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Sun J, Yang G, Yang C. Influence of postoperative hypoalbuminemia and human serum albumin supplementation on incision healing following total knee arthroplasty for knee osteoarthritis: a retrospective study. Sci Rep 2024; 14:17354. [PMID: 39075140 PMCID: PMC11286832 DOI: 10.1038/s41598-024-68482-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 07/24/2024] [Indexed: 07/31/2024] Open
Abstract
With distinct advantages in clinical application, total knee arthroplasty (TKA) is an effective surgical option for treating end-stage osteoarthritis in the knee. After TKA, incisional problems are one of the major factors influencing the speed in which patients recover. Although it is widely acknowledged that preoperative hypoalbuminemia and the incidence of incisional complications are significantly associated, it is still unclear if postoperative hypoalbuminemia raises the risk of incisional complications following TKA. Furthermore, human serum albumin (HSA) is frequently utilized domestically and internationally to treat postoperative hypoalbuminemia; nevertheless, there is ongoing discussion on whether HSA supplementation can enhance postoperative clinical outcomes. To investigate the relationship between hypoalbuminemia and suboptimal incision healing following TKA, as well as to determine whether HSA supplementation can enhance incision healing after surgery, we collected clinical data for this study. The study sample consisted of 22 patients with poorly healed incisions and 120 cases with normal healing of incisions who underwent TKA treatment for knee osteoarthritis (KOA) in the operator's hospital's Department of Orthopaedics between July 1, 2020, and July 1, 2023. To determine the prevalence of postoperative poor incision healing, data on patients' basic characteristics, preoperative test results, surgical data, postoperative test results, and postoperative incision healing were gathered. The contributing factors to inadequate recovery after surgery were examined using SPSS software. After controlling for confounding variables, a multivariate regression analysis model was used to examine the relationship between postoperative hypoalbuminemia, HSA supplementation, and poor incision healing. 22 cases (15.49%) had poor wound healing following surgery. The findings of multivariate regression analysis after controlling for confounders indicated that there was no correlation between poor wound healing and postoperative albumin level (P > 0.05). Similarly, there was no association (P > 0.05) seen between HSA supplementation and poor incision healing. Following the TKA, postoperative hypoalbuminemia does not raise the risk of incisional problems, and postoperative HSA supplementation neither lowers nor enhances the risk of inadequate incisional healing.
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Affiliation(s)
- Jian Sun
- Department of Orthopaedic Surgery, Shanghai Public Health Clinical Center (Fudan University), No. 2901, Caolang Road, Jinshan District, Shanghai City, China
| | - Guangling Yang
- Department of Orthopaedic Surgery, Shanghai Public Health Clinical Center (Fudan University), No. 2901, Caolang Road, Jinshan District, Shanghai City, China
| | - Chenglin Yang
- Department of Orthopaedic Surgery, Shanghai Public Health Clinical Center (Fudan University), No. 2901, Caolang Road, Jinshan District, Shanghai City, China.
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, China.
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Seguí-Ripoll JM, Candela-Gomis A, Compañy-Catalá L, Francés-Guarinos R, Payá-Romá A, Compañ-Rosique A, Such-Ronda J, Zapater-Hernández P. Lipid peroxidation and liver damage in double and simple common bile duct ligation models in male Sprague-Dawley rats. Life Sci 2023; 334:122238. [PMID: 37925139 DOI: 10.1016/j.lfs.2023.122238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 10/29/2023] [Accepted: 10/31/2023] [Indexed: 11/06/2023]
Abstract
AIMS Bacterial translocation, defined as the presence of living bacteria or bacterial fragments in both mesenteric lymph nodes or systemic circulation, can cause a severe inflammatory reaction in patients with cirrhosis. This study aimed to compare lipid peroxidation associated with liver damage in different experimental models of bile duct ligation: proximal double ligation and transection versus proximal simple ligation versus sham. MATERIALS AND METHODS Sixty-two male rats underwent one of three bile duct surgical interventions: proximal double ligation and transection (n = 22); proximal simple ligation (n = 19); or sham operation (n = 21). We performed microbiological culture of mesenteric lymph nodes; portal and cava blood, spleen and liver cultures; and histological analysis of liver parenchyma. Samples of blood and liver were obtained at laparotomy for malondialdehyde quantification. KEY FINDINGS Serum malondialdehyde levels were significantly higher in simple ligature animals (3.7 nmol/mg, standard deviation [SD] 2.1) compared to controls (1.6 nmol/mg SD 0.5; p = 0.001) or double ligature (0.3 nmol/mg SD 0.3; p = 0.001). Liver malondialdehyde levels were significantly higher in animals subjected to double ligation vs controls (9.0 nmol/mg SD 2.8 vs. 1.7 nmol/mg SD 1.0; p = 0.0007) and simple ligature (2.9 nmol/mg SD 2.0; p = 0.0001). Overall incidence of bacterial translocation was similar in simple and double ligatures (22.2 % and 21 % respectively), and significantly higher than in controls. SIGNIFICANCE the type of bile duct ligation influences the type and localization of lipid peroxidation, but does not influence the development of bacterial translocation.
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Affiliation(s)
- José Miguel Seguí-Ripoll
- Department of Clinical Medicine, Miguel Hernández University, Elche, Spain; Internal Medicine Department, University Hospital of San Juan de Alicante, Spain.
| | - Asunción Candela-Gomis
- General and Digestive Surgery Service, University Hospital of San Juan de Alicante, Spain; Pathology and Surgery Department, Miguel Hernández University, Elche, Spain.
| | | | - Rubén Francés-Guarinos
- CIBERehd, Health Institute Carlos III, Madrid, Spain; Department of Clinical Medicine (Immunology Area), Miguel Hernández University, San Juan, Spain.
| | - Artemio Payá-Romá
- Pathology Department, Hospital General Universitario, Alicante, Spain.
| | - Antonio Compañ-Rosique
- General and Digestive Surgery Service, University Hospital of San Juan de Alicante, Spain; Pathology and Surgery Department, Miguel Hernández University, Elche, Spain.
| | - José Such-Ronda
- Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates; Lerner School of Medicine, Case Western Reserve University, Cleveland, OH, USA.
| | - Pedro Zapater-Hernández
- Unit of Clinical Pharmacology, General University Hospital of Alicante, Spain; IDiBE Institute, Miguel Hernández University, Elche, Spain; CIBERehd, Health Institute Carlos III, Madrid, Spain.
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Xie J, Liu H, Deng S, Niu T, Wang J, Wang H, Chen F, Zheng Z, Li Z. Association between immediate postoperative hypoalbuminemia and surgical site infection after posterior lumbar fusion surgery. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:2012-2019. [PMID: 37027034 DOI: 10.1007/s00586-023-07682-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 02/14/2023] [Accepted: 03/22/2023] [Indexed: 04/08/2023]
Abstract
PURPOSE In this study, we intended to investigate the association between immediate postoperative hypoalbuminemia and surgical site infection (SSI), and determine a threshold value for postoperative hypoalbuminemia that can assist in risk stratification in patients after posterior lumbar fusion surgery. METHODS From January 2017 to December 2021, 466 consecutive patients who underwent posterior lumbar fusion surgery were selected to analyze the relationship between immediate postoperative hypoalbuminemia and SSI. Multivariate logistic regression analysis was performed to identify the independent risk factors of SSI and postoperative hypoalbuminemia. Receiver Operating Characteristic (ROC) analysis was used to determine the optimal value for postoperative hypoalbuminemia, and subsequent grouping was based on the identified threshold. RESULTS Of the total 466 patients, 25 patients (5.4%) developed SSI after surgery, and lower postoperative albumin (OR: 0.716, 95% CI: 0.611-0.840, p < 0.001) was independently associated with SSI. ROC analysis showed that the cutoff value of postoperative hypoalbuminemia was 32 g/L with a sensitivity of 0.760, specificity of 0.844, and a Youden index of 0.604. Postoperative SSI was more common in patients with postoperative hypoalbuminemia than in those without (21.6% vs. 1.6%, p < 0.001). Age, gender and operative duration were found to be independent predictors of postoperative hypoalbuminemia. CONCLUSIONS This study showed that immediate postoperative hypoalbuminemia was an independent risk factor for the development of SSI in patients who underwent posterior lumbar fusion. Even in patients with a normal preoperative serum albumin level, there was an increased risk of SSI when the postoperative albumin within 24 h was < 32 g/L.
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Affiliation(s)
- Jiahua Xie
- Department of Spine Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China
| | - Hui Liu
- Department of Spine Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China
| | - Siping Deng
- Department of Spine Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China
| | - Tianzuo Niu
- Department of Spine Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China
| | - Jianru Wang
- Department of Spine Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China
| | - Hua Wang
- Department of Spine Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China
| | - Fan Chen
- Department of Spine Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China
| | - Zhaomin Zheng
- Department of Spine Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China
| | - Zemin Li
- Department of Spine Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China.
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Long B, Gottlieb M. Emergency medicine updates: Spontaneous bacterial peritonitis. Am J Emerg Med 2023; 70:84-89. [PMID: 37244043 DOI: 10.1016/j.ajem.2023.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/11/2023] [Accepted: 05/12/2023] [Indexed: 05/29/2023] Open
Abstract
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.
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Affiliation(s)
- Brit Long
- SAUSHEC, Emergency Medicine, Brooke Army Medical Center, United States of America.
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States of America
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Nanchal R, Subramanian R, Alhazzani W, Dionne JC, Peppard WJ, Singbartl K, Truwit J, Al-Khafaji AH, Killian AJ, Alquraini M, Alshammari K, Alshamsi F, Belley-Cote E, Cartin-Ceba R, Hollenberg SM, Galusca DM, Huang DT, Hyzy RC, Junek M, Kandiah P, Kumar G, Morgan RL, Morris PE, Olson JC, Sieracki R, Steadman R, Taylor B, Karvellas CJ. Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: Neurology, Peri-Transplant Medicine, Infectious Disease, and Gastroenterology Considerations. Crit Care Med 2023; 51:657-676. [PMID: 37052436 DOI: 10.1097/ccm.0000000000005824] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
OBJECTIVES To develop evidence-based recommendations for clinicians caring for adults with acute liver failure (ALF) or acute on chronic liver failure (ACLF) in the ICU. DESIGN The guideline panel comprised 27 members with expertise in aspects of care of the critically ill patient with liver failure or methodology. We adhered to the Society of Critical Care Medicine standard operating procedures manual and conflict-of-interest policy. Teleconferences and electronic-based discussion among the panel, as well as within subgroups, served as an integral part of the guideline development. INTERVENTIONS In part 2 of this guideline, the panel was divided into four subgroups: neurology, peri-transplant, infectious diseases, and gastrointestinal groups. We developed and selected Population, Intervention, Comparison, and Outcomes (PICO) questions according to importance to patients and practicing clinicians. For each PICO question, we conducted a systematic review and meta-analysis where applicable. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence to decision framework to facilitate recommendations formulation as strong or conditional. We followed strict criteria to formulate best practice statements. MEASUREMENTS AND MAIN RESULTS We report 28 recommendations (from 31 PICO questions) on the management ALF and ACLF in the ICU. Overall, five were strong recommendations, 21 were conditional recommendations, two were best-practice statements, and we were unable to issue a recommendation for five questions due to insufficient evidence. CONCLUSIONS Multidisciplinary, international experts formulated evidence-based recommendations for the management ALF and ACLF patients in the ICU, acknowledging that most recommendations were based on low quality and indirect evidence.
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Affiliation(s)
- Rahul Nanchal
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI
| | | | - Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Joanna C Dionne
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | - David T Huang
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Mats Junek
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Gagan Kumar
- Northeast Georgia Medical Center, Gainesville, GA
| | - Rebecca L Morgan
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Peter E Morris
- University of Kentucky College of Medicine, Lexington, KY
| | - Jody C Olson
- Kansas University Medical Center, Kansas City, KS
| | | | - Randolph Steadman
- University of California Los Angeles Medical Center, Los Angeles, CA
| | | | - Constantine J Karvellas
- Department of Critical Care Medicine and Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, AB, Canada
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van Os W, Wulkersdorfer B, Eberl S, Oesterreicher Z, Schwabl P, Reiberger T, Paternostro R, Weber M, Willinger B, Zeitlinger M. Bacterial growth and ceftriaxone activity in individual ascitic fluids in an in vitro model of spontaneous bacterial peritonitis. Front Pharmacol 2023; 14:1124821. [PMID: 37063261 PMCID: PMC10090294 DOI: 10.3389/fphar.2023.1124821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 03/20/2023] [Indexed: 03/31/2023] Open
Abstract
Introduction: The environment of the infection site affects bacterial growth and antibiotic activity. When bacterial growth and antibiotic activity are studied in body fluids, samples of multiple subjects are usually pooled, averaging out potentially relevant differences in composition. The ascitic fluid (AF) environment is frequently associated with spontaneous bacterial peritonitis (SBP) in cirrhotic patients. In this study, bacterial growth and ceftriaxone activity were evaluated in individual AF using an in vitro model of SBP, reflecting the environment and pharmacokinetics at the infection site.Methods: AF was obtained from nine cirrhotic patients with non-infected ascites. Growth of nine bacterial strains (three Escherichia coli, four Staphylococcus aureus, one Enterococcus faecalis, and one Klebsiella pneumoniae) in individual AF was assessed and correlated with biomarkers including potential risk factors for SBP. Ceftriaxone time-kill experiments, in which the pharmacokinetic profile observed in AF following a 1 g intravenous infusion was replicated, were performed with two E. coli and two S. aureus isolates with minimum inhibitory concentrations around the ceftriaxone resistance breakpoint.Results: Significant correlations were found between bacterial growth and AF levels of protein (Spearman’s rank correlation coefficient ρ = −0.35), albumin (ρ = −0.31), and complement C3c (ρ = −0.28), and serum levels of bilirubin (ρ = 0.39) and aspartate aminotransferase (ρ = 0.25). Ceftriaxone was active in AF, even against resistant isolates, generally resulting in ≥2 log reductions in bacterial count within 24 h.Conclusion: Ascites patients may be predisposed to or protected against SBP based on the antimicrobial capacity of their AF. Ceftriaxone at clinical AF concentrations is active in the AF environment.
