Spontaneous bacterial peritonitis: a historical perspective

A Historical Overview of Spontaneous Bacterial Peritonitis: From Rare to Resistant

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The outcome of living donor liver transplant recipients with recent episodes of spontaneous bacterial peritonitis

BACKGROUND

spontaneous bacterial peritonitis (SBP) is a common complication in patients with cirrhosis and is associated with a high mortality rate. Only a few reports have analyzed the impact of treated SBP that occurs in the immediate pre-operative period on outcome after a living donor liver transplantation (LDLT). The results of whether post-transplant patients are dependent on pre-transplant infections are still debatable and unclear. Therefore, this study examined the outcomes of LDLT recipients with recent episodes of SBP and LDLT recipients without prior episodes of SBP.

PATIENTS

the records of 62 LDLT recipients who underwent LDLT were retrospectively reviewed. Twenty-four (36 %) recipients had at least one episode of SBP before LDLT. However, active SBP was not present in any of the recipients at the time of LDLT. Both recipient groups were compared in terms of demographic profile, perioperative and postoperative variables and outcomes.

RESULTS

higher pre-operative Child-Turcotte-Pugh (CTP) score (mean [SD] 11.77 [1.37] vs 10.5 [1.22], p < 0.001) and prior history of renal dysfunction (mean serum creatinine [SD] 1.715 [1.08] vs 1.02 [0.479] mg/dl, p = 0.002) were more commonly associated with the SBP group as compared to the non-SBP group. However, there was no statistically significant difference between the two groups in terms of the following variables: previous diabetes mellitus (3 [12.5 %] vs 6 [15.8 %]), pre-operative model for end-stage liver disease (MELD) score (median [IQR] 21 [10-37] vs 22 [9-39]), operative time (mean [SD] 789.57 [153.49] vs 800.86 [138.69] min), total number of blood transfusion (median [IQR] 10 [2-19] vs 8 [1-18]), hospital stay (median 21 vs 20 days), re-exploration (4 [16.6 %] vs 2 [5.3 %]), postoperative sepsis (8 [33 %] vs 5 [13 %]) and 30-day mortality (3 [12.5 %] vs 2 [5.3 %]).

CONCLUSIONS

the presence of previous episodes of pre-operative SBP in LDLT recipients does not result in adverse post-operative short-term outcomes.

Liver Cirrhosis Complications Management at the Emergency Department

BACKGROUND AND AIMS

Liver cirrhosis (LC) of any origin has always been a source of several emergencies for physicians working at the Emergency Department (ER). LC patients can present with several complications that are sometimes difficult to recognize and treat. Thus, we reviewed the literature evidence for the diagnosis and management of several LC related emergencies.

METHODS

We conducted a search on the main medical databases for papers, reviews, metanalyses, case series, and RCTs using the following keywords and their associations: liver cirrhosis, variceal hemorrhage, ascites, hepatic encephalopathy, spontaneous bacterial peritonitis, hepato-renal syndrome, emergency.

RESULTS

Main LC emergencies are upper gastrointestinal hemorrhage, decompensated ascites and spontaneous bacterial peritonitis, hepatic encephalopathy, hepato-renal syndrome. Their management is partly medical and interventional. Very often, the final cure of some complications, such as hepato-renal syndrome, is represented by liver transplantation.

CONCLUSION

Although LC prevalence is going to fall in the following years, due to HBV and HCV optimized treatments, its complications represent a significant admission percentage at the ER and challenge for physicians' skills.

Survival benefit associated with early detection of spontaneous bacterial peritonitis in veteran inpatients with cirrhotic ascites

Background

Spontaneous bacterial peritonitis (SBP) is common in hospitalized cirrhotic patients with ascites and carries high mortality. This study aimed to determine whether early diagnostic paracentesis (EDP) <12 h of hospitalization conveys an intermediate‐term (6‐month) survival benefit in cirrhotic patients diagnosed with SBP.

Methods

Consecutive US veterans with cirrhosis diagnosed with SBP over 13 years at a single VA medical center were reviewed retrospectively. Kaplan‐Meyer analyses assessed the effects of EDP on survival.

Results

A total of 79 cirrhotic patients were diagnosed with SBP (61.8 ± 8.8 years, n = 77 male, n = 52 [66.8%] Caucasian, n = 23 [29.1%] African‐American). Underlying liver diseases included hepatitis c viral infection (HCV) (17.5%), alcohol (28.6%), alcohol and HCV (30.1%), and cryptogenic/metabolic (15.9%). Median baseline model for end‐stage liver disease (MELD) was 12 (range 6–34), and median MELD at presentation was 18. Seven subjects had a history of hepatocellular carcinoma (11.1%), and 26 (41.3%) presented with sepsis. Thirty‐three (52.4%) subjects died within 6 months after the SBP admission. Of the subjects, 41 (65.1%) underwent EDP, of which 23 (56.0%) survived at least 6 months, compared to only 7 of the 22 patients (31.8%) undergoing paracentesis >12 h from presentation (P = 0.057). The maximal benefit of EDP on survival was observed beyond days 14 and 30; at these time points, no statistical difference in mortality was discernable (P = 0.55 and 0.71). In a multivariate model including age, MELD at admission, hepatocellular cancer, and sepsis criteria, EDP (p 0.034) positively impacted patient survival at 6 months.

Conclusions

EDP is associated with improved 6‐month mortality in cirrhotic patients with ascites. In this veteran cohort, EDP was as important as MELD as a predictor of intermediate‐term survival.

[Spontaneous Bacterial Peritonitis]

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.

Epidemiology and management of healthcare-associated bloodstream infections in non-neutropenic immunosuppressed patients: a review of the literature

Advancements in medicine have led to a considerable increase in the proportion of patients living with severe chronic diseases, malignancies, and HIV infections. Most of these conditions are associated with acquired immune-deficient states and treatment-related immunosuppression. Although infections as a result of neutropenia have long been recognized and strategies for management were developed, non-neutropenic immunosuppression has been overlooked. Recently, community-acquired infections in patients with frequent, significant exposure to healthcare settings and procedures have been classified as 'healthcare-associated infections' since they are more similar to hospital-acquired infections. Most of the non-neutropenic immunosuppressed patients have frequent contact with the healthcare system due to their chronic and severe diseases. In this review, we focus on the healthcare-associated bloodstream infections in the most common non-neutropenic immunosuppressive states and provide an update of the recent evidence for the management of these infections.

