Risk of a first community-acquired spontaneous bacterial peritonitis in cirrhotics with low ascitic fluid protein levels

Characterisation of bacteria in ascites--reporting the potential of culture-independent, molecular analysis

Spontaneous bacterial peritonitis (SBP) is a severe complication of liver disease. A significant proportion of patients have culture-negative ascites, despite having similar signs, symptoms and mortality to those with SBP. Therefore, empirical antibiotic treatment for infection is often started without knowledge of the causative organisms. Here, we investigated the potential of molecular techniques to provide rapid and accurate characterisation of the bacteria present in ascitic fluid. Ascites samples were obtained from 29 cirrhotic patients undergoing clinically indicated therapeutic paracentesis. Bacterial content was determined by terminal restriction fragment length polymorphism (T-RFLP) analysis, quantitative polymerase chain reaction (PCR) and 16S ribosomal clone sequence analysis. Bacterial signal was detected in all samples, compared to three out of ten using standard methods. Bacterial loads ranged from 5.5 x 10(2) to 5.4 x 10(7) cfu/ml, with a mean value of 1.9 x 10(6) cfu/ml (standard deviation +/- 9.6 x 10(6) cfu/ml). In all but one instance, bacterial species identified by culture were also confirmed by molecular analyses. Preliminary data presented here suggests that culture-independent, molecular analyses could provide rapid characterisation of the bacterial content of ascites fluid, providing a basis for the investigation of SBP development and allowing early and targeted antibiotic intervention.

Editorial: Clostridium difficile infection: Yet another predictor of poor outcome in cirrhosis

The development of Clostridium difficile infection in cirrhosis is predictive of death, independent of severity of liver disease. The main risk factors are the use of antibiotics and proton-pump inhibitors (PPIs). This is further evidence that supports the wise and cautious use of antibiotics in cirrhosis and suggests avoiding the use of PPIs in these patients except for indications of proven benefit.

Secondary bacterial peritonitis in cirrhosis: a retrospective study of clinical and analytical characteristics, diagnosis and management

BACKGROUND & AIMS

Secondary bacterial peritonitis in cirrhotic patients is an uncommon entity that has been little reported. Our aim is to analyse the frequency, clinical characteristics, treatment and prognosis of patients with secondary peritonitis in comparison to those of patients with spontaneous bacterial peritonitis (SBP).

METHODS

Retrospective analysis of 24 cirrhotic patients with secondary peritonitis compared with 106 SBP episodes.

RESULTS

Secondary peritonitis represented 4.5% of all peritonitis in cirrhotic patients. Patients with secondary peritonitis showed a significantly more severe local inflammatory response than patients with SBP. Considering diagnosis of secondary peritonitis, the sensitivity of Runyon's criteria was 66.6% and specificity 89.7%, Runyon's criteria and/or polymicrobial ascitic fluid culture were present in 95.6%, and abdominal computed tomography was diagnostic in 85% of patients in whom diagnosis was confirmed by surgery or autopsy. Mortality during hospitalization was higher in patients with secondary peritonitis than in those with SBP (16/24, 66.6% vs. 28/106, 26.4%) (p<0.001). There was a trend to lower mortality in secondary peritonitis patients who underwent surgery (7/13, 53.8%) than in those who received medical treatment only (9/11, 81.8%) (p=0.21). Considering surgically treated patients, the time between diagnostic paracentesis and surgery was shorter in survivors than in non-survivors (3.2+/-2.4 vs. 7.2+/-6.1 days, p=0.31).

CONCLUSIONS

Secondary peritonitis is an infrequent complication in cirrhotic patients but mortality is high. A low threshold of suspicion on the basis of Runyon's criteria and microbiological data, together with an aggressive approach that includes prompt abdominal computed tomography and early surgical evaluation, could improve prognosis in these patients.

Clinical features and prognosis of spontaneous bacterial peritonitis in korean patients with liver cirrhosis: a multicenter retrospective study

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.

Care of the cirrhotic patient

Timely surveillance for varices and hepatocellular carcinoma, prophylaxis against spontaneous bacterial peritonitis (SBP) improve survival in patients awaiting transplantation. Early diagnosis of minimal or overt hepatic encephalopathy can delay life threatening complications, reduce need for hospitalization, and potentially improve survival pending liver transplantation.

Role of fluoroquinolones in the primary prophylaxis of spontaneous bacterial peritonitis: meta-analysis

BACKGROUND & AIMS

The use of antibiotics in the primary prophylaxis for spontaneous bacterial peritonitis (SBP) in patients with cirrhosis is controversial. Our purpose was to determine the beneficial effect of fluoroquinolones as compared with placebo in primary prophylaxis of SBP in high-risk patients with cirrhosis by using meta-analysis.

METHODS

Medline, Embase, Cochrane, and Web of Science databases were searched in all languages until August 2008 for randomized placebo-controlled studies evaluating the role of fluoroquinolones in primary prevention of SBP in patients with low protein ascites (total ascitic protein, <1.5 g/dL) and without history of SBP. Two investigators independently performed literature search and data extraction, and then another investigator independently reviewed whether the studies met prespecified criteria and rechecked data extraction. Odds ratios (Peto method) for the risk reduction with fluoroquinolones were calculated for each study and combined by using a random-effects model.

RESULTS

Four randomized controlled studies met predefined criteria. The odds ratios for developing first episode of SBP, serious infections, and mortality with fluoroquinolone prophylaxis (n = 194) versus placebo (n = 190) were 0.18 (95% confidence interval [CI], 0.09-0.35), 0.18 (95% CI, 0.10-0.32), and 0.60 (95% CI, 0.37-0.97), respectively. All studies were unidirectional in showing the beneficial effect of fluoroquinolone prophylaxis. We were limited by finding few studies with relatively small sample sizes.

CONCLUSIONS

Daily oral fluoroquinolone prophylaxis reduces the risk of development of first episode of SBP and mortality in cirrhotic patients with low total protein in the ascitic fluid. Fluoroquinolones might be advisable for the primary prophylaxis of SBP in selected high-risk patients with cirrhosis.

Are ascitic electrolytes usable in cirrhotic patients? Correlation of sodium, potassium, chloride, urea, and creatinine concentrations in ascitic fluid and blood

BACKGROUND

Treatment of ascitic cirrhosis requires monitoring of blood biochemistry. A direct measure of ascites could simplify the medical procedure. We aimed to assess the correlation of sodium (Na), potassium (K), chloride (Cl), urea (U), and creatinine (Creat) in ascitic fluid and venous blood.

