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Long B, Gottlieb M. Emergency medicine updates: Spontaneous bacterial peritonitis. Am J Emerg Med 2023; 70:84-89. [PMID: 37244043 DOI: 10.1016/j.ajem.2023.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/11/2023] [Accepted: 05/12/2023] [Indexed: 05/29/2023] Open
Abstract
INTRODUCTION Spontaneous bacterial peritonitis (SBP) is a common infection in patients with cirrhosis and ascites and is associated with significant risk of mortality. Therefore, it is important for emergency medicine clinicians to be aware of the current evidence regarding the diagnosis and management of this condition. OBJECTIVE This paper evaluates key evidence-based updates concerning SBP for the emergency clinician. DISCUSSION SBP is commonly due to Gram-negative bacteria, but infections due to Gram-positive bacteria and multidrug resistant bacteria are increasing. The typical presentation of SBP includes abdominal pain, worsening ascites, fever, or altered mental status in a patient with known liver disease; however, some patients may be asymptomatic or present with only mild symptoms. Paracentesis is the diagnostic modality of choice and should be performed in any patient with ascites and concern for SBP or upper gastrointestinal bleeding, or in those being admitted for a complication of cirrhosis. Ultrasound should be used to optimize the procedure. An ascites absolute neutrophil count (ANC) ≥ 250 cells/mm3 is diagnostic of SBP. Ascitic fluid should be placed in blood culture bottles to improve the culture yield. Leukocyte esterase reagent strips can be used for rapid diagnosis if available. While many patients will demonstrate coagulation panel abnormalities, routine transfusion is not recommended. Management traditionally includes a third-generation cephalosporin, but specific patient populations may require more broad-spectrum coverage with a carbapenem or piperacillin-tazobactam. Albumin infusion is associated with reduced risk of renal impairment and mortality. CONCLUSIONS An understanding of literature updates can improve the care of patients with suspected SBP.
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Affiliation(s)
- Brit Long
- SAUSHEC, Emergency Medicine, Brooke Army Medical Center, United States of America.
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States of America
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Lee CH, Kang HJ, Yu SY, Seo SY, Kim SH, Kim SW, Lee SO, Lee ST, Kim IH. Initial treatment response and short-term mortality of spontaneous bacterial peritonitis in cirrhotic patients with hepatocellular carcinoma. Sci Rep 2023; 13:6067. [PMID: 37055466 PMCID: PMC10101952 DOI: 10.1038/s41598-023-32006-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 03/21/2023] [Indexed: 04/15/2023] Open
Abstract
This study aimed to investigate the initial treatment response and short-term mortality of spontaneous bacterial peritonitis (SBP) in cirrhotic patients with hepatocellular carcinoma (HCC) compared with those without HCC. A total of 245 patients with liver cirrhosis diagnosed with SBP between January 2004 and December 2020 were included. Of these, 107 (43.7%) were diagnosed with HCC. Overall, the rates of initial treatment failure, 7-day and 30-day mortality were 91 (37.1%), 42 (17.1%), and 89 (36.3%), respectively. While the baseline CTP score, MELD score, culture-positive rate, and rates of antibiotic resistance did not differ between both groups, patients with HCC had a higher rate of initial treatment failure than those without HCC patients (52.3% vs. 25.4%, P < 0.001). Similarly, 30-day mortality was also significantly higher in patients with HCC (53.3% vs. 23.2%, P < 0.001). In the multivariate analysis, HCC, renal impairment, CTP grade C, and antibiotic resistance were independent factors for initial treatment failure. Furthermore, HCC, hepatic encephalopathy, MELD score, and initial treatment failure were independent risk factors for 30-day mortality, with statistically significant poor survival outcomes in patients with HCC (P < 0.001). In conclusion, HCC is an independent risk factor for initial treatment failure and high short-term mortality in patients with cirrhosis with SBP. It has been suggested that more attentive therapeutic strategies are required to improve the prognosis of patients with HCC and SBP.
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Affiliation(s)
- Chang Hun Lee
- Department of Internal Medicine, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonbuk National University Medical School and Hospital, Geonjiro 20, Dukjin-Gu, Jeonju, Jeonbuk, 54907, South Korea
| | - Hye Jin Kang
- Department of Internal Medicine, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonbuk National University Medical School and Hospital, Geonjiro 20, Dukjin-Gu, Jeonju, Jeonbuk, 54907, South Korea
| | - Song Yi Yu
- Department of Internal Medicine, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonbuk National University Medical School and Hospital, Geonjiro 20, Dukjin-Gu, Jeonju, Jeonbuk, 54907, South Korea
| | - Seung Young Seo
- Department of Internal Medicine, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonbuk National University Medical School and Hospital, Geonjiro 20, Dukjin-Gu, Jeonju, Jeonbuk, 54907, South Korea
| | - Seong Hun Kim
- Department of Internal Medicine, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonbuk National University Medical School and Hospital, Geonjiro 20, Dukjin-Gu, Jeonju, Jeonbuk, 54907, South Korea
| | - Sang Wook Kim
- Department of Internal Medicine, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonbuk National University Medical School and Hospital, Geonjiro 20, Dukjin-Gu, Jeonju, Jeonbuk, 54907, South Korea
| | - Seung Ok Lee
- Department of Internal Medicine, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonbuk National University Medical School and Hospital, Geonjiro 20, Dukjin-Gu, Jeonju, Jeonbuk, 54907, South Korea
| | - Soo Teik Lee
- Department of Internal Medicine, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonbuk National University Medical School and Hospital, Geonjiro 20, Dukjin-Gu, Jeonju, Jeonbuk, 54907, South Korea
| | - In Hee Kim
- Department of Internal Medicine, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonbuk National University Medical School and Hospital, Geonjiro 20, Dukjin-Gu, Jeonju, Jeonbuk, 54907, South Korea.
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Kim M, Cardoso FS, Pawlowski A, Wunderink R, Ladner DP, Abraldes JG, Karvellas CJ. The impact of multidrug-resistant microorganisms on critically ill patients with cirrhosis in the intensive care unit: a cohort study. Hepatol Commun 2023; 7:e0038. [PMID: 36669500 PMCID: PMC10019237 DOI: 10.1097/hc9.0000000000000038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 11/14/2022] [Indexed: 01/22/2023] Open
Abstract
The impact of multidrug-resistant (MDR) colonization and MDR infection in critically ill cirrhosis patients remains unclear. We assessed the association of MDR colonization and MDR infection with these patients' survival. Observational cohort study including adult cirrhosis patients admitted to 5 intensive care units at Northwestern Memorial Hospital (Chicago, Illinois, USA) on January 1, 2010, to December 31, 2017. Patients admitted for elective liver transplant or with previous liver transplant were excluded. Patients were screened for MDR colonization on intensive care unit admission. Infection diagnoses during the intensive care unit stay were considered. The primary endpoint was hospital transplant-free survival. Among 600 patients included, 362 (60%) were men and median (interquartile range) age was 58.0 (49.0, 64.0) years. Median (interquartile range) Model for End-stage Liver Disease, Sequential Organ Failure Assessment, and Chronic Liver Failure-Acute-on-Chronic Liver Failure scores on intensive care unit day 1 were 28.0 (20.0, 36.0), 9.0 (6.0, 13.0), and 55.0 (48.0, 64.0), respectively. Overall, 76 (13%) patients were transplanted and 443 (74%) survived the hospital stay. Infections were diagnosed in 347 (58%) patients: pneumonia in 197 (33%), urinary tract infection in 119 (20%), peritonitis in 93 (16%), bloodstream infection in 99 (16%), Clostridium difficile colitis in 9 (2%), and catheter tip infection in 7 (1%). MDR colonization and MDR infection were identified in 200 (33%) and 69 (12%) patients, respectively. MDR colonization was associated with MDR infection (p < 0.001). MDR colonization or MDR infection was associated with higher number and duration of antibiotics (p < 0.001). Following adjustment for covariables (age, sex, etiology, portal hypertension, and Sequential Organ Failure Assessment score), MDR colonization [OR (95% CI), 0.64 (0.43, 0.95)] or MDR infection [adjusted OR (95% CI), 0.22 (0.12, 0.40)] were independently associated with lower transplant-free survival. Among critically ill cirrhosis patients, MDR colonization or MDR infection portended a worse prognosis.
