Spontaneous bacterial peritonitis in asymptomatic outpatients with cirrhotic ascites

Chinese consensus on the management of liver cirrhosis

Liver cirrhosis, characterized by diffuse necrosis, insufficient regeneration of hepatocytes, angiogenesis, severe fibrosis, and the formation of pseudolobules, is a progressive, chronic liver disease induced by a variety of causes. It is clinically characterized by liver function damage and portal hypertension, and many complications may occur in its late stage. Based on the updated practice guidelines, expert consensuses, and research advances on the diagnosis and treatment of cirrhosis, the Chinese Society of Gastroenterology of Chinese Medical Association established the current consensus to standardize the clinical diagnosis and management of liver cirrhosis and guide clinical practice. This consensus contains 43 statements on the etiology, pathology and pathogenesis, clinical manifestations, major complications, diagnosis, treatment, prognosis, and chronic disease control of liver cirrhosis. Since several practice guidelines and expert consensuses on the complications of liver cirrhosis have been published, this consensus emphasizes the research progress of liver cirrhosis itself.

Optimization of Kidney Health in Liver Transplant Candidates: Pretransplant Considerations and Modalities

Patients with decompensated end-stage liver disease (ESLD) are at increased risk for mortality, and only liver transplantation (LT) offers meaningful hope for survival. These patients are at risk for kidney dysfunction through the continuum of care for ESLD including LT. We discuss the role of accurate estimation and measurement of baseline glomerular filtration rate in assessment of kidney dysfunction among those with ESLD. Optimizing kidney function is a vital goal in the management of these patients before LT. In this review, we summarize salient aspects of assessing and optimizing kidney function in this patient population. Precipitating factors and different causes of acute kidney injury are discussed, including hepatorenal syndrome. We further review treatment options for acute kidney injury including volume management. The role of vasopressor therapy, renal replacement therapy, and transjugular intrahepatic portosystemic shunting are discussed.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

Delayed Diagnostic Paracentesis Is Associated with Increased Preventable Healthcare Utilization in Disadvantaged Patient Populations with Advanced Liver Disease and Elevated INR

BACKGROUND

Patients hospitalized with cirrhosis, ascites, and elevated INR often experience delays in timely diagnostic paracentesis.

AIMS

Identify whether delays in diagnostic paracentesis were associated with adverse outcomes in a hospital system serving a large disadvantaged population.

METHODS

Retrospective cohort analysis of patients admitted from January 2017 to October 2019 with cirrhosis, ascites, and INR ≥ 1.5 across a multi-hospital health system in central Texas. We examined demographic and clinical characteristics of patients with diagnostic paracentesis (1) ≤ 24 h; (2) > 24 h; (3) therapeutic only or no paracentesis. We used logistic regression to examine differences in clinical outcomes controlling for confounders.

RESULTS

479 patients met inclusion criteria. 30.0% (N = 143) were Latino, 6.7% (N = 32) African American, and 67.8% (N = 325) under or uninsured. 54.1% of patients received a diagnostic paracentesis ≤ 24 h of admission and 21.1% did not receive a diagnostic paracentesis during the hospitalization. Undergoing diagnostic paracentesis > 24 h of admission was associated with a 2.3 day increase in length of stay (95% CI 0.8-3.8), and OR 1.7 for an Emergency Room visit within 30 days of discharge (95% CI 1.1-2.7) compared to receiving a diagnostic paracentesis ≤ 24 h. Patients receiving diagnostic paracentesis in radiology were more likely to have a delay in procedure OR 5.8 (95% CI 2.8-8.6).

CONCLUSION

Delayed diagnostic paracentesis is associated with increased preventable healthcare utilization compared with timely diagnostic paracentesis. Health systems should support efforts to ensure timely diagnostic paracentesis for patients with advanced liver disease, including performance at the bedside.

Bacterascites confers poor patient prognosis beyond MELD prediction

Spontaneous bacterial peritonitis (SBP) is a well-recognized clinical entity with a poor prognosis. In comparison, the prevalence, microbiological flora, and prognostic significance of bacterascites (BA) (the presence of organism on culture but ascitic PMN <250 cells/mm³) is largely unknown. We, therefore, assessed the prognosis and predictors of outcome in patients with BA in comparison with those with SBP. Ascitic fluid cultures from consecutive patients with cirrhosis from 2008 to 2018 were reviewed retrospectively, and patients with SBP and BA were identified. Baseline demographic, laboratory, and microbiological data were collated and analyzed as prognostic indicators, and clinical outcomes were recorded. Patients were censored at the time of LT, death, or last follow-up. For this study 176 and 213 cases of SBP and BA, respectively, were identified and included. Patients with SBP had significantly higher Model for End-Stage Liver Disease (MELD) ( p =<0.01), peripheral blood WCC ( p < 0.01), and higher rates of Enterobacteriaceae ( p < 0.01) and multi-drug resistant pathogens ( p < 0.01). Survival at 1 and 3 months was lower in patients with SBP ( p < 0.01) when compared with BA but at 6 months and beyond, no significant difference remained. After the exclusion of deaths within 30 days of presentation, survival between SBP and BA was equivocal at all time points. Mortality was substantially higher across all MELD groupings for both SBP and BA when compared with the predicted mortality calculated by the MELD score alone. BA has a negative impact on patient survival above that predicted by the MELD score. It has similar impact to SBP on patient survival beyond 1 month suggesting it should be seen as a poor prognostic marker and prompt consideration of LT where appropriate. Further studies evaluating the role of secondary prophylaxis in this group are required.

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

GOALS

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

BACKGROUND

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

STUDY

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

RESULTS

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

CONCLUSIONS

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

Prevalence of Spontaneous Bacterial Peritonitis (SBP) in Hepatitis B (HBV), and Hepatitis C (HCV) Liver Cirrhosis: A Systematic Review and Meta-Analysis

Background and Aim: Spontaneous bacterial peritonitis (SBP) is a common infection in liver cirrhosis. This systematic review and meta-analysis provide detailed information on the prevalence of SBP among hepatitis B virus (HBV) and hepatitis C virus (HCV)-related liver cirrhosis globally. Methods: A systematic search for articles describing the prevalence of SBP in HBV and HCV-related cirrhosis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Our search returned ten (10) eligible articles involving 1713 viral cirrhosis cases representing eight (8) countries. A meta-analysis was performed on our eligible studies using the random effect model. A protocol was registered with PROSPERO (CRD42022321790). Results: The pooled prevalence of SBP in HBV-associated cirrhosis had the highest estimate [8.0% (95% CI, 2.7−21.0%; I2 = 96.13%; p < 0.001)], followed by SBP in HCV-associated liver cirrhosis [4.0% (95% CI, 1.3%−11.5%; I2 = 88.99%; p < 0.001)]. China (61.8%, CI: 57.1−66.3%), the USA (50.0%, CI: 34.6−65.4%), and Holland (31.1%, CI: 21.6−42.5%) had the highest estimate for SBP in HBV associated liver cirrhosis, SBP in HCV associated liver cirrhosis and SBP in HBV + HCV associated liver cirrhosis respectively. There was a significant difference in the prevalence of SBP in viral hepatitis-associated liver cirrhosis with the year of sampling and method of SBP detection at P < 0.001. There was an increase in SBP incidence at the beginning of 2016 across the liver cirrhosis in this study. Conclusion: The findings of this review revealed a rise in the incidence of SBP in viral hepatitis over the last decade. The latter indicates a possible future rise in the global prevalence of SBP among HBV and HCV-related liver cirrhosis.