METHODS

Ascitic fluid and venous blood samples were collected simultaneously from 70 cirrhotic patients. Na, K, Cl, U, and Creat were measured in all samples using a biochemical auto-analyzer.

RESULTS

Results are expressed as the mean and SD of 200 concomitant samples of ascitic fluid and venous blood (mmol/L for Na, K, and Cl; g/L for U; mg/L for Creat). In ascites and blood the results were, respectively: 133.1+/-6.6 and 131.8+/-6.3 for Na (p<0.0001, r=0.95), 4.1+/-0.8 and 4.3+/-0.9 for K (p<0.0001, r=0.90), 107.2+/-7.6 and 101+/-7 for Cl (p<0.0001, r=0.93), 0.54+/-0.52 and 0.53+/-0.5 for U (p<0.0001, r=0.99), and 9.8+/-7.5 and 11+/-7 for Creat (p<0.0001, r=0.99). Analysis of ascites predicted blood results for different cut-offs (Na< or =125, K< or =3.2, K> or =5.5 and Creat> or =14) with a sensitivity of 1.00, 0.89, 0.71, and 0.92, and a specificity of 1.00, 0.95, 0.98, and 0.92, respectively.

CONCLUSIONS

Correlations for Na, K, Cl, U, and Creat are strong between ascites and venous blood in cirrhotic patients. These parameters could, therefore, be assayed directly in ascitic fluid to monitor diuretic therapy in patients without venous access or when biochemical measurements, such as liver tests or coagulation tests, are not required, and in patients with poor venous access.

Role of host and bacterial virulence factors in Escherichia coli spontaneous bacterial peritonitis

OBJECTIVES

Host factors and bacterial virulence determinants may play a role in Escherichia coli (E. coli) spontaneous bacterial peritonitis. We evaluated the importance of these factors in the emergence of fluoroquinolone-resistant strains and outcome in cirrhotic patients with E. coli spontaneous bacterial peritonitis.

METHODS

E. coli spontaneous bacterial peritonitis was detected in a 2-year period in three tertiary hospitals. Clinical and bacteriological data were obtained. Phylogenetic group and 15 virulence genes of E. coli strains were analyzed by polymerase gene reaction and compared with 50 isolates from pyelonephritis patients.

RESULTS

Forty-seven E. coli spontaneous bacterial peritonitis patients were identified, 18 (38%) were fluoroquinolone-resistant, a 12% increase compared with our earlier series from 1997 to 2002. Fluoroquinolone resistance was associated with norfloxacin prophylaxis, increased resistance to trimethoprim-sulfamethoxazole and cefotaxime, and less bacterial virulence, as demonstrated by a higher prevalence of 'nonpathogenic' phylogenetic groups A+B1 (56 vs. 28%; P=0.04) and lower virulence scores in fluoroquinolone-resistant E. coli compared with fluoroquinolone-susceptible E. coli. E. coli strains from cirrhotic patients belonged more frequently to 'nonpathogenic' phylogenetic groups A+B1, had fewer virulence factors and higher rates of fluoroquinolone resistance than isolates from pyelonephytis patients. Immunosuppression was independently associated with in-hospital and 3-month mortality. Bacterial virulence factors were unrelated to mortality.

CONCLUSION

Fluoroquinolone-resistant E. coli spontaneous bacterial peritonitis prevalence is increasing because of norfloxacin prophylaxis. Strains from peritonitis are less virulent than strains from pyelonephritis because of a higher prevalence of A+B1 phylogeny and quinolone resistance. Mortality is related to immunosuppression, but not to bacterial virulence factors.

Management of chronic liver failure until liver transplantation

Chronic liver failure is an important cause of morbidity and mortality and is the long-term consequence of many chronic liver diseases. In addition to determining the specific cause of the chronic liver disease, which may be amenable to targeted therapy, it is important to treat the sequelae of chronic liver failure effectively to improve quality of life, to prolong survival, and to provide a bridge to liver transplantation. Once a patient who has chronic liver failure develops hepatic decompensation, liver transplantation is the definitive treatment for those who qualify. Management of chronic liver failure is the focus of this article.

Ciprofloxacin in primary prophylaxis of spontaneous bacterial peritonitis: a randomized, placebo-controlled study

BACKGROUND/AIMS

Low protein concentration in ascitic fluid has been identified as a risk factor for spontaneous bacterial peritonitis (SBP). Until now, primary prophylaxis has not been recommended in these patients. The aim was to investigate the efficacy of long-term administration of ciprofloxacin to prevent SBP.

METHODS

One hundred cirrhotic patients with <1.5 g/dl of total protein in ascitic fluid were randomized prospectively, in a double blind fashion to receive ciprofloxacin 500 mg/day (n=50) or placebo (n=50) for 12 months.

RESULTS

Baseline data were similar in both groups. In the ciprofloxacin group, SBP occurred almost four times less frequently than in the placebo group but it was not statistically significant. The probability of survival at 12 months was significantly higher in patients receiving ciprofloxacin (86% versus 66%) (p<0.04). SBP and sepsis were the most frequent causes of death in the placebo group whereas gastrointestinal bleeding was responsible for the most deaths in the ciprofloxacin group. The probability of remaining free of bacterial infections was higher in patients receiving ciprofloxacin (80% versus 55%) (p=0.05).

CONCLUSIONS

Patients with cirrhosis and low protein concentration in ascitic fluid are candidates to receive long-term prophylaxis to reduce the risk of infections and improve survival.

Primary prophylaxis of spontaneous bacterial peritonitis delays hepatorenal syndrome and improves survival in cirrhosis

BACKGROUND & AIMS

Norfloxacin is highly effective in preventing spontaneous bacterial peritonitis recurrence in cirrhosis, but its role in the primary prevention of this complication is uncertain.

METHODS

Patients with cirrhosis and low protein ascitic levels (<15 g/L) with advanced liver failure (Child-Pugh score > or = 9 points with serum bilirubin level > or = 3 mg/dL) or impaired renal function (serum creatinine level > or = 1.2 mg/dL, blood urea nitrogen level > or = 25 mg/dL, or serum sodium level < or = 130 mEq/L) were included in a randomized controlled trial aimed at comparing norfloxacin (35 patients) vs placebo (33 patients) in the primary prophylaxis of spontaneous bacterial peritonitis. The main end points of the trial were 3-month and 1-year probability of survival. Secondary end points were 1-year probability of development of spontaneous bacterial peritonitis and hepatorenal syndrome.

RESULTS

Norfloxacin administration reduced the 1-year probability of developing spontaneous bacterial peritonitis (7% vs 61%, P < .001) and hepatorenal syndrome (28% vs 41%, P = .02), and improved the 3-month (94% vs 62%, P = .003) and the 1-year (60% vs 48%, P = .05) probability of survival compared with placebo.

