Long-term prognosis of cirrhosis after spontaneous bacterial peritonitis treated with ceftriaxone

The Value of Neutrophil-to-Lymphocyte Ratio to Identify Bacterial Infection and Predict Short-Term Mortality in Patients with Acutely Decompensated Cirrhosis

Liver cirrhosis patients are highly susceptible to infections, affecting survival, but current parameters for detecting infection are not reliable enough in this population. We investigated the ability of white blood cell (WBC), ∆WBC, neutrophil and ∆neutrophil counts, neutrophil-to-lymphocyte (NLR) and ∆NLR ratios and C-reactive protein (CRP) and procalcitonin (PCT) levels to identify infection and predict short-term mortality in liver cirrhosis patients. We recruited 233 patients with liver cirrhosis hospitalized with acute decompensation (AD) who had an outpatient visit within 1 month (baseline laboratory data) and followed them for 90 days. Difference between laboratory values at baseline and the AD episode was defined as delta (∆) values of the parameters. Delta values did not increase the diagnostic and predictive ability of investigated parameters. The CRP level was found to be the best diagnostic marker for infection in patients with cirrhosis. However, NLR seems to be superior for short-term mortality prediction, better than the WBC count. Distinguishing inflammations of different origin is a remaining clinical challenge in acutely decompensated cirrhosis. Based on our results, NLR might be more suitable for predicting short-term mortality in patients with AD than the WBC count currently included in the CLIF-C AD score.

Early readmissions of spontaneous bacterial peritonitis in the USA: Insights into an emerging challenge

BACKGROUND AND AIM

Early readmissions of spontaneous bacterial peritonitis (SBP) are often associated with poor outcomes. We compared characteristics and outcomes for index and 30-day readmissions of SBP in the USA.

METHODS

We analyzed the Nationwide Readmissions Database for 2018 to identify all adult (≥ 18 years) 30-day readmissions of SBP in the USA. Hospitalization characteristics and outcomes for index and 30-day readmissions of SBP were compared. Independent predictors of 30-day readmissions were also identified.

RESULTS

In 2018, of the 5,797 index admissions for SBP, 30% (1726) were readmitted within 30 day. At the time of readmission, the most common admitting diagnosis was alcoholic cirrhosis of the liver with ascites (11.8%) followed by sepsis due to an unspecified organism (9.2%). SBP as an admitting diagnosis was identified for only 8.3% of these 30-day readmissions. Compared with index admissions, 30-day readmissions of SBP had a lower mean age (56.1 vs 58.6 years, P < 0.001) without a statistically significant difference for gender. Furthermore, 30-day readmissions of SBP were associated with significantly higher odds of inpatient mortality (10% vs 4.9%, OR: 2.15, 95% CI: 1.66-2.79, P < 0.001), and mean total hospital charge ($85,031 vs $56,000, mean difference: 29,032, 95% CI: 12,867-45,197, P < 0.001) compared with index admissions. The presence of chronic pulmonary disease, liver failure, inpatient dialysis, and discharge against medical advice were identified as independent predictors for increased 30-day readmissions of SBP.

CONCLUSION

The 30-day readmission rate of SBP was 30% and these readmissions were associated with higher odds of inpatient mortality compared with index admissions.

Predictors of immediate and short-term mortality in spontaneous bacterial peritonitis

BACKGROUND

There is scarce data from the Indian subcontinent on the outcomes following spontaneous bacterial peritonitis (SBP).

AIM

To study the immediate (within 30 days) and short-term mortality (31-90 days) associated with SBP and to determine the predictors of the same.

METHODS

This prospective observational study was done among patients with liver cirrhosis who underwent paracentesis. Patient data included age, gender, co-morbidity, cirrhosis-related complications, model of end-stage liver disease (MELD), and Child-Turcotte-Pugh (CTP) scores. SBP was diagnosed based on ascitic fluid polymorphonuclear leukocyte count > 250/mm³ with or without ascitic fluid culture positivity.