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Affiliation(s)
- Wisse van Os
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | | | - Sabine Eberl
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Zoe Oesterreicher
- Department of Internal Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University of Vienna, Vienna, Austria
| | - Philipp Schwabl
- Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Rafael Paternostro
- Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Maria Weber
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Birgit Willinger
- Department of Microbiology, Medical University of Vienna, Vienna, Austria
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
- *Correspondence: Markus Zeitlinger,
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Wang Y, Lu X, Gao Y, Liu N, Jiang H, Chen S, Chen M. The predictive value of prognostic nutritional index on early complications after robot-assisted radical cystectomy. Front Surg 2022; 9:985292. [DOI: 10.3389/fsurg.2022.985292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 10/31/2022] [Indexed: 11/17/2022] Open
Abstract
ObjectiveThe purpose of the study was to evaluate the predictive value of prognostic nutritional index (PNI) on early complications (within 30-day) after robot-assisted radical cystectomy (RARC) and urinary diversion.Patients and methodsPatients underwent RARC and urinary diversion between November 2018 and December 2021 in our centre were screened in this retrospective study. Baseline characteristics and perioperative data were recorded. Early complications after surgery were classified according to Clavien-Dindo system. Univariate and multivariate logistic analysis were performed to decide the potential factors associated with post-RARC complications. The receiver operating characteristic (ROC) curve was conducted to determine the predictive value of PNI on early overall and major complications after RARC.ResultsOverall 139 men and 13 women with a median age of 69 years and mean BMI of 24.4 kg/m2 were included in this study. As for urinary diversion, most patients (n = 111, 73%) received cutaneous ureterostomy, 36 patients (23.7%) underwent orthotopic neobladder and 5 patients (3.3%) received ileal conduit. The incidence of postoperative complication rate was 44.7%, which included 82.2% minor complications and 17.8% major complications. Further univariate and multivariate logistic analyses demonstrated that hypertension (OR = 2.96, 95% CI: 1.24–7.07, P = 0.015), PNI (OR = 0.73, 95% CI: 0.62–0.86, P < 0.001), and CCI (OR = 1.44, 95% CI: 1.01–2.06, P = 0.047) were independent risk factors of early complications after RARC. Moreover, PNI (OR = 0.72, 95% CI: 0.60–0.86, P < 0.001) was also the predictor of major complications after RARC. The ROC curve demonstrated that PNI (AUC = 0.829; AUC = 0.840) has a great predictive value in early overall and major complications after RARC.ConclusionPNI can be an early alert for RARC patients thus aiding in closer monitoring and postoperative management.
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Spontaneous Bacterial Peritonitis in Decompensated Liver Cirrhosis—A Literature Review. LIVERS 2022. [DOI: 10.3390/livers2030018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Spontaneous bacterial peritonitis (SBP) is defined as a bacterial infection of the ascitic fluid without a surgically treatable intra-abdominal infection source. SBP is a common, severe complication in cirrhosis patients with ascites, and if left untreated, in-hospital mortality may exceed 90%. However, the incidence of SBP has been lowered to approx. 20% through early diagnosis and antibiotic therapy. Clinical awareness, prompt diagnosis, and immediate treatment are advised when caring for these patients to reduce mortality and morbidity. Aim: To discuss important issues comprising types of SBP, pathogenesis, bacteriology, including the emergence of multidrug-resistant (MDR) microorganisms, prompt diagnosis, risk factors, prognosis, treatment strategies, as well as recurrence prevention through antibiotic prophylaxis until liver transplantation and future trends in treating and preventing SBP in detail. Methods: This article is a literature review and appraisal of guidelines, randomized controlled trials, meta-analyses, and other review articles found on PubMed from between 1977 and 2022. Results: There are three types of SBP. Bacterial translocation from GI tract is the most common source of SBP. Therefore, two thirds of SBP cases were caused by Gram-negative bacilli, of which Escherichia coli is the most frequently isolated pathogen. However, a trend of Gram-positive cocci associated SBP has been demonstrated in recent years, possibly related to more invasive procedures and long-term quinolone prophylaxis. A diagnostic paracentesis should be performed in all patients with cirrhosis and ascites who require emergency room care or hospitalization, who demonstrate or report consistent signs/symptoms in order to confirm evidence of SBP. Distinguishing SBP from secondary bacterial peritonitis is essential because the conditions require different therapeutic strategies. The standard treatment for SBP is prompt broad-spectrum antibiotic administration and should be tailored according to community-acquired SBP, healthcare-associated or nosocomial SBP infections and local resistance profile. Albumin supplementation, especially in patients with renal impairment, is also beneficial. Selective intestinal decontamination is associated with a reduced risk of bacterial infection and mortality in high-risk group. Conclusions: The standard treatment for SBP is prompt broad-spectrum antibiotic administration and should be tailored according to community-acquired SBP, healthcare-associated or nosocomial SBP infections and local resistance profile. Since the one-year overall mortality rates for SBP range from 53.9 to 78%, liver transplantation should be seriously considered for SBP survivors who are good candidates for transplantation. Further development of non-antibiotic strategies based on pathogenic mechanisms are also urgently needed.
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Diagnostic Potential of Calprotectin for Spontaneous Bacterial Peritonitis in Patients Withliver Cirrhosis and Ascites. Pril (Makedon Akad Nauk Umet Odd Med Nauki) 2021; 42:97-106. [PMID: 35032370 DOI: 10.2478/prilozi-2021-0040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The development of spontaneous bacterial peritonitis (SBP) is a serious and life-threatening condition in patients with cirrhosis and ascites. The aim of this study was to determine the diagnostic potential of calprotectin in ascites, for SBP in patients with liver cirrhosis and ascites before and after antibiotic treatment and to compare the mean values of calprotectin in ascites in patients with and without SBP. This prospective-observational study was comprised of 70 patients with cirrhosis and ascites, divided into two groups, the SBP and the non-SBP group. Quantitative measurements of calprotectin in ascites was completed with the Quantum Blue Calprotectin Ascites test (LF-ASC25), using the Quantum Blue Reader. The average value of calprotectin in the SBP group was 1.5 ± 0.40 μg / mL, and in the non-SBP group it was lower (0.4 ± 0.30). The difference between the mean values was statistically significant with p <0.05. The mean value of calprotectin in ascites before therapy among the SBP group was 1.5 ± 0.4, and after antibiotic therapy, the value decreased significantly to 1.0 ± 0.6; the difference between the mean values was statistically significant with p <0.05. ROC analysis indicated that calprotectin contributed to the diagnosis of SBP with a 94.3% sensitivity rating (to correctly identify positives), and the specificity was 62.5%, which corresponded to the value of 0.275. Our research confirmed that ascitic calprotectin was a good predictor, and is significantly associated with the occurrence of SBP in patients with liver cirrhosis. By monitoring the value of calprotectin in ascites on the 7th day of antibiotic treatment, the effectiveness of antibiotic treatment in patients with SBP can be determined.
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Abstract
Surgical site infections (SSIs) are among the most common and most costly health care-associated infections, leading to adverse patient outcomes and death. Wound contamination occurs with each incision, but proven strategies exist to decrease the risk of SSI. In particular, improved adherence to evidence-based preventive measures related to appropriate antimicrobial prophylaxis can decrease the rate of SSI. Aggressive surgical debridement and effective antimicrobial therapy are needed to optimize the treatment of SSI.
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Affiliation(s)
- Jessica Seidelman
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University School of Medicine, Duke University, Durham, NC, USA; Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University Medical Center, Durham, NC, USA.
| | - Deverick J Anderson
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University School of Medicine, Duke University, Durham, NC, USA; Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University Medical Center, Durham, NC, USA
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Torp N, Israelsen M, Madsen B, Lutz P, Jansen C, Strassburg C, Mortensen C, Knudsen AW, Sorensen GL, Holmskov U, Schlosser A, Thiele M, Trebicka J, Krag A. Corrigendum to 'Level of MFAP4 in ascites independently predicts 1-year transplant-free survival in patients with cirrhosis' [JHEP Reports 3 (2021) 100287]. JHEP Rep 2021; 3:100353. [PMID: 34693237 PMCID: PMC8514409 DOI: 10.1016/j.jhepr.2021.100353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 03/11/2021] [Accepted: 03/18/2021] [Indexed: 11/29/2022] Open
Abstract
Background & Aims Prognostic models of cirrhosis underestimate disease severity for patients with cirrhosis and ascites. Microfibrillar-associated protein 4 (MFAP4) is an extracellular matrix protein linked to hepatic neoangiogenesis and fibrogenesis. We investigated ascites MFAP4 as a predictor of transplant-free survival in patients with cirrhosis and ascites. Methods A dual-centre observational study of patients with cirrhosis and ascites recruited consecutively in relation to a paracentesis was carried out. Patients were followed up for 1 year, until death or liver transplantation (LTx). Ascites MFAP4 was tested with the model for end-stage liver disease (MELD-Na), CLIF Consortium Acute Decompensation (CLIF-C AD), and Child-Pugh score in Cox regression models. Results Ninety-three patients requiring paracentesis were included. Median ascites MFAP4 was 29.7 U/ml [22.3–41.3], and MELD-Na was 19 [16–23]. A low MELD-Na score (<20) was observed in 49 patients (53%). During follow-up, 20 patients died (22%), and 6 received LTx (6%). High ascites MFAP4 (>29.7 U/ml) was associated with 1-year transplant-free survival (p = 0.002). In Cox regression, ascites MFAP4 and MELD-Na independently predicted 1-year transplant-free survival (hazard ratio [HR] = 0.97, p = 0.03, and HR = 1.08, p = 0.01, respectively). Ascites MFAP4 and CLIF-C AD also predicted survival independently (HR = 0.96, p = 0.02, and HR = 1.05, p = 0.03, respectively), whereas only ascites MFAP4 did, controlling for the Child-Pugh score (HR = 0.97, p = 0.03, and HR = 1.18, p = 0.16, respectively). For patients with MELD-Na <20, ascites MFAP4 but not ascites protein predicted 1-year transplant-free survival (HR 0.91, p = 0.02, and HR = 0.94, p = 0.17, respectively). Conclusions Ascites MFAP4 predicts 1-year transplant-free survival in patients with cirrhosis and ascites. In patients with low MELD-Na scores, ascites MFAP4, but not total ascites protein, significantly predicted 1-year transplant-free survival. Lay summary Patients with cirrhosis who have fluid in the abdomen, ascites, are at an increased risk of death and in need for liver transplantation. Our study identified patients with ascites and a poor prognosis by measuring microfibrillar associated protein 4 (MFAP4), a protein present in the abdominal fluid. Patients with low levels of the MFAP4 protein are at particularly increased risk of death or liver transplantation, suggesting that clinical care should be intensified in this group of patients. MFAP4 is a protein linked to liver fibrosis that can be found in the ascitic fluid in patients with cirrhosis. MFAP4 in the ascitic fluid correlates with MELD-Na, Child-Pugh, and CLIF-C AD. Ascites MFAP4 independently predicts 1-year transplant-free survival in patients with cirrhosis and ascites. Ascites MFAP4 but not total ascites protein is associated with transplant-free survival in patients with MELD-Na <20. Future prognostic models in decompensated cirrhosis may be enhanced by the incorporation of ascites MFAP4.
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Key Words
- Biomarker
- CLIF-C AD, CLIF Consortium Acute Decompensation
- CPS, Child-Pugh score
- CRP, C-reactive protein
- CT, computed tomography
- Decompensated
- ECM, extracellular matrix
- Fibrosis
- GFR, glomerular filtration rate
- HR, hazard ratio
- INR, internationalised normal ratio
- LTx, liver transplantation
- Liver disease
- MELD-Na, model for end-stage liver disease
- MFAP4, microfibrillar associated protein 4
- Mortality
- NASH, non-alcoholic steatohepatitis
- Prognosis
- SBP, spontaneous bacterial peritonitis
- eGFR, estimated GFR
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Affiliation(s)
- Nikolaj Torp
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Mads Israelsen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Bjørn Madsen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Philipp Lutz
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
| | - Christian Jansen
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
| | | | - Christian Mortensen
- Gastro Unit, Medical Division, Copenhagen University Hospital, Hvidovre, Denmark
| | - Anne Wilkens Knudsen
- Gastro Unit, Medical Division, Copenhagen University Hospital, Hvidovre, Denmark
| | - Grith Lykke Sorensen
- Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Uffe Holmskov
- Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Anders Schlosser
- Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Maja Thiele
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jonel Trebicka
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Internal Medicine I, University Hospital of Frankfurt, Frankfurt, Germany.,European Foundation for the Study of Chronic Liver Failure (EF-CLIF), Barcelona, Spain.,Institute for Bioengineering of Catalonia, Barcelona, Spain
| | - Aleksander Krag
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
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Haque LY, Garcia‐Tsao G. A Historical Overview of Spontaneous Bacterial Peritonitis: From Rare to Resistant. Clin Liver Dis (Hoboken) 2021; 18:63-75. [PMID: 34745584 PMCID: PMC8555457 DOI: 10.1002/cld.1122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 03/26/2021] [Indexed: 02/04/2023] Open
Abstract
Content available: Author Audio Recording.