CONCLUSIONS

Primary prophylaxis with norfloxacin has a great impact in the clinical course of patients with advanced cirrhosis. It reduces the incidence of spontaneous bacterial peritonitis, delays the development of hepatorenal syndrome, and improves survival.

Pretransplant management of the cirrhotic patient

Cirrhosis is the twelfth commonest cause of death in the United States, with more than 27,000 deaths and more than 421,000 hospitalizations annually. Currently, there are more than 17,000 patients awaiting liver transplantation in the United States across the 11 United Network for Organ Sharing regions. Approximately 10% of such patients will die awaiting transplantation.

Prevention and treatment of infections in patients with cirrhosis

Patients with cirrhosis have altered immune defenses and are considered immunocompromised individuals. Changes in gut motility, mucosal defense and microflora allow for translocation of enteric bacteria into mesenteric lymph nodes and the blood stream. Additionally, the cirrhotic liver is ineffective at clearing bacteria and associated endotoxins from the blood thus allowing for seeding of the sterile peritoneal fluid. Thus, hospitalised cirrhotic patients, particularly those with gastrointestinal hemorrhage, are at high risk of developing bacterial infections, the most common being spontaneous bacterial peritonitis. Given the significant morbidity and mortality associated with spontaneous bacterial peritonitis and the fact that half of the cases are community acquired, all hospitalised cirrhotic patients should have a diagnostic paracentesis to exclude infection. Those admitted with gastrointestinal bleed and a negative paracentesis require short-term prophylaxis with norfloxacin. A third generation cephalosporin is the treatment of choice for spontaneous bacterial peritonitis and, once the acute infection is resolved, secondary prophylaxis with oral norfloxacin is warranted. Patients who develop renal dysfunction at the time of active infection have the highest mortality and require adjunctive albumin therapy. This article reviews the pathogenesis of SBP, the evidence behind the antibiotics used, the rationale for adjunctive albumin therapy in the setting of acute renal failure, and the role of prophylactic antibiotics in specific high-risk populations.

Diagnostic value of two reagent strips (Multistix 8 SG and Combur 2 LN) in cirrhotic patients with spontaneous bacterial peritonitis and symptomatic bacterascites

OBJECTIVE

Spontaneous bacterial peritonitis is a life-threatening complication in patients with liver cirrhosis requiring a rapid diagnosis. We have tested two reagent strips, Multistix 8 SG and Combur 2 LN for bedside diagnosis of spontaneous bacterial peritonitis and symptomatic bacterascites, a variant of spontaneous bacterial peritonitis.

METHODS

Responses of the two strips in colorimetric scale were compared with results given by cyto-bacteriological analysis of ascitic fluid. Results with positivity in grades 1 and 2 of colorimetric scale were analyzed.

RESULTS

Four hundred and forty three paracentesis were performed in 116 patients including 46 samples of ascitic fluid with spontaneous bacterial peritonitis occurring in 25 patients and 20 samples of ascitic fluid with symptomatic bacterascites occurring in 17 patients. Forty two percent of spontaneous bacterial peritonitis were culture-negative neutrocytic ascites, gram-positive pathogens and enterobacteriaceae were responsible for 36% and 21% episodes of spontaneous bacterial peritonitis and 71% and 29% episodes of symptomatic bacterascites respectively. Fifty seven percent of spontaneous bacterial peritonitis had polymorphonuclear cell count<1000/mm3. For spontaneous bacterial peritonitis diagnosis, grade 1 positive Multistix and Combur tests had a sensitivity of 69.6% and 80.4% respectively, and a negative predictive value of 96% and 97.3%. Grade 2 positivity increased specificity to 98% and 99.2% and positive predictive value to 75% and 91% for the two strips respectively. Grade 1 positive tests had a sensitivity of 100% and 90% and a negative predictive value of 100% and 99.4% respectively for diagnosis of spontaneous bacterial peritonitis with polymorphonuclear count > 1000/mm3. For symptomatic bacterascites diagnosis, grade 1 positive tests had a sensitivity of 22.4% and 44.4% respectively and a negative predictive value of 96% and 97%.

CONCLUSION

Although Combur had a higher sensitivity than Multistix for the diagnosis of spontaneous bacterial peritonitis, sensitivity of the two strips remains low with polymorphonuclear cell count<1000/mm3. Grade 2 positive Combur test had an acceptable positive predictive value. Sensitivity of both strips is insufficient for diagnosis of symptomatic bacterascites. Rapid cyto-bacteriological analysis of ascitic fluid remains necessary for diagnosis of these complications.

Prognostic significance of infection acquisition sites in spontaneous bacterial peritonitis: nosocomial versus community acquired

Spontaneous bacterial peritonitis (SBP) is an ascitic fluid infection as a complication of end stage liver disease. The outcome is related to the severity of hepatorenal function, gastrointestinal bleeding, and many others; however it is not well known whether the infection acquisition sites have an effect on the prognosis of SBP. In order to identify the prognostic significance of the acquisition sites, we studied 106 patients who were diagnosed as culture positive SBP between October 1998 and August 2003. Thirty-two episodes were nosocomial and 74 were community acquired. Gram-negative bacilli such as Escherichia coli were dominant in both of the nosocomial and community-acquired SBPs. Despite significantly higher resistance to cefotaxime in nosocomial isolates compared to community-acquired isolates (77.8% vs. 13.6%, p=0.001), no difference was found regarding short or long term prognosis. Infection acquisition sites were not related to short or long term prognosis either. Shock, gastrointestinal bleeding and renal dysfunction were related to short term prognosis. Only Child-Pugh class C was identified as an independent prognostic factor of long-term survival.

Spontaneous bacterial peritonitis: a therapeutic update

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.