RESULTS

Of the 870 patients with cirrhosis and ascites registered during the study period, 610 fulfilled the criteria for inclusion. Altogether, 122 patients with SBP were identified: 52 (42.6%) died, 40 (32.8%) survived without liver transplant, and 30 (24.6%) underwent liver transplantation within 3 months. Thirty-two patients (26.2%) were blood culture posi tive for bacteria and 7 (5.7%) demonstrable bacterial growth in ascitic fluid. Blood culture positivity was significantly higher in the group with immediate mortality (p < 0.0001) and was also significantly associated (p 0.005) with mortality at 3 months.

CONCLUSION

Nearly two-fifths (42.6%) of the study cohort died within 3 months of an episode of SBP. Four-fifths of these patients died within 30 days. Blood culture positivity was significantly associated with immediate and short-term mortality.

Initial choice of antibiotic in recurrent spontaneous bacterial peritonitis: A retrospective study

Context:

Spontaneous bacterial peritonitis (SBP) is a commonly encountered infection seen in the setting of ascites secondary to advanced liver disease. Recurrence of SBP is common and is associated with high mortality. This study was designed to recognize a better initial choice of antibiotic in case of recurrent SBP – a third-generation cephalosporin or a carbapenem.

Aims:

This study aims to determine a better initial choice of antibiotic in case of recurrent SBP and to compare the all-cause mortality among two different groups of patients treated with a third-generation cephalosporin and a carbapenem.

Settings and Design:

This study was conducted among fifty patients presenting with recurrent SBP visiting the emergency department (ED) at a tertiary care center and who were subsequently admitted in a gastroenterology intensive care unit, during a period of 1 year.

Subjects and Methods:

This is a retrospective, observational study conducted among patients with chronic liver disease and diagnosed with recurrent SBP visiting the ED at a tertiary care center in South India treated with either of two classes of antibiotics – third-generation cephalosporins or carbapenems, and their outcomes were compared. Recurrence is defined as an episode of SBP after resolution of the first index case of SBP within 1 year.

Statistical Analysis Used:

Statistical analysis was done using IBM SPSS version 23.0 (SPSS Inc., Chicago, IL, USA). All categorical variables were represented as percentages, and all continuous variables were represented as mean ± standard deviation. To test the statistical significance of the association of categorical variables with the outcome, Chi-square test was used. P <0.05 was considered statistically significant.

Results:

A total of fifty patients with recurrent SBP were included in the study, of which 44 (88%) patients were male and 6 patients were female (12%). Twenty-nine (58%) patients survived and 21 (42%) patients expired within 28 days. Twenty-seven (54%) patients were treated with third-generation cephalosporins and 23 (46%) were treated with carbapenems. It was observed that mortality was statistically significantly lower among patients treated with carbapenem (P = 0.001). The incidence of acute kidney injury was also lower among patients treated with a carbapenem than patients treated with a third-generation cephalosporin (40.7% vs. 59.25%, respectively).

Conclusions:

Initiation of a carbapenem significantly reduced the all-cause mortality when compared to a third-generation cephalosporin as an initial antibiotic of choice in recurrent SBP.

Spontaneous bacterial peritonitis in patients with cirrhosis: incidence, outcomes, and treatment strategies

Spontaneous bacterial peritonitis is the most frequent bacterial infection in patients with cirrhosis. The reported incidence varies between 7% and 30% in hospitalized patients with cirrhosis and ascites, representing one of their main complications. Outcomes in patients with spontaneous bacterial peritonitis are poor since acute kidney injury, acute-on-chronic liver failure, and death occur in as much as 54%, 60%, and 40% of the patients, respectively, at midterm. Early antibiotic treatment of spontaneous bacterial peritonitis is crucial. However, the landscape of microbiological resistance is continuously changing, with an increasing spread of multidrug-resistant organisms that make its current management more challenging. Thus, the selection of the empirical antibiotic treatment should be guided by the severity and location where the infection was acquired, the risk factors for multidrug-resistant organisms, and the available information on the local expected bacteriology. The use of albumin as a complementary therapy for selected high-risk patients with spontaneous bacterial peritonitis is recommended in addition to antibiotics. Even though antibiotic prophylaxis has proven to be effective to prevent spontaneous bacterial peritonitis, a careful selection of high-risk candidates is crucial to avoid antibiotic overuse. In this article we review the pathogenesis, risk factors, and prognosis of spontaneous bacterial peritonitis, as well as the current evidence regarding its treatment and prophylaxis.

