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Yin X, Qin E, Song R, Bao X, Dong J, Hou W, Hua W, Tu B, Zhang Y, Meng Q. Diagnostic model for spontaneous bacterial peritonitis in cirrhotic patients with ascites: a multicenter cohort study. Eur J Gastroenterol Hepatol 2024; 36:1319-1328. [PMID: 39292981 PMCID: PMC11424056 DOI: 10.1097/meg.0000000000002841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Accepted: 06/03/2024] [Indexed: 09/20/2024]
Abstract
INTRODUCTION Spontaneous bacterial peritonitis (SBP) is a potentially life-threatening complication of cirrhotic ascites. Early diagnosis and treatment of SBP are essential to improve the survival rates and prognosis of patients. We aimed to identify the predictors of SBP to establish a new noninvasive early diagnostic tool. METHODS We screened 1618 patients who underwent paracentesis due to cirrhotic ascites between January 2017 and December 2018 in three hospitals. We evaluated the symptomatic, clinical, and laboratory parameters to identify the predictors of SBP. The primary diagnostic model was displayed as a nomogram. RESULTS The model included abdominal pain, diarrhea, white blood cell count, neutrophil percentage, procalcitonin, C-reactive protein, lactate dehydrogenase, glucose, and Model for End-stage Liver Disease score. The model's diagnostic performance was good, with an AUC of 0.84 [95% confidence interval (CI), 0.81-0.87] in the training cohort. In the validation cohort, the diagnostic ability was also good, with AUCs of 0.87 (95% CI, 0.83-0.91) and 0.90 (95% CI, 0.87-0.94) for inner and outer validation queues, respectively. Moreover, the decision curve analysis confirmed the clinical utility of the nomogram model. In addition, we developed a Microsoft Excel calculation model to allow convenient adoption of the model in clinical practice. CONCLUSION We developed good performing diagnostic models for SBP.
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Affiliation(s)
- Xuehong Yin
- Department of Critical Care Medicine of Liver Disease, Beijing You-An Hospital, Capital Medical University
| | - Enqiang Qin
- Department of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital
| | - Rui Song
- Center of Infectious Disease, Capital Medical University, Beijing Ditan Hospital
| | - Xuli Bao
- Department of Critical Care Medicine of Liver Disease, Beijing You-An Hospital, Capital Medical University
| | - Jinling Dong
- Department of Critical Care Medicine of Liver Disease, Beijing You-An Hospital, Capital Medical University
| | - Wei Hou
- Department of Critical Care Medicine of Liver Disease, Beijing You-An Hospital, Capital Medical University
| | - Wei Hua
- Department of Critical Care Medicine of Liver Disease, Beijing You-An Hospital, Capital Medical University
| | - Bo Tu
- Department of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital
| | - Yuening Zhang
- Department of Gastroenterology and Hepatology, Beijing You-An Hospital, Capital Medical University, Beijing, China
| | - Qinghua Meng
- Department of Critical Care Medicine of Liver Disease, Beijing You-An Hospital, Capital Medical University
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Beyoğlu D, Idle JR. The gut microbiota - a vehicle for the prevention and treatment of hepatocellular carcinoma. Biochem Pharmacol 2022; 204:115225. [PMID: 35998677 DOI: 10.1016/j.bcp.2022.115225] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 08/15/2022] [Accepted: 08/16/2022] [Indexed: 12/24/2022]
Abstract
Hepatocellular carcinoma (HCC) arises principally against a background of cirrhosis and these two diseases are responsible globally for over 2 million deaths a year. There are few treatment options for liver cirrhosis and HCC, so it is vital to arrest these pathologies early in their development. To do so, we propose dietary and therapeutic solutions that involve the gut microbiota and its consequences. Integrated dietary, environmental and intrinsic signals result in a bidirectional connection between the liver and the gut with its microbiota, known as the gut-liver axis. Numerous lifestyle factors can result in dysbiosis with a change in the functional composition and metabolic activity of the microbiota. A panoply of metabolites can be produced by the microbiota, including ethanol, secondary bile acids, trimethylamine, indole, quinolone, phenazine and their derivatives and the quorum sensor acyl homoserine lactones that may contribute to HCC but have yet to be fully investigated. Gram-negative bacteria can activate the pattern recognition receptor toll-like receptor 4 (TLR4) in the liver leading to nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) signaling, which can contribute to HCC initiation and progression. The goal in preventing HCC should be to ensure a healthy gut microbiota using probiotic supplements containing beneficial bacteria and prebiotic plant fibers such as oligosaccharides that stimulate their growth. The clinical development of TLR4 antagonists is urgently needed to counteract the pathological effects of dysbiosis on the liver and other organs. Further nutrigenomic studies are required to understand better how the diet influences the gut microbiota and its adverse effects on the liver.
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Affiliation(s)
- Diren Beyoğlu
- Arthur G. Zupko Institute for Systems Pharmacology and Pharmacogenomics, Arnold and Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, Brooklyn, New York 11201, USA
| | - Jeffrey R Idle
- Arthur G. Zupko Institute for Systems Pharmacology and Pharmacogenomics, Arnold and Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, Brooklyn, New York 11201, USA.
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Deleuran T, Watson H, Vilstrup H, Jepsen P. Spontaneous bacterial peritonitis has no effect on the long-term prognosis of cirrhosis patients with ascites. Ann Hepatol 2022; 27:100711. [PMID: 35447366 DOI: 10.1016/j.aohep.2022.100711] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 03/30/2022] [Accepted: 04/07/2022] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Spontaneous bacterial peritonitis (SBP) is a frequent complication to cirrhosis with an unclear long-term prognosis. We aimed to examine its effect on mortality in two independent patient cohorts. PATIENTS AND METHODS We used Danish healthcare data on cirrhosis patients with a first-time paracentesis in 2000-2014 and data from three randomized controlled trials on satavaptan treatment of ascites conducted in 2006-2008. We used the Kaplan-Meier method to estimate cumulative mortality, and Cox regression to compare the confounder-adjusted mortality hazard for patients with vs. without SBP. RESULTS In the Danish Healthcare Cohort, we included 1.282 patients of whom 133 (10.4%) had SBP. The SBP patients' cumulative 4-month mortality was 51.2% (95% CI: 43.0-59.9%) vs. 34.7% (95% CI: 32.0-37.6) in those without SBP. The SBP patients' confounder-adjusted mortality hazard was 1.54-fold higher (95% CI: 1.18-2.00) in the four months after paracentesis, but was not increased thereafter (confounder-adjusted mortality hazard 1.02, 95% 0.72-1.46). In the satavaptan trial data of 1,198 cirrhosis patients with ascites, the 93 patients with SBP had a cumulative 4-month mortality of 38.6% (95% CI: 29.3-49.7) compared with 11.4% (95% CI: 8.5-15.2) in those without. The SBP patients' confounder-adjusted mortality hazard ratio was 3.86 (95% CI: 2.44-6.12) during the first four months, and was 1.23 (95% CI: 0.54-2.83) thereafter. CONCLUSIONS In both cohorts of patients with cirrhosis, an SBP episode had a high short-term mortality compared to patients without SBP, and had no lasting effect on the long-term mortality.
