Predictors of Short-Term Mortality Following First Episode of Spontaneous Bacterial Peritonitis in Hospitalized Cirrhotic Patients

Quadruple Complication in a Patient With Liver Cirrhosis: A Diagnostic Conundrum

The incidence of bacterial infections is high in patients with liver cirrhosis (LC) due to compromised immune systems. They are associated with acute hepatic decompensation, multiorgan dysfunction, high morbidity, and mortality and account for 25-46% of all hospitalizations. The mortality rate is about 30% after one month and increases to 63% at one-year follow-up. While spontaneous bacterial peritonitis (SBP), urinary tract infections, soft tissue infections, and respiratory tract infections (pneumonia) are some of the common infections, SBP accounts for 25-31% of the cases and is the most frequent bacterial infection. Impaired activity of the phagocytes of the reticuloendothelial system, decreased production of the complement, and bacteria gaining access into the systemic circulation through the porto-systemic shunts are some of the causes of high-risk bacterial infection in patients with LC. The diagnosis of bacterial infection may be challenging as the typical symptoms like fever may not always be evident. We present a very challenging, middle-aged patient of cirrhosis with diabetes mellitus (DM) who presented with infections at multiple sites like SBP due to Serratia ficaria, multiple pyemic liver abscesses, left peri-nephric abscess with septicaemia, further complicated by portal vein thrombosis - all during single hospital admission. SBP was unique in the sense that no case of SBP due to Serratia ficaria has been published in the literature to date. The stormy clinical course, management, and outcome of the patient are described here.

[Prognosis and risk factors for mortality in cirrhotic patients with probable spontaneous bacterial peritonitis]

OBJECTIVE

To investigate the survival outcomes and risk factors for mortality in cirrhotic patients with probable spontaneous bacterial peritonitis (SBP).

METHODS

We retrospectively analyzed the clinical data of 323 cirrhotic patients with ascites admitted from June 2021 to May 2022, including 115 patients with SBP [ascites polymorphonuclear leucocyte (PMN) count ≥250/mm3], 52 patients with bacterascites (PMN count < 250/mm3 with positive microbiological finding in ascites), 67 patients with probable SBP (PMN count < 250/mm3 with negative microbiological finding in ascites but clinical symptoms of SBP) and 89 patients without infection (PMN count < 250/mm3 with negative microbiological finding without clinical symptoms of SBP). The clinical characteristics, laboratory data and 90-day mortality of the patients were compared among the 4 groups. Cox proportional hazard model and propensity score matching (PSM) in a 1∶1 ratio were used to analyze the risk factors for mortality in patients with probable SBP.

RESULTS

The patients with probable SBP had a 90-day mortality rate of 43.28%, similar to those of patients with SBP (46.95%, P=0.121) and bacterascites (48.07%, P=0.805) but significantly higher than that of non-infected patients (11.23%, P < 0.001). In the 46 pairs of patients matched using PSM, the 90-day mortality rates were higher in probable SBP group than in non-infected group both before (43.28% vs 11.23%, P < 0.001) and after PSM (34.78% vs 15.21%, P=0.038). Cox regression analysis indicated that probable SBP was an independent predictor of 90-day mortality in cirrhotic patients with ascites (HR=1.539, 95% CI: 1.048-2.261, P=0.028). A Model for End-Stage Liver Disease (MELD) score > 15 (HR=1.943, 95% CI: 1.118-3.377, P=0.018) and procalcitonin level > 0.48 ng/mL (HR=1.989, 95% CI: 1.111-3.560, P=0.021) at diagnostic paracentesis were both independent risk factors for 90-day mortality in patients with probable SBP.

CONCLUSION

Cirrhotic patients with probable SBP have poor survival outcomes, and their management should be further optimized based on their MELD score and procalcitonin level.