Spontaneous bacterial peritonitis has no effect on the long-term prognosis of cirrhosis patients with ascites

INTRODUCTION AND OBJECTIVES

Spontaneous bacterial peritonitis (SBP) is a frequent complication to cirrhosis with an unclear long-term prognosis. We aimed to examine its effect on mortality in two independent patient cohorts.

PATIENTS AND METHODS

We used Danish healthcare data on cirrhosis patients with a first-time paracentesis in 2000-2014 and data from three randomized controlled trials on satavaptan treatment of ascites conducted in 2006-2008. We used the Kaplan-Meier method to estimate cumulative mortality, and Cox regression to compare the confounder-adjusted mortality hazard for patients with vs. without SBP.

RESULTS

In the Danish Healthcare Cohort, we included 1.282 patients of whom 133 (10.4%) had SBP. The SBP patients' cumulative 4-month mortality was 51.2% (95% CI: 43.0-59.9%) vs. 34.7% (95% CI: 32.0-37.6) in those without SBP. The SBP patients' confounder-adjusted mortality hazard was 1.54-fold higher (95% CI: 1.18-2.00) in the four months after paracentesis, but was not increased thereafter (confounder-adjusted mortality hazard 1.02, 95% 0.72-1.46). In the satavaptan trial data of 1,198 cirrhosis patients with ascites, the 93 patients with SBP had a cumulative 4-month mortality of 38.6% (95% CI: 29.3-49.7) compared with 11.4% (95% CI: 8.5-15.2) in those without. The SBP patients' confounder-adjusted mortality hazard ratio was 3.86 (95% CI: 2.44-6.12) during the first four months, and was 1.23 (95% CI: 0.54-2.83) thereafter.

CONCLUSIONS

In both cohorts of patients with cirrhosis, an SBP episode had a high short-term mortality compared to patients without SBP, and had no lasting effect on the long-term mortality.

Clinical, Laboratory and Bacterial Profile of Spontaneous Bacterial Peritonitis in Vietnamese Patients with Liver Cirrhosis

Aim

Methods

Results

Conclusion

The periscreen strip is an accurate and rapid method to diagnose spontaneous bacterial peritonitis among patients with acute-on-chronic liver failure

BACKGROUND

Leukocyte esterase reagent strips may help diagnose spontaneous bacterial peritonitis (SBP), but their effective application among patients with acute-on-chronic liver failure (ACLF) remains unknown.

AIM

This study aimed to assess the performance of periscreen strips in the rapid diagnosis of SBP among patients with ACLF.

METHODS

Periscreen strips were used to test 261 ascites samples taken from 251 inpatients with ACLF between January 2014 and June 2019. The colors of the reagent strip were divided into four colorimetric graduations ('negative', 'trace', 'small', and 'large'), among which 'trace' is used as the SBP detection threshold. The polymorphonuclear neutrophils (PMN) of ascites ≥250/mm3 was used as the gold standard for SBP diagnosis.

RESULTS

SBP was detected in 92 (35.2%) ascite samples. The ascites PMN count of 'negative' (32.5/mm3) was lower than those of 'trace' (248.2/mm3), 'small' (379.0/mm3), and 'large' (7426.0/mm3) (P < 0.001). The colorimetric graduations of the strips were positively correlated with ascites PMN count (r = 0.867, P < 0.001). Periscreen strips had 100% sensitivity, 91.1% specificity, 86.0% positive predictive value, 100% negative predictive value, 11.3 positive likelihood ratios, and 0 negative likelihood ratios. For patients with negative results judged by the gold standard, ascites white blood cells count [odds ratio (OR) = 1.007) and ascites PMN count (OR = 1.028) were independent predictors of false-positive cases.

CONCLUSION

Liver failure did not affect the diagnostic performance of periscreen strips. Therefore, these strips can efficiently and rapidly diagnose SBP among patients with ACLF.

An exploratory study of ascitic fluid lactate as prognostic factor of mortality in cirrhotic patients with spontaneous bacterial peritonitis

BACKGROUND

The diagnostic value of ascitic fluid lactate (AF lactate) was previously evaluated in spontaneous bacterial peritonitis (SBP) but its prognostic value was not established.

AIM

To assess the prognostic value of AF lactate in SBP.

METHODS

We prospectively studied 63 consecutive patients with SBP. Fifty patients with acute-on-chronic liver failure (ACLF) or acute decompensation (AD) (ACLF/AD group) without SBP and 30 with stable decompensated cirrhosis (DC) were included as controls. In SBP, mortality was recorded at 30, 90 and 180 days.

RESULTS

Arterial and AF lactate were significantly higher in SBP compared to other groups. Analyzing the SBP group alone, AF lactate accurately differentiated survivors from nonsurvivors in all time points. The prognostic performance of AF lactate was improved over time, with the area under the receiver operating characteristic computed at 0.894, 0.927 and 0.934 at 30, 90 and 180 days, respectively. The cutoff level of 2 mmol/L was associated with 100, 100 and 94.7% sensitivity, 57.9, 73.3 and 80% specificity, 61, 80.5 and 87.8% positive predictive value and 100, 100 and 90.9% negative predictive value, respectively. Arterial lactate, neutrophil-to-lymphocyte ratio (NLR) and Model for End-Stage Liver Disease (MELD) score predicted outcomes less accurately than AF lactate. Patients with AF lactate >2 mmol/L had a worse prognosis compared to patients with ≤2 mmol/L (log-rank P < 0.001). No case with AF lactate ≤2 mmol/L died within 90 days postSBP diagnosis. In Cox multivariate analysis at all time points, only AF lactate and NLR were independent predictors of mortality.

CONCLUSION

An AF lactate level of 2 mmol/L has a high ability to differentiate survivors from nonsurvivors in the first 180 days postSBP. Its prognostic value outperformed arterial-lactate, NLR and MELD.

Incidence of spontaneous bacterial peritonitis among asymptomatic cirrhosis patients undergoing outpatient paracentesis: a systematic review and meta-analysis

INTRODUCTION

Spontaneous bacterial peritonitis (SBP) is a common complication of decompensated cirrhosis with high morbidity and mortality rate. There is a paucity of evidence regarding the incidence of SBP in asymptomatic liver cirrhosis patients undergoing routine out-patient large-volume paracentesis (LVP). The aim of this study was to perform a systematic review and meta-analysis to determine the incidence of SBP among asymptomatic decompensated cirrhosis patients undergoing routine outpatient LVP.

