To Study the Incidence, Predictive Factors and Clinical Outcome of Spontaneous Bacterial Peritonitis in Patients of Cirrhosis with Ascites

Etiological Spectrum of Cirrhosis in India: A Systematic Review and Meta-analysis

BACKGROUND

Cirrhosis is a significant cause of morbidity and mortality globally and in India. This systematic review and meta-analysis aimed to ascertain the etiological spectrum and changing trends of cirrhosis in India.

METHODS

We searched electronic databases, including Pubmed/Medline, Scopus, and Embase. We included original studies that reported the etiology of cirrhosis in the Indian population.

RESULTS

We included 158 studies (adults: 147, children: 11). The overall pooled estimate of alcohol as a cause of cirrhosis in adults was 43.2% (95% confidence interval (CI) 39.8-46.6%; I2 = 97.8%), followed by nonalcoholic fatty liver disease (NAFLD)/cryptogenic in 14.4%, 95% CI (11.7-17.3%; I2 = 98.4%), hepatitis B virus (HBV) in 11.5%, 95% CI (9.8-13.3%; I2 = 96.6%), and hepatitis C virus (HCV) in 6.2%, 95% CI (4.8-7.8%; I2 = 97.2%) of the included patients. The most common cause of cirrhosis in all zones was alcohol-related. Comparison of etiologies over time revealed a reduction in the viral hepatitis-related and an increase in the proportion of alcohol-related and NAFLD/cryptogenic-related cirrhosis. The overall pooled estimates of various etiologies in children were: HBV in 10.7%, 95% CI (4.6-18.7%; I2 = 91.0%), NAFLD/Cryptogenic in 22.3%, 95% CI (9.0-39.2%; I2 = 96.7%), and HCV in 2.0%, 95% CI (0.0-8.5%; I2 = 94.6%).

CONCLUSIONS

Alcohol is the most common etiology of cirrhosis in adults in India. The proportions of alcohol and NAFLD-related cirrhosis are increasing, and those of viral hepatitis-related cirrhosis are reducing. The results of our meta-analysis will help formulate health policies and the allocation of resources.

Establishment and Validation of a Non-Invasive Diagnostic Nomogram to Identify Spontaneous Bacterial Peritonitis in Patients With Decompensated Cirrhosis

BACKGROUND

Spontaneous bacterial peritonitis (SBP) is a common and life-threatening infection in patients with decompensated cirrhosis (DC), and it is accompanied with high mortality and morbidity. However, early diagnosis of spontaneous bacterial peritonitis (SBP) is not possible because of the lack of typical symptoms or the low patient compliance and positivity rate of the ascites puncture test. We aimed to establish and validate a non-invasive diagnostic nomogram to identify SBP in patients with DC.

METHOD

Data were collected from 4,607 patients with DC from July 2015 to December 2019 in two tertiary hospitals in Chongqing, China (A and B). Patients with DC were divided into the SBP group (995 cases) and the non-SBP group (3,612 cases) depending on whether the patients had SBP during hospitalization. About 70% (2,685 cases) of patients in hospital A were randomly selected as the traindata, and the remaining 30% (1,152 cases) were used as the internal validation set. Patients in hospital B (770 cases) were used as the external validation set. The univariate analysis and least absolute shrinkage and selection operator (LASSO) regression were used to screen variables, and logistic regression was used to determine independent predictors to construct a nomogram to identify patients with SBP. Area under curve (AUC), calibration curve, and dynamic component analysis (DCA) were carried out to determine the effectiveness of the nomogram.

RESULT

The nomogram was composed of seven variables, namely, mean red blood cell hemoglobin concentration (odds ratio [OR] = 1.010, 95% CI: 1.004-1.016), prothrombin time (OR = 1.038, 95% CI: 1.015-1.063), lymphocyte percentage (OR = 0.955, 95% CI: 0.943-0.967), prealbumin (OR = 0.990, 95% CI: 0.987-0.993), total bilirubin (OR = 1.003 95% CI: 1.002-1.004), abnormal C-reactive protein (CRP) level (OR = 1.395, 95% CI: 1.107-1.755), and abnormal procalcitonin levels (OR = 1.975 95% CI: 1.522-2.556). Good discrimination of the model was observed in the internal and external validation sets (AUC = 0.800 and 0.745, respectively). The calibration curve result indicated that the nomogram was well-calibrated. The DCA curve of the nomogram presented good clinical application ability.

