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Kim WR, Raghunathan K, Martin GS, Davis EA, Sindhwani NS, Telang S, Lodaya K. Timely Albumin Infusion May Improve Resource Utilization in Patients with Cirrhosis and Spontaneous Bacterial Peritonitis. BIOMED RESEARCH INTERNATIONAL 2024; 2024:6673823. [PMID: 38899040 PMCID: PMC11186688 DOI: 10.1155/2024/6673823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 04/02/2024] [Accepted: 05/09/2024] [Indexed: 06/21/2024]
Abstract
Spontaneous bacterial peritonitis is a life-threatening complication of cirrhosis that can increase healthcare utilization. The impact of albumin administration timing on hospital resource utilization and its optimal timing is unclear, despite its efficacy in improving survival for cirrhosis patients with spontaneous bacterial peritonitis. A retrospective study was conducted to evaluate the influence of the timing of albumin administration on the length of stay and total hospital cost for patients with cirrhosis and spontaneous bacterial peritonitis who require fluid resuscitation. The study utilized de-identified data from Cerner Health Facts® data. Adult inpatients with a diagnosis of cirrhosis and SBP receiving ≥1 antibiotic and fluid resuscitation between January 1, 2009, and April 30, 2018, were included and stratified by albumin administration timing: ≤24 hours from hospital admission ("timely albumin") or >24 hours of admission or no albumin ("non-timely albumin"). We used a Kaplan-Meier curve with log-rank test to evaluate the association between timing of albumin administration and time to hospital discharge and a generalized linear model to examine the association between albumin timing and total hospital costs. We identified 1,308 hospitalizations, of which 301 contained valid cost data. The timely albumin group had a median time to discharge of 6.95 days compared to 7.78 days in the non-timely group (p = 0.02). Cost model showed that receiving timely albumin incurred 16% lower costs (p = 0.027) than patients in the non-timely albumin group. Timely albumin administration with an antibiotic regimen may shorten the length of stay and lower costs, thereby reducing hospital resource utilization in patients with cirrhosis and spontaneous bacterial peritonitis requiring fluid resuscitation.
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Affiliation(s)
- W. Ray Kim
- Division of Gastroenterology and HepatologyStanford University, Stanford, CA, USA
| | | | - Greg S. Martin
- Department of MedicineEmory University, Atlanta, GA, USA
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Mohammed Abdul MK, Osman KT, Cappuccio JM, Spencer C, Satapathy SK. Nosocomial spontaneous bacterial peritonitis is associated with high mortality - a systematic review and meta-analysis. Expert Rev Gastroenterol Hepatol 2023; 17:1333-1339. [PMID: 37982715 DOI: 10.1080/17474124.2023.2284825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 11/14/2023] [Indexed: 11/21/2023]
Abstract
INTRODUCTION It is unclear if Nosocomial Spontaneous Bacteria Peritonitis (NSBP) is associated with higher mortality compared with community acquired spontaneous bacterial peritonitis. METHODS Database search from inception to May 2022 was conducted. The databases included MEDLINE, EMBASE, Cochrane registry of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus. Inclusion criteria were as follows: adult patients, age >18 years, with a diagnosis of NSBP. Pooled estimates of mortality were calculated following the restricted maximum likelihood method. The mortality rate between NSBP and CA-SBP was reported as odds ratio (OR) and 95% confidence interval (CI). Data synthesis was obtained using random effects meta-analysis. Heterogeneity was reported as I2. RESULTS A total of 482 unique titles were screened. Twenty-two articles were included. A total of 2,145 patients with NSBP were included. Patients were followed for a median of 90 days. The pooled mortality rate of NSBP was 52.51% (95% CI 42.77-62.06%; I2 83.72%). Seven studies compared the mortality outcome of patients with NSBP and CA-SBP. NSBP was significantly associated with a higher rate of mortality (OR 2.78, 95% CI 1.87-4.11; I2 36.00%). CONCLUSION NSBP was associated with higher mortality rate compared to CA-SBP, which could be due to a higher rate of resistance organisms.
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Affiliation(s)
| | - Karim T Osman
- Department of Internal Medicine, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Joseph M Cappuccio
- Department of Internal Medicine, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Carol Spencer
- Department of Library Services, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Sanjaya K Satapathy
- Sandra Atlas Bass Center for Liver Diseases and Transplantation, Manhasset, NY, USA
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Mohy-ud-din N, Noll A, Jonassaint N. CON: Ascitic fluid cell count should not be routinely sent with every therapeutic paracentesis to assess for spontaneous bacterial peritonitis. Clin Liver Dis (Hoboken) 2023; 22:143-145. [PMID: 37908868 PMCID: PMC10615510 DOI: 10.1097/cld.0000000000000081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 06/05/2023] [Indexed: 11/02/2023] Open
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Dawit L, Lee V, Lehoang D, Furey C, Chowdhury A, Mai TA, Angajala V, Park JH, Khadarian K, She R, Vergara-Lluri M, Kahn J, Dodge JL, Saito T. Clinical Significance of Ascitic Fluid Polymorphonuclear Leukocyte Percentage in Patients With Cirrhosis Without Spontaneous Bacterial Peritonitis. Clin Transl Gastroenterol 2023; 14:e00614. [PMID: 37436155 PMCID: PMC10522094 DOI: 10.14309/ctg.0000000000000614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 06/10/2023] [Accepted: 06/26/2023] [Indexed: 07/13/2023] Open
Abstract
INTRODUCTION Absolute polymorphonuclear leukocyte (PMN) count (PMN-C) ≥250 cells/mm 3 in ascites is the diagnostic hallmark of spontaneous bacterial peritonitis (SBP) and is associated with high morbidity and mortality. However, the clinical significance of ascitic PMN percentage (PMN-%) and PMN-C in the absence of SBP as additional biomarkers for mortality and future incidence of SBP has not been determined. METHODS This retrospective cohort included adults with cirrhosis undergoing first-recorded paracentesis with initial PMN-C < 250 cells/mm 3 at 2 tertiary medical centers between 2015 and 2020. Patients with prior SBP were excluded. Outcomes were death and SBP development. Cox regression estimated hazard ratios (HRs) for risk of death and SBP development and Akaike information criterion to compare model fit. RESULTS Three hundred eighty-four adults (73% male, median age 58 years, 67% with alcohol-associated cirrhosis, median PMN-C 14 cells/mm 3 [interquartile range 5-34], and median PMN-% 10% [interquartile range 4-20]) were included in this study. Univariate risk of death increased 10% per 25-unit increase in PMN-C (95% confidence interval 1.01-1.21, P = 0.03) and 19% per 10-unit increase in PMN-% (95% confidence interval 1.06-1.33, P = 0.003) with PMN-% demonstrating better model fit in assessing mortality risk (Akaike information criterion: 1,044 vs 1,048, respectively). In models adjusted for age, chronic hepatitis C virus infection, and Model for End-Stage Liver Disease-Sodium, PMN-% was associated with risk of death (PMN-% 10%-29%, HR 1.17, P = 0.50; PMN-% ≥ 30% group, HR 1.94, P = 0.03; vs PMN-% < 10%) and SBP development (PMN-% 10%-29%, HR 1.68, P = 0.07; PMN-% ≥ 30%, HR 3.48, P < 0.001; vs PMN-% < 10%). DISCUSSION Our results suggest PMN-% at first paracentesis represents a better biomarker compared with PMN-C for assessing risk of death and future SBP development in patients with PMN-C < 250 cells/mm 3 .
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Affiliation(s)
- Lillian Dawit
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Vivian Lee
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - David Lehoang
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Cameron Furey
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Aneesa Chowdhury
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Thu Anne Mai
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Varun Angajala
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Joo Hye Park
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Kevork Khadarian
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Rosemary She
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Maria Vergara-Lluri
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jeffrey Kahn
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jennifer L. Dodge
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- USC Research Center for Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Takeshi Saito
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- USC Research Center for Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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van Os W, Wulkersdorfer B, Eberl S, Oesterreicher Z, Schwabl P, Reiberger T, Paternostro R, Weber M, Willinger B, Zeitlinger M. Bacterial growth and ceftriaxone activity in individual ascitic fluids in an in vitro model of spontaneous bacterial peritonitis. Front Pharmacol 2023; 14:1124821. [PMID: 37063261 PMCID: PMC10090294 DOI: 10.3389/fphar.2023.1124821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 03/20/2023] [Indexed: 03/31/2023] Open
Abstract
Introduction: The environment of the infection site affects bacterial growth and antibiotic activity. When bacterial growth and antibiotic activity are studied in body fluids, samples of multiple subjects are usually pooled, averaging out potentially relevant differences in composition. The ascitic fluid (AF) environment is frequently associated with spontaneous bacterial peritonitis (SBP) in cirrhotic patients. In this study, bacterial growth and ceftriaxone activity were evaluated in individual AF using an in vitro model of SBP, reflecting the environment and pharmacokinetics at the infection site.Methods: AF was obtained from nine cirrhotic patients with non-infected ascites. Growth of nine bacterial strains (three Escherichia coli, four Staphylococcus aureus, one Enterococcus faecalis, and one Klebsiella pneumoniae) in individual AF was assessed and correlated with biomarkers including potential risk factors for SBP. Ceftriaxone time-kill experiments, in which the pharmacokinetic profile observed in AF following a 1 g intravenous infusion was replicated, were performed with two E. coli and two S. aureus isolates with minimum inhibitory concentrations around the ceftriaxone resistance breakpoint.Results: Significant correlations were found between bacterial growth and AF levels of protein (Spearman’s rank correlation coefficient ρ = −0.35), albumin (ρ = −0.31), and complement C3c (ρ = −0.28), and serum levels of bilirubin (ρ = 0.39) and aspartate aminotransferase (ρ = 0.25). Ceftriaxone was active in AF, even against resistant isolates, generally resulting in ≥2 log reductions in bacterial count within 24 h.Conclusion: Ascites patients may be predisposed to or protected against SBP based on the antimicrobial capacity of their AF. Ceftriaxone at clinical AF concentrations is active in the AF environment.