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Affiliation(s)
- Minjee Kim
- Division of Neurocritical Care, Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Filipe S. Cardoso
- Transplant Unit and Intensive Care Unit, Curry Cabral Hospital, Nova Medical School, Lisbon, Portugal
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada
| | - Anna Pawlowski
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Richard Wunderink
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Daniela P. Ladner
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Juan G. Abraldes
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada
| | - Constantine J. Karvellas
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada
- Division of Gastroenterology (Liver Unit),Department of Critical Care Medicine University of Alberta, Edmonton, Alberta, Canada
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Nguyen LC, Lo TTB, La HD, Doan HTN, Le NT. Clinical, Laboratory and Bacterial Profile of Spontaneous Bacterial Peritonitis in Vietnamese Patients with Liver Cirrhosis. Hepat Med 2022; 14:101-109. [PMID: 35936811 PMCID: PMC9348134 DOI: 10.2147/hmer.s369966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 07/21/2022] [Indexed: 11/23/2022] Open
Abstract
Aim Methods Results Conclusion
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Affiliation(s)
- Long Cong Nguyen
- Gastroenterology and Hepatology Center, Bach Mai Hospital, Hanoi, Vietnam
- University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
- Correspondence: Long Cong Nguyen, Institution: Gastroenterology and Hepatology Center, Bach Mai hospital, Hanoi, Vietnam, Email
| | | | - Huong Dieu La
- Gastroenterology and Hepatology Center, Bach Mai Hospital, Hanoi, Vietnam
| | - Ha Thi-Ngoc Doan
- Gastroenterology and Hepatology Center, Bach Mai Hospital, Hanoi, Vietnam
| | - Ngoan Tran Le
- Institute of Research and Development, Duy Tan University, Da Nang, Vietnam
- Department of Public Health, School of Medicine, International University of Health and Welfare, Tochigi, Japan
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Ghweil AA, Bazeed SES, Al Rawy MH, Khodeary A, El-Amir MI. Fluoroquinolone-resistant strains in cirrhotic patients with spontaneous bacterial peritonitis: microbiological and molecular aspects. Eur J Gastroenterol Hepatol 2022; 34:64-68. [PMID: 32804847 DOI: 10.1097/meg.0000000000001908] [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] [Indexed: 12/10/2022]
Abstract
OBJECTIVES This study aimed to determine the causative bacterial agents of spontaneous bacterial peritonitis (SBP) in patients with cirrhosis and to define antibiotic-resistance patterns in addition to identifying the genetic mutations in the quinolone resistance determining regions (QRDRs). PATIENTS AND METHODS Twenty milliliters of ascetic fluid was obtained from 51 patients with SBP. The antibiotic-sensitivity patterns of different strains were determined by the Kirby-Bauer method. Extracted bacterial DNA was used to determine the mutations in four different genes in QRDRs (gyrA, gyrB, parC, and parE) by sequencing after gene amplification by PCR. RESULTS Gram-negative bacilli were detected in 60.7% of the patients. Escherichia coli was detected in 33.3% of the patients, and Staphylococcus aureus was detected in 21.6%. Gram-negative bacilli showed the best sensitivity to meropenem (90.3%), followed by amikacin (83.9%). Gram-positive cocci were sensitive to vancomycin and oxacillin at 90 and 80%, respectively. Fluoroquinolone resistance was detected in 27% of the bacterial strains. Mutations in the gyrA and parC genes were detected in quinolone-resistant strains (64.3 and 35.7%, respectively). Several mutations were found in the gyrA gene (Ser83Leu, Ser81Phe, and Ser-84Leu). Ser80Ile and Ser79Tyr mutations were detected in the parC gene. No mutation was detected in the parE gene. CONCLUSION Frequent use of antibiotics as prophylaxis against SBP leads to an increase in antibiotic resistance and changes the microbial pattern of causative agents. The gyrA gene mutation was the most common mutation detected in fluoroquinolone-resistant strains.
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Affiliation(s)
- Ali A Ghweil
- Department of Tropical Medicine and Gastroenterology, Faculty of Medicine, South Valley University, Qena
| | | | - M H Al Rawy
- Department of Clinical Pathology, Faculty of Medicine, Sohag University, Sohag
| | - Ashraf Khodeary
- Department of Clinical Pathology, Faculty of Medicine, Sohag University, Sohag
| | - Mostafa I El-Amir
- Department of Medical Microbiology and Immunology, Faculty of Medicine, South Valley University, Qena, Egypt
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Samonakis DN, Gatselis N, Bellou A, Sifaki-Pistolla D, Mela M, Demetriou G, Thalassinos E, Rigopoulou EI, Kevrekidou P, Tziortziotis I, Azariadi K, Kavousanaki M, Digenakis E, Vassiliadis T, Kouroumalis EA, Dalekos GN. Spontaneous bacterial peritonitis: a prospective Greek multicenter study of its epidemiology, microbiology, and outcomes. Ann Gastroenterol 2022; 35:80-87. [PMID: 34987293 PMCID: PMC8713337 DOI: 10.20524/aog.2021.0674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 07/20/2021] [Indexed: 11/11/2022] Open
Abstract
Background Spontaneous bacterial peritonitis (SBP) is an ominous complication of decompensated cirrhosis. This study aimed to assess several epidemiological, clinical, microbiological and outcome characteristics in Greek patients with SBP, as no solid representative nationwide data of this type was available. Methods During a 3-year period, 77 consecutive patients with SBP (61 male; median age: 67 years; model for end-stage liver disease [MELD] score: 20), diagnosed and followed in 5 tertiary liver units, were prospectively recruited and studied. Various prognostic factors for disease outcome were studied. Results Thirty-eight patients had alcohol-related cirrhosis, 17 viral hepatitis, 6 non-alcoholic steatohepatitis, 6 autoimmune liver diseases, and 10 cryptogenic cirrhosis. Hepatocellular carcinoma (HCC) was present in 23 (29.9%), whereas 10 (13%) had portal vein thrombosis. The first SBP episode at baseline was community-acquired in 53 (68.8%), while in 24 (31.1%) was hospital-acquired, with predominant symptoms abdominal pain and encephalopathy. A positive ascitic culture was documented in 36% of patients in the initial episode, with almost equal gram (+) and gram (-) pathogens, including 3 multidrug-resistant pathogens. Significant factors for 6-month survival were: higher MELD score, previous b-blocker use, lower serum albumin, higher lactate on admission and need for vasopressors, while factors for 12-month survival were MELD score and lactate. For overall survival, higher MELD score and lactate along with HCC presence were negative predictive factors. Conclusions MELD score, lactate, albumin, HCC and treatment with vasopressors were predictive of survival in SBP patients. In hospital-acquired SBP the prevalence of difficult-to-treat pathogens was higher.