Proton pump inhibitors do not increase the risk for recurrent spontaneous bacterial peritonitis in patients with cirrhosis

BACKGROUND AND AIM

The present study aimed to assess the real impact of proton pump inhibitor (PPI) use on incidence of recurrent spontaneous bacterial peritonitis (SBP) in a homogenous population composed of cirrhotic patients with a previous SBP where differences related with SBP incidence between PPI users and non-users are less likely to exist.

METHODS

This retrospective cohort study enrolled 307 cirrhotic patients taking diuretics for ascites control and had a previous SBP. Patients who took any PPI for at least 1 week prior to a second SBP were included in the PPI group. The incidence of a second SBP was a primary outcome and was compared between PPI group and non-PPI group before and after propensity score matching. Risk factors for a second SBP were investigated by multivariate analysis.

RESULTS

Second SBP occurred in 17 patients (29.3%) during mean 52.1 ± 5.2 months of PPI group and in 60 patients (24.1%) during mean 61.9 ± 4.8 months of non-PPI group, which did not differ (P = .185). In the matched cohort, second SBP similarly occurred in both groups [29.3% of PPI group vs 26.8% of non-PPI group (P = .271)]. According to the multivariate analysis, Child-Pugh score was the only significant risk factor for a second SBP (hazard ratio 1.68, 95% confidence interval, 1.13-2.50, P = .001). Isolated bacteria and clinical outcomes such as of mortality, presence of sepsis, and hospital stay did not differ between the two groups in the matched cohort.

CONCLUSION

Proton pump inhibitor use is not a risk factor for recurrent SBP in cirrhotic patients.

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

BACKGROUND

Spontaneous bacterial peritonitis (SBP) is a severe and often fatal infection in patients with cirrhosis and ascites.

AIM

To review the known and changing bacteriology, risk factors, ascitic fluid interpretation, steps in performing paracentesis, treatment, prophylaxis and evolving perspectives related to SBP.

METHODS

Information was obtained from reviewing medical literature accessible on PubMed Central. The search term 'spontaneous bacterial peritonitis' was cross-referenced with 'bacteria', 'risk factors', 'ascites', 'paracentesis', 'ascitic fluid analysis', 'diagnosis', 'treatment', 'antibiotics', 'prophylaxis', 'liver transplantation' and 'nutrition'.

RESULTS

Gram-positive cocci (GPC) such as Staphylococcus, Enterococcus as well as multi-resistant bacteria have become common pathogens and have changed the conventional approach to treatment of SBP. Health care-associated and nosocomial SBP infections should prompt greater vigilance and consideration for alternative antibiotic coverage. Acid suppressive and beta-adrenergic antagonist therapies are strongly associated with SBP in at-risk individuals.

CONCLUSIONS

Third-generation, broad-spectrum cephalosporins remain a good initial choice for SBP treatment. Levofloxacin is an acceptable alternative for patients not receiving long-term flouroquinolone prophylaxis or for those with a penicillin allergy. For uncomplicated SBP, early oral switch therapy is reasonable. Alternative antibiotics such as pipercillin-tazobactam should be considered for patients with nosocomial SBP or for patients who fail to improve on traditional antibiotic regimens. Selective albumin supplementation remains an important adjunct in SBP treatment. Withholding acid suppressive medication deserves strong consideration, and discontinuing beta-adrenergic antagonist therapy in patients with end-stage liver disease and resistant ascites is standard care. Liver transplant evaluation should be undertaken for patients who develop SBP barring contraindications.

The need for antibiotic stewardship and treatment standardization in the care of cirrhotic patients with spontaneous bacterial peritonitis - a retrospective cohort study examining the effect of ceftriaxone dosing

Background: Spontaneous bacterial peritonitis (SBP) is a common, often fatal affliction for cirrhotic patients. Despite all clinical trials of ceftriaxone for SBP using 2g daily, it is often given at 1g daily.

Aim: We evaluated survival after SBP as a function of ceftriaxone dosage.

Methods:  A retrospective cohort of all patients who received ceftriaxone for SBP (greater than 250 neutrophils in the ascites).