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Affiliation(s)
- Wisse van Os
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | | | - Sabine Eberl
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Zoe Oesterreicher
- Department of Internal Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University of Vienna, Vienna, Austria
| | - Philipp Schwabl
- Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Rafael Paternostro
- Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Maria Weber
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Birgit Willinger
- Department of Microbiology, Medical University of Vienna, Vienna, Austria
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
- *Correspondence: Markus Zeitlinger,
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Crocombe D, Ahmed N, Balakrishnan I, Bordea E, Chau M, China L, Corless L, Danquah V, Dehbi HM, Dillon JF, Forrest EH, Freemantle N, Gear DP, Hollywood C, Hunter R, Jeyapalan T, Kallis Y, McPherson S, Munteanu I, Portal J, Richardson P, Ryder SD, Virk A, Wright G, O'Brien A. ASEPTIC: primary antibiotic prophylaxis using co-trimoxazole to prevent SpontanEous bacterial PeritoniTIs in Cirrhosis-study protocol for an interventional randomised controlled trial. Trials 2022; 23:812. [PMID: 36167573 PMCID: PMC9513307 DOI: 10.1186/s13063-022-06727-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 09/08/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Bacterial infection is a major cause of mortality in patients with cirrhosis. Spontaneous bacterial peritonitis (SBP) is a serious and common infection in patients with cirrhosis and ascites. Secondary prophylactic antibiotic therapy has been shown to improve outcomes after an episode of SBP but primary prophylaxis to prevent the first episode of SBP remains contentious. The aim of this trial is to assess whether primary antibiotic prophylaxis with co-trimoxazole improves overall survival compared to placebo in adults with cirrhosis and ascites. METHODS The ASEPTIC trial is a multicentre, placebo-controlled, double-blinded, randomised controlled trial (RCT) in England, Scotland, and Wales. Patients aged 18 years and older with cirrhosis and ascites requiring diuretic treatment or paracentesis, and no current or previous episodes of SBP, are eligible, subject to exclusion criteria. The trial aims to recruit 432 patients from at least 30 sites. Patients will be randomised in a 1:1 ratio to receive either oral co-trimoxazole 960 mg or an identical placebo once daily for 18 months, with 6 monthly follow-up visits thereafter (with a maximum possible follow-up period of 48 months, and a minimum of 18 months). The primary outcome is overall survival. Secondary outcomes include the time to the first incidence of SBP, hospital admission rates, incidence of other infections (including Clostridium difficile) and antimicrobial resistance, patients' health-related quality of life, health and social care resource use, incidence of cirrhosis-related decompensation events, liver transplantation, and treatment-related serious adverse events. DISCUSSION This trial will investigate the efficacy, safety, and cost-effectiveness of co-trimoxazole for patients with liver cirrhosis and ascites to determine whether this strategy improves clinical outcomes. Given there are no treatments that improve survival in decompensated cirrhosis outside of liver transplant, if the trial has a positive outcome, we anticipate widespread adoption of primary antibiotic prophylaxis. TRIAL REGISTRATION ClinicalTrials.gov NCT043955365 . Registered on 18 April 2020. Research ethical approval was granted by the Research Ethics Committee (South Central - Oxford B; REC 19/SC/0311) and the Medicines and Healthcare products Regulatory Agency (MHRA).
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Affiliation(s)
- Dominic Crocombe
- UCL Institute of Liver and Digestive Health, Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, London, UK
| | - Norin Ahmed
- University College London Comprehensive Clinical Trials Unit, London, UK
| | - Indran Balakrishnan
- Royal Free London NHS Foundation Trust, University College London, London, UK
| | - Ekaterina Bordea
- University College London Comprehensive Clinical Trials Unit, London, UK
| | - Marisa Chau
- University College London Comprehensive Clinical Trials Unit, London, UK
| | - Louise China
- UCL Institute of Liver and Digestive Health, Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, London, UK
| | | | - Victoria Danquah
- University College London Comprehensive Clinical Trials Unit, London, UK
| | - Hakim-Moulay Dehbi
- University College London Comprehensive Clinical Trials Unit, London, UK
| | - John F Dillon
- Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee, UK
| | - Ewan H Forrest
- Gastroenterology Unit, Glasgow Royal Infirmary, University of Glasgow, Glasgow, UK
| | - Nick Freemantle
- University College London Comprehensive Clinical Trials Unit, London, UK
| | | | - Coral Hollywood
- Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - Rachael Hunter
- University College London Comprehensive Clinical Trials Unit, London, UK
| | - Tasheeka Jeyapalan
- University College London Comprehensive Clinical Trials Unit, London, UK
| | - Yiannis Kallis
- The Blizard Institute, Queen Mary University of London, London, UK
| | - Stuart McPherson
- Liver Unit, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, The Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Iulia Munteanu
- University College London Comprehensive Clinical Trials Unit, London, UK
| | - Jim Portal
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Paul Richardson
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Stephen D Ryder
- NIHR Nottingham Biomedical Research Centre at Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, UK
| | - Amandeep Virk
- University College London Comprehensive Clinical Trials Unit, London, UK
| | - Gavin Wright
- Mid & South Essex NHS Foundation Trust, Basildon, UK
| | - Alastair O'Brien
- UCL Institute of Liver and Digestive Health, Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, London, UK. a.o'.,University College London Comprehensive Clinical Trials Unit, London, UK. a.o'.,University College London Hospitals NHS Foundation Trust, London, UK. a.o'
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Wu PS, Wang YW, Tai CC, Hsieh YC, Lee PC, Huang CC, Huang YH, Hou MC, Lin HC, Lee KC. Early echocardiographic signs of diastolic dysfunction predict acute kidney injury in cirrhotic patients. J Chin Med Assoc 2020; 83:984-990. [PMID: 32889984 PMCID: PMC7647425 DOI: 10.1097/jcma.0000000000000422] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Cardiovascular dysfunction in cirrhotic patients affects survival and the development of cirrhotic complications. We aimed to evaluate potential echocardiographic parameters to predict mortality and acute kidney injury (AKI) in cirrhotic patients. METHODS A total of 103 cirrhotic patients who underwent echocardiography between February 2009 and August 2016 in Taipei Veterans General Hospital were retrospectively enrolled. Cardiac function was evaluated using transthoracic two-dimensional echocardiography with tissue Doppler imaging. Cox hazard regression analysis was used for assessing predictors for 1-year mortality and AKI within 1 year. RESULTS Baseline echocardiographic parameters were similar between survivors (n = 92) and nonsurvivors (n = 11). Lower serum levels of albumin, as well as higher albumin-bilirubin (ALBI) scores, Child-Pugh scores, and model for end-stage liver disease scores were observed in nonsurvivors. Cox proportional hazard regression analysis revealed Child-Pugh score as the only predictor of 1-year mortality. Baseline serum creatinine (Cr) > 1.5 mg/dL, total bilirubin > 2 mg/dL, and a higher E/e' ratio predict occurrence of AKI within 1 year. Among patients with serum Cr < 1.5 mg/dL, an increased atrial filling velocity and higher ALBI scores predict AKI occurrence within 1 year. CONCLUSION Severity of underlying liver disease but not echocardiographic parameters predicts 1-year mortality in cirrhosis. Early echocardiographic signs of diastolic dysfunction and higher ALBI scores may predict development of AKI in cirrhotic patients with serum Cr < 1.5 mg/dL.
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Affiliation(s)
- Pei-Shan Wu
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC
| | - Ying-Wen Wang
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC
- Department of Healthcare and Service Center, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Cheng-Chun Tai
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC
| | - Yun-Cheng Hsieh
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC
| | - Pei-Chang Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC
| | - Chin-Chou Huang
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yi-Hsiang Huang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC
| | - Ming-Chih Hou
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC
| | - Han-Chieh Lin
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC
| | - Kuei-Chuan Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC
- Address correspondence. Dr. Kuei-Chuan Lee, Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, 201, Section 2, Shi-Pai Road, Taipei 112, Taiwan, ROC. E-mail address: (K.-C. Lee)
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Moon H, Kim HJ, Woo SM, Park IH, Sim SH. Discrimination of ascitic fluid infection in malignant ascites by polymorphonuclear neutrophil ratio and count: Investigating the validity of count ≥250/mm 3 as the one-size-fits-all criterion. Asia Pac J Clin Oncol 2020; 17:e87-e93. [PMID: 32762145 DOI: 10.1111/ajco.13344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 03/16/2020] [Indexed: 11/28/2022]
Abstract
AIM Neutrocytic ascites, traditionally defined as a polymorphonuclear neutrophil count ≥250/mm3 , is infrequently reported during paracenteses to relieve malignant ascites (MA). This study aims to explore new potential diagnostic criteria to discriminate ascitic fluid infection associated with MA and to examine the clinical and laboratory characteristics of neutrocytic ascites. METHODS The investigators retrospectively collected data on paracenteses to relieve MA at the Emergency Department of National Cancer Center, Korea, from January 2014 to February 2017. We analyzed the patients whose ascites fulfilled the traditional criteria for classification as neutrocytic ascites; polymorphonuclear neutrophils ≥250/mm3 with no history of either hepatocellular carcinoma or liver cirrhosis. RESULTS In total, 1467 patients underwent paracentesis to relieve MA. Excluding 98 follow-up paracenteses cases, 112 cases (8.2%) showed neutrocytic ascites. Of these 112 patients, 27 (24.1%) had positive culture results. Receiver-operating characteristic analysis indicated that the area under the curve (AUC) values were 0.90 (95% CI 0.82-0.95) and 0.86 (95% CI 0.78-0.92) for polymorphonuclear neutrophil ratio and count, respectively. The difference between the two AUCs was not statistically significant (P = .29). Moreover, the best cutoff points were 70% and 1500/mm3 for polymorphonuclear neutrophil ratio and count, respectively. In addition, extensive liver metastasis was a significant independent risk factor of MA associated with ascitic fluid infection. CONCLUSIONS Both polymorphonuclear neutrophil ratio and count had good discriminative abilities for culture results in MA. Polymorphonuclear neutrophil ratio was somewhat better despite lacking statistical significance compared to polymorphonuclear neutrophil count, with 70% as best cutoff.
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Affiliation(s)
- Hae Moon
- Department of Internal Medicine, National Cancer Center, Goyang, Republic of Korea
| | - Hak Jin Kim
- Department of Cardiology, Center for Clinical Specialty, National Cancer Center, Goyang, Republic of Korea
| | - Sang Myung Woo
- Center for Liver Cancer, National Cancer Center, Goyang, Republic of Korea
| | - In Hae Park
- Center for Breast Cancer, National Cancer Center, Goyang, Republic of Korea
| | - Sung Hoon Sim
- Center for Breast Cancer, National Cancer Center, Goyang, Republic of Korea
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Abstract
Bacterial infection remains a leading cause of mortality and morbidity for patients with cirrhosis, with hospitalization, alterations in the intestinal microbiota, and therapeutic drugs all implicated in its development. Bacterial infections also remain the most common precipitant of acute-on-chronic liver failure, with infection occurring as a direct consequence of the progression of this syndrome. Furthermore, recent epidemiological analyses have demonstrated that infections due to multidrug-resistant bacteria are occurring with increasing frequency in patients with cirrhosis. Despite significant advances in the understanding of the pathophysiological processes triggered by an infection in patients with cirrhosis, a demonstrable survival benefit for the sickest patients who require ICU admission has not yet occurred. Early diagnosis of infection and appropriate antimicrobial treatment is essential to ensuring optimal outcomes for these patients. This review provides an evidence-based analysis of both the current strategies for prevention and the recommended management of common bacterial infections in patients with cirrhosis.
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Affiliation(s)
- Mary D Cannon
- Institute of Liver Studies, King's College Hospital, London, SE5 9RS, UK.
| | - Paul Martin
- Division of Gastroenterology and Hepatology, University of Miami, Miami, FL, USA
| | - Andres F Carrion
- Division of Gastroenterology and Hepatology, University of Miami, Miami, FL, USA
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10
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Ghafar AA, Rozaik S, Akef A. Rifaximin plus norfloxacin versus norfloxacin alone in primary prophylaxis of spontaneous bacterial peritonitis in patients with variceal bleeding. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2019. [DOI: 10.4103/ejim.ejim_6_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Fouad TR, Abdelsameea E, Elsabaawy M, Ashraf Eljaky M, Zaki El-Shenawy S, Omar N. Urinary neutrophil gelatinase-associated lipocalin for diagnosis of spontaneous bacterial peritonitis. Trop Doct 2019; 49:189-192. [PMID: 30786830 DOI: 10.1177/0049475519830265] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2024]
Abstract
Cirrhotic patients with ascites are at high risk of developing spontaneous bacterial peritonitis (SBP). After exclusion of patients with acute kidney injury (AKI) or other infections, urinary neutrophil gelatinase-associated lipocalin (NGAL) levels were compared between two matched groups of Egyptian cirrhotic patients with ascites, mostly secondary to hepatitis C infection (98%). Group 1 had SBP (n = 41) and group 2 did not (n = 45). By univariate analysis, urinary-NGAL, high total bilirubin, serum creatinine, international normalised ratio and the Model of End-Stage Liver Disease (MELD) score and low platelet count were all significantly correlated with the presence of SBP, but only urinary-NGAL could independently predict development of SBP (P = 0.001). Urinary-NGAL at a cut-off value of 1225 pg/mL, showed a sensitivity of 95% and a specificity of 76%, and is therefore a most useful tool.