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Affiliation(s)
- Dimitrios N Samonakis
- Department of Gastroenterology and Hepatology, University Hospital of Heraklion Crete, Greece (Dimitrios N. Samonakis, George Demetriou, Emmanuel Digenakis, Elias A. Kouroumalis)
| | - Nikolaos Gatselis
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Greece (Nikolaos Gatselis, Aristea Bellou, Eirini I. Rigopoulou, Kalliopi Azariadi, George N. Dalekos)
| | - Aristea Bellou
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Greece (Nikolaos Gatselis, Aristea Bellou, Eirini I. Rigopoulou, Kalliopi Azariadi, George N. Dalekos).,3 Department of Internal Medicine, Papageorgiou General Hospital, Aristotle University of Thessaloniki, Greece (Aristea Bellou, Polyxeni Kevrekidou, Themistoklis Vassiliadis)
| | - Dimitra Sifaki-Pistolla
- Clinic of Social and Family Medicine, School of Medicine, University of Crete, Heraklion, Crete, Greece (Dimitra Sifaki-Pistolla, Ioannis Tziortziotis)
| | - Maria Mela
- Department of Gastroenterology, Evangelismos Hospital, Athens, Greece (Maria Mela)
| | - George Demetriou
- Department of Gastroenterology and Hepatology, University Hospital of Heraklion Crete, Greece (Dimitrios N. Samonakis, George Demetriou, Emmanuel Digenakis, Elias A. Kouroumalis)
| | - Evangelos Thalassinos
- Department of Internal Medicine, Venizeleion Hospital, Heraklion, Crete, Greece (Evangelos Thalassinos, Melina Kavousanaki)
| | - Eirini I Rigopoulou
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Greece (Nikolaos Gatselis, Aristea Bellou, Eirini I. Rigopoulou, Kalliopi Azariadi, George N. Dalekos)
| | - Polyxeni Kevrekidou
- 3 Department of Internal Medicine, Papageorgiou General Hospital, Aristotle University of Thessaloniki, Greece (Aristea Bellou, Polyxeni Kevrekidou, Themistoklis Vassiliadis)
| | - Ioannis Tziortziotis
- Clinic of Social and Family Medicine, School of Medicine, University of Crete, Heraklion, Crete, Greece (Dimitra Sifaki-Pistolla, Ioannis Tziortziotis)
| | - Kalliopi Azariadi
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Greece (Nikolaos Gatselis, Aristea Bellou, Eirini I. Rigopoulou, Kalliopi Azariadi, George N. Dalekos)
| | - Melina Kavousanaki
- Department of Internal Medicine, Venizeleion Hospital, Heraklion, Crete, Greece (Evangelos Thalassinos, Melina Kavousanaki)
| | - Emmanuel Digenakis
- Department of Gastroenterology and Hepatology, University Hospital of Heraklion Crete, Greece (Dimitrios N. Samonakis, George Demetriou, Emmanuel Digenakis, Elias A. Kouroumalis)
| | - Themistoklis Vassiliadis
- 3 Department of Internal Medicine, Papageorgiou General Hospital, Aristotle University of Thessaloniki, Greece (Aristea Bellou, Polyxeni Kevrekidou, Themistoklis Vassiliadis)
| | - Elias A Kouroumalis
- Department of Gastroenterology and Hepatology, University Hospital of Heraklion Crete, Greece (Dimitrios N. Samonakis, George Demetriou, Emmanuel Digenakis, Elias A. Kouroumalis)
| | - George N Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Greece (Nikolaos Gatselis, Aristea Bellou, Eirini I. Rigopoulou, Kalliopi Azariadi, George N. Dalekos)
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Spontaneous Bacterial Peritonitis among Cirrhotic Patients: Prevalence, Clinical Characteristics, and Outcomes. J Clin Med 2021; 11:jcm11010227. [PMID: 35011969 PMCID: PMC8746105 DOI: 10.3390/jcm11010227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 12/25/2021] [Accepted: 12/30/2021] [Indexed: 12/16/2022] Open
Abstract
(1) Background: Spontaneous bacterial peritonitis (SBP) is a feared complication of liver cirrhosis. We investigated the prevalence of SBP, positive ascitic fluid cultures, and risk factors for mortality. (2) Methods: A retrospective analysis of all patients with cirrhosis hospitalized or in follow-up in a single center between 1996 and 2020. The clinical data, long-term complications, and mortality of SBP patients were compared with those of non-SBP patients. Ascitic fluid positive culture was compared with those without growth. (3) Results: We included 1035 cirrhotic patients, of which 173 (16.7%) developed SBP. Ascitic fluid culture growth was found in 47.4% of the SBP cases, with Escherichia coli bacteria detected in 38%, 24.4% grew ESBL-producing bacteria, and 14.5% displayed multidrug resistance. In a Cox regression model, SBP, male sex, prolonged INR at diagnosis, and hepatocellular carcinoma were found to be risk factors for mortality in cirrhotic patients. The long-term all-cause mortality was 60% in non-SBP and 90% in SBP patients. (4) Conclusions: Only a minority of cirrhotic patients developed SBP, 47.4% of which had positive ascitic fluid cultures with high antibiotic resistance. Growth of ESBL and multidrug resistant organisms is becoming more frequent in the clinical setting, reaching SBP mortality of 90%.
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Noh BG, Lee N, Lee BC, Yoon M. Selected deceased donor liver transplantation in controlled Fournier's gangrene: a case report. KOREAN JOURNAL OF TRANSPLANTATION 2021; 35:195-199. [PMID: 35769247 PMCID: PMC9235450 DOI: 10.4285/kjt.21.0013] [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: 06/07/2021] [Revised: 07/26/2021] [Accepted: 07/27/2021] [Indexed: 11/21/2022] Open
Abstract
Bacterial infection represents a turning point in the natural history of cirrhosis, causing the development of acute-on-chronic liver failure. It significantly affects the outcome of patients listed for liver transplantation. We report the case of a 57-year-old man who had been regularly treated for hepatitis B virus, alcoholic liver cirrhosis, and hepatic failure. The patient was hospitalized again due to variceal bleeding and hepatic coma. He visited the emergency room with painful anal swelling, dysuria, icteric sclera, and serious abdominal distension. The painful anal swelling and necrosis progressed; thus, he was diagnosed with Fournier's gangrene. Enterococcus faecium and Candida albicans were detected in the blood. Gangrene wound debris was studied extensively. Despite appropriate antibiotic treatment, vancomycin-resistant enterococcus and C. albicans were continuously present in the blood. Wide debridement of the wound and T-colostomy were performed. After this, norepinephrine and vasopressin were used to maintain stable vital signs. It was difficult to establish a liver transplant operation. Despite repeated bleeding, bacterial infections improved with additional antibiotics. Finally, selected deceased donor liver transplantation in controlled Fournier's gangrene was successfully performed. Controlled infections may be allowed in transplantation surgery.
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Affiliation(s)
- Byeong Gwan Noh
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University Hospital, Busan, Korea
| | - Nuri Lee
- Department of Surgery, Veterans Health Service Medical Center, Seoul, Korea
| | - Byoung Chul Lee
- Division of Colorectal Surgery, Department of Surgery, Pusan National University Hospital, Busan, Korea
| | - Myunghee Yoon
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
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Tay PWL, Xiao J, Tan DJH, Ng C, Lye YN, Lim WH, Teo VXY, Heng RRY, Yeow MWX, Lum LHW, Tan EXX, Kew GS, Lee GH, Muthiah MD. An Epidemiological Meta-Analysis on the Worldwide Prevalence, Resistance, and Outcomes of Spontaneous Bacterial Peritonitis in Cirrhosis. Front Med (Lausanne) 2021; 8:693652. [PMID: 34422858 PMCID: PMC8375592 DOI: 10.3389/fmed.2021.693652] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 07/12/2021] [Indexed: 01/30/2023] Open
Abstract
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.