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Affiliation(s)
- Thomas Deleuran
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus 8200, Denmark; Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark.
| | - Hugh Watson
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus 8200, Denmark; Evotec ID, Lyon, France
| | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus 8200, Denmark
| | - Peter Jepsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus 8200, Denmark
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Haque LY, Garcia‐Tsao G. A Historical Overview of Spontaneous Bacterial Peritonitis: From Rare to Resistant. Clin Liver Dis (Hoboken) 2021; 18:63-75. [PMID: 34745584 PMCID: PMC8555457 DOI: 10.1002/cld.1122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 03/26/2021] [Indexed: 02/04/2023] Open
Abstract
Content available: Author Audio Recording.
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Affiliation(s)
- Lamia Y. Haque
- Section of Digestive DiseasesYale School of MedicineNew HavenCT
- Department of MedicineYale School of MedicineNew HavenCT
| | - Guadalupe Garcia‐Tsao
- Section of Digestive DiseasesYale School of MedicineNew HavenCT
- Department of MedicineYale School of MedicineNew HavenCT
- Digestive DiseasesVeterans Administration Connecticut Healthcare SystemWest HavenCT
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Badawi R, Asghar MN, Abd-Elsalam S, Elshweikh SA, Haydara T, Alnabawy SM, Elkadeem M, ElKhalawany W, Soliman S, Elkhouly R, Soliman S, Watany M, Khalif M, Elfert A. Amyloid A in Serum and Ascitic Fluid as a Novel Diagnostic Marker of Spontaneous Bacterial Peritonitis. Antiinflamm Antiallergy Agents Med Chem 2020; 19:140-148. [PMID: 30931865 PMCID: PMC7475799 DOI: 10.2174/1871523018666190401154447] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 03/13/2019] [Accepted: 03/21/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Diagnosis of Spontaneous Bacterial Peritonitis (SBP) depends mainly on ascetic fluid culture which may be negative in spite of the clinical suggestion of SBP and high ascetic fluid neutrophilic count. AIMS This study aimed to evaluate the biological importance of amyloid A biomarker in both serum and ascetic fluid to diagnose SBP as early as possible and to compare it to other markers (C-reactive protein (CRP), and the neutrophil-to-lymphocyte ratio (NLR)). METHODS This study included 37 patients with hepatic ascites; twenty-two of them had SBP, and 15 patients did not have SBP. Serum and ascetic fluid amyloid A, ascetic fluid neutrophil, C-reactive protein, and neutrophil-to-lymphocyte ratio were measured in all subjects before the start of antimicrobial chemotherapy to the infected ones. RESULTS Both the serum and ascetic fluid amyloid and also, CRP were significantly higher in patients infected with ascetic fluid than others. The cut-off point of serum amyloid A for early detection of SBP was 9.25ug/ml with the high sensitivity and specificity. For ascetic amyloid A, the sensitivity and specificity were 90.09% and 60% at cut-off point 2.85ug/ml, respectively. CONCLUSION Amyloid A in serum and ascitic fluid can be considered as a good biomarker for early diagnosis of SBP.
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Affiliation(s)
- Rehab Badawi
- Tropical Medicine and Infectious Diseases, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Muhammad N. Asghar
- Department of Biosciences, Abo Akademi University, 20500 Turku, Finland
- Department of Medical Biology, University of Quebec at Trois-Riveres, Quebec, Canada
| | - Sherief Abd-Elsalam
- Tropical Medicine and Infectious Diseases, Faculty of Medicine, Tanta University, Tanta, Egypt
| | | | - Tamer Haydara
- Internal Medicine Department, Kafr-Elsheikh University, Kafr El-Shaikh, Egypt
| | | | - Mahmoud Elkadeem
- Tropical Medicine and Infectious Diseases, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Walaa ElKhalawany
- Tropical Medicine and Infectious Diseases, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Samah Soliman
- Tropical Medicine and Infectious Diseases, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Reham Elkhouly
- Tropical Medicine and Infectious Diseases, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Shimaa Soliman
- Public Health and Community Medicine, Faculty of Medicine, Menoufia University Menoufia, Egypt
| | - Mona Watany
- Clinical Pathology, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Mai Khalif
- Tropical Medicine and Infectious Diseases, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Asem Elfert
- Tropical Medicine and Infectious Diseases, Faculty of Medicine, Tanta University, Tanta, Egypt
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Abdel-Razik A, Mousa N, Abdel-Aziz M, Elsherbiny W, Zakaria S, Shabana W, Abed S, Elhelaly R, Elzehery R, Eldars W, El-Bendary M. Mansoura simple scoring system for prediction of spontaneous bacterial peritonitis: lesson learnt. Eur J Gastroenterol Hepatol 2019; 31:1017-1024. [PMID: 30694910 DOI: 10.1097/meg.0000000000001364] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND OBJECTIVE Spontaneous bacterial peritonitis (SBP) is a common bacterial infection with life-threatening sequelae in cirrhotic ascites. The purpose of this retrospective cohort study was to recognize the predictors of SBP to build up a noninvasive system to exclude or establish an episode of SBP. PATIENTS AND METHODS Of 1194 consecutive patients with cirrhotic ascites, only 966 patients were enrolled in this study. SBP was diagnosed once polymorphonuclear count was at least 250 cells/mm and/or there was a positive ascitic fluid culture result. Biochemical and clinical parameters were evaluated as predictors of SBP. A scoring system was established in the training group of 682 and validated in a second group of 284 participants. RESULTS The incidence of SBP was 12.3 and 12% in the training and validation groups, respectively. Age of at least 55 years, mean platelet volume (MPV) of at least 8.5 fl, neutrophil-to-lymphocyte ratio (NLR) of at least 2.5, and C-reactive protein (CRP) of at least 40 mg/l were identified as independent predictors of SBP. A scoring system including these four variables (age, MPV, and NLR with 1 point each, whereas CRP with 2 points) achieves a specificity of 98.2% with a positive predictive value for the diagnosis of SBP of 88.1% (score≥4). At a threshold of 1 point, the negative predictive value is 97.5% with a sensitivity of 92.9%. SBP is not associated with a high Model for End-stage Liver Disease score (P=0.135). CONCLUSION The combination of age, MPV, NLR, and CRP in a simple scoring system, Mansoura simple scoring system, supports quick and accurate exclusion or diagnosis of SBP.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Waleed Eldars
- Medical Microbiology and Immunology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Na HY, Kim JH, Choe WH, Kwon SY, Yoo BC. Clinical Features of Spontaneous Bacterial Peritonitis: A 10-year Experience from a Single Center. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2017; 69:129-134. [PMID: 28239081 DOI: 10.4166/kjg.2017.69.2.129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background/Aims Spontaneous bacterial peritonitis (SBP) is one of critical complications in liver cirrhosis patients with ascites. We aimed to review clinical course of SBP patients in a 10-year period from single center. Methods This study enrolled SBP patients between 2005 and 2015. Their medical records were reviewed. The laboratory findings of serum and ascites were examined, and characteristics of isolated microorganisms in ascites were analyzed. Results Total 51 patients were enrolled. Male patients were predominant (64.7%), and mean age was 59.20 years. The most common etiology of cirrhosis was alcohol (41.2%), followed by hepatitis B (39.2%). Microorganism was isolated from the ascites in 31 patients (60.78%). The proportions of Gram negative and Gram positive were 80.64% and 19.36%. The proportions of Escherichia coli, Klebsiella, and Streptococcus species were 29.41%, 19.61% and 11.76%. Among Escherichia colis, 4 cases were ESBL positive (7.84%). The most commonly used first-line antibiotic was cefotaxime (80.40%). Prophylactic antibiotics treatment was performed only in 8 patients, and SBP was recurred in 7 patients (13.72%). When comparing the SBP recurrence group and the non-recurrence group, there were no significant differences in laboratory findings of serum and ascitic fluid. Conclusions SBP is still a critical complication in cirrhosis patients with ascites, and the clinical features of SBP have not been altered much compared with those in 1990's. The effective treatment of SBP is still very important for a better prognosis of cirrhosis patients.
