1
|
Verma R, Satapathy SK, Bilal M. Procalcitonin and C-reactive protein in the diagnosis of spontaneous bacterial peritonitis. Transl Gastroenterol Hepatol 2022; 7:36. [PMID: 36300145 PMCID: PMC9468983 DOI: 10.21037/tgh-19-297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 05/12/2021] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Spontaneous bacterial peritonitis (SBP) is a serious complication of cirrhosis and is associated with high morbidity and mortality. Rapid institution of appropriate antibiotics is central to the improved patient outcome. Correctly obtaining ascites fluid for analysis has several technical and logistic limitations resulting in overuse of empiric antibiotics when patients are admitted to the hospital with suspected SBP. Procalcitonin and C-reactive protein (CRP) are non-invasive markers of infection. We conducted a study to illustrate the role of these markers in making the diagnosis of SBP in patients with cirrhosis. METHODS A total of 45 patients were enrolled in this prospective cohort study, 14 (31.1%) of which were found to have SBP. Ascitic fluid neutrophils, serum procalcitonin and CRP levels were measured prior to initiation of antibiotics and these parameters were compared between the two groups. Area under receiver operator characteristic (AUROC) curves were used to assess the diagnostic accuracy of procalcitonin and CRP in this population. We defined neutrocytic SBP group as a combination of patients who had classic SBP (positive ascitic culture and >250 neutrophils/mm3) and culture-negative neutrocytic ascites. RESULTS Serum procalcitonin (2.81±2.59 vs. 0.43±0.48 ng/mL; P=0.0032), serum CRP (60.30±44.48 vs. 22.2±23.28; P=0.0055) and ascitic fluid neutrophil levels (49.23±30.90 vs. 16.7±20.39; P=0.0064) were significantly higher in SBP group than non-SBP group. AUROC for procalcitonin (cut-off >2.0 ng/mL) was 0.75 (95% CI, 0.61-0.88), CRP (cut-off >3.0 mg/L) was 0.55 (95% CI, 0.43-0.68) and for procalcitonin combined with CRP was 0.76 (95% CI, 0.61-0.90) for diagnosing all-cause SBP. In a subgroup analysis of patients with neutrocytic SBP, AUROC for procalcitonin was 0.88 (95% CI, 0.74-1.00), CRP was 0.62 (95% CI, 0.45-0.79) and for procalcitonin combined with CRP was 0.93 (95% CI, 0.81-1.00). Addition of CRP to procalcitonin did not significantly change the AUROC for diagnosis of SBP. CONCLUSIONS Serum procalcitonin could be used as an adjunctive non-invasive biomarker in diagnosing SBP with a high degree of accuracy in cirrhotic patients. Addition of CRP does not seem to significantly increase the diagnostic accuracy of procalcitonin.
Collapse
Affiliation(s)
- Rajanshu Verma
- Transplant Hepatology/Gastroenterology fellow, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Sanjaya K. Satapathy
- Department of Transplant Surgery, Methodist University Hospital Transplant Institute/University of Tennessee Health Sciences Center, Memphis, TN, USA
- Medical Director of Liver Transplantation, Division of Hepatology, Sandra Atlas Bass Center for Liver Diseases and Liver Transplantation, Northwell Health/North Shore University Hospital, Manhasset, New York, USA
| | - Muhammad Bilal
- Department of Gastroenterology, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| |
Collapse
|
2
|
Trasolini R, Zhu K, Klemm N, Park S, Salh B. Fecal Leukocyte Esterase, an Alternative Biomarker to Fecal Calprotectin in Inflammatory Bowel Disease: A Pilot Series. GASTRO HEP ADVANCES 2022; 1:45-51. [PMID: 39129926 PMCID: PMC11307677 DOI: 10.1016/j.gastha.2021.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 10/14/2021] [Indexed: 08/13/2024]
Abstract
Background and Aims Fecal calprotectin (FC) is a noninvasive biomarker used in inflammatory bowel disease (IBD) management and risk stratification of nonspecific gastrointestinal symptoms. Leukocyte esterase is an inexpensive and widely available point-of-care inflammatory marker present on urinalysis test strips. We aim to assess the diagnostic accuracy of fecal leukocyte esterase (FLE) relative to FC and endoscopy and demonstrate its use as an alternative biomarker for IBD. Methods In this prospective cohort study, 70 patients who had FC ordered as part of standard clinical care also received FLE testing. FLE levels were compared with various FC cutoff values and endoscopy and pathology findings as the gold standard. Results As the FC cutoff increased from 50 to 500 μg/g, FLE sensitivity increased from 67% to 95% while the specificity decreased from 86% to 76%. The area under the receiver operating characteristic (AUROC) curve increased from 0.79 to 0.90. An FLE of ≥1+ had the best test characteristics. Among patients who underwent endoscopic evaluation, FLE demonstrated an identical sensitivity (75%) and specificity (86%) to FC in predicting endoscopic inflammation. AUROC was 0.80 for FLE and 0.85 for FC with an optimal cutoff of ≥2+ and 301 μg/g, respectively. When used to distinguish between patients with active IBD and no/inactive IBD, FLE had a sensitivity of 84% and specificity of 90%, comparable with the 84% and 83%, respectively, of FC. AUROC was 0.88 for FLE and 0.91 for FC with an optimal cutoff of ≥2+ and 145 μg/g, respectively. Conclusion FLE demonstrates adequate correlation and comparable accuracy with FC in predicting endoscopic inflammation and distinguishing between patients with active vs inactive IBD.