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Affiliation(s)
- Phoebe Wen Lin Tay
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Jieling Xiao
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Darren Jun Hao Tan
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Cheng Ng
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Yan Nerng Lye
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Wen Hui Lim
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Vanessa Xin Yi Teo
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Ryan Rui Yang Heng
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Marcus Wei Xuan Yeow
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Lionel Hon Wai Lum
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Division of Infectious Diseases, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Eunice Xiang Xuan Tan
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Hospital, Singapore, Singapore
| | - Guan Sen Kew
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Guan Huei Lee
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Hospital, Singapore, Singapore
| | - Mark D Muthiah
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Hospital, Singapore, Singapore
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Pimentel R, Leitão J, Gregório C, Santos L, Carvalho A, Figueiredo P. Spontaneous Bacterial Peritonitis in Cirrhotic Patients: A Shift in the Microbial Pattern? A Retrospective Analysis. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2021; 29:256-266. [PMID: 35979243 PMCID: PMC9274822 DOI: 10.1159/000518585] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 07/08/2021] [Indexed: 11/19/2022]
Abstract
<b><i>Introduction:</i></b> Over the last decade, a shift in the spontaneous bacterial peritonitis (SBP) microbial pattern toward an increasing incidence of gram-positive and multidrug-resistant (MDR) bacteria has been reported. Systematic surveillance of the local microbiological scenario and antibiotic resistance is crucial to SBP treatment success. The main objective of this study was to evaluate the microbiological profile and bacterial resistance of SBP pathogens in a Portuguese cohort to allow selection of the most appropriate empirical antibiotics. <b><i>Methods:</i></b> This is a single-center retrospective study including 63 adult cirrhotic patients with culture-positive SBP. Patients were identified using a hospital general diagnostic database and searching for all SBP events (neutrophil count in ascitic fluid ≥250/mm<sup>3</sup>) from January 1, 2012, to December 31, 2017. Patients were excluded if they had culture-negative SBP, secondary peritonitis, peritoneal dialysis, a liver transplant, or immunodeficiency. The site of SBP acquisition was classified as nosocomial if it was diagnosed 48 h or longer after hospitalization or as nonnosocomial if it was diagnosed within the first 48 h. MDR bacteria were those with an acquired resistance to at least 1 agent in 3 or more antimicrobial categories. All statistical analyses were carried out using IBM SPSS Statistics software version 22 (IBM, New York, USA). <b><i>Results:</i></b> The study cohort comprised 53 (84.1%) men. The mean age of the patients was 60.6 ± 11.2 years. Alcohol was the most common etiology (88.9%) and most patients had advanced liver cirrhosis (87.1%, Child C). Gram-negative bacteria were slightly more frequent than gram-positive bacteria (56.9 vs. 43.1%). <i>Escherichia coli</i> was the most common pathogen (33.8%). Nineteen (31.7%) bacteria were classified as MDR. Resistance to third-generation cephalosporins, quinolones, piperacillin-tazobactam, and carbapenems was found in 31.7, 35, 26.7, and 18.3% of the cases, respectively. The rates of gram-positive bacteria were similar between nosocomial and nonnosocomial episodes (45 vs. 42.2%; <i>p</i> = 0.835). MDR bacteria were more common in the nosocomial group (50 vs. 23.8%; <i>p</i> = 0.046). Resistance to third-generation cephalosporins (50 vs. 23.8%; <i>p</i> = 0.046), piperacillin-tazobactam (44.4 vs. 19.1%; <i>p</i> = 0.041), and carbapenems (33.3 vs. 11.9%; <i>p</i> = 0.049) occurred more frequently in nosocomial episodes. Resistance to first-line antibiotic occurred in 29.3% of the patients, being more common in the nosocomial group (44.4 vs. 22.5%; <i>p</i> = 0.089). <b><i>Conclusion:</i></b> Although gram-negative bacteria remain the most common causative microorganisms, our results emphasize the shift in SBP microbiological etiology, as almost half of the isolated microorganisms were gram positive. The emergence of bacteria resistant to traditionally recommended empirical antibiotics underlines the importance of basing this choice on local flora and antibiotic susceptibility data, allowing a more rational and successful use of antibiotics.
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Affiliation(s)
- Raquel Pimentel
- Department of Gastroenterology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- *Raquel Pimentel,
| | - Jorge Leitão
- Department of Internal Medicine, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Carlos Gregório
- Department of Gastroenterology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Lélita Santos
- Department of Internal Medicine, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Armando Carvalho
- Department of Internal Medicine, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Pedro Figueiredo
- Department of Gastroenterology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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Recurrent and Treatment-Unresponsive Spontaneous Bacterial Peritonitis Worsens survival in Decompensated Liver Cirrhosis. J Clin Exp Hepatol 2021; 11:334-342. [PMID: 33994716 PMCID: PMC8103328 DOI: 10.1016/j.jceh.2020.08.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 08/30/2020] [Indexed: 12/12/2022] Open
Abstract
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.
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Key Words
- ALP, alkaline phosphatase
- ALT, alanine aminotransferase
- AST, aspartate aminotransferase
- BMI, body mass index
- CLIF-SOFA, chronic liver failure-sequential organ failure assessment
- CP, Child-Pugh
- CRP, C-reactive protein
- EPS, hepatic encephalopathy
- HBV, hepatitis B virus
- HCV, hepatitis C virus
- INR, international normalized ratio
- LT, liver transplantation
- MELD, model of end-stage liver disease
- OR, odds ratio
- PLT, platelet
- SBP, Spontaneous bacterial peritonitis
- SIRS, systemic inflammatory response syndrome
- WBC, white blood cell
- antibiotic-resistant infections
- ascites
- gGT, gamma-glutamyl transpeptidase
- liver transplantation
- survival
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Santoiemma PP, Dakwar O, Angarone MP. A retrospective analysis of cases of Spontaneous Bacterial Peritonitis in cirrhosis patients. PLoS One 2020; 15:e0239470. [PMID: 32986728 PMCID: PMC7521743 DOI: 10.1371/journal.pone.0239470] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 09/04/2020] [Indexed: 12/18/2022] Open
Abstract
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.
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Affiliation(s)
- Phillip Pasquale Santoiemma
- Department of Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Omar Dakwar
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Michael Peter Angarone
- Department of Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
- * E-mail:
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13
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Glaess SS, Attridge RL, Brady RL, Attridge RT. Evaluation of prophylactic antibiotic regimens on recurrence and mortality in spontaneous bacterial peritonitis. Ann Hepatol 2019; 18:841-848. [PMID: 31611065 DOI: 10.1016/j.aohep.2019.06.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 06/18/2019] [Accepted: 06/20/2019] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Limited data describe current SBP epidemiology and specific secondary SBP prophylactic regimens, leading to variable prescribing practices. This work aims to compare 90-day and one-year SBP recurrence and mortality based on secondary SBP antibiotic prophylaxis regimens. MATERIALS AND METHODS We performed a retrospective cohort of patients >18 years with an SBP diagnosis from 2010 to 2015 at two academic institutions. Eligible patients had ascitic PMN counts ≥250cells/mm3 or a positive ascitic culture. Patients were compared based on secondary SBP prophylaxis regimens (i.e., daily, intermittent, or no prophylaxis). RESULTS Of 791 patients with ascitic fluid samples, 86 patients were included. Antibiotic prophylaxis included daily (n=34), intermittent (n=36), or no prophylaxis (n=16). Nearly half of SBP episodes had a positive ascitic fluid culture; 50% were gram-negative pathogens, and 50% were gram-positive pathogens. Daily and intermittent regimens had similar rates of recurrence at 90-days (19.4% vs. 14.7%, p=0.60) and one-year (33.3% vs. 26.5%, p=0.53). Similarly, mortality did not differ among daily and intermittent regimens at 90-days (32.4% vs. 30.6%, p=0.87) or one-year (67.6% vs. 63.9%, p=0.74). When comparing any prophylaxis vs. no prophylaxis, there were no differences in 90-day or one-year recurrence or mortality. CONCLUSIONS In patients with a history of SBP, our data indicate similar outcomes with daily, intermittent, or no secondary antibiotic prophylaxis. With available data, including ours, demonstrating a changing epidemiology for SBP pathogens, further data is required to determine if traditional approaches to secondary SBP prophylaxis remain appropriate.