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Affiliation(s)
- Ha Young Na
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Jeong Han Kim
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Won Hyeok Choe
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - So Young Kwon
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Byung Chul Yoo
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
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A Case of Pneumococcal Peritonitis after Caesarean Section in a Healthy Woman. Case Rep Surg 2015; 2015:350573. [PMID: 26550516 PMCID: PMC4623358 DOI: 10.1155/2015/350573] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Accepted: 10/05/2015] [Indexed: 12/03/2022] Open
Abstract
Pneumococcal peritonitis is prevalent in children and adults with comorbidities but extremely rare in healthy adults. Here we describe a case of pneumococcal peritonitis in a previously healthy woman with no known risk factors who presented with constipation, abdominal pain, and distention. Her only past medical history was an uncomplicated C-section two months prior to presentation. A laparotomy revealed a pneumococcal peritonitis without visible source of infection. The patient remained hospitalized until completion of antibiotic regimen with Ceftriaxone and resolution of symptoms. This report adds to the small body of evidence showing possible pneumococcal peritonitis in healthy young adults.
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Hashemian AM, Ahmadi K, Zamani Moghaddam H, Zakeri H, Davoodi Navakh SA, Sharifi MD, Bahrami A. Diagnostic Value of Leukocyte Esterase Test Strip Reagents for Rapid Clinical Diagnosis of Spontaneous Bacterial Peritonitis in Patients Admitted to Hospital Emergency Departments in Iran. IRANIAN RED CRESCENT MEDICAL JOURNAL 2015; 17:e21341. [PMID: 26568859 PMCID: PMC4640055 DOI: 10.5812/ircmj.21341] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 12/01/2014] [Accepted: 02/21/2015] [Indexed: 01/07/2023]
Abstract
Background: Spontaneous bacterial peritonitis (SBP) is a common and important clinical problem and is life-threatening in decompensated liver disease. Ascites fluid test by leukocyte esterase test strip has been recently proposed as an effective and rapid method to diagnose SBP in patients with cirrhosis. Objectives: This study aimed to evaluate sensitivity and specificity of leukocyte esterase test strip in the diagnosis of SBP. Patients and Methods: The population of this research was all patients with cirrhosis and ascites admitted to the emergency room at Imam Reza (AS) hospital, Mashhad. A written consent was taken for inclusion in the study. 50 mL ascites sample was taken from all patients for use in a urine test strip (LER) (Urine Test Strips Convergys®Urine Matrix 11). The patient’s ascites samples were evaluated for cell counting. Positive dipstick test for LER in this study considered as grade 3 +. The values of WBC > 500 cell/mm3 or PMN > 250 cell/mm3 considered as positive result of the gold standard method for the diagnosis of SBP. Results: In this study, 100 patients with ascites due to cirrhosis, with an average age of 38.9 ± 6.54 years were evaluated. Twenty cases had positive results, of whom 17 cases were also detected based on the standard diagnostic criteria and other three cases were healthy individuals. Thus, sensitivity, specificity, positive and negative predictive values, and accuracy of the method were 95%, 96.3%, 85%, 97.5% and 95%, respectively. Conclusions: The use of leukocyte esterase urine dipstick test can be a quick and easy method in early diagnosis of SBP to start the treatment until preparation of SBP-cell count results.
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Affiliation(s)
- Amir Masoud Hashemian
- Department of Emergency Medicine, Imam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, IR Iran
| | - Koorosh Ahmadi
- Department of Emergency Medicine, Alborz University of Medical Sciences, Karaj, IR Iran
| | - Hamid Zamani Moghaddam
- Department of Emergency Medicine, Imam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, IR Iran
| | - Hosein Zakeri
- Department of Emergency Medicine, Hasheminejad Hospital, Faculty of Medicine, Mashhad University of Medical Sciences , Mashhad, IR Iran
| | | | - Mohammad Davood Sharifi
- Department of Emergency Medicine, Imam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, IR Iran
- Corresponding Author: Mohammad Davood Sharifi, Department of Emergency Medicine, Imam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, IR Iran. Tel: +98-9151156758, Fax: +98-5138525312, E-mail:
| | - Abdollah Bahrami
- Department of Internal Medicine, Mashhad University of Medical Sciences, Mashhad, IR Iran
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Dever JB, Sheikh MY. Review article: spontaneous bacterial peritonitis--bacteriology, diagnosis, treatment, risk factors and prevention. Aliment Pharmacol Ther 2015; 41:1116-31. [PMID: 25819304 DOI: 10.1111/apt.13172] [Citation(s) in RCA: 121] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2015] [Revised: 02/02/2015] [Accepted: 03/03/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Spontaneous bacterial peritonitis (SBP) is a severe and often fatal infection in patients with cirrhosis and ascites. AIM To review the known and changing bacteriology, risk factors, ascitic fluid interpretation, steps in performing paracentesis, treatment, prophylaxis and evolving perspectives related to SBP. METHODS Information was obtained from reviewing medical literature accessible on PubMed Central. The search term 'spontaneous bacterial peritonitis' was cross-referenced with 'bacteria', 'risk factors', 'ascites', 'paracentesis', 'ascitic fluid analysis', 'diagnosis', 'treatment', 'antibiotics', 'prophylaxis', 'liver transplantation' and 'nutrition'. RESULTS Gram-positive cocci (GPC) such as Staphylococcus, Enterococcus as well as multi-resistant bacteria have become common pathogens and have changed the conventional approach to treatment of SBP. Health care-associated and nosocomial SBP infections should prompt greater vigilance and consideration for alternative antibiotic coverage. Acid suppressive and beta-adrenergic antagonist therapies are strongly associated with SBP in at-risk individuals. CONCLUSIONS Third-generation, broad-spectrum cephalosporins remain a good initial choice for SBP treatment. Levofloxacin is an acceptable alternative for patients not receiving long-term flouroquinolone prophylaxis or for those with a penicillin allergy. For uncomplicated SBP, early oral switch therapy is reasonable. Alternative antibiotics such as pipercillin-tazobactam should be considered for patients with nosocomial SBP or for patients who fail to improve on traditional antibiotic regimens. Selective albumin supplementation remains an important adjunct in SBP treatment. Withholding acid suppressive medication deserves strong consideration, and discontinuing beta-adrenergic antagonist therapy in patients with end-stage liver disease and resistant ascites is standard care. Liver transplant evaluation should be undertaken for patients who develop SBP barring contraindications.
