1
|
Response-Guided Therapy With Cefotaxime, Ceftriaxone, or Ciprofloxacin for Spontaneous Bacterial Peritonitis: A Randomized Trial: A Validation Study of 2021 AASLD Practice Guidance for SBP. Am J Gastroenterol 2023; 118:654-663. [PMID: 36594820 DOI: 10.14309/ajg.0000000000002126] [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] [Received: 07/27/2022] [Accepted: 11/11/2022] [Indexed: 01/04/2023]
Abstract
INTRODUCTION For the treatment of spontaneous bacterial peritonitis (SBP), cefotaxime, ceftriaxone, and ciprofloxacin were used as first-line agents. However, considering the increasing rate of antibiotic resistance, it is unclear which of these drugs can be initially recommended. This study aimed to compare the current efficacy of the 3 antibiotics, namely cefotaxime, ceftriaxone, and ciprofloxacin, for the treatment of SBP in patients with cirrhosis with ascites, when guided by therapeutic responses. METHODS This study was a multicenter, prospective, randomized controlled trial. The inclusion criteria were 16- to 75-year-old patients with liver cirrhosis with ascites, having polymorphonuclear cell count of >250/mm 3 . We performed a follow-up paracentesis at 48 hours to decide continuing or changing the assigned antibiotics and then assessed the resolution rates at 120 and 168 hours of treatment. RESULTS A total of 261 patients with cirrhosis who developed SBP were enrolled. Most of the patients were diagnosed as those with SBP within 48 hours of admission. The resolution rates at 120 hours, which is the primary endpoint, were 67.8%, 77.0%, and 73.6% in the cefotaxime, ceftriaxone, and ciprofloxacin groups, respectively ( P = 0.388), by intension-to-treat analysis. The 1-month mortality was similar among the groups ( P = 0.770). The model for end-stage liver disease score and the SBP resolution were significant factors for survival. CONCLUSION The efficacy of empirical antibiotics, such as cefotaxime, ceftriaxone, and ciprofloxacin, against SBP was not significantly different. In addition, these antibiotics administered based on response-guided therapy were still efficacious as initial treatment for SBP, especially in those with community-acquired infections.
Collapse
|
2
|
Zoratti C, Moretti R, Rebuzzi L, Albergati IV, Di Somma A, Decorti G, Di Bella S, Crocè LS, Giuffrè M. Antibiotics and Liver Cirrhosis: What the Physicians Need to Know. Antibiotics (Basel) 2021; 11:31. [PMID: 35052907 PMCID: PMC8772826 DOI: 10.3390/antibiotics11010031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 12/23/2021] [Accepted: 12/24/2021] [Indexed: 12/13/2022] Open
Abstract
The liver is the primary site of drug metabolism, which can be altered by a variety of diseases affecting the liver parenchyma, especially in patients with liver cirrhosis. The use of antibiotics in patients with cirrhosis is usually a matter of concern for physicians, given the lack of practical knowledge for drug choice and eventual dose adjustments in several clinical scenarios. The aim of the current narrative review is to report, as broadly as possible, basic, and practical knowledge that any physician should have when approaching a patient with liver cirrhosis and an ongoing infection to efficiently choose the best antibiotic therapy.
Collapse
Affiliation(s)
- Caterina Zoratti
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy; (C.Z.); (R.M.); (L.R.); (I.V.A.); (A.D.S.); (S.D.B.); (L.S.C.)
| | - Rita Moretti
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy; (C.Z.); (R.M.); (L.R.); (I.V.A.); (A.D.S.); (S.D.B.); (L.S.C.)
| | - Lisa Rebuzzi
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy; (C.Z.); (R.M.); (L.R.); (I.V.A.); (A.D.S.); (S.D.B.); (L.S.C.)
| | - Irma Valeria Albergati
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy; (C.Z.); (R.M.); (L.R.); (I.V.A.); (A.D.S.); (S.D.B.); (L.S.C.)
| | - Antonietta Di Somma
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy; (C.Z.); (R.M.); (L.R.); (I.V.A.); (A.D.S.); (S.D.B.); (L.S.C.)
| | - Giuliana Decorti
- Institute for Maternal and Child Health-IRCCS Burlo Garofolo, 34137 Trieste, Italy;
| | - Stefano Di Bella
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy; (C.Z.); (R.M.); (L.R.); (I.V.A.); (A.D.S.); (S.D.B.); (L.S.C.)
| | - Lory Saveria Crocè
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy; (C.Z.); (R.M.); (L.R.); (I.V.A.); (A.D.S.); (S.D.B.); (L.S.C.)
- Italian Liver Foundation, 34149 Trieste, Italy
| | - Mauro Giuffrè
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy; (C.Z.); (R.M.); (L.R.); (I.V.A.); (A.D.S.); (S.D.B.); (L.S.C.)
- Italian Liver Foundation, 34149 Trieste, Italy
| |
Collapse
|
3
|
Pörner D, Von Vietinghoff S, Nattermann J, Strassburg CP, Lutz P. Advances in the pharmacological management of bacterial peritonitis. Expert Opin Pharmacother 2021; 22:1567-1578. [PMID: 33878993 DOI: 10.1080/14656566.2021.1915288] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Bacterial peritonitis is an infection with high mortality if not treated immediately. In the absence of an intraabdominal source of infection, bacterial peritonitis may arise in patients with liver cirrhosis, in patients on peritoneal dialysis (PD) for end-stage renal disease or in patients with tuberculosis. In patients with cirrhosis, bacterial peritonitis may trigger acute on chronic liver failure with substantial mortality despite optimal treatment. In patients on PD, peritonitis may make continuation of PD impossible, necessitating the switch to hemodialysis.Areas covered: Recovery from peritonitis and prevention of complications depend on timely pharmacological management. Challenges are the broad microbiological spectrum with growing rates of antimicrobial resistance, the underlying chronic liver or kidney failure and high rates of relapse. The authors provide a review of predisposing conditions, diagnosis, and prevention of bacterial peritonitis with a particular focus on the pharmacological management.Expert opinion: Diagnosis of the type of bacterial peritonitis is essential to pharmacological management. In patients with spontaneous bacterial peritonitis, broad-spectrum antibiotics should be given intravenously in conjunction with albumin. In patients on PD, antibiotic therapy should be preferably applied intraperitoneally with empirical coverage of gram-positive and gram-negative bacteria. Secondary peritonitis usually requires surgical or interventional treatment.
Collapse
Affiliation(s)
- Daniel Pörner
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, Bonn, Germany
| | - Sibylle Von Vietinghoff
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, Bonn, Germany
| | - Jacob Nattermann
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, Bonn, Germany
- German Center for Infection Research (DZIF), University Hospital Bonn, Venusberg-Campus 1, Bonn, Germany
| | - Christian P Strassburg
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, Bonn, Germany
- German Center for Infection Research (DZIF), University Hospital Bonn, Venusberg-Campus 1, Bonn, Germany
| | - Philipp Lutz
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, Bonn, Germany
- German Center for Infection Research (DZIF), University Hospital Bonn, Venusberg-Campus 1, Bonn, Germany
| |
Collapse
|
4
|
ASSESSMENT OF THE FREQUENCY AND RATIONALITY OF PRESCRIBED MEDICINES IN PATIENTS WITH LIVER CIRRHOSIS. EUREKA: HEALTH SCIENCES 2021. [DOI: 10.21303/2504-5679.2021.001599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The aim. Assessment of the dynamics of prescribing drugs to patients with liver cirrhosis (LC, K 74), in terms of real clinical practice by methods of clinical and economic analysis.
Materials and methods. 355 medical cards of inpatients with cirrhosis of the liver, which were divided into 4 groups depending on the period of stay of patients in the hospital. Methods: compatible retrospective ABC-frequency analysis, which ranked drugs consumed by patients in real clinical practice, according to the frequency of appointment using ABC-segmentation according to the Pareto principle (A – 80 % of drugs appointments: B – 15 %: C – 5 %); VEN-analysis, which divides the consumed drugs on a formal basis depending on the presence / absence of a particular drug in the regulations: vital (Vital or V), necessary (Essential or E) and secondary (Non-essential or N).
Results. Cirrhosis of the liver in recent years has been on the 10th - 11th place among the causes of death in the world. The analysis of prescribed drugs to patients with LC in real clinical practice in Ivano-Frankivsk region of Ukraine revealed that over the years doctors prescribed fewer drugs on average per patient (11.4 drugs → 8.8 drugs), which can be considered a positive fact. Among the prescribed drugs, drugs of group A – “Drugs that affect the digestive system and metabolism” prevailed, the share of which increased and was the highest in 2019 – 2020 (2007–2009 – 44.6 %; 2012–2013 – 46.6 %; 2015–2016 – 48.1 %; 2019–2020 – 48.55 %); the share of dietary supplements also increased from 1.65 % to 6.52 %.
Conclusions. Combined ABC-frequency and VEN-analyzes showed that the leaders in the years of hospital stay were the following drugs: Sodium chloride, Ademetionine, Pantoprazole, Spironolactone, Thioctic acid, Ornithine, Asparaginate K-Mg, Torasemide, Furosemide. However, the vital class V included only 9–11 % of drugs from the whole set of prescribed drugs, which requires systemic correction in accordance with European recommendations.