Clinical features and outcome of spontaneous bacterial peritonitis in HIV-infected cirrhotic patients: a case-control study

The aim of this study was to evaluate the clinical characteristics and outcome of spontaneous bacterial peritonitis, a serious complication in patients with cirrhosis and ascites, in an HIV-infected cirrhotic population. Thirty-five HIV-infected cirrhotic patients who developed spontaneous bacterial peritonitis during a 12-year period were compared with 70 non-HIV-infected cirrhotic subjects. Patients were matched according to the date of the first episode of spontaneous bacterial peritonitis. A bacteriological diagnosis was made in 37 of 47 (79%) and in 50 of 97 (52%) episodes in the HIV group and in the non-HIV group, respectively (p=0.003), and Streptococcus pneumoniae was isolated more frequently in the HIV group (22 vs. 8%, p=0.02). Median survival after the initial diagnosis of spontaneous bacterial peritonitis was 2.9 and 14.0 months in the HIV group and non-HIV group, respectively. Age (hazard ratio [HR] 1.04; 95%CI 1.01-1.07), male sex (HR 2.55; 95%CI 1.34-4.83), Child-Pugh score at first spontaneous bacterial peritonitis episode (HR 1.29; 95%CI 1.10-1.54), renal impairment at first spontaneous bacterial peritonitis episode (HR 2.61; 95%CI 1.49-4.62), and HIV infection (HR 9.81; 95%CI 4.03-23.84) were independently associated with higher long-term mortality after the first diagnosis of spontaneous bacterial peritonitis. In conclusion, HIV-infected cirrhotic patients with spontaneous bacterial peritonitis have a higher rate of bacteriological diagnosis and a more frequent pneumococcal etiology than non-HIV-infected subjects. Life expectancy in these patients, once spontaneous bacterial peritonitis has developed, is poor. These data are particularly relevant for determining the optimal time for liver transplantation in this population.

Perméabilité intestinale et cirrhose

Patients with cirrhosis are at increased risk of developing infections due to bacterial translocation. This process depends on three principal factors: bacterial overgrowth, immunodepression, and altered intestinal permeability. Intestinal barrier functions may be disturbed in cirrhosis, related to the toxic effects of alcohol (on mucosa and biological membranes) and portal hypertensive enteropathy. Few studies on the assessment of intestinal permeability in cirrhotic patients are available, and contradictory results may be explained by methodological differences. However, four studies using a differential sugar absorption test (lactulose-mannitol test, a combination of an oligosaccharide and a monosaccharide) showed an increased intestinal permeability in cirrhotic patients. The recurrence of spontaneous bacterial peritonitis can be appreciated only by one similar case history, a low rate of protides in ascites (<10 g/L), bilirubinemia > 55 micromol/L, and thrombocytopenia<98.000/mm3. These results suggest that primary antibiotherapy prophylaxis should be recommended, but this recommendation is limited by the risk of bacterial resistant selection and by the fact that no patient survival benefits was shown. Intestinal permeability could be another predictive factor to justify preventive antibiotherapy; but more studies are needed and methods should be standardized (technique used to measure permeability, patient groups involved).

Trimethoprim-sulfamethoxazole versus norfloxacin in the prophylaxis of spontaneous bacterial peritonitis in cirrhosis

BACKGROUND

The prognosis of patients with chronic liver disease and spontaneous bacterial peritonitis is poor, being of great importance its prevention.

AIM

To compare the effectiveness of trimethoprim-sulfamethoxazole versus norfloxacin for prevention of spontaneous bacterial peritonitis in patients with cirrhosis and ascites.

PATIENTS AND METHODS

Fifty seven patients with cirrhosis and ascites were evaluated between March 1999 and March 2001. All of them had a previous episode of spontaneous bacterial peritonitis or had ascitic fluid protein concentration < or = 1 g/dL and/or serum bilirubin > or = 2.5 mg/dL. The patients were randomly assigned to receive either 800/160 mg/day of trimethoprim-sulfamethoxazole 5 days a week or 400 mg of norfloxacin daily. The mean time of observation was 163 days for the norfloxacin group and 182 days for the trimethoprim-sulfamethoxazole group. In the statistical analysis, differences were considered significant at the level of 0.05.

RESULTS

According to the inclusion criteria, 32 patients (56%) were treated with norfloxacin and 25 (44%) with trimethoprim-sulfamethoxazole. Spontaneous bacterial peritonitis occurred in three patients receiving norfloxacin (9.4%) and in four patients receiving trimethoprim-sulfamethoxazole (16.0%). Extraperitoneal infections occurred in 10 patients receiving norfloxacin (31.3%) and in 6 patients receiving trimethoprim-sulfamethoxazole (24.0%). Death occurred in seven patients (21.9%) who received norfloxacin and in five (20.0%) who received trimethoprim-sulfamethoxazole. Side effects occurred only in the trimethoprim-sulfamethoxazole group.

CONCLUSION

In spite of the reduced number of patients and time of observation, trimethoprim-sulfamethoxazole and norfloxacin were equally effective in spontaneous bacterial peritonitis prophylaxis, suggesting that trimethoprim-sulfamethoxazole is a valid alternative to norfloxacin.

Pharmacologic treatment of portal hypertension in the prevention of community-acquired spontaneous bacterial peritonitis

INTRODUCTION

Given that beta-blockers reduce the incidence of bacterial translocation in cirrhotic rats, the aim of this study was to compare the long-term incidence of spontaneous bacterial peritonitis in cirrhotic patients submitted to pharmacologic versus endoscopic treatment to prevent variceal rebleeding.

PATIENTS AND METHODS

Two hundred and thirty patients with variceal hemorrhage were included in two previous randomized trials performed to compare the efficacy of medication (nadolol plus isosorbide mononitrate, n=115) versus endoscopic treatment (n=115) with sclerotherapy or ligation for the prevention of rebleeding.

RESULTS

The mean follow-up was 23+/-1.4 months. The characteristics of the patients and the number of patients on long-term prophylaxis with norfloxacin were similar in both groups. The incidence of spontaneous bacterial peritonitis was lower in the medication group (9 versus 14.7%, P=NS). The probability of spontaneous bacterial peritonitis was also lower in the medication group (6 versus 12% at 1 year, 22 versus 36% at 5 years; P=0.08), due to a significantly lower probability of community-acquired spontaneous bacterial peritonitis in this group (1 versus 10% at 1 year, 18 versus 32% at 5 years; P=0.02). Patients with no hemodynamic response to therapy had a significantly higher probability to develop community-acquired spontaneous bacterial peritonitis during follow-up than hemodynamic responders (P<0.03). Long-term probability of developing community-acquired spontaneous bacterial peritonitis is lower in patients submitted to pharmacologic treatment for preventing variceal rebleeding than in those submitted to endoscopic treatment.

CONCLUSION

Long-term pharmacologic prophylaxis of variceal rebleeding contributes to the prevention of community-acquired spontaneous bacterial peritonitis.