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Affiliation(s)
- J B Dever
- Department of Gastroenterology, VA San Diego Healthcare System, San Diego, CA, USA
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Wehmeyer MH, Krohm S, Kastein F, Lohse AW, Lüth S. Prediction of spontaneous bacterial peritonitis in cirrhotic ascites by a simple scoring system. Scand J Gastroenterol 2014; 49:595-603. [PMID: 24673156 DOI: 10.3109/00365521.2013.848471] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Spontaneous bacterial peritonitis (SBP) is a life-threatening complication in patients with liver cirrhosis. The aim of this prospective study was to identify predictors of SBP in order to develop a noninvasive method to identify or exclude an episode of SBP. PATIENTS AND METHODS Three hundred and ninety-two consecutive patients, who underwent paracentesis from March 2008 through January 2012 in our department due to cirrhotic ascites, were screened. Ninety-six patients were excluded, mostly due to prior application of antibiotics. SBP was defined by an absolute neutrophil count≥250 cells/µL ascites. We evaluated various clinical and laboratory parameters as potential predictors of SBP. A scoring system was developed in a training set of 220 and validated in a second set of 76 patients. RESULTS Fifty-eight patients (26%) in the training set and 17 patients in the validation set (22%) suffered from SBP. Thrombocytopenia≤100,000 cells/µL, age>60 years and CRP>60 mg/L were identified as independent predictors of SBP. A scoring system combining these three parameters (weighting thrombocytopenia and age with 1 point each, but CRP with 2 points) reaches a positive predictive value for the diagnosis of SBP of 81.8% with a specificity of 98.8% (score≥3). The negative predictive value at a threshold of 1 point is 93.5% with a sensitivity of 87.9%. Notably, a high MELD score is not associated with SBP (p=0.3344). CONCLUSIONS Combination of age, CRP and platelet count in a simple scoring system helps in the rapid diagnosis or exclusion of SBP.
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Affiliation(s)
- Malte H Wehmeyer
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf , Hamburg , Germany
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Toward reliable and rapid bedside diagnosis of spontaneous bacterial peritonitis in cirrhotic patients. EGYPTIAN LIVER JOURNAL 2014. [DOI: 10.1097/01.elx.0000445721.66780.68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Tsung PC, Ryu SH, Cha IH, Cho HW, Kim JN, Kim YS, Moon JS. Predictive factors that influence the survival rates in liver cirrhosis patients with spontaneous bacterial peritonitis. Clin Mol Hepatol 2013; 19:131-9. [PMID: 23837137 PMCID: PMC3701845 DOI: 10.3350/cmh.2013.19.2.131] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Revised: 02/23/2013] [Accepted: 02/27/2013] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND/AIMS Spontaneous bacterial peritonitis (SBP) has been known to greatly influence the survival rate of patients with liver cirrhosis. However, the factors that affect the survival rate in patients with SBP need to be clarified. METHODS This study enrolled 95 liver cirrhosis patients diagnosed with SBP. The laboratory findings of their serum and ascitic fluid were examined and the characteristics of the isolated microorganisms in their peritoneal fluid were analyzed. RESULTS The proportion of patients with culture-positive SBP was 41.1%, and 47 microorganisms were isolated from the ascitic fluid. The proportions of cultured bacteria that were Gram negative and Gram positive were 57.4% and 40.4%, respectively. The proportions of Escherichia coli, Klebsiella species, and Streptococcus species were 25.5%, 19.1%, and 19.1%, respectively. Enterococcus species represented 12.8% of the microorganisms cultured. The overall survival rates at 6, 12, and 24 months were 44.5%, 37.4%, and 32.2%, respectively. There was no relationship between the bacterial factors and the survival rate in SBP. Multivariate analysis revealed that the presence of hepatocellular carcinoma (HCC; P=0.001), higher serum bilirubin levels (≥3 mg/dL, P=0.002), a prolonged serum prothrombin time (i.e., international normalized ratio >2.3, P<0.001), renal dysfunction (creatinine >1.3 mg/dL, P<0.001), and lower glucose levels in the ascitic fluid (<50 mg/dL, P<0.001) were independent predictive factors of overall survival rate. CONCLUSIONS HCC, higher serum bilirubin levels, a prolonged serum prothrombin time, renal dysfunction, and lower ascitic glucose levels are associated with higher mortality rates in cirrhotic patients with SBP.
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Affiliation(s)
- Pei Chuan Tsung
- Division of Gastroenterology, Department of Internal Medicine, Inje University Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
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Yamou R, Najih M, Absi M, Ouanani M, Echerrab M, EL Alami H, Amraoui M, Errougani A, Chkoff MR. [Primitive peritonitis: real entity but difficult to diagnose]. Pan Afr Med J 2012; 12:83. [PMID: 23077704 PMCID: PMC3473969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2012] [Accepted: 07/16/2012] [Indexed: 11/08/2022] Open
Abstract
Les péritonites primitives sont rares chez des patients sans facteurs de risques. Elles simulent les péritonites secondaires. C'est pourquoi leur diagnostic ne peut être que peropératoire. Nous rapportons deux cas de péritonites primitives dans le but de discuter leurs aspects diagnostique et thérapeutiques.
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Affiliation(s)
- Rajae Yamou
- Service des urgences chirurgicales viscérales, Hôpital Ibn Sina, Rabat, Maroc,Corresponding author: Rajae Yamoul, Service de chirurgie viscérale, Hôpital militaire d'instruction Mohammed V, Rabat, Maroc. Adresse: Service de chirurgie viscérale, Hôpital militaire d'instruction Mohammed V, Rabat, Maroc
| | - Mohammed Najih
- Service des urgences chirurgicales viscérales, Hôpital Ibn Sina, Rabat, Maroc
| | - Mohamed Absi
- Service des urgences chirurgicales viscérales, Hôpital Ibn Sina, Rabat, Maroc
| | - Mohamed Ouanani
- Service des urgences chirurgicales viscérales, Hôpital Ibn Sina, Rabat, Maroc
| | - Mahjoub Echerrab
- Service des urgences chirurgicales viscérales, Hôpital Ibn Sina, Rabat, Maroc
| | - Hassan EL Alami
- Service des urgences chirurgicales viscérales, Hôpital Ibn Sina, Rabat, Maroc
| | - Mohamed Amraoui
- Service des urgences chirurgicales viscérales, Hôpital Ibn Sina, Rabat, Maroc
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Ribeiro TC, Chebli JM, Kondo M, Gaburri PD, Chebli LA, Feldner ACA. Spontaneous bacterial peritonitis: How to deal with this life-threatening cirrhosis complication? Ther Clin Risk Manag 2011; 4:919-25. [PMID: 19209274 PMCID: PMC2621420 DOI: 10.2147/tcrm.s2688] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Spontaneous bacterial peritonitis (SBP) is one of the most common and life-threatening complications of cirrhosis. It occurs in 10% to 30% of patients admitted to hospital and recent studies tend to demonstrate that SBP incidence seems to be decreasing in its frequency. A bacterial overgrowth with translocation through the increased permeable small intestinal wall and impaired defense mechanisms is considered to be the main mechanism associated with its occurrence. The Gram-negative aerobic bacteria are the major responsible for SBP episodes and Gram-positive bacteria, mainly Staphylococcus aureus, are being considered an emergent agent causing SBP. The prompt diagnosis of SBP is the key factor for reduction observed in mortality rates in recent years. The clinical diagnosis of SBP is neither sensitive nor specific and the search for new practical and available tools for a rapid diagnosis of SBP is an important endpoint of current studies. Reagent strips were considered a promising and faster way of SBP diagnosis. The prompt use of empirical antibiotics, mostly cefotaxime, improves significantly the short-term prognosis of cirrhotic patients with SBP. The recurrence rate of SBP is high and antibiotic prophylaxis has been recommended in high-risk settings. Unfortunately, the long-term prognosis remains poor.