METHODS

A systematic search of Ovid Medline, Embase, Web of Science and CENTRAL electronic databases was performed in January 2021, along with a manual search of reference lists of retrieved articles. Data were extracted to determine the incidence of SBP [polymorphonuclear cells (PMNs) greater than 250 PMNs/mm3 with or without positive culture] and the incidence of all positive paracentesis (SBP or bacterascites-positive ascitic culture but no elevation in PMNs).

RESULTS

A total of 504 studies were retrieved with 16 studies being included in the review. A total of 1532 patients were included with a total of 4016 paracentesis performed. The incidence of a positive paracentesis (SBP and/or bacterascitis) was 4% [95% confidence interval (CI), 3-6%]. However, the incidence of definite SBP was 2% (95% CI, 1-3%).

CONCLUSION

The incidence of SBP in asymptomatic outpatients with decompensated cirrhosis requiring LVP is low. The benefit of routine analysis of all paracentesis samples in this population is questionable. Further studies are required to determine the cost-effectiveness of routine analysis and to determine if certain subgroups are at higher risk of SBP that require routine analysis.

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

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

A Latin American survey on demographic aspects of hospitalized, decompensated cirrhotic patients and the resources for their management

INTRODUCTION & OBJECTIVES

Liver cirrhosis is a major cause of mortality worldwide. Adequate diagnosis and treatment of decompensating events requires of both medical skills and updated technical resources. The objectives of this study were to search the demographic profile of hospitalized cirrhotic patients in a group of Latin American hospitals and the availability of expertise/facilities for the diagnosis and therapy of decompensation episodes.

METHODS

A cross sectional, multicenter survey of hospitalized cirrhotic patients.

RESULTS

377 patients, (62% males; 58±11 years) (BMI>25, 57%; diabetes 32%) were hospitalized at 65 centers (63 urbans; 57 academically affiliated) in 13 countries on the survey date. Main admission causes were ascites, gastrointestinal bleeding, hepatic encephalopathy and spontaneous bacterial peritonitis/other infections. Most prevalent etiologies were alcohol-related (AR) (40%); non-alcoholic-steatohepatitis (NASH) (23%), hepatitis C virus infection (HCV) (7%) and autoimmune hepatitis (AIH) (6%). The most frequent concurrent etiologies were AR+NASH. Expertise and resources in every analyzed issue were highly available among participating centers, mostly accomplishing valid guidelines. However, availability of these facilities was significantly higher at institutions located in areas with population>500,000 (n=45) and in those having a higher complexity level (Gastrointestinal, Liver and Internal Medicine Departments at the same hospital (n=22).

CONCLUSIONS

The epidemiological etiologic profile in hospitalized, decompensated cirrhotic patients in Latin America is similar to main contemporary emergent agents worldwide. Medical and technical resources are highly available, mostly at great population urban areas and high complexity medical centers. Main diagnostic and therapeutic approaches accomplish current guidelines recommendations.

Is Serum-Ascites Vitamin D Gradient a Valid Marker for Diagnosing Spontaneous Bacterial Peritonitis in Patients with Cirrhotic Ascites?

OBJECTIVE

Spontaneous bacterial peritonitis (SBP) is considered the paradigmatic model of infection in patients with liver cirrhosis. Therefore, there is a need for an accurate and rapid method for SBP diagnosis. The aim of this study was to evaluate the validity of serum-ascites 25-hydroxyvitamin D (25-OH vitamin D) gradient (SADG) as a marker for diagnosing SBP in patients with cirrhotic ascites.

METHODS

We conducted a cross-sectional analytic study of 88 patients with portal hypertensive ascites resulting from liver cirrhosis of any etiology. The demographic, clinical, and laboratory characteristics of the patients were recorded. The level of 25-OH vitamin D in serum and ascitic fluid was measured using high-performance liquid chromatography autoanalyzer. The SADG was calculated with the formula: 25-OH vitamin D in serum - 25-OH vitamin D in ascites.

RESULTS

Vitamin D deficiency was detected in 89.8% of the studied patients. The SADG values ranged between 0 and 69.2 ng/mL, with a median value of 5.58 ng/mL. It was significantly lower in patients with SBP than in those without SBP (P = .004). The area under the curve for SADG in exclusion of SBP was 0.67 at a cutoff value of ≥5.57 ng/mL.

CONCLUSION

We found that SADG may be a valid marker of SBP in patients with cirrhotic ascites.

Empirical Treatment With Carbapenem vs Third-generation Cephalosporin for Treatment of Spontaneous Bacterial Peritonitis

BACKGROUND & AIMS

Third-generation cephalosporins (TGCs) are recommended as first-line antibiotics for treatment of spontaneous bacterial peritonitis (SBP). However, antibiotics against multidrug-resistant organisms (such as carbapenems) might be necessary. We aimed to evaluate whether carbapenems are superior to TGC for treatment of SBP.

METHODS

We performed a retrospective study of 865 consecutive patients with a first presentation of SBP (275 culture positive; 103 with TGC-resistant bacterial infections) treated at 7 referral centers in Korea, from September 2013 through January 2018. The primary outcome was in-hospital mortality. We made all comparisons using data from patients whose baseline characteristics were balanced by inverse probability of treatment weighting.

RESULTS

Of patients who initially received empirical treatment with antibiotics, 95 (11.0%) received carbapenems and 655 (75.7%) received TGCs. Among the entire study cohort, there was no significant difference in in-hospital mortality between the carbapenem (25.8%) and TGC (25.3%) groups (adjusted odds ratio [aOR], 0.97; 95% CI, 0.85-1.11; P = .66). In the subgroup of patients with high chronic liver failure-sequential organ failure assessment (CLIF-SOFA) scores (score of 7 or greater, n = 314), carbapenem treatment was associated with lower in-hospital mortality (23.1%) than in the TGC group (38.8%) (aOR, 0.84; 95% CI, 0.75-0.94; P=.002). In contrast, among patients with lower CLIF-SOFA scores (n = 436), in-hospital mortality did not differ significantly between the carbapenem group (24.7%) and the TGC group (16.0%) (aOR, 1.06; 95% CI, 0.85-1.32; P = .58).

CONCLUSIONS

For patients with a first presentation of SBP, empirical treatment with carbapenem does not reduce in-hospital mortality compared to treatment with TGCs. However, among critically ill patients (CLIF-SOFA scores ≥7), empirical carbapenem treatment was significantly associated with lower in-hospital mortality than TGCs.