CONCLUSION

This study identified the independent risk factors of SBP in patients with DC and used them to construct a nomogram, which may provide clinical reference information for the diagnosis of SBP in patients with DC.

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.

Predictors of spontaneous bacterial peritonitis in Romanian adults with liver cirrhosis: Focus on the neutrophil-to-lymphocyte ratio

Spontaneous bacterial peritonitis (SBP) is a severe complication of liver cirrhosis whose diagnosis is based on a polymorphonuclear leukocyte (PMN) value >250 mm³, yet this PMN value cannot identify all existing types. The aim of our study was to determine the clinical and biological factors that were associated with SBP and predict its occurrence, focusing on the neutrophil-to-lymphocyte ratio (NLR) as one of them. Our retrospective study included 216 patients with liver cirrhosis who were hospitalized between December 2019 and January 2010 at the Emergency County Clinical Hospital of 'St. Apostle Andrew' in Constanta, Romania. Demographic, clinical, and laboratory data were collected from patient observation sheets. The patients were divided into two groups: One group of patients with SBP and the other without SBP. The diagnosis of SBP was made when patients presented with PMN >250 mm³ and other causes of secondary bacterial peritonitis were excluded. The mean age of the patients was 61.25±10.67 years, and the alcoholic etiology of liver cirrhosis was most common (44%). Univariate logistic regression analysis showed that there was an association between biological parameters, such as serum white blood cells, total platelet count, total bilirubin, serum albumin, international normalized ratio, creatinine, erythrocyte sedimentation rate (ESR), serum sodium, alkaline reserve, and NLR, and clinical parameters, such us upper gastrointestinal bleeding and cardiac comorbidities in the occurrence of SBP. Multivariate analysis identified ESR and NLR as predictive factors in the occurrence of SBP. The area under the curve (AUC) was 0.916 [P<0.001, 95% confidence interval (CI) 0.870-0.949] for ESR and AUC was 0.963 (P<0.001, 95% CI 0.928-0.984) for NLR, respectively. In conclusion, the combination of these 2 biological parameters is useful in identifying or excluding SBP.

The Diagnostic Value of CD11b Expression on Peripheral Blood Neutrophils for Detection of Spontaneous Bacterial Peritonitis

Background: Spontaneous bacterial peritonitis (SBP) is associated with the highest mortality among end-stage cirrhotic liver disease patients. Neutrophil CD11b expression increases on the neutrophil surface within 5 min of exposure to bacteria. Paracentesis remains the only accepted method for accurate evaluation of patients, with many drawbacks; hence, a diagnostic noninvasive marker with a very high sensitivity and high diagnostic accuracy is very necessary. Aim of the study: to evaluate the neutrophil CD11b as a non-invasive biomarker for the diagnosis of SBP, comparing its sensitivity and specificity to other traditional methods. Patients and Methods: 200 patients who had liver cirrhosis with ascites were recruited to the Hepatology department inpatient wards of the National Liver Institute, Menoufia University. They were divided into Group I: 100 patients with SBP and Group II: 100 patients with non SBP ascites. All studied patients were subjected to full clinical examination, abdominal ultrasound, paracentesis, and laboratory investigations including ascetic fluid (AF) examinations. The CD11b expression and its mean fluorescence intensity (MFI) were assessed on peripheral blood neutrophils by flowcytometry. Results: There was a significant increase in the MFI of CD11b in the SBP group compared to the non SBP group. At cut off >20 for MFI of CD11b with a sensitivity of 100% and specificity of 100% can discriminate between SBP and non SBP cases followed by ascetic fluid TLC examination at a cut off 0.26 (×103) with a sensitivity of 92%, and specificity of 96%, then, AF neutrophil count at cut off 0.25 (×103) with a sensitivity of 80%, specificity of 100%, and AF culture examination with a sensitivity of 56% and specificity of 100%. Conclusion: The measurement of CD11b MFI on peripheral blood neutrophils is a useful non-invasive marker with high sensitivity and specificity to predict SBP compared with other methods. Further large-scale studies are needed to study the value of CD11b MFI level in the SBP follow-up therapy.