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Affiliation(s)
- Tarsila Cr Ribeiro
- Division of Gastroenterology, Department of Medicine of University Federal de São Paulo, UNIFESP, EPM, São Paulo, São Paulo, Brazil
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Perumalswami PV, Schiano TD. The management of hospitalized patients with cirrhosis: the Mount Sinai experience and a guide for hospitalists. Dig Dis Sci 2011; 56:1266-81. [PMID: 21416246 DOI: 10.1007/s10620-011-1619-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Accepted: 02/05/2011] [Indexed: 12/15/2022]
Abstract
BACKGROUND Cirrhosis and chronic liver disease carry appreciable morbidity and mortality. Cirrhotic patients frequently require hospitalization and their care is both extremely complex and labor-intensive. AIM We seek to provide a review for gastroenterologists, hepatologists, internists, and hospitalists on the approach to care in patients hospitalized for complications related to end-stage liver disease. METHODS The Mount Sinai Medical Center's inpatient liver service has developed an integrated team approach for cirrhotic patients and throughout the years has educated fellows-in-training and medical house staff on both the treatment principles and "pearls" in managing the hospitalized cirrhotic patient. We reviewed the literature and provide recommendations on the management of complications of end-stage liver disease. Additionally, we provide a review of the protocols used at our institution in the care for cirrhotic patients. RESULTS Major complications of advanced liver disease include infection, ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, portal hypertension, variceal hemorrhage, hepatorenal syndrome, and hepatocellular carcinoma. Management of these complications involves selecting the appropriate diagnostic studies and prompt administration of therapy. CONCLUSIONS There are many complications of cirrhosis. Management of these complications can be complex and are targeted at stabilizing the patient's clinical condition. Liver transplantation remains the only definitive treatment.
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Affiliation(s)
- Ponni V Perumalswami
- Division of Liver Diseases, The Mount Sinai Medical Center, Mount Sinai School of Medicine, One Gustave Levy Place, Box 1104, New York, NY 10029, USA
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Waisman DC, Tyrrell GJ, Kellner JD, Garg S, Marrie TJ. Pneumococcal peritonitis: Still with us and likely to increase in importance. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2010; 21:e23-7. [PMID: 21358876 PMCID: PMC2852291 DOI: 10.1155/2010/867571] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Pneumococcal peritonitis is uncommon and poorly understood. METHODS As part of a five-year study (2000 to 2004) of invasive pneumococcal disease (IPD) in Alberta, all cases of peritonitis due to Streptococcus pneumoniae were reviewed and compared with all other cases of IPD. RESULTS Twenty-three of 1768 (1.3%) IPD patients were found to have peritonitis. Patients with peritonitis were more likely to have cirrhosis, hepatitis C, alcoholism and HIV/AIDS, than the remainder of the patients with IPD. The all-cause mortality did not differ between the two groups. Peritonitis was classified as primary in nine (39%) patients, secondary in 12 (52%) patients, and genitourinary in females, specifically, in two (9%) patients. Pneumococcal serotypes causing peritonitis were under-represented in current vaccines - 17% among peritonitis patients versus 53% for the remainder of IPD patients for the 7-valent pneumococcal conjugate vaccine, and 56% versus 86% for the 23-valent pneumococcal polysaccharide vaccine. CONCLUSIONS Peritonitis represents a small subset of patients with IPD, but one that is likely to grow in importance given the increase in the number of patients with hepatitis C and HIV, and the reduced coverage of peritonitis serotypes in currently available vaccines.
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Affiliation(s)
- Darcy C Waisman
- University College Dublin, Dublin, Ireland
- Department of Medicine, Faculty of Medicine and Dentistry
| | - Gregory J Tyrrell
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton
| | | | - Sipi Garg
- EPICORE centre, University of Alberta, Edmonton, Alberta
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Heo J, Seo YS, Yim HJ, Hahn T, Park SH, Ahn SH, Park JY, Park JY, Kim MY, Park SK, Cho M, Um SH, Han KH, Kim HS, Baik SK, Kim BI, Cho SH. Clinical features and prognosis of spontaneous bacterial peritonitis in korean patients with liver cirrhosis: a multicenter retrospective study. Gut Liver 2009; 3:197-204. [PMID: 20431746 PMCID: PMC2852707 DOI: 10.5009/gnl.2009.3.3.197] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2009] [Accepted: 06/21/2009] [Indexed: 12/18/2022] Open
Abstract
Background/Aims Although early recognition and treatment with effective antibiotics have lead to improvements in the prognosis of patients with spontaneous bacterial peritonitis (SBP), it remains to be a serious complication in cirrhotic patients. This study was designed to evaluate the clinical manifestations and prognosis of patients with liver cirrhosis and SBP in Korea. Methods This was a multicenter retrospective study examining 157 episodes of SBP in 145 patients with cirrhosis. SBP was diagnosed based on a polymorphonuclear cell count in ascitic fluid of >250 cells/mm3 in the absence of data compatible with secondary peritonitis. Results The mean age of the cohort was 56 years, and 121 (77%) of the 157 episodes of SBP occurred in men. Microorganisms were isolated in 66 episodes (42%): Gram-negative bacteria in 54 (81.8%), Gram-positive in 11 (16.7%), and Candida in 1. Isolated Gram-negative organisms were resistant to third-generation cephalosporin in 6 cases (17%), to ciprofloxacin in 11 (20.8%), and to penicillin in 33 (62.3%). The treatment failure and in-hospital mortality rates were 12.1% and 21%, respectively. A high Model of End-Stage Liver Disease (MELD) score, SBP caused by extended-spectrum β-lactamase-producing organisms, and hepatocellular carcinoma were independent prognostic factors of high in-hospital mortality. Conclusions SBP remains to be a serious complication with high in-hospital mortality, especially in patients with a high MELD score.
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Affiliation(s)
- Jeong Heo
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, Korea
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Abstract
Since its initial description in 1964, research has transformed spontaneous bacterial peritonitis (SBP) from a feared disease (with reported mortality of 90%) to a treatable complication of decompensated cirrhosis, albeit with steady prevalence and a high recurrence rate. Bacterial translocation, the key mechanism in the pathogenesis of SBP, is only possible because of the concurrent failure of defensive mechanisms in cirrhosis. Variants of SBP should be treated. Leucocyte esterase reagent strips have managed to shorten the ‘tap-to-shot’ time, while future studies should look into their combined use with ascitic fluid pH. Third generation cephalosporins are the antibiotic of choice because they have a number of advantages. Renal dysfunction has been shown to be an independent predictor of mortality in patients with SBP. Albumin is felt to reduce the risk of renal impairment by improving effective intravascular volume, and by helping to bind pro-inflammatory molecules. Following a single episode of SBP, patients should have long-term antibiotic prophylaxis and be considered for liver transplantation.
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20
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Haghighat M, Dehghani SM, Alborzi A, Imanieh MH, Pourabbas B, Kalani M. Organisms causing spontaneous bacterial peritonitis in children with liver disease and ascites in Southern Iran. World J Gastroenterol 2006; 12:5890-5892. [PMID: 17007059 PMCID: PMC4100674 DOI: 10.3748/wjg.v12.i36.5890] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2006] [Revised: 08/15/2006] [Accepted: 08/23/2006] [Indexed: 02/06/2023] Open
Abstract
AIM To determine the causative agents of spontaneous bacterial peritonitis (SBP) in children with liver disease and ascites in our center. METHODS During a 2.5 year period, from September 2003 to March 2006, 12 patients with 13 episodes of SBP were studied. In all cases at the time of admission serum albumin and glucose, urinalysis and urine culture was performed. Analysis [white blood cell (WBC) count with differential, albumin, glucose], gram stain, culture by BACTEC method and antibiogram was done on ascitic fluids. Abdominal paracentesis was repeated after 48 h of antibiotic therapy for bacteriologic assay. The patients were followed for at least three months in a gastroenterology clinic. RESULTS There were 7 girls (58%) and 5 boys (42%) with a median age of 5.2 years (range, 6 mo to 16 years). All cases had positive ascitic fluid culture. Gram stain was positive in 5 (38.5%) of them. The isolated organisms were S. pneumoniae in 5 (38.5%), E. coli in 2 (15.3%), S. viridans in 2 (15.3%), and K. pneumoniae, H. influenza, Enterococci, and nontypable Streptococcus each in one (7.7%). All of them except Enterococci were sensitive to ciprofloxacin and ceftriaxone. All ascitic fluid cultures were negative after 48 h of antibiotic therapy. CONCLUSION S. pneumoniae is the most common cause of SBP in the pediatric age group and we recommend a third generation cephalosporine (e.g., Ceftriaxione or Cefotaxime) for empirical therapy in children with SBP.