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Affiliation(s)
- Tamer R Fouad
- 1 Hepatology and Gastroenterology Department, National Liver Institute, Menofia University, Menofia Governate, Egypt
| | - Eman Abdelsameea
- 1 Hepatology and Gastroenterology Department, National Liver Institute, Menofia University, Menofia Governate, Egypt
| | - Maha Elsabaawy
- 1 Hepatology and Gastroenterology Department, National Liver Institute, Menofia University, Menofia Governate, Egypt
| | - M Ashraf Eljaky
- 1 Hepatology and Gastroenterology Department, National Liver Institute, Menofia University, Menofia Governate, Egypt
| | - Soha Zaki El-Shenawy
- 2 Clinical Biochemistry Department, National Liver Institute, Menofia University, Menofia Governate, Egypt
| | - Nabil Omar
- 1 Hepatology and Gastroenterology Department, National Liver Institute, Menofia University, Menofia Governate, Egypt
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12
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Duah A, Nkrumah KN. Spontaneous bacterial peritonitis among adult patients with ascites attending Korle-Bu Teaching Hospital. Ghana Med J 2019; 53:37-43. [PMID: 31138942 PMCID: PMC6527825 DOI: 10.4314/gmj.v53i1.6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Background Spontaneous bacterial peritonitis (SBP) is one of the most common and life-threatening complications of ascites, mostly in patients with cirrhotic ascites and children with nephrotic syndrome. Recognition and prompt treatment of this condition is essential to prevent serious morbidity and mortality. It is therefore important to determine the prevalence of SBP among in-patients with ascites attending our facility and to determine the clinical characteristics associated with SBP among these patients. Methods A cross-sectional study was conducted involving 140 patients with ascites irrespective of the underlying cause from 25th March 2016 to 25th November 2016. Demographic information and clinical data were collected using a standardized questionnaire. Ascitic fluid culture, the gold standard for SBP diagnosis and ascitic fluid cell count was done. Positive ascitic fluid culture and/ or ascitic polymorpho nuclear leukocyte ≥250cells/mm3 were diagnostic for SBP. Results Of the 140 patients with ascites the mean age was 44.7±13.2 years. There were seventy six (76) male and sixty four (64) female patients. The prevalence of SBP was 21.43% (30/140). Majority, (41.7%) of the bacteria isolated from ascitic fluid with SBP was Escherichia coli. History of jaundice, low arterial blood pressure on admission and encephalopathy were found to be independent predictors of SBP. Conclusion SBP is common among patients with ascites admitted at the Korle-Bu Teaching Hospital. Jaundice, encephalopathy and low blood pressure are highly suggestive of SBP and diagnostic paracentesis should be done immediately on admission to confirm the diagnosis. Funding None.
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Affiliation(s)
- Amoako Duah
- Department of Medicine, St. Dominic Hospital, P.O. Box 59, Akwatia, Ghana
| | - Kofi N Nkrumah
- Department of Medicine nd Therapeutics, School of Medicine and Dentistry, College Of Health Science, University Of Ghana, P.O. Box 4236, Korle-Bu, Accra, Ghana
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13
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Shamseya MM, Madkour MA. Rifaximin: A reasonable alternative for norfloxacin in the prevention of spontaneous bacterial peritonitis in patients with HCV-related liver cirrhosis. ALEXANDRIA JOURNAL OF MEDICINE 2019. [DOI: 10.1016/j.ajme.2015.09.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Mohammed M. Shamseya
- Department of Clinical and Experimental Internal Medicine, Medical Research Institute, University of Alexandria, EgyptDepartment of Clinical and Experimental Internal Medicine, Medical Research Institute, University of Alexandria, Egypt
| | - Marwa A. Madkour
- Department of Clinical and Experimental Internal Medicine, Medical Research Institute, University of Alexandria, EgyptDepartment of Clinical and Experimental Internal Medicine, Medical Research Institute, University of Alexandria, Egypt
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14
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Duah A, Nkrumah KN. Prevalence and predictors for spontaneous bacterial peritonitis in cirrhotic patients with ascites admitted at medical block in Korle-Bu Teaching Hospital, Ghana. Pan Afr Med J 2019; 33:35. [PMID: 31384350 PMCID: PMC6658157 DOI: 10.11604/pamj.2019.33.35.18029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Accepted: 04/03/2019] [Indexed: 02/06/2023] Open
Abstract
Introduction Spontaneous bacterial peritonitis (SBP) is one of the most common and life-threatening complications of patients with cirrhotic ascites. Recognition and prompt treatment of this condition is essential to prevent serious morbidity and mortality. This study aimed to determine the prevalence of SBP among in-patients with cirrhotic ascites attending our facility and to determine the clinical and laboratory parameters associated with SBP. Methods A cross-sectional study was conducted involving one hundred and three (103) patients admitted at medical block in the Korle-Bu Teaching Hospital (KBTH) with cirrhotic ascites from 25th March, 2016 to 25th November, 2016. Demographic and clinical data were collected using a standardized questionnaire. Ascitic fluid culture and cell count were conducted. Positive ascitic fluid culture and/or ascitic polymorphonuclear leukocyte ≥ 250cells/mm3 were diagnostic for SBP. Results Of the 103 patients with cirrhotic ascites, the mean age was 43.5 ± 12.2 years. There were fifty eight (58) male patients. The prevalence of SBP was 25.24% (26/103). Majority, 5 (55.6%) of the bacteria isolated from ascitic fluid with SBP was Escherichia coli. Severe ascites and high INR were found to be independent predictors of SBP. Conclusion SBP is common among patients with cirrhotic ascites admitted at KBTH. Severe ascites and high INR were highly suggestive of SBP. Diagnostic paracentesis should be done immediately on admission to confirm the diagnosis irrespective of the clinical characteristics as part of baseline investigation.
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Affiliation(s)
- Amoako Duah
- Department of Medicine, St Dominic Hospital, Akwatia, Ghana
| | - Kofi Nyaako Nkrumah
- Department of Medicine and Therapeutictics, School of Medicine and Dentistry, College Of Health Science, University Of Ghana, Korle-Bu, Accra, Ghana
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15
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Abstract
Spontaneous bacterial peritonitis (SBP) is defined as bacterial infections that occur in patients with cirrhosis and ascites without any significant intraperitoneal infection, accounting for approximately 10-30% of bacterial infections in hospitalized patients. SBP develops in patients with liver cirrhosis because bacterial translocations are increased by changes in the intestinal bacteria and mucosal barriers. In addition, the decreased host immune response cannot remove the bacteria and their products. The most common cause of SBP is Gram-negative bacteria, such as Escherichia coli and Klebsiella species, and infections by Gram-positive bacteria are increasing. SBP is diagnosed by the presence of >250 polymorphonuclear leukocyte/mm3 in ascites after paracentesis. If SBP is diagnosed, empirical antibiotic therapy should be started immediately. Empirical antibiotic treatment should distinguish between community acquired infections and nosocomial infections. Cirrhotic patients with gastrointestinal bleeding or low ascitic protein concentrations should consider primary prevention and those who recover from SBP should consider secondary prevention. This review describes the pathophysiology, diagnosis, treatment, and prevention of SBP.
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Affiliation(s)
- Do Seon Song
- Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
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16
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Trends in Hospitalization, Acute Kidney Injury, and Mortality in Patients With Spontaneous Bacterial Peritonitis. J Clin Gastroenterol 2019; 53:e68-e74. [PMID: 29252684 DOI: 10.1097/mcg.0000000000000973] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
GOALS The purpose of our study was to evaluate trends of hospitalization, acute kidney injury (AKI) and mortality in cirrhotic patients with spontaneous bacterial peritonitis (SBP). BACKGROUND SBP is a frequent bacterial infection in cirrhotic patients leading to increased morbidity and mortality. MATERIALS AND METHODS A total of 4,840,643 patients hospitalized with cirrhosis from 2005 to 2014 were identified using the Nationwide Inpatient Sample database, of which 115,359 (2.4%) had SBP. We examined annual trends and used multivariable mixed-effects logistic regression analyses to obtain adjusted odds ratios by accounting for hospital level and patient level variables. RESULTS We identified a striking increase in hospitalizations for SBP in cirrhotic patients (0.45% to 3.12%) and AKI in SBP patients (25.6% to 46.7%) from 2005 to 2014. Inpatient mortality decreased over the study period in patients with SBP (19.1% to 16.1%) and in patients with SBP plus AKI (40.9% to 27.6%). Patients with SBP had a higher inpatient mortality rate than those without SBP [15.5% vs. 6%, adjusted odd ratio (aOR): 2.02, P<0.001]. AKI was 2-fold more prevalent in cirrhotics with SBP than those without SBP (42.8% vs. 17.2%, aOR: 1.91, P<0.001) and concomitant AKI was associated with a 6-fold mortality increase (aOR: 5.84, P<0.001). Cirrhotic patients with SBP had higher hospitalization costs and longer length of stays than patients without SBP. CONCLUSIONS Despite a higher hospitalization rate and prevalence of concomitant AKI, mortality in patients with SBP decreased during the study period. SBP is associated with high likelihood of development of AKI, which in turn, increases mortality.
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Metwally K, Fouad T, Assem M, Abdelsameea E, Yousery M. Predictors of Spontaneous Bacterial Peritonitis in Patients with Cirrhotic Ascites. J Clin Transl Hepatol 2018; 6:372-376. [PMID: 30637213 PMCID: PMC6328737 DOI: 10.14218/jcth.2018.00001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 06/07/2018] [Accepted: 06/22/2018] [Indexed: 12/14/2022] Open
Abstract
Background and Aims: Spontaneous bacterial peritonitis (SBP) is a serious complication of liver cirrhosis and a prognostic model to predict it is needed. This study was designed to test the ability of different laboratory tests and the new scoring system by Wehmeyer and colleagues (consisting of age, C-reactive protein (CRP) and platelet count) to predict it. Methods: Three-hundred patients admitted to the National Liver Institute, University of Menoufia, Egypt (2015-2016) with liver cirrhosis and ascites were included in our study. SBP was diagnosed if ascetic neutrophil count was ≥250/µL with no sign of secondary peritonitis. Results: The patient population had age range of 29-81 years old, was 60% men and showed a majority (91.7%) with primary cause of liver disease being hepatitis C. By univariate analysis, associations with age, total bilirubin, aspartate aminotransferase level, creatinine level, international normalized ratio, model for end-stage liver disease score, total leucocytic count, platelet count and CRP level were significant. By multivariate analysis, independent predictors were age, platelet count and CRP level (p = 0.004, 0.013 and <0.001, respectively). CRP at a cut-off point ≥13.5 mg/L could predict SBP (sensitivity of 86.4% and specificity of 66.0%). Wehmeyer's SBP scoring system was predictive (p < 0.001); only 4% of patients with 0 score developed SBP (CRP cut-off of 30 mg/L), while 92.8% with score of 3 or 4 developed SBP. By using our modified Wehmeyer score with CRP cut-off value of 13.5 mg/L, no patient with 0 score developed SBP. Conclusions: Age, CRP level and platelet count are independent predictors for SBP and a scoring system including them could easily predict the condition. SBP diagnosis could be excluded in patients with 0 score, using CRP cut-off value of 13.5 mg/L.