Ascites and spontaneous bacterial peritonitis in patients with liver cirrhosis

Liver cirrhosis is a frequent phenomenon in chronic liver diseases such as hepatitis B, hepatitis C, alcohol-related liver damage, autoimmune hepatitis and hemochromatosis. Ascites is the most frequent complication of cirrhosis. We discuss pathogenesis, diagnosis and state-of-the-art clinical management of ascites with emphasis on recent promising developments, such as covered transjugular intrahepatic portosystemic shunt (TIPS). Spontaneous bacterial peritonitis occurs in up to 10% of patients with ascites because of bacterial overgrowth with translocation through the increased permeable small intestinal wall and impaired defence mechanisms. The addition of albumin to standard antibiotic therapy may decrease mortality of spontaneous bacterial peritonitis by decreasing the incidence of renal insufficiency. Patients with coexistent marked hyperbilirubinaemia or pre-existent renal impairment could benefit from adjuvant albumin. Probiotics (bacterial food supplements) have been claimed to improve the state of underlying liver disease and may be useful in the primary and secondary prevention of spontaneous bacterial peritonitis.

Long-Term Prophylaxis of Spontaneous Bacterial Peritonitis in Patients with Cirrhosis

OBJECTIVE:

To review the literature regarding long-term prophylaxis of spontaneous bacterial peritonitis (SBP) in patients with cirrhosis.

DATA SOURCES:

A MEDLINE (1967–September 2004) and bibliographic search of the English-language literature was conducted using the search terms spontaneous bacterial peritonitis, cirrhosis, antimicrobial, and prophylaxis.

DATA SYNTHESIS:

Long-term antimicrobial prophylaxis has been shown to decrease recurrent SBP in cirrhotics with a prior episode. Prophylaxis in patients with low ascitic fluid protein has also been shown to reduce the incidence of SBP; however, studies are too in-homogeneous to identify subgroups that benefit the most.

CONCLUSIONS:

Long-term antimicrobial therapy should be considered for secondary prophylaxis of SBP. Studies should be done to confirm this benefit and identify subsets of patients with low ascitic fluid protein who clearly benefit.

Norfloxacin and cisapride combination decreases the incidence of spontaneous bacterial peritonitis in cirrhotic ascites

BACKGROUND

Spontaneous bacterial peritonitis (SBP) is a serious complication of cirrhosis with ascites, having high recurrence despite antibiotic prophylaxis. Small bowel dysmotility and bacterial overgrowth have been documented to be related to SBP. The purpose of the present paper was (i) to study whether addition of a prokinetic agent to norfloxacin ameliorates the development of SBP in high-risk patients; and (ii) to identify risk factors for SBP development.

METHODS

A prospective, single blinded, randomized controlled trial was conducted in high-risk cirrhotic patients with ascites who had either recovered from an episode of SBP or who had low ascitic fluid protein. Norfloxacin 400 mg once daily (group I) or norfloxacin 400 mg once daily with cisapride 20 mg twice a day (group II) was given and occurrence of side-effects of therapy and mortality were recorded.

RESULTS

Of the 94 patients, 48 (51%) were in group I, and 46 (49%) in group II. The actuarial probability of developing SBP at 12 month in group I was 56.8% and in group II, 21.7% (P = 0.026). Treatment failure was observed in five patients (10%) in group I and none in group II (P = 0.003). The actuarial probability of death at 18 months was 20.6% in group I and 6.2% in group II (P = 0.1). Low serum albumin, low ascitic fluid protein and alcoholic cirrhosis were related to development of SBP (P < 0.05). Additionally, low serum albumin (2.8 g/dL), gastrointestinal bleeding, alcoholic cirrhosis and low ascitic fluid protein were significantly associated with multiple occurrences of SBP.

CONCLUSIONS

Prophylaxis with norfloxacin and cisapride significantly reduces the incidence of SBP in high-risk cirrhosis patients; low serum albumin, low ascitic fluid protein and alcoholic cirrhosis predispose to the development of SBP in high-risk cirrhosis patients; and low ascitic fluid protein should also be considered as a risk factor for the development of SBP requiring prophylaxis.

[Primary peritonitis in previously healthy children]

INTRODUCTION

Primary peritonitis occurs rarely in childhood, affecting mainly children with nephrosis or liver disease and only rarely occurring in previously healthy children. The aim of this case report is to describe the clinical features and natural course of primary peritonitis in six previously healthy children and to review the literature on the topic.

MATERIAL AND METHOD

The clinical features and course of primary peritonitis in six previously healthy children are described. The diagnosis was made at laparotomy, which showed no intraabdominal findings, such as intestinal perforation.

RESULTS

Presentation was acute and all the patients presented within 24 h of onset of symptoms. The most common presenting features were fever (100 %) and abdominal pain (100 %). Leucocytosis (> 15,000/mm3) was observed in four patients (66 %). Microorganisms were isolated from peritoneal fluid in four patients (Escherichia coli in two, Streptococcus pneumoniae in one and Gram-negative bacteria in one). Recovery was rapid and no postoperative complications were observed.

CONCLUSION

Primary peritonitis in patients without underlying causes is clinically indistinguishable from acute appendicitis and diagnosis is usually made at surgery. The hallmarks of therapy are antibiotics and prompt exploratory laparotomy with appendectomy and the prognosis is good.

Usefulness of routine analysis of ascitic fluid at the time of therapeutic paracentesis in asymptomatic outpatients

AIM

The guidelines of the American Association for the Study of Liver Diseases recommend performing exploratory paracentesis on each patient with cirrhosis and chronic ascites. The aim of the study was to evaluate the prevalence of spontaneous bacterial peritonitis and culture-negative neutrocytic ascites in a large population of consecutive asymptomatic cirrhotic ascitic ambulatory patients.

METHODS

Patients with cirrhosis and tense ascites hospitalized from January to September 2000 in 5 hepatogastroenterology units prospectively underwent an exploratory paracentesis with cytobacteriological, biochemical and bedside inoculation into aerobic and anaerobic blood culture bottles. Patients studied were not receiving antibiotics except for norfloxacin and had no obvious sign of infection such as fever or hypothermia, chills, unusual abdominal tenderness, de novo or worsening hepatic encephalopathy, recent gastrointestinal bleeding, acute renal failure or marked arterial hypotension. Clinical and biological findings and ascitic fluid cytological and bacteriological results were evaluated at each exploratory paracentesis. The results are given in mean +/- standards deviations with range.

RESULTS

Sixty-seven cirrhotic patients (48M/19F, mean age 59 +/- 9 years) had 270 therapeutic paracenteses, preceded by an exploratory aspiration. Fifty-nine patients (88%) had alcoholic cirrhosis. Twenty-five patients (37.3%) received norfloxacin. At first paracentesis 41 (61.2%) and 26 (38.8%) patients were class B and C respectively according to the Child-Pugh classification; the mean Child-Pugh score was 9 +/- 1.5. None had suspicion of infection. The mean number of paracenteses was 5 +/- 4.3 per patient; 59.6% of the paracenteses (161) were compensated with human albumin. Ascitic protein concentration was 17.5 +/- 8.6 g/l, ascitic fluid cell count and number of neutrophils were 127 +/- 155/mm3 and 5.9 +/- 14/mm3 (0-60), respectively. No patient had spontaneous bacterial peritonitis nor culture-negative neutrocytic ascites; 10 cases of monomicrobial bacterascites were observed, all with commensal germs.