Collapse
Affiliation(s)
- Roberto Trasolini
- Department of Gastroenterology, Center for Advanced Endoscopy, Beth Israel Deaconess Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Kai Zhu
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Natasha Klemm
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sophia Park
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Baljinder Salh
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Gastroenterology, University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
3
|
Li C, Su HB, Hu JH. The periscreen strip is an accurate and rapid method to diagnose spontaneous bacterial peritonitis among patients with acute-on-chronic liver failure. Eur J Gastroenterol Hepatol 2021; 33:e206-e213. [PMID: 35048646 DOI: 10.1097/meg.0000000000002007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Leukocyte esterase reagent strips may help diagnose spontaneous bacterial peritonitis (SBP), but their effective application among patients with acute-on-chronic liver failure (ACLF) remains unknown. AIM This study aimed to assess the performance of periscreen strips in the rapid diagnosis of SBP among patients with ACLF. METHODS Periscreen strips were used to test 261 ascites samples taken from 251 inpatients with ACLF between January 2014 and June 2019. The colors of the reagent strip were divided into four colorimetric graduations ('negative', 'trace', 'small', and 'large'), among which 'trace' is used as the SBP detection threshold. The polymorphonuclear neutrophils (PMN) of ascites ≥250/mm3 was used as the gold standard for SBP diagnosis. RESULTS SBP was detected in 92 (35.2%) ascite samples. The ascites PMN count of 'negative' (32.5/mm3) was lower than those of 'trace' (248.2/mm3), 'small' (379.0/mm3), and 'large' (7426.0/mm3) (P < 0.001). The colorimetric graduations of the strips were positively correlated with ascites PMN count (r = 0.867, P < 0.001). Periscreen strips had 100% sensitivity, 91.1% specificity, 86.0% positive predictive value, 100% negative predictive value, 11.3 positive likelihood ratios, and 0 negative likelihood ratios. For patients with negative results judged by the gold standard, ascites white blood cells count [odds ratio (OR) = 1.007) and ascites PMN count (OR = 1.028) were independent predictors of false-positive cases. CONCLUSION Liver failure did not affect the diagnostic performance of periscreen strips. Therefore, these strips can efficiently and rapidly diagnose SBP among patients with ACLF.
Collapse
Affiliation(s)
- Chen Li
- Liver Failure Treatment and Research Center, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | | | | |
Collapse
|
4
|
The diagnostic accuracy of ascitic calprotectin for the early diagnosis of spontaneous bacterial peritonitis: systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2021; 33:312-318. [PMID: 32541235 DOI: 10.1097/meg.0000000000001813] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Spontaneous bacterial peritonitis (SBP) is a common complication in patients with cirrhosis and has an incidence of up to 30% in hospitalized patients. Importantly, it may raise their mortality rate up to 30%. Hence, a delayed diagnosis is associated with poor prognosis. This systematic review aims to assess the diagnostic accuracy of ascitic fluid calprotectin for the early diagnosis of SBP in patients with ascites. This study was conducted in accordance with the PRISMA statement. A systematic literature search was conducted from inception to February 2020 in the following electronic bibliographic databases: MEDLINE, Scopus, The Cochrane Library and OpenGrey. Quality Assessment of Diagnostic Accuracy Studies tool was used to assess risk of bias. Ten studies were included in the qualitative and quantitative synthesis. Hierarchical summary receiver operating characteristic curves were plotted and the summary sensitivity of a positive ascitic fluid calprotectin assessment to detect SBP was 93% [95% confidence interval (CI) 90-95%] while the summary specificity was 89% (95% CI 80-95%), irrespectively of the method used. The positive likelihood ratio and negative likelihood ratio of the test were 8.7 (95% CI 4.4-17.1) and 0.08 (85% CI 0.06-0.12). All studies showed positive correlation between ascitic calprotectin and polymorphonuclear (PMN) leukocyte count. Ascitic calprotectin appears to be an excellent alternative to PMN leucocyte count of ≥250 cells/mm3 for the diagnosis of SBP with much faster time to diagnosis. Owing to its substantially high negative predictive value, the test can accurately exclude SBP avoiding unnecessary antibiotics in suspected patients.
Collapse
|
5
|
Zheng QY, Zhang GQ. Application of leukocyte esterase strip test in the screening of periprosthetic joint infections and prospects of high-precision strips. ARTHROPLASTY 2020; 2:34. [PMID: 35236471 PMCID: PMC8796411 DOI: 10.1186/s42836-020-00053-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 10/12/2020] [Indexed: 12/19/2022] Open
Abstract
Periprosthetic joint infection (PJI) represents one of the most challenging complications after total joint arthroplasty (TJA). Despite the availability of a variety of diagnostic techniques, the diagnosis of PJI remains a challenge due to the lack of well-established diagnostic criteria. The leucocyte esterase (LE) strips test has been proved to be a valuable diagnostic tool for PJI, and its weight in PJI diagnostic criteria has gradually increased. Characterized by its convenience, speed and immediacy, leucocyte esterase strips test has a prospect of broad application in PJI diagnosis. Admittedly, the leucocyte esterase strips test has some limitations, such as imprecision and liability to interference. Thanks to the application of new technologies, such as machine reading, quantitative detection and artificial intelligence, the LE strips test is expected to overcome the limitations and improve its accuracy.
Collapse
|
6
|
Nasereslami M, Khamnian Z, Moaddab Y, Jalali Z. Diagnostic and prognostic role of ascitic fluid calprotectin level: six-month outcome findings in cirrhotic patients. Scand J Gastroenterol 2020; 55:1093-1098. [PMID: 32715845 DOI: 10.1080/00365521.2020.1794023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
AIM To assess the role of ascites calprotectin in early detection of SBP in patients with cirrhosis and to investigate its prognostic value in determination of the 6-month outcome. Methods and material: In this cross-sectional study, patients with liver cirrhosis who were consecutively referred to Imam Reza hospital, tertiary referral center in the northwest of Iran, underwent abdominal paracentesis. The samples were collected for measurement of calprotectin, albumin, total protein, WBCs, and PMNs. RESULTS The mean age of a total of 87 included patients was 56.86 (SD 16.05) years old with over half of the subjects (55.2%) being female. About 28.7% of performed paracenteses tested positive for SBP. Ascitic calprotectin was positively correlated to the PMN counts. Patients with SBP were found to have higher levels of ascites albumin, total protein, and calprotectin. Only 51 individuals survived the 6-month follow-up period and mortality outcomes were significantly related to the levels of aforementioned biochemical markers (p-value <.05). CONCLUSION Alongside with standard PMN counts, calprotectin measurement in the ascitic fluid could be used as an available test for early diagnosis of SBP. Calprotectin can also serve as a valuable prognostic marker in the evaluation of cirrhotic patients.