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Affiliation(s)
- Mahmood Haghighat
- Department of Pediatric Gastroenterology, Shiraz University of Medical Science, Shiraz, Iran
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Strauss E, Caly WR. Spontaneous bacterial peritonitis: a therapeutic update. Expert Rev Anti Infect Ther 2006; 4:249-60. [PMID: 16597206 DOI: 10.1586/14787210.4.2.249] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Spontaneous bacterial peritonitis (SBP) is one of the main infectious complications of cirrhosis and occurs in 8-30% of hospitalized patients with ascites. SBP is characterized by infection of the ascitic fluid (AF) in the absence of any primary focus of intra-abdominal infection. The main route by which the AF becomes infected is the hematogenous route. The pathogenic mechanism by which infection develops is bacterial translocation from the intestinal flora to the mesenteric lymph nodes and from there to the bloodstream. Contributing factors are an increased growth of Gram-negative aerobic bacilli in the jejunum, changes in the intestinal barrier and in addition factors which could reduce the local flow of blood. For clinical diagnosis, patients with SBP may present signs of peritoneal irritation and pain, together with changes in gastrointestinal motility, sometimes with nausea, vomiting, diarrhea or ileus. Many patients, however, may not present any symptoms or signs as a result of the presence of SBP. Diagnostic paracentesis of the AF must be performed for every patient with cirrhosis, hospitalized with ascites. Laboratory diagnosis of SBP is carried out by polymorphonuclear count in the AF, together with a positive culture from the AF, which is characteristically monomicrobial. Escherichia coli has been the main bacterium isolated from AF as well as other Gram-negative bacteria from the Enterobacteriaceae family and Streptococcus genus. A more rapid diagnosis of SBP can be obtained via the use of leukocyte esterase, which is present in biological fluids and reacts with a component of the dipstick, changing its color. During the acute phase of SBP, antibiotics should be initiated promptly once the clinical and laboratory diagnosis of SBP has been made, before the result of AF culture. Cefotaxime or other third-generation cephalosporins have been considered the first-choice empirical antibiotics in the treatment of cirrhotic patients with SBP, and is efficacious in approximately 90% of cases. Broad-spectrum quinolones, which are almost completely absorbed after oral administration and diffuse rapidly through the AF, are currently used for oral treatment of uncomplicated SBP. Patients who have already had a previous episode of SBP, with a 69% probability of recurrence within a year, will benefit from prophylactic treatment. Cirrhotic patients with a high risk of SBP and other infections, such as those with gastrointestinal bleeding, also benefit from primary prophylaxis and norfloxacin has been used with success.
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Affiliation(s)
- Edna Strauss
- University of São Paulo, School of Medicine, São Paulo, Brazil.
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Vieira SMG, Matte U, Kieling CO, Barth AL, Ferreira CT, Souza AF, Taniguchi A, da Silveira TR. Infected and noninfected ascites in pediatric patients. J Pediatr Gastroenterol Nutr 2005; 40:289-94. [PMID: 15735482 DOI: 10.1097/01.mpg.0000154659.54735.1d] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To determine the prevalence of spontaneous bacterial peritonitis, ascites with bacterial infection and noninfected ascites in pediatric patients with portal hypertensive ascites and to compare the clinical and laboratory features of infected and noninfected ascites. METHODS Forty-one episodes of portal hypertensive ascites (serum-ascites albumin gradient >1.1 g/dL) in 31 patients were studied. Median age was 2.9 years. Twenty-four (77.4%) patients were cirrhotic and 20 (83.3%) were classified as Child-Pugh C. Median pediatric end-stage liver disease score was 18.5. The following ascites features were assessed: polymorphonuclear neutrophil cell count, cytology, pH, concentration of glucose, lactic dehydrogenase, total protein and albumin, Gram stain and bacteriological culture. Blood was sampled for complete blood count, coagulation studies, liver and renal function tests. Groups were compared by Mann-Whitney and chi tests (P < 0.05). RESULTS Noninfected ascites were observed in 29 of 41 samples, spontaneous bacterial peritonitis in eight of 41 and ascites with bacterial infection in four of 41. The most prevalent clinical features were fever, voluminous ascites and encephalopathy, but there were no significant differences in the clinical features of the groups. All patients with infected ascites were cirrhotic. There was no statistical difference in Child-Pugh or pediatric end-stage liver disease status between patients with infected and noninfected ascites. Culture of ascetic fluid was positive in four of eight cases of spontaneous bacterial peritonitis. Gram-negative rods were the most prevalent bacteria cultured. Except for serum albumin, no statistical differences in biochemical markers were observed between patients with infected and noninfected ascites. CONCLUSIONS The prevalence of infected ascites was 29.2%. With the exception of serum albumin, there were no differences in the clinical and biochemical features of patients with infected ascites and noninfected ascites.
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Abstract
Spontaneous bacterial peritonitis (SBP) is a bacterial infection of ascitic fluid in patients with decompensated cirrhosis. The modifier 'spontaneous' distinguishes this from surgical peritonitis. The infecting organisms are usually enteric gram-negatives which have translocated from the bowel. Symptoms of infection occur in most patients with SBP, including fever, abdominal pain, mental status changes, and ileus. A high index of suspicion should exist for SBP in patients with cirrhosis and ascites. Diagnostic abdominal paracentesis can be undertaken with minimal risk and should be performed in all patients admitted to the hospital, during times of worsening clinical appearance, or when gastrointestinal bleeding occurs. The ascitic fluid polymorphonuclear cell count is the most sensitive test in evaluating for infection. Cultures of the ascitic fluid are helpful in identifying the organism and are best performed by bedside injection of blood culture bottles. Ascites total protein, lactate dehydrogenase, and glucose levels can assist in distinguishing SBP from secondary peritonitis. Empirical therapy is recommended after paracentesis if suspicion for infection exists. Cefotaxime is the best-studied antibiotic for this purpose and has excellent penetration into ascites with no nephrotoxicity. Prophylaxis should be limited to high-risk settings. Mortality rates in SBP have declined dramatically, largely due to earlier detection and improved therapy.
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Affiliation(s)
- Todd A Sheer
- Department of Internal Medicine, Division of Gastroenterology, Naval Medical Center San Diego, San Diego, Calif. 92134, USA.
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Affiliation(s)
- Adrian Reuben
- Division of GI/Hepatology, Department of Medicine, Medical University of South Carolina, USA
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Affiliation(s)
- Guadalupe Garcia-Tsao
- Yale University School of Medicine and CT-VA Healthcare System, 333 Cedar Street, New Haven, CT 06510, USA.