Collapse
|
5
|
Liu J, Gao Y, Wang X, Qian Z, Chen J, Huang Y, Meng Z, Lu X, Deng G, Liu F, Zhang Z, Li H, Zheng X. Culture-Positive Spontaneous Ascitic Infection in Patients with Acute Decompensated Cirrhosis: Multidrug-Resistant Pathogens and Antibiotic Strategies. Yonsei Med J 2020; 61:145-153. [PMID: 31997623 PMCID: PMC6992456 DOI: 10.3349/ymj.2020.61.2.145] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 12/13/2019] [Accepted: 12/16/2019] [Indexed: 12/15/2022] Open
Abstract
PURPOSE This study investigated multidrug-resistant (MDR) pathogens and antibiotic strategies of culture-positive spontaneous ascitic infection (SAI) in patients with acute decompensated cirrhosis. MATERIALS AND METHODS We retrospectively analyzed 432 acute decompensated cirrhotic patients with culture-positive SAI from 11 teaching hospitals in China (January 2012 to May 2018). A Cox proportional hazards model analysis was conducted to identify independent predictors of 28-day mortality. RESULTS A total of 455 strains were isolated from 432 ascitic culture samples. Gram-negative bacteria (GNB), gram-positive bacteria (GPB), and fungi caused 52.3, 45.5, and 2.2% of all SAI episodes, respectively. Episodes were classified as nosocomial (41.2%), healthcare-related (34.7%), and community-acquired (24.1%). Escherichia coli (13.4%) and Klebsiella pneumoniae (2.4%) were extended-spectrum β-lactamase producing isolates. The prevalence of methicillin-resistant Staphylococcus aureus was 1.1%. Ceftazidime, cefepime, aztreonam, and amikacin were recommended as first-line antibiotics agents for non-MDR GNB infections; piperacillin/tazobactam and carbapenems for MDR GNB in community-acquired and healthcare-related or nosocomial infections, respectively; and vancomycin or linezolid for GPB infections, regardless of drug-resistance status. Multivariate analysis revealed days of hospital stay before SAI, upper gastrointestinal bleeding, white blood cell count, alanine aminotransferase, serum creatinine concentration, total bilirubin, and international normalized ratio as key independent predictors of 28-day mortality. CONCLUSION MDR pathogens and antibiotic strategies were identified in patients with acute decompensated cirrhosis with culture-positive SAI, which may help optimize therapy and improve clinical outcomes.
Collapse
Affiliation(s)
- Jing Liu
- Department of Infectious Diseases, Institute of Infection and Immunology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Chinese Acute-on-Chronic Liver Failure Consortium, CATCH-LIFE, Shanghai, China
| | - Yanhang Gao
- Chinese Acute-on-Chronic Liver Failure Consortium, CATCH-LIFE, Shanghai, China
- Department of Hepatology, The First Hospital of Jilin University, Changchun, China
| | - Xianbo Wang
- Chinese Acute-on-Chronic Liver Failure Consortium, CATCH-LIFE, Shanghai, China
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Zhiping Qian
- Chinese Acute-on-Chronic Liver Failure Consortium, CATCH-LIFE, Shanghai, China
- Department of Liver Intensive Care Unit, Shanghai Public Health Clinical Centre, Fudan University, Shanghai, China
| | - Jinjun Chen
- Chinese Acute-on-Chronic Liver Failure Consortium, CATCH-LIFE, Shanghai, China
- Hepatology Unit, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yan Huang
- Chinese Acute-on-Chronic Liver Failure Consortium, CATCH-LIFE, Shanghai, China
- Department of Infectious Disease, Hunan Key Laboratory of Viral Hepatitis, Xiangya Hospital, Central South University, Changsha, China
| | - Zhongji Meng
- Chinese Acute-on-Chronic Liver Failure Consortium, CATCH-LIFE, Shanghai, China
- Department of Infectious Disease, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Xiaobo Lu
- Chinese Acute-on-Chronic Liver Failure Consortium, CATCH-LIFE, Shanghai, China
- Liver Disease Center, First Affiliated Hospital of Xinjiang Medical University, Urumuqi, China
| | - Guohong Deng
- Chinese Acute-on-Chronic Liver Failure Consortium, CATCH-LIFE, Shanghai, China
- Department of Infectious Diseases, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Feng Liu
- Chinese Acute-on-Chronic Liver Failure Consortium, CATCH-LIFE, Shanghai, China
- Department of Infectious Diseases and Hepatology, The Second Hospital of Shandong University, Jinan, China
| | - Zhiguo Zhang
- School of Medicine and Health Management, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Hai Li
- Chinese Acute-on-Chronic Liver Failure Consortium, CATCH-LIFE, Shanghai, China
- Department of Gastroenterology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xin Zheng
- Department of Infectious Diseases, Institute of Infection and Immunology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Chinese Acute-on-Chronic Liver Failure Consortium, CATCH-LIFE, Shanghai, China.
| |
Collapse
|
6
|
Iogna Prat L, Wilson P, Freeman SC, Sutton AJ, Cooper NJ, Roccarina D, Benmassaoud A, Plaz Torres MC, Hawkins N, Cowlin M, Milne EJ, Thorburn D, Pavlov CS, Davidson BR, Tsochatzis E, Gurusamy KS. Antibiotic treatment for spontaneous bacterial peritonitis in people with decompensated liver cirrhosis: a network meta-analysis. Cochrane Database Syst Rev 2019; 9:CD013120. [PMID: 31524949 PMCID: PMC6746213 DOI: 10.1002/14651858.cd013120.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Approximately 2.5% of all hospitalisations in people with cirrhosis are for spontaneous bacterial peritonitis (SBP). Antibiotics, in addition to supportive treatment (fluid and electrolyte balance, treatment of shock), form the mainstay treatments of SBP. Various antibiotics are available for the treatment of SBP, but there is uncertainty regarding the best antibiotic for SBP. OBJECTIVES To compare the benefits and harms of different antibiotic treatments for spontaneous bacterial peritonitis (SBP) in people with decompensated liver cirrhosis. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trials registers until November 2018 to identify randomised clinical trials on people with cirrhosis and SBP. SELECTION CRITERIA We included only randomised clinical trials (irrespective of language, blinding, or publication status) in adults with cirrhosis and SBP. We excluded randomised clinical trials in which participants had previously undergone liver transplantation. DATA COLLECTION AND ANALYSIS Two review authors independently identified eligible trials and collected data. The outcomes for this review included mortality, serious adverse events, any adverse events, resolution of SBP, liver transplantation, and other decompensation events. We performed a network meta-analysis with OpenBUGS using Bayesian methods and calculated the odds ratio, rate ratio, and hazard ratio with 95% credible intervals (CrIs) based on an available-case analysis, according to the National Institute of Health and Care Excellence (NICE) Decision Support Unit guidance. MAIN RESULTS We included a total of 12 trials (1278 participants; 13 antibiotics) in the review. Ten trials (893 participants) were included in one or more outcomes in the review. The trials that provided the information included patients having cirrhosis with or without other features of decompensation of varied aetiologies. The follow-up in the trials ranged from one week to three months. All the trials were at high risk of bias. Only one trial was included under each comparison for most of the outcomes. Because of these reasons, there is very low certainty in all the results. The majority of the randomised clinical trials used third-generation cephalosporins, such as intravenous ceftriaxone, cefotaxime, or ciprofloxacin as one of the interventions.Overall, approximately 75% of trial participants recovered from SBP and 25% of people died within three months. There was no evidence of difference in any of the outcomes for which network meta-analysis was possible: mortality (9 trials; 653 participants), proportion of people with any adverse events (5 trials; 297 participants), resolution of SBP (as per standard definition, 9 trials; 873 participants), or other features of decompensation (6 trials; 535 participants). The effect estimates in the direct comparisons (when available) were very similar to those of network meta-analysis. For the comparisons where network meta-analysis was not possible, there was no evidence of difference in any of the outcomes (proportion of participants with serious adverse events, number of adverse events, and proportion of participants requiring liver transplantation). Due to the wide CrIs and the very low-certainty evidence for all the outcomes, significant benefits or harms of antibiotics are possible.None of the trials reported health-related quality of life, number of serious adverse events, or symptomatic recovery from SBP. FUNDING the source of funding for two trials were industrial organisations who would benefit from the results of the trial; the source of funding for the remaining 10 trials was unclear. AUTHORS' CONCLUSIONS Short-term mortality after SBP is about 25%. There is significant uncertainty about which antibiotic therapy is better in people with SBP.We need adequately powered randomised clinical trials, with adequate blinding, avoiding post-randomisation dropouts (or performing intention-to-treat analysis), and using clinically important outcomes, such as mortality, health-related quality of life, and adverse events.
Collapse
Affiliation(s)
- Laura Iogna Prat
- Royal Free Hospital and the UCL Institute of Liver and Digestive HealthSheila Sherlock Liver CentreLondonUK
| | - Peter Wilson
- University College London Hospitals NHS Foundation TrustClinical Microbiology and Virology5th Floor Central250 Euston RoadLondonUKNW1 2PG
| | - Suzanne C Freeman
- University of LeicesterDepartment of Health SciencesUniversity RoadLeicesterUKLE1 7RH
| | - Alex J Sutton
- University of LeicesterDepartment of Health SciencesUniversity RoadLeicesterUKLE1 7RH
| | - Nicola J Cooper
- University of LeicesterDepartment of Health SciencesUniversity RoadLeicesterUKLE1 7RH
| | - Davide Roccarina
- Royal Free Hospital and the UCL Institute of Liver and Digestive HealthSheila Sherlock Liver CentreLondonUK
| | - Amine Benmassaoud
- Royal Free Hospital and the UCL Institute of Liver and Digestive HealthSheila Sherlock Liver CentreLondonUK
| | | | - Neil Hawkins
- University of GlasgowHEHTAUniversity Ave Glasgow G12 8QQGlasgowUK
| | | | | | - Douglas Thorburn
- Royal Free Hospital and the UCL Institute of Liver and Digestive HealthSheila Sherlock Liver CentreLondonUK
| | - Chavdar S Pavlov
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalCochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
- 'Sechenov' First Moscow State Medical UniversityCenter for Evidence‐Based MedicinePogodinskja st. 1\1MoscowRussian Federation119881
| | - Brian R Davidson
- University College LondonDivision of Surgery and Interventional ScienceLondonUKNW3 2QG
| | - Emmanuel Tsochatzis
- Royal Free Hospital and the UCL Institute of Liver and Digestive HealthSheila Sherlock Liver CentreLondonUK
| | - Kurinchi Selvan Gurusamy
- 'Sechenov' First Moscow State Medical UniversityCenter for Evidence‐Based MedicinePogodinskja st. 1\1MoscowRussian Federation119881
- University College LondonDivision of Surgery and Interventional ScienceLondonUKNW3 2QG
| | | |
Collapse
|
7
|
Fiore M, Di Franco S, Alfieri A, Passavanti MB, Pace MC, Kelly ME, Damiani G, Leone S. Spontaneous bacterial peritonitis caused by Gram-negative bacteria: an update of epidemiology and antimicrobial treatments. Expert Rev Gastroenterol Hepatol 2019; 13:683-692. [PMID: 31107612 DOI: 10.1080/17474124.2019.1621167] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction: Spontaneous bacterial peritonitis (SBP) is a main infectious complication in end-stage liver disease (ESLD) patients. The increasing trend of bacterial resistance in ESLD patients with SBP has been associated with low treatment efficacy of traditional therapy. Cephalosporin use has been restricted to community-acquired infections and in areas/health care settings with low rates of multidrug-resistant (MDR) bacteria. To date, several changes are necessary with regard to empiric therapy recommendations in areas/health care settings with high rates of MDR bacteria. Areas covered: An overview of the epidemiology and antimicrobial treatments of SBP caused by Gram-negative bacteria. Expert opinion: Broad-spectrum antibiotics have been recommended as empiric therapy for suspected SBP in areas/health care settings with high rates of MDR bacteria and secondary treatment, with newer antibiotics, for SBP caused by MDR-Gram-negative bacteria (i.e. new beta-lactam/beta-lactamase inhibitor combinations, cefiderocol, plazomicin, and eravacycline) either alone or in combination.