Outcomes of spontaneous bacterial peritonitis in liver transplant recipients with allograft failure

BACKGROUND

Spontaneous bacterial peritonitis (SBP) carries appreciable morbidity and mortality in the pre-liver transplant (LT) setting. However, the occurrence of SBP and its consequences in the post-LT setting have not been well characterized.

METHODS

This is a retrospective study of SBP occurring in post-LT patients between January 2007 and December 2012. Outcomes were compared to a cohort of post-LT patients with allograft failure and ascites without SBP.

RESULTS

The most common indication for liver transplantation in this cohort was hepatitis C. A total of 29 episodes of SBP in 21 patients were identified. Escherichia coli (19%) and Klebsiella pneumoniae (10%) were the most frequent pathogens identified. Six patients died during their first episode of SBP. Ten patients were eventually listed for liver re-transplantation (re-LT) after their first episode of SBP; 5 of these patients were transplanted and the other 5 died. Of the 5 who were transplanted, 2 died shortly after re-transplant, and 3 are still alive. The cause of death in the majority of patients was infection (83.3%). The median time from onset of ascites to death was 214 days (range: 10-1085 days) and from the first episode of SBP to death was 50.5 days (range: 4-549 days). In contrast, the median time from onset of ascites to death in patients with allograft failure and ascites without SBP was 331.5 days (45-2400 days).

CONCLUSIONS

Allograft failure with ascites is a poor prognostic factor and these patients should be considered high risk for re-LT. SBP may accelerate the time to mortality.

Immune function biomarker QuantiFERON-monitor is associated with infection risk in cirrhotic patients

AIM

To investigate whether a novel immune function biomarker QuantiFERON-Monitor (QFM) can identify cirrhotic patients at greatest risk of infection.

METHODS

Adult cirrhotic patients on the liver transplant waiting list were recruited for this observational cohort study from a tertiary liver transplant referral unit. The immune function biomarker, QFM was performed using the same method as the widely available Quantiferon-gold assay, and measures output in interferon gamma in IU/mL after dual stimulation of the innate and adaptive immune systems. Ninety-one cirrhotic patients were recruited, with 47 (52%) transplanted on the day of their QFM. The remaining 44 (48%) were monitored for infections until transplant, death, or census date of 1st February 2014.

RESULTS

Cirrhotic patients express a median QFM significantly lower than healthy controls (94.5 IU/mL vs 423 IU/mL), demonstrating that they are severely immunosuppressed. Several factors including model for end stage liver disease, presence of hepatocellular carcinoma, bilirubin, international normalized ratio and haemoglobin were associated with QFM on univariate analysis. Disease aetiology did not appear to impact QFM. On multivariate analysis, only Child-Pugh score and urea were significantly associated with a patient's immune function as objectively measured by QFM. In the 44 patients who were not transplanted immediately after their blood test and could be monitored for subsequent infection risk, 13 (29.5%) experienced a pre-transplant infection a median 20 d (range 2-182) post-test. QFM < 214 IU/mL was associated with HR = 4.1 (P = 0.01) for infection. A very low QFM < 30 IU/mL was significantly associated (P = 0.003) with death in three patients who died while awaiting transplantation (HR = 56.6).

CONCLUSION

QFM is lower in cirrhotics, allowing objective determinations of an individual's unique level of immune dysfunction. Low QFM was associated with increased susceptibility to infection.

The benefit of paracentesis on hospitalized adults with cirrhosis and ascites

BACKGROUND AND AIM

The aim of this study is to assess paracentesis utilization and outcomes in hospitalized adults with cirrhosis and ascites.

METHODS

The 2011 Nationwide Inpatient Sample was used to identify adults, non-electively admitted with diagnoses of cirrhosis and ascites. The primary endpoint was in-hospital mortality. Variables included patient and hospital demographics, early (Day 0 or 1) or late (Day 2 or later) paracentesis, hepatic decompensation, and spontaneous bacterial peritonitis.

RESULTS

Out of 8 023 590 admissions, 31 614 met inclusion criteria. Among these hospitalizations, approximately 51% (16 133) underwent paracentesis. The overall in-hospital mortality rate was 7.6%. There was a significantly increased mortality among patients who did not undergo paracentesis (8.9% vs 6.3%, P < 0.001). Patients who did not receive paracentesis died 1.83 times more often in the hospital than those patients who did receive paracentesis (95% confidence interval 1.66-2.02). Patients undergoing early paracentesis showed a trend towards reduction in mortality (5.5% vs 7.5%) compared with those undergoing late paracentesis. Patients admitted on a weekend demonstrated less frequent use of early paracentesis (50% weekend vs 62% weekday) and demonstrated increased mortality (adjusted odds ratio 1.12 95% confidence interval 1.01-1.25). Among patients diagnosed with spontaneous bacterial peritonitis, early paracentesis was associated with shorter length of stay (7.55 vs 11.45 days, P < 0.001) and decreased hospitalization cost ($61 624 vs $107 484, P < 0.001).

CONCLUSION

Paracentesis is under-utilized among cirrhotic patients presenting with ascites and is associated with decreased in-hospital mortality. These data support the use of paracentesis as a key inpatient quality measure among hospitalized adults with cirrhosis. Future studies are needed to investigate the barriers to paracentesis use on admission.