Timing of paracentesis and outcomes in hospitalized patients with decompensated cirrhosis

BACKGROUND

Ascites is one of the most common complications of cirrhosis, placing a significant burden on the healthcare system. Data regarding the optimal time of paracentesis and outcomes among patients with cirrhosis and ascites are scarce.

AIM

To assess the outcomes of patients who underwent paracentesis within 12 h after admission compared to patients who underwent paracentesis later than 12 h.

METHODS

The study included 185 patients with cirrhosis and ascites who underwent paracentesis. The early paracentesis group was defined as paracentesis performed < 12 h after admission (65 patients) and the delayed paracentesis group was defined as paracentesis performed > 12 h after admission (120 patients). New-onset complications of cirrhosis, length of hospital stay, weekday or weekend admission, in-hospital mortality rate, and 90-d readmission rates were assessed and compared between the groups.

RESULTS

Significantly more patients in the delayed paracentesis group than in the early paracentesis group developed hepatic encephalopathy (45% vs 21.5%, P < 0.01), hepato-renal syndrome (21.6% vs 9.2%, P = 0.03) and infections (25% vs 10.7%, P = 0.02) during hospitalization. There were no statistically significant differences in the occurrence of spontaneous bacterial peritonitis and upper gastrointestinal bleeding between the two groups. Length of stay was shorter in the early paracentesis group than in the delayed paracentesis group (6.7 d vs 12.2 d) and in-hospital mortality was lower among patients in the early paracentesis group. Patients in the delayed paracentesis group had a higher risk of developing complications during hospitalization.

CONCLUSION

Early paracentesis (within 12 h after admission) could be a new inpatient quality metric among patients hospitalized with cirrhosis and ascites as it is associated with fewer complications of cirrhosis, lower in-hospital mortality and shorter length of stay.

Emerging Gram-positive bacteria and drug resistance in cirrhosis patients with spontaneous bacterial peritonitis: A retrospective study

Spontaneous bacterial peritonitis (SBP) is one of the most severe complications in liver cirrhosis (LC) patients with ascites. The aim of the present study was to retrospectively analyze the bacterial spectrum and drug resistance in ascites culture of patients with SBP. A total of 3, 189 patients with ascites were enrolled in the present study, including 912 LC patients, of which 247 had SBP. It was revealed that in the 3, 189 patients, the ratio of SBP exhibited annual increases, especially in 2015, and this trend remained when cases were divided into two groups: Group A (admission, 2011-2013) and Group B (admission, 2014-2016). The 247 SBP patients were then stratified into two groups: Group 1 (admission, 2011-2013) and Group 2 (admission, 2014-2016). The rate of infection with gram-positive bacteria (GPB) was markedly higher in Group 2 compared with Group 1. Over time, GPB and gram-negative bacteria (GNB) were increased, while the increase of GPB was greater than that of GNB. Direct bilirubin and C-reactive protein levels, and the positive rate of ascites culture in Group 2 were greater than in Group 1. Furthermore, marked differences in serological and ascitic indexes or pathogeny, as well as complications between the patients with GPB and GNB infection were observed. The results regarding drug sensitivity revealed that the resistance rate of GPB and GNB to penicillin (ampicillin) was 100%, while the resistance rate to amikacin, imipenem, meropenem and piperacillin/tazobactam was 0% for GNB, and similarly, the resistance rate to vancomycin, teicoplanin, amikacin and linezolid was 0% for GPB. The results suggested that combined use of ampicillin/sulbactam or piperacillin/tazobactam should be selected forempirical therapy. In cases of nosocomial infection, these drugs should be combined with vancomycin, linezolid or teicoplanin when required.

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.