Collapse
Affiliation(s)
- Marco Fiore
- a Department of Women , Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli" , Naples , Italy
| | - Sveva Di Franco
- a Department of Women , Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli" , Naples , Italy
| | - Aniello Alfieri
- a Department of Women , Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli" , Naples , Italy
| | - Maria Beatrice Passavanti
- a Department of Women , Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli" , Naples , Italy
| | - Maria Caterina Pace
- a Department of Women , Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli" , Naples , Italy
| | - Molly E Kelly
- b Case Western Reserve University School of Medicine , Cleveland , OH , USA
| | - Giovanni Damiani
- c Department of Pathophysiology and Transplantation , University of Milan , Italy
| | - Sebastiano Leone
- d Division of Infectious Diseases , "San Giuseppe Moscati" Hospital , Avellino , Italy
| |
Collapse
|
8
|
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.
Collapse
Affiliation(s)
- Do Seon Song
- Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| |
Collapse
|
9
|
Maraolo AE, Buonomo AR, Zappulo E, Scotto R, Pinchera B, Gentile I. Unsolved Issues in the Treatment of Spontaneous Peritonitis in Patients with Cirrhosis: Nosocomial Versus Community-acquired Infections and the Role of Fungi. Rev Recent Clin Trials 2019; 14:129-135. [PMID: 30514194 DOI: 10.2174/1574887114666181204102516] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 11/26/2018] [Accepted: 11/27/2018] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Historically, spontaneous bacterial peritonitis (SBP) has represented one of the most frequent and relevant infectious complications of advanced liver disease, and this is still valid today. Nevertheless, in recent years the role of fungi as causative pathogens of primary peritonitis in patients with cirrhosis has become not negligible. Another issue is linked with the traditional distinction, instrumental in therapeutic choice, between community-acquired and nosocomial forms, according to the onset. Between these two categories, another one has been introduced: the so-called "healthcare-associated infections". OBJECTIVE To discuss the most controversial aspects in the management of SBP nowadays in the light of best available evidence. METHODS A review of recent literature through MEDLINE was performed. RESULTS The difference between community-acquired and nosocomial infections is crucial to guide empiric antibiotic therapy, since the site of acquisition impact on the likelihood of multidrug-resistant bacteria as causative agents. Therefore, third-generation cephalosporins cannot be considered the mainstay of treatment in each episode. Furthermore, the distinction between healthcare-associated and nosocomial form seems very subtle, especially in areas wherein antimicrobial resistance is widespread, warranting broad-spectrum antibiotic regimens for both. Finally, spontaneous fungal peritonitis is a not common but actually underestimated entity, linked to high mortality. Especially in patients with septic shock and/or failure of an aggressive antibiotic regimen, the empiric addition of an antifungal agent might be considered. CONCLUSION Spontaneous bacterial peritonitis is one of the most important complications in patients with cirrhosis. A proper empiric therapy is crucial to have a positive outcome. In this respect, a careful assessment of risk factors for multidrug-resistant pathogens is crucial. Likewise important, mostly in nosocomial cases, is not to overlook the probability of a fungal ascitic infection, namely a spontaneous fungal peritonitis.
Collapse
Affiliation(s)
- Alberto Enrico Maraolo
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, 80131, Naples, Italy
| | - Antonio Riccardo Buonomo
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, 80131, Naples, Italy
| | - Emanuela Zappulo
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, 80131, Naples, Italy
| | - Riccardo Scotto
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, 80131, Naples, Italy
| | - Biagio Pinchera
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, 80131, Naples, Italy
| | - Ivan Gentile
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, 80131, Naples, Italy
| |
Collapse
|
10
|
KASL clinical practice guidelines for liver cirrhosis: Ascites and related complications. Clin Mol Hepatol 2018; 24:230-277. [PMID: 29991196 PMCID: PMC6166105 DOI: 10.3350/cmh.2018.1005] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 04/06/2018] [Indexed: 02/07/2023] Open
|
11
|
Maraolo AE, Gentile I, Pinchera B, Nappa S, Borgia G. Current and emerging pharmacotherapy for the treatment of bacterial peritonitis. Expert Opin Pharmacother 2018; 19:1317-1325. [PMID: 30071176 DOI: 10.1080/14656566.2018.1505867] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Spontaneous bacterial peritonitis (SBP) is the quintessential model of bacterial infection in cirrhotic patients. In these particularly frail subjects, infections clearly worsen prognosis increasing substantially mortality. Furthermore, treatment of SBP has become more challenging because of the growing impact of multidrug-resistant (MDR) bacteria. AREAS COVERED This review addresses the reasons behind the change in therapeutic recommendations for SBP that have occurred in the past few years, by focusing on the following aspects: the importance of an early appropriate empirical treatment, the difference between nosocomial and non-nosocomial forms and the overall microbiological shift (rise of Gram-positive bacteria and MDR strains) that have affected SBP. EXPERT OPINION Until recently, third-generation cephalosporins have represented the cornerstone of SBP treatment, a safe choice covering the most important causative agents, namely Enterobacteriaceae. Unfortunately, massive exposure to health systems makes cirrhotic patients prone to MDR infections, which poses significant challenges, all the while not forgetting to strike a balance between effective antimicrobial activity and the risk of toxicity in these fragile subjects. Moreover, there is sparse information about new antibiotics in cirrhotic patients and about drugs levels in ascitic fluid. Therefore, further research is needed to optimize the treatment of SBP.
Collapse
Affiliation(s)
- Alberto Enrico Maraolo
- a Department of Clinical Medicine and Surgery, Section of Infectious Diseases , University of Naples Federico II , Naples , Italy
| | - Ivan Gentile
- a Department of Clinical Medicine and Surgery, Section of Infectious Diseases , University of Naples Federico II , Naples , Italy
| | - Biagio Pinchera
- a Department of Clinical Medicine and Surgery, Section of Infectious Diseases , University of Naples Federico II , Naples , Italy
| | - Salvatore Nappa
- a Department of Clinical Medicine and Surgery, Section of Infectious Diseases , University of Naples Federico II , Naples , Italy
| | - Guglielmo Borgia
- a Department of Clinical Medicine and Surgery, Section of Infectious Diseases , University of Naples Federico II , Naples , Italy
| |
Collapse
|
12
|
EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol 2018; 69:406-460. [PMID: 29653741 DOI: 10.1016/j.jhep.2018.03.024] [Citation(s) in RCA: 1549] [Impact Index Per Article: 258.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 03/28/2018] [Indexed: 02/06/2023]
|
13
|
Ning NZ, Li T, Zhang JL, Qu F, Huang J, Liu X, Li Z, Geng W, Fu JL, Huan W, Zhang SY, Bao CM, Wang H. Clinical and bacteriological features and prognosis of ascitic fluid infection in Chinese patients with cirrhosis. BMC Infect Dis 2018; 18:253. [PMID: 29866104 PMCID: PMC5987451 DOI: 10.1186/s12879-018-3101-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 04/17/2018] [Indexed: 12/13/2022] Open
Abstract
Background Spontaneous bacterial peritonitis (SBP) and bacterascites (BA) represent frequent and serious complications in cirrhosis patients with ascites. However, few detailed data are available regarding the clinical and bacteriological feature of SBP or BA patients in China. Methods We retrospectively analyzed bacteriological and clinical characteristics of patients with SBP and BA at Beijing 302 Hospital in China from January 2012 to December 2015. Results A total of 600 patients with SBP (n = 408) or BA (n = 192) were enrolled. Patients with BA appeared to have a less severe clinical manifestation and lower mortality rate than patients with SBP. Gram-negative bacteria formed the majority of pathogens in SBP (73.9%) and BA (55.8%) cases. Higher ascitic fluid polymorphonuclear leucocytes (PMN) count and hepatocellular carcinoma were independent risk factors for BA episode progressing to SBP. The concentration of blood urea nitrogen (BUN) was independent risk factor for 30-day mortality of BA patients. For patients with SBP, the independent risk factors for 30-day mortality were age, Model for End-Stage Liver Disease (MELD) score, septic shock and hepatocellular carcinoma. Patients with third-generation cephalosporin or carbapenems resistant infection had a significantly lower survival probability. There were significant differences in clinical characteristics and outcome among the major bacteria. Multivariate analysis showed that patients infected with Klebsiella spp. had higher hazard ratio of 30-day mortality. Conclusion Our study reported the bacteriological and clinical characteristics of patients with SBP and BA. Higher ascitic fluid PMN count and hepatocellular carcinoma were found to be independent risk factors for BA episode progressed to SBP. Outcome of ascitic fluid infection in patients with cirrhosis was influenced by the type of bacteria and antimicrobial susceptibility. Electronic supplementary material The online version of this article (10.1186/s12879-018-3101-1) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Nian-Zhi Ning
- The State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, No.20 Dongda Street, Fengtai District, Beijing, 100071, China
| | - Tao Li
- The State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, No.20 Dongda Street, Fengtai District, Beijing, 100071, China
| | - Ju-Ling Zhang
- Clinical Diagnostic Center, Beijing 302 Hospital, No. 100 Western 4th Middle Ring Road, Beijing, 100039, China
| | - Fen Qu
- Clinical Diagnostic Center, Beijing 302 Hospital, No. 100 Western 4th Middle Ring Road, Beijing, 100039, China
| | - Jie Huang
- The State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, No.20 Dongda Street, Fengtai District, Beijing, 100071, China
| | - Xiong Liu
- The State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, No.20 Dongda Street, Fengtai District, Beijing, 100071, China
| | - Zhan Li
- The State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, No.20 Dongda Street, Fengtai District, Beijing, 100071, China
| | - Wei Geng
- Clinical Diagnostic Center, Beijing 302 Hospital, No. 100 Western 4th Middle Ring Road, Beijing, 100039, China
| | - Jun-Liang Fu
- Research Center for Biological Therapy, Institute of Translational Hepatology, Beijing 302 Hospital, Beijing, 100039, China
| | - Wang Huan
- Clinical Diagnostic Center, Beijing 302 Hospital, No. 100 Western 4th Middle Ring Road, Beijing, 100039, China
| | - Shu-Yong Zhang
- Clinical Diagnostic Center, Beijing 302 Hospital, No. 100 Western 4th Middle Ring Road, Beijing, 100039, China
| | - Chun-Mei Bao
- Clinical Diagnostic Center, Beijing 302 Hospital, No. 100 Western 4th Middle Ring Road, Beijing, 100039, China.