Clostridium difficile infection in patients with liver disease: a review

Over the past two decades, there has been a dramatic worldwide increase in both the incidence and severity of Clostridium difficile infection (CDI). Paralleling the increased incidence of CDI in the general population, there has been increased interest in CDI among patients with liver disease, particularly in those with liver cirrhosis and post liver transplantation. MEDLINE and several other electronic databases from January 1995 to December 2014 were searched in order to identify potentially relevant literature. Patients with cirrhosis and liver transplant recipients are at high risk for the development CDI because of antibiotics and proton pump inhibitors use, frequent and prolonged hospitalization, immunosuppressant therapy, and multiple comorbidities. Enzyme immunoassay to detect C. difficile toxins A and B in stool remains the most widely used test for CDI diagnosis, although, more recently, polymerase chain reaction (PCR)-based assays have become the preferred diagnostic test in many laboratories. Metronidazole and vancomycin, given orally, have proved to be effective in the treatment of CDI. Both cirrhotic patients and liver transplant recipients with CDI have longer length of hospital stay, increased mortality, and higher healthcare costs than those without CDI. A rapid diagnosis and adequate therapy of CDI are of paramount importance to improve liver disease patients' outcome. The aim of this review is to provide up-to-date information on the epidemiology, risk factors, pathogenesis, treatment, and outcomes in liver disease patients with CDI.

Diagnostic Value of Leukocyte Esterase Test Strip Reagents for Rapid Clinical Diagnosis of Spontaneous Bacterial Peritonitis in Patients Admitted to Hospital Emergency Departments in Iran

Background:

Spontaneous bacterial peritonitis (SBP) is a common and important clinical problem and is life-threatening in decompensated liver disease. Ascites fluid test by leukocyte esterase test strip has been recently proposed as an effective and rapid method to diagnose SBP in patients with cirrhosis.

Objectives:

This study aimed to evaluate sensitivity and specificity of leukocyte esterase test strip in the diagnosis of SBP.

Patients and Methods:

The population of this research was all patients with cirrhosis and ascites admitted to the emergency room at Imam Reza (AS) hospital, Mashhad. A written consent was taken for inclusion in the study. 50 mL ascites sample was taken from all patients for use in a urine test strip (LER) (Urine Test Strips Convergys®Urine Matrix 11). The patient’s ascites samples were evaluated for cell counting. Positive dipstick test for LER in this study considered as grade 3 +. The values of WBC > 500 cell/mm³ or PMN > 250 cell/mm³ considered as positive result of the gold standard method for the diagnosis of SBP.

Results:

In this study, 100 patients with ascites due to cirrhosis, with an average age of 38.9 ± 6.54 years were evaluated. Twenty cases had positive results, of whom 17 cases were also detected based on the standard diagnostic criteria and other three cases were healthy individuals. Thus, sensitivity, specificity, positive and negative predictive values, and accuracy of the method were 95%, 96.3%, 85%, 97.5% and 95%, respectively.

Conclusions:

The use of leukocyte esterase urine dipstick test can be a quick and easy method in early diagnosis of SBP to start the treatment until preparation of SBP-cell count results.

Mean platelet volume as a novel predictor of systemic inflammatory response in cirrhotic patients with culture-negative neutrocytic ascites

AIM: To identify a mean platelet volume (MPV) cutoff value which should be able to predict the presence of bacterial infection.

METHODS: An observational, analytic, retrospective study. We evaluated medical records of cirrhotic patients who were hospitalized from January 2012 to January 2014 at the Gastroenterology Department of “Hospital General de México Dr. Eduardo Liceaga”, we included 51 cirrhotic patients with ascites fluid infection (AFI), and 50 non-infected cirrhotic patients as control group. Receiver operator characteristic curves were used to identify the best cutoff value of several parameters from hematic cytometry, including MPV, to predict the presence of ascites fluid infection.

RESULTS: Of the 51 cases with AFI, 48 patients (94.1%) had culture-negative neutrocytic ascites (CNNA), 2 (3.9%) had bacterial ascites, and one (2%) had spontaneous bacterial peritonitis. Infected patients had greater count of leucocytes and polymorphonuclear cells, greater levels of MPV and cardiac frequency (P < 0.0001), and lower mean arterial pressure compared with non-infected patients (P = 0.009). Leucocytes, polymorphonuclear count, MPV and cardiac frequency resulted to be good or very good predictive variables of presence of AFI in cirrhotic patients (area under the receiving operating characteristic > 0.80). A cutoff MPV value of 8.3 fl was the best to discriminate between cirrhotic patients with AFI and those without infection.

CONCLUSION: Our results support that MPV can be an useful predictor of systemic inflammatory response syndrome in cirrhotic patients with AFI, particularly CNNA.

First report of Kocuria marina spontaneous peritonitis in a child

Background

Spontaneous bacterial peritonitis (SBP) is a rare affection in the pediatric population. It usually occurs when concurrent conditions are present, such as nephrotic syndrome, peritoneal dialysis or liver disease. We report a case of spontaneous bacterial peritonitis due to Kocuria marina in a 2-year-old child with no underlying risk factor. This is both the first description of an infection caused by this rare pathogen in a child and the first reported case of primary peritonitis caused by K. marina in a patient with no predisposing condition.

Case presentation

A 2 year-old boy presented to the Pediatric Emergency Department with clinical signs of peritonitis. Laparoscopic surgical exploration confirmed purulent, generalized peritonitis without perforation. Culture of the peritoneal fluid revealed the presence of Kocuria marina, a Gram-positive coccoid environmental bacteria. After peritoneal lavage and appropriate antibiotic treatment, the patient improved and was discharged without sequel.

Conclusion

The present report illustrates the first clinical presentation of Kocuria marina SBP in a child with no underlying risk factor. Although never previously described in healthy patients, this pathogen may therefore be considered as a possible cause of SBP in a child. This unusual finding extends the spectrum of infectious diseases caused by Kocuria marina beyond the scope of the previously described susceptible population.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-014-0719-5) contains supplementary material, which is available to authorized users.

Delayed paracentesis is associated with increased in-hospital mortality in patients with spontaneous bacterial peritonitis

OBJECTIVES

Spontaneous bacterial peritonitis (SBP) is associated with high mortality. Early paracentesis (EP) is essential for rapid diagnosis and optimal treatment. The aim of the study is to compare the outcomes of patients with SBP who received EP vs. delayed paracentesis (DP).