CONCLUSIONS

In the absence of obvious signs of infection, the prevalence of spontaneous bacterial peritonitis and culture-negative neutrocytic ascites in asymptomatic cirrhotic outpatients with ascites is near 0%. Moreover, for 100 large volume paracenteses, not performing exploratory paracentesis corresponds to a savings of 5,500 euros, without risk for these patients.

Diagnosis of spontaneous bacterial peritonitis in cirrhotic patients by use of two reagent strips

OBJECTIVE

Spontaneous bacterial peritonitis (SBP) is one of the potentially life-threatening complications in ascitic cirrhotic patients with a mortality rate ranging between 30 and 50%. The improved survival might be explained by a more rapid diagnosis and treatment. The aim of our study was to assess the utility of two reagent strips, the Multistix test and the Combur(2) test LN, for the rapid diagnosis of SBP.

METHODS

Thirty-one unselected consecutive cirrhotic patients with ascites were included and a total of 100 paracenteses were performed. All ascitic fluid was analysed with the two reagent strips, leucocyte and polymorphonuclear (PMN) leucocyte cell count and blood-bottle culture if the strips were positive. The strips were considered positive if the colour turned to purple: i.e. grade 3 or 4 for the Multistix test and 2 or 3 for the Combur(2) test LN on a colorimetric scale.

RESULTS

We diagnosed nine infections of which four were SBP defined by PMN > or = 250 cells/mm(3) and a positive culture in ascitic fluid and five were culture negative neutrocytic ascites (PMN > or = 250 cells/mm(3) and a negative culture). The results of the two strips were concordant and were negative in only one SBP. The sensitivity, specificity, positive and negative predictive values of these two strips were 89%, 100%, 100% and 99%, respectively.

CONCLUSIONS

These reagent strips are very sensitive and specific for the diagnosis of SBP, allowing immediate commencement of empirical antibiotic therapy. These strips should be used for the diagnosis of SBP, especially on an emergency basis.

[Spontaneous bacterial peritonitis]

Spontaneous bacterial peritonitis occurs in 30% of patients with ascites due to cirrhosis leading to high morbidity and mortality rates. The pathogenesis of spontaneous bacterial peritonitis is related to altered host defenses observed in end-stage liver disease, overgrowth of microorganisms, and bacterial translocation from the intestinal lumen to mesenteric lymph nodes. Clinical manifestations vary from severe to slight or absent, demanding analysis of the ascitic fluid. The diagnosis is confirmed by a number of neutrophils over 250/mm3 associated or not to bacterial growth in culture of an ascites sample. Enterobacteriae prevail and Escherichia coli has been the most frequent bacterium reported. Mortality rates decreased markedly in the last two decades due to early diagnosis and prompt antibiotic treatment. Third generation intravenous cephalosporins are effective in 70% to 95% of the cases. Recurrence of spontaneous bacterial peritonitis is common and can be prevented by the continuous use of oral norfloxacin. The development of bacterial resistance demands the search for new options in the prophylaxis of spontaneous bacterial peritonitis; probiotics are a promising new approach, but deserve further evaluation. Short-term antibiotic prophylaxis is recommended for patients with cirrhosis and ascites shortly after an acute episode of gastrointestinal bleeding.

Recent increase in antibiotic-resistant microorganisms in patients with spontaneous bacterial peritonitis adversely affects the clinical outcome in Korea

BACKGROUND AND AIM

Recently, antibiotic-resistant microorganisms have been increasingly noted in Korean patients with spontaneous bacterial peritonitis (SBP). The present study investigated the changing pattern of antibiotic resistance and its effects on the clinical outcome in treating SBP.

METHODS

The present study retrospectively analyzed 87 episodes of SBP in 1995, 222 in 1998, and 271 in 1999. The isolated microorganisms and their antibiotic susceptibility were compared, and prognostic factors for survival were analyzed.

RESULTS

Microorganisms were isolated in 41% of total episodes. The three most frequently isolated organisms were Escherichia coli (48%), Klebsiella pneumoniae (15%), and Aeromonas (8%). Strains that were resistant to cefotaxime in Gram-negative bacilli significantly increased from 7% in 1995 to 28% in 1999, and those to ciprofloxacin increased from 10% to 32%. Treatment failure also increased from 6% to 23%. Combined hepatocellular carcinoma and SBP caused by extended-spectrum beta-lactamase-producing strains were two independent prognostic factors for survival.

CONCLUSION

Considering the increase in antibiotic-resistant microorganisms related to SBP, measures to prevent the in-hospital spread of resistant strains and the indiscriminate use of antibiotics should be instituted more stringently.

Role of immunosuppression in the development of quinolone-resistant Escherichia coli spontaneous bacterial peritonitis and in the mortality of E. coli spontaneous bacterial peritonitis

BACKGROUND

Norfloxacin decreases the incidence of spontaneous bacterial peritonitis in cirrhotics, but promotes the appearance of quinolone-resistant Escherichia coli.

AIM

: To define the characteristics of quinolone-resistant E. coli spontaneous bacterial peritonitis.

METHODS

E. coli-positive ascitic fluid cultures were identified during a 6-year period. Data on quinolone-sensitive and quinolone-resistant E. coli spontaneous bacterial peritonitis were compared.

RESULTS

One hundred and two E. coli-positive ascitic fluid cultures were detected. Cirrhotics accounted for 67 cases. Spontaneous bacterial peritonitis was found in 47 of the 67 (70%) cases [35 (74%) caused by quinolone-sensitive and 12 (26%) caused by quinolone-resistant E. coli]. Norfloxacin prophylaxis was higher in the quinolone-resistant group (92% vs. 6%, P < 0.001). Compared with patients with quinolone-sensitive E. coli spontaneous bacterial peritonitis, those with quinolone-resistant E. coli spontaneous bacterial peritonitis showed a higher prevalence of associated immunosuppressive factors (immunosuppressive drugs, human immunodeficiency virus infection or cancer) (92% vs. 20%, P < 0.001). Steroid therapy was independently associated with quinolone-resistant E. coli spontaneous bacterial peritonitis (odds ratio, 49; 95% confidence interval, 3.4-699; P = 0.004). The Child-Pugh score (P = 0.03), immunosuppression (P = 0.02) and renal failure (P = 0.01) were independent predictors of E. coli spontaneous bacterial peritonitis-related mortality.