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Affiliation(s)
- Shelley S Glaess
- University of the Incarnate Word Feik School of Pharmacy, San Antonio, TX, USA; South Texas Veterans Health Care System, Audie L. Murphy Division, San Antonio, TX, USA; UT Health San Antonio, San Antonio, TX, USA; University Health System, San Antonio, TX, USA; CHRISTUS Santa Rosa Hospital Westover Hills, San Antonio, TX, USA.
| | - Rebecca L Attridge
- University of the Incarnate Word Feik School of Pharmacy, San Antonio, TX, USA; UT Health San Antonio, San Antonio, TX, USA; University Health System, San Antonio, TX, USA
| | - Rebecca L Brady
- University of the Incarnate Word Feik School of Pharmacy, San Antonio, TX, USA; UT Health San Antonio, San Antonio, TX, USA; University Health System, San Antonio, TX, USA
| | - Russell T Attridge
- University of the Incarnate Word Feik School of Pharmacy, San Antonio, TX, USA; South Texas Veterans Health Care System, Audie L. Murphy Division, San Antonio, TX, USA
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14
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Facciorusso A, Antonino M, Orsitto E, Sacco R. Primary and secondary prophylaxis of spontaneous bacterial peritonitis: current state of the art. Expert Rev Gastroenterol Hepatol 2019; 13:751-759. [PMID: 31304804 DOI: 10.1080/17474124.2019.1644167] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Spontaneous bacterial peritonitis represents a frequent and severe complication in cirrhotic patients with ascites. In daily practice, the diagnosis of spontaneous bacterial peritonitis might be challenging in the absence of the typical signs and symptoms of infection such as fever or leukocytosis. Areas covered: Aim of this review is to revise the current state of the art on primary and secondary spontaneous bacterial peritonitis. Literature search in Medline/Pubmed was performed. Expert opinion: Historically, gram-negative bacteria were the most frequent etiologic agents of spontaneous bacterial peritonitis, with Escherichia coli and Klebsiella spp. being the most frequently isolated bacteria. However, major changes in this regard occurred over the last few decades with an increasing prevalence of gram-positive, quinolone-resistant, and multidrug-resistant bacteria. In particular, the increasing prevalence of quinolone-resistant bacteria challenged the prominent role of norfloxacin in spontaneous bacterial peritonitis prevention. Given the high mortality rate and the risk of developing the hepatorenal syndrome, prophylaxis of spontaneous bacterial peritonitis is indicated in three high-risk populations: patients with acute gastrointestinal hemorrhage, patients with low total protein content in ascitic fluid and advanced cirrhosis, and patients with a previous history of spontaneous bacterial peritonitis (secondary prophylaxis).
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Affiliation(s)
- Antonio Facciorusso
- a Department of Medical Sciences, Ospedali Riuniti di Foggia , Foggia , Italy
| | - Matteo Antonino
- a Department of Medical Sciences, Ospedali Riuniti di Foggia , Foggia , Italy
| | - Eugenio Orsitto
- b Department of Radiology, Azienda Ospedaliero-Universitaria Pisana , Pisa , Italy
| | - Rodolfo Sacco
- a Department of Medical Sciences, Ospedali Riuniti di Foggia , Foggia , Italy
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Lameirão Gomes C, Violante Silva R, Carrola P, Presa J. Bacterial Infections in Patients with Liver Cirrhosis in an Internal Medicine Department. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2019; 26:324-332. [PMID: 31559323 PMCID: PMC6751436 DOI: 10.1159/000494568] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 10/12/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND AIMS Liver cirrhosis (LC) is the end stage of multiple processes that lead to hepatic failure and is the 10th most common cause of death in the Western world. Bacterial infections are one of the most important clinical problems in patients with LC, as their underlying immune status is compromised. Approximately 60% of bacterial infections in cirrhotic patients are community acquired (CA) and 40% are nosocomial. The most common infections in cirrhotic patients are spontaneous bacterial peritonitis (SBP) (25%), urinary tract infection (UTI) (20%), pneumonia (15%), bacteremia (12%), and cellulitis (2-11%). The aim of this study was to evaluate the most frequent infections in patients with LC and describe the evolution of the microbiology in these patients. MATERIAL AND METHODS This is a retrospective analysis of 4 interspersed years (2008, 2010, 2012, and 2014) that included 372 patients. Demographic characteristics were evaluated, including gender, age, type of infection, bacteria resistance profile, antibiotic use, Child-Pugh-Turcotte and Model for End-Stage Liver Disease scores, and mortality rate. RESULTS The mean age of all patients enrolled in this study was 64.5 ± 12.2 years. Male patients were significantly more prevalent than female ones (72 vs. 28%). In the 4 analyzed years, the following numbers of infections occurred: 71 infections (49% CA and 51% nosocomial) in 2008; 86 infections (60.5% CA and 39.5% nosocomial) in 2010; 99 infections (56.6% CA and 43.4% nosocomial) in 2012; and 116 infections (70.7% CA and 29.3% nosocomial) in 2014. The most frequent infections were UTI (32.5%), respiratory tract infection (29.3%), SBP (26.1%), and cellulitis (6.2%). A microbiological agent was identified in 32.4, 59.3, 53.5, and 61.2% of infections in 2008, 2010, 2012, and 2014, respectively, with a predominance of gram-negative bacilli. In all series, a third-generation cephalosporin was the most frequent antibiotic used empirically. The majority of patients was in stage B (42.7%) of the Child-Pugh-Turcotte score, followed by stage C (39.3%) and stage A (18%). Mortality increased significantly over the years, from 7% in 2008 to 25% in 2014 (p = 0.016). CONCLUSIONS The present study showed a high prevalence of bacterial infections in patients with LC. A high rate of suspicion is needed for an infectious process in these patients, and an appropriate antibiotic treatment can decrease the morbidity and mortality in cirrhotic patients.