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Affiliation(s)
- Lamia Y. Haque
- Section of Digestive DiseasesYale School of MedicineNew HavenCT
- Department of MedicineYale School of MedicineNew HavenCT
| | - Guadalupe Garcia‐Tsao
- Section of Digestive DiseasesYale School of MedicineNew HavenCT
- Department of MedicineYale School of MedicineNew HavenCT
- Digestive DiseasesVeterans Administration Connecticut Healthcare SystemWest HavenCT
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13
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Karnsakul W, Wasuwanich P, Ingviya T, Laengvejkal P, Vasilescu A, Imteyaz H, Scheimann AO. Clinical usage of serum albumin to ascitic fluid albumin gradient and ascitic fluid total protein in pediatric ascites. Clin Res Hepatol Gastroenterol 2021; 45:101549. [PMID: 33268292 DOI: 10.1016/j.clinre.2020.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 09/05/2020] [Accepted: 09/08/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Abdominal paracentesis is performed as a diagnostic test in children with ascites. Serum albumin to ascitic fluid albumin gradient (SAAG) is frequently used in adults to distinguish types of portal hypertension. We aim to investigate the utilization of SAAG and other biomarkers in determining the etiology of significant ascites in children. METHODS In this retrospective study, children aged 0-21 years with significant ascites were identified using International Classification of Diseases, Ninth Revision (ICD-9) codes and medical records during the period 1983-2010. Medical records of children who had abdominal paracentesis were examined in detail. RESULTS 207 children had significant ascites and of those children, 20 (9.6%) had abdominal paracentesis. Our data showed that high albumin gradient (SAAG ≥ 1.1 g/dL) differentiates causes of ascites secondary to portal hypertension (cirrhosis, hepatic vein outflow obstruction, or congestive hepatopathy) from other causes. In addition, ascitic fluid total protein (AFTP) may help in differential diagnosis of ascites. Children with high SAAG manifest clinical features of portal hypertension including esophageal varices or variceal hemorrhage. CONCLUSION Among patients with initially unclear causes of ascites, SAAG and AFTP can provide guidance for appropriate investigations.
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Affiliation(s)
- Wikrom Karnsakul
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Paul Wasuwanich
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Chemistry and Biochemistry, University of Notre Dame, Notre Dame, IN, USA
| | - Thammasin Ingviya
- Medical Data Center for Research and Innovation, Prince of Songkla University, Songkhla, Thailand; Department of Family and Preventive Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Pavis Laengvejkal
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alexandra Vasilescu
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hejab Imteyaz
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ann O Scheimann
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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14
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Torp N, Israelsen M, Madsen B, Lutz P, Jansen C, Strassburg C, Mortensen C, Knudsen AW, Sorensen GL, Holmskov U, Schlosser A, Thiele M, Trebicka J, Krag A. Level of MFAP4 in ascites independently predicts 1-year transplant-free survival in patients with cirrhosis. JHEP Rep 2021; 3:100287. [PMID: 34041469 PMCID: PMC8141937 DOI: 10.1016/j.jhepr.2021.100287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 03/11/2021] [Accepted: 03/18/2021] [Indexed: 11/28/2022] Open
Abstract
Background & Aims Prognostic models of cirrhosis underestimate disease severity for patients with cirrhosis and ascites. Microfibrillar-associated protein 4 (MFAP4) is an extracellular matrix protein linked to hepatic neoangiogenesis and fibrogenesis. We investigated ascites MFAP4 as a predictor of transplant-free survival in patients with cirrhosis and ascites. Methods A dual-centre observational study of patients with cirrhosis and ascites recruited consecutively in relation to a paracentesis was carried out. Patients were followed up for 1 year, until death or liver transplantation (LTx). Ascites MFAP4 was tested with the model for end-stage liver disease (MELD-Na), CLIF Consortium Acute Decompensation (CLIF-C AD), and Child-Pugh score in Cox regression models. Results Ninety-three patients requiring paracentesis were included. Median ascites MFAP4 was 29.7 U/L [22.3–41.3], and MELD-Na was 19 [16–23]. A low MELD-Na score (<20) was observed in 49 patients (53%). During follow-up, 20 patients died (22%), and 6 received LTx (6%). High ascites MFAP4 (>29.7 U/L) was associated with 1-year transplant-free survival (p = 0.002). In Cox regression, ascites MFAP4 and MELD-Na independently predicted 1-year transplant-free survival (hazard ratio [HR] = 0.97, p = 0.03, and HR = 1.08, p = 0.01, respectively). Ascites MFAP4 and CLIF-C AD also predicted survival independently (HR = 0.96, p = 0.02, and HR = 1.05, p = 0.03, respectively), whereas only ascites MFAP4 did, controlling for the Child-Pugh score (HR = 0.97, p = 0.03, and HR = 1.18, p = 0.16, respectively). For patients with MELD-Na <20, ascites MFAP4 but not ascites protein predicted 1-year transplant-free survival (HR 0.91, p = 0.02, and HR = 0.94, p = 0.17, respectively). Conclusions Ascites MFAP4 predicts 1-year transplant-free survival in patients with cirrhosis and ascites. In patients with low MELD-Na scores, ascites MFAP4, but not total ascites protein, significantly predicted 1-year transplant-free survival. Lay summary Patients with cirrhosis who have fluid in the abdomen, ascites, are at an increased risk of death and in need for liver transplantation. Our study identified patients with ascites and a poor prognosis by measuring microfibrillar associated protein 4 (MFAP4), a protein present in the abdominal fluid. Patients with low levels of the MFAP4 protein are at particularly increased risk of death or liver transplantation, suggesting that clinical care should be intensified in this group of patients. MFAP4 is a protein linked to liver fibrosis that can be found in the ascitic fluid in patients with cirrhosis. MFAP4 in the ascitic fluid correlates with MELD-Na, Child-Pugh, and CLIF-C AD. Ascites MFAP4 independently predicts 1-year transplant-free survival in patients with cirrhosis and ascites. Ascites MFAP4 but not total ascites protein is associated with transplant-free survival in patients with MELD-Na <20. Future prognostic models in decompensated cirrhosis may be enhanced by the incorporation of ascites MFAP4.
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Key Words
- Biomarker
- CLIF-C AD, CLIF Consortium Acute Decompensation
- CPS, Child-Pugh score
- CRP, C-reactive protein
- CT, computed tomography
- Decompensated
- ECM, extracellular matrix
- Fibrosis
- GFR, glomerular filtration rate
- HR, hazard ratio
- INR, internationalised normal ratio
- LTx, liver transplantation
- Liver disease
- MELD-Na, model for end-stage liver disease
- MFAP4, microfibrillar associated protein 4
- Mortality
- NASH, non-alcoholic steatohepatitis
- Prognosis
- SBP, spontaneous bacterial peritonitis
- eGFR, estimated GFR
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Affiliation(s)
- Nikolaj Torp
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Mads Israelsen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Bjørn Madsen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Philipp Lutz
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
| | - Christian Jansen
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
| | | | - Christian Mortensen
- Gastro Unit, Medical Division, Copenhagen University Hospital, Hvidovre, Denmark
| | - Anne Wilkens Knudsen
- Gastro Unit, Medical Division, Copenhagen University Hospital, Hvidovre, Denmark
| | - Grith Lykke Sorensen
- Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Uffe Holmskov
- Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Anders Schlosser
- Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Maja Thiele
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jonel Trebicka
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Internal Medicine I, University Hospital of Frankfurt, Frankfurt, Germany.,European Foundation for the Study of Chronic Liver Failure (EF-CLIF), Barcelona, Spain.,Institute for Bioengineering of Catalonia, Barcelona, Spain
| | - Aleksander Krag
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
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15
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Yu J, Kim HY, Kong YG, Park JH, Seo YJ, Kim YK. De Ritis ratio as a predictor of 1-year mortality after burn surgery. Burns 2021; 47:1865-1872. [PMID: 33832798 DOI: 10.1016/j.burns.2021.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/06/2021] [Accepted: 02/05/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Burn is an overwhelming injury. The De Ritis ratio, defined as aspartate aminotransferase to alanine aminotransferase ratio, can be used to predict poor outcomes. We evaluated the risk factors, including the De Ritis ratio, associated with 1-year mortality after burn surgery. METHODS Patients who underwent burn surgery from 2009 to 2019 were retrospectively evaluated. Multivariate Cox regression analysis was conducted to evaluate the risk factors for 1-year mortality after burn surgery. Receiver operating characteristic (ROC) curve analysis of the De Ritis ratio was performed to predict postoperative 1-year mortality. Kaplan-Meier survival analysis was also conducted. Other postoperative outcomes, such as durations of hospital and intensive care unit stays, acute kidney injury, and major adverse cardiac events, were evaluated. RESULTS One-year mortality after burn surgery occurred in 247 (19.9%) of 1244 patients. The risk factors for 1-year mortality after burn surgery were the De Ritis ratio, age, American Society of Anesthesiologists physical status, diabetes mellitus, total body surface area burned, inhalation injury, serum creatinine level, and serum albumin level. The area under the ROC curve for the De Ritis ratio was 0.716 (optimal cutoff=1.9). The 1-year mortality rate after burn surgery was significantly higher in patients with a De Ritis ratio >1.9 than in those with a De Ritis ratio ≤1.9 (35.8% vs. 11.8%, P<0.001). The survival rate was significantly higher in patients with a De Ritis ratio ≤1.9 than in those with a De Ritis ratio >1.9 (log-rank test, P<0.001). Intensive care unit stay, acute kidney injury, and major adverse cardiac events were significantly higher in patients with a De Ritis ratio >1.9 than in those with a De Ritis ratio ≤1.9 (P=0.006, P<0.001, and P<0.001, respectively). CONCLUSIONS The preoperative De Ritis ratio was a risk factor for 1-year mortality after burn surgery. The De Ritis ratio >1.9 was significantly associated with an increased 1-year mortality after burn surgery. These findings emphasized the importance of identifying burn patients with an increased De Ritis ratio to reduce the mortality after burn surgery.
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Affiliation(s)
- Jihion Yu
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hee Yeong Kim
- Department of Anesthesiology and Pain Medicine, National Medical Center, Seoul, Republic of Korea
| | - Yu-Gyeong Kong
- Department of Anesthesiology and Pain Medicine, Hangang Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Ji Hyun Park
- Department of Anesthesiology and Pain Medicine, National Medical Center, Seoul, Republic of Korea
| | - Young Joo Seo
- Department of Anesthesiology and Pain Medicine, Hangang Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea.
| | - Young-Kug Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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16
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Yu J, Hong B, Park JY, Hwang JH, Kim YK. Impact of Prognostic Nutritional Index on Postoperative Pulmonary Complications in Radical Cystectomy: A Propensity Score-Matched Analysis. Ann Surg Oncol 2020; 28:1859-1869. [PMID: 32776190 PMCID: PMC7415333 DOI: 10.1245/s10434-020-08994-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 07/22/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Radical cystectomy is a standard treatment for muscle-invasive bladder cancer but frequently entails postoperative pulmonary complications (PPCs). Nutrition is closely associated with postoperative outcomes. Therefore, we evaluated the impact of preoperative prognostic nutritional index (PNI) on PPCs in radical cystectomy. METHODS PNI was calculated as 10 × (serum albumin) + 0.005 × (total lymphocyte count). The risk factors for PPCs were evaluated using multivariate logistic regression analysis. A receiver operating characteristic curve analysis of PNI was performed, and an optimal cut-off value was identified. Propensity score-matched analysis was used to determine the impact of PNI on PPCs. Postoperative outcomes were also evaluated. RESULTS PPCs occurred in 112 (13.6%) of 822 patients. Multivariate logistic regression analysis identified PNI, age, and serum creatinine level as risk factors. The area under the receiver operating characteristic curve of PNI for predicting PPCs was 0.714 (optimal cut-off value: 45). After propensity score matching, the incidence of PPCs in the PNI ≤ 45 group was significantly higher compared with the PNI > 45 group (20.8% vs. 6.8%; p < 0.001), and PNI ≤ 45 was associated with a higher incidence of PPCs (odds ratio 3.308, 95% confidence interval 1.779-6.151; p < 0.001). The rates of intensive care unit admission and prolonged (> 2 days) stay thereof were higher in patients who developed PPCs. CONCLUSIONS Preoperative PNI ≤ 45 was associated with a higher incidence of PPCs in radical cystectomy, suggesting that PNI provides useful information regarding pulmonary complications after radical cystectomy.
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Affiliation(s)
- Jihion Yu
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Bumsik Hong
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jun-Young Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jai-Hyun Hwang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young-Kug Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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Ali B, Salim A, Alam A, Zuberi BF, Ali Z, Azam Z, Kamani L, Farooqi JI, Salih M, Nawaz AA, Chaudhry AA, Hashmi ZY, Siddique M. HEP-Net opinion on the management of ascites and its complications in the setting of decompensated cirrhosis in the resource constrained environment of Pakistan. Pak J Med Sci 2020; 36:1117-1132. [PMID: 32704299 PMCID: PMC7372671 DOI: 10.12669/pjms.36.5.2407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Approximately one half of patients develop ascites within 10 years of diagnosis of compensated cirrhosis. It is a poor prognostic indicator, with only 50% surviving beyond two years. Mortality worsens significantly to 20% to 50% at one year if the ascites becomes refractory to medical therapy. Pakistan has one of the highest prevalence of viral hepatitis in the world and patients with ascites secondary to liver cirrhosis make a major percentage of both inpatient and outpatient burden. Studies indicate that over 80% of patients admitted with ascites have liver cirrhosis as the cause. This expert opinion suggests proper assessment of patients with ascites in the presence of underlying cirrhosis. This expert opinion includes appropriate diagnosis and management of uncomplicated ascites, refractory ascites and complicated ascites (including spontaneous bacterial peritonitis (SBP) ascites, hepatorenal syndrome (HRS) and hyponatremia. The purpose behind this expert opinion is to help consultants, postgraduate trainees, medical officers and primary care physicians optimally manage their patients with cirrhosis and ascites in a resource constrained setting as is often encountered in a developing country like Pakistan.