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Affiliation(s)
- Khaled Metwally
- Hepatology and Gastroenterology department, National Liver Institute, Menoufia University, Egypt
- *Correspondence to: Khaled Metwally, Liver and Gastroenterology Unit, National Liver Institute, University of Menoufyia, Menofyia Governorate, Egypt. Tel: +20-100-0486019, Fax: + 20-48-2222740, E-mail:
| | - Tamer Fouad
- Hepatology and Gastroenterology department, National Liver Institute, Menoufia University, Egypt
| | - Medhat Assem
- Hepatology and Gastroenterology department, National Liver Institute, Menoufia University, Egypt
| | - Eman Abdelsameea
- Hepatology and Gastroenterology department, National Liver Institute, Menoufia University, Egypt
| | - Mohamed Yousery
- Hepatology and Gastroenterology department, National Liver Institute, Menoufia University, Egypt
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18
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Spontaneous bacterial peritonitis - therapeutic challenges in the era of increasing drug resistance of bacteria. Clin Exp Hepatol 2018; 4:224-231. [PMID: 30603669 PMCID: PMC6311748 DOI: 10.5114/ceh.2018.80123] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Accepted: 11/04/2018] [Indexed: 12/17/2022] Open
Abstract
Spontaneous bacterial peritonitis (SBP) is one of the most common bacterial infections in patients with liver cirrhosis and it significantly contributes to the deterioration of the prognosis and increased risk of mortality. Previous data suggested that the most common pathogens causing SBP are G-negative aerobic bacteria and treatment recommended by the international guidelines (EASL, AASLD) is highly effective. In recent years, due to the widespread use of antibiotic prophylaxis and the increased frequency of hospitalization along with the use of invasive procedures in patients with cirrhosis, the involvement of Gram-positive cocci and multi-drug resistant bacteria in the etiology of SBP is increasing. This is related to the lowering of the effectiveness of the first-line therapy used so far and worsening of the prognosis, increasing in-hospital mortality. In this work we summarize current data on the characteristics of pathogens responsible for SBP in the context of currently recommended treatment regimens.
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19
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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
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20
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Rauber P, Lammert F, Grotemeyer K, Appenrodt B. Immature platelet fraction and thrombopoietin in patients with liver cirrhosis: A cohort study. PLoS One 2018; 13:e0192271. [PMID: 29438423 PMCID: PMC5810997 DOI: 10.1371/journal.pone.0192271] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 01/18/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND AND AIMS Thrombocytopenia occurs frequently in patients with cirrhosis. The immature platelet fraction (IPF%) is measured to differentiate the causes of thrombocytopenia. To date the relevance of thrombopoietin (TPO) in the context of cirrhosis is unknown. The aim of our study was to investigate the cause of thrombocytopenia in patients with liver cirrhosis by measuring IPF%, TPO and spleen size. In addition we examined the use of IPF% to evaluate the severity of cirrhosis and its complications. METHODS Overall, we included 88 in-patients with cirrhosis in our study. The collected data comprises current health status, blood parameters, severity of cirrhosis evaluated by Child-Pugh score and MELD score, spleen diameter, ascites and esophageal varices. The IPF% was measured using an automatic hematology analyzer. TPO was measured with ELISA. RESULTS IPF% (p = 0.003) and spleen diameter (p = 0.001) were significantly higher in patients with thrombocytopenia. There was no significant difference in TPO between patients with and without thrombocytopenia. The mean values of IPF% varied significantly (p = 0.044) in Child-Pugh stages. IPF% was significantly (p = 0.005) elevated in patients with esophageal varices. Moreover, IPF% higher than 3.85% displayed sensitivity of 76.6% and specificity of 52.4% with an area under receiver operating curve characteristics of 0.669 for the presence of esophageal varices. CONCLUSION On closer examination of the three compartments known to have an influence on platelet count splenomegaly seems to be the major cause of thrombocytopenia in patients with cirrhosis according to current knowledge. Higher IPF% in patients with thrombocytopenia indicates peripheral consumption of platelets. The relation between spleen diameter and platelet count indicates the spleen to be the major place of platelets' consumption. TPO did not differ between patients with and without thrombocytopenia. Furthermore, we cannot exclude an influence of impaired thrombopoietin synthesis on platelet counts. The association between IPF% and platelet count suggests that there is physiological regulation of platelets in patients with cirrhosis. In our study IPF% is associated with esophageal varices and the stage of cirrhosis. Further studies are needed to confirm these results.
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Affiliation(s)
- Philip Rauber
- Department of Neurology, Saarland University Medical Center, Homburg/Saar, Germany
- * E-mail:
| | - Frank Lammert
- Department of Medicine II, Saarland University Medical Center, Homburg/Saar, Germany
| | - Katharina Grotemeyer
- Department of Medicine II, Saarland University Medical Center, Homburg/Saar, Germany
| | - Beate Appenrodt
- Department of Medicine II, Saarland University Medical Center, Homburg/Saar, Germany
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21
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Mo S, Bendtsen F, Wiese SS, Kimer N. Low ascitic fluid total protein levels is not associated to the development of spontaneous bacterial peritonitis in a cohort of 274 patients with cirrhosis. Scand J Gastroenterol 2018; 53:200-205. [PMID: 29214880 DOI: 10.1080/00365521.2017.1411973] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Spontaneous bacterial peritonitis (SBP) is a complication to decompensated cirrhosis. Fluoroquinolones may prevent SBP. However, predictive markers for SBP are wanted. Guidelines suggest that patients with ascitic fluid protein below 15 g/l receive fluoroquinolones to prevent SBP. This study aimed to assess the clinical utility of low ascitic fluid protein in predicting SBP in patients with cirrhosis and ascites. METHODS A total of 274 patients with cirrhosis and ascites underwent paracentesis between January 2010 and June 2015. Patients were followed until two years, development of SBP, initiation of ciprofloxacin, death or liver transplantation. Data were compared between groups of patients with 'high' or 'low' ascitic protein. RESULTS SBP developed in 31 patients (11.3%). No difference in mean ascitic fluid protein levels were found (SBP, mean: 8.5 g/l and no SBP 8.2 g/l, p = .825). SBP developed at equal rates in patients with 'high' or 'low' ascitic protein (10.8% (≤15 g/l) and 14.0% (>15 g/l), p = .599). The same trend was observed when adjusting the threshold below 10 g/l (11.9% (≤10 g/l) and 10.2% (>10 g/l), p = .697). CONCLUSIONS Low ascitic fluid protein does not predict SBP in patients with cirrhosis and ascites. Better markers are needed.
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Affiliation(s)
- Silje Mo
- a Gastro Unit 360, Medical Division , Copenhagen University Hospital , Hvidovre , Denmark
| | - Flemming Bendtsen
- a Gastro Unit 360, Medical Division , Copenhagen University Hospital , Hvidovre , Denmark
| | - Signe Skovgaard Wiese
- a Gastro Unit 360, Medical Division , Copenhagen University Hospital , Hvidovre , Denmark
| | - Nina Kimer
- a Gastro Unit 360, Medical Division , Copenhagen University Hospital , Hvidovre , Denmark
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22
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Abstract
Alcohol-related liver disease (ALD) remains the most important cause of death due to alcohol. Infections, particularly bacterial infections, are one of the most frequent and severe complications of advanced ALDs, such as alcoholic cirrhosis and severe alcoholic hepatitis (sAH). The specific mechanisms responsible for this altered host defence are yet to be deciphered. The aim of the present study is to review the current knowledge of infectious complications in ALD and its pathophysiological mechanisms, distinguishing the role of alcohol consumption and the contribution of different forms of ALD. To date, corticosteroids are the only treatment with proven efficacy in sAH, but their impact on the occurrence of infections remains controversial. The combination of an altered host defence and corticosteroid treatment in sAH has been suggested as a cause of opportunistic fungal and viral infections. A high level of suspicion with systematic screening and prompt, adequate treatment are warranted to improve outcomes in these patients. Prophylactic or preemptive strategies in this high-risk population might be a preferable option, because of the high short-term mortality rate despite adequate therapies. However, these strategies should be assessed in well-designed trials before clinical implementation.
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Hung TH, Tsai CC, Hsieh YH, Tsai CC, Tseng CW, Tseng KC. The Effect of the First Spontaneous Bacterial Peritonitis Event on the Mortality of Cirrhotic Patients with Ascites: A Nationwide Population-Based Study in Taiwan. Gut Liver 2017; 10:803-7. [PMID: 27563023 PMCID: PMC5003205 DOI: 10.5009/gnl13468] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Revised: 03/06/2014] [Accepted: 03/10/2014] [Indexed: 12/15/2022] Open
Abstract
Background/Aims Spontaneous bacterial peritonitis (SBP) contributes to poorer short-term mortality in cirrhotic patients with ascites. However, it is unknown how long the effect of the first SBP event persists in these patients. Methods The National Health Insurance Database, derived from the Taiwan National Health Insurance Program, was used to identify and enroll 7,892 cirrhotic patients with ascites who were hospitalized between January 1 and December 31, 2007. All patients were free from episodes of SBP from 1996 to 2006. Results The study included 1,176 patients with SBP. The overall 30-day, 90-day, 1-year, and 3-year mortality rates in this group were 21.8%, 38.9%, 57.5%, and 73.4%, respectively. The overall 30-day, 90-day, 1-year, and 3-year mortality rates in the non-SBP group were 15.7%, 32.5%, 53.3%, and 72.5%, respectively. After adjusting for gender, age, and other medical comorbidities, the adjusted hazard ratios of SBP for 30-day, 30- to 90-day, 90-day to 1-year, and 1- to 3-year mortality were 1.49 (95% confidence interval [CI], 1.30 to 1.71), 1.19 (95% CI, 1.02 to 1.38), 1.04 (95% CI, 0.90 to 1.20), and 0.90 (95% CI, 0.77 to 1.05), respectively, compared with the non-SBP group. Conclusions The effect of SBP on the mortality of cirrhotic patients with ascites disappeared in those surviving more than 90 days after the first SBP event.
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Affiliation(s)
- Tsung-Hsing Hung
- Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chen-Chi Tsai
- Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Yu-Hsi Hsieh
- Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chih-Chun Tsai
- Department of Mathematics, Tamkang University, Tamsui, Taiwan
| | - Chih-Wei Tseng
- Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Kuo-Chih Tseng
- Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
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Fernández J, Acevedo J, Prado V, Mercado M, Castro M, Pavesi M, Arteaga M, Sastre L, Juanola A, Ginès P, Arroyo V. Clinical course and short-term mortality of cirrhotic patients with infections other than spontaneous bacterial peritonitis. Liver Int 2017; 37:385-395. [PMID: 27558198 DOI: 10.1111/liv.13239] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 08/11/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Clinical course and risk factors of death in non-spontaneous bacterial peritonitis (SBP) infections are poorly known. We assessed the prevalence of acute kidney injury (AKI) and type-1 hepatorenal syndrome (HRS), hospital, 30-day and 90-day mortality and risk factors of death in 441 decompensated patients. METHODS Analysis of 615 non-SBP infections (161 urinary infections (UTI), 95 cellulitis, 92 suspected infections, 92 bacteraemias, 84 pneumonias, 21 bronchitis, 18 cholangitis, 15 spontaneous empyema, 13 secondary peritonitis, 24 other). RESULTS Ninety-six percent of infections solved. AKI and type-1 HRS were developed in 37% and 9% of infections respectively. Overall hospital, 30-day and 90-day mortality rates were 11%, 12% and 18% respectively. Clinical course and mortality differed markedly across infections. Endocarditis, osteoarticular infections, pneumonia, spontaneous bacteraemia, cholangitis, secondary peritonitis and UTI showed higher rates of AKI. Prevalence of type-1 HRS was not significantly different among infections. Endocarditis, secondary peritonitis, pneumonia and bacteraemia showed lower rates of renal impairment resolution and higher hospital mortality associated with AKI (42% vs 12%, P<.0001) or type-1 HRS (71% vs 27%, P=.003) than the rest of infections. Age (HR: 1.04), serum sodium (HR: 0.91), serum bilirubin (HR: 1.06), INR (HR: 1.91), hepatic encephalopathy (HR: 2.44), ascites (HR: 3.06) and multidrug-resistant isolation (HR: 2.27) at infection diagnosis were independent predictors of death during hospitalization. CONCLUSIONS Non-SBP infections constitute a heterogeneous group regarding clinical course and prognosis. Endocarditis, secondary peritonitis, pneumonia and bacteraemia show worse prognosis. The combination of data of liver and renal dysfunction and of the type of infection allows the identification of patients with poor prognosis.