Collapse
Affiliation(s)
- Maryam Nasereslami
- Liver and Gastrointestinal Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Zhila Khamnian
- Liver and Gastrointestinal Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Yaghoub Moaddab
- Liver and Gastrointestinal Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Zahra Jalali
- Liver and Gastrointestinal Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| |
Collapse
|
7
|
Wu X, Luo J, Huang W, Jia B, Luo T. Role of ascitic endocan levels in the diagnosis of spontaneous bacterial peritonitis in decompensated cirrhosis. Biomarkers 2020; 25:360-366. [PMID: 32364003 DOI: 10.1080/1354750x.2020.1764107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Objective: To assess the role of ascitic endocan levels in the diagnosis of spontaneous bacterial peritonitis (SBP) in decompensated cirrhosis.Methods: Ascites samples, as well as demographic and laboratory data, were collected at admission from patients with decompensated cirrhosis. Ascitic endocan, tumour necrosis factor-α (TNF-α), and interleukin-6 (IL-6) levels were measured by ELISA. The influencing factors of SBP, the correlation of ascitic endocan with other inflammatory indicators, and the diagnostic value of ascitic endocan for SBP were analyzed.Results: A total of 167 patients were enrolled, 39 with the SBP group and 128 in the non-SBP group. Ascitic endocan, TNF-α, and IL-6 levels were significantly higher in the SBP group than in the non-SBP group (p < 0.001). Multivariate analysis demonstrated that ascitic endocan was an independent risk factor for SBP [OR = 1.006 (95% CI: 1.002-1.011); p < 0.001]. Endocan was positively correlated with ascites polymorphonuclear leukocytes, TNF-α, and IL-6. ROC curve analysis showed that ascitic endocan had an AUC of 0.805 for the diagnosis of SBP (p < 0.001) and had a sensitivity of 82.1% and specificity of 73.4% when the cut-off value was 295.011 pg/ml.Conclusions: Ascitic endocan level is an independent risk factor and a valuable diagnostic indicator for SBP in decompensated cirrhosis.
Collapse
Affiliation(s)
- Xianmei Wu
- Key Laboratory of Infectious and Parasitic Diseases in Chongqing, Department of Infectious Disease, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Junli Luo
- Key Laboratory of Infectious and Parasitic Diseases in Chongqing, Department of Infectious Disease, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wenxiang Huang
- Key Laboratory of Infectious and Parasitic Diseases in Chongqing, Department of Infectious Disease, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Bei Jia
- Key Laboratory of Infectious and Parasitic Diseases in Chongqing, Department of Infectious Disease, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Tao Luo
- Department of Geriatrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| |
Collapse
|
8
|
Liu H, Zhu P, Nie C, Ye Q, Gao Y, Liu H, Pang G, Han T. The value of ascitic neutrophil gelatinase-associated lipocalin in decompensated liver cirrhosis with spontaneous bacterial peritonitis. J Clin Lab Anal 2020; 34:e23247. [PMID: 32100329 PMCID: PMC7307354 DOI: 10.1002/jcla.23247] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 01/08/2020] [Accepted: 01/29/2020] [Indexed: 12/13/2022] Open
Abstract
Background Spontaneous bacterial peritonitis (SBP) is one of the most critical complications of decompensated liver cirrhosis. This study aimed to assess whether ascitic neutrophil gelatinase‐associated lipocalin (NGAL), a reliable inflammation biomarker, can be used to detect SBP in decompensated cirrhosis patients and to predict mortality from decompensated cirrhosis‐related SBP. Methods This study included 204 hospitalized patients with ascites of decompensated liver cirrhosis and follow‐up of 28 days. We measured ascitic NGAL levels by the latex‐enhanced immunoturbidimetric method. Simultaneously, we observed the patterns of ascitic NGAL levels in the SBP group after 7 days of anti‐infection treatment with third‐generation cephalosporins. Results The ascitic NGAL levels significantly increased in the SBP group compared with that in the non‐SBP group, 111(83.9, 178) ng/mL vs 48(35.4, 63) ng/mL, P < .001. Likewise, the ascitic NGAL levels of SBP were higher than non‐SBP with or without renal dysfunction. There was a positive relationship between ascitic NGAL and ascitic polymorphonuclear (PMN) leukocyte and a negative relationship between ascitic NGAL and ascitic albumin in the SBP group. An ascitic NGAL cutoff of 108.95 ng/mL was used for predicting a poor prognosis for SBP patients. Ascitic NGAL and the model for end‐stage liver disease score were independent risk factors in decompensated liver cirrhosis patients with SBP through multivariate Cox regression. A dynamic trend of ascitic NGAL in SBP patients was consistent with the clinical prognosis. Conclusion Ascitic NGAL may not only be a biomarker for monitoring SBP but also a predictor for more severe outcomes in decompensated cirrhosis‐related SBP.
Collapse
Affiliation(s)
- Hua Liu
- Department of Hepatology, The Third Central Clinical College of Tianjin Medical University, Tianjin, China.,Department of Hepatology, The Third Central Hospital of Tianjin, Tianjin, China.,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, China.,Tianjin Institute of Hepatobiliary Disease, Tianjin, China
| | - Ping Zhu
- Department of Hepatology, The Third Central Clinical College of Tianjin Medical University, Tianjin, China.,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, China.,Tianjin Institute of Hepatobiliary Disease, Tianjin, China.,Artificial Cell Engineering Technology Research Center, Tianjin, China
| | - Caiyun Nie
- Department of Oncology, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China.,Department of Oncology, Henan Cancer Hospital, Zhengzhou, China
| | - Qing Ye
- Department of Hepatology, The Third Central Hospital of Tianjin, Tianjin, China.,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, China.,Tianjin Institute of Hepatobiliary Disease, Tianjin, China.,Artificial Cell Engineering Technology Research Center, Tianjin, China
| | - Yanying Gao
- Department of Hepatology, The Third Central Hospital of Tianjin, Tianjin, China.,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, China.,Tianjin Institute of Hepatobiliary Disease, Tianjin, China.,Artificial Cell Engineering Technology Research Center, Tianjin, China
| | - Huaiping Liu
- Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, China.,Tianjin Institute of Hepatobiliary Disease, Tianjin, China.,Artificial Cell Engineering Technology Research Center, Tianjin, China.,Department of Clinical Laboratory, The Third Central Hospital of Tianjin, Tianjin, China
| | - Guoju Pang
- Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, China.,Tianjin Institute of Hepatobiliary Disease, Tianjin, China.,Artificial Cell Engineering Technology Research Center, Tianjin, China.,Department of Clinical Laboratory, The Third Central Hospital of Tianjin, Tianjin, China
| | - Tao Han
- Department of Hepatology, The Third Central Clinical College of Tianjin Medical University, Tianjin, China.,Department of Hepatology, The Third Central Hospital of Tianjin, Tianjin, China.,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, China.,Tianjin Institute of Hepatobiliary Disease, Tianjin, China
| |
Collapse
|
9
|
Chinnock B, Woolard RE, Hendey GW, Crawford S, Mainis L, Vo D, Wells RN, Ramirez R, Bengiamin DI. Sensitivity of a bedside reagent strip for the detection of spontaneous bacterial peritonitis in ED patients with ascites. Am J Emerg Med 2019; 37:2155-2158. [PMID: 30737002 DOI: 10.1016/j.ajem.2019.01.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 01/24/2019] [Accepted: 01/24/2019] [Indexed: 10/27/2022] Open
Abstract
STUDY OBJECTIVE To determine the sensitivity of a highly sensitive bedside leukocyte esterase reagent strip (RS) for detection of spontaneous bacterial peritonitis (SBP) in emergency department (ED) ascites patients undergoing paracentesis. METHODS We conducted a prospective, observational cohort study of ED ascites patients undergoing paracentesis at two academic facilities. Two practitioners, blinded to each other's results, did a bedside RS analysis of the peritoneal fluid in each patient and documented the RS reading at 3-min according to manufacturer-specified colorimetric strip reading as either "negative", "trace", "small", or "large". The primary outcome measure was sensitivity of the RS strip for SBP (absolute neutrophil count ≥ 250 cells/mm3) at the "trace" threshold (positive equals trace or greater). RESULTS There were 330 cases enrolled, with 635 fluid analyses performed. Of these, 40 fluid samples had SBP (6%). Bedside RS had a sensitivity, specificity, positive predictive value, and negative predictive value of 95% (95% CI 82%-99%), 48% (95% CI 44%-52%), 11% (95% CI 10%-11%), and 99% (95% CI 97%-99%) respectively at the "trace" threshold for the detection of SBP. CONCLUSION Bedside use of the RS in ED ascites patients demonstrated high sensitivity for SBP. Given the wide confidence intervals, we cannot currently recommend it as a stand-alone test. We recommend further study with a larger number of SBP patients, potentially combining a negative RS result with low clinical suspicion to effectively rule out SBP without formal laboratory analysis.