CONCLUSIONS

Associated immunosuppression is an important co-factor for the development of quinolone-resistant E. coli spontaneous bacterial peritonitis and for E. coli spontaneous bacterial peritonitis-related mortality.

Low complement levels and opsonic activity in hepatic hydrothorax: its relationship with spontaneous bacterial empyema

GOALS

To analyze the pleural fluid factors that might cause spontaneous bacterial empyema (SBEM) in patients with cirrhotic hydrothorax.

BACKGROUND

Pathogenic mechanism of SBEM of cirrhotic patients is probably similar to that of spontaneous bacterial peritonitis, but local factors affecting pleural fluid have not been studied.

STUDY

Determination of C3, C4, and opsonic activity levels of pleural fluid in a cohort of patients with pleural effusions of different causes.

RESULTS

Forty-eight patients had hepatic hydrothorax; 8, heart failure and 45, exudates (9, tuberculosis; 21, malignancies; 10, other). Of the 48 cirrhotic patients, 15 developed SBEM on admission. The pleural fluid of cirrhotic patients showed significantly lower levels of total protein, complement, and opsonic activity than did the fluids of patients with other causes of SBEM. Patients who developed SBEM had lower concentrations of pleural fluid total protein and C3 and had a higher Child-Pugh score than patients who did not develop the infection.

CONCLUSION

Cirrhotic patients with hepatic hydrothorax have lower pleural fluid opsonic activity and C3 levels than those found in the pleural fluid of patients with other causes. Patients who develop SBEM have lower levels of pleural fluid C3, pleural fluid total protein, and a higher Child-Pugh score than those who do not develop SBEM.

Spontaneous Bacterial Peritonitis

Spontaneous bacterial peritonitis (SBP) is the prototypical ascitic fluid infection occurring in patients with advanced liver disease and ascites. The key to successful treatment of SBP is a knowledge of appropriate antibiotic regimens and an understanding of the setting in which infection develops, particularly those individuals at high risk for infection. A high index of suspicion should lead to early diagnostic paracentesis and ascitic fluid analysis. Treatment of SBP involves the use of non-nephrotoxic broad-spectrum antibiotics expected to cover the typical bacterial flora associated with SBP. SBP typically involves infection with a single organism, with Escherichia coli, Klebsiella spp, and Streptococcus spp responsible for nearly three fourths of cases. The treatment of choice is cefotaxime 2 g given intravenously every 8 hours for a total of 5 days. The antibiotic regimen is adjusted based on the results of ascitic fluid cultures. Other antibiotic regimens for SBP are less well studied. Given the significant morbidity and mortality rates associated with SBP, efforts to prevent its development and recurrence with antibiotic prophylaxis are warranted. The most extensively studied form of prophylaxis involves selective intestinal decontamination (SID) with the oral fluoroquinolone norfloxacin. Individuals with low-protein ascites (ascitic fluid total protein < 1g/dL) benefit from SID with norfloxacin 400 mg daily during times of hospitalization. Long-term primary prophylaxis during outpatient management of individuals awaiting liver transplantation with severe ascites and advanced liver failure should also be considered. Patients with cirrhosis and upper gastrointestinal bleeding should receive norfloxacin 400 mg twice daily for 1 week following their bleed. Those individuals surviving an episode of SBP should be treated with norfloxacin 400 mg daily until the risk of SBP is removed by definitive resolution of the ascites or liver transplantation surgery. Although the infection-related mortality associated with SBP has decreased to less than 10%, hospitalization-related mortality remains as high as 30% as a result of the severe underlying liver disease in which the infection arises and the marked generation of cytokines and nitric oxide resulting from the infection. Recently, the simultaneous administration of intravenous albumin and antibiotics for SBP has been shown to result in the decreased development of azotemia and hospitalization-related mortality. Further improvement in the outcomes of SBP will require treatments targeting this cytokine cascade rather than the development of more potent antibiotics.

[Prevalence and prognosis of spontaneous bacterial peritonitis. Experience in patients from a general hospital in Porto Alegre, RS, Brazil (1991-2000)]

BACKGROUND

Spontaneous bacterial peritonitis is a frequent complication that occurs in patients with cirrhosis and ascites and has a recurrence rate of 70% in 1 year. In addition, this infection determines a poor short and long-term prognosis and a shorter survival rate.

AIMS

Evaluate the prevalence of spontaneous bacterial peritonitis in cirrhotic patients with ascites and the effect of its occurrence on the survival.

PATIENTS/METHODS

One thousand and thirty admissions of patients with cirrhosis and ascites were reviewed and 114 episodes of spontaneous bacterial peritonitis were documented in 94 patients. The ascitic analysis was accomplished in all patients. The diagnosis of this infection was established when the ascitic fluid polymorphonuclear count was equal or above 250 cells mm3.

RESULTS

The prevalence of this infection was 11.1% and the mortality rate 21.9%. Spontaneous bacterial peritonitis was community acquired in 61.4% and hospital acquired in 37.7%. The mortality rate was 18.6% and 27.9%, respectively. The infection resolved in 91.1% of the episodes by the analysis of ascitic fluid at 48 hours on antibiotics. The use of prophylactic antibiotics was documented in 22.3% of the episodes, but there are not significant differences on the mortality or type of bacteria isolated when comparing the patients with or without this treatment.

CONCLUSIONS

Spontaneous bacterial peritonitis is a common complication in patients with cirrhosis and ascites and determines a worse prognosis, mainly when related with absence of initial response to antibiotics.

Bacterial infections in cirrhosis: epidemiological changes with invasive procedures and norfloxacin prophylaxis

The extensive use of invasive procedures and of long-term norfloxacin prophylaxis in the management of cirrhotic patients may have influenced the epidemiology of bacterial infections in cirrhosis. We conducted a prospective evaluation of all bacterial infections diagnosed in patients with cirrhosis in a Liver Unit between April 1998 and April 2000. A total of 405 patients presented 572 bacterial infections in 507 admissions. Spontaneous bacterial peritonitis was the most frequent infection (138 cases). Gram-positive cocci were responsible for 53% of total bacterial infections in the study, being the main bacteria isolated in nosocomial infections (59%). Patients requiring treatment in an intensive care unit and those submitted to invasive procedures presented a higher rate of infections caused by gram-positive cocci (77% vs. 48%, P <.001 and 58% vs. 40%, P <.02, respectively). Fifty percent of culture-positive spontaneous bacterial peritonitis in patients on long-term norfloxacin administration (n = 93) and 16% in patients not receiving this therapy (n = 414) were caused by quinolone-resistant gram-negative bacilli, P =.01. The rate of culture-positive spontaneous bacterial peritonitis caused by trimethoprim-sulfamethoxazole-resistant gram-negative bacilli was also very high in patients on long-term norfloxacin administration (44% vs. 18%, P =.09). In conclusion, infections caused by gram-positive cocci have markedly increased in cirrhosis. This phenomenon may be related to the current high degree of instrumentation of cirrhotic patients. Quinolone-resistant spontaneous bacterial peritonitis constitutes an emergent problem in patients on long-term norfloxacin prophylaxis, with trimethoprim-sulfamethoxazole not being a valid alternative.