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Affiliation(s)
- Bushra Ali
- Bushra Ali, Fatima Memorial Medical and Dental College, Lahore, Pakistan
| | - Adnan Salim
- Adnan Salim, Shaikh Zayed Postgraduate Medical Institute, Lahore, Pakistan
| | - Altaf Alam
- Altaf Alam, Shaikh Zayed Postgraduate Medical Institute, Lahore, Pakistan
| | - Bader Faiyaz Zuberi
- Bader Faiyaz Zuberi, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Zeeshan Ali
- Zeeshan Ali, Jinnah Postgraduate Medical Centre, Karachi, Pakistan
| | - Zahid Azam
- Zahid Azam, NILGID, Dow University of Health Sciences, Karachi, Pakistan
| | - Lubna Kamani
- Lubna Kamani, Liaquat National Hospital, Karachi, Pakistan
| | | | - Muhammed Salih
- Muhammed Salih, Quaid e Azam International Hospital, Islamabad, Pakistan
| | - Arif Amir Nawaz
- Arif Amir Nawaz, Fatima Memorial Medical and Dental College, Lahore, Pakistan
| | | | | | - Masood Siddique
- Masood Siddique, Jinnah Memorial Hospital, Rawalpindi, Pakistan
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Abstract
BACKGROUND AND AIMS Recurrence of spontaneous bacterial peritonitis (SBP) is still a matter of debate. We conducted this study to evaluate the probable factors that predict the recurrence of SBP in patients who recovered from the first episode of SBP and the long-term outcomes of SBP recurrence. METHODS One hundred twenty-four patients diagnosed with liver cirrhosis, SBP and did not receive secondary prophylaxis either with norfloxacin or other antibiotics were included in this prospective cohort pilot study. Clinical, biochemical and ascitic fluid analysis parameters were evaluated. Ascitic fluid interferon-γ-induced protein (IP-10), calprotectin, interleukin-6 and tumor necrosis factor-α were measured by ELISA. RESULTS Of these, 76 patients survived with an in-hospital mortality rate of 38.7%. The survivors were classified into two groups according to recurrence and nonrecurrence of SBP and survival time, clinical parameters and cause of death were investigated. Thirty-one participants had one or more attacks of SBP, with a recurrence rate of 40.8% within one-year follow-up. Before discharge, multivariate analysis showed that ascitic IP-10 (≥1220 pg/ml), ascitic calprotectin (≥550 ng/ml), serum albumin (≤2.5 g/dl), nonuse of prophylactic β-blockers and use of proton-pump inhibitors (PPIs) were the independent variables in predicting recurrent SBP. Sepsis-related organ failure was the most common etiology of mortality in the recurrent SBP group within 3 and 6 months. CONCLUSION Increased ascitic calprotectin and IP-10, hypoalbuminemia, nonuse of prophylactic β-blockers and use of PPI were independently associated with increased SBP recurrence rate. Sepsis-related organ failure was the most common etiology of mortality.
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19
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Systemic review and network meta-analysis: Prophylactic antibiotic therapy for spontaneous bacterial peritonitis. World J Hepatol 2020. [DOI: 10.4254/wjh.v12.i5.229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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20
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Faust N, Yamada A, Haider H, Komaki Y, Komaki F, Micic D, Sakuraba A. Systemic review and network meta-analysis: Prophylactic antibiotic therapy for spontaneous bacterial peritonitis. World J Hepatol 2020; 12:239-252. [PMID: 32547691 PMCID: PMC7280858 DOI: 10.4254/wjh.v12.i5.239] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 03/26/2020] [Accepted: 04/23/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Spontaneous bacterial peritonitis (SBP) is an important prognostic factor for outcomes in patients with cirrhosis. Antibiotic prophylaxis is recommended in patients at high risk for developing SBP, but the choice of antibiotics remains unclear.
AIM To evaluate the efficacy of various antibiotics for prophylaxis of SBP based on randomized control trials (RCTs).
METHODS Electronic databases were searched through November 2018 for RCTs evaluating the efficacy of therapies for primary or secondary prophylaxis of SBP. The primary outcome was the development of SBP. Sensitivity analyses limited to studies of primary or secondary prophylaxis and studies reported after 2010 were performed. The secondary outcome was the risk of all-cause mortality or transplant. The outcomes were assessed by rank of therapies based on network meta-analyses. Individual meta-analyses were also performed.
RESULTS Thirteen RCTs (1742 patients) including norfloxacin, ciprofloxacin, rifaximin, trimethoprim-sulfamethoxazole (TMP-SMX), or placebo/no comparator were identified. Individual meta-analyses showed superiority of rifaximin over norfloxacin as well as norfloxacin and TMP-SMX over placebo. Network meta-analysis demonstrated the rank of efficacy in reducing the risk of SBP as: Rifaximin, ciprofloxacin, TMP-SMX, norfloxacin, and placebo/no comparator. Rifaximin ranked highest in sensitivity analyses limited to studies of primary or secondary prophylaxis and studies reported after 2010. Similarly, rifaximin ranked highest in reducing the risk of death/transplant.
CONCLUSION The present comprehensive network meta-analysis provides RCT based evidence for superior efficacy of rifaximin compared to other antibiotics for the prophylaxis of SBP and reducing risk of death/transplant. Further RCTs are warranted to confirm our findings.
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Affiliation(s)
- Nolan Faust
- Department of Medicine, The University of Chicago, Chicago, IL 60637, United States
| | - Akihiro Yamada
- Section of Gastroenterology, Hepatology and Nutrition, Department of Medicine, The University of Chicago Medicine, Chicago, IL 60637, United States
- Section of Gastroenterology, Department of Internal Medicine, Toho University Sakura Medical Center, Sakura 2850841, Japan
| | - Haider Haider
- Section of Gastroenterology, Hepatology and Nutrition, Department of Medicine, The University of Chicago Medicine, Chicago, IL 60637, United States
| | - Yuga Komaki
- Section of Gastroenterology, Hepatology and Nutrition, Department of Medicine, The University of Chicago Medicine, Chicago, IL 60637, United States
- Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima 890-8544, Japan
| | - Fukiko Komaki
- Section of Gastroenterology, Hepatology and Nutrition, Department of Medicine, The University of Chicago Medicine, Chicago, IL 60637, United States
| | - Dejan Micic
- Section of Gastroenterology, Hepatology and Nutrition, Department of Medicine, The University of Chicago Medicine, Chicago, IL 60637, United States
| | - Atsushi Sakuraba
- Section of Gastroenterology, Hepatology and Nutrition, Department of Medicine, The University of Chicago Medicine, Chicago, IL 60637, United States
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Numan L, Elkafrawy A, Kaddourah O, Brotherton T, Saeed L, Zafar Y, Tomaw A, Foxworth J, Al-Sayyed L. Spontaneous Bacterial Peritonitis: We Are Still Behind. Cureus 2020; 12:e7711. [PMID: 32431989 PMCID: PMC7233508 DOI: 10.7759/cureus.7711] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 04/17/2020] [Indexed: 12/15/2022] Open
Abstract
Spontaneous bacterial peritonitis (SBP) is an infection in the ascitic fluid. Despite published guidelines, an inappropriate diagnosis of SBP is frequent. In this study, we aim to evaluate guideline adherence in diagnosing SBP. This is a retrospective study conducted between January 2015 and January 2018. Based on the American Association for the Study of Liver Diseases (AASLD) and the European Association for the Study of Liver (EASL), two authors judged guideline adherence in SBP diagnosis and management. One hundred and six patients were included in the study, and 93% were hospitalized. The mean age was 56.9 years, and 62 patients were males. In addition, Caucasians were the most common ethnicity (86.8%). The authors judged that only 52.4% of patients were appropriately diagnosed, and only 67.3% were managed with proper treatment. Inpatient mortality was documented in five patients, and the readmission rate within 30-days after discharge was 29.3%. In conclusion, SBP is a common complication of cirrhosis, which can be managed with adherence to published guidelines. In our population, guidelines were not implemented in diagnosing nearly half the SBP patients, mostly due to misdiagnosis of SBP with secondary peritonitis or non-neutrocytic bacteriascites, starting antibiotics before performing the paracentesis, and even giving broad-coverage antibiotics when not indicated. Further efforts are needed to enhance adherence to guidelines in clinical practice.
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Affiliation(s)
- Laith Numan
- Internal Medicine, University of Missouri-Kansas City School of Medicine, Kansas City, USA
| | - Ahmed Elkafrawy
- Internal Medicine, University of Missouri-Kansas City School of Medicine, Kansas City, USA
| | - Osama Kaddourah
- Internal Medicine, University of Missouri-Kansas City School of Medicine, Kansas City, USA
| | - Tim Brotherton
- Internal Medicine, University of Missouri-Kansas City School of Medicine, Kansas City, USA
| | - Lyla Saeed
- Internal Medicine, University of Missouri-Kansas City School of Medicine, Kansas City, USA
| | - Yousaf Zafar
- Internal Medicine, University of Missouri-Kansas City School of Medicine, Kansas City, USA
| | - Andrew Tomaw
- Internal Medicine, University of Missouri-Kansas City School of Medicine, Kansas City, USA
| | - John Foxworth
- Internal Medicine, University of Missouri-Kansas City School of Medicine, Kansas City, USA
| | - Leen Al-Sayyed
- Gastroenterology and Hepatology, University of Missouri-Kansas City School of Medicine, Kansas City, USA
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22
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Selgas R, Bajo MA, Jimenez C, Sanchez C, Del Peso G, Cacho G, Diaz C, Fernandez-Reyes MJ, De Alvaro F. Peritoneal Dialysis in Liver Disorders. Perit Dial Int 2020. [DOI: 10.1177/089686089601601s41] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The purpose of this paper is to review the specific role of peritoneal dialysis (PD) in patients with liver disorders. We will pay attention to the confluence of liver diseases and situations for which chronic dialysis treatment is required. Hemodialysis (HD) and peritoneal membranes are safe barriers against the passage of the hepatitis C virus; consequently, while peritoneal effluent or HD ultrafiltrate drained from hepatitis S patients/carriers is infective, that from hepatitis C patients does not appear to present this risk. An important issue is horizontal transmission, which appears to occur with both viruses in HD units, and which is absent in peritoneal dialysis units. The incidence of hepatitis C among continuous ambulatory peritoneal dialysis (CAPD) patients is quite low, while it may reach almost 50% -60% of HD patients in some units. While hepatitis C transmission mechanisms are not completely understood and a vaccine is not available, PD provides some degree of protection when compared with HD, for end-stage renal disease patients. In summary, our experience and that of others, with a total of 19 PD-treated chronic liver disease patients, supports CAPD as the treatment of choice for cirrhotic patients with ascites who require chronic dialysis. Data on peritoneal diffusion of low molecular weight substances revealed a marked increase in most patients. The ultrafiltration capacity was clearly augmented with respect to noncirrhotic patients, making the use of hypertonic bags unnecessary. Hemodynamic tolerance was excellent. Complications and death were mainly related to liver disease complications. Spontaneous bacterial peritonitis (SSP), caused by gram-negative germs, is the most important complication directly related to ascites and may have some points in common with PD-related peritonitis. However, and in contrast to most PD peritonitis, two pathogenetic mechanisms have been suggested for SSP: (1) translocation of bacteria from the gut to the mesenteric lymph nodes, and (2) bacteremia in these patients is secondary to the general abnormal host defense mechanisms. Local factors such as intrahepatic shunting and the impairment of bactericidal activity in ascitic fluid favor the bacteria ascites. The hypothesis of a direct transmural contamination from bowel to ascitic fluid has been relegated to secondary bacterial peritonitis. Would cirrhotic patients with temporal or permanent renal function compromise benefit from peritoneal catheter placement and other PD practices to perform repetitive small ascitic drainages at home? Perhaps the time has arrived when hepatologists and PD nephrologists begin to work shoulder to shoulder in this particular field, as we have a common problem, the peritoneal cavity filled with fluid.
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Affiliation(s)
- Rafael Selgas
- Servicio de Nefrologia, Hospital Universitario La Paz, Madrid, Spain
| | | | - Carlos Jimenez
- Servicio de Nefrologia, Hospital Universitario La Paz, Madrid, Spain
| | - Carmen Sanchez
- Servicio de Nefrologia, Hospital Universitario La Paz, Madrid, Spain
| | - Gloria Del Peso
- Servicio de Nefrologia, Hospital Universitario La Paz, Madrid, Spain
| | - Guillermo Cacho
- Servicio de Gastroenterologia, Hospital Puerta de Hierro, Madrid, Spain
| | - Candida Diaz
- Servicio de Nefrologia, Hospital Universitario La Paz, Madrid, Spain
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23
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Yu J, Hong JP, Suh HP, Park JY, Kim DH, Ha S, Lee J, Hwang JH, Kim YK. Prognostic Nutritional Index is a Predictor of Free Flap Failure in Extremity Reconstruction. Nutrients 2020; 12:nu12020562. [PMID: 32098138 PMCID: PMC7071524 DOI: 10.3390/nu12020562] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 02/18/2020] [Accepted: 02/19/2020] [Indexed: 02/07/2023] Open
Abstract
The nutritional condition of patients is an important prognostic factor in various diseases. Free flap failure is a serious complication in patients undergoing free flap reconstruction, increasing morbidity and hospital costs. We evaluated the predictive factors, including the prognostic nutritional index (PNI), associated with free flap failure in extremity reconstruction. The PNI was calculated as follows: 10 × serum albumin (g/dL) + 0.005 × total lymphocyte count (per mm3), with a PNI <40 defined as low. Univariate and multivariate logistic regression analyses were performed to evaluate factors predictive of free flap failure. Postoperative outcomes, including duration of hospital stay and rate and duration of intensive care unit admission, were also evaluated. Of the 625 patients included, 38 (6.1%) experienced free flap failure. Multivariate logistic regression analysis revealed that predictors of free flap failure were female (odds ratio: 2.094; p = 0.031) and a low PNI (odds ratio: 3.859; p <0.001). The duration of hospital stay was significantly longer in patients who did than those who did not experience free flap failure (62.1 ± 55.5 days vs. 28.3 ± 24.4 days, p <0.001). A low PNI is associated with free flap failure, leading to prolonged hospital stay. This result suggests that the PNI can be simply and effectively used to predict free flap failure.