Collapse
Affiliation(s)
- Brian Chinnock
- Department of Emergency Medicine, UCSF-Fresno Medical Education Program, Fresno, CA, United States of America.
| | - Robert E Woolard
- Department of Emergency Medicine, Texas Tech University Health Sciences Center - El Paso, El Paso, TX, United States of America
| | - Gregory W Hendey
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Scott Crawford
- Department of Emergency Medicine, Texas Tech University Health Sciences Center - El Paso, El Paso, TX, United States of America
| | - Leann Mainis
- Department of Emergency Medicine, UCSF-Fresno Medical Education Program, Fresno, CA, United States of America
| | - Daniel Vo
- Department of Emergency Medicine, UCSF-Fresno Medical Education Program, Fresno, CA, United States of America
| | - Radosveta N Wells
- Department of Emergency Medicine, Texas Tech University Health Sciences Center - El Paso, El Paso, TX, United States of America
| | - René Ramirez
- Department of Emergency Medicine, UCSF-Fresno Medical Education Program, Fresno, CA, United States of America
| | - Deena I Bengiamin
- Department of Emergency Medicine, Loma Linda University Medical Center, Loma Linda, CA, United States of America
| |
Collapse
|
10
|
Kandeel S, Megahed A, Ebeid M, Constable P. Evaluation of 3 esterase tests for the diagnosis of subclinical mastitis at dry-off and freshening in dairy cattle. J Dairy Sci 2019; 102:1402-1416. [DOI: 10.3168/jds.2017-14345] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 12/25/2018] [Indexed: 11/19/2022]
|
11
|
Adjusted Intensive Care Infection Score (ICIS Δ)-A new approach for prediction of ascitic fluid infection in patients with cirrhosis. Dig Liver Dis 2019; 51:104-111. [PMID: 30042037 DOI: 10.1016/j.dld.2018.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 06/07/2018] [Accepted: 06/11/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Early and accurate diagnosis is the key to improving survival in cirrhotic patients with ascitic fluid infection. AIMS To investigate the usefulness of adjusted Intensive Care Infection Score (ICISΔ) for diagnosis of ascites infection in cirrhotic patients. METHODS Cirrhotic patients with ascites (n = 125) were enrolled, and the efficacy of ICIS and ICISΔ for predicting ascites infection was evaluated. ICISΔ was created by using the weighted variation of each ICIS parameter. RESULTS The area under the curves (AUCs) of ICIS for the diagnosis of ascites infection were 0.90 (95% CI: 0.84-0.95), 0.85 (95% CI: 0.79-0.90), and 0.87 (95% CI: 0.81-0.93), for SBP, culture-negative SBP, and combined SBP/culture-negative SBP, respectively. ICIS was optimized and diagnostic accuracy was obviously improved. ICISΔ had high AUCs of 0.99 (95% CI: 0.93-1.00) for SBP, 0.98 (95% CI: 0.83-1.00) for culture-negative SBP, and 0.98 (95% CI: 0.94-1.00) for the combination group. The optimal cutoff was identified as ICISΔ > 2, which had >97.8% sensitivity and 100% specificity for diagnosis of both SBP and culture-negative SBP. The ICISΔ had significantly higher AUCs than PCT and CPR in both groups (P = 0.002-0.008). ICISΔ kinetics could differentiate between SBP and culture-negative SBP patients. From sterile ascites, through culture-negative SBP to SBP, three ICISΔ parameters showed an increasing trend. CONCLUSIONS ICIS and ICISΔ are simple, rapid, accurate and cost-effective methods for the diagnosis of ascites infection in cirrhotic patients.
Collapse
|
12
|
Righi E. Management of bacterial and fungal infections in end stage liver disease and liver transplantation: Current options and future directions. World J Gastroenterol 2018; 24:4311-4329. [PMID: 30344417 PMCID: PMC6189843 DOI: 10.3748/wjg.v24.i38.4311] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Revised: 09/11/2018] [Accepted: 10/05/2018] [Indexed: 02/06/2023] Open
Abstract
Patients with liver cirrhosis are susceptible to infections due to various mechanisms, including abnormalities of humoral and cell-mediated immunity and occurrence of bacterial translocation from the intestine. Bacterial infections are common and represent a reason for progression to liver failure and increased mortality. Fungal infections, mainly caused by Candida spp., are often associated to delayed diagnosis and high mortality rates. High level of suspicion along with prompt diagnosis and treatment of infections are warranted. Bacterial and fungal infections negatively affect the outcomes of liver transplant candidates and recipients, causing disease progression among patients on the waiting list and increasing mortality, especially in the early post-transplant period. Abdominal, biliary tract, and bloodstream infections caused by Gram-negative bacteria [e.g., Enterobacteriaceae and Pseudomonas aeruginosa (P. aeruginosa)] and Staphylococcus spp. are commonly encountered in liver transplant recipients. Due to frequent exposure to broad-spectrum antibiotics, invasive procedures, and prolonged hospitalizations, these patients are especially at risk of developing infections caused by multidrug resistant bacteria. The increase in antimicrobial resistance hampers the choice of an adequate empiric therapy and warrants the knowledge of the local microbial epidemiology and the implementation of infection control measures. The main characteristics and the management of bacterial and fungal infections in patients with liver cirrhosis and liver transplant recipients are presented.