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Abstract
This article reviews the progress made during the last century in understanding and managing ascites. The list of known causes of ascites has lengthened considerably. There is improved understanding of the mechanism of ascites formation and the pathophysiology of the renal sodium retention that accompanies portal hypertensive ascites. Management of ascites has become substantially easier with the advent of new diuretics, and new procedures such as peritoneovenous shunting, transjugular intrahepatic portosystemic stent placement, and liver transplantation.
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Affiliation(s)
- T B Reynolds
- Department of Medicine, Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Bac DJ. Spontaneous bacterial peritonitis: an indication for liver transplantation? SCANDINAVIAN JOURNAL OF GASTROENTEROLOGY. SUPPLEMENT 1996; 218:38-42. [PMID: 8865449 DOI: 10.3109/00365529609094729] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Spontaneous bacterial peritonitis (SBP) is a serious complication in patients with cirrhosis and ascites with a poor prognosis. The survival pattern and the reasons for not performing a liver transplantation after an episode of SBP were analysed. METHODS A retrospective analysis during the period 1987-1992 in a tertiary referral and liver transplantation centre. RESULTS Sixty episodes of SBP were diagnosed in 52 patients with ascites. Thirty-two percent of the patients died within 30 days and 78% within 1 year. Forty patients who survived less than 1 year did not receive a liver transplantation for the following reasons: death within 30 days (n = 12), age above 65 years (n = 10), medical contraindications (n = 6), active alcohol abuse (n = 6), refusal of transplantation (n = 2), death while being analysed for, or awaiting transplantation (n = 4). Two patients had an auxiliary liver transplantation but died postoperatively. CONCLUSION SBP is a serious complication in patients with cirrhosis and ascites, with a high first-year mortality and a high recurrence rate. Although long-term survival after an episode of SBP is possible, liver transplantation should be considered for the patients with a progressive liver disease after a first episode of SBP.
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Affiliation(s)
- D J Bac
- Dept. of Gastroenterology and Hepatology, University Hospital Rotterdam-Dijkzigt, The Netherlands
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Abstract
Bacterial peritonitis presents with classic symptoms of fever and abdominal pain. Some patients, however, are completely asymptomatic. Death in the short term is considerable, especially in patients with alcoholic cirrhosis. Cystic fibrosis patients occasionally develop biliary cirrhosis and may have secondary hypersplenism, varices, and ascites. These patients should be at risk for spontaneous bacterial peritonitis. Spontaneous bacterial peritonitis is described in two patients with longstanding hepatic cirrhosis secondary to cystic fibrosis. Both had required splenectomy for complications of portal hypertension. This is a previously unreported, but potentially fatal, complication of cystic fibrosis liver disease. Early diagnostic paracentesis is essential so that appropriate acute management, including antimicrobial treatment can be started. In the long term, these patients deserve immediate paracentesis for any evidence of recurrence. Whether the patient is treated with chronic (continuous) antimicrobial prophylaxis or only receives antimicrobial treatment during periods when bacteraemia is possible (for example, dental work, bronchoscopy), it would seem reasonable in patients with cystic fibrosis to use a wide spectrum antimicrobial agent with activity against Pseudomonas aeruginosa, other common Gram negative organisms, and Staphylococcus aureus.
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Affiliation(s)
- C F Doershuk
- Leroy W Matthews Cystic Fibrosis Center, Rainbow Babies, Cleveland, Ohio
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Affiliation(s)
- J A Cuthbert
- Department of Internal Medicine, University of Texas Southwestern Medical School, Dallas 75235-8887
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Becq-Giraudon B, Breux J, Silvain C, Cazenave-Roblot F, Morichau-Beauchant M. Les infections spontanees du liquide d'ascite chez le cirrhotique. Med Mal Infect 1988. [DOI: 10.1016/s0399-077x(88)80181-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Abstract
Spontaneous bacterial peritonitis occurs frequently in cirrhotic patients. In order to define more accurately the spectrum of this disease, 55 cases of spontaneous peritonitis were compared with 56 controls (patients with negative ascitic fluid cultures). Of several presenting symptoms, only vomiting (p less than 0.01), fever (p less than 0.05), and severe gastrointestinal bleeding (p less than 0.05) were more prevalent in cases than controls. There were no physical signs and no laboratory studies that separated the two groups except for elevated serum amylases in controls. Studies of peritoneal fluid were rarely helpful and cell counts overlapped in the cases and controls. Spontaneous peritonitis is usually seen in patients with severe liver disease, but there are few distinctive symptoms, signs, or laboratory findings. The mortality rate is high, and it is uncertain from our data that antibiotic therapy alters this prognosis.
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Stassen WN, McCullough AJ, Bacon BR, Gutnik SH, Wadiwala IM, McLaren C, Kalhan SC, Tavill AS. Immediate diagnostic criteria for bacterial infection of ascitic fluid. Evaluation of ascitic fluid polymorphonuclear leukocyte count, pH, and lactate concentration, alone and in combination. Gastroenterology 1986; 90:1247-54. [PMID: 3956943 DOI: 10.1016/0016-5085(86)90392-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
We prospectively evaluated the ascitic fluid (AF) polymorphonuclear cell (PMN) count, pH, and lactate concentration in single ascitic fluids from 60 patients to determine their relative predictive values for the immediate diagnosis of ascitic fluid infection. Nine of the 60 ascitic fluids were malignant. Of the remaining 51 samples, nine from cirrhotic patients were infected. The mean AF pH, lactate concentration, and PMN count in the infected group were 7.20 +/- 0.19, 80 +/- 51 mg/dl, and 18,199 +/- 19,650 cells/mm3, respectively, and all were significantly different from the corresponding values in noninfected ascites. Mean arterial blood-ascitic fluid (B-AF) pH and lactate gradients in the infected group were 0.23 +/- 0.17 and -46 +/- 31 mg/dl, respectively, and were significantly different from the corresponding values in noninfected ascites (p less than 0.05). Significant differences were not found between infected and malignant ascites, except for the AF PMN count (p less than 0.001). In cirrhosis with ascites, an AF pH less than or equal to 7.34 was the most specific single test (100%) and had the highest diagnostic accuracy (98%). In the larger group of patients with ascites of diverse etiology, a B-AF pH gradient greater than or equal to 0.10 or an AF PMN count greater than or equal to 500 cells/mm3 were the single tests with the highest diagnostic accuracy (92%). Combining an AF PMN count greater than 500 cells/mm3 with any of the other diagnostic criteria increased the specificity and diagnostic accuracy (up to 98%) compared to the best single criterion. Although our data support the use of a number of different combinations of AF measurements for the immediate diagnosis of infection, the simplest and most readily obtainable measurements are the pH and PMN count. Therefore, in the clinical setting we recommend the use of either an AF pH less than or equal to 7.34 or a B-AF pH gradient greater than or equal to 0.10 in combination with an AF PMN count greater than 500 cells/mm3 to obtain the highest degree of accuracy in the immediate diagnosis of ascitic fluid infection.