METHODS

Consecutive patients who were diagnosed with SBP (ascites neutrophil count ≥250 cells/mm(3) and clinical evidence of cirrhosis) <72 h from the first physician encounter at two centers were identified. EP was defined by receiving paracentesis <12 h and DP 12-72 h from hospitalization. Primary outcome was in-hospital mortality.

RESULTS

The mean age of 239 patients with SBP was 53±10 years; mean Model for End-Stage Liver Disease (MELD) score was 22±9. In all, 98 (41%) patients who received DP had a higher in-hospital mortality (27% vs. 13%, P=0.007) compared with 141 (59%) who received EP. Furthermore, DP group had longer intensive care days (4.0±9.5 vs. 1.3±4.1, P=0.008), hospital days (13.0±14.7 vs. 8.4±7.4, P=0.005), and higher 3-month mortality (28/76, 37% vs. 21/98, 21%; P=0.03) compared with the EP group. Adjusting for MELD score ≥22 (adjusted odds ratio (AOR)=5.7, 95% confidence interval (CI)=1.8-18.5) and creatinine levels ≥1.5 mg/dl (AOR=3.2, 95% CI=1.4-7.2), DP was associated with increased in-hospital mortality (AOR=2.7, 95% CI=1.3-4.8). Each hour delay in paracentesis was associated with a 3.3% (95% CI=1.3-5.4%) increase in in-hospital mortality after adjusting for MELD score and creatinine levels.

CONCLUSIONS

Hospitalized patients with SBP who received DP had a 2.7-fold increased risk of mortality adjusting for MELD score and renal dysfunction. Diagnostic paracentesis performed <12 h from hospitalization in patients with cirrhosis and ascites may improve short-term survival.

Diagnosis of spontaneous bacterial peritonitis and an in situ hybridization approach to detect an "unidentified" pathogen

Spontaneous bacterial peritonitis (SBP) is a frequent and severe complication in cirrhotic patients with ascites. Although identifying the pathogen(s) plays a major role in the management of infectious diseases, ascitic fluid cultures often show negative results in patients with clinical signs and symptoms of SBP, and ascitic fluid cell analyses are the gold standard method for diagnosing SBP. SBP is generally diagnosed based on an increased number of polymorphonuclear neutrophils in the ascitic fluid (>250/mm(3)), and the identification of the causal pathogen may not be given consideration. We newly developed an in situ hybridization (ISH) method to provide early and direct evidence of bacterial infection in ascites in patients with SBP. This paper will review the diagnosis of SBP, including our novel approach with ISH method to detect bacterial DNA in SBP ascitic fluid.

Diagnosis of spontaneous bacterial peritonitis and an in situ hybridization approach to detect an "unidentified" pathogen

Spontaneous bacterial peritonitis (SBP) is a frequent and severe complication in cirrhotic patients with ascites. Although identifying the pathogen(s) plays a major role in the management of infectious diseases, ascitic fluid cultures often show negative results in patients with clinical signs and symptoms of SBP, and ascitic fluid cell analyses are the gold standard method for diagnosing SBP. SBP is generally diagnosed based on an increased number of polymorphonuclear neutrophils in the ascitic fluid (>250/mm(3)), and the identification of the causal pathogen may not be given consideration. We newly developed an in situ hybridization (ISH) method to provide early and direct evidence of bacterial infection in ascites in patients with SBP. This paper will review the diagnosis of SBP, including our novel approach with ISH method to detect bacterial DNA in SBP ascitic fluid.

Management of end-stage liver disease

Patients with cirrhosis who experience hepatic decompensation, such as the development of ascites, SBP, variceal hemorrhage, or hepatic encephalopathy, or who develop HCC, are at a higher risk of mortality. Management should be focused on the prevention of recurrence of complications, and these patients should be referred for consideration of liver transplantation.

Multidisciplinary approach for HCC patients: hepatology for the oncologists

Hepatocellular carcinoma (HCC) is a complex and heterogeneous disease, often associated with underlying conditions, like cirrhosis or other relevant co-morbidities that worsen the prognosis and make the clinical management more challenging. Current recommendations emphasize the importance of a multidisciplinary approach for the management of HCC patients and stress the crucial role of careful prevention and the management of cirrhosis-associated complications. This article discusses the importance of a multidisciplinary approach in the treatment of HCC patients. Current recommendations for the treatment of cirrhotic patients with HCC are also reviewed.

Non-hemorrhagic acute complications associated with cirrhosis and portal hypertension

Timely recognition and management of acute complications of cirrhosis is of significant importance in order to reduce morbidity and mortality, especially in the hospitalized patient. In this review, we present a practical approach to the identification and management of non-hemorrhagic acute complications of cirrhosis, specifically bacterial infections, acute kidney injury, and acute exacerbation of hepatic encephalopathy, focusing on patient stratification.

[Management of decompensated liver cirrhosis in the intensive care unit]

Liver cirrhosis is the end-stage of long-standing chronic liver diseases. The occurrence of complications from liver cirrhosis increases the mortality risk, but the prognosis can be improved by optimal management in the intensive care unit (ICU). Defined diagnostic algorithms allow the etiology and presence of typical complications upon presentation to the ICU to be identified. Acute variceal bleeding requires endoscopic intervention, vasoactive drugs, antibiotics, supportive intensive care measures and, where necessary, urgent transjugular intrahepatic portosystemic shunt (TIPS) procedure. Spontaneous bacterial peritonitis needs to be diagnosed and immediately treated in patients with ascites. Hepatorenal syndrome should be treated by albumin and terlipressin. In case of respiratory failure, differential diagnosis should not only consider pneumonia, pulmonary embolism and cardiac failure, but also hepatic hydrothorax, portopulmonary hypertension and hepatopulmonary syndrome. The feasibility of liver transplantation should be always discussed in patients with decompensated cirrhosis. Artificial liver support devices may only serve as a bridging procedure until transplant.

Evaluation of different therapeutic approaches for spontaneous bacterial peritonitis

BACKGROUND AND STUDY AIMS

Spontaneous bacterial peritonitis (SBP) is a significant cause of mortality in cirrhosis. Reducing toxic burden of infected ascitic fluid through paracentesis needs further studies as adjunctive therapy of SBP. We aimed to evaluate different therapies for SBP.