| | - Hui Wang
- The State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, No.20 Dongda Street, Fengtai District, Beijing, 100071, China.
| |
Collapse
|
14
|
The emergency medicine evaluation and management of the patient with cirrhosis. Am J Emerg Med 2018; 36:689-698. [DOI: 10.1016/j.ajem.2017.12.047] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 12/21/2017] [Accepted: 12/22/2017] [Indexed: 12/12/2022] Open
|
15
|
Are third-generation cephalosporins still the empirical antibiotic treatment of community-acquired spontaneous bacterial peritonitis? A systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2018; 30:329-336. [PMID: 29303883 DOI: 10.1097/meg.0000000000001057] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Spontaneous bacterial peritonitis (SBP) is a common complication among cirrhotic patients. Guidelines recommend third-generation cephalosporins (3GCs) as empiric antibiotic therapy (EAT) of SBP. Recently, a broad-spectrum EAT was shown to be more effective than cephalosporins in the treatment of nosocomial spontaneous bacterial peritonitis (N-SBP); however, the prevalence of 3GCs-resistant bacteria is high in the nosocomial setting and broad-spectrum EAT cannot be used in all cases of SBP. AIM The aim of this study was to evaluate the 3GCs resistance distribution between N-SBP and community-acquired spontaneous bacterial peritonitis (CA-SBP) to clarify whether 3GCs are still an effective therapeutic intervention for CA-SBP. METHODS We searched for studies that reported the aetiology of SBP and the resistance profile of both gram-positive and gram-negative bacteria in MEDLINE and Google Scholar databases (since 1 January 2000 to 30 April 2017). A meta-analysis was carried out to estimate the risk difference [relative risk (RR) and 95% confidence intervals (CIs)] for 3GCs resistance in N-SBP and CA-SBP. Heterogeneity was assessed using the I-test. RESULTS A total of eight studies were included, including 1074 positive cultures of ascitic fluid in cirrhotic patients; 462 positive cultures were from N-SBP and, among these, 251 (54.3%) were 3GCs resistant. Six hundred and twelve positive cultures were from CA-SBP and, among these, 207 (33.8%) were 3GCs-resistant SBP. A pooled RR of 3GCs resistance in N-SBP compared with CA-SBP showed a significant difference (RR=1.67, 95% CI: 1.14-2.44; P=0.008). We carried out two subgroup analyses: the first according to the median year of study observation (before vs. since 2008) and the second according to the country of the study (China vs. others). The studies carried out before 2008 (327 SBP-positive culture) showed a significantly higher risk for 3GCs-resistant strains in N-SBP compared with CA-SBP (RR=2.36, 95% CI: 1.39-3.99; P=0.001), whereas this was not found in SBP acquired after 2008 (RR=1.24, 95% CI: 0.83-1.84; P=0.29). N-SBP occurring in China had no significantly higher risk for 3GCs-resistant strains compared with CA-SBP (RR=1.44, 95% CI: 0.87-2.37; P=0.16). CONCLUSION Our findings suggest that although the pooled RR of 3GCs resistance in N-SBP compared with CA-SBP show that 3GCs are still an effective option for the treatment of CA-SBP, the subanalysis of studies that enroled patients in the last decade did not show a significant higher RR of 3GCs resistance in N-SBP compared with CA-SBP. Therefore, in centres where local patterns of antimicrobial susceptibility (with low rates of 3GCs resistance) are not available, 3GCs should not be used initially for CA-SBP treatment. Future studies are needed to confirm this trend of 3GCs resistance.
Collapse
|
16
|
Piano S, Tonon M, Angeli P. Management of ascites and hepatorenal syndrome. Hepatol Int 2017; 12:122-134. [DOI: 10.1007/s12072-017-9815-0] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 07/27/2017] [Indexed: 12/11/2022]
|
17
|
Gómez-Hurtado I, Such J, Francés R. Microbiome and bacterial translocation in cirrhosis. GASTROENTEROLOGIA Y HEPATOLOGIA 2016; 39:687-696. [PMID: 26775042 DOI: 10.1016/j.gastrohep.2015.10.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 10/20/2015] [Accepted: 10/22/2015] [Indexed: 02/06/2023]
Abstract
Qualitative and quantitative changes in gut microbiota play a very important role in cirrhosis. Humans harbour around 100 quintillion gut bacteria, thus representing around 10 times more microbial cells than eukaryotic ones. The gastrointestinal tract is the largest surface area in the body and it is subject to constant exposure to these living microorganisms. The existing symbiosis, proven by the lack of proinflammatory response against commensal bacteria, implies the presence of clearly defined communication lines that contribute to the maintenance of homeostasis of the host. Therefore, alterations of gut flora seem to play a role in the pathogenesis and progress of multiple liver and gastrointestinal diseases. This has made its selective modification into an area of high therapeutic interest. Bacterial translocation is defined as the migration of bacteria or bacterial products from the intestines to the mesenteric lymph nodes. It follows that alteration in gut microbiota have shown importance, at least to some extent, in the pathogenesis of several complications arising from terminal liver disease, such as hepatic encephalopathy, portal hypertension and spontaneous bacterial peritonitis. This review sums up, firstly, how liver disease can alter the common composition of gut microbiota, and secondly, how this alteration contributes to the development of complications in cirrhosis.
Collapse
Affiliation(s)
- Isabel Gómez-Hurtado
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, España
| | - José Such
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, España; Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dabi, Emiratos Árabes Unidos
| | - Rubén Francés
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, España; Departamento de Medicina Clínica, Universidad Miguel Hernández, San Juan de Alicante, Alicante, España.
| |
Collapse
|
18
|
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.
Collapse
Affiliation(s)
- J B Dever
- Department of Gastroenterology, VA San Diego Healthcare System, San Diego, CA, USA
| | | |
Collapse
|
19
|
Lutz P, Nischalke HD, Strassburg CP, Spengler U. Spontaneous bacterial peritonitis: The clinical challenge of a leaky gut and a cirrhotic liver. World J Hepatol 2015; 7:304-314. [PMID: 25848460 PMCID: PMC4381159 DOI: 10.4254/wjh.v7.i3.304] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 11/30/2014] [Accepted: 12/31/2014] [Indexed: 02/06/2023] Open
Abstract
Spontaneous bacterial peritonitis (SBP) is a frequent, life-threatening bacterial infection in patients with liver cirrhosis and ascites. Portal hypertension leads to increased bacterial translocation from the intestine. Failure to eliminate invading pathogens due to immune defects associated with advanced liver disease on the background of genetic predisposition may result in SBP. The efficacy of antibiotic treatment and prophylaxis has declined due to the spread of multi-resistant bacteria. Patients with nosocomial SBP and with prior antibiotic treatment are at a particularly high risk for infection with resistant bacteria. Therefore, it is important to adapt empirical treatment to these risk factors and to the local resistance profile. Rifaximin, an oral, non-absorbable antibiotic, has been proposed to prevent SBP, but may be useful only in a subset of patients. Since novel antibiotic classes are lacking, we have to develop prophylactic strategies which do not induce bacterial resistance. Farnesoid X receptor agonists may be a candidate, but so far, clinical studies are not available. New diagnostic tests which can be carried out quickly at the patient’s site and provide additional prognostic information would be helpful. Furthermore, we need tools to predict antibiotic resistance in order to tailor first-line antibiotic treatment of spontaneous bacterial peritonitis to the individual patient and to reduce mortality.