Review article: spontaneous bacterial peritonitis--diagnosis, treatment and prevention

Spontaneous bacterial peritonitis is a serious complication of cirrhotic ascites, arising most frequently in those with advanced liver disease. Its development leads to a further reduction in the effective arterial blood volume, and it has a mortality rate equivalent to that of a variceal bleed. However, problems remain with regard to the identification and optimal treatment of spontaneous bacterial peritonitis. Several important studies and consensus documents on the condition have recently been published which aid in the identification of patients at risk and help to guide therapy. In this review, we discuss these publications and address the issues of diagnosis, treatment and both primary and secondary prophylaxis of spontaneous bacterial peritonitis in the light of recent data.

Small intestinal bacterial overgrowth in patients with cirrhosis: prevalence and relation with spontaneous bacterial peritonitis

OBJECTIVES

The significance of small intestinal bacterial overgrowth in patients with cirrhosis is not fully understood and its diagnostic criteria are not uniform. We examined the association of small intestinal bacterial overgrowth with spontaneous bacterial peritonitis and compared various microbiological criteria.

METHODS

Jejunal secretions from 70 patients with cirrhosis were cultivated quantitatively and classified according to various definitions. Clinical characteristics of patients were evaluated and the incidence of spontaneous bacterial peritonitis was monitored during a 1-yr follow-up.

RESULTS

Small intestinal bacterial overgrowth, defined as > or = 10(5) total colony-forming units/ml jejunal secretions, was present in 61% of patients. Small intestinal bacterial overgrowth was associated with acid-suppressive therapy (p = 0.01) and hypochlorhydria (p < 0.001). Twenty-nine patients with persistent ascites were observed. Six episodes of spontaneous bacterial peritonitis occurred after an average 12.8 wk. Occurence of spontaneous bacterial peritonitis correlated with ascitic fluid protein concentration (p = 0.01) and serum bilirubin (p = 0.04) but not with small intestinal bacterial overgrowth (p = 0.39). Its association with acid-suppressive therapy was of borderline significance (hazard ratio = 7.0, p = 0.08).

CONCLUSIONS

Small intestinal bacterial overgrowth in cirrhotic patients is associated with acid-suppressive therapy and hypochlorhydria, but not with spontaneous bacterial peritonitis. The potential role of acid-suppressive therapy in the pathogenesis of spontaneous bacterial peritonitis merits further studies.

Clinical management of ascites and its complications

Development of ascites is a poor prognostic sign with a 1 year mortality rate of up to 50%. Cirrhotic patients who develop ascites should therefore be evaluated for liver transplantation. Even though current therapies of ascites are not associated with a survival benefit, the elimination of ascites will improve quality of life and prevent the development of lethal complications such as SBP and HRS. Therapy of ascites should be directed at correcting the pathophysiologic abnormalities that lead to ascites formation, namely sodium retention, reduced effective arterial blood volume, and sinusoidal hypertension.

Ascitic fluid analysis: the role of biochemistry and haematology

In specific settings, biochemical and haematological analysis of ascitic fluid may provide answers to important clinical questions. This review seeks to outline the value and limitations of ascitic fluid analysis and the main clinical scenarios in which it may be useful.

Spontaneous bacterial peritonitis--in-hospital mortality, predictors of survival, and health care costs from 1988 to 1998

OBJECTIVES

Spontaneous bacterial peritonitis (SBP) is a complication of end-stage liver disease with a reported mortality of 30-50%. In this study, we investigated the outcome of all patients admitted to Maryland hospitals with SBP from 1988 to 1998. Main outcomes considered included trends in survival rates over time, changes in the length of stay, total health care costs, and variables that predicted survival rates.

METHODS

We used the Maryland Health Services Cost Review database of all patients admitted to Maryland hospitals with an International Classification of Diseases (Ninth Revision) code for both peritonitis and cirrhosis from 1988 to 1998.

RESULTS

A total of 348 patients were admitted with an in-hospital mortality of 32.6%; there was no significant change in mortality rate during this period. The survival rate was similar in the university and community hospitals. In the logistic regression analysis, age (p = 0.001) and intensive care unit stay (p = 0.0001) were found to significantly influence the survival rates; those patients who had an intensive care unit stay were 2.8 times more likely to die than those who did not have an intensive care unit stay, controlling for age. The average length of hospital stay remained unchanged (13.5 +/- 12.7 days) during the study period. Although the median hospital charge (excluding professional fees) remained unchanged, mean inflation-adjusted charges increased from $7,897 in 1988 to $25,902 in

CONCLUSIONS

The mortality rate associated with SBP has remained unchanged over an 11-yr period from 1988 to 1998. The mortality showed a strong correlation with age and intensive care unit stay. The median hospital stay and median charges remained unchanged during this period, but mean costs increased significantly because of increased use of resources by a few patients.

Spontaneous fungal peritonitis (Candida glabrata) in a patient with cirrhosis

We report a case of spontaneous fungal peritonitis in a patient with cirrhosis. A 70-year-old woman with cirrhosis secondary to autoimmune hepatitis was admitted with fever and abdominal distention. Paracentesis revealed neutrocytosis, and despite appropriate antibacterial coverage, no clinical improvement was noted and the ascitic fluid white cell count increased on repeat paracentesis. Two consecutive ascitic fluid cultures grew Candida glabrata, and antifungal therapy with amphotericin was initiated, pending sensitivity of the isolate. Because of worsening renal function, amphotericin was discontinued and itraconazole was started, as sensitivity of the isolate was then available. Antifungal therapy resulted in resolution of ascitic fluid neutrocytosis and culture negativity. However, the patient's renal function continued to deteriorate, necessitating hemodialysis. Despite multiple courses of antibiotics, she died of fulminant sepsis and multiorgan failure.