Intraabdominal urokinase in the treatment of loculated infected ascites in cirrhosis

Cirrhotic patients may present loculated ascites. We report a case of a 49-years old patient with cirrhosis and loculated infected ascites. Conventional and ultrasound (US)-guided paracentesis were ineffective. Moreover, US-guided drainages with 10 F drains could drain only small quantities of ascites localized in the largest loculated areas. Despite an adapted and long antibiotic therapy, the infection persisted. Intraabdominal fibrinolysis allowed the destruction of the fibrin septa, a better drainage and the sterilization of the ascites fluid. This is the first case report of effective intraabdominal fibrinolysis with urokinase in difficult to treat loculated infected ascites.

Accuracy of Leukocyte Esterase Reagent Strip (LERS) test for rapid bedside screening of spontaneous bacterial peritonitis: An observational study

Introduction:

Spontaneous bacterial peritonitis (SBP) is a frequent and severe complication in cirrhotic patients with ascites. SBP is generally diagnosed based on an increased number of polymorphonuclear neutrophils in the ascitic fluid (>250/mm³) and positive culture. Usually fluid analysis and culture take time and precious hours are lost in starting therapy. Leukocyte Esterase Reagent Strips (LERS) have consistently given a high negative predictive value (>95% in the majority of the studies).

Aims and Objectives:

Aim was to evaluate the diagnostic utility of leukocyte esterase reagent strip for rapid diagnosis of SBP in patients who underwent abdominal paracentesis and to calculate the sensitivity, specificity, positive, and negative predictive values.

Methodology:

The study was carried out on 64 patients with ascites. Cell count of AF as determined by colorimetric scale of Multistix 10 SG reagent strip was compared with counting chamber method (PMNL count ≥250 cells/mm³ was considered positive).

Results:

Of the 64 patients SBP was diagnosed in 17 patients, 47 patients were negative for SBP by manual cell count. At cut off of 2+; sensitivity to diagnose SBP was 100%; specificity of 94%; PPV being 57% and NPV of 94%. at the cut off level of 3+; sensitivity decreased down to 76%; specificity increased to 100%; PPV of 100% and NPV of 93.75%. Overall accuracy at 2 + and 3 + was respectively 94.5% and 93.75%.

Conclusion:

In this study we have found good sensitivity and specificity for the prompt detection of elevated polymorphonuclear neutrophil count. A negative test result excludes SBP with a high degree of certainty. Thus, it represents a convenient, inexpensive, simple bedside screening tool for SBP diagnosis.

Recurrent and Treatment-Unresponsive Spontaneous Bacterial Peritonitis Worsens survival in Decompensated Liver Cirrhosis

BACKGROUND

Spontaneous bacterial peritonitis (SBP) remains a major complication of cirrhosis. However, the incidence and the real impact of SBP in determining patient survival rates remain unclear. This study aims to evaluate the incidence and risk factors for SBP development and the role of SBP in predicting transplant-free survival.

METHODS

Two hundred two consecutive patients underwent 492 paracenteses with biochemical and microbiological analysis of the ascitic fluid. When multiple paracenteses had been performed on a given patient, the first SBP-positive paracentesis or the first paracentesis conducted when none was diagnostic for SBP was included in the study.

RESULTS

SBP was detected in 28 of 202 (13.9%) patients; in 26 of 28 patients, the neutrophil count in the ascitic fluid was ≥250 cells/μl, and in 15 of 28 patients, the cultures were positive. Variables independently associated with SBP were as follows: a higher model of end-stage liver disease (MELD) score, the serum glucose value, elevated CRP serum levels, and higher potassium serum levels. Overall, the median (range) transplant-free survival was 289 (54-1253) days. One hundred (49.5%) patients died, whereas 35 patients (17.3%) underwent liver transplantation. Independent predictors of death or liver transplantation were a higher MELD score and the development of SBP, especially if it was antibiotic-resistant or recurrent SBP.

CONCLUSION

The occurrence of SBP is associated with more severe liver dysfunction in conjunction with the presence of inflammation. Unlike the occurrence of SBP per se, failure of first-line antibiotic treatment and SBP recurrence appear to strongly influence the mortality rate.

Guidelines on the management of ascites in cirrhosis

The British Society of Gastroenterology in collaboration with British Association for the Study of the Liver has prepared this document. The aim of this guideline is to review and summarise the evidence that guides clinical diagnosis and management of ascites in patients with cirrhosis. Substantial advances have been made in this area since the publication of the last guideline in 2007. These guidelines are based on a comprehensive literature search and comprise systematic reviews in the key areas, including the diagnostic tests, diuretic use, therapeutic paracentesis, use of albumin, transjugular intrahepatic portosystemic stent shunt, spontaneous bacterial peritonitis and beta-blockers in patients with ascites. Where recent systematic reviews and meta-analysis are available, these have been updated with additional studies. In addition, the results of prospective and retrospective studies, evidence obtained from expert committee reports and, in some instances, reports from case series have been included. Where possible, judgement has been made on the quality of information used to generate the guidelines and the specific recommendations have been made according to the 'Grading of Recommendations Assessment, Development and Evaluation (GRADE)' system. These guidelines are intended to inform practising clinicians, and it is expected that these guidelines will be revised in 3 years' time.

Malnutrition in cirrhosis: More food for thought

Malnutrition is highly prevalent in liver cirrhosis and its presence carries important prognostic implications. The clinical conditions and pathophysiological mechanisms that cause malnutrition in cirrhosis are multiple and interrelated. Anorexia and liver decompensation symptoms lead to poor dietary intake; metabolic changes characterised by elevated energy expenditure, reduced glycogen storage, an accelerated starvation response and protein catabolism result in muscle and fat wasting; and, malabsorption renders the cirrhotic patient unable to fully absorb or utilise food that has been consumed. Malnutrition is therefore a considerable challenge to manage effectively, particularly as liver disease progresses. A high energy, high protein diet is recognised as standard of care, yet patients struggle to follow this recommendation and there is limited evidence to guide malnutrition interventions in cirrhosis and liver transplantation. In this review, we seek to detail the factors which contribute to poor nutritional status in liver disease, and highlight complexities far greater than "poor appetite" or "reduced oral intake" leading to malnutrition. We also discuss management strategies to optimise nutritional status in this patient group, which target the inter-related mechanisms unique to advanced liver disease. Finally, future research requirements are suggested, to develop effective treatments for one of the most common and debilitating complications afflicting cirrhotic patients.

Natural history of grade 1 ascites in patients with liver cirrhosis

BACKGROUND

No evidence is available on the natural history of grade 1 ascites and its progression to grade 2/3 in patients with liver cirrhosis. The aim of the current study was to address this issue, to assess the development of main comorbid disorders closely related to ascites progression, and to identify the predictive factors for survival in this setting.

METHODS

Consecutive Caucasian cirrhotic patients with grade 1 ascites were retrospectively analyzed. None of patients was under treatment with diuretics at diagnosis. Control groups consisted of 145 cirrhotics with grade 2/3 ascites and 175 cirrhotics without ascites.