PATIENTS AND METHODS

Thirty-six cirrhotic ascitic patients with SBP were examined and classified according to treatment modality (5-7 days) into: Group A received cefotaxime, group B received cefotaxime and albumin 1.5 g/kg body weight within 6h of SBP being diagnosed and 1g/kg body weight on day 3, group C received cefotaxime and paracentesis with volume dependent albumin infusion. Control group of 12 cirrhotic ascitic patients free from SBP were included. Routine laboratory tests, ascitic fluid analysis for leucocytes and culture were done, inflammatory mediators such as nitric oxide and tumour necrosis factor alpha were measured in serum and ascitic fluid. Duplex-Doppler assessment of portal flow volume and renal resistive index, Echocardiography to measure end diastolic and end systolic volumes, stroke volume and cardiac output were done. Tests were carried out before and after therapy.

RESULTS

Treatment response was assessed by, cardiac haemodynamics, portal and renal flow and NO and TNF. All studied parameters; laboratory, cardiac, Doppler exhibited a significant improvement in group B in contrast to the other groups as demonstrated by post therapy reduction of (blood and ascitic fluid WBCs & PNLS, serum and ascitic NO & TNF and renal resistive index), elevation of (serum albumin and portal flow volume) and improvement of cardiac haemodynamic.

CONCLUSION

Treatment of spontaneous bacterial peritonitis by cefotaxime and body weight based albumin infusion gave most favourable results compared to other regimens. Postulation of removing toxic burden through paracentesis has not been confirmed.

Risk factors for resistance to ceftriaxone and its impact on mortality in community, healthcare and nosocomial spontaneous bacterial peritonitis

BACKGROUND & AIMS

The recent emergence of third-generation cephalosporin resistance in spontaneous bacterial peritonitis is of great concern, although neither the risk factors for resistance nor its real impact on mortality have been well defined.

METHODS

We conducted a retrospective study of all spontaneous bacterial peritonitis episodes with positive blood and/or ascitic culture at our center (2001-2009). Episodes were classified according to the place of acquisition: community, healthcare system, or nosocomial.

RESULTS

Two hundred and forty-six episodes were analyzed in 200 patients (150 males, 57.3 years): 34.6% community-acquired, 38.6% healthcare system-acquired, and 26.8% nosocomially-acquired. Third-generation cephalosporin resistance occurred in 21.5% (7.1% community-acquired, 21.1% healthcare system-acquired, 40.9% nosocomially-acquired). These resistant cases were categorized as extended-spectrum β-lactamase-producing Gram-negative bacilli, other resistant Gram-negative bacilli, and Enterococci. Risk factors for resistance were previous use of cephalosporins, diabetes mellitus, upper gastrointestinal bleeding, nosocomial acquisition, and a low polymorphonuclear count in ascites. Regarding third-generation cephalosporin resistance, adequate empirical treatment was 80.7%. Independent predictors of mortality were nosocomial acquisition, poor hepato-renal function, immunosuppressive therapy, a marked inflammatory response during the episode and either third-generation cephalosporin-resistance or low rates of adequate empirical treatment.

CONCLUSIONS

The risk of third-generation cephalosporin resistance was particularly high in nosocomially-acquired episodes of spontaneous bacterial peritonitis, but also occurred in healthcare system-acquired cases. The extent of resistance and the adequacy of empirical antibiotics had a significant effect on mortality along with the patient's hepato-renal function. These data can help determine the most suitable empirical antimicrobial treatments in these patients.

Improving survival in decompensated cirrhosis

Mortality in cirrhosis is consequent of decompensation, only treatment being timely liver transplantation. Organ allocation is prioritized for the sickest patients based on Model for End Stage Liver Disease (MELD) score. In order to improve survival in patients with high MELD score it is imperative to preserve them in suitable condition till transplantation. Here we examine means to prolong life in high MELD score patients till a suitable liver is available. We specially emphasize protection of airways by avoidance of sedatives, avoidance of Bilevel Positive Airway Pressure, elective intubation in grade III or higher encephalopathy, maintaining a low threshold for intubation with lesser grades of encephalopathy when undergoing upper endoscopy or colonoscopy as pre transplant evaluation or transferring patient to a transplant center. Consider post-pyloric tube feeding in encephalopathy to maintain muscle mass and minimize risk of aspiration. In non intubated and well controlled encephalopathy, frequent physical mobility by active and passive exercises are recommended. When renal replacement therapy is needed, night-time Continuous Veno-Venous Hemodialysis may be useful in keeping the daytime free for mobility. Sparing and judicious use of steroids needs to be borne in mind in treatment of ARDS and acute hepatitis from alcohol or autoimmune process.

Critical care management of patients with end-stage liver disease

OBJECTIVES

To review the management of complications related to end-stage liver disease in the intensive care unit. The goal of this review is to address topics important to the practicing physician.

DATA SOURCES

We performed an organ system-based PubMed literature review focusing on the diagnosis and treatment of critical complications of end-stage liver disease. DATA SYNTHESIS AND FINDINGS: When available, preferential consideration was given to randomized controlled trials. In the absence of trials, observational and retrospective studies and consensus opinions were included. We present our recommendations for the neurologic, cardiovascular, pulmonary, gastrointestinal, renal, and infectious complications of end-stage liver disease.

CONCLUSIONS

Complications related to end-stage liver disease have significant morbidity and mortality. Management of these complications in the intensive care unit requires awareness and expertise among physicians from a wide variety of fields.

The management of hospitalized patients with cirrhosis: the Mount Sinai experience and a guide for hospitalists

BACKGROUND

Cirrhosis and chronic liver disease carry appreciable morbidity and mortality. Cirrhotic patients frequently require hospitalization and their care is both extremely complex and labor-intensive.

AIM

We seek to provide a review for gastroenterologists, hepatologists, internists, and hospitalists on the approach to care in patients hospitalized for complications related to end-stage liver disease.