Collapse
|
20
|
Piroth L, Pechinot A, Di Martino V, Hansmann Y, Putot A, Patry I, Hadou T, Jaulhac B, Chirouze C, Rabaud C, Lozniewski A, Neuwirth C, Chavanet P, Minello A. Evolving epidemiology and antimicrobial resistance in spontaneous bacterial peritonitis: a two-year observational study. BMC Infect Dis 2014; 14:287. [PMID: 24884471 PMCID: PMC4055793 DOI: 10.1186/1471-2334-14-287] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 05/14/2014] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Current recommendations for empirical antimicrobial therapy in spontaneous bacterial peritonitis (SBP) are based on quite old trials. Since microbial epidemiology and the management of patients have changed, whether these recommendations are still appropriate must be confirmed. METHODS An observational study that exhaustively collected the clinical and biological data associated with positive ascitic fluid cultures was conducted in four French university hospitals in 2010-2011. RESULTS Two hundred and sixty-eight documented positive cultures were observed in 190 cirrhotic patients (median age 61.5 years, 58.5% Child score C). Of these, 57 were classified as confirmed SBP and 140 as confirmed bacterascites. The predominant flora was Gram-positive cocci, whatever the situation (SBP, bacterascites, nosocomial/health-care related or not). Enteroccocci (27.7% E. faecium) were isolated in 24% of the episodes, and in 48% from patients receiving quinolone prophylaxis. E. coli were susceptible to amoxicillin-clavulanate and to third-generation cephalosporins in 62.5% and 89.5% of cases, respectively. No single antibiotic allowed antimicrobial coverage of more than 60%. Only combinations such as amoxicillin + third-generation cephalosporin or cotrimoxazole allowed coverage close to 75-80% in non-nosocomial episodes. Combinations based on broader spectrum antibiotics should be considered for empirical therapy of nosocomial infections. CONCLUSIONS Our study confirmed the changing spectrum of pathogens in SBP and bacterascites, and the need for more complex antibiotic strategies than those previously recommended. Our findings also underline the need for new clinical trials conducted in the current epidemiological context.
Collapse
Affiliation(s)
- Lionel Piroth
- Département d'Infectiologie, CHU Dijon, Dijon, France.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Abstract
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.
Collapse
Affiliation(s)
- Iris W Liou
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, 1959 Northeast Pacific Street, Box 356175, Seattle, WA 98195-6175, USA.
| |
Collapse
|
22
|
Collins P, Ayres L, Valliani T. Drug therapies in liver disease. Clin Med (Lond) 2013; 13:585-91. [PMID: 24298107 PMCID: PMC5873662 DOI: 10.7861/clinmedicine.13-6-585] [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] [Indexed: 11/27/2022]
Abstract
The likelihood of a general physician encountering a patient with compensated and decompensated liver disease is increasing. This article provides an overview of pharmaceutical agents currently used in the management of cirrhosis and is designed to allow a better understanding of the rationale for using certain drugs in patients with often complex pathology.
Collapse
Affiliation(s)
- Peter Collins
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | | |
Collapse
|
23
|
Neff GW, Kemmer N, Duncan C, Alsina A. Update on the management of cirrhosis - focus on cost-effective preventative strategies. CLINICOECONOMICS AND OUTCOMES RESEARCH 2013; 5:143-52. [PMID: 23626470 PMCID: PMC3632499 DOI: 10.2147/ceor.s30675] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Cirrhosis is a chronic liver disease stage that encompasses a variety of etiologies resulting in liver damage. This damage may induce secondary complications such as portal hypertension, esophageal variceal bleeding, spontaneous bacterial peritonitis, and hepatic encephalopathy. Screening for and management of these complications incurs substantial health care costs; thus, determining the most economical and beneficial treatment strategies is essential. This article reviews the economic impact of a variety of prophylactic and treatment regimens employed for cirrhosis-related complications. Prophylactic use of β-adrenergic blockers for portal hypertension and variceal bleeding appears to be cost-effective, but the most economical regimen for treatment of initial bleeding is unclear given that cost comparisons of pharmacologic and surgical regimens are lacking. In contrast, prophylaxis for spontaneous bacterial peritonitis cannot be recommended. Standard therapy for spontaneous bacterial peritonitis includes antibiotics, and the overall economic impact of these medications depends largely on their direct cost. However, the potential development of bacterial antibiotic resistance and resulting clinical failure should also be considered. Nonabsorbable disaccharides are standard therapies for hepatic encephalopathy; however, given their questionable efficacy, the nonsystemic antibiotic rifaximin may be a more cost-effective, long-term treatment for hepatic encephalopathy, despite its increased direct cost, because of its demonstrated efficacy and prevention of hospitalization. Further studies evaluating the cost burden of cirrhosis and cirrhosis-related complications, including screening costs, the cost of treatment and maintenance therapy, conveyance to liver transplantation, liver transplantation success, and health-related quality of life after transplantation, are essential for evaluation of the economic burden of hepatic encephalopathy and all cirrhosis-related complications.
Collapse
|
24
|
Pleguezuelo M, Benitez JM, Jurado J, Montero JL, De la Mata M. Diagnosis and management of bacterial infections in decompensated cirrhosis. World J Hepatol 2013; 5:16-25. [PMID: 23383362 PMCID: PMC3562722 DOI: 10.4254/wjh.v5.i1.16] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Revised: 08/29/2012] [Accepted: 11/25/2012] [Indexed: 02/06/2023] Open
Abstract
Bacterial infections are one of the most frequent complications in cirrhosis and result in high mortality rates. Patients with cirrhosis have altered and impaired immunity, which favours bacterial translocation. Episodes of infections are more frequent in patients with decompensated cirrhosis than those with compensated liver disease. The most common and life-threatening infection in cirrhosis is spontaneous bacterial peritonitis followed by urinary tract infections, pneumonia, endocarditis and skin and soft-tissue infections. Patients with decompensated cirrhosis have increased risk of developing sepsis, multiple organ failure and death. Risk factors associated with the development of infections are severe liver failure, variceal bleeding, low ascitic protein level and prior episodes of spontaneous bacterial peritonitis (SBP). The prognosis of these patients is closely related to a prompt and accurate diagnosis. An appropriate treatment decreases the mortality rates. Preventive strategies are the mainstay of the management of these patients. Empirical antibiotics should be started immediately following the diagnosis of SBP and the first-line antibiotic treatment is third-generation cephalosporins. However, the efficacy of currently recommended empirical antibiotic therapy is very low in nosocomial infections including SBP, compared to community-acquired episodes. This may be associated with the emergence of infections caused by Enterococcus faecium and extended-spectrum β-lactamase-producing Enterobacteriaceae, which are resistant to the first line antimicrobial agents used for treatment. The emergence of resistant bacteria, underlines the need to restrict the use of prophylactic antibiotics to patients with the greatest risk of infections. Nosocomial infections should be treated with wide spectrum antibiotics. Further studies of early diagnosis, prevention and treatment are needed to improve the outcomes in patients with decompensated cirrhosis.
Collapse
Affiliation(s)
- Maria Pleguezuelo
- Maria Pleguezuelo, Jose Manuel Benitez, Juan Jurado, Jose Luis Montero, Manuel De la Mata, Liver Research Unit, Reina Sofia University Hospital, Avda Menendez Pidal s/n, 14004 Cordoba, Spain
| | | | | | | | | |
Collapse
|
25
|
Spontaneous Bacterial Peritonitis Caused by Listeria monocytogenes Associated with Ascitic Fluid Lymphocytosis: A Case Report and Review of Current Empiric Therapy. Case Reports Hepatol 2013; 2013:832457. [PMID: 25383227 PMCID: PMC4208429 DOI: 10.1155/2013/832457] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 07/17/2013] [Indexed: 01/15/2023] Open
Abstract
Spontaneous bacterial peritonitis (SBP) is a potentially deadly complication of ascites. We describe a case of SBP caused by Listeria monocytogenes in a patient with alcoholic cirrhosis. This was associated with the unusual finding of ascitic fluid lymphocytosis, which previously had only been associated with tuberculoid or malignant ascites. Given increasing rates of cefotaxime-resistant SBP alongside the possibility of Listeriosis, the use of cefotaxime as first-line therapy in SBP should be reevaluated.
Collapse
|
26
|
Abstract
Bacterial infections are very frequent in advanced cirrhosis and become the first cause of death of these patients. Despite numerous experimental data and significant advances in the understanding of the pathogenesis of sepsis in cirrhosis, the outcome remains poor. Classical diagnostic parameters such as C-reactive protein and SIRS criteria have less diagnostic capacity in the cirrhotic population, often delaying the diagnosis and the management of bacterial infection. Prompt and appropriate empirical antibiotic treatment of infection and early resuscitation of patients with severe sepsis or septic shock are essential in determining patient's outcome. A strategy of careful restriction of prophylactic antibiotics to the high-risk populations could reduce the spread of multidrug resistant bacteria. This review is focused on the currently recommended diagnostic, therapeutic and prophylactic strategies for bacterial infections in the cirrhotic population.
Collapse
Affiliation(s)
- Javier Fernández
- Liver Unit, IMDiM, Hospital Clínic, Universidad de Barcelona, IDIBAPS and CIBERehd, Barcelona, Spain.
| | | |
Collapse
|
27
|
Abstract
Care of the liver transplant candidate is one of the most challenging, yet rewarding aspects of hepatology. Anticipation and intervention for the major complications of advanced liver disease increase the likelihood of survival until transplant.
Collapse
Affiliation(s)
- Hui-Hui Tan
- Department of Gastroenterology & Hepatology, Singapore General Hospital.
| | | |
Collapse
|
28
|
Bruns T, Peter J, Hagel S, Pfeifer R, Prinz P, Stallmach A. Homozygous carrier of the NOD2 1007fs frame-shift mutation presenting with refractory community-acquired spontaneous bacterial peritonitis and developing fatal pulmonary mucormycosis: A case report. Hepatol Res 2011; 41:1009-14. [PMID: 21951874 DOI: 10.1111/j.1872-034x.2011.00850.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Genetic variants of the innate immune system contribute to episodes of spontaneous bacterial peritonitis (SBP) in patients with cirrhosis. We herein report the case of a patient with the homozygous nucleotide-binding oligomerization domain containing 2 (NOD2) frame-shift mutation 1007fs presenting with sepsis and community-acquired SBP by Escherichia coli. Secondary peritonitis, pancreatic ascites and malignant causes were excluded by extensive diagnostic work-up. First-line treatment with ceftriaxone was not successful despite in vitro sensitivity of the isolated strain. Despite prolonged second-line treatment with imipenem/cilastatin and intermittent ascites drainage, the ascitic fluid neutrophil count remained markedly elevated in this patient. In the course of the disease the patient developed pneumonia with identification of the typical hyphae of mucormycosis in the bronchoalveolar lavage and died of sepsis with multi-organ failure. On the basis of this observation, variants of the innate immunity have to be considered in therapy-refractory SBP, even when they are community-acquired and caused by cephalosporin-sensitive Enterobacteriaceae.