Collapse
Affiliation(s)
- Elda Righi
- Department of Infectious Diseases, Santa Maria della Misericordia University Hospital, Udine 33100, Italy
| |
Collapse
|
13
|
The emergency medicine evaluation and management of the patient with cirrhosis. Am J Emerg Med 2018; 36:689-698. [PMID: 29290508 DOI: 10.1016/j.ajem.2017.12.047] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 12/21/2017] [Accepted: 12/22/2017] [Indexed: 12/12/2022] Open
|
14
|
Núñez Moral M, Martínez-Camblor P, Méndez González A, Rodríguez Suárez C, Sánchez Álvarez JE. MUL+DO: a multicomponent index for the quick diagnosis of peritonitis in peritoneal dialysis patients. Nefrologia 2017; 38:273-278. [PMID: 29224952 DOI: 10.1016/j.nefro.2017.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Revised: 08/27/2017] [Accepted: 09/10/2017] [Indexed: 10/18/2022] Open
Abstract
Peritoneal infection is a common problem that has a negative impact on the survival of patients and the technique. The early administration of peritoneal infection treatment reduces complications. The goal of this study is to propose a multicomponent index (MUL+DO) for the quick and efficient diagnosis of peritoneal infection. We selected a training cohort of peritoneal effluent samples which were analysed by Multistix ® 10 SG Siemens test strips for leukocyte detection. Then, each sample was examined according to the gold standard: number of leukocytes, polymorphonuclear percentage and microbiological culture. We constructed the MUL+DO index by adding one point to the MULTISTIX [0-1-2-3] modified chromatic scale if the patient reported pain. The MUL+DO index ranged from 0 to 4. A model validation cohort was then created. MUL+DO was applied to each sample and leukocytes and polymorphonuclear percentage were also assessed. The training cohort ultimately included 134 samples, 34 of which with infection (25.4% [17.6-33.1]). Samples with a MUL+DO value greater than 1 presented a sensitivity and specificity of 100%. The validation cohort included 100 samples with 16 infections (16% [8.3-23.7]). Assuming a sample with a MUL+DO value greater than 1 to be positive, we obtained a sensitivity of 100% and a specificity of 95.2%. The MUL+DO index applied to the training cohort showed a perfect separation of the positive and negative populations. All positive patients presented a score ≥2. In the validation cohort, the MUL+DO reported a sensitivity of 100% and a specificity of 95.2%.
Collapse
Affiliation(s)
- Miguel Núñez Moral
- Área de Gestión de Nefrología, Unidad de Diálisis Peritoneal, Hospital Universitario Central de Asturias, Oviedo, Principado de Asturias, España.
| | - Pablo Martínez-Camblor
- Geisel School of Medicine at Dartmouth, Hanover, NH, EE. UU.; Universidad Autónoma de Chile, Santiago, Chile
| | - Alejandra Méndez González
- Área de Gestión de Nefrología, Unidad de Diálisis Peritoneal, Hospital Universitario Central de Asturias, Oviedo, Principado de Asturias, España
| | - Carmen Rodríguez Suárez
- Área de Gestión de Nefrología, Unidad de Diálisis Peritoneal, Hospital Universitario Central de Asturias, Oviedo, Principado de Asturias, España
| | - Jose Emilio Sánchez Álvarez
- Área de Gestión de Nefrología, Unidad de Diálisis Peritoneal, Hospital Universitario Central de Asturias, Oviedo, Principado de Asturias, España
| |
Collapse
|
15
|
Kawaratani H, Fukui H, Yoshiji H. Treatment for cirrhotic ascites. Hepatol Res 2017; 47:166-177. [PMID: 27363974 DOI: 10.1111/hepr.12769] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 06/23/2016] [Accepted: 06/27/2016] [Indexed: 12/11/2022]
Abstract
Common complications of decompensated liver cirrhosis are esophageal varices, hepatic encephalopathy and ascites. After the onset of complications, the prognosis worsens. In patients with ascites, the 5-year mortality rate is 44%. Furthermore, hyponatremia, spontaneous bacterial translocation and hepatorenal syndrome also greatly worsen the prognosis. Effective treatment of cirrhotic ascites improves the quality of life and survival rate. Recently, the newly produced diuretic, tolvaptan (vasopressin V2 receptor antagonist), was reported to be effective in the treatment of refractory ascites in liver cirrhosis; however, there has not been an associated positive effect on the prognosis. There are various types of treatment for ascites, such as large-volume paracenteses, a cell-free and concentrated ascites reinfusion therapy, a transjugular intrahepatic portosystemic shunt, and a peritoneo-venous shunt. Although they improve the prognosis, liver transplantation remains the ultimate form of treatment. The present article discusses the therapeutic management of cirrhotic ascites.