METHODS

The Mount Sinai Medical Center's inpatient liver service has developed an integrated team approach for cirrhotic patients and throughout the years has educated fellows-in-training and medical house staff on both the treatment principles and "pearls" in managing the hospitalized cirrhotic patient. We reviewed the literature and provide recommendations on the management of complications of end-stage liver disease. Additionally, we provide a review of the protocols used at our institution in the care for cirrhotic patients.

RESULTS

Major complications of advanced liver disease include infection, ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, portal hypertension, variceal hemorrhage, hepatorenal syndrome, and hepatocellular carcinoma. Management of these complications involves selecting the appropriate diagnostic studies and prompt administration of therapy.

CONCLUSIONS

There are many complications of cirrhosis. Management of these complications can be complex and are targeted at stabilizing the patient's clinical condition. Liver transplantation remains the only definitive treatment.

Autopsy findings of a patient with rapidly progressive massive ascites caused by alcoholic cirrhosis

A 54-year-old man, who lived alone, was hospitalized due to rapid deterioration of the general condition over a three-week period caused by alcoholic cirrhosis. One month after he left hospital, he was found dead in his house by his friend. Three days before he was found dead, he had met his friend and seemed to be in poor condition. Autopsy was conducted by a medical examiner to clarify the cause of death. Externally, signs of severe jaundice were apparent over the whole body, along with extensive abdominal swelling and edema of the extremities. Autopsy findings demonstrated that the abdominal cavity contained an amount of massive turbid and slight pale reddish brown ascites (23 l). There were no findings of severe peritoneal inflammation. The liver (650 g) was elastic hard and had a micro-nodular surface, which showed severe atrophy. Microscopic examination of the liver showed clear pseudolobule with severe fibrosis in the stroma. There were no significant changes in the heart or brain. The stomach was empty and only a slight amount of intestinal contents. There was no ethanol detected in the blood or urine. The direct cause of his death was circulatory dysfunction due to massive accumulation of the ascites. The reasons for the massive ascites accumulation over 20 l in this case were (1) that he had no serious complications other than ascites; and (2) he did not have any medical treatment just before his death.

Prevention and management of bacterial infections in cirrhosis

Patients with cirrhosis of liver are at risk of developing serious bacterial infections due to altered immune defenses. Despite the widespread use of broad spectrum antibiotics, bacterial infection is responsible for up to a quarter of the deaths of patients with liver disease. Cirrhotic patients with gastrointestinal bleed have a considerably higher incidence of bacterial infections particularly spontaneous bacterial peritonitis. High index of suspicion is required to identify infections at an early stage in the absence of classical signs and symptoms. Energetic use of antibacterial treatment and supportive care has decreased the morbidity and mortality over the years; however, use of antibiotics has to be judicious, as their indiscriminate use can lead to antibiotic resistance with potentially disastrous consequences. Preventive strategies are still in evolution and involve use of antibiotic prophylaxis in patients with gastrointestinal bleeding and spontaneous bacterial infections and selective decontamination of the gut and oropharynx.

Spontaneous bacterial peritonitis: from pathophysiology to prevention

Patients with cirrhosis present an increased susceptibility to bacterial infections, which are the cause of hospital admission in about 10% of patients and are present in about 40% of those admitted for ongoing complications. Lastly, about a third of patients develop nosocomial infections. Spontaneous bacterial peritonitis (SBP) is the most frequent infection in advanced cirrhosis; it is mostly caused by Gram-negative bacteria of intestinal origin, but Gram-positive cocci can be involved in nosocomial-acquired SBP. Its occurrence is associated with complications, such as renal and circulatory failure, cardiac dysfunction, coagulopathy, encephalopathy, and relative adrenal insufficiency, ultimately leading to multi-organ failure and death within a few days or weeks in about 30% of cases. The main mechanism underlying the development of SBP, as well as other bacterial infections in cirrhosis, is represented by bacterial translocation from the intestinal lumen to mesenteric lymph nodes or other extraintestinal organs and sites. This process is facilitated by several factors, including changes in intestinal flora, portal hypertension, and, mainly, impairment in local/systemic immune defense mechanisms. Bacterial infections in advanced cirrhosis evoke an enhanced systemic inflammatory response, which explains the ominous fate of PBS. Indeed, an exaggerated production of cytokines ensues, which ultimately activates vasodilating systems and generates reactive oxygen species. Primary antibiotic prophylaxis of PBS is warranted in those conditions implying an increased incidence of bacterial infections, such as gastro-intestinal bleeding and low protein content in ascites associated with severe liver and/or renal dysfunction. Fluoroquinolones are commonly employed, but the frequent occurrence of resistant bacterial strains make third generation cephalosporins preferable in specific settings. The high PBS recurrence indicates secondary antibiotic prophylaxis.

Nucleotide-binding oligomerization domain containing 2 (NOD2) variants are genetic risk factors for death and spontaneous bacterial peritonitis in liver cirrhosis

Spontaneous bacterial peritonitis (SBP), a severe complication in patients with advanced liver cirrhosis, has been attributed to bacterial translocation from the intestine. Variants of the NOD2 (nucleotide-binding oligomerization domain containing 2) gene have been associated with impaired mucosal barrier function in Crohn disease. We hypothesized that the risk of acquiring SBP is increased in patients with cirrhosis carrying NOD2 variants. We recruited 150 nonselected patients with liver cirrhosis and ascites admitted to our unit, monitored survival, and recorded the development of SBP prospectively and retrospectively. SBP was defined as the presence of polymorphonuclear neutrophil (PMN) cells >250 per microL of ascitic fluid. Patients were genotyped for the NOD2 variants p.R702W, p.G908R, and c.3020insC. During a median follow-up of 155 days, 54 patients (36%) died and SBP was diagnosed in 30 patients (20%). The occurrence of SBP was increased significantly (P = 0.008) in carriers of NOD2 variants (odds ratio [OR] = 3.06). Retrospectively, SBP was observed in 22 additional patients, and the combined prospective and retrospective analysis substantiated the association between NOD2 and SBP (P = 0.004; OR = 2.98). Of note, carriers of NOD2 risk alleles showed a significantly (P = 0.007) reduced mean survival time (274 days) in comparison to patients with wildtype genotypes (395 days).