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Affiliation(s)
- Jihion Yu
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (J.Y.); (J.-Y.P.); (D.-H.K.); (S.H.); (J.L.); (J.-H.H.)
| | - Joon Pio Hong
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (J.P.H.); (H.P.S.)
| | - Hyunsuk Peter Suh
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (J.P.H.); (H.P.S.)
| | - Jun-Young Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (J.Y.); (J.-Y.P.); (D.-H.K.); (S.H.); (J.L.); (J.-H.H.)
| | - Doo-Hwan Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (J.Y.); (J.-Y.P.); (D.-H.K.); (S.H.); (J.L.); (J.-H.H.)
| | - Seungsoo Ha
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (J.Y.); (J.-Y.P.); (D.-H.K.); (S.H.); (J.L.); (J.-H.H.)
| | - Joonho Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (J.Y.); (J.-Y.P.); (D.-H.K.); (S.H.); (J.L.); (J.-H.H.)
| | - Jai-Hyun Hwang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (J.Y.); (J.-Y.P.); (D.-H.K.); (S.H.); (J.L.); (J.-H.H.)
| | - Young-Kug Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (J.Y.); (J.-Y.P.); (D.-H.K.); (S.H.); (J.L.); (J.-H.H.)
- Correspondence: ; Tel.: +82-2-3010-5976
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24
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Abstract
Bacterial infection remains a leading cause of mortality and morbidity for patients with cirrhosis, with hospitalization, alterations in the intestinal microbiota, and therapeutic drugs all implicated in its development. Bacterial infections also remain the most common precipitant of acute-on-chronic liver failure, with infection occurring as a direct consequence of the progression of this syndrome. Furthermore, recent epidemiological analyses have demonstrated that infections due to multidrug-resistant bacteria are occurring with increasing frequency in patients with cirrhosis. Despite significant advances in the understanding of the pathophysiological processes triggered by an infection in patients with cirrhosis, a demonstrable survival benefit for the sickest patients who require ICU admission has not yet occurred. Early diagnosis of infection and appropriate antimicrobial treatment is essential to ensuring optimal outcomes for these patients. This review provides an evidence-based analysis of both the current strategies for prevention and the recommended management of common bacterial infections in patients with cirrhosis.
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Affiliation(s)
- Mary D Cannon
- Institute of Liver Studies, King's College Hospital, London, SE5 9RS, UK.
| | - Paul Martin
- Division of Gastroenterology and Hepatology, University of Miami, Miami, FL, USA
| | - Andres F Carrion
- Division of Gastroenterology and Hepatology, University of Miami, Miami, FL, USA
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25
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Sasidharan Nair GV, Mathen PG, Pillai MG, Gireesh Kumar KP, Velayudhan KK, Sreekrishnan TP. Initial choice of antibiotic in recurrent spontaneous bacterial peritonitis: A retrospective study. Int J Crit Illn Inj Sci 2019; 9:187-190. [PMID: 31879606 PMCID: PMC6927126 DOI: 10.4103/ijciis.ijciis_49_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 09/05/2019] [Accepted: 10/25/2019] [Indexed: 11/23/2022] Open
Abstract
Context: Spontaneous bacterial peritonitis (SBP) is a commonly encountered infection seen in the setting of ascites secondary to advanced liver disease. Recurrence of SBP is common and is associated with high mortality. This study was designed to recognize a better initial choice of antibiotic in case of recurrent SBP – a third-generation cephalosporin or a carbapenem. Aims: This study aims to determine a better initial choice of antibiotic in case of recurrent SBP and to compare the all-cause mortality among two different groups of patients treated with a third-generation cephalosporin and a carbapenem. Settings and Design: This study was conducted among fifty patients presenting with recurrent SBP visiting the emergency department (ED) at a tertiary care center and who were subsequently admitted in a gastroenterology intensive care unit, during a period of 1 year. Subjects and Methods: This is a retrospective, observational study conducted among patients with chronic liver disease and diagnosed with recurrent SBP visiting the ED at a tertiary care center in South India treated with either of two classes of antibiotics – third-generation cephalosporins or carbapenems, and their outcomes were compared. Recurrence is defined as an episode of SBP after resolution of the first index case of SBP within 1 year. Statistical Analysis Used: Statistical analysis was done using IBM SPSS version 23.0 (SPSS Inc., Chicago, IL, USA). All categorical variables were represented as percentages, and all continuous variables were represented as mean ± standard deviation. To test the statistical significance of the association of categorical variables with the outcome, Chi-square test was used. P <0.05 was considered statistically significant. Results: A total of fifty patients with recurrent SBP were included in the study, of which 44 (88%) patients were male and 6 patients were female (12%). Twenty-nine (58%) patients survived and 21 (42%) patients expired within 28 days. Twenty-seven (54%) patients were treated with third-generation cephalosporins and 23 (46%) were treated with carbapenems. It was observed that mortality was statistically significantly lower among patients treated with carbapenem (P = 0.001). The incidence of acute kidney injury was also lower among patients treated with a carbapenem than patients treated with a third-generation cephalosporin (40.7% vs. 59.25%, respectively). Conclusions: Initiation of a carbapenem significantly reduced the all-cause mortality when compared to a third-generation cephalosporin as an initial antibiotic of choice in recurrent SBP.
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Affiliation(s)
| | - Prannoy George Mathen
- Department of Emergency Medicine and Critical Care, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - M Gopalakrishna Pillai
- Department of Internal Medicine, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - K P Gireesh Kumar
- Department of Emergency Medicine and Critical Care, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - K K Velayudhan
- Department of Internal Medicine, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - T P Sreekrishnan
- Department of Emergency Medicine and Critical Care, Amrita Institute of Medical Sciences, Kochi, Kerala, India
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26
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Integrated model for end-stage liver disease maybe superior to some other model for end-stage liver disease-based systems in addition to Child-Turcotte-Pugh and albumin-bilirubin scores in patients with hepatitis B virus-related liver cirrhosis and spontaneous bacterial peritonitis. Eur J Gastroenterol Hepatol 2019; 31:1256-1263. [PMID: 31498284 DOI: 10.1097/meg.0000000000001481] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES For mortality prediction of spontaneous bacterial peritonitis (SBP) in patients with cirrhosis, no direct comparisons have been made among the eight models, Child-Turcotte-Pugh (CTP) score, model for end-stage liver disease (MELD), MELD-Na, integrated MELD (iMELD) score, MELD to sodium (MESO) index, modification of the MELD scoring system (Refit MELD), Refit MELD-Na and Albumin-Bilirubin (ALBI) score. MATERIALS AND METHODS Between January 2005 and July 2017, 314 patients who met the criteria for liver cirrhosis with the first episode of SBP were enrolled in this retrospective study. Clinical and laboratory data were obtained at diagnosis. Patients were followed up until February 2018 or death. RESULTS Patients were predominantly middle-aged male. Hepatitis B virus (HBV) infection accounted for the majority of the etiologies (41.7%) with 33.6% of the patients received antivirals. The in-hospital mortality rate was 39.8%. The cumulative 3-month and 6-month mortality rates were 51.6 and 60.2%, respectively. For patients with HBV related, not hepatitis C virus or alcohol related, liver cirrhosis, iMELD had the highest area under receiver operating characteristic curve (AUC) and was significantly superior to MELD, MESO, and Refit MELD in addition to CTP and ALBI scores in predicting 3-month and 6-month mortality. CONCLUSION For patients with HBV-related liver cirrhosis and SBP, iMELD had the highest AUC among these eight models and was significantly superior to MELD, MESO, and Refit MELD in addition to CTP and ALBI scores in predicting 3-month and 6-month mortalities.
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27
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Incidence and Risk Factors of Pulmonary Complications after Robot-Assisted Laparoscopic Prostatectomy: A Retrospective Observational Analysis of 2208 Patients at a Large Single Center. J Clin Med 2019; 8:jcm8101509. [PMID: 31547129 PMCID: PMC6833011 DOI: 10.3390/jcm8101509] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/10/2019] [Accepted: 09/18/2019] [Indexed: 01/04/2023] Open
Abstract
Robot-assisted laparoscopic prostatectomy (RALP) is a minimally invasive technique for the treatment of prostate cancer. RALP requires the patient to be placed in the steep Trendelenburg position, along with pneumoperitoneum, which may increase the risk of postoperative pulmonary complications (PPCs). This large single-center retrospective study evaluated the incidence and risk factors of PPCs in 2208 patients who underwent RALP between 2014 and 2017. Patients were divided into those with (PPC group) and without (non-PPC group) PPCs. Postoperative outcomes were evaluated, and univariate and multivariate logistic regression analyses were performed to assess risk factors of PPCs. PPCs occurred in 682 patients (30.9%). Risk factors of PPCs included age (odds ratio [OR], 1.023; p = 0.001), body mass index (OR, 1.061; p = 0.001), hypoalbuminemia (OR, 1.653; p = 0.008), and positive end-expiratory pressure (PEEP) application (OR, 0.283; p < 0.001). The incidence of postoperative complications, rate of intensive care unit (ICU) admission, and duration of ICU stay were significantly greater in the PPC group than in the non-PPC group. In conclusion, the incidence of PPCs in patients who underwent RALP under pneumoperitoneum in the steep Trendelenburg position was 30.9%. Factors associated with PPCs included older age, higher body mass index, hypoalbuminemia, and lack of PEEP.
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28
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Tang TY, Zong Y, Shen YN, Guo CX, Zhang XZ, Zou XW, Yao WY, Liang TB, Bai XL. Predicting surgical site infections using a novel nomogram in patients with hepatocelluar carcinoma undergoing hepatectomy. World J Clin Cases 2019; 7:2176-2188. [PMID: 31531313 PMCID: PMC6718804 DOI: 10.12998/wjcc.v7.i16.2176] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 06/22/2019] [Accepted: 07/03/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Surgical site infections (SSI) remain a major cause of morbidity after hepatectomy for hepatocellular carcinoma (HCC).
AIM To identify the risk factors associated with SSI, and develop a nomogram to predict SSI among patients undergoing hepatectomy.
METHODS We retrospectively reviewed the data of patients diagnosed with HCC undergoing hepatectomy at two academic institutions in China, and evaluated the occurrence of SSI. Independent risk factors for SSI were identified using univariate and multivariate analyses. Based on these independent risk factors, a nomogram was established using the data of patients in the first institution, and was validated using data from an external independent cohort from the second institution.
RESULTS The nomogram was established using data from 309 patients, whereas the validation cohort used data from 331 patients. The operation duration, serum albumin level, repeat hepatectomy, and ASA score were identified as independent risk factors. The concordance index (C-index) of the nomogram for SSI prediction in the training cohort was 0.86; this nomogram also performed well in the external validation cohort, with a C-index of 0.84. Accordingly, we stratified patients into three groups, with a distinct risk range based on the nomogram prediction, to guide clinical practice.
CONCLUSION Our novel nomogram offers good preoperative prediction for SSIs in patients undergoing hepatectomy.
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Affiliation(s)
- Tian-Yu Tang
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310000, Zhejiang Province, China
| | - Yi Zong
- The 5th Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, the Second Military Medical University, Shanghai 20000, China
| | - Yi-Nan Shen
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310000, Zhejiang Province, China
| | - Cheng-Xiang Guo
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310000, Zhejiang Province, China
| | - Xiao-Zhen Zhang
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310000, Zhejiang Province, China
| | - Xiu-Wen Zou
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310000, Zhejiang Province, China
| | - Wei-Yun Yao
- Department of Surgery, Changxing People’s Hospital, Huzhou 313000, Zhejiang Province, China
| | - Ting-Bo Liang
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310000, Zhejiang Province, China
| | - Xue-Li Bai
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310000, Zhejiang Province, China
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Facciorusso A, Antonino M, Orsitto E, Sacco R. Primary and secondary prophylaxis of spontaneous bacterial peritonitis: current state of the art. Expert Rev Gastroenterol Hepatol 2019; 13:751-759. [PMID: 31304804 DOI: 10.1080/17474124.2019.1644167] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Spontaneous bacterial peritonitis represents a frequent and severe complication in cirrhotic patients with ascites. In daily practice, the diagnosis of spontaneous bacterial peritonitis might be challenging in the absence of the typical signs and symptoms of infection such as fever or leukocytosis. Areas covered: Aim of this review is to revise the current state of the art on primary and secondary spontaneous bacterial peritonitis. Literature search in Medline/Pubmed was performed. Expert opinion: Historically, gram-negative bacteria were the most frequent etiologic agents of spontaneous bacterial peritonitis, with Escherichia coli and Klebsiella spp. being the most frequently isolated bacteria. However, major changes in this regard occurred over the last few decades with an increasing prevalence of gram-positive, quinolone-resistant, and multidrug-resistant bacteria. In particular, the increasing prevalence of quinolone-resistant bacteria challenged the prominent role of norfloxacin in spontaneous bacterial peritonitis prevention. Given the high mortality rate and the risk of developing the hepatorenal syndrome, prophylaxis of spontaneous bacterial peritonitis is indicated in three high-risk populations: patients with acute gastrointestinal hemorrhage, patients with low total protein content in ascitic fluid and advanced cirrhosis, and patients with a previous history of spontaneous bacterial peritonitis (secondary prophylaxis).