Collapse
Affiliation(s)
- Tony Bruns
- Division of Gastroenterology, Hepatology and Infectious Diseases, Department of Internal Medicine II Department of Internal Medicine I, Jena University Hospital The Integrated Research and Treatment Center for Sepsis Control and Care (CSCC), Jena, Germany
| | | | | | | | | | | |
Collapse
|
29
|
Biecker E. Diagnosis and therapy of ascites in liver cirrhosis. World J Gastroenterol 2011; 17:1237-48. [PMID: 21455322 PMCID: PMC3068258 DOI: 10.3748/wjg.v17.i10.1237] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2010] [Revised: 12/22/2010] [Accepted: 12/29/2010] [Indexed: 02/06/2023] Open
Abstract
Ascites is one of the major complications of liver cirrhosis and is associated with a poor prognosis. It is important to distinguish noncirrhotic from cirrhotic causes of ascites to guide therapy in patients with noncirrhotic ascites. Mild to moderate ascites is treated by salt restriction and diuretic therapy. The diuretic of choice is spironolactone. A combination treatment with furosemide might be necessary in patients who do not respond to spironolactone alone. Tense ascites is treated by paracentesis, followed by albumin infusion and diuretic therapy. Treatment options for refractory ascites include repeated paracentesis and transjugular intrahepatic portosystemic shunt placement in patients with a preserved liver function. Potential complications of ascites are spontaneous bacterial peritonitis (SBP) and hepatorenal syndrome (HRS). SBP is diagnosed by an ascitic neutrophil count > 250 cells/mm3 and is treated with antibiotics. Patients who survive a first episode of SBP or with a low protein concentration in the ascitic fluid require an antibiotic prophylaxis. The prognosis of untreated HRS type 1 is grave. Treatment consists of a combination of terlipressin and albumin. Hemodialysis might serve in selected patients as a bridging therapy to liver transplantation. Liver transplantation should be considered in all patients with ascites and liver cirrhosis.
Collapse
|
30
|
Taneja SK, Dhiman RK. Prevention and management of bacterial infections in cirrhosis. Int J Hepatol 2011; 2011:784540. [PMID: 22229097 PMCID: PMC3168849 DOI: 10.4061/2011/784540] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Accepted: 06/03/2011] [Indexed: 12/31/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Sunil K. Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education & Research, Chandigarh 160012, India
| | - Radha K. Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education & Research, Chandigarh 160012, India,*Radha K. Dhiman:
| |
Collapse
|
31
|
Abstract
Spontaneous bacterial peritonitis (SBP) is one of the most serious complications occurring in cirrhotic patients with ascites. Therefore, an effective therapy is always required starting immediately after diagnosis. There are three aims of therapy: (1) to eradicate the bacterial strain responsible of the infection; (2) to prevent renal failure; and (3) to prevent SBP recurrence. The first end point is achievable by means of a large-spectrum antibiotic therapy. Empirical antibiotic therapy can be started with a third-generation cephalosporin, amoxicillin-clavulanate or a quinolone. The effectiveness of antibiotics should be verified by determining the percent reduction of polymorphonuclear cells count in the ascitic fluid. If bacteria result to be resistant to the empirical therapy, a further antibiotic must be given according to the in vitro bacterial susceptibility. In most cases, a 5-day antibiotic therapy is enough to eradicate the bacterial strain. Severe renal failure occurs in about 30% of patients with SBP, independently of the response to antibiotics, and it is associated with elevated mortality. The early administration of large amount of human albumin showed to be able to reduce the episodes of renal failure and to improve survival. After the resolution of an episode of SBP, the recurrence is frequent. Therefore, an intestinal decontamination with oral norfloxacin has been shown to significantly reduce this risk and is widely practised. However, such a long-term prophylaxis, as well as the current increased use of invasive procedures, favours the increase of bacterial infections, including SBP, contracted during the hospitalization (nosocomial infections) and sustained by multi-resistant bacteria. This involves the necessity to use a different strategy of antibiotic prophylaxis as well as a more strict surveillance of patients at risk.
Collapse
Affiliation(s)
- Francesco Salerno
- Department of Internal Medicine, Policlinico IRCCS San Donato, Università di Milano, Via Morandi, 30, 20097, San Donato Milanese, Italy.
| | | |
Collapse
|
32
|
Arvaniti V, D'Amico G, Fede G, Manousou P, Tsochatzis E, Pleguezuelo M, Burroughs AK. Infections in patients with cirrhosis increase mortality four-fold and should be used in determining prognosis. Gastroenterology 2010; 139:1246-56, 1256.e1-5. [PMID: 20558165 DOI: 10.1053/j.gastro.2010.06.019] [Citation(s) in RCA: 762] [Impact Index Per Article: 54.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2010] [Revised: 05/18/2010] [Accepted: 06/08/2010] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS A staged prognostic model of cirrhosis based on varices, ascites, and bleeding has been proposed. We analyzed data on infections in patients with cirrhosis to determine whether it is also a prognostic factor. METHODS Studies were identified by MEDLINE, EMBASE, COCHRANE, and ISI Web of Science searches (1978-2009); search terms included sepsis, infection, mortality, and cirrhosis. Studies (n = 178) reporting more than 10 patients and mortality data were evaluated (225 cohorts, 11,987 patients). Mortality after 1, 3, and 12 months was compared with severity, site, microbial cause of infection, etiology of cirrhosis, and publication year. Pooled odds ratio of death was compared for infected versus noninfected groups (18 cohorts, 2317 patients). RESULTS Overall median mortality of infected patients was 38%: 30.3% at 1 month and 63% at 12 months. Pooled odds ratio for death of infected versus noninfected patients was 3.75 (95% confidence interval, 2.12-4.23). In 101 studies that reported spontaneous bacterial peritonitis (7062 patients), the median mortality was 43.7%: 31.5% at 1 month and 66.2% at 12 months. In 30 studies that reported bacteremia (1437 patients), the median mortality rate was 42.2%. Mortality before 2000 was 47.7% and after 2000 was 32.3% (P = .023); mortality was reduced only at 30 days after spontaneous bacterial peritonitis (49% vs 31.5%; P = .005). CONCLUSIONS In patients with cirrhosis, infections increase mortality 4-fold; 30% of patients die within 1 month after infection and another 30% die by 1 year. Prospective studies with prolonged follow-up evaluation and to evaluate preventative strategies are needed.
Collapse
Affiliation(s)
- Vasiliki Arvaniti
- The Sheila Sherlock Liver Centre, and University Department of Surgery, Royal Free Hospital and University College London, London, United Kingdom
| | | | | | | | | | | | | |
Collapse
|
33
|
EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol 2010; 53:397-417. [PMID: 20633946 DOI: 10.1016/j.jhep.2010.05.004] [Citation(s) in RCA: 1093] [Impact Index Per Article: 78.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2010] [Accepted: 05/25/2010] [Indexed: 02/07/2023]
|
34
|
Piroth L, Pechinot A, Minello A, Jaulhac B, Patry I, Hadou T, Hansmann Y, Rabaud C, Chavanet P, Neuwirth C. Bacterial epidemiology and antimicrobial resistance in ascitic fluid: a 2-year retrospective study. ACTA ACUST UNITED AC 2010; 41:847-51. [PMID: 19922067 DOI: 10.3109/00365540903244535] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The bacterial epidemiology of bacterascites and spontaneous bacterial peritonitis is evolving. Four hundred and eleven strains isolated from ascites in cirrhotic patients from 5 French hospitals were isolated in 2006 and 2007. Of these, 114 were definitely associated with spontaneous bacterial peritonitis. The proportion of Gram-positive and Gram-negative agents was quite similar, even after excluding coagulase-negative staphylococci, or when considering only definite spontaneous bacterial peritonitis or community-acquired strains. Staphylococci and Escherichia coli were the most frequent pathogens, but enterococci were also involved in nearly 15% of the cases. Among the E. coli, 28% were intermediate or resistant to amoxicillin+clavulanate, 5.3% expressed cephalosporinases or extended beta-lactamases and 17.3% were intermediate or resistant to fluoroquinolones. Resistance to methicillin was observed in 27% of Staphylococcus aureus. Cefotaxime and amoxicillin-clavulanate remained the most effective 'single' agents, however on less than 70% of isolates. Some combinations (such as cefotaxime+amoxicillin) extended coverage to a further 15% of strains. Since inadequate empiric antibiotic therapy is associated with increased mortality, these combinations may be of great interest as first-line treatment, even though they may also lead to the development of antimicrobial resistance. Repeated epidemiological surveys and new clinical trials are thus needed.
Collapse
|
35
|
Lata J, Stiburek O, Kopacova M. Spontaneous bacterial peritonitis: a severe complication of liver cirrhosis. World J Gastroenterol 2010. [PMID: 19938187 DOI: 10.3748/wig.15.5505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
This report presents a survey of current knowledge concerning one of the relatively frequent and severe complications of liver cirrhosis and associated ascites-spontaneous bacterial peritonitis. Epidemiology, aetiology, pathogenesis, clinical manifestation, diagnosis and present possibilities of treatment are discussed.