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Abstract
Spontaneous bacterial peritonitis is an infection of the ascitic fluid of patients who, in general, have severe chronic liver disease. Several variants of this disease exist including bacterascites, culture-negative neutrocytic ascites, and secondary bacterial peritonitis. Spontaneous bacterial peritonitis is frequently manifested by signs and symptoms of peritonitis although the findings may be subtle; however, occasionally it may be completely without clinical manifestation. The clinician must have a high index of suspicion in order to make this diagnosis at a relatively earlier stage of infection. An abdominal paracentesis is required to make the diagnosis of spontaneous bacterial peritonitis. This paracentesis should be performed on all patients who are admitted to the hospital for ascites and should be repeated if there is any manifestation of bacterial infection during the hospitalization. Patients with severe intrahepatic shunting--as manifested by marked redistribution of activity from the liver to the spleen and to the bone marrow on liver-spleen scan as well as patients with an ascitic fluid total protein concentration of less than 1 g/dl--appear to be particularly susceptible to bacterial infection of their ascites. In order to optimize the yield of ascitic fluid culture, it is probably appropriate to inject blood culture bottles with ascites at the bedside immediately after the abdominal paracentesis. The mortality of spontaneous bacterial peritonitis continues to be very high. Perhaps routine admission paracentesis and prompt empiric antibiotic therapy with a third-generation cephalosporin will decrease the mortality of this infection if the Gram stain of the ascitic fluid demonstrates bacteria or the ascitic fluid neutrophil count is greater than 250 cells/cu mm. Repeating the paracentesis after 48 hours of treatment to reculture the fluid and reassess the ascitic fluid neutrophil count appears to be the best way to assess efficacy of treatment. After 48 hours of treatment the ascitic fluid neutrophil count should be less than 50% of the original value if the antimicrobial therapy is appropriate. The optimal duration of antibiotic treatment is unknown; however, until controlled trials provide data regarding duration of treatment it is appropriate to treat with parenteral antibiotics for 10 to 14 days. Research is also needed to determine if there are measures which can be taken to prevent the development of spontaneous peritonitis.
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Rolston DDK, Farthing MJG, Clark ML, Dawson AM. Citrate in oral rehydration therapy. Gut 1985; 26:429. [PMID: 3979915 PMCID: PMC1432516 DOI: 10.1136/gut.26.4.429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Stassen WN, McCullough AJ, Hilton PK. Spontaneous bacterial peritonitis caused by Neisseria gonorrhoeae. Evidence for a transfallopian route of infection. Gastroenterology 1985; 88:804-7. [PMID: 3917960 DOI: 10.1016/0016-5085(85)90155-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
We describe the clinical and laboratory features of a case of spontaneous bacterial peritonitis caused by Neisseria gonorrhoeae in a sexually active woman with Laennec's cirrhosis, ascites, and asymptomatic cervical gonorrhea. Treatment of the infection with high-dose parenteral penicillin was associated with resolution of the infection. This first report of spontaneous gonococcal peritonitis provides highly suggestive evidence that the transfallopian route is a mechanism whereby bacteria may enter the peritoneal cavity. Appropriate cultures for this organism should be included when a woman with chronic liver disease, who is sexually active, presents with spontaneous peritonitis.
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Abstract
Five cases of primary peritonitis are presented, with a sixth related case of pneumococcal peritonitis secondary to a ruptured ovarian cyst. The patients comprised 4 young girls who recovered, and 2 elderly females who died. Pneumococci were isolated in 3 patients; no organism was found in the other 3. One case of primary measles peritonitis has no apparent precedent.
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Affiliation(s)
- Finlay A. Macrae
- Department of GastroenterologyThe Royal Melbourne HospitalMelbourneVic.3050
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Weinstein MP, Iannini PB, Stratton CW, Eickhoff TC. Spontaneous bacterial peritonitis. A review of 28 cases with emphasis on improved survival and factors influencing prognosis. Am J Med 1978; 64:592-8. [PMID: 645725 DOI: 10.1016/0002-9343(78)90578-8] [Citation(s) in RCA: 140] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
During a five year period, 28 episodes of spontaneous bacterial peritonitis were documented. The number of cases recognized annually increased during the study period. Clinical and laboratory features of spontaneous bacterial peritonitis were similar to those previously reported; however, mortality was considerably lower (57 per cent). Factors associated with adverse prognosis were increasing hepatic encephalopathy, more than 85 per cent granulocytes in peripheral blood or ascitic fluid, total bilirubin greater than 8 mg/dl and serum albumin less than 2.5 g/dl. Temperature greater than 38 degrees C was associated with increased survival. Infection by enteric organisms was associated with higher mortality than infection by nonenteric organisms. Unexpectedly, patients with bacteremia fared no worse than those whose blood remained sterile. The data suggest that in patients with leukocyte counts greater than 1,000 cells/mm3 and more than 85 per cent granulocytes in their ascitic fluid, the likelihood of spontaneous bacterial peritonitis is high. Such patients deserve empiric antibiotic therapy pending the results of appropriate cultures.
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Targan SR, Chow AW, Guze LB. Role of anaerobic bacteria in spontaneous peritonitis of cirrhosis: report of two cases and review of the literature. Am J Med 1977; 62:397-403. [PMID: 190883 DOI: 10.1016/0002-9343(77)90837-3] [Citation(s) in RCA: 54] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The role of anaerobic or microaerophillic bacteria in spontaneous peritonitis of cirrhosis has not been clearly defined. Among 126 cases recorded in the literature, in only eight (6 per cent), including the two reported here, was bacterascites associated with anaerobic or microaerophilic bacteria. Clinical features in these cases were indistinguishable from those associated with aerobic bacteria. However, polymicrobial bacterascites occurred in four of eight cases associated with anaerobes, as contrasted with only 10 of 118 cases (8 per cent) associated with aerobes alone. On the other hand, concurrent bacteremia occurred in only one of eight cases associated with anaerobes as contrasted with 52 of 118 cases (44 per cent) of aerobic spontaneous peritonitis. Experimental evidence is cited in an attempt to explain this relatively low incidence of spontaneous peritonitis associated with anaerobic or microaerophilic bacteria, despite the high density of these organisms in the normal bowel flora.
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Curry N, McCallum RW, Guth PH. Spontaneous peritonitis in cirrhotic ascites. A decade of experience. THE AMERICAN JOURNAL OF DIGESTIVE DISEASES 1974; 19:685-92. [PMID: 4602054 DOI: 10.1007/bf01844937] [Citation(s) in RCA: 57] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Shapera RM, Matsen JM. Host factors and capsular typing of body fluid isolates in fulminant pneumococcal infections. Infect Immun 1972; 5:132-6. [PMID: 4144203 PMCID: PMC422333 DOI: 10.1128/iai.5.1.132-136.1972] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
A 10-year retrospective study was made to determine the spectrum of underlying disease in, and the capsular types of pneumococci isolated from, blood and body fluids of 140 hospitalized patients. Fifteen serotypes were found among 82 typed isolates, 53% of which were types 8, 14, or 23. There was a predominance of males and a high incidence of underlying pneumonia, chronic liver disease, nephrotic syndrome, cerebrospinal fluid rhinorrhea, and malignancy. Mortality rates were higher among the very young and aged, and the immunologically comprised host at either extreme of life was more susceptible to disseminated pneumococcal infection. Pneumococci of the higher capsular types were prominent in children, and those of the lower types in adults, a finding in agreement with other recent studies.
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Ginsberg MD. Spontaneous group B streptococcal bacteremia complicating hepatic cirrhosis. Report of two cases. THE AMERICAN JOURNAL OF DIGESTIVE DISEASES 1968; 13:1065-71. [PMID: 5722635 DOI: 10.1007/bf02233551] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Infected Ascitic Fluid in Cirrhosis. BRITISH MEDICAL JOURNAL 1964; 2:774. [PMID: 20790301 PMCID: PMC1816519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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