RESULTS

Diuretics were initiated in 58 patients with grade 1 ascites at baseline by the attending physician. At the last follow up, 29 patients had no ascites, 33 patients had grade 1 and 38 patients had grade 2/3 ascites. No variable was found to be an independent predictor of grade 2/3 ascites. Seven patients developed spontaneous bacterial peritonitis while under treatment with diuretics; at that time only 1 patient had grade 1 ascites. The mortality rate was similar among all examined groups.

CONCLUSIONS

This study suggests that the presence of grade 1 ascites does not constitute a precursor of grade 2/3 ascites in patients with cirrhosis. Thus, patients with grade 1 ascites do not require specific treatment with diuretics.

A retrospective analysis of cases of Spontaneous Bacterial Peritonitis in cirrhosis patients

Background & aims

Spontaneous Bacterial Peritonitis (SBP) is an infection in patients with cirrhosis and carries significant mortality. The management of SBP is evolving with the rise of multidrug resistant organisms. Our aim was to perform a retrospective analysis to determine if identification of bacteria in culture could aid in prognosis and provide information regarding optimal treatment.

Methods

We analyzed our 10-year experience of SBP in a single academic center (Northwestern Memorial Hospital). We obtained information regarding SBP prophylaxis, culture data and resistance patterns of bacteria, choice/duration of inpatient antibiotics, and key laboratory measurements and determined outcomes including mortality, hospital duration, and ICU stay.

Results

Patients with SBP had a 17.8% mortality and had culture positive SBP 34.4% of the time. Antimicrobial resistance was seen in 21.3% of cases and trended towards worsening mortality, with worsened mortality associated with first line use of piperacillin-tazobactam (p = 0.0001). Patients on SBP prophylaxis who developed SBP had improved mortality (p<0.0001) unless there was a positive culture, in which case patients had worsened mortality (p = 0.019). Patient with a higher PMN counts after repeat paracentesis had higher mortality (p = 0.02).

Conclusions

Our results show that SBP continues to be a morbid and deadly condition and identification of an organism is key in treatment. The standard initial antibiotic for SBP may need to be modified to reflect emerging resistant pathogens and gram-positive organisms. Further, antibiotic prophylaxis should be utilized only in select cases to prevent development of resistance.

Ascitic calprotectin for the diagnosis of spontaneous bacterial peritonitis: a systematic review and meta-analysis

Calprotectin is a promising diagnostic biomarker for spontaneous bacterial peritonitis (SBP) among cirrhotic patients, but published studies report a wide variation of its diagnostic accuracy. We systematically searched six databases for eligible studies (i.e., all original studies that reported ascitic calprotectin as a diagnostic marker for SBP in cirrhotic patients), and assessed their quality with the Quality Assessment of Diagnostic Accuracy Studies-2 tool. We calculated the pooled sensitivity, specificity, positive and negative likelihood ratios (PLR and NLR), and diagnostic odds ratio (DOR) using the bivariate mixed-effect model. We constructed the summary receiver operating characteristic and determined the area under the curve (AUC). We registered the study protocol in PROSPERO (CRD42019125476). Our search retrieved 102 studies, of which 10 were included in the analysis. The overall risk of bias of these studies ranged from low to moderate. There was no heterogeneity from the threshold effect (Spearman correlation coefficient = 0.100, P value = 0.770). The pooled estimates [95% confidence intervals (CIs)] for ascitic calprotectin were as follows: sensitivity 0.91 (95% CI: 0.88-0.94), specificity 0.87 (95% CI: 0.68-0.96), PLR 7.18 (95% CI: 2.52-20.43), NLR 0.10 (95% CI: 0.07-0.15), DOR 71.91 (95% CI: 19.42-266.34), and AUC 0.92 (95% CI: 0.90-0.94). The sensitivity analysis did not detect outliers, and the model had a robust goodness of fit. There was no significant publication bias detected (Deeks test of asymmetry, P value = 0.79). Ascitic calprotectin is a promising diagnostic biomarker for SBP in cirrhotic patients.

Predictors of immediate and short-term mortality in spontaneous bacterial peritonitis

BACKGROUND

There is scarce data from the Indian subcontinent on the outcomes following spontaneous bacterial peritonitis (SBP).

AIM

To study the immediate (within 30 days) and short-term mortality (31-90 days) associated with SBP and to determine the predictors of the same.

METHODS

This prospective observational study was done among patients with liver cirrhosis who underwent paracentesis. Patient data included age, gender, co-morbidity, cirrhosis-related complications, model of end-stage liver disease (MELD), and Child-Turcotte-Pugh (CTP) scores. SBP was diagnosed based on ascitic fluid polymorphonuclear leukocyte count > 250/mm³ with or without ascitic fluid culture positivity.

RESULTS

Of the 870 patients with cirrhosis and ascites registered during the study period, 610 fulfilled the criteria for inclusion. Altogether, 122 patients with SBP were identified: 52 (42.6%) died, 40 (32.8%) survived without liver transplant, and 30 (24.6%) underwent liver transplantation within 3 months. Thirty-two patients (26.2%) were blood culture posi tive for bacteria and 7 (5.7%) demonstrable bacterial growth in ascitic fluid. Blood culture positivity was significantly higher in the group with immediate mortality (p < 0.0001) and was also significantly associated (p 0.005) with mortality at 3 months.

CONCLUSION

Nearly two-fifths (42.6%) of the study cohort died within 3 months of an episode of SBP. Four-fifths of these patients died within 30 days. Blood culture positivity was significantly associated with immediate and short-term mortality.

Spontaneous Bacterial Peritonitis: We Are Still Behind

Spontaneous bacterial peritonitis (SBP) is an infection in the ascitic fluid. Despite published guidelines, an inappropriate diagnosis of SBP is frequent. In this study, we aim to evaluate guideline adherence in diagnosing SBP. This is a retrospective study conducted between January 2015 and January 2018. Based on the American Association for the Study of Liver Diseases (AASLD) and the European Association for the Study of Liver (EASL), two authors judged guideline adherence in SBP diagnosis and management. One hundred and six patients were included in the study, and 93% were hospitalized. The mean age was 56.9 years, and 62 patients were males. In addition, Caucasians were the most common ethnicity (86.8%). The authors judged that only 52.4% of patients were appropriately diagnosed, and only 67.3% were managed with proper treatment. Inpatient mortality was documented in five patients, and the readmission rate within 30-days after discharge was 29.3%. In conclusion, SBP is a common complication of cirrhosis, which can be managed with adherence to published guidelines. In our population, guidelines were not implemented in diagnosing nearly half the SBP patients, mostly due to misdiagnosis of SBP with secondary peritonitis or non-neutrocytic bacteriascites, starting antibiotics before performing the paracentesis, and even giving broad-coverage antibiotics when not indicated. Further efforts are needed to enhance adherence to guidelines in clinical practice.