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Affiliation(s)
- Javier Fernández
- Liver Unit, Hospital Clinic, Barcelona, Spain.,IDIBAPS, University of Barcelona, Barcelona, Spain.,CIBEREHED, Barcelona, Spain.,EASL-CLIF Consortium-Efclif, Barcelona, Spain
| | - Juan Acevedo
- Liver Unit, Hospital Clinic, Barcelona, Spain.,IDIBAPS, University of Barcelona, Barcelona, Spain.,CIBEREHED, Barcelona, Spain
| | - Verónica Prado
- Liver Unit, Hospital Clinic, Barcelona, Spain.,IDIBAPS, University of Barcelona, Barcelona, Spain.,CIBEREHED, Barcelona, Spain
| | | | - Miriam Castro
- Liver Unit, Hospital Clinic, Barcelona, Spain.,IDIBAPS, University of Barcelona, Barcelona, Spain.,CIBEREHED, Barcelona, Spain
| | | | - Mireya Arteaga
- Liver Unit, Hospital Clinic, Barcelona, Spain.,IDIBAPS, University of Barcelona, Barcelona, Spain.,CIBEREHED, Barcelona, Spain
| | - Lydia Sastre
- Liver Unit, Hospital Clinic, Barcelona, Spain.,IDIBAPS, University of Barcelona, Barcelona, Spain.,CIBEREHED, Barcelona, Spain
| | | | - Pere Ginès
- Liver Unit, Hospital Clinic, Barcelona, Spain.,IDIBAPS, University of Barcelona, Barcelona, Spain.,CIBEREHED, Barcelona, Spain.,EASL-CLIF Consortium-Efclif, Barcelona, Spain
| | - Vicente Arroyo
- Liver Unit, Hospital Clinic, Barcelona, Spain.,IDIBAPS, University of Barcelona, Barcelona, Spain.,CIBEREHED, Barcelona, Spain.,EASL-CLIF Consortium-Efclif, Barcelona, Spain
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25
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Na HY, Kim JH, Choe WH, Kwon SY, Yoo BC. Clinical Features of Spontaneous Bacterial Peritonitis: A 10-year Experience from a Single Center. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2017; 69:129-134. [PMID: 28239081 DOI: 10.4166/kjg.2017.69.2.129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background/Aims Spontaneous bacterial peritonitis (SBP) is one of critical complications in liver cirrhosis patients with ascites. We aimed to review clinical course of SBP patients in a 10-year period from single center. Methods This study enrolled SBP patients between 2005 and 2015. Their medical records were reviewed. The laboratory findings of serum and ascites were examined, and characteristics of isolated microorganisms in ascites were analyzed. Results Total 51 patients were enrolled. Male patients were predominant (64.7%), and mean age was 59.20 years. The most common etiology of cirrhosis was alcohol (41.2%), followed by hepatitis B (39.2%). Microorganism was isolated from the ascites in 31 patients (60.78%). The proportions of Gram negative and Gram positive were 80.64% and 19.36%. The proportions of Escherichia coli, Klebsiella, and Streptococcus species were 29.41%, 19.61% and 11.76%. Among Escherichia colis, 4 cases were ESBL positive (7.84%). The most commonly used first-line antibiotic was cefotaxime (80.40%). Prophylactic antibiotics treatment was performed only in 8 patients, and SBP was recurred in 7 patients (13.72%). When comparing the SBP recurrence group and the non-recurrence group, there were no significant differences in laboratory findings of serum and ascitic fluid. Conclusions SBP is still a critical complication in cirrhosis patients with ascites, and the clinical features of SBP have not been altered much compared with those in 1990's. The effective treatment of SBP is still very important for a better prognosis of cirrhosis patients.
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Affiliation(s)
- Ha Young Na
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Jeong Han Kim
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Won Hyeok Choe
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - So Young Kwon
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Byung Chul Yoo
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
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The Periscreen Strip Is Highly Efficient for the Exclusion of Spontaneous Bacterial Peritonitis in Cirrhotic Outpatients. Am J Gastroenterol 2016; 111:1402-1409. [PMID: 27619833 DOI: 10.1038/ajg.2016.344] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 07/26/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES We aimed to assess the performance of a new strip (Periscreen) for the rapid diagnosis of spontaneous bacterial peritonitis (SBP). METHODS Ascitic fluid (AF) of cirrhotic patients hospitalized between March 2014 and August 2015 was independently tested by two readers using the new strip, which has four colorimetric graduations (negative, trace, small, and large). SBP was diagnosed on neutrophils in ascites>250/mm3. Ascites not related to portal hypertension were excluded. RESULTS Overall, 649 patients from 21 French centers were included and 1,402 AF (803 AF samples from 315 outpatients and 599 samples from 334 inpatients) were assessed. Eighty-four AF samples (17 AF in 9 outpatients and 67 AF in 31 inpatients) were diagnosed as SBP. The prevalence of SBP was 6% (2.1% in outpatients vs. 11.2% in inpatients; P<0.001) and 7.2% in patients with symptoms suggestive of SBP (3% in outpatients vs. 11.3% in inpatients; P<0.001). The κ value for inter-reader agreement was 0.81 (95% confidence interval: 0.77-0.84) when using the "trace" threshold. Considering discordant results (n=131) as positive to interpret the diagnostic performance of the strip at the "trace" threshold, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 91.7, 57.1, 12.0, and 99.1%, respectively. At this "trace" threshold, sensitivity and NPV were both 100% in outpatients, and 89.5 and 97.9% in inpatients, respectively. At the "small" threshold, sensitivity, specificity, PPV and NPV were 81.0, 85.9, 25.9 and 98.7%, respectively. CONCLUSIONS The Periscreen strip is a rapid and highly efficient tool for excluding SBP in the outpatient setting.
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McDonald DP, Leithead JA, Gunson BK, Ferguson JW. Subclinical spontaneous bacterial peritonitis at the time of liver transplantation does not impact on outcomes. Eur J Gastroenterol Hepatol 2016; 28:101-6. [PMID: 26445380 DOI: 10.1097/meg.0000000000000473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Liver transplant recipients are often screened for spontaneous bacterial peritonitis during the immediate preoperative evaluation to determine medical fitness to proceed. However, it is unknown whether subclinical spontaneous bacterial peritonitis impacts on post-transplant outcomes. Our aim was to determine whether subclinical spontaneous bacterial peritonitis detected at the preoperative evaluation influences the decision to proceed, and subsequent postoperative morbidity and mortality. METHODS This study is a single-centre study of 1231 adults attending for possible first elective single-organ liver transplantation between January 2000 and December 2011. RESULTS A total of 434 patients underwent ascitic fluid sampling on 460 occasions. Nineteen samples fulfilled the diagnostic criteria for spontaneous bacterial peritonitis (4.8%), including one that was culture positive (Candida spp.). Patients with spontaneous bacterial peritonitis had a higher serum bilirubin level than nonspontaneous bacterial peritonitis patients (P=0.018). Out of the 19 patients, 16 (84.2%) with a positive sample proceeded to transplantation on that occasion; the ascitic microscopy result did not influence the decision to proceed in any clinically stable patient. The 30-day post-transplant survival was 93.8% for spontaneous bacterial peritonitis patients and 96.2% for nonspontaneous bacterial peritonitis patients (P=0.478). After adjusting for recipient age, UK Score for Patients with End-Stage Liver Disease (UKELD) and donor risk index, there was no association between a positive tap and death within 30 days (P=0.649). CONCLUSION Subclinical spontaneous bacterial peritonitis is rare in patients admitted for elective liver transplantation, does not influence the decision to proceed and is not associated with increased post-transplant mortality. Our findings suggest that routine preoperative ascitic fluid sampling is not indicated in clinically stable potential transplant recipients.
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Affiliation(s)
- Damhnaic P McDonald
- aMedical School bNIHR Biomedical Research Unit and Centre for Liver Research, University of Birmingham cLiver Unit, Queen Elizabeth Hospital, Birmingham dDepartment of Hepatology, Addenbrooke's Hospital, Cambridge, UK
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Assem M, Elsabaawy M, Abdelrashed M, Elemam S, Khodeer S, Hamed W, Abdelaziz A, El-Azab G. Efficacy and safety of alternating norfloxacin and rifaximin as primary prophylaxis for spontaneous bacterial peritonitis in cirrhotic ascites: a prospective randomized open-label comparative multicenter study. Hepatol Int 2015; 10:377-85. [PMID: 26660707 DOI: 10.1007/s12072-015-9688-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 11/06/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIM Primary prevention of spontaneous bacterial peritonitis (SBP) is an important strategy to reduce morbidity and mortality in cirrhotic patients with ascites. Efficacy and safety of alternating rifaximin and norfloxacin as primary prophylaxis is questionable. METHODS Three hundred thirty-four cirrhotic patients with high SAAG (≥1.1) ascites, protein level in ascitic fluid less than 1.5 g/dL with advanced liver disease (Child-Pugh score >9 points with serum bilirubin level >3 mg/dL) or renal impairment (serum creatinine level >1.2 mg/dL, blood urea nitrogen level >25 mg/dL, or serum sodium level <130 mEq/L) were included in an open-label, randomized study aimed at comparing alternating use of norfloxacin and rifaximin vs. norfloxacin or rifaximin alone as primary prophylaxis for SBP. Both intention-to-treat and per-protocol efficacy analyses were done after 6 months of treatment by assessment of ascitic fluid neutrophil count. Safety analysis was done for all intention-to-treat populations. RESULTS Alternating norfloxacin and rifaximin showed superior prophylaxis by intention-to-treat (74.7 vs. 56.4% vs. 68.3%, p < 0.048). Pairwise analysis showed that alternating regimen had lower probability to develop SBP when compared to a norfloxacin-based regimen in intention-to-treat (p = 0.016) and per protocol analysis (p = 0.039). There was no difference among the studied groups regarding the incidence and severity of adverse events reported. CONCLUSIONS Alternating norfloxacin- and rifaximin-based primary prophylaxis for SBP showed higher efficacy with the same safety profile when compared with monotherapy of norfloxacin.