Collapse
Affiliation(s)
- Hideto Kawaratani
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Hiroshi Fukui
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Hitoshi Yoshiji
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Nara, Japan
| |
Collapse
|
16
|
The Periscreen Strip Is Highly Efficient for the Exclusion of Spontaneous Bacterial Peritonitis in Cirrhotic Outpatients. Am J Gastroenterol 2016; 111:1402-1409. [PMID: 27619833 DOI: 10.1038/ajg.2016.344] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 07/26/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES We aimed to assess the performance of a new strip (Periscreen) for the rapid diagnosis of spontaneous bacterial peritonitis (SBP). METHODS Ascitic fluid (AF) of cirrhotic patients hospitalized between March 2014 and August 2015 was independently tested by two readers using the new strip, which has four colorimetric graduations (negative, trace, small, and large). SBP was diagnosed on neutrophils in ascites>250/mm3. Ascites not related to portal hypertension were excluded. RESULTS Overall, 649 patients from 21 French centers were included and 1,402 AF (803 AF samples from 315 outpatients and 599 samples from 334 inpatients) were assessed. Eighty-four AF samples (17 AF in 9 outpatients and 67 AF in 31 inpatients) were diagnosed as SBP. The prevalence of SBP was 6% (2.1% in outpatients vs. 11.2% in inpatients; P<0.001) and 7.2% in patients with symptoms suggestive of SBP (3% in outpatients vs. 11.3% in inpatients; P<0.001). The κ value for inter-reader agreement was 0.81 (95% confidence interval: 0.77-0.84) when using the "trace" threshold. Considering discordant results (n=131) as positive to interpret the diagnostic performance of the strip at the "trace" threshold, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 91.7, 57.1, 12.0, and 99.1%, respectively. At this "trace" threshold, sensitivity and NPV were both 100% in outpatients, and 89.5 and 97.9% in inpatients, respectively. At the "small" threshold, sensitivity, specificity, PPV and NPV were 81.0, 85.9, 25.9 and 98.7%, respectively. CONCLUSIONS The Periscreen strip is a rapid and highly efficient tool for excluding SBP in the outpatient setting.
Collapse
|
17
|
Bunchorntavakul C, Chamroonkul N, Chavalitdhamrong D. Bacterial infections in cirrhosis: A critical review and practical guidance. World J Hepatol 2016; 8:307-321. [PMID: 26962397 PMCID: PMC4766259 DOI: 10.4254/wjh.v8.i6.307] [Citation(s) in RCA: 141] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 11/23/2015] [Accepted: 01/29/2016] [Indexed: 02/06/2023] Open
Abstract
Bacterial infection is common and accounts for major morbidity and mortality in cirrhosis. Patients with cirrhosis are immunocompromised and increased susceptibility to develop spontaneous bacterial infections, hospital-acquired infections, and a variety of infections from uncommon pathogens. Once infection develops, the excessive response of pro-inflammatory cytokines on a pre-existing hemodynamic dysfunction in cirrhosis further predispose the development of serious complications such as shock, acute-on-chronic liver failure, renal failure, and death. Spontaneous bacterial peritonitis and bacteremia are common in patients with advanced cirrhosis, and are important prognostic landmarks in the natural history of cirrhosis. Notably, the incidence of infections from resistant bacteria has increased significantly in healthcare-associated settings. Serum biomarkers such as procalcitonin may help to improve the diagnosis of bacterial infection. Preventive measures (e.g., avoidance, antibiotic prophylaxis, and vaccination), early recognition, and proper management are required in order to minimize morbidity and mortality of infections in cirrhosis.
Collapse
|
18
|
Nousbaum JB. [Spontaneous bacterial peritonitis in patients with cirrhosis]. Presse Med 2015; 44:1235-42. [PMID: 26358667 DOI: 10.1016/j.lpm.2015.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 07/09/2015] [Indexed: 11/19/2022] Open
Abstract
Spontaneous bacterial peritonitis (SBP) is a severe complication occurring in patients with cirrhosis, and is associated with high mortality. Liver transplantation should be considered after a first episode of SBP. Gram-negative bacilli are the major cause of SBP, however there is an increasing trend of Gram-positive cocci related SBP. Management includes empirical antibiotic treatment and albumin infusion. The choice of antibiotics depends on the site of acquisition (community-acquired vs nosocomial or health-care associated infection) and local resistance profile, due to the emergence of drug-resistant bacteria. Secondary prophylaxis is recommended after resolution of SBP and reduces recurrence and mortality. Primary prophylaxis in patients with low protein ascites (<15 g/L) should be restricted to patients with severe cirrhosis awaiting for liver transplantation.
Collapse
Affiliation(s)
- Jean-Baptiste Nousbaum
- CHU La Cavale-Blanche, service d'hépato-gastroentérologie, boulevard Tanguy-Prigent, 29609 Brest cedex, France.
| |
Collapse
|
19
|
Lutz P, Nischalke HD, Strassburg CP, Spengler U. Spontaneous bacterial peritonitis: The clinical challenge of a leaky gut and a cirrhotic liver. World J Hepatol 2015; 7:304-314. [PMID: 25848460 PMCID: PMC4381159 DOI: 10.4254/wjh.v7.i3.304] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 11/30/2014] [Accepted: 12/31/2014] [Indexed: 02/06/2023] Open
Abstract
Spontaneous bacterial peritonitis (SBP) is a frequent, life-threatening bacterial infection in patients with liver cirrhosis and ascites. Portal hypertension leads to increased bacterial translocation from the intestine. Failure to eliminate invading pathogens due to immune defects associated with advanced liver disease on the background of genetic predisposition may result in SBP. The efficacy of antibiotic treatment and prophylaxis has declined due to the spread of multi-resistant bacteria. Patients with nosocomial SBP and with prior antibiotic treatment are at a particularly high risk for infection with resistant bacteria. Therefore, it is important to adapt empirical treatment to these risk factors and to the local resistance profile. Rifaximin, an oral, non-absorbable antibiotic, has been proposed to prevent SBP, but may be useful only in a subset of patients. Since novel antibiotic classes are lacking, we have to develop prophylactic strategies which do not induce bacterial resistance. Farnesoid X receptor agonists may be a candidate, but so far, clinical studies are not available. New diagnostic tests which can be carried out quickly at the patient’s site and provide additional prognostic information would be helpful. Furthermore, we need tools to predict antibiotic resistance in order to tailor first-line antibiotic treatment of spontaneous bacterial peritonitis to the individual patient and to reduce mortality.