A novel serum index for accurate diagnosis of spontaneous bacterial peritonitis in cirrhotic patients without other infections

Background

The accurate non-invasive diagnosis of spontaneous bacterial peritonitis (SBP) in patients with decompensated liver cirrhosis has not been achieved yet. The aim of the study was to obtain an unmistakable diagnosis of SBP using a new simple serum bioscore, made by combined measurement of procalcitonin (PCT), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP), which we called the PEC index. This cross-sectional analytic study comprised 178 cirrhotic patients with ascites (60 patients with SBP and 118 patients with sterile ascites), after excluding non-SBP infection, during the period from March 2019 until September 2019. In all participants, serum levels of PCT, ESR, and CRP were measured, and PEC index was calculated [PEC index = PCT × (ESR + CRP)].

Results

Patients with SBP (n = 60) had significantly higher serum PEC index than those with sterile ascites (n = 118) (41.0/31.2–93.0 vs. 9.9/5.9–15.0, P < 0.001). PEC index distinguished culture positive cases significantly (P < 0.001). Using receiver operating characteristic (ROC) statistics, the sensitivity and specificity of PCT, at a cutoff value of 0.590 ng/mL, for SBP diagnosis, were 81.67% and 93.33%, respectively (area under the curve [AUC] = 0.879; 95% confidence interval [CI] 0.809–0.948). The sensitivity and specificity of ESR, at a cutoff value of 27.0 mm/hour, were 73.33% and 61.67%, respectively (AUC = 0.679; 95% CI 0.581–0.776). The sensitivity and specificity of CRP, at a cutoff value of 21.0 mg/L, were 93.33% and 51.67%, respectively (AUC = 0.736; 95% CI 0.639–0.833). While, the sensitivity and specificity of PEC index, at a cutoff value of 20, were highest (98.33% and 96.67%, respectively, AUC = 0.977; 95% CI 0.940–0.996).

Conclusion

Serum PEC index makes an accurate noninvasive diagnosis of SBP, after excluding other infections.

Clinical audit to determine efficacy of daily infusion of low dose of 20% albumin in combination with antibiotics in patients with spontaneous bacterial peritonitis

Aim of the study

The recommended high dose albumin treatment for spontaneous bacterial peritonitis (SBP) is not possible in the Indian setting due to financial constraints. Aim of the study was the retrospective audit to determine the outcome of patients with SBP on combination treatment of low dose albumin and appropriate antibiotics.

Material and methods

Patients undergoing abdominal paracentesis in the period 2016-2018 were included. Patient details including age, gender, co-morbidity profile, details of previous hospitalisation and antibiotics, MELD score, and ascitic fluid analysis were noted. Details of albumin use and antibiotics were retrieved. SBP was classified based on mode of acquisition of infection and severity risk based on laboratory parameters. Statistics – χ² test, Mann-Whitney U test, relative risk calculation. A p value of < 0.05 was considered as significant.

Results

24 (18.8%), 38 (29.7%) and 66 patients (51.5%) belonged to low, intermediate and high risk SBP groups, respectively. The median dose of albumin was 20 g/day for a median duration of 5 days (range 1-8). Between the 3 subgroups, there was no significant difference in the median age; the majority were men. Antibiotic escalation was necessary in intermediate and high risk cases (42.1% vs. 84.8%, p < 0.0001). The mortality rate in intermediate and high risk groups was 29% and 42%, respectively (p = 0.18). Between the 2 subgroups of intermediate risk, patients with serum bilirubin < 4 mg/dl and serum creatinine > 1 mg/dl were significantly older (54 vs. 49 years, p = 0.02), and had high mortality (40.7% vs. 0%). Cirrhosis-related complications (CRC; one or more in combinations) were more frequent in high risk and intermediate risk patients (p = 0.001) with a 7-8 times higher risk of mortality compared to those who had no CRC.

Conclusions

Our protocol is associated with high mortality in intermediate and high risk SBP patients. Presence of one or more CRC increases the risk of mortality several fold.

Serum CD64 and ascitic fluid calprotectin and microRNA-155 as potential biomarkers of spontaneous bacterial peritonitis

AIM

Patients with ascites are at a higher risk for associated of on top bacterial infections with subsequent life-threatening complications. We aimed to evaluate CD64, calprotectin, and microRNA-155 (miR-155) levels as diagnostic markers of spontaneous bacterial peritonitis (SBP) and the effect of using more than one use on the same spot over their diagnostic efficiency.

PATIENTS AND METHODS

An observational comparative study included 103 patients with ascites admitted to the Tropical Medicine Department, Mansoura University Hospital, Egypt, divided into two groups: case group (64 patients) with ascites with SBP and control group (39 patients) with decompensated cirrhotic non-SBP ascites. Twenty milliliters of ascetic fluid was obtained from all participants for bacterial culture, and assessment of calprotectin and miR-155, in addition to 2 ml blood for the CD64 marker expression assay by a flowcytometer.

RESULTS

The sensitivity and specificity of CD64 expression assay were 95.3 and 92.3%, respectively, area under the curve (AUC)=0.93, whereas those of ascetic fluid calprotectin and miR-155 were 87.5 and 82.1%, AUC=0.90 and 95.3 and 97.4%, with AUC of 0.95. Combined blood CD64 and ascetic fluid calprotectin had a diagnostic accuracy of 0.988 for blood CD64 and ascetic fluid miR-155, AUC=0.991, and that for ascetic fluid calprotectin and miR-155 was 0.988. On using the three studied markers together, the diagnostic accuracy was the best recorded, AUC=0.994. P values were less than 0.001.

CONCLUSION

CD64, calprotectin, and miR-155 were good diagnostic markers of SBP and on using this combination, greater efficiency in diagnosis was achieved.

Evidence of Significant Ceftriaxone and Quinolone Resistance in Cirrhotics with Spontaneous Bacterial Peritonitis

OBJECTIVES

There are few studies addressing the impact of cephalosporin and quinolone resistance on hospital length of stay and mortality in spontaneous bacterial peritonitis (SBP). We aim to describe the shifting epidemiology of SBP at our institution and its impact on clinical outcomes.

METHODS

We performed a single-center retrospective cohort study of all cases of SBP from 2005 to 2015 at a transplant center. Cases were identified using hospital billing data. Patient data were confirmed using the electronic medical record. Univariate and multivariate logistic regression and Cox proportional hazards models were used to identify factors that were associated with prolonged hospital length of stay and reduced survival. Culture-positive cases (N = 56) were compared to culture-negative cases (N = 104). Subpopulation analysis of the culture-positive cases compared ceftriaxone-resistant (N = 25) to ceftriaxone-susceptible (N = 31) cases.

RESULTS

We identified 160 cases of SBP (56 culture positive and 104 culture negative; 21 nosocomial, 79 hospital associated, and 60 community acquired). Forty-five percent (N = 25 total, 13 hospital associated and 6 nosocomial) of bacterial isolates were resistant to ceftriaxone, with 37.5% (N = 21) being gram positive, including 8 methicillin-resistant staphylococcus and 6 vancomycin-resistant enterococcus. Multivariate analysis identified hospital-associated SBP, age, alcoholic cirrhosis, and MELD-Na score as variables associated with worse survival (P < 0.05), with a trend toward worse survival in culture-positive cases (P = 0.123). Only MELD-Na was associated with prolonged length of stay.