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Affiliation(s)
- Antonio Facciorusso
- a Department of Medical Sciences, Ospedali Riuniti di Foggia , Foggia , Italy
| | - Matteo Antonino
- a Department of Medical Sciences, Ospedali Riuniti di Foggia , Foggia , Italy
| | - Eugenio Orsitto
- b Department of Radiology, Azienda Ospedaliero-Universitaria Pisana , Pisa , Italy
| | - Rodolfo Sacco
- a Department of Medical Sciences, Ospedali Riuniti di Foggia , Foggia , Italy
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30
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Wong YJ, Kalki RC, Lin KW, Kumar R, Tan J, Teo EK, Li JW, Ang TL. Short- and long-term predictors of spontaneous bacterial peritonitis in Singapore. Singapore Med J 2019; 61:419-425. [PMID: 31363784 DOI: 10.11622/smedj.2019085] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | | | - Kenneth Weicong Lin
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Rahul Kumar
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Jessica Tan
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Eng Kiong Teo
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - James Weiquan Li
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
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31
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Miyashita H, Okamoto K, Kobayashi T, Wakabayashi Y, Kitaura S, Ikeuchi K, Ishigaki K, Nakai Y, Okugawa S, Koike K, Moriya K. Bacterial peritonitis in a patient with malignant ascites caused by pancreatic carcinoma: Case report and review of literature. J Infect Chemother 2019; 25:473-476. [PMID: 30738726 DOI: 10.1016/j.jiac.2019.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 01/07/2019] [Accepted: 01/20/2019] [Indexed: 11/21/2022]
Abstract
Bacterial peritonitis, an infection of the ascitic fluid, can be classified etiologically as spontaneous or secondary bacterial peritonitis. The former is mainly caused by portal hypertension and its subsequent effects, whereas the latter is caused by the direct dissemination of bacteria into the peritoneal cavity. Previous reports have described some distinguishing features of these two entities. Here, we report the first known case of bacterial peritonitis with Aeromonas hydrophilia and Escherichia coli in a patient with malignant ascites associated with pancreatic carcinoma who exhibited features of both spontaneous and secondary peritonitis. Our report suggests that clinicians should also consider bacterial peritonitis in patients with malignant ascites who present with ostensibly cancer-related symptoms.
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Affiliation(s)
- Hirotaka Miyashita
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Koh Okamoto
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan.
| | - Tatsuya Kobayashi
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | | | - Satoshi Kitaura
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Kazuhiko Ikeuchi
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Kazunaga Ishigaki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yosuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shu Okugawa
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kyoji Moriya
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
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Abstract
Spontaneous bacterial peritonitis (SBP) is defined as bacterial infections that occur in patients with cirrhosis and ascites without any significant intraperitoneal infection, accounting for approximately 10-30% of bacterial infections in hospitalized patients. SBP develops in patients with liver cirrhosis because bacterial translocations are increased by changes in the intestinal bacteria and mucosal barriers. In addition, the decreased host immune response cannot remove the bacteria and their products. The most common cause of SBP is Gram-negative bacteria, such as Escherichia coli and Klebsiella species, and infections by Gram-positive bacteria are increasing. SBP is diagnosed by the presence of >250 polymorphonuclear leukocyte/mm3 in ascites after paracentesis. If SBP is diagnosed, empirical antibiotic therapy should be started immediately. Empirical antibiotic treatment should distinguish between community acquired infections and nosocomial infections. Cirrhotic patients with gastrointestinal bleeding or low ascitic protein concentrations should consider primary prevention and those who recover from SBP should consider secondary prevention. This review describes the pathophysiology, diagnosis, treatment, and prevention of SBP.
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Affiliation(s)
- Do Seon Song
- Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
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Marciano S, Díaz JM, Dirchwolf M, Gadano A. Spontaneous bacterial peritonitis in patients with cirrhosis: incidence, outcomes, and treatment strategies. Hepat Med 2019; 11:13-22. [PMID: 30666172 PMCID: PMC6336019 DOI: 10.2147/hmer.s164250] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Spontaneous bacterial peritonitis is the most frequent bacterial infection in patients with cirrhosis. The reported incidence varies between 7% and 30% in hospitalized patients with cirrhosis and ascites, representing one of their main complications. Outcomes in patients with spontaneous bacterial peritonitis are poor since acute kidney injury, acute-on-chronic liver failure, and death occur in as much as 54%, 60%, and 40% of the patients, respectively, at midterm. Early antibiotic treatment of spontaneous bacterial peritonitis is crucial. However, the landscape of microbiological resistance is continuously changing, with an increasing spread of multidrug-resistant organisms that make its current management more challenging. Thus, the selection of the empirical antibiotic treatment should be guided by the severity and location where the infection was acquired, the risk factors for multidrug-resistant organisms, and the available information on the local expected bacteriology. The use of albumin as a complementary therapy for selected high-risk patients with spontaneous bacterial peritonitis is recommended in addition to antibiotics. Even though antibiotic prophylaxis has proven to be effective to prevent spontaneous bacterial peritonitis, a careful selection of high-risk candidates is crucial to avoid antibiotic overuse. In this article we review the pathogenesis, risk factors, and prognosis of spontaneous bacterial peritonitis, as well as the current evidence regarding its treatment and prophylaxis.
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Affiliation(s)
- Sebastián Marciano
- Liver Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina,
- Department of Research, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina,
| | - Juan Manuel Díaz
- Liver Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina,
| | - Melisa Dirchwolf
- Hepatology Unit, Hospital Privado de Rosario, Santa Fe, Argentina
| | - Adrián Gadano
- Liver Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina,
- Department of Research, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina,
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Oey RC, van Buuren HR, de Jong DM, Erler NS, de Man RA. Bacterascites: A study of clinical features, microbiological findings, and clinical significance. Liver Int 2018; 38:2199-2209. [PMID: 29992711 PMCID: PMC6282964 DOI: 10.1111/liv.13929] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 06/14/2018] [Accepted: 07/06/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Knowledge about bacterascites is limited and management guidelines are based on small patient series. The purpose of this study was to add further insight into the clinical characteristics, microbiological findings, and prognosis of patients diagnosed with bacterascites. METHODS Retrospective analysis of patients with advanced chronic liver disease diagnosed with bacterascites and SBP between January 2003 and August 2016. RESULTS In this study, 123 patients were included with 142 episodes of bacterascites. The median MELD score was 20 and clinical symptoms of infection were present in 78%. Empiric antibiotic treatment was initiated in 68%. In 26 untreated patients undergoing repeated paracentesis, 42% were diagnosed with either ongoing bacterascites or SBP. The presence of signs or symptoms of infection was not an independent predictor for mortality or spontaneous resolution of infection. The 1-month and 1-year mortality rates of the 123 patients studied, were 32% and 60%, respectively; these results were in line with data pertaining to the prognosis of SBP. CONCLUSIONS Patients with bacterascites and SBP are highly comparable with respect to severity of liver disease and overall prognosis. If left untreated, bacterascites is likely to persist or to evolve to SBP in a significant proportion of patients. The results of this study support current guidelines regarding the treatment of ascitic fluid infection, but could not confirm the prognostic relevance of symptomatic disease at the time of diagnosis. We suggest that the threshold to initiate antibiotic treatment, in particular in cases with severely advanced liver disease, should be low.
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Affiliation(s)
- Rosalie C. Oey
- Department of Gastroenterology and HepatologyErasmus MCUniversity Medical CenterRotterdamThe Netherlands
| | - Henk R. van Buuren
- Department of Gastroenterology and HepatologyErasmus MCUniversity Medical CenterRotterdamThe Netherlands
| | - David M. de Jong
- Department of Gastroenterology and HepatologyErasmus MCUniversity Medical CenterRotterdamThe Netherlands
| | - Nicole S. Erler
- Department of BiostatisticsErasmus MCUniversity Medical CenterRotterdamThe Netherlands
| | - Robert A. de Man
- Department of Gastroenterology and HepatologyErasmus MCUniversity Medical CenterRotterdamThe Netherlands
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Baldolli A, Daurel C, Verdon R, de La Blanchardière A. High mortality in peritonitis due to Mycobacterium avium complex: retrospective study and systematic literature review. Infect Dis (Lond) 2018; 51:81-90. [PMID: 30318980 DOI: 10.1080/23744235.2018.1519639] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND Mycobacterium avium complex (MAC) infection is often disseminated and mainly involves lymph nodes, spleen, liver or bone marrow. Peritonitis due to MAC infection (PMAC) is a very uncommon manifestation. METHODS In this report, after describing the case of the only PMAC infection in our 10-year retrospective study, which occurred in an AIDS patient who was non-adherent to highly active antiretroviral therapy (HAART), we performed a systematic literature review of documented bacteriological PMAC. RESULTS Including our patient, 51 cases of PMAC have been reported. Patients were most often male (sex ratio 2.14), with a median age of 41 years (2.8-72) and an immunodeficiency in all cases, most often AIDS (57%), cirrhosis (20%) and continuous ambulatory peritoneal dialysis (CAPD) (18%). Ascites was more often chylous (54%) than exudative (46%) and, in this case, lymphocytic (60%), with an inconstantly positive acid-fast bacilli smear (54%). Non-disseminated PMAC patients were more likely to have peritoneal dialysis (39% versus 6.5%, p < .01) or cancer with immunosuppressive therapy (39% versus 0%, p < .0001), while AIDS was the leading underlying disease in disseminated-PMAC patients (83% versus 11%, p < .001). Mortality was high (50%), with no difference between disseminated and non-disseminated PMAC. CONCLUSIONS This report highlights the need to be aware of an atypical presentation of PMAC infection, which is associated with a high rate of mortality even for non-disseminated infection.
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Affiliation(s)
- Aurélie Baldolli
- a Infectious Diseases Department , CHU de Caen , Caen , France.,b Groupe de Recherche sur l'Adaptation Microbienne (GRAM 2.0), Normandie University , Caen , France
| | - Claire Daurel
- c Microbiology Department, CHU de Caen , Caen , France
| | - Renaud Verdon
- a Infectious Diseases Department , CHU de Caen , Caen , France.,b Groupe de Recherche sur l'Adaptation Microbienne (GRAM 2.0), Normandie University , Caen , France
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Mortality from Spontaneous Bacterial Peritonitis Among Hospitalized Patients in the USA. Dig Dis Sci 2018; 63:1327-1333. [PMID: 29480417 PMCID: PMC5897146 DOI: 10.1007/s10620-018-4990-y] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 02/19/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Spontaneous bacterial peritonitis (SBP) is a serious complication of cirrhosis and is associated with significant morbidity and mortality. In this study, we examined the clinical characteristics and risk factors associated with mortality in hospitalized patients presenting with SBP. METHODS The Nationwide Inpatient Sample was queried for all hospitalizations involving SBP from 2006 to 2014 using the International Classification of Disease-9-CM Code. Logistic regression was performed to evaluate the association between SBP mortality and factors such as age, gender, race/ethnicity, and concomitant medical conditions at presentation (e.g., variceal hemorrhage, hepatic encephalopathy, acute renal failure, coagulopathy, and other infections including pneumonia). The lengths of stay (LOS) and total charges were also examined. RESULTS From 2006 to 2014, there were 88,167 SBP hospitalizations with 29,963 deaths (17.6% in-hospital mortality). The mean age of patients who died in the hospital was higher (58.2 years vs. 55.8, p < 0.01) than those who survived the admission. Acute alcoholic hepatitis was noted among a higher proportion of patients who died (7.0 vs. 5.9%, p < 0.01), who were also likely to have more medical comorbidities. In multivariable analysis, older age, female gender, hepatic encephalopathy, coagulopathy, variceal hemorrhage, sepsis, pneumonia, and acute kidney injury were associated with increased in-hospital mortality. This group also had longer LOS (11.6 days vs. 9.1, p < 0.01) and higher total charges ($138,273 vs. $73,533, p < 0.01). CONCLUSION SBP is associated with significant in-hospital mortality, especially in patients with concurrent risk factors. SBP remains a significant burden to the healthcare system.
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Mo S, Bendtsen F, Wiese SS, Kimer N. Low ascitic fluid total protein levels is not associated to the development of spontaneous bacterial peritonitis in a cohort of 274 patients with cirrhosis. Scand J Gastroenterol 2018; 53:200-205. [PMID: 29214880 DOI: 10.1080/00365521.2017.1411973] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Spontaneous bacterial peritonitis (SBP) is a complication to decompensated cirrhosis. Fluoroquinolones may prevent SBP. However, predictive markers for SBP are wanted. Guidelines suggest that patients with ascitic fluid protein below 15 g/l receive fluoroquinolones to prevent SBP. This study aimed to assess the clinical utility of low ascitic fluid protein in predicting SBP in patients with cirrhosis and ascites. METHODS A total of 274 patients with cirrhosis and ascites underwent paracentesis between January 2010 and June 2015. Patients were followed until two years, development of SBP, initiation of ciprofloxacin, death or liver transplantation. Data were compared between groups of patients with 'high' or 'low' ascitic protein. RESULTS SBP developed in 31 patients (11.3%). No difference in mean ascitic fluid protein levels were found (SBP, mean: 8.5 g/l and no SBP 8.2 g/l, p = .825). SBP developed at equal rates in patients with 'high' or 'low' ascitic protein (10.8% (≤15 g/l) and 14.0% (>15 g/l), p = .599). The same trend was observed when adjusting the threshold below 10 g/l (11.9% (≤10 g/l) and 10.2% (>10 g/l), p = .697). CONCLUSIONS Low ascitic fluid protein does not predict SBP in patients with cirrhosis and ascites. Better markers are needed.