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Affiliation(s)
- Cristina Lameirão Gomes
- Liver Unit, Internal Medicine Department, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
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16
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Sousa Cardoso F. Bacterial Infections in Patients with Cirrhosis Admitted to the Hospital. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2019; 26:312-313. [PMID: 31559321 PMCID: PMC6751434 DOI: 10.1159/000495769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 11/22/2018] [Indexed: 06/10/2023]
Affiliation(s)
- Filipe Sousa Cardoso
- Intensive Care Unit, Curry Cabral Hospital, Central Lisbon Hospital Center, Nova University, Lisbon, Portugal
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17
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Wong YJ, Kalki RC, Lin KW, Kumar R, Tan J, Teo EK, Li JW, Ang TL. Short- and long-term predictors of spontaneous bacterial peritonitis in Singapore. Singapore Med J 2019; 61:419-425. [PMID: 31363784 DOI: 10.11622/smedj.2019085] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Spontaneous bacterial peritonitis (SBP) is the commonest complication of liver cirrhosis. Timely and appropriate treatment of SBP is crucial, particularly with the rising worldwide prevalence of multidrug-resistant organisms (MDROs). We aimed to investigate the clinical outcomes of SBP in Singapore. METHODS All cirrhotic patients with SBP diagnosed between January 2014 and December 2017 were included. Nosocomial SBP (N-SBP) was defined as SBP diagnosed more than 48 hours after hospitalisation. Clinical outcomes were analysed as categorical outcomes using univariate and multivariate analysis. RESULTS There were 33 patients with 39 episodes of SBP. Their mean age was 64.5 years and 69.7% were male. The commonest aetiology of cirrhosis was hepatitis B (27.3%). The Median Model for End-stage Liver Disease (MELD) score was 17; 33.3% had acute-on-chronic liver failure and 60.6% had septic shock at presentation. N-SBP occurred in 25.6% of SBP cases. N-SBP was more commonly associated with MDROs, previous antibiotic use in the past three months (p = 0.014) and longer length of stay (p = 0.011). The 30-day and 90-day mortality among SBP patients was 30.8% and 51.3%, respectively. MELD score > 20 was a predictor for 30-day mortality. N-SBP and MELD score > 20 were predictors for 90-day mortality. CONCLUSION N-SBP was significantly associated with recent antibiotic use, longer hospitalisation, more resistant organisms and poorer survival among patients with SBP. N-SBP and MELD score predict higher mortality in SBP. Judicious use of antibiotics may reduce N-SBP and improve survival among cirrhotic patients.
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Affiliation(s)
- Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | | | - Kenneth Weicong Lin
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Rahul Kumar
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Jessica Tan
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Eng Kiong Teo
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - James Weiquan Li
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
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High Prevalence of Multidrug Resistant Bacteria in Cirrhotic Patients with Spontaneous Bacterial Peritonitis: Is It Time to Change the Standard Antimicrobial Approach? Can J Gastroenterol Hepatol 2019; 2019:6963910. [PMID: 31214551 PMCID: PMC6535816 DOI: 10.1155/2019/6963910] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 03/20/2019] [Accepted: 04/03/2019] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Spontaneous bacterial peritonitis (SBP) has a deleterious clinical impact in end-stage liver disease, and multidrug resistance has increased, raising concern about effectiveness of traditional antibiotic regimens. PATIENTS AND METHODS Single-center retrospective study of ascitic fluid infections in cirrhotic patients. RESULTS We analyzed medical records related to 2129 culture-positive ascitic fluid and found 183 samples from cirrhotic patients. There were 113 monobacterial SBP cases from 97 cirrhotic patients; 57% of patients were male; hepatitis C and alcohol were the main etiologies for cirrhosis. Multidrug resistant bacteria were isolated in 46.9% of SBP samples, and third-generation cephalosporin and quinolone resistant reached 38.9% and 25.7% of SBP cases. CONCLUSION SBP due to multidrug resistant bacteria is a growing problem, and one should consider reported resistance profiles for the decision-making process of empirical first-line treatment prescription.
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Spontaneous bacterial peritonitis recurrence in patients with cirrhosis receiving secondary prophylaxis with norfloxacin. Eur J Gastroenterol Hepatol 2019; 31:540-546. [PMID: 30557229 DOI: 10.1097/meg.0000000000001331] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Few studies carried out more than 20 years ago have evaluated spontaneous bacterial peritonitis (SBP) recurrence in patients receiving secondary antibiotic prophylaxis. These studies reported a 1-year recurrence rate of 20-26%. Changes in the bacteriology of SBP over the last few years might have negative effects on secondary prophylaxis. Our primary aim was to estimate the incidence of SBP recurrence in patients with cirrhosis receiving secondary prophylaxis with norfloxacin and to explore the factors associated with SBP recurrence. PATIENTS AND METHODS This was a retrospective cohort study of patients receiving norfloxacin for the secondary prophylaxis of SBP from 1 March 2003 to 31 March 2016. Follow-up was performed for 365 days after secondary prophylaxis was started. A competing risk analysis approach was used. RESULTS A total of 115 patients were included. The prevalence of quinolone-resistant and multiresistant bacteria in the first episode of SBP among patients with culture-positive SBP was 70.96% [95% confidence interval (CI): 51.96-85.77%] and 12.90% (95% CI: 3.63-29.83%), respectively. The cumulative incidence of SBP recurrence was 28.53% (95% CI: 20.15-37.45%) after 365 days. Male patients showed an estimated subhazard ratio of SBP recurrence of 2.52 (95% CI: 1.07-5.91, P=0.034). No other risk factors for SBP recurrence were identified. The overall cumulative incidence of death after 365 days was 21.57% (95% CI: 14.14-30.04%), without significant differences among patients with or without SBP recurrence. CONCLUSION Even though changes in the bacteriology of SBP occurred over time, its recurrence rate in patients receiving norfloxacin remains similar to what was reported in the initial studies.
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20
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Marciano S, Díaz JM, Dirchwolf M, Gadano A. Spontaneous bacterial peritonitis in patients with cirrhosis: incidence, outcomes, and treatment strategies. Hepat Med 2019; 11:13-22. [PMID: 30666172 PMCID: PMC6336019 DOI: 10.2147/hmer.s164250] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Spontaneous bacterial peritonitis is the most frequent bacterial infection in patients with cirrhosis. The reported incidence varies between 7% and 30% in hospitalized patients with cirrhosis and ascites, representing one of their main complications. Outcomes in patients with spontaneous bacterial peritonitis are poor since acute kidney injury, acute-on-chronic liver failure, and death occur in as much as 54%, 60%, and 40% of the patients, respectively, at midterm. Early antibiotic treatment of spontaneous bacterial peritonitis is crucial. However, the landscape of microbiological resistance is continuously changing, with an increasing spread of multidrug-resistant organisms that make its current management more challenging. Thus, the selection of the empirical antibiotic treatment should be guided by the severity and location where the infection was acquired, the risk factors for multidrug-resistant organisms, and the available information on the local expected bacteriology. The use of albumin as a complementary therapy for selected high-risk patients with spontaneous bacterial peritonitis is recommended in addition to antibiotics. Even though antibiotic prophylaxis has proven to be effective to prevent spontaneous bacterial peritonitis, a careful selection of high-risk candidates is crucial to avoid antibiotic overuse. In this article we review the pathogenesis, risk factors, and prognosis of spontaneous bacterial peritonitis, as well as the current evidence regarding its treatment and prophylaxis.
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Affiliation(s)
- Sebastián Marciano
- Liver Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina,
- Department of Research, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina,
| | - Juan Manuel Díaz
- Liver Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina,
| | - Melisa Dirchwolf
- Hepatology Unit, Hospital Privado de Rosario, Santa Fe, Argentina
| | - Adrián Gadano
- Liver Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina,
- Department of Research, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina,
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Xu X, Duan Z, Ding H, Li W, Jia J, Wei L, Linghu E, Zhuang H. Chinese guidelines on the management of ascites and its related complications in cirrhosis. Hepatol Int 2019; 13:1-21. [PMID: 30656520 DOI: 10.1007/s12072-018-09923-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 12/20/2018] [Indexed: 12/12/2022]
Abstract
The Chinese Society of Hepatology developed the current guidelines for the Management of Ascites and Its Related Complications in Cirrhosis based on the published evidences and the panelists' consensus. The guidelines provided recommendations for the diagnosis and management of cirrhotic ascites emphasizing a step-wise approach with the first-, second-, and third-line therapy. For refractory ascites, vasoconstrictors and albumin are recommended for splanchnic vasodilation and selective vasopressin (V2) receptor antagonists for moderate-to-severe hyponatremia. For spontaneous bacterial peritonitis, empirical anti-infection treatment was recommended based on the local microbiological examination of community- or hospital-acquired infections. For hepatorenal syndrome, the administration of vasopressor terlipressin and albumin is recommended.