Collapse
|
20
|
Chugh K, Agrawal Y, Goyal V, Khatri V, Kumar P. Diagnosing bacterial peritonitis made easy by use of leukocyte esterase dipsticks. Int J Crit Illn Inj Sci 2015; 5:32-7. [PMID: 25810962 PMCID: PMC4366826 DOI: 10.4103/2229-5151.152337] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Spontaneous bacterial peritonitis (SBP) requires rapid diagnosis for the initiation of antibiotics. Its diagnosis is usually based on manual examination of ascitic fluid (AF) having long reporting time. AF infection is diagnosed when the fluid polymorphonuclear leukocyte (PMNL) concentration ≥250 cells/mm(3). AIMS AND OBJECTIVES Aim was to evaluate the diagnostic utility of leukocyte esterase (LE) reagent strip for rapid diagnosis of SBP in patients who underwent abdominal paracentesis and to calculate the sensitivity, specificity, positive, and negative predictive values. MATERIALS AND METHODS The study was carried out on 103 patients with ascites. Cell count of AF as determined by colorimetric scale of Multistix 10 SG reagent strip was compared with counting chamber method (PMNL count ≥250 cells/mm(3) was considered positive). RESULTS AND OBSERVATIONS Of the 103 patients SBP was diagnosed in 20 patients, 83 patients were negative for SBP by manual cell count. The sensitivity and specificity of the LE test for detecting neutrocytic SBP taking grade 2 as cut off were 95% and 96.4% respectively, with a positive predictive value of 86.4% and a negative predictive value of 98.8%. Diagnostic accuracy of LE test was 96.1%. DISCUSSION There was a good correlation between the reagent strip result and PMNL count. The LE strip test is based on the esterase activity of activated granulocytes which reacts with an ester-releasing hydroxyphenylpyrrole causing a colour change in the azo dye of reagent strip. It is a very sensitive and specific method for the prompt detection of elevated PMNL count, and represents a convenient, inexpensive, simple, and bedside method for diagnosis of SBP. A negative LE test result excludes SBP with a high degree of certainty.
Collapse
Affiliation(s)
- Kiran Chugh
- Department of Biochemistry, Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Yuthika Agrawal
- Department of Biochemistry, Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Vipin Goyal
- Department of Chest and TB, Shree Guru Gobind Singh Tricentenary Medical College, Budhera, Gurgaon, Haryana, India
| | - Vinod Khatri
- Department of Medicine, Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Pradeep Kumar
- Department of Medicine, Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| |
Collapse
|
21
|
Diagnosis of spontaneous bacterial peritonitis and an in situ hybridization approach to detect an "unidentified" pathogen. Int J Hepatol 2014. [PMID: 25132996 DOI: 10.1155/2014] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Spontaneous bacterial peritonitis (SBP) is a frequent and severe complication in cirrhotic patients with ascites. Although identifying the pathogen(s) plays a major role in the management of infectious diseases, ascitic fluid cultures often show negative results in patients with clinical signs and symptoms of SBP, and ascitic fluid cell analyses are the gold standard method for diagnosing SBP. SBP is generally diagnosed based on an increased number of polymorphonuclear neutrophils in the ascitic fluid (>250/mm(3)), and the identification of the causal pathogen may not be given consideration. We newly developed an in situ hybridization (ISH) method to provide early and direct evidence of bacterial infection in ascites in patients with SBP. This paper will review the diagnosis of SBP, including our novel approach with ISH method to detect bacterial DNA in SBP ascitic fluid.
Collapse
|
22
|
Enomoto H, Inoue SI, Matsuhisa A, Nishiguchi S. Diagnosis of spontaneous bacterial peritonitis and an in situ hybridization approach to detect an "unidentified" pathogen. Int J Hepatol 2014; 2014:634617. [PMID: 25132996 PMCID: PMC4123576 DOI: 10.1155/2014/634617] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 07/01/2014] [Accepted: 07/04/2014] [Indexed: 01/19/2023] Open
Abstract
Spontaneous bacterial peritonitis (SBP) is a frequent and severe complication in cirrhotic patients with ascites. Although identifying the pathogen(s) plays a major role in the management of infectious diseases, ascitic fluid cultures often show negative results in patients with clinical signs and symptoms of SBP, and ascitic fluid cell analyses are the gold standard method for diagnosing SBP. SBP is generally diagnosed based on an increased number of polymorphonuclear neutrophils in the ascitic fluid (>250/mm(3)), and the identification of the causal pathogen may not be given consideration. We newly developed an in situ hybridization (ISH) method to provide early and direct evidence of bacterial infection in ascites in patients with SBP. This paper will review the diagnosis of SBP, including our novel approach with ISH method to detect bacterial DNA in SBP ascitic fluid.
Collapse
Affiliation(s)
- Hirayuki Enomoto
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Mukogawacho 1-1, Nishinomiya, Hyogo 663-8501, Japan
| | - Shin-ichi Inoue
- Research & Development Center, Fuso Pharmaceutical Industries, Ltd., Morinomiya 2-3-30, Joto-ku, Osaka 536-8523, Japan
| | - Akio Matsuhisa
- Research & Development Center, Fuso Pharmaceutical Industries, Ltd., Morinomiya 2-3-30, Joto-ku, Osaka 536-8523, Japan
| | - Shuhei Nishiguchi
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Mukogawacho 1-1, Nishinomiya, Hyogo 663-8501, Japan
| |
Collapse
|
23
|
Fagiuoli S, Colli A, Bruno R, Burra P, Craxì A, Gaeta GB, Grossi P, Mondelli MU, Puoti M, Sagnelli E, Stefani S, Toniutto P. Management of infections in cirrhotic patients: report of a consensus conference. Dig Liver Dis 2014; 46:204-12. [PMID: 24021271 DOI: 10.1016/j.dld.2013.07.015] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 07/04/2013] [Accepted: 07/17/2013] [Indexed: 12/11/2022]
Abstract
The statements produced by the consensus conference on infection in end-stage liver disease promoted by the Italian Association for the Study of the Liver, are here reported. The topics of epidemiology, risk factors, diagnosis, prophylaxis, and treatment of infections in patient with compensated and decompensated liver cirrhosis were reviewed by a scientific board of experts who proposed 26 statements that were graded according to level of evidence and strength of recommendation, and approved by an independent jury. Each topic was explored focusing on the more relevant clinical questions. By systematic literature search of available evidence, comparison and discussion of expert opinions, pertinent statements answering specific questions were presented and approved. Short comments were added to explain the basis for grading evidence particularly on case of controversial areas.