CONCLUSIONS

The burden of resistant pathogens causing SBP is significant, notably in hospital-associated SBP. Culture-positive SBP may represent a higher risk group compared to culture-negative SBP.

Mansoura simple scoring system for prediction of spontaneous bacterial peritonitis: lesson learnt

BACKGROUND AND OBJECTIVE

Spontaneous bacterial peritonitis (SBP) is a common bacterial infection with life-threatening sequelae in cirrhotic ascites. The purpose of this retrospective cohort study was to recognize the predictors of SBP to build up a noninvasive system to exclude or establish an episode of SBP.

PATIENTS AND METHODS

Of 1194 consecutive patients with cirrhotic ascites, only 966 patients were enrolled in this study. SBP was diagnosed once polymorphonuclear count was at least 250 cells/mm and/or there was a positive ascitic fluid culture result. Biochemical and clinical parameters were evaluated as predictors of SBP. A scoring system was established in the training group of 682 and validated in a second group of 284 participants.

RESULTS

The incidence of SBP was 12.3 and 12% in the training and validation groups, respectively. Age of at least 55 years, mean platelet volume (MPV) of at least 8.5 fl, neutrophil-to-lymphocyte ratio (NLR) of at least 2.5, and C-reactive protein (CRP) of at least 40 mg/l were identified as independent predictors of SBP. A scoring system including these four variables (age, MPV, and NLR with 1 point each, whereas CRP with 2 points) achieves a specificity of 98.2% with a positive predictive value for the diagnosis of SBP of 88.1% (score≥4). At a threshold of 1 point, the negative predictive value is 97.5% with a sensitivity of 92.9%. SBP is not associated with a high Model for End-stage Liver Disease score (P=0.135).

CONCLUSION

The combination of age, MPV, NLR, and CRP in a simple scoring system, Mansoura simple scoring system, supports quick and accurate exclusion or diagnosis of SBP.

Spontaneous bacterial peritonitis caused by Gram-negative bacteria: an update of epidemiology and antimicrobial treatments

Introduction: Spontaneous bacterial peritonitis (SBP) is a main infectious complication in end-stage liver disease (ESLD) patients. The increasing trend of bacterial resistance in ESLD patients with SBP has been associated with low treatment efficacy of traditional therapy. Cephalosporin use has been restricted to community-acquired infections and in areas/health care settings with low rates of multidrug-resistant (MDR) bacteria. To date, several changes are necessary with regard to empiric therapy recommendations in areas/health care settings with high rates of MDR bacteria. Areas covered: An overview of the epidemiology and antimicrobial treatments of SBP caused by Gram-negative bacteria. Expert opinion: Broad-spectrum antibiotics have been recommended as empiric therapy for suspected SBP in areas/health care settings with high rates of MDR bacteria and secondary treatment, with newer antibiotics, for SBP caused by MDR-Gram-negative bacteria (i.e. new beta-lactam/beta-lactamase inhibitor combinations, cefiderocol, plazomicin, and eravacycline) either alone or in combination.

Urinary neutrophil gelatinase-associated lipocalin for diagnosis of spontaneous bacterial peritonitis

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.

Spontaneous bacterial peritonitis among adult patients with ascites attending Korle-Bu Teaching Hospital

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.

Prevalence and predictors for spontaneous bacterial peritonitis in cirrhotic patients with ascites admitted at medical block in Korle-Bu Teaching Hospital, Ghana

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 25^th March, 2016 to 25^th 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.

Risk factors predicting nosocomial, healthcare-associated and community-acquired infection in spontaneous bacterial peritonitis and survival outcome

Aim of the study

To determine risk factors predicting nosocomial, healthcare-associated and community-acquired infection in spontaneous bacterial peritonitis (SBP) and survival outcome.

Material and methods

This prospective observational study included confirmed cases of cirrhosis with ascites requiring paracentesis, age > 18 years, either gender, any aetiology and Child-Turcotte-Pugh (CTP) stage, with or without cirrhosis-related complications. Patient data included age, gender, co-morbidity, model for end-stage liver disease (MELD) score, CTP score, cirrhosis-related complications, details of previous hospitalization, ascitic tapping and antibiotics instituted. SBP was diagnosed as ascitic fluid polymorphonuclear leucocyte count greater than 250/mm³ (0.25 × 10⁹/l) and/or culture positivity for a single organism. Statistics - chi square test, Mann-Whitney U test, ANOVA, survival plot. A p value < 0.05 was statistically significant.

Results

610 cases fulfilled the criteria for inclusion. 122 (20%) patients had SBP: community-acquired SBP 37 (30.3%), nosocomial SBP 19 (16.5%) and healthcare-associated SBP 66 (54.5%). The majority were men (106; 86%) with median age of 51.5 (27-78) years. A significantly higher percentage of community-acquired SBP belonged to CTP class B. Thirtytwo and 7 patients respectively were blood and ascitic fluid culture positive. Significant nosocomial SBP were blood culture positive (p < 0.02). The most common isolates were E. coli followed by Klebsiella. Survival plot analysis at 3 months showed the worst survival for nosocomial SBP (p = 0.0009).

Conclusions

Prevalence of SBP in our study was 20%, the majority with healthcare-associated SBP belonging to CTP C. Patients with nosocomial SBP had significant bacteremia with high mortality.

Infections in Cirrhosis

Purpose of review

Patients with cirrhosis are at high risk of developing serious infections. Bacterial infections remain the most common cause of morbidity and mortality in these patients. This review is focused on the prevalence of infections in those with cirrhosis, including multidrug-resistant (MDR) pathogens, pathogenesis of infection-related acute-on-chronic liver failure (ACLF), current treatment recommendations, and prophylactic strategies in patients with cirrhosis.

Recent findings

Recent epidemiological studies have noted an emerging prevalence of MDR bacterial infections and associated with poor prognosis, and a high rate of treatment failure and mortality. Therefore, new recommendations on empirical antibiotic use based on epidemiological data have been developed in order to improve outcomes.

Summary

Spontaneous bacterial peritonitis (SBP) and urinary tract infection (UTI) are the most frequent infections followed by pneumonia, cellulitis, and bacteremia, while pneumonia carries the highest risk of mortality. The incidence of MDR bacterial infections has been increasing, especially in healthcare-associated settings. Second infections that develop during hospitalization, multiple organ failures, and high MELD score are associated with poor survival. Preventive measures, early diagnosis, and adequate treatment of infections are essential key concepts in minimizing morbidity and mortality in patients with cirrhosis.

Spontaneous bacterial peritonitis - therapeutic challenges in the era of increasing drug resistance of bacteria

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.