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Affiliation(s)
- Xiaoyuan Xu
- Department of Infectious Diseases, Peking University First Hospital, Beijing, 100034, China.
| | - Zhongping Duan
- Artificial Liver Center, Beijing You-An Hospital, Capital Medical University, Beijing, 100069, China
| | - Huiguo Ding
- Center for Hepatology and Gastroenterology, Beijing You-An Hospital, Capital Medical University, Beijing, China
| | - Wengang Li
- Liver Tumor Diagnosis, Treatment and Research Center, 302 Military Hospital of China, Beijing, China
| | - Jidong Jia
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lai Wei
- Institute of Hepatology, Peking University People's Hospital, Beijing, China
| | - Enqiang Linghu
- Department of Gastroenterology, Chinese PLA General Hospital, Beijing, China
| | - Hui Zhuang
- Department of Pathogen Biology, Peking University Health Science Center, Beijing, China
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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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23
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Predicting mortality in patients with spontaneous bacterial peritonitis using routine inflammatory and biochemical markers. Eur J Gastroenterol Hepatol 2018. [PMID: 29521663 DOI: 10.1097/meg.0000000000001111] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Ferrarese A, Zanetto A, Becchetti C, Sciarrone SS, Shalaby S, Germani G, Gambato M, Russo FP, Burra P, Senzolo M. Management of bacterial infection in the liver transplant candidate. World J Hepatol 2018; 10:222-230. [PMID: 29527258 PMCID: PMC5838441 DOI: 10.4254/wjh.v10.i2.222] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 12/29/2017] [Accepted: 01/24/2018] [Indexed: 02/06/2023] Open
Abstract
Bacterial infection (BI) is a common cause of impairment of liver function in patients with cirrhosis, especially in the liver transplant candidates. These patients share an immunocompromised state and increased susceptibility to develop community and hospital-acquired infections. The changing epidemiology of BI, with an increase of multidrug resistant strains, especially in healthcare-associated settings, represents a critical issue both in the waiting list and in the post-operative management. This review focused on the role played by BI in patients awaiting liver transplantation, evaluating the risk of drop-out from the waiting list, the possibility to undergo liver transplantation after recovery from infection or during a controlled infection.
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Affiliation(s)
- Alberto Ferrarese
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Alberto Zanetto
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Chiara Becchetti
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Salvatore Stefano Sciarrone
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Sarah Shalaby
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Giacomo Germani
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Martina Gambato
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Francesco Paolo Russo
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Marco Senzolo
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
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25
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Shizuma T. Spontaneous bacterial and fungal peritonitis in patients with liver cirrhosis: A literature review. World J Hepatol 2018; 10:254-266. [PMID: 29527261 PMCID: PMC5838444 DOI: 10.4254/wjh.v10.i2.254] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 12/31/2017] [Accepted: 01/24/2018] [Indexed: 02/06/2023] Open
Abstract
Spontaneous bacterial (SBP) and spontaneous fungal peritonitis (SFP) can be a life-threatening infection in patients with liver cirrhosis (LC) and ascites. One of the possible mechanisms of developing SBP is bacterial translocation. Although the number of polymorphonuclear cells in the culture of ascitic fluid is diagnostic for SBP, secondary bacterial peritonitis is necessary to exclude. The severity of underlying liver dysfunction is predictive of developing SBP; moreover, renal impairment and infections caused by multidrug-resistant (MDR) organism are associated with a fatal prognosis of SBP. SBP is treated by antimicrobials, but initial empirical treatment may not succeed because of the presence of MDR organisms, particularly in nosocomial infections. Antibiotic prophylaxis is recommended for patients with LC at a high risk of developing SBP, gastrointestinal bleeding, or a previous episode of SBP, but the increase in the risk of developing an infection caused by MDR organisms is a serious concern globally. Less is known about SFP in patients with LC, but the severity of underlying liver dysfunction may increase the hospital mortality. SFP mortality has been reported to be higher than that of SBP partially because the difficulty of early differentiation between SFP and SBP induces delayed antifungal therapy for SFP.
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Affiliation(s)
- Toru Shizuma
- Department of Physiology, Tokai University School of Medicine, Isehara 2591193, Japan
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26
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Han D, Wang R, Yu Y, Sun M, Teschke R, Romeiro FG, Mancuso A, Song T, Peng Z, Han B, Zhou X, Bao W, Li Q, Zheng K, Li Y, Bai Z, Guo X, Qi X. Xuebijing Injection Combined with Antibiotics for the Treatment of Spontaneous Bacterial Peritonitis in Liver Cirrhosis: A Meta-Analysis. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2018; 2018:2989846. [PMID: 29743922 PMCID: PMC5884321 DOI: 10.1155/2018/2989846] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 01/12/2018] [Accepted: 02/15/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIM Spontaneous bacterial peritonitis (SBP) is one of the most common complications of liver cirrhosis. Antibiotics are the main treatment regimen of SBP. Traditional Chinese medicine Xuebijing injection has been used in such patients. Our study aimed to overview the efficacy of Xuebijing injection combined with antibiotics for the treatment of SBP. METHOD We searched the PubMed, Embase, China National Knowledge Infrastructure, VIP, and Wanfang databases. The search items included "Xuebijing", "peritonitis", "liver cirrhosis", and "random" to identify all relevant randomized controlled trials (RCTs). The Cochrane risk of bias tool was used to assess the study quality. The odd ratios (ORs) with 95% confidence intervals (CIs) were calculated by using a random-effect model. Heterogeneity was also calculated. RESULTS A total of 9 RCTs were included. The study quality was unsatisfied. The overall (OR = 2.95, 95% CI = 1.97-4.42, p < 0.00001) and complete (OR = 2.18, 95% CI = 1.57-3.04, p < 0.00001) responses were significantly higher in the Xuebijing injection combined with antibiotics group than the antibiotics alone group. The incidence of cirrhosis related complications, including hepatic encephalopathy and hepatorenal syndrome, was lower in the Xuebijing injection combined with antibiotics group than the antibiotics alone group. No significant heterogeneity was observed among studies. CONCLUSION Additional use of Xuebijing injection may improve the efficacy of antibiotics for the treatment of SBP in liver cirrhosis. However, due to a low level of current evidence, we did not establish any recommendation regarding the use of Xuebijing injection for the treatment of SBP.