CONCLUSION

Common NOD2 variants linked previously to impaired mucosal barrier function may be genetic risk factors for death and SBP. These findings might serve to identify patients with cirrhotic ascites eligible for preemptive antibiotic treatment.

Impact of pretransplant infections on clinical outcomes of liver transplant recipients

Whether pretransplant nonviral infections influence outcomes after transplantation in liver transplant recipients in the current era is not well defined. One hundred consecutive patients undergoing liver transplantation in 2005-2008 were studied. Demographics, posttransplant clinical events, and mortality were compared between recipients with and without infections within 12 months before transplantation. In all, 32% of the patients (32/100) developed 45 episodes of pretransplant infections, which included spontaneous bacterial peritonitis (35.6%), bloodstream infections (28.9%), cellulitis (13.3%), pneumonia (8.9%), urinary tract infections (6.7%), and other infections (6.7%). Compared with 68 recipients without pretransplant infections, those with infections had a higher Model for End-Stage Liver Disease score and a lower likelihood of transplantation from home and required longer and more frequent hospital care before and after transplantation (P < 0.05). Mortality at 90 (9.4% versus 2.9%) and 180 days (15.6% versus 10.3%) post-transplant did not differ significantly between recipients with and without pretransplant infections (P = not significant). A higher Model for End-Stage Liver Disease score (P < 0.05) and posttransplant infections (P < 0.05 and P < 0.001), but not pretransplant infections, were associated with posttransplant mortality at 90 and 180 days. In conclusion, pretransplant infections that have been adequately treated do not pose a significant risk for poor outcomes, including posttransplant mortality.

Pneumococcal peritonitis: Still with us and likely to increase in importance

BACKGROUND

Pneumococcal peritonitis is uncommon and poorly understood.

METHODS

As part of a five-year study (2000 to 2004) of invasive pneumococcal disease (IPD) in Alberta, all cases of peritonitis due to Streptococcus pneumoniae were reviewed and compared with all other cases of IPD.

RESULTS

Twenty-three of 1768 (1.3%) IPD patients were found to have peritonitis. Patients with peritonitis were more likely to have cirrhosis, hepatitis C, alcoholism and HIV/AIDS, than the remainder of the patients with IPD. The all-cause mortality did not differ between the two groups. Peritonitis was classified as primary in nine (39%) patients, secondary in 12 (52%) patients, and genitourinary in females, specifically, in two (9%) patients. Pneumococcal serotypes causing peritonitis were under-represented in current vaccines - 17% among peritonitis patients versus 53% for the remainder of IPD patients for the 7-valent pneumococcal conjugate vaccine, and 56% versus 86% for the 23-valent pneumococcal polysaccharide vaccine.

CONCLUSIONS

Peritonitis represents a small subset of patients with IPD, but one that is likely to grow in importance given the increase in the number of patients with hepatitis C and HIV, and the reduced coverage of peritonitis serotypes in currently available vaccines.

Management and treatment of patients with cirrhosis and portal hypertension: recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program

Cirrhosis represents the end stage of any chronic liver disease. Hepatitis C and alcohol are currently the main causes of cirrhosis in the United States. Although initially cirrhosis is compensated, it eventually becomes decompensated, as defined by the presence of ascites, variceal hemorrhage, encephalopathy, and/or jaundice. These management recommendations are divided according to the status, compensated or decompensated, of the cirrhotic patient, with a separate section for the screening, diagnosis, and management of hepatocellular carcinoma (HCC), as this applies to patients with both compensated and decompensated cirrhosis. In the compensated patient, the main objective is to prevent variceal hemorrhage and any practice that could lead to decompensation. In the decompensated patient, acute variceal hemorrhage and spontaneous bacterial peritonitis are severe complications that require hospitalization. Hepatorenal syndrome is also a severe complication of cirrhosis but one that usually occurs in patients who are already in the hospital and, as it represents an extreme of the hemodynamic alterations that lead to ascites formation, it is placed under treatment of ascites. Recent advances in the pathophysiology of the complications of cirrhosis have allowed for a more rational management of cirrhosis and also for the stratification of patients into different risk groups that require different management. These recommendations are based on evidence in the literature, mainly from randomized clinical trials and meta-analyses of these trials. When few or no data exist from well-designed prospective trials, emphasis is given to results from large series and consensus conferences with involvement of recognized experts. A rational management of cirrhosis will result in improvements in quality of life, treatment adherence, and, ultimately, in outcomes.

Spontaneous bacterial peritonitis

Since its initial description in 1964, research has transformed spontaneous bacterial peritonitis (SBP) from a feared disease (with reported mortality of 90%) to a treatable complication of decompensated cirrhosis, albeit with steady prevalence and a high recurrence rate. Bacterial translocation, the key mechanism in the pathogenesis of SBP, is only possible because of the concurrent failure of defensive mechanisms in cirrhosis. Variants of SBP should be treated. Leucocyte esterase reagent strips have managed to shorten the ‘tap-to-shot’ time, while future studies should look into their combined use with ascitic fluid pH. Third generation cephalosporins are the antibiotic of choice because they have a number of advantages. Renal dysfunction has been shown to be an independent predictor of mortality in patients with SBP. Albumin is felt to reduce the risk of renal impairment by improving effective intravascular volume, and by helping to bind pro-inflammatory molecules. Following a single episode of SBP, patients should have long-term antibiotic prophylaxis and be considered for liver transplantation.