Routine analysis of ascitic fluid for evidence of infection in children with chronic liver disease: Is it mandatory?

Ascitic fluid infection is a major cause of morbidity and mortality in cirrhotic patients, requiring early diagnosis and therapy. We aimed to determine predictors of ascitic fluid infection in children with chronic liver disease. The study included 45 children with chronic liver disease and ascites who underwent 66 paracentesis procedures. Full history taking and clinical examination of all patients were obtained including fever, abdominal pain and tenderness and respiratory distress. Investigations included: complete blood count, C-reactive protein, full liver function tests, ascitic fluid biochemical analysis, cell count and culture. Our results showed that patients' ages ranged between 3 months to 12 years. Prevalence of ascitic fluid infection was 33.3%. Gram-positive bacteria were identified in six cases, and Gram-negative bacteria in five. Fever and abdominal pain were significantly more associated with infected ascites (p value = 0.004, 0.006). Patients with ascitic fluid infection had statistically significant elevated absolute neutrophilic count and C-reactive protein. Logistic regression analysis showed that fever, abdominal pain, elevated absolute neutrophilic count and positive C-reactive protein are independent predictors of ascitic fluid infection. Fever, elevated absolute neutrophilic count and positive C-reactive protein raise the probability of ascitic fluid infection by 3.88, 9.15 and 4.48 times respectively. The cut-off value for C-reactive protein for ascitic fluid infection was 7.2 with sensitivity 73% and specificity of 71%. In conclusion, prevalence of ascitic fluid infection in pediatric patients with chronic liver disease and ascites was 33.3%. Fever, abdominal pain, positive C-reactive protein and elevated absolute neutrophilic count are strong predictors of ascitic fluid infection. Therefore an empirical course of first-line antibiotics should be immediately started with presence of any of these predictors after performing ascitic fluid tapping for culture and sensitivity. In absence of these infection parameters, routine ascitic fluid analysis could be spared.

Predicting mortality in patients with spontaneous bacterial peritonitis using routine inflammatory and biochemical markers

OBJECTIVES

Spontaneous bacterial peritonitis (SBP) is a common and high-mortality infectious complication of patients with cirrhosis. New inflammatory markers are associated with morbidity/mortality in various diseases. The aim of our study was to find the 30-day mortality rate of SBP and their predictors.

PATIENTS AND METHODS

Seventy patients with cirrhosis complicated with SBP and 55 non-SBP controls were enrolled into the study, and patients were evaluated for mortality rate and its predictors.

RESULTS

The 30-day and 3-month mortality rates in the SBP group were 26.1 and 50.7%, respectively. Mortality rates were higher in the SBP group than in the controls. Symptoms at hospital admission and cell counts in ascitic fluid made no difference in predicting 30-day mortality. Patients with SBP with high serum neutrophil counts, high neutrophil-lymphocyte ratio, high C reactive protein (CRP)/albumin ratio, and high model for end-stage liver disease (MELD) score had higher 30-day mortality rates. We determined optimal cutoff values of MELD scores and serum neutrophil counts for predicting 30-day mortality as 20.5 and 6850/mm, respectively. The sensitivity and specificity for the MELD cutoff value were 83.3 and 80.4%, respectively. We also followed up patients for 60 months after SBP; the patients with high inflammatory markers and MELD scores at the time of SBP diagnosis had worse survival compared with the group with lower levels.

CONCLUSION

Our results suggest that SBP has high 30-day mortality. MELD scores and inflammatory markers (CRP, CRP albumin ratio, neutrophil-lymphocyte ratio) may be used to predict mortality in patients with SBP.

Echocardiographic and Electrocardiographic Predictors of Adverse Outcomes in Spontaneous Bacterial Peritonitis

BACKGROUND

Patients with cirrhosis who develop Spontaneous Bacterial Peritonitis (SBP) suffer from cirrhotic cardiomyopathy which is characterized by impaired contractility in response to stress despite a relatively normal resting cardiac output. We hypothesized that electrocardiographic and echocardiographic information would help prognosticate patients developing SBP in addition to existing scoring systems.

METHODS

Cirrhotic patients admitted to Einstein Medical Center from 01/01/2005 to 6/30/2012 for SBP, and did not receive a transplant within one year, were included. Patients were classified as QTc low vs. high, and E/E' low vs. high at cut points ≥480 ms for QTc and ≥10 for E/E' ratio. We estimated 1-year survival using Kaplan Meier curves. Regression analysis and Cox proportional hazards model were used for QTc and E/E' ratio, respectively, for assessing 1-year survival.

RESULTS

Among 112 patients with electrocardiogam, 78 were classified as QTc low. Among 64 patients with echocardiograms, 23 were classified as E/E' low. Higher QTc was associated with increased in-hospital acute kidney injury. QTc and E/E' ratio predicted worse 1-year survival (HR = 2.16, 95% CI 1.29-3.49; HR 2.65, 95% CI 1.31-5.35, respectively) on univariate and multivariate analysis (OR = 1.02, 95% CI 1.01-1.03; HR = 3.26, 95% CI 1.22-9.82 respectively) after adjusting for both Child Pugh stage, MELD score among other risk factors.

CONCLUSION

In conclusion, cirrhotic patients with SBP who present with a prolonged QTc interval are at a greater risk for acute renal failure during hospitalization. High QTc duration and an E/E' ratio of ≥10 independently predict increased mortality at 1-year follow-up.

Detection of bacterial DNA by in situ hybridization in patients with decompensated liver cirrhosis

Background

Spontaneous bacterial peritonitis (SBP) is often difficult to diagnose because bacteria in ascites cannot be detected accurately by conventional culture. In situ hybridization (ISH) was previously developed for rapid detection of genes from bacteria phagocytized by neutrophils. SBP may develop after bacteria enter into the systemic circulation following bacterial translocation. Therefore, we performed ISH to identify bacteria in blood samples collected from patients with decompensated liver cirrhosis (LC).

Methods

In this retrospective study, peripheral blood samples were collected from 60 patients with decompensated LC, and bacteria were detected by both blood culture and ISH. Moreover, 35 patients underwent paracentesis for diagnosis of SBP.

Results

Eight of 35 patients were diagnosed with SBP by polymorphonuclear neutrophil counts, and one patient was diagnosed with bacterascites. Seven of the nine patients showed positive results for ISH, whereas bacteria were detected in only two cases by blood culture. Thirty-seven of 60 cases (62%) showed positive results for ISH, whereas only six samples (10%) were positive by blood culture analysis. Compared with the 23 cases of negative ISH, the 37 cases of positive ISH showed a higher frequency of fever, higher Child-Pugh scores, and lower albumin levels.

Conclusions

Detection of bacteria by ISH suggested that bacterial translocation, which cannot be proven by conventional culture, occurred in these patients, and that ISH could be helpful for the early diagnosis of some types of infection and prevention of SBP in these patients.