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Affiliation(s)
- Dan Han
- 1Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
- 2Postgraduate College, Liaoning University of Traditional Chinese Medicine, Shenyang, China
| | - Ran Wang
- 1Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
| | - Yang Yu
- 2Postgraduate College, Liaoning University of Traditional Chinese Medicine, Shenyang, China
| | - Mingyu Sun
- 3Institute of Liver Diseases, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Rolf Teschke
- 4Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, Hanau, Germany
- 5Teaching Hospital of the Medical Faculty, Goethe University, Frankfurt/Main, Germany
| | - Fernando Gomes Romeiro
- 6Department of Internal Medicine, Botucatu Medical School, Universidade Estadual Paulista (UNESP), Av. Prof. Mário Rubens Guimarães Montenegro, s/n, Distrito de Rubião Jr., 18 608 917 Botucatu, SP, Brazil
| | | | - Tingxue Song
- 1Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
- 2Postgraduate College, Liaoning University of Traditional Chinese Medicine, Shenyang, China
| | - Zhong Peng
- 1Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
- 8Postgraduate College, Dalian Medical University, Dalian, China
| | - Bing Han
- 9Postgraduate College, Jinzhou Medical University, Jinzhou, China
| | - Xinmiao Zhou
- 9Postgraduate College, Jinzhou Medical University, Jinzhou, China
| | - Wenchun Bao
- 1Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
- 2Postgraduate College, Liaoning University of Traditional Chinese Medicine, Shenyang, China
| | - Qianqian Li
- 1Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
- 8Postgraduate College, Dalian Medical University, Dalian, China
| | - Kexin Zheng
- 1Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
- 9Postgraduate College, Jinzhou Medical University, Jinzhou, China
| | - Yingying Li
- 1Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
- 9Postgraduate College, Jinzhou Medical University, Jinzhou, China
| | - Zhaohui Bai
- 1Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
- 10Postgraduate College, Shenyang Pharmaceutical University, Shenyang, China
| | - Xiaozhong Guo
- 1Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
- 2Postgraduate College, Liaoning University of Traditional Chinese Medicine, Shenyang, China
| | - Xingshun Qi
- 1Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
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27
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Fiore M, Maraolo AE, Leone S, Gentile I, Cuomo A, Schiavone V, Bimonte S, Pace MC, Cascella M. Spontaneous peritonitis in critically ill cirrhotic patients: a diagnostic algorithm for clinicians and future perspectives. Ther Clin Risk Manag 2017; 13:1409-1414. [PMID: 29081656 PMCID: PMC5652902 DOI: 10.2147/tcrm.s144262] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Spontaneous peritonitis (SP) is the most common infection among decompensated end-stage liver disease patients. SP is the infection of ascitic fluid (neutrophil ascitic count ≥250/mL) without an alternative focus of abdominal infection. According to the causative agent, clinicians can make the diagnosis of spontaneous bacterial peritonitis or spontaneous fungal peritonitis. The mortality rate is very high, ranging from one-fifth of the patients with spontaneous bacterial peritonitis to four-fifths of the patients with spontaneous fungal peritonitis. An immediate and accurate diagnosis can improve the outcome in end-stage liver disease patients. The aim of this work is to provide physicians with a practical diagnostic guidance for SP diagnosis according to current evidence, in order to improve the management of cirrhotic patients with infected ascitic fluid.
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Affiliation(s)
- Marco Fiore
- Department of Anaesthesiological, Surgical and Emergency Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Alberto Enrico Maraolo
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - Sebastiano Leone
- Division of Infectious Diseases, "San Giuseppe Moscati" Hospital, Avellino, Italy
| | - Ivan Gentile
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - Arturo Cuomo
- Division of Anesthesia, Department of Anesthesia and Pain Medicine, Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale, Naples, Italy
| | - Vincenzo Schiavone
- Division of Anesthesia and Intensive Care, Hospital "Pineta Grande", Castel Volturno, Italy
| | - Sabrina Bimonte
- Division of Anesthesia, Department of Anesthesia and Pain Medicine, Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale, Naples, Italy
| | - Maria Caterina Pace
- Department of Anaesthesiological, Surgical and Emergency Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Marco Cascella
- Division of Anesthesia, Department of Anesthesia and Pain Medicine, Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale, Naples, Italy
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28
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Lutz P, Nischalke HD, Krämer B, Goeser F, Kaczmarek DJ, Schlabe S, Parcina M, Nattermann J, Hoerauf A, Strassburg CP, Spengler U. Antibiotic resistance in healthcare-related and nosocomial spontaneous bacterial peritonitis. Eur J Clin Invest 2017; 47:44-52. [PMID: 27861767 DOI: 10.1111/eci.12701] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 11/07/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Spontaneous bacterial peritonitis (SBP) can be life threatening in patients with liver cirrhosis. In contrast to community-acquired SBP, no standard treatment has been established for healthcare-related and nosocomial SBP. MATERIALS AND METHODS We prospectively collected healthcare-related and nosocomial SBP cases from March 2012 till February 2016 at the Department of Internal Medicine I of the University of Bonn and analysed the prevalence of antibiotic resistance among the isolated bacteria. SBP was diagnosed according to international guidelines. Ciprofloxacin, ceftriaxone and meropenem were used as reference substance for resistance to quinolones, third-generation cephalosporins and carbapenems, respectively. RESULTS Ninety-two SBP episodes in 86 patients were identified: 63 episodes (69%) were nosocomial. Escherichia coli, Klebsiella species, enterococci and streptococci were most frequently isolated. Frequencies of these microorganisms were comparable for healthcare-related and nosocomial SBP (14% vs. 11%, 14% vs. 8%, 14% vs. 5% and 10% vs. 6%, respectively). In general, antibiotic resistance was higher in isolates from nosocomial than from healthcare-related SBP (50% vs. 18% for quinolones, 30% vs. 11% for piperacillin-tazobactam; P > 0·05), but comparable concerning third-generation cephalosporins (30% vs. 33%). All microorganisms were sensitive to carbapenems apart from nosocomial infections with Enterococcus faecium (n = 3) and Candida albicans (n = 1) due to intrinsic resistance or lack of microbiological efficacy, respectively. No multidrug-resistant microorganisms were detected. Resistance to initial antibiotic treatment affected 30-day survival negatively (18% vs. 68%; P = 0·002). CONCLUSION Resistance to initial antibiotic treatment was associated with increased mortality. With resistance to cephalosporins being frequent, piperacillin-tazobactam or carbapenems might be preferred as treatment of SBP.
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Affiliation(s)
- Philipp Lutz
- Department of Internal Medicine I, University of Bonn, Bonn, Germany.,German Center for Infection Research, partner site Bonn-Cologne, Bonn, Germany
| | - Hans Dieter Nischalke
- Department of Internal Medicine I, University of Bonn, Bonn, Germany.,German Center for Infection Research, partner site Bonn-Cologne, Bonn, Germany
| | - Benjamin Krämer
- Department of Internal Medicine I, University of Bonn, Bonn, Germany.,German Center for Infection Research, partner site Bonn-Cologne, Bonn, Germany
| | - Felix Goeser
- Department of Internal Medicine I, University of Bonn, Bonn, Germany.,German Center for Infection Research, partner site Bonn-Cologne, Bonn, Germany
| | - Dominik J Kaczmarek
- Department of Internal Medicine I, University of Bonn, Bonn, Germany.,German Center for Infection Research, partner site Bonn-Cologne, Bonn, Germany
| | - Stefan Schlabe
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
| | - Marijo Parcina
- German Center for Infection Research, partner site Bonn-Cologne, Bonn, Germany.,Institute of Medical Microbiology, Immunology and Parasitology, University of Bonn, Bonn, Germany
| | - Jacob Nattermann
- Department of Internal Medicine I, University of Bonn, Bonn, Germany.,German Center for Infection Research, partner site Bonn-Cologne, Bonn, Germany
| | - Achim Hoerauf
- German Center for Infection Research, partner site Bonn-Cologne, Bonn, Germany.,Institute of Medical Microbiology, Immunology and Parasitology, University of Bonn, Bonn, Germany
| | - Christian P Strassburg
- Department of Internal Medicine I, University of Bonn, Bonn, Germany.,German Center for Infection Research, partner site Bonn-Cologne, Bonn, Germany
| | - Ulrich Spengler
- Department of Internal Medicine I, University of Bonn, Bonn, Germany.,German Center for Infection Research, partner site Bonn-Cologne, Bonn, Germany
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