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Affiliation(s)
- M Assem
- Hepatology Department, National Liver Institute, Menoufia University, Shebeen El Koom, Menoufia, 52311, Egypt.
| | - M Elsabaawy
- Hepatology Department, National Liver Institute, Menoufia University, Shebeen El Koom, Menoufia, 52311, Egypt
| | - M Abdelrashed
- Internal Medicine Department, Al Noor Hospital, M.O.H, Mecca, Saudi Arabia
| | - S Elemam
- Tropical Medicine Department, King Khalid Hospital, M.O.H, Tabuk, Saudi Arabia
| | - S Khodeer
- Internal Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - W Hamed
- Tropical Medicine Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - A Abdelaziz
- Clinical Pathology Department, National Liver Institute, Menoufia University, Shebeen El Koom, Menoufia, 52311, Egypt
| | - G El-Azab
- Hepatology Department, National Liver Institute, Menoufia University, Shebeen El Koom, Menoufia, 52311, Egypt
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29
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Nousbaum JB. [Spontaneous bacterial peritonitis in patients with cirrhosis]. Presse Med 2015; 44:1235-42. [PMID: 26358667 DOI: 10.1016/j.lpm.2015.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 07/09/2015] [Indexed: 11/19/2022] Open
Abstract
Spontaneous bacterial peritonitis (SBP) is a severe complication occurring in patients with cirrhosis, and is associated with high mortality. Liver transplantation should be considered after a first episode of SBP. Gram-negative bacilli are the major cause of SBP, however there is an increasing trend of Gram-positive cocci related SBP. Management includes empirical antibiotic treatment and albumin infusion. The choice of antibiotics depends on the site of acquisition (community-acquired vs nosocomial or health-care associated infection) and local resistance profile, due to the emergence of drug-resistant bacteria. Secondary prophylaxis is recommended after resolution of SBP and reduces recurrence and mortality. Primary prophylaxis in patients with low protein ascites (<15 g/L) should be restricted to patients with severe cirrhosis awaiting for liver transplantation.
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Affiliation(s)
- Jean-Baptiste Nousbaum
- CHU La Cavale-Blanche, service d'hépato-gastroentérologie, boulevard Tanguy-Prigent, 29609 Brest cedex, France.
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30
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Schwabl P, Bucsics T, Soucek K, Mandorfer M, Bota S, Blacky A, Hirschl AM, Ferlitsch A, Trauner M, Peck-Radosavljevic M, Reiberger T. Risk factors for development of spontaneous bacterial peritonitis and subsequent mortality in cirrhotic patients with ascites. Liver Int 2015; 35:2121-8. [PMID: 25644943 DOI: 10.1111/liv.12795] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 01/27/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patients with ascites are at risk for developing spontaneous bacterial peritonitis (SBP) - a severe complication associated with high mortality. We aimed to identify risk factors for SBP development and mortality to optimize stratification for primary prophylaxis and therapeutic strategies to improve survival. METHODS 575 patients with cirrhosis and ascites undergoing paracentesis at a tertiary care hospital were included in this retrospective cohort study. Demographical, clinical and laboratory parameters were recorded at first paracentesis and during follow-up. Multivariate logistic regression analysis was used to identify independent predictors of SBP development and mortality. RESULTS Child-Pugh stage C (OR: 3.323; P = 0.009), ascitic fluid polymorph-nuclear cell (PMN) count (OR: 1.544; P = 0.028) and low serum sodium (OR: 0.917; P = 0.029) emerged as independent risk factors for SBP development. SBP-naïve patients undergoing paracentesis and presenting with PMN-counts ≥100 cells/μl, or hyponatraemia <125 mM were at highest risk for developing SBP. Increases in MELD and CRP levels indicated SBP development, while no changes where observed in a matched control group with sterile ascites at multiple paracenteses. MELD score (OR: 1.565; P = 0.001) and CRP (OR: 1.067; P = 0.037) were identified as independent risk factors for 30-day mortality after SBP diagnosis. In particular SBP patients with MELD≥22, CRP ≥3.5 mg/dl and development of grade III/IV hepatic encephalopathy showed highest mortality. CONCLUSIONS Low serum sodium levels, Child-Pugh stage C and elevated ascites PMN counts (≥100 cells/μl) indicate a significant risk for SBP development. SBP-related mortality is highest in patients with MELD≥22 and elevated CRP levels.
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Affiliation(s)
- Philipp Schwabl
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Theresa Bucsics
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Kathrin Soucek
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Simona Bota
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Alexander Blacky
- Division of Microbiology, Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Alexander M Hirschl
- Division of Microbiology, Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Arnulf Ferlitsch
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Markus Peck-Radosavljevic
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
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Jalan R, Fernandez J, Wiest R, Schnabl B, Moreau R, Angeli P, Stadlbauer V, Gustot T, Bernardi M, Canton R, Albillos A, Lammert F, Wilmer A, Mookerjee R, Vila J, Garcia-Martinez R, Wendon J, Such J, Cordoba J, Sanyal A, Garcia-Tsao G, Arroyo V, Burroughs A, Ginès P. Bacterial infections in cirrhosis: a position statement based on the EASL Special Conference 2013. J Hepatol 2014; 60:1310-24. [PMID: 24530646 DOI: 10.1016/j.jhep.2014.01.024] [Citation(s) in RCA: 598] [Impact Index Per Article: 59.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 12/30/2013] [Accepted: 01/26/2014] [Indexed: 02/08/2023]
Abstract
Bacterial infections are very common and represent one of the most important reasons of progression of liver failure, development of liver-related complications, and mortality in patients with cirrhosis. In fact, bacterial infections may be a triggering factor for the occurrence of gastrointestinal bleeding, hypervolemic hyponatremia, hepatic encephalopathy, kidney failure, and development of acute-on-chronic liver failure. Moreover, infections are a very common cause of repeated hospitalizations, impaired health-related quality of life, and increased healthcare costs in cirrhosis. Bacterial infections develop as a consequence of immune dysfunction that occurs progressively during the course of cirrhosis. In a significant proportion of patients, infections are caused by gram-negative bacteria from intestinal origin, yet gram-positive bacteria are a frequent cause of infection, particularly in hospitalized patients. In recent years, infections caused by multidrug-resistant bacteria are becoming an important clinical problem in many countries. The reduction of the negative clinical impact of infections in patients with cirrhosis may be achieved by a combination of prophylactic measures, such as administration of antibiotics, to reduce the occurrence of infections in high-risk groups together with early identification and management of infection once it has developed. Investigation on the mechanisms of altered gut microflora, translocation of bacteria, and immune dysfunction may help develop more effective and safe methods of prevention compared to those that are currently available. Moreover, research on biomarkers of early infection may be useful in early diagnosis and treatment of infections. The current manuscript reports an in-depth review and a position statement on bacterial infections in cirrhosis.
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Affiliation(s)
- Rajiv Jalan
- Liver Failure Group, UCL Institute for Liver and Digestive Health, Royal Free Hospital, UK
| | - Javier Fernandez
- Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Reiner Wiest
- Department of Gastroenterology, UVCM, Inselspital, 3010 Bern, Switzerland
| | - Bernd Schnabl
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Richard Moreau
- INSERM U773, Centre de Recherche Biomédicale Bichat-Beaujon CRB3, UMRS 773, Université Paris-Diderot Paris, Service d'Hépatologie, Hôpital Beaujon, APHP, Clichy, France
| | - Paolo Angeli
- Unit of Hepatic Emergencies and Liver Transplantation, Department of Medicine, University of Padova, Italy
| | - Vanessa Stadlbauer
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Austria
| | - Thierry Gustot
- Department of Gastroenterology and Hepato-Pancreatology, Erasme Hospital, Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium
| | - Mauro Bernardi
- Department of Medical and Surgical Sciences, University of Bologna, Italy
| | - Rafael Canton
- Department of Microbiology, Hospital Universitario Ramón y Cajal and Intituto Ramon y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Agustin Albillos
- Gastroenterology Service, University Hospital Ramon y Cajal, Madrid, Spain
| | - Frank Lammert
- Department of Medicine II, Saarland University Medical Center, Homburg, Germany
| | - Alexander Wilmer
- Medical Intensive Care Unit, University Hospital Gasthuisberg, Leuven, Belgium
| | - Rajeshwar Mookerjee
- Liver Failure Group, UCL Institute for Liver and Digestive Health, Royal Free Hospital, UK
| | - Jordi Vila
- Department of Microbiology, Hospital Clínic, School of Medicine, University of Barcelona, Barcelona, Spain
| | - Rita Garcia-Martinez
- Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Julia Wendon
- Institute of Liver Studies and Critical Care, Kings College London, Kings College Hospital, UK
| | - José Such
- Department of Clinical Medicine, Miguel Hernández University, Alicante, CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Juan Cordoba
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Arun Sanyal
- Charles Caravati Professor of Medicine, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Guadalupe Garcia-Tsao
- Department of Medicine, Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT, USA
| | - Vicente Arroyo
- Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Andrew Burroughs
- The Royal Free Shelia Sherlock Liver Centre and University Department of Surgery, University College London and Royal Free Hospital, UK
| | - Pere Ginès
- Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERehd, Instituto de Salud Carlos III, Madrid, Spain.
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Wehmeyer MH, Krohm S, Kastein F, Lohse AW, Lüth S. Prediction of spontaneous bacterial peritonitis in cirrhotic ascites by a simple scoring system. Scand J Gastroenterol 2014; 49:595-603. [PMID: 24673156 DOI: 10.3109/00365521.2013.848471] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Spontaneous bacterial peritonitis (SBP) is a life-threatening complication in patients with liver cirrhosis. The aim of this prospective study was to identify predictors of SBP in order to develop a noninvasive method to identify or exclude an episode of SBP. PATIENTS AND METHODS Three hundred and ninety-two consecutive patients, who underwent paracentesis from March 2008 through January 2012 in our department due to cirrhotic ascites, were screened. Ninety-six patients were excluded, mostly due to prior application of antibiotics. SBP was defined by an absolute neutrophil count≥250 cells/µL ascites. We evaluated various clinical and laboratory parameters as potential predictors of SBP. A scoring system was developed in a training set of 220 and validated in a second set of 76 patients. RESULTS Fifty-eight patients (26%) in the training set and 17 patients in the validation set (22%) suffered from SBP. Thrombocytopenia≤100,000 cells/µL, age>60 years and CRP>60 mg/L were identified as independent predictors of SBP. A scoring system combining these three parameters (weighting thrombocytopenia and age with 1 point each, but CRP with 2 points) reaches a positive predictive value for the diagnosis of SBP of 81.8% with a specificity of 98.8% (score≥3). The negative predictive value at a threshold of 1 point is 93.5% with a sensitivity of 87.9%. Notably, a high MELD score is not associated with SBP (p=0.3344). CONCLUSIONS Combination of age, CRP and platelet count in a simple scoring system helps in the rapid diagnosis or exclusion of SBP.
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Affiliation(s)
- Malte H Wehmeyer
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf , Hamburg , Germany
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Leithead JA, Hayes PC, Ferguson JW. Review article: advances in the management of patients with cirrhosis and portal hypertension-related renal dysfunction. Aliment Pharmacol Ther 2014; 39:699-711. [PMID: 24528130 DOI: 10.1111/apt.12653] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 10/12/2013] [Accepted: 01/19/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND In cirrhosis, portal hypertension is associated with a spectrum of renal dysfunction that has significant implications for morbidity and mortality. AIM To discuss recent progress in the patho-physiological mechanisms and therapeutic options for portal hypertension-related renal dysfunction. METHODS A literature search using Pubmed was performed. RESULTS Portal hypertension-related renal dysfunction occurs in the setting of marked neuro-humoral and circulatory derangement. A systemic inflammatory response is a pathogenetic factor in advanced disease. Such physiological changes render the individual vulnerable to further deterioration of renal function. Patients are primed to develop acute kidney injury when exposed to additional 'hits', such as sepsis. Recent progress has been made regarding our understanding of the aetiopathogenesis. However, treatment options once hepatorenal syndrome develops are limited, and prognosis remains poor. Various strategies to prevent acute kidney injury are suggested. CONCLUSION Prevention of acute kidney injury in high risk patients with cirrhosis and portal hypertension-related renal dysfunction should be a clinical priority.