Prevention and treatment of infections in patients with cirrhosis

Patients with cirrhosis have altered immune defenses and are considered immunocompromised individuals. Changes in gut motility, mucosal defense and microflora allow for translocation of enteric bacteria into mesenteric lymph nodes and the blood stream. Additionally, the cirrhotic liver is ineffective at clearing bacteria and associated endotoxins from the blood thus allowing for seeding of the sterile peritoneal fluid. Thus, hospitalised cirrhotic patients, particularly those with gastrointestinal hemorrhage, are at high risk of developing bacterial infections, the most common being spontaneous bacterial peritonitis. Given the significant morbidity and mortality associated with spontaneous bacterial peritonitis and the fact that half of the cases are community acquired, all hospitalised cirrhotic patients should have a diagnostic paracentesis to exclude infection. Those admitted with gastrointestinal bleed and a negative paracentesis require short-term prophylaxis with norfloxacin. A third generation cephalosporin is the treatment of choice for spontaneous bacterial peritonitis and, once the acute infection is resolved, secondary prophylaxis with oral norfloxacin is warranted. Patients who develop renal dysfunction at the time of active infection have the highest mortality and require adjunctive albumin therapy. This article reviews the pathogenesis of SBP, the evidence behind the antibiotics used, the rationale for adjunctive albumin therapy in the setting of acute renal failure, and the role of prophylactic antibiotics in specific high-risk populations.

Peritonitis after liver transplantation: Incidence, risk factors, microbiology profiles, and outcome

Peritonitis occurring after liver transplantation (PLT) has been poorly characterized to date. The aims of this study were to define the incidence, risk factors, microbiology profiles, and outcome of nonlocalized PLT. This was a retrospective study of 950 cadaveric liver transplantation (LT) procedures in 837 patients, followed for a mean of 1,086 days (range, 104-2,483 days) after LT. PLT was defined as the presence of at least one positive ascitic fluid culture after LT. There were 108 PLT episodes in 91 patients occurring at a median of 14 days (range, 1-102 days) after LT. Significant risk factors associated with the development of PLT by multivariate analysis included pre-LT model for end-stage liver disease score, duration of LT surgery, Roux-en-Y biliary anastomosis, and renal replacement therapy after LT. Biliary complications, intra-abdominal bleeding, and bowel leak/perforation were associated with 34.3%, 26.9%, and 18.5% of episodes, respectively. Multiple organisms, gram-positive cocci, fungus, and multidrug-resistant bacteria were isolated in 61.1%, 92.6%, 25.9%, and 76.9% of ascitic fluid cultures, respectively. The 28 fungal PLT episodes were associated with bowel leak/perforation and polymicrobial peritonitis. Patients who developed PLT after their first LT had a significantly greater risk of graft loss or mortality compared to unaffected patients. Parameters significantly associated with these adverse outcomes by multivariate analysis were recipient age at LT and bowel leak or perforation after LT. In conclusion, PLT is a serious infectious complication of LT, associated with significant intra-abdominal pathology and reduced recipient and graft survival.

Spontaneous bacterial peritonitis: a therapeutic update

Spontaneous bacterial peritonitis (SBP) is one of the main infectious complications of cirrhosis and occurs in 8-30% of hospitalized patients with ascites. SBP is characterized by infection of the ascitic fluid (AF) in the absence of any primary focus of intra-abdominal infection. The main route by which the AF becomes infected is the hematogenous route. The pathogenic mechanism by which infection develops is bacterial translocation from the intestinal flora to the mesenteric lymph nodes and from there to the bloodstream. Contributing factors are an increased growth of Gram-negative aerobic bacilli in the jejunum, changes in the intestinal barrier and in addition factors which could reduce the local flow of blood. For clinical diagnosis, patients with SBP may present signs of peritoneal irritation and pain, together with changes in gastrointestinal motility, sometimes with nausea, vomiting, diarrhea or ileus. Many patients, however, may not present any symptoms or signs as a result of the presence of SBP. Diagnostic paracentesis of the AF must be performed for every patient with cirrhosis, hospitalized with ascites. Laboratory diagnosis of SBP is carried out by polymorphonuclear count in the AF, together with a positive culture from the AF, which is characteristically monomicrobial. Escherichia coli has been the main bacterium isolated from AF as well as other Gram-negative bacteria from the Enterobacteriaceae family and Streptococcus genus. A more rapid diagnosis of SBP can be obtained via the use of leukocyte esterase, which is present in biological fluids and reacts with a component of the dipstick, changing its color. During the acute phase of SBP, antibiotics should be initiated promptly once the clinical and laboratory diagnosis of SBP has been made, before the result of AF culture. Cefotaxime or other third-generation cephalosporins have been considered the first-choice empirical antibiotics in the treatment of cirrhotic patients with SBP, and is efficacious in approximately 90% of cases. Broad-spectrum quinolones, which are almost completely absorbed after oral administration and diffuse rapidly through the AF, are currently used for oral treatment of uncomplicated SBP. Patients who have already had a previous episode of SBP, with a 69% probability of recurrence within a year, will benefit from prophylactic treatment. Cirrhotic patients with a high risk of SBP and other infections, such as those with gastrointestinal bleeding, also benefit from primary prophylaxis and norfloxacin has been used with success.

Portal hypertension

PURPOSE OF REVIEW

Report on significant advances in the pathophysiology, diagnosis, and management of the complications of portal hypertension that have occurred in the last year.

RECENT FINDINGS

The specific areas reviewed refer to experimental studies aimed at modifying the factors that lead to portal hypertension (increased intrahepatic vascular resistance and splanchnic vasodilatation) and recent advances in the diagnosis and management of the complications of portal hypertension. The specific complications reviewed in this paper are varices and variceal bleeding (primary prophylaxis, treatment of the acute episode, and secondary prophylaxis), ascites and some of its complications (hyponatremia, hepatic hydrothorax), hepatorenal syndrome, spontaneous bacterial peritonitis, and hepatic encephalopathy.

SUMMARY

Important studies, mostly prospective, regarding the management of the complications of portal hypertension are reviewed, including trials that demonstrate the value of the hepatic venous pressure gradient in predicting these complications, a trial of beta-blockers in patients with small varices, a randomized trial of transjugular intrahepatic portosystemic shunt using covered stents and another pilot study using this shunt in the treatment of hepatorenal syndrome, a trial of antibiotic prophylaxis in preventing early variceal rebleeding, and a trial of synbiotic therapy in hepatic encephalopathy. These trials will contribute to advancing the practice of hepatology and defining future research areas.