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Affiliation(s)
- Silje Mo
- a Gastro Unit 360, Medical Division , Copenhagen University Hospital , Hvidovre , Denmark
| | - Flemming Bendtsen
- a Gastro Unit 360, Medical Division , Copenhagen University Hospital , Hvidovre , Denmark
| | - Signe Skovgaard Wiese
- a Gastro Unit 360, Medical Division , Copenhagen University Hospital , Hvidovre , Denmark
| | - Nina Kimer
- a Gastro Unit 360, Medical Division , Copenhagen University Hospital , Hvidovre , Denmark
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38
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Affiliation(s)
- Matthew A Chin
- Division of Gastroenterology, John Muir Specialty Medical Group, Walnut Creek, CA, USA
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39
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Gentile I, Buonomo AR, Scotto R, Zappulo E, Borgia G. Infections worsen prognosis of patients with cirrhosis irrespective of the liver disease stage. Eur J Intern Med 2017; 46:e45-e47. [PMID: 28918985 DOI: 10.1016/j.ejim.2017.09.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 09/07/2017] [Accepted: 09/11/2017] [Indexed: 02/06/2023]
Affiliation(s)
- Ivan Gentile
- Department of Clinical Medicine and Surgery - Section of Infectious Disease, University "Federico II" of Naples, Italy
| | - Antonio Riccardo Buonomo
- Department of Clinical Medicine and Surgery - Section of Infectious Disease, University "Federico II" of Naples, Italy.
| | - Riccardo Scotto
- Department of Clinical Medicine and Surgery - Section of Infectious Disease, University "Federico II" of Naples, Italy
| | - Emanuela Zappulo
- Department of Clinical Medicine and Surgery - Section of Infectious Disease, University "Federico II" of Naples, Italy
| | - Guglielmo Borgia
- Department of Clinical Medicine and Surgery - Section of Infectious Disease, University "Federico II" of Naples, Italy
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40
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Gaduputi V, Tariq H, Chandrala C, Sakam S, Abbas N, Chilimuri S. Computerized Tomography-Guided Paracentesis: An Effective Alternative to Bedside Paracentesis? J Clin Med Res 2016; 9:92-97. [PMID: 28090224 PMCID: PMC5215012 DOI: 10.14740/jocmr2832w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2016] [Indexed: 12/19/2022] Open
Abstract
Background Ascites remains the most common cause of hospitalization among patients with decompensated cirrhosis. Paracentesis is a relatively safe procedure with low complication rates. Computerized tomography (CT)-guided therapeutic paracentesis could be a safe and effective alternative to unaided or aided (ultrasonogram-guided) bedside paracentesis. In this retrospective study, we aimed to compare the efficacy, safety, and cost-effectiveness of CT-guided paracentesis with bedside paracentesis. Methods The period of study was from 2002 to 2012. All patients with cirrhosis who underwent therapeutic paracentesis were included in the study. These patients were divided into two groups. Group I consisted of patients who underwent CT-guided pigtail catheter insertion with ascitic fluid drainage. Group II consisted of patients who underwent beside therapeutic paracentesis after localization of fluid either by physical examination or sonographic localization. We measured the efficacy of CT-guided paracentesis and bedside paracentesis in terms of volume of fluid removed, length of stay, discharge doses of diuretics (spironolactone and furosemide) and number of days to readmission for symptomatic ascites. We also computed the cost-effectiveness of CT-guided therapeutic paracentesis when compared to a bedside procedure. Fischer exact test was used to analyze the distribution of categorical data and unpaired t-test was used for comparison of means. Results There were a total of 546 unique patients with diagnosed cirrhosis who were admitted to the hospital with symptomatic ascites and underwent therapeutic paracentesis. Two hundred and forty-seven patients underwent CT-guided paracentesis, while 272 patients underwent bedside paracentesis. There was significant inverse correlation between the amount of ascitic fluid removed and total length of stay in the hospital. We found that the volume of fluid removed via a CT-guided pigtail insertion and drainage (2.72 ± 2.02 L) is significantly higher when compared to fluid removed via bedside paracentesis (1.94 ± 1.69). We also found that the interval time period between two successive therapeutic paracenteses was significantly longer for CT group (106.56 ± 75.2 days) when compared to the bedside group (25.57 ± 7.68 days). Conclusion CT-guided paracentesis with pigtail catheter insertion and drainage is a clinically effective, cheap and safe alternative to conventional bedside paracentesis.
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Affiliation(s)
- Vinaya Gaduputi
- Department of Medicine, Bronx Lebanon Hospital Center, 1650 Selwyn Ave., Suite #10C, Bronx, NY 10457, USA
| | - Hassan Tariq
- Department of Medicine, Bronx Lebanon Hospital Center, 1650 Selwyn Ave., Suite #10C, Bronx, NY 10457, USA
| | - Chaitanya Chandrala
- Department of Medicine, Bronx Lebanon Hospital Center, 1650 Selwyn Ave., Suite #10C, Bronx, NY 10457, USA
| | - Sailaja Sakam
- Department of Medicine, Bronx Lebanon Hospital Center, 1650 Selwyn Ave., Suite #10C, Bronx, NY 10457, USA
| | - Naeem Abbas
- Department of Medicine, Bronx Lebanon Hospital Center, 1650 Selwyn Ave., Suite #10C, Bronx, NY 10457, USA
| | - Sridhar Chilimuri
- Department of Medicine, Bronx Lebanon Hospital Center, 1650 Selwyn Ave., Suite #10C, Bronx, NY 10457, USA
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Guillaume M, Robic MA, Péron JM, Selves J, Otal P, Sirach E, Vinel JP, Bureau C. Clinical characteristics and outcome of cirrhotic patients with high protein concentrations in ascites: a prospective study. Eur J Gastroenterol Hepatol 2016; 28:1268-74. [PMID: 27380602 DOI: 10.1097/meg.0000000000000697] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The protein concentration in ascites is usually low in cirrhosis because capillarization and defenestration of the sinusoids limit diffusion of large proteins from plasma to the space of Disse. However, some cirrhotic patients have high-protein ascites (HPA). AIM The aim of this study was to describe and compare the characteristics and prognosis between cirrhotic patients with HPA (>20 g/l) and patients with low-protein ascites (LPA). PATIENTS AND METHODS In this longitudinal observational prospective cohort study, all consecutive cirrhotic patients with ascites hospitalized in our tertiary liver center were included and followed for up to 2 years, provided that they had no other cause of HPA. HPA was defined as protein concentrations of more than 20 g/l. RESULTS Among 107 patients included, 19 (17.8%) had HPA. HPA patients had more refractory ascites (63 vs. 34%), better liver functions, and a higher 1-year transplant-free survival rate compared with LPA patients (P<0.05). Portal hypertension parameters were not different. During follow-up, 47% of HPA patients were treated by transjugular intrahepatic portosystemic shunts versus 18% of LPA patients, whereas 15 LPA patients required liver transplantation for end-stage liver disease versus only one HPA patient. We observed higher protein filtration and less pericellular, centrilobular, and sinusoidal fibrosis in cirrhotic HPA livers compared with LPA livers. CONCLUSION Almost 20% of cirrhotic patients with ascites have HPA (>20 g/l). These patients have better liver functions and a higher 1-year survival than those with LPA, even though ascites are more often refractory.
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Affiliation(s)
- Maeva Guillaume
- aDepartment of Hepatology and Gastroenterology bDepartment of Anatomy and Cytopathology,Institut Universitaire du Cancer de Toulouse - Oncopole cDepartment of Radiology, University Hospital of Toulouse, University Paul Sabatier Toulouse III, Toulouse, France
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Lheureux O, Trepo E, Hites M, Cotton F, Wolff F, Surin R, Creteur J, Vincent JL, Gustot T, Jacobs F, Taccone FS. Serum β-lactam concentrations in critically ill patients with cirrhosis: a matched case-control study. Liver Int 2016; 36:1002-10. [PMID: 26645828 DOI: 10.1111/liv.13039] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 11/26/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS The pharmacokinetics of β-lactam antibiotics have not been well defined in critically ill patients with cirrhosis. METHODS We reviewed data from critically ill patients with cirrhosis and matched controls in whom routine therapeutic drug monitoring of two broad-spectrum β-lactam antibiotics (piperacillin/tazobactam and meropenem) had been performed. Serum drug concentrations were measured twice by high-performance liquid chromatography. Antibiotic pharmacokinetics were calculated using a one-compartment model. We considered that therapy was adequate when serum drug concentrations were between 4 and 8 times the minimal inhibitory concentration of Pseudomonas aeruginosa during optimal periods of time for each drug (≥ 50% for piperacillin/tazobactam; ≥ 40% for meropenem). RESULTS We studied 38 patients with cirrhosis (16 for piperacillin/tazobactam and 22 for meropenem) and 38 matched controls. Drug dosing was similar in the two groups. The pharmacokinetics analysis showed a lower volume of distribution of meropenem (P = 0.05) and a lower antibiotic clearance of piperacillin/tazobactam (P = 0.009) in patients with cirrhosis than in the matched controls. Patients with cirrhosis were more likely than those without cirrhosis to have excessive serum β-lactam concentrations (P = 0.015), in particular for piperacillin/tazobactam. CONCLUSIONS Standard β-lactam antibiotics regimens resulted in excessive serum concentrations in two thirds of the patients with cirrhosis. This was particularly true for piperacillin/tazobactam, probably because of reduced drug clearance.
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Affiliation(s)
- Olivier Lheureux
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Eric Trepo
- Department of Gastroenterology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.,Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium
| | - Maya Hites
- Department of Infectious Diseases, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Frederic Cotton
- Department of Clinical Biochemistry, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Fleur Wolff
- Department of Clinical Biochemistry, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Rudy Surin
- Department of Infectious Diseases, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Thierry Gustot
- Department of Gastroenterology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.,Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium
| | - Frederique Jacobs
- Department of Infectious Diseases, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Khalil MAM, Ghazni MS, Tan J, Naseer N, Khalil MAU. Spontaneous Bacterial Peritonitis and Anasarca in a Female Patient with Ovarian Hyperstimulation Syndrome Complicated by Respiratory and Kidney Failure. Case Rep Gastroenterol 2016; 10:423-430. [PMID: 27721728 PMCID: PMC5043260 DOI: 10.1159/000446766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 05/11/2016] [Indexed: 11/19/2022] Open
Abstract
Ovarian hyperstimulation syndrome (OHSS) was first described in 1960. It may occur as a complication of gonadotropin hormone therapy during assisted pregnancy or for primary infertility. A 26-year-old female patient with polycystic ovarian syndrome and primary infertility was treated to conceive. She received intravenous gonadotropin-releasing hormone (GnRH) along with follicle-stimulating hormone in an outside private clinic. She presented to the emergency department with abdominal and chest pain, loose stool, vomiting, shortness of breath and decreasing urine output. She was found to have edema, ascites, effusion and acute kidney injury (AKI). Considering the symptoms preceding the drug history and anasarca, a diagnosis of severe OHSS was made. Ascites was further complicated by spontaneous bacterial peritonitis (SBP), which had already been reported before. We speculate that low immunity due to decreased immunoglobulin in patients with OHSS makes them prone to SBP. In our case, septicemia secondary to SBP and fluid loss due to capillary leakage from OHSS resulted in AKI and respiratory failure. This critically ill patient was treated in a special care unit, and she fully recovered with supportive measures. Severe OHSS may present as anasarca including ascites which can develop SBP leading to sepsis and multiorgan failure.
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Affiliation(s)
| | | | - Jackson Tan
- Department of Nephrology, RIPAS Hospital, Bandar Seri Begawan, Brunei
| | - Nazish Naseer
- Section of Nephrology, Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
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Lutz P, Krämer B, Kaczmarek DJ, Hübner MP, Langhans B, Appenrodt B, Lammert F, Nattermann J, Hoerauf A, Strassburg CP, Spengler U, Nischalke HD. A variant in the nuclear dot protein 52kDa gene increases the risk for spontaneous bacterial peritonitis in patients with alcoholic liver cirrhosis. Dig Liver Dis 2016; 48:62-8. [PMID: 26493630 DOI: 10.1016/j.dld.2015.09.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Revised: 08/18/2015] [Accepted: 09/20/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Spontaneous bacterial peritonitis is frequently a fatal infection in patients with liver cirrhosis. We investigated if nuclear dot protein 52kDa (NDP52), a negative regulator of toll-like receptor (TLR) signalling and autophagy adaptor protein, might be involved. METHODS Two cohorts comprising 152 (derivation cohort) and 198 patients (validation cohort) with decompensated liver cirrhosis and 168 healthy controls were genotyped for the rs2303015 polymorphism in the NDP52 gene and prospectively followed-up for spontaneous bacterial peritonitis. RESULTS Overall, 57 (38%) patients in the derivation cohort and 77 (39%) in the validation cohort had spontaneous bacterial peritonitis. Cirrhosis was due to alcohol abuse in 57% of the derivation and 66% of the validation cohort. In patients with alcoholic cirrhosis, patients with spontaneous bacterial peritonitis had an increased frequency of the NDP52 rs2303015 minor variant in the derivation (p=0.04) and in the validation cohort (p=0.01). Multivariate analysis confirmed this minor variant (odds ratio 4.7, p=0.002) and the TLR2 -16934 TT variant (odds ratio 2.5, p=0.008) as risk factors for spontaneous bacterial peritonitis. In addition, presence of the NDP52 minor variant affected survival negatively. CONCLUSION Presence of the NDP52 rs2303015 minor variant increases the risk for spontaneous bacterial peritonitis in patients with alcoholic cirrhosis.