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Affiliation(s)
- J A Leithead
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK; NIHR Biomedical Research Unit and Centre for Liver Research, University of Birmingham, Birmingham, UK
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Fagiuoli S, Colli A, Bruno R, Burra P, Craxì A, Gaeta GB, Grossi P, Mondelli MU, Puoti M, Sagnelli E, Stefani S, Toniutto P. Management of infections in cirrhotic patients: report of a consensus conference. Dig Liver Dis 2014; 46:204-12. [PMID: 24021271 DOI: 10.1016/j.dld.2013.07.015] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 07/04/2013] [Accepted: 07/17/2013] [Indexed: 12/11/2022]
Abstract
The statements produced by the consensus conference on infection in end-stage liver disease promoted by the Italian Association for the Study of the Liver, are here reported. The topics of epidemiology, risk factors, diagnosis, prophylaxis, and treatment of infections in patient with compensated and decompensated liver cirrhosis were reviewed by a scientific board of experts who proposed 26 statements that were graded according to level of evidence and strength of recommendation, and approved by an independent jury. Each topic was explored focusing on the more relevant clinical questions. By systematic literature search of available evidence, comparison and discussion of expert opinions, pertinent statements answering specific questions were presented and approved. Short comments were added to explain the basis for grading evidence particularly on case of controversial areas.
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Affiliation(s)
- Stefano Fagiuoli
- Gastroenterology and Transplant Hepatology, Papa Giovanni XXIII Hospital, Bergamo, Italy.
| | | | - Raffaele Bruno
- Department of Infectious Diseases, IRCCS San Matteo, University of Pavia, Pavia, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Antonio Craxì
- Gastroenterology and Hepatology, Di.Bi.M.I.S., University of Palermo, Italy
| | - Giovan Battista Gaeta
- Infectious Diseases, Department of Internal and Experimental Medicine, Second University of Naples, Italy
| | - Paolo Grossi
- Infectious & Tropical Diseases Unit, Department of Surgical & Morphological Sciences, Insubria University, Varese, Italy
| | - Mario U Mondelli
- Research Laboratories, Department of Infectious Diseases, Fondazione IRCCS Policlinico San Matteo and Department of Internal Medicine, University of Pavia, Italy
| | - Massimo Puoti
- Infectious Diseases Department, Niguarda Cà Granda Hospital, Milano, Italy
| | - Evangelista Sagnelli
- Department of Mental Health and Preventive Medicine, Second University of Naples, Italy
| | - Stefania Stefani
- Department of Bio-Medical Sciences, Section of Microbiology, University of Catania, Italy
| | - Pierluigi Toniutto
- Department of Medical Sciences, Experimental and Clinical, Medical Liver Transplant Section, Internal Medicine, University of Udine, Italy
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Thiele GB, da Silva OM, Fayad L, Lazzarotto C, Ferreira MDA, Marconcini ML, Dantas-Corrêa EB, Schiavon LDL, Narciso-Schiavon JL. Clinical and laboratorial features of spontaneous bacterial peritonitis in southern Brazil. SAO PAULO MED J 2014; 132:205-10. [PMID: 25055065 PMCID: PMC10496729 DOI: 10.1590/1516-3180.2014.1324698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 08/07/2013] [Accepted: 08/15/2013] [Indexed: 12/21/2022] Open
Abstract
CONTEXT AND OBJECTIVE Spontaneous bacterial peritonitis (SBP) is a severe complication that occurs in 8-27% of hospitalized patients with liver cirrhosis and ascites, with high mortality rates. This study aimed to identify the clinical characteristics associated with SBP. DESIGN AND SETTING Cross-sectional study, conducted in a public university. METHODS The study consecutively included individuals with liver cirrhosis and ascites between September 2009 and March 2012. Forty-five patients were included: mean age 53.2 ± 12.3 years, 82.2% male, 73.8% Caucasian, mean Model of End-stage Liver Disease (MELD) score of 19.5 ± 7.2, and 33.3% with SBP. The subjects were divided into two groups: SBP and controls. RESULTS Comparison between individuals with SBP and controls showed that those with SBP had lower mean prothrombin activity time (36.1 ± 16.0% versus 47.1 ± 17.2%; P = 0.044) and lower median serum-ascites albumin gradient (SAAG) (1.2 versus 1.7, P = 0.045). There was a tendency towards higher mean MELD in the SBP group, not significant (22.2 ± 7.6 versus 17.9 ± 6.7; P = 0.067). There was a strong positive correlation between the neutrophil count in ascitic fluid and serum leukocyte count (r = 0.501; P = 0.001) and a negative correlation between the neutrophil count in ascitic fluid with prothrombin activity time (r = -0.385; P = 0.011). CONCLUSION A few characteristics are associated with the presence of SBP, especially liver dysfunction, SAAG and peripheral leukocytosis.
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Affiliation(s)
- Gabriela Bicca Thiele
- Medical Student. Universidade Federal de Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
| | - Otávio Marcos da Silva
- Medical Student. Universidade Federal de Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
| | - Leonardo Fayad
- MD. Resident in Gastroenterology, Núcleo de Estudos em Gastroenterologia e Hepatologia (NEGH), Universidade Federal de Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
| | - César Lazzarotto
- MD, MSc. Resident in Gastroenterology, Núcleo de Estudos em Gastroenterologia e Hepatologia (NEGH), Universidade Federal de Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
| | | | - Maíra Luciana Marconcini
- Medical Student. Universidade Federal de Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
| | - Esther Buzaglo Dantas-Corrêa
- MD, PhD. Adjunct Professor in Gastroenterology, Núcleo de Estudos em Gastroenterologia e Hepatologia (NEGH), Universidade Federal de Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
| | - Leonardo de Lucca Schiavon
- MD, PhD. Adjunct Professor in Gastroenterology, Núcleo de Estudos em Gastroenterologia e Hepatologia (NEGH), Universidade Federal de Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
| | - Janaína Luz Narciso-Schiavon
- MD, PhD. Adjunct Professor in Gastroenterology, Núcleo de Estudos em Gastroenterologia e Hepatologia (NEGH), Universidade Federal de Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
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Wiest R, Lawson M, Geuking M. Pathological bacterial translocation in liver cirrhosis. J Hepatol 2014; 60:197-209. [PMID: 23993913 DOI: 10.1016/j.jhep.2013.07.044] [Citation(s) in RCA: 524] [Impact Index Per Article: 52.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Revised: 06/20/2013] [Accepted: 07/19/2013] [Indexed: 12/11/2022]
Affiliation(s)
- Reiner Wiest
- Department Gastroenterology, Inselspital, University Hospital, Bern 3010, Switzerland.
| | - Melissa Lawson
- Maurice Müller Laboratories, Universitätsklinik für Viszerale Chirurgie und Medizin (UVCM), University of Bern, Bern 3010, Switzerland
| | - Markus Geuking
- Maurice Müller Laboratories, Universitätsklinik für Viszerale Chirurgie und Medizin (UVCM), University of Bern, Bern 3010, Switzerland
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Cadranel JF, Nousbaum JB, Bessaguet C, Nahon P, Nguyen-Khac E, Moreau R, Thévenot T, Silvain C, Bureau C, Nouel O, Pilette C, Paupard T, Pauwels A, Sapey T, Grangé JD, Tran A. Low incidence of spontaneous bacterial peritonitis in asymptomatic cirrhotic outpatients. World J Hepatol 2013; 5:104-8. [PMID: 23556041 PMCID: PMC3612567 DOI: 10.4254/wjh.v5.i3.104] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Revised: 09/24/2012] [Accepted: 11/14/2012] [Indexed: 02/06/2023] Open
Abstract
AIM To compare the incidence of spontaneous bacterial peritonitis in cirrhotic outpatients and inpatients undergoing therapeutic paracentesis METHODS From January 1 to May 31, 2004, 1041 patients from 70 different hospitals underwent 2123 therapeutic abdominal paracentesis (AP) performed as a outpatient procedure in 355 and as inpatient procedure in 686 cases respectively. The following parameters were compared prospectively between outpatients and inpatients: spontaneous bacterial peritonitis (SBP) prevalence, age, gender, cause of cirrhosis, symptoms, score and grade according to Child-Pugh classification, cirrhosis complications, antibiotics treatment, serum creatinine, platelet count and ascitic protein concentration. RESULTS SBP was observed in 91 patients. In the whole population the SBP prevalence was 8.7% (95%CI: 7.2-10.6) it was 11.7% (95%CI: 9.5-14.3) in inpatients and 3.1% (95%CI: 1.7-5.5) in outpatients (P < 0.00001). SBP prevalence was 8.3% (95%CI: 4.3-15.6) in symptomatic outpatients vs 1.2% (95%CI: 0.4-3.4) in asymptomatic outpatients (P < 0.002). Patients undergoing outpatient AP were significantly different from those undergoing inpatient AP; they were older (61.1 ± 11.1 years vs 59.4 ± 11.7 years; P = 0.028), cause of cirrhosis was less often alcohol (83 .7 vs 88.2%; P < 0.001), Child-Pugh score was lower (8.9 vs 10.1; P < 0.001) and more often B than C (63.7% vs 38%; P < 0.001). In addition, in outpatients the platelet count was higher (161 ± 93 Giga/L vs 143 ± 89 Giga/L; P = 0.003), serum total bilirubin concentration was lower (38.2 ± 60.7 μmol/L vs 96.3 ± 143.3 μmol/L; P < 0.0001), and ascitic protein concentration higher (17.9 ± 10.7 g/L vs 14.5 ± 10.9 g/L; P < 0.001) than in inpatients. CONCLUSION In asymptomatic cirrhotic outpatients, the incidence of spontaneous bacterial peritonitis is low thus exploratory paracentesis could be avoided in these patients without significant risk.
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Affiliation(s)
- Jean-François Cadranel
- Jean-François Cadranel, Liver, Gastroenterology and Nutrition Department, Centre Hospitalier Laennec, 60100 Creil, France
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38
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Yang SC, Wu KL, Wang JH, Lee CH, Kuo YH, Tai WC, Chen CH, Chiou SS, Lu SN, Hu TH, Changchien CS, Chuah SK. The effect of systemic antibiotic prophylaxis for cirrhotic patients with peptic ulcer bleeding after endoscopic interventions. Hepatol Int 2012. [DOI: 10.1007/s12072-012-9378-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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39
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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.
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Affiliation(s)
- Javier Fernández
- Liver Unit, IMDiM, Hospital Clínic, Universidad de Barcelona, IDIBAPS and CIBERehd, Barcelona, Spain.
