient paracentesis is frequently not performed or delayed. We developed a quality improvement (QI) initiative aimed at increasing the proportion of admitted patients with cirrhosis who undergo paracentesis and EP.

DESIGN

Pre-post study of a QI initiative.

SETTING

A tertiary care hospital in a major metropolitan area.

PATIENTS

Hospitalised patients with cirrhosis and ascites.

INTERVENTIONS

We targeted care providers in the emergency department (ED) by raising awareness of the importance of EP, developing criteria to identify patients at highest risk of SBP who were prioritised for EP by ED providers and restructuring the ED environment to enable timely paracentesis.

RESULTS

76 patients meeting inclusion criteria were admitted during the postintervention 9-month study period. Of these, 91% (69/76) underwent paracentesis during admission versus 71 % (77/109) preintervention (p=0.001). 81% (56/69) underwent EP within 12 hours of presentation or after a predefined acceptable reason for delay versus 48% (37/77) preintervention (p=0.001). There were no significant differences in in-hospital mortality or length of stay before and after intervention.

CONCLUSION

A multidisciplinary QI intervention targeting care in the ED successfully increased the proportion of patients with cirrhosis and ascites undergoing diagnostic paracentesis during admission and EP within 12 hours of presentation.

Prognosis of Spontaneous Bacterial Peritonitis in Hepatocellular Carcinoma Patients

BACKGROUND

Spontaneous bacterial peritonitis (SBP) is a serious infectious complication in patients with liver cirrhosis. However, information about prognosis of SBP in hepatocellular carcinoma (HCC) patients is limited. We investigated the clinical course of SBP in HCC patients.

METHODS

This study enrolled patients diagnosed with SBP between 2005 and 2017. Medical records of patients were reviewed and clinical course was compared between the non-HCC and HCC groups.

RESULTS

In total, 123 SBP cases including 49 HCC cases were enrolled. Men were predominant (48/74, 64.9% vs. 34/49, 69.4%; P = 0.697); median age was 58 years in both non-HCC and HCC groups (P = 0.887). The most common etiology was alcohol (32/74, 43.2%) in non-HCC group and hepatitis B (30/49, 61.2%) in HCC group (P = 0.009). Antibiotic resistance rate was higher in non-HCC than in HCC group (29.7% vs. 12.2%; P = 0.028); in-hospital mortality did not differ between the groups (25/74, 33.8% vs. 13/49, 26.5%; P = 0.431). Development rate of hepatorenal syndrome did not differ between non-HCC and HCC group (14/74, 18.9% vs. 10/49, 20.4%; P = 1.000), but hepatic encephalopathy was less common in HCC group (26/74, 35.2% vs. 9/49, 18.3%; P = 0.008). The most important predictor of in-hospital mortality in patients with HCC was white blood cell count above 11,570 cells/mm³ (odds ratio, 6.629; 95% confidence interval, 1.652-26.590; P = 0.008).

CONCLUSION

Prognosis of SBP in HCC patients is relatively less severe. This result may be related with reduced antibiotics resistance and lower development rates of other complications, such as hepatic encephalopathy. Degree of systemic inflammation may be the most important factor for in-hospital mortality.

Analysis of Risk Factors for Patients with Liver Cirrhosis Complicated with Spontaneous Bacterial Peritonitis

BACKGROUND

We aimed to explore risk factors for patients with liver cirrhosis complicated with spontaneous bacterial peritonitis (SBP).

METHODS

The clinical data of 195 patients with liver cirrhosis complicated with SBP (study group), admitted from March 2014 to March 2018 in Tianjin Medical University General Hospital, Tianjin, China and 195 patients without liver cirrhosis complicated with SBP (control group) were retrospectively analyzed. Clinical manifestations of patients and laboratory findings were analyzed. Univariate and multivariate Logistic regression analysis were used for independent risk factors for the occurrence of SBP.

RESULTS

There were significant differences in patients between study group and control group in Child-Pugh classification, peripheral blood white blood cell (WBC), serum C-reactive protein (CRP), serum total bilirubin (TBil), ascites WBC, ascites albumin (ALB), and the ratio of complicated with upper gastrointestinal hemorrhage, hepatorenal syndrome, hepatic encephalopathy and hyponatremia (P<0.01); Logistic regression analysis found that Child-Pugh classification, serum CRP, ascites WBC, ascites ALB, upper gastrointestinal hemorrhage, hepatorenal syndrome, hepatic encephalopathy and hyponatremia were related to the occurrence of SBP; and Child-Pugh classification, ascites ALB, upper gastrointestinal hemorrhage, hepatorenal syndrome and hyponatremia were its independent risk factors.

CONCLUSION

Child-Pugh classification, ascites ALB, upper gastrointestinal hemorrhage, hepatorenal syndrome and hyponatremia are independent risk factors for the occurrence of liver cirrhosis complicated with SBP. Cautions should be raised for patients with liver cirrhosis for this. In the early stage, we should make effective antibiotic anti-bacterial infection program, actively prevent and control the occurrence of SBP, improving the survival rate of patients.

Spontaneous Bacterial Peritonitis in Afebrile Cirrhotic Patients; Report from a Referral Transplantation Center

Spontaneous bacterial peritonitis (SBP) is a complication of liver cirrhosis with adverse effect on patient prognosis. Early diagnosis and treatment is highly important, especially in patients without remarkable manifestations. We designed this study to determine the prevalence of SBP among afebrile cirrhotic patients and identify high-risk subgroups in a referral center in southern Iran. This cross-sectional study evaluated all afebrile cirrhotic patients, admitted to the gastroenterology ward of Namazi hospital (affiliated with Shiraz University of Medical Sciences, Shiraz, Iran) over a 6-month period in 2017, for the presence and correlates of SBP.

Demographic data, clinical findings, and comorbidities were recorded. Ascitic fluid white blood cells (WBC) count >500 and neutrophil count >250 indicated bacterial peritonitis. In total, 97 afebrile cirrhotic patients comprising of 63 (64.9%) men and 34 (35.1%) women were included. All patients had ascites and 89 (91.8%) had abdominal tenderness. Accordingly, abdominal distension was the top presentation. Confirmed etiologies or comorbidities such as HBS, HCV, and liver cancer or metastasis existed in 46 patients. Thirteen (13.4%) had SBP. The correlations of gender (p=0.331), decreased level of consciousness (p=0.145), tenderness (p=0.315). With regards to the type of presentations, only DLOC showed to be significantly higher in SBP negative patients (p=0.022, OR=0.09. 95%CI=0.01–0.62). Also, using binary logistic regression, the correlation of age with SBP was statistically non-significant (coefficient= ⎼0.013, p=0.595). Our findings indicated that routine paracentesis in all cirrhotic patients regardless of fever can help diagnose a number of potentially neglected patients and improve their outcome.