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Affiliation(s)
- Philipp Lutz
- Department of Internal Medicine I, University of Bonn, Bonn, Germany; German Center for Infection Research, Germany.
| | - Benjamin Krämer
- Department of Internal Medicine I, University of Bonn, Bonn, Germany; German Center for Infection Research, Germany
| | - Dominik J Kaczmarek
- Department of Internal Medicine I, University of Bonn, Bonn, Germany; German Center for Infection Research, Germany
| | - Marc P Hübner
- Institute for Medical Microbiology, Immunology and Parasitology, University of Bonn, Bonn, Germany; German Center for Infection Research, Germany
| | - Bettina Langhans
- Department of Internal Medicine I, University of Bonn, Bonn, Germany; German Center for Infection Research, Germany
| | - Beate Appenrodt
- Department of Medicine II, Saarland University Medical Center, Saarland University, Homburg, Germany
| | - Frank Lammert
- Department of Medicine II, Saarland University Medical Center, Saarland University, Homburg, Germany
| | - Jacob Nattermann
- Department of Internal Medicine I, University of Bonn, Bonn, Germany; German Center for Infection Research, Germany
| | - Achim Hoerauf
- Institute for Medical Microbiology, Immunology and Parasitology, University of Bonn, Bonn, Germany; German Center for Infection Research, Germany
| | - Christian P Strassburg
- Department of Internal Medicine I, University of Bonn, Bonn, Germany; German Center for Infection Research, Germany
| | - Ulrich Spengler
- Department of Internal Medicine I, University of Bonn, Bonn, Germany; German Center for Infection Research, Germany
| | - Hans Dieter Nischalke
- Department of Internal Medicine I, University of Bonn, Bonn, Germany; German Center for Infection Research, Germany
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Chen CT, Tseng YC, Yang CW, Lin HH, Chen PJ, Huang TY, Shih YL, Chang WK, Hsieh TY, Chu HC. Increased Risks of Spontaneous Bacterial Peritonitis and Interstitial Lung Disease in Primary Biliary Cirrhosis Patients With Concomitant Sjögren Syndrome. Medicine (Baltimore) 2016; 95:e2537. [PMID: 26765478 PMCID: PMC4718304 DOI: 10.1097/md.0000000000002537] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 11/25/2015] [Accepted: 12/21/2015] [Indexed: 12/11/2022] Open
Abstract
The incidence of Sjögren syndrome (SS) in primary biliary cirrhosis (PBC) patients is high. The influence of SS on the clinical outcomes of PBC patients, however, remains unclear. Our study retrospectively collected data on PBC-only patients and PBC patients with concomitant SS (PBC-SS) to compare the clinical differences of long-term outcomes between them.A total of 183 patients were diagnosed with PBC from January 1999 to December 2014 at our hospital. Of these, the authors excluded patients with diabetes, hypertension, advanced liver cirrhosis at initial diagnosis of PBC (Child-Turcotte-Pugh classification score of ≥7) and other liver diseases (ie, alcoholic liver disease, alpha-antitrypsin deficiency, viral hepatitis, and primary sclerosing cholangitis), and autoimmune diseases such as systemic lupus erythematosus and rheumatoid arthritis. Of the remaining 125 patients, 77 (61.6%) were PBC-only and 48 (38.4%) were PBC-SS patients.The mean follow-up duration was 8.76 years. During the observation period, the incidence of interstitial lung disease was higher in the PBC-SS group than in the PBC-only group (P = 0.005). The occurrence of spontaneous bacterial peritonitis was significantly different in PBC-SS patients than in PBC-only patients (P = 0.002). The overall survival was lower in PBC-SS patients than in PBC-only patients (P = 0.033). Although the incidence of hepatocellular carcinoma, end-stage renal disease, variceal bleeding, and hypothyroidism were all higher in the PBC-SS group than in the PBC-only group, the differences were not significant.Our study suggests that PBC-SS patients have a higher risk of developing interstitial lung disease and spontaneous bacterial peritonitis and have a poor prognosis. Aggressive surveillance of thyroid and pulmonary functions should therefore be performed in these patients.
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Affiliation(s)
- Chun-Ting Chen
- From the Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China (C-TC, Y-CT, C-WY, H-HL, P-JC, T-YH, Y-LS, W-KC, T-YH); and Division of Gastroenterology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan, Republic of China (H-CC)
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46
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Hepatic Failure. PRINCIPLES OF ADULT SURGICAL CRITICAL CARE 2016. [PMCID: PMC7123541 DOI: 10.1007/978-3-319-33341-0_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The progression of liver disease can cause several physiologic derangements that may precipitate hepatic failure and require admission to an intensive care unit. The underlying pathology may be acute, acute-on chronic, or chronic in nature. Liver failure may manifest with a variety of clinical signs and symptoms that need prompt attention. The compromised synthetic and metabolic activity of the failing liver affects all organ systems, from neurologic to integumentary. Supportive care and specific therapies should be instituted in order to improve outcome and minimize time of recovery. In this chapter we will discuss the definition, clinical manifestations, workup, and management of acute and chronic liver failure and the general principles of treatment of these patients. Management of liver failure secondary to certain common etiologies will also be presented. Finally, liver transplantation and alternative therapies will also be discussed.
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47
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Assem M, Elsabaawy M, Abdelrashed M, Elemam S, Khodeer S, Hamed W, Abdelaziz A, El-Azab G. Efficacy and safety of alternating norfloxacin and rifaximin as primary prophylaxis for spontaneous bacterial peritonitis in cirrhotic ascites: a prospective randomized open-label comparative multicenter study. Hepatol Int 2015; 10:377-85. [PMID: 26660707 DOI: 10.1007/s12072-015-9688-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 11/06/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIM Primary prevention of spontaneous bacterial peritonitis (SBP) is an important strategy to reduce morbidity and mortality in cirrhotic patients with ascites. Efficacy and safety of alternating rifaximin and norfloxacin as primary prophylaxis is questionable. METHODS Three hundred thirty-four cirrhotic patients with high SAAG (≥1.1) ascites, protein level in ascitic fluid less than 1.5 g/dL with advanced liver disease (Child-Pugh score >9 points with serum bilirubin level >3 mg/dL) or renal impairment (serum creatinine level >1.2 mg/dL, blood urea nitrogen level >25 mg/dL, or serum sodium level <130 mEq/L) were included in an open-label, randomized study aimed at comparing alternating use of norfloxacin and rifaximin vs. norfloxacin or rifaximin alone as primary prophylaxis for SBP. Both intention-to-treat and per-protocol efficacy analyses were done after 6 months of treatment by assessment of ascitic fluid neutrophil count. Safety analysis was done for all intention-to-treat populations. RESULTS Alternating norfloxacin and rifaximin showed superior prophylaxis by intention-to-treat (74.7 vs. 56.4% vs. 68.3%, p < 0.048). Pairwise analysis showed that alternating regimen had lower probability to develop SBP when compared to a norfloxacin-based regimen in intention-to-treat (p = 0.016) and per protocol analysis (p = 0.039). There was no difference among the studied groups regarding the incidence and severity of adverse events reported. CONCLUSIONS Alternating norfloxacin- and rifaximin-based primary prophylaxis for SBP showed higher efficacy with the same safety profile when compared with monotherapy of norfloxacin.
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Affiliation(s)
- M Assem
- Hepatology Department, National Liver Institute, Menoufia University, Shebeen El Koom, Menoufia, 52311, Egypt.
| | - M Elsabaawy
- Hepatology Department, National Liver Institute, Menoufia University, Shebeen El Koom, Menoufia, 52311, Egypt
| | - M Abdelrashed
- Internal Medicine Department, Al Noor Hospital, M.O.H, Mecca, Saudi Arabia
| | - S Elemam
- Tropical Medicine Department, King Khalid Hospital, M.O.H, Tabuk, Saudi Arabia
| | - S Khodeer
- Internal Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - W Hamed
- Tropical Medicine Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - A Abdelaziz
- Clinical Pathology Department, National Liver Institute, Menoufia University, Shebeen El Koom, Menoufia, 52311, Egypt
| | - G El-Azab
- Hepatology Department, National Liver Institute, Menoufia University, Shebeen El Koom, Menoufia, 52311, Egypt
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48
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Kathpalia P, Bhatia A, Robertazzi S, Ahn J, Cohen SM, Sontag S, Luke A, Durazo-Arvizu R, Pillai AA. Indwelling peritoneal catheters in patients with cirrhosis and refractory ascites. Intern Med J 2015; 45:1026-31. [DOI: 10.1111/imj.12843] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Accepted: 06/22/2015] [Indexed: 12/13/2022]
Affiliation(s)
- P. Kathpalia
- Division of Gastroenterology and Hepatology; University of California, San Francisco; San Francisco California USA
| | - A. Bhatia
- Division of Gastroenterology; Hepatology and Nutrition; Loyola University Medical Center; Maywood Illinois USA
| | - S. Robertazzi
- Department of Transplant Surgery; Medstar Georgetown University Hospital; Washington District of Columbia USA
| | - J. Ahn
- Department of Gastroenterology and Hepatology; Oregon Health and Science University; Portland Oregon USA
| | - S. M. Cohen
- Department of Gastroenterology and Hepatology; University Hospitals Case Medical Center; Cleveland Ohio USA
| | - S. Sontag
- Division of Gastroenterology, Hepatology and Nutrition, Edward Hines; Jr VA Hospital; Hines Illinois USA
| | - A. Luke
- Department of Public Health Sciences; Loyola University Medical Center; Maywood Illinois USA
| | - R. Durazo-Arvizu
- Department of Public Health Sciences; Loyola University Medical Center; Maywood Illinois USA
| | - A. A. Pillai
- Department of Gastroenterology and Hepatology; Emory University Hospital; Atlanta Georgia USA
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Bruns T, Lutz P, Stallmach A, Nischalke HD. Low ascitic fluid protein does not indicate an increased risk for spontaneous bacterial peritonitis in current cohorts. J Hepatol 2015; 63:527-8. [PMID: 26015370 DOI: 10.1016/j.jhep.2015.03.040] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Revised: 03/06/2015] [Accepted: 03/12/2015] [Indexed: 12/18/2022]
Affiliation(s)
- Tony Bruns
- Department of Internal Medicine IV (Gastroenterology, Hepatology, and Infectious Diseases), Jena University Hospital, Jena, Germany; The Integrated Research and Treatment Center for Sepsis Control and Care (CSCC), Jena, Germany.
| | - Philipp Lutz
- Department of Internal Medicine I, Bonn University Hospital, Bonn, Germany; German Center for Infection Research, Germany.
| | - Andreas Stallmach
- Department of Internal Medicine IV (Gastroenterology, Hepatology, and Infectious Diseases), Jena University Hospital, Jena, Germany; The Integrated Research and Treatment Center for Sepsis Control and Care (CSCC), Jena, Germany
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50
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Dever JB, Sheikh MY. Review article: spontaneous bacterial peritonitis--bacteriology, diagnosis, treatment, risk factors and prevention. Aliment Pharmacol Ther 2015; 41:1116-31. [PMID: 25819304 DOI: 10.1111/apt.13172] [Citation(s) in RCA: 115] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2015] [Revised: 02/02/2015] [Accepted: 03/03/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Spontaneous bacterial peritonitis (SBP) is a severe and often fatal infection in patients with cirrhosis and ascites. AIM To review the known and changing bacteriology, risk factors, ascitic fluid interpretation, steps in performing paracentesis, treatment, prophylaxis and evolving perspectives related to SBP. METHODS Information was obtained from reviewing medical literature accessible on PubMed Central. The search term 'spontaneous bacterial peritonitis' was cross-referenced with 'bacteria', 'risk factors', 'ascites', 'paracentesis', 'ascitic fluid analysis', 'diagnosis', 'treatment', 'antibiotics', 'prophylaxis', 'liver transplantation' and 'nutrition'. RESULTS Gram-positive cocci (GPC) such as Staphylococcus, Enterococcus as well as multi-resistant bacteria have become common pathogens and have changed the conventional approach to treatment of SBP. Health care-associated and nosocomial SBP infections should prompt greater vigilance and consideration for alternative antibiotic coverage. Acid suppressive and beta-adrenergic antagonist therapies are strongly associated with SBP in at-risk individuals. CONCLUSIONS Third-generation, broad-spectrum cephalosporins remain a good initial choice for SBP treatment. Levofloxacin is an acceptable alternative for patients not receiving long-term flouroquinolone prophylaxis or for those with a penicillin allergy. For uncomplicated SBP, early oral switch therapy is reasonable. Alternative antibiotics such as pipercillin-tazobactam should be considered for patients with nosocomial SBP or for patients who fail to improve on traditional antibiotic regimens. Selective albumin supplementation remains an important adjunct in SBP treatment. Withholding acid suppressive medication deserves strong consideration, and discontinuing beta-adrenergic antagonist therapy in patients with end-stage liver disease and resistant ascites is standard care. Liver transplant evaluation should be undertaken for patients who develop SBP barring contraindications.
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Affiliation(s)
- J B Dever
- Department of Gastroenterology, VA San Diego Healthcare System, San Diego, CA, USA
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