Collapse
|
36
|
Güçlü M, Sakallı H, Yakar T, Uncu H. Effect of Cefepime in Patients with Cirrhosis
and Spontaneous Acid Infection. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2010. [DOI: 10.29333/ejgm/82794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
37
|
Abstract
Sepsis is physiologically viewed as a proinflammatory and procoagulant response to invading pathogens. There are three recognized stages in the inflammatory response with progressively increased risk of end-organ failure and death: sepsis, severe sepsis, and septic shock. Patients with cirrhosis are prone to develop sepsis, sepsis-induced organ failure, and death. There is evidence that in cirrhosis, sepsis is accompanied by a markedly imbalanced cytokine response ("cytokine storm"), which converts responses that are normally beneficial for fighting infections into excessive, damaging inflammation. Molecular mechanisms for this excessive proinflammatory response are poorly understood. In patients with cirrhosis and severe sepsis, high production of proinflammatory cytokines seems to play a role in the worsening of liver function and the development of organ/system failures such as shock, renal failure, acute lung injury or acute respiratory distress syndrome, coagulopathy, or hepatic encephalopathy. In addition, these patients may have sepsis-induced hyperglycemia, defective arginine-vasopressin secretion, adrenal insufficiency, or compartmental syndrome. In patients with cirrhosis and spontaneous bacterial peritonitis (SBP), early use of antibiotics and intravenous albumin administration decreases the risk for developing renal failure and improves survival. There are no randomized studies that have been specifically performed in patients with cirrhosis and severe sepsis to evaluate treatments that have been shown to improve outcome in patients without cirrhosis who have severe sepsis or septic shock. These treatments include recombinant human activated C protein and protective-ventilation strategy for respiratory failure. Other treatments should be evaluated in the cirrhotic population with severe sepsis including the early use of antibiotics in "non-SBP" infections, vasopressor therapy, hydrocortisone, renal-replacement therapy and liver support systems, and selective decontamination of the digestive tract or oropharynx.
Collapse
Affiliation(s)
- Thierry Gustot
- INSERM, U773, Centre de Recherche Bichat-Beaujon CRB3, Paris 75018, France.
| | | | | | | | | |
Collapse
|
38
|
Lata J, Stiburek O, Kopacova M. Spontaneous bacterial peritonitis: A severe complication of liver cirrhosis. World J Gastroenterol 2009; 15:5505-10. [PMID: 19938187 PMCID: PMC2785051 DOI: 10.3748/wjg.15.5505] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
This report presents a survey of current knowledge concerning one of the relatively frequent and severe complications of liver cirrhosis and associated ascites-spontaneous bacterial peritonitis. Epidemiology, aetiology, pathogenesis, clinical manifestation, diagnosis and present possibilities of treatment are discussed.
Collapse
|
39
|
Heo J, Seo YS, Yim HJ, Hahn T, Park SH, Ahn SH, Park JY, Park JY, Kim MY, Park SK, Cho M, Um SH, Han KH, Kim HS, Baik SK, Kim BI, Cho SH. Clinical features and prognosis of spontaneous bacterial peritonitis in korean patients with liver cirrhosis: a multicenter retrospective study. Gut Liver 2009; 3:197-204. [PMID: 20431746 PMCID: PMC2852707 DOI: 10.5009/gnl.2009.3.3.197] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2009] [Accepted: 06/21/2009] [Indexed: 12/18/2022] Open
Abstract
Background/Aims Although early recognition and treatment with effective antibiotics have lead to improvements in the prognosis of patients with spontaneous bacterial peritonitis (SBP), it remains to be a serious complication in cirrhotic patients. This study was designed to evaluate the clinical manifestations and prognosis of patients with liver cirrhosis and SBP in Korea. Methods This was a multicenter retrospective study examining 157 episodes of SBP in 145 patients with cirrhosis. SBP was diagnosed based on a polymorphonuclear cell count in ascitic fluid of >250 cells/mm3 in the absence of data compatible with secondary peritonitis. Results The mean age of the cohort was 56 years, and 121 (77%) of the 157 episodes of SBP occurred in men. Microorganisms were isolated in 66 episodes (42%): Gram-negative bacteria in 54 (81.8%), Gram-positive in 11 (16.7%), and Candida in 1. Isolated Gram-negative organisms were resistant to third-generation cephalosporin in 6 cases (17%), to ciprofloxacin in 11 (20.8%), and to penicillin in 33 (62.3%). The treatment failure and in-hospital mortality rates were 12.1% and 21%, respectively. A high Model of End-Stage Liver Disease (MELD) score, SBP caused by extended-spectrum β-lactamase-producing organisms, and hepatocellular carcinoma were independent prognostic factors of high in-hospital mortality. Conclusions SBP remains to be a serious complication with high in-hospital mortality, especially in patients with a high MELD score.
Collapse
Affiliation(s)
- Jeong Heo
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, Korea
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Riggio O, Angeloni S. Ascitic fluid analysis for diagnosis and monitoring of spontaneous bacterial peritonitis. World J Gastroenterol 2009; 15:3845-50. [PMID: 19701963 PMCID: PMC2731245 DOI: 10.3748/wjg.15.3845] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Polymorphonuclear (PMN) cell count in the ascitic fluid is essential for the diagnosis and management of spontaneous bacterial peritonitis (SBP). To date, PMN cell count is routinely performed by traditional manual counting. However, this method is time-consuming, costly, and not always timely available. Therefore, considerable efforts have been made in recent years to develop an alternative test for a more rapid diagnosis and monitoring of SBP. The use of urinary reagent strips was proposed to achieve an “instant” bedside diagnosis of SBP. A series of reports evaluated the urine strip test for SBP diagnosis and reported promising results. However, a recent large multicenter study revealed a surprising lack of diagnostic efficacy of the urine screening test for SBP diagnosis. Another method, more recently proposed as an alternative to the manual PMN count, is the measurement of lactoferrin in ascitic fluid, but the data available on the diagnostic value of this test are limited to a single study. However, both urinary reagent strips and ascitic lactoferrin tests are qualitative methods and need, therefore, to be further confirmed by standard cytology of the ascitic fluid. To date, the only quantitative method proposed as a valid alternative to manual PMN counting is automated blood cell counters, commonly used in all laboratories for blood cell counting. Data available in the literature on the diagnostic performance of this method are limited but very promising, and this tool seems to have the potential to replace the manual counting method.
Collapse
|
41
|
|
42
|
Garcia-Tsao G, Lim JK. 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. Am J Gastroenterol 2009; 104:1802-29. [PMID: 19455106 DOI: 10.1038/ajg.2009.191] [Citation(s) in RCA: 170] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
Collapse
|
43
|
Antonanzas F, Rodríguez-Ibeas R, Juárez C, Hutter F, Lorente R, Pinillos M. Transferability indices for health economic evaluations: methods and applications. HEALTH ECONOMICS 2009; 18:629-43. [PMID: 18677724 DOI: 10.1002/hec.1397] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
In this paper, we have elaborated an index in two phases to measure the degree of transferability of the results of the economic evaluation of health technologies. In the first phase, we have considered the objective factors (critical and non-critical) to derive a general transferability index, which can be used to measure this internal property of the studies of economic evaluation applied to health technologies. In the second phase, with a more specific index, we have measured the degree of applicability of the results of a given study to a different setting. Both indices have been combined (arithmetic and geometric mean) to obtain a global transferability index. We have applied the global index to a sample of 27 Spanish studies on infectious diseases. We have obtained an average value for the index of 0.54, quite far from the maximum theoretical value of 1. We also found that 11 studies lacked some critical factor and were directly deemed as not transferable.
Collapse
Affiliation(s)
- Fernando Antonanzas
- Departamento de Economía y Empresa, Universidad de La Rioja, C/ La Cigüena 60, Logrono, Spain.
| | | | | | | | | | | |
Collapse
|
44
|
Failure of current antibiotic first-line regimens and mortality in hospitalized patients with spontaneous bacterial peritonitis. Infection 2009; 37:2-8. [PMID: 19169633 DOI: 10.1007/s15010-008-8060-9] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2008] [Accepted: 05/05/2008] [Indexed: 12/11/2022]
Abstract
BACKGROUND Increases in Gram-positive infections and infections with Enterobacteriaceae with antimicrobial resistance have been reported in patients with spontaneous bacterial peritonitis (SBP). This study was performed to investigate the rate of treatment failures of recommended empirical therapies and the impact on mortality. PATIENTS AND METHODS A prospectively collected database comprising 101 patients with SBP (70 nosocomial, 31 community acquired) treated at a university hospital between 2002 and 2006 in Munich, Germany, was analyzed. RESULTS 17 patients initially received a broader than recommended antibiotic regimen. Most of these were treated in the intensive care unit because of severe sepsis/septic shock. Hospital mortality in this group was 82%. A modification of therapy was necessary in 24 of the 84 patients receiving one of the published first-line therapies (cefotaxime, ampicillin/clavulanate, or ciprofloxacin). Mortality was significantly higher in these patients than in those with no change in treatment (66.7% vs 30%, p = 0.002). In 29 patients with positive cultures, mortality was also higher in those with an ineffective first-line treatment (90% vs 45%, p = 0.032). In the multivariable analysis, a modification of antibiotic treatment was an independent risk factor for mortality (odds ratio 5.876, 95% confidence interval 1.826-18.910, p = 0.003). In 41 culture-positive cases, the most commonly cultured pathogens were Escherichia coli (n = 17) and Enterococcus faecium (n = 10). Of the encountered bacterial microorganisms, 14 (33.3%) were resistant to cefotaxime, 17 (38.6%) were resistant to amoxicillin/clavulanate, and 19 (45.2%) were resistant to ciprofloxacin. 29 (64.4%) of the isolates were resistant to one of the recommended firstline antibiotic regimens, and 11 (24.4%) of the isolates were resistant to all three. CONCLUSION Recommended empirical antibiotic regimens fail to achieve the desired effect in a substantial number of hospitalized patients with SBP. This has a negative impact on mortality.