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40
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Schmid S, Wiest R, Salzberger B, Klebl F. Spontan bakterielle Peritonitis. Med Klin Intensivmed Notfmed 2012; 107:548-52. [DOI: 10.1007/s00063-012-0084-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Accepted: 01/26/2012] [Indexed: 12/15/2022]
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41
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Shi KQ, Fan YC, Ying L, Lin XF, Song M, Li LF, Yu XY, Chen YP, Zheng MH. Risk stratification of spontaneous bacterial peritonitis in cirrhosis with ascites based on classification and regression tree analysis. Mol Biol Rep 2011; 39:6161-9. [DOI: 10.1007/s11033-011-1432-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2011] [Accepted: 12/19/2011] [Indexed: 12/13/2022]
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Ribeiro TC, Chebli JM, Kondo M, Gaburri PD, Chebli LA, Feldner ACA. Spontaneous bacterial peritonitis: How to deal with this life-threatening cirrhosis complication? Ther Clin Risk Manag 2011; 4:919-25. [PMID: 19209274 PMCID: PMC2621420 DOI: 10.2147/tcrm.s2688] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Spontaneous bacterial peritonitis (SBP) is one of the most common and life-threatening complications of cirrhosis. It occurs in 10% to 30% of patients admitted to hospital and recent studies tend to demonstrate that SBP incidence seems to be decreasing in its frequency. A bacterial overgrowth with translocation through the increased permeable small intestinal wall and impaired defense mechanisms is considered to be the main mechanism associated with its occurrence. The Gram-negative aerobic bacteria are the major responsible for SBP episodes and Gram-positive bacteria, mainly Staphylococcus aureus, are being considered an emergent agent causing SBP. The prompt diagnosis of SBP is the key factor for reduction observed in mortality rates in recent years. The clinical diagnosis of SBP is neither sensitive nor specific and the search for new practical and available tools for a rapid diagnosis of SBP is an important endpoint of current studies. Reagent strips were considered a promising and faster way of SBP diagnosis. The prompt use of empirical antibiotics, mostly cefotaxime, improves significantly the short-term prognosis of cirrhotic patients with SBP. The recurrence rate of SBP is high and antibiotic prophylaxis has been recommended in high-risk settings. Unfortunately, the long-term prognosis remains poor.
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Affiliation(s)
- Tarsila Cr Ribeiro
- Division of Gastroenterology, Department of Medicine of University Federal de São Paulo, UNIFESP, EPM, São Paulo, São Paulo, Brazil
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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.
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Soriano G, Esparcia O, Montemayor M, Guarner-Argente C, Pericas R, Torras X, Calvo N, Román E, Navarro F, Guarner C, Coll P. Bacterial DNA in the diagnosis of spontaneous bacterial peritonitis. Aliment Pharmacol Ther 2011; 33:275-84. [PMID: 21083594 DOI: 10.1111/j.1365-2036.2010.04506.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Despite inoculation into blood culture bottles, ascitic fluid culture is negative in 50% of cases of spontaneous bacterial peritonitis (SBP). AIM To determine whether 16S rDNA gene detection by real-time polymerase chain reaction (PCR) and sequencing increases the efficacy of culture in microbiological diagnosis of spontaneous bacterial peritonitis. METHODS We prospectively included 55 consecutive spontaneous bacterial peritonitis episodes in cirrhotic patients, 20 cirrhotic patients with sterile ascites and 27 patients with neoplasic ascites. Ascitic fluid was inoculated into blood culture bottles at the bedside and tested for bacterial DNA by real-time PCR and sequencing of 16S rDNA gene. RESULTS Bacterial DNA was detected in 23/25 (92%) culture-positive SBP, 16/30 (53%) culture-negative SBP (P = 0.002 with respect to culture-positive SBP), 12/20 (60%) sterile ascites (P = 0.01 with respect to culture-positive SBP) and 0/27 neoplasic ascites (P < 0.001 with respect to other groups). Sequencing identified to genus or species level 12 culture-positive SBP, six culture-negative SBP and six sterile ascites. In the remaining cases with positive PCR, sequencing did not yield a definitive bacterial identification. CONCLUSIONS Bacterial DNA was not detected in almost half the culture-negative spontaneous bacterial peritonitis episodes. Methodology used in the present study did not always allow identification of amplified bacterial DNA.
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Affiliation(s)
- G Soriano
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Institut d'Investigacions Biomèdiques Sant Pau, Spain.
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Segarra-Newnham M, Henneman A. Antibiotic prophylaxis for prevention of spontaneous bacterial peritonitis in patients without gastrointestinal bleeding. Ann Pharmacother 2010; 44:1946-54. [PMID: 21098755 DOI: 10.1345/aph.1p317] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVE To review relevant studies for both primary and secondary antibiotic prophylaxis of spontaneous bacterial peritonitis (SBP) in patients with cirrhosis without gastrointestinal bleeding. DATA SOURCES A search of PubMed (1980-July 2010) was conducted using the terms prophylaxis, SBP, and antibiotics. A manual review of bibliographies was conducted for inclusion of relevant articles. STUDY SELECTION AND DATA EXTRACTION Prospective studies and meta-analyses published in English were included. DATA SYNTHESIS Ten trials and 3 meta-analyses were included. Of the 10 trials, 2 examined the use of secondary prophylaxis for prevention of subsequent episodes of SBP, 4 examined the use of primary prophylaxis to prevent an initial SBP episode, and 4 examined the use of antibiotic prophylaxis in a mixed population. Seven trials evaluated the use of an antibiotic compared to placebo or no treatment. Only 1 trial evaluated norfloxacin versus trimethoprim/sulfamethoxazole. Trial duration varied from 24 days to 12 months. In general, trials examining norfloxacin as secondary prophylaxis found significantly decreased occurrence of SBP but no significant difference in mortality rates. Primary prophylaxis studies found no significant difference in the incidence of infections, including SBP, with norfloxacin or ciprofloxacin treatment but significantly lower incidence of gram-negative infections. Mixed population studies found a significantly decreased incidence of SBP but no significant difference in mortality. In the 3 meta-analyses, a significant decrease in mortality and an overall decrease in SBP incidence in the treatment groups were noted. CONCLUSIONS Based on currently available data, the use of prophylactic antibiotic therapy is warranted for the prevention of recurrent SBP in patients with cirrhosis and ascites. In patients with low ascetic fluid protein and at least 1 more risk factor, primary prophylaxis may be considered. Further studies with improved methodology are needed to determine whether prophylactic antibiotic therapy has an impact on mortality.
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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.
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Affiliation(s)
- Francesco Salerno
- Department of Internal Medicine, Policlinico IRCCS San Donato, Università di Milano, Via Morandi, 30, 20097, San Donato Milanese, Italy.
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47
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Arvaniti V, D'Amico G, Fede G, Manousou P, Tsochatzis E, Pleguezuelo M, Burroughs AK. Infections in patients with cirrhosis increase mortality four-fold and should be used in determining prognosis. Gastroenterology 2010; 139:1246-56, 1256.e1-5. [PMID: 20558165 DOI: 10.1053/j.gastro.2010.06.019] [Citation(s) in RCA: 762] [Impact Index Per Article: 54.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2010] [Revised: 05/18/2010] [Accepted: 06/08/2010] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS A staged prognostic model of cirrhosis based on varices, ascites, and bleeding has been proposed. We analyzed data on infections in patients with cirrhosis to determine whether it is also a prognostic factor. METHODS Studies were identified by MEDLINE, EMBASE, COCHRANE, and ISI Web of Science searches (1978-2009); search terms included sepsis, infection, mortality, and cirrhosis. Studies (n = 178) reporting more than 10 patients and mortality data were evaluated (225 cohorts, 11,987 patients). Mortality after 1, 3, and 12 months was compared with severity, site, microbial cause of infection, etiology of cirrhosis, and publication year. Pooled odds ratio of death was compared for infected versus noninfected groups (18 cohorts, 2317 patients). RESULTS Overall median mortality of infected patients was 38%: 30.3% at 1 month and 63% at 12 months. Pooled odds ratio for death of infected versus noninfected patients was 3.75 (95% confidence interval, 2.12-4.23). In 101 studies that reported spontaneous bacterial peritonitis (7062 patients), the median mortality was 43.7%: 31.5% at 1 month and 66.2% at 12 months. In 30 studies that reported bacteremia (1437 patients), the median mortality rate was 42.2%. Mortality before 2000 was 47.7% and after 2000 was 32.3% (P = .023); mortality was reduced only at 30 days after spontaneous bacterial peritonitis (49% vs 31.5%; P = .005). CONCLUSIONS In patients with cirrhosis, infections increase mortality 4-fold; 30% of patients die within 1 month after infection and another 30% die by 1 year. Prospective studies with prolonged follow-up evaluation and to evaluate preventative strategies are needed.
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Affiliation(s)
- Vasiliki Arvaniti
- The Sheila Sherlock Liver Centre, and University Department of Surgery, Royal Free Hospital and University College London, London, United Kingdom
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48
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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]
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49
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Guarner-Argente C, Sánchez E, Vidal S, Román E, Concepción M, Poca M, Sánchez D, Juárez C, Soriano G, Guarner C. Toll-like receptor 4 D299G polymorphism and the incidence of infections in cirrhotic patients. Aliment Pharmacol Ther 2010; 31:1192-9. [PMID: 20222908 DOI: 10.1111/j.1365-2036.2010.04291.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Toll-like receptor (TLR) 4 genetic polymorphisms, mainly D299G, have been associated with increased predisposition to infection in several populations. AIM To retrospectively analyse the relationship between the presence of the TLR4 D299G polymorphism and the incidence of bacterial infections in cirrhotic patients. METHODS We included 111 consecutive cirrhotic patients hospitalized with ascites and we determined the presence of the TLR4 D299G polymorphism by PCR-RFLP (polymerase chain reaction-restriction fragment length polymorphism) and its relationship with the incidence of previous bacterial infections. RESULTS Ten out of 111 (9%) cirrhotic patients presented with the TLR4 D299G polymorphism. The mean follow-up from first decompensation of cirrhosis until current admission was longer in D299G polymorphism patients than in wild-type patients (53.8 +/- 40.7 vs. 35.4 +/- 48.3 months, P = 0.03). D299G polymorphism patients showed a trend towards a higher incidence of history of previous infections (80% vs. 56.4%, P = 0.19), as well as a higher number of infections (2.8 +/- 2.3 vs. 1.0 +/- 1.3, P = 0.01) and bacteriaemias (0.4 +/- 1.0 vs. 0.04 +/- 0.2, P = 0.02) per patient than wild-type patients. CONCLUSIONS Toll-like receptor 4 D299G polymorphism could influence not only the predisposition to bacterial infections but also the evolution of the disease in cirrhotic patients. Further prospective studies in larger series of patients are warranted.
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Affiliation(s)
- C Guarner-Argente
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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Rogers GB, Russell LE, Preston PG, Marsh P, Collins JE, Saunders J, Sutton J, Fine D, Bruce KD, Wright M. Characterisation of bacteria in ascites--reporting the potential of culture-independent, molecular analysis. Eur J Clin Microbiol Infect Dis 2010; 29:533-41. [PMID: 20238135 DOI: 10.1007/s10096-010-0891-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2010] [Accepted: 02/15/2010] [Indexed: 02/07/2023]
Abstract
Spontaneous bacterial peritonitis (SBP) is a severe complication of liver disease. A significant proportion of patients have culture-negative ascites, despite having similar signs, symptoms and mortality to those with SBP. Therefore, empirical antibiotic treatment for infection is often started without knowledge of the causative organisms. Here, we investigated the potential of molecular techniques to provide rapid and accurate characterisation of the bacteria present in ascitic fluid. Ascites samples were obtained from 29 cirrhotic patients undergoing clinically indicated therapeutic paracentesis. Bacterial content was determined by terminal restriction fragment length polymorphism (T-RFLP) analysis, quantitative polymerase chain reaction (PCR) and 16S ribosomal clone sequence analysis. Bacterial signal was detected in all samples, compared to three out of ten using standard methods. Bacterial loads ranged from 5.5 x 10(2) to 5.4 x 10(7) cfu/ml, with a mean value of 1.9 x 10(6) cfu/ml (standard deviation +/- 9.6 x 10(6) cfu/ml). In all but one instance, bacterial species identified by culture were also confirmed by molecular analyses. Preliminary data presented here suggests that culture-independent, molecular analyses could provide rapid characterisation of the bacterial content of ascites fluid, providing a basis for the investigation of SBP development and allowing early and targeted antibiotic intervention.
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Affiliation(s)
- G B Rogers
- Molecular Microbiology Research Group, PSD, King's College London, London, UK.
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