Collapse
Affiliation(s)
- Stefano Fagiuoli
- Gastroenterology and Transplant Hepatology, Papa Giovanni XXIII Hospital, Bergamo, Italy.
| | | | - Raffaele Bruno
- Department of Infectious Diseases, IRCCS San Matteo, University of Pavia, Pavia, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Antonio Craxì
- Gastroenterology and Hepatology, Di.Bi.M.I.S., University of Palermo, Italy
| | - Giovan Battista Gaeta
- Infectious Diseases, Department of Internal and Experimental Medicine, Second University of Naples, Italy
| | - Paolo Grossi
- Infectious & Tropical Diseases Unit, Department of Surgical & Morphological Sciences, Insubria University, Varese, Italy
| | - Mario U Mondelli
- Research Laboratories, Department of Infectious Diseases, Fondazione IRCCS Policlinico San Matteo and Department of Internal Medicine, University of Pavia, Italy
| | - Massimo Puoti
- Infectious Diseases Department, Niguarda Cà Granda Hospital, Milano, Italy
| | - Evangelista Sagnelli
- Department of Mental Health and Preventive Medicine, Second University of Naples, Italy
| | - Stefania Stefani
- Department of Bio-Medical Sciences, Section of Microbiology, University of Catania, Italy
| | - Pierluigi Toniutto
- Department of Medical Sciences, Experimental and Clinical, Medical Liver Transplant Section, Internal Medicine, University of Udine, Italy
| |
Collapse
|
24
|
Enomoto H, Inoue SI, Matsuhisa A, Aizawa N, Imanishi H, Saito M, Iwata Y, Tanaka H, Ikeda N, Sakai Y, Takashima T, Shimomura S, Iijima H, Nakamura H, Nishiguchi S. Development of a new in situ hybridization method for the detection of global bacterial DNA to provide early evidence of a bacterial infection in spontaneous bacterial peritonitis. J Hepatol 2012; 56:85-94. [PMID: 21835139 DOI: 10.1016/j.jhep.2011.06.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Revised: 06/05/2011] [Accepted: 06/16/2011] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Despite the importance of identifying the causative pathogen(s), ascitic fluid cultures are occasionally negative in patients with spontaneous bacterial peritonitis (SBP). A novel strategy using the in situ hybridization (ISH) method was introduced to detect the bacterial genomic DNA phagocytized in the blood of patients with sepsis. In the present study, we developed a new ISH probe to detect global bacterial DNA (named as GB probe) and evaluated its utility for detecting the phagocytized bacterial DNA in SBP ascites. METHODS Hybridization of bacterial DNA with the GB probe was examined by dot-blot and ISH tests. In addition, the utility of the ISH method to detect the bacterial DNA in the leukocytes of SBP ascites was evaluated. RESULTS The GB probe hybridized with the genomic DNA of all 59 bacterial strains tested (59 species of 36 genus). Eleven of 51 patients with ascites (out of total 542 cirrhotic inpatients) were categorized as SBP. The ISH tests showed positive results in 10 of 11 SBP cases. However, the ISH tests all showed negative results in the 40 non-SBP ascitic samples. Therefore, the ISH tests yielded highly sensitive and specific results for detecting the phagocytized bacterial DNA in the leukocytes of SBP ascites. Moreover, all of the ISH test results were obtained within only one day. CONCLUSIONS Our newly established ISH method was found to provide both a rapid and sensitive detection of bacterial DNA in SBP ascites, thus suggesting its utility for providing early and direct evidence of bacterial infection in SBP ascites.
Collapse
Affiliation(s)
- Hirayuki Enomoto
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Mukogawa-cho 1-1, Nishinomiya, Hyogo 663-8501, Japan
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Bonnel AR, Bunchorntavakul C, Reddy KR. Immune dysfunction and infections in patients with cirrhosis. Clin Gastroenterol Hepatol 2011; 9:727-38. [PMID: 21397731 DOI: 10.1016/j.cgh.2011.02.031] [Citation(s) in RCA: 273] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Revised: 02/22/2011] [Accepted: 02/27/2011] [Indexed: 02/06/2023]
Abstract
Patients with cirrhosis are immunocompromised and susceptible to infections. Although detection and treatment of spontaneous bacterial peritonitis (SBP) have improved, overall survival rates have not increased greatly in recent decades-infection still increases mortality 4-fold among patients with cirrhosis. Hospitalized patients with cirrhosis have the highest risk of developing infections, especially patients with gastrointestinal (GI) hemorrhage. Bacterial infections occur in 32% to 34% of patients with cirrhosis who are admitted to the hospital and 45% of patients with GI hemorrhage. These rates are much higher than the overall rate of infection in hospitalized patients (5%-7%). The most common are SBP (25% of infections), urinary tract infection (20%), and pneumonia (15%). Bacterial overgrowth and translocation from the GI tract are important steps in the pathogenesis of SBP and bacteremia-these processes increase levels of endotoxins and cytokines that induce the inflammatory response and can lead to septic shock, multiorgan dysfunction, and death. A number of other bacterial and fungal pathogens are more common and virulent in patients with cirrhosis than in the overall population. We review the pathogenesis of infections in these patients, along with diagnostic and management strategies.
Collapse
Affiliation(s)
- Alexander R Bonnel
- Division of Gastroenterology/Hepatology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | |
Collapse
|
26
|
Koulaouzidis A, Cadranel JF, Nahon P, Khac EN, Moreau R, Thévenot T, Silvain C, Bureau C, Nouel O, Pilette C, Paupard T, Vanbiervliet G, Oberti F, Davion T, Jouannaud V, Roche B, Bernard PH, Beaulieu S, Danne O, Thabut D, Chagneau-Derrode C, de Lédinghen V, Mathurin P, Pauwels A, Bronowicki JP, Habersetzer F, Abergel A, Audigier JC, Sapey T, Grangé JD, Tran A. Diagnosis of spontaneous bacterial peritonitis: An update on leucocyte esterase reagent strips. World J Gastroenterol 2011; 17:1091-4. [PMID: 21448413 PMCID: PMC3063900 DOI: 10.3748/wjg.v17.i9.1091] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2010] [Revised: 01/18/2011] [Accepted: 01/25/2011] [Indexed: 02/06/2023] Open
Abstract
Ascites remain the commonest complication of decompensated cirrhosis. Spontaneous bacterial peritonitis (SBP) is defined as the infection of ascitic fluid (AF) in the absence of a contiguous source of infection and/or an intra-abdominal inflammatory focus. An AF polymorphonuclear (PMN) leucocyte count ≥ 250/mm3 -irrespective of the AF culture result- is universally accepted nowadays as the best surrogate marker for diagnosing SBP. Frequently the results of the manual or automated PMN count do not reach the hands of the responsible medical personnel in a timely manner. However, this is a crucial step in SBP management. Since 2000, 26 studies (most of them published as full papers) have checked the validity of using leukocyte esterase reagent strips (LERS) in SBP diagnosis. LERS appear to have low sensitivity for SBP, some LERS types more than others. On the other hand, though, LERS have consistently given a high negative predictive value (> 95% in the majority of the studies) and this supports the use of LERS as a preliminary screening tool for SBP diagnosis. Finally, an AF-tailored dipstick has been developed. Within the proper setting, it is set to become the mainstream process for handling AF samples.
Collapse
|