Collapse
|
45
|
Chavez-Tapia NC, Soares-Weiser K, Brezis M, Leibovici L. Antibiotics for spontaneous bacterial peritonitis in cirrhotic patients. Cochrane Database Syst Rev 2009; 2009:CD002232. [PMID: 19160207 PMCID: PMC7100568 DOI: 10.1002/14651858.cd002232.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Spontaneous bacterial peritonitis is a complication of cirrhotic ascites that occurs in the absence of any intra-abdominal, surgically treatable source of infection. Antibiotic therapy is indicated and should be initiated as soon as possible to avoid severe complications that may lead to death. It has been proposed that empirical treatment should cover gram-negative enteric bacteria and gram-positive cocci, responsible for up to 90% of spontaneous bacterial peritonitis cases. OBJECTIVES This review aims to evaluate the beneficial and harmful effects of different types and modes of antibiotic therapy in the treatment of spontaneous bacterial peritonitis in cirrhotic patients. SEARCH STRATEGY We performed electronic searches in The Cochrane Hepato-Biliary Group Controlled Trials Register (July 2008), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 3, 2008), MEDLINE (1950 to July 2008), EMBASE (1980 to July 2008), and Science Citation Index EXPANDED (1945 to July 2008). In addition, we handsearched the references of all identified studies and contacted the first author of each included trial. SELECTION CRITERIA Randomised studies comparing different types of antibiotics for spontaneous bacterial peritonitis in cirrhotic patients. DATA COLLECTION AND ANALYSIS Data were independently extracted from the trials by at least two authors. Peto odds ratios or average differences, with their 95% confidence intervals, were estimated. MAIN RESULTS This systematic review attempted to summarise evidence from randomised clinical trials on the treatment of spontaneous bacterial peritonitis. Thirteen studies were included; each one of them compared different antibiotics in their experimental and control groups. No meta-analyses could be performed, though data on the main outcomes were collected and analysed separately for each included trial. Currently, the evidence showing that lower dosage or short-term treatment with third generation cephalosporins is as effective as higher dosage or long-term treatment is weak. Oral quinolones could be considered an option for those with less severe manifestations of the disease. AUTHORS' CONCLUSIONS This review provides no clear evidence for the treatment of cirrhotic patients with spontaneous bacterial peritonitis. In practice, third generation cephalosporins have already been established as the standard treatment of spontaneous bacterial peritonitis, and it is clear, that empirical antibiotic therapy should be provided in any case. However, until large, well-conducted trials provide more information, practice will remain based on impression, not evidence.
Collapse
Affiliation(s)
- Norberto C Chavez-Tapia
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga #5, Mexico City, Distrito Federal, Mexico, 14000.
| | | | | | | |
Collapse
|
46
|
Bert F, Panhard X, Johnson J, Lecuyer H, Moreau R, Le Grand J, Johnston B, Sinègre M, Valla D, Nicolas-Chanoine MH. Genetic background of Escherichia coli isolates from patients with spontaneous bacterial peritonitis: relationship with host factors and prognosis. Clin Microbiol Infect 2009; 14:1034-40. [PMID: 19040475 DOI: 10.1111/j.1469-0691.2008.02088.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Spontaneous bacterial peritonitis (SBP) is a severe complication in patients with cirrhosis and ascites. It is predominantly caused by Escherichia coli. The phylogenetic group and virulence genotype of E. coli isolates causing SBP were investigated, and the association of these characteristics with host factors and prognosis was examined. Seventy-six episodes of E. coli SBP that occurred over a 9-year period were studied. The phylogenetic group of the isolates and the presence of 36 virulence factor genes were investigated. The influence of bacterial and host factors on in-hospital mortality was assessed by multiple logistic regression. Phylogenetic groups A, B1, B2 and D were found in 26%, 4%, 46% and 24% of the isolates, respectively. Virulence factor genes were more frequent in B2 isolates than in non-B2 isolates (mean virulence score 15.4 vs. 7.3, p <10(-4)). Ciprofloxacin resistance was significantly associated with non-B2 groups and a low virulence score. Host factors independently associated with a shift from B2 to non-B2 isolates were norfloxacin prophylaxis (OR 13.01, p 0.0213) and prothrombin ratio (OR 1.04 for a 10% decrease, p 0.0211). The model for end-stage liver disease (MELD) score (OR 1.83, p 0.0007) and hospital-acquired SBP (OR 4.13, p 0.0247) were independent predictors of in-hospital mortality. In contrast, outcome was not influenced by the phylogenetic group or the virulence profile. These findings indicate that the characteristics of E. coli isolates causing SBP vary with the severity of liver disease and with fluoroquinolone prophylaxis. Host factors are more important than bacterial factors in predicting in-hospital mortality.
Collapse
Affiliation(s)
- F Bert
- Service de Microbiologie, Hôpital AP-HP Beaujon, Clichy, France.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
47
|
Angeloni S, Leboffe C, Parente A, Venditti M, Giordano A, Merli M, Riggio O. Efficacy of current guidelines for the treatment of spontaneous bacterial peritonitis in the clinical practice. World J Gastroenterol 2008; 14:2757-62. [PMID: 18461661 PMCID: PMC2709049 DOI: 10.3748/wjg.14.2757] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To verify the validity of the International Ascites Club guidelines for treatment of spontaneous bacterial peritonitis (SBP) in clinical practice.
METHODS: All SBP episodes occurring in a group of consecutive cirrhotics were managed accordingly and included in the study. SBP was diagnosed when the ascitic fluid polymorphonuclear (PMN) cell count was > 250 cells/mm3, and empirically treated with cefotaxime.
RESULTS: Thirty-eight SBP episodes occurred in 32 cirrhotics (22 men/10 women; mean age: 58.6 ± 11.2 years). Prevalence of SBP, in our population, was 17%. Ascitic fluid culture was positive in nine (24%) cases only. Eleven episodes were nosocomial and 71% community-acquired. Treatment with cefotaxime was successful in 59% of cases, while 41% of episodes required a modification of the initial antibiotic therapy because of a less-than 25% decrease in ascitic PMN count at 48 h. Change of antibiotic therapy led to the resolution of infection in 87% of episodes. Among the cases with positive culture, the initial antibiotic therapy with cefotaxime failed at a percentage (44%) similar to that of the whole series. In these cases, the isolated organisms were either resistant or with an inherent insufficient susceptibility to cefotaxime.
CONCLUSION: In clinical practice, ascitic PMN count is a valid tool for starting a prompt antibiotic treatment and evaluating its efficacy. The initial treatment with cefotaxime failed more frequently than expected. An increase in healthcare-related infections with antibiotic-resistant pathogens may explain this finding. A different first-line antibiotic treatment should be investigated.
Collapse
|
48
|
Kuiper JJ, de Man RA, van Buuren HR. Review article: Management of ascites and associated complications in patients with cirrhosis. Aliment Pharmacol Ther 2007; 26 Suppl 2:183-93. [PMID: 18081661 DOI: 10.1111/j.1365-2036.2007.03482.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Ascites is the most common complication of cirrhosis, associated with an expected survival below 50% after 5 years. Prognosis is particularly poor for patients with refractory ascites and for those developing complications, including spontaneous bacterial peritonitis (SBP) and hepatorenal syndrome (HRS). AIM To provide an evidence-based overview of the pathophysiology, diagnosis and clinical management of ascites secondary to liver cirrhosis. METHODS Review based on relevant medical literature. RESULTS Portal hypertension, splanchnic vasodilatation and renal sodium retention are fundamental in the pathophysiology of ascites formation. The SAAG (serum-ascites albumin gradient) allows reliable assessment of the cause of ascites. The majority of cirrhotic patients with ascites can be managed with dietary sodium restriction in combination with diuretic agents. Large volume paracentesis with albumin suppletion and TIPS are therapeutic options in patients with refractory ascites. Prophylactic antibiotics for SBP should be given in certain patient populations. CONCLUSIONS Recent advances in the diagnosis and treatment of ascites and associated complications have improved the medical management and poor prognosis of patients with these manifestations of advanced liver disease. Early diagnosis, adequate treatment and focus on prevention of complications remain essential as well as timely referral for liver transplantation.
Collapse
Affiliation(s)
- J J Kuiper
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands.
| | | | | |
Collapse
|
49
|
Abstract
Bacterial infections are well described complications of cirrhosis that greatly increase mortality rates. Two factors play important roles in the development of bacterial infections in these patients: the severity of liver disease and gastrointestinal haemorrhage. The most common infections are spontaneous bacterial peritonitis, urinary tract infections, pneumonia and sepsis. Gram-negative and gram-positive bacteria are equal causative organisms. For primary prophylaxis, short-term antibiotic treatment (oral norfloxacin or ciprofloxacin) is indicated in cirrhotic patients (with or without ascites) admitted with gastrointestinal haemorrhage (variceal or non-variceal). Administration of norfloxacin is advisable for hospitalized patients with low ascitic protein even without gastrointestinal haemorrhage. The first choice in empirical treatment of spontaneous bacterial peritonitis is the iv. III. generation cephalosporin; which can be switched for a targeted antibiotic regime based on the result of the culture. The duration of therapy is 5-8 days. Amoxicillin/clavulanic acid and fluoroquinolones--patients not on prior quinolone prophylaxis--were shown to be as effective and safe as cefotaxime. In patients with evidence of improvement, iv. antibiotics can be switched safely to oral antibiotics after 2 days. In case of renal dysfunction, iv albumin should also be administered. Long-term antibiotic prophylaxis is recommended in patients who have recovered from an episode of spontaneous bacterial peritonitis (secondary prevention). For "selective intestinal decontamination", poorly absorbed oral norfloxacin is the preferred schedule. Oral ciprofloxacin or levofloxacin (added gram positive spectrum) all the more are reasonable alternatives. Trimethoprim/sulfamethoxazole is only for patients who are intolerant to quinolones. Prophylaxis is indefinite until disappearance of ascites, transplant or death. Long-term prophylaxis is currently not recommended for patients without previous spontaneous bacterial peritonitis episode, not even when refractory ascites or low ascites protein content is present.
Collapse
Affiliation(s)
- Mária Papp
- Debreceni Egyetem, Orvos- és Egészségtudományi Centrum, Altalános Orvostudományi Kar Belgyógyászati Intézet, Gasztroenterológiai Tanszék Debrecen Nagyerdei krt. 98. 4012, Hungary.
| | | | | | | |
Collapse
|
50
|
Abstract
Cirrhosis is the twelfth commonest cause of death in the United States, with more than 27,000 deaths and more than 421,000 hospitalizations annually. Currently, there are more than 17,000 patients awaiting liver transplantation in the United States across the 11 United Network for Organ Sharing regions. Approximately 10% of such patients will die awaiting transplantation.
Collapse
Affiliation(s)
- Priya Grewal
- The Division of Liver Diseases, Recanati-Miller Transplantation Institute, The Mount Sinai Medical Center, One Gustave L. Levy Place, Box 1104, New York, NY 10029, USA.
| | | |
Collapse
|