Results: As opposed to 1 gram, median survival is longer for patients receiving 2 grams (228 days vs. 102 days (p = 0.26) and one year survival is significantly higher (p = 0.0034).  After adjusting for baseline Model for End Stage Liver Disease (MELD) score, however, this difference was no longer significant.  Similarly, there was a significantly shorter length of intensive care for patients receiving 2 g (0.59 ± 1.78 days vs. 3.26 ± 6.9, p = 0.034), odds ratio 0.11 (95% CI 0.02 - 0.65). This difference, too, was no longer significant after controlling for the MELD score - odds ratio 0.21 (95% CI 0.04 - 1.07). Additionally, 70% of patients received at least one additional antibiotic; over 25 different medications were used in various combinations.

Conclusions:  Patients receiving 2 g of ceftriaxone may require fewer intensive care days and may enjoy an improved survival compared to those receiving 1 g daily. The complexity of antibiotic regimens to which cirrhotic patients are exposed must be studied further and rationalized.  We recommend fastidious antibiotic stewardship for patients with cirrhosis. Efforts should be made to craft local standards for the treatment of SBP that include appropriate antibiotic selection and dose.

Immune dysfunction and infections in patients with cirrhosis

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.

Infections in patients with cirrhosis increase mortality four-fold and should be used in determining prognosis

BACKGROUND & AIMS

A staged prognostic model of cirrhosis based on varices, ascites, and bleeding has been proposed. We analyzed data on infections in patients with cirrhosis to determine whether it is also a prognostic factor.

METHODS

Studies were identified by MEDLINE, EMBASE, COCHRANE, and ISI Web of Science searches (1978-2009); search terms included sepsis, infection, mortality, and cirrhosis. Studies (n = 178) reporting more than 10 patients and mortality data were evaluated (225 cohorts, 11,987 patients). Mortality after 1, 3, and 12 months was compared with severity, site, microbial cause of infection, etiology of cirrhosis, and publication year. Pooled odds ratio of death was compared for infected versus noninfected groups (18 cohorts, 2317 patients).

RESULTS

Overall median mortality of infected patients was 38%: 30.3% at 1 month and 63% at 12 months. Pooled odds ratio for death of infected versus noninfected patients was 3.75 (95% confidence interval, 2.12-4.23). In 101 studies that reported spontaneous bacterial peritonitis (7062 patients), the median mortality was 43.7%: 31.5% at 1 month and 66.2% at 12 months. In 30 studies that reported bacteremia (1437 patients), the median mortality rate was 42.2%. Mortality before 2000 was 47.7% and after 2000 was 32.3% (P = .023); mortality was reduced only at 30 days after spontaneous bacterial peritonitis (49% vs 31.5%; P = .005).

CONCLUSIONS

In patients with cirrhosis, infections increase mortality 4-fold; 30% of patients die within 1 month after infection and another 30% die by 1 year. Prospective studies with prolonged follow-up evaluation and to evaluate preventative strategies are needed.

Z-FA.FMK activates duodenal epithelial cell proliferation through oxidative stress, NF-kappaB and IL-1beta in D-GalN/TNF-alpha-administered mice

This study was designed to evaluate the effect of Z-FA.FMK (benzyloxycarbonyl-l-phenylalanyl-alanine-fluoromethylketone), a pharmacological inhibitor of cathepsin B, on the proliferation of duodenal mucosal epithelial cells and the cellular system that controls this mechanism in these cells in vivo. For this investigation, BALB/c male mice were divided into four groups. The first group received physiological saline, the second group was administered Z-FA.FMK, the third group received D-GalN (D-galactosamine) and TNF-alpha (tumour necrosis factor-alpha) and the fourth group was given both D-GalN/TNF-alpha and Z-FA.FMK. When D-GalN/TNF-alpha was administered alone, we observed an increase in IL-1beta-positive and active NF-kappaB-positive duodenal epithelial cells, a decrease in PCNA (proliferative cell nuclear antigen)-positive duodenal epithelial cells and an increase in degenerative changes in duodenum. On the other hand, Z-FA.FMK pretreatment inhibited all of these changes. Furthermore, lipid peroxidation, protein carbonyl and collagen levels were increased, glutathione level and superoxide dismutase activity were decreased, while there was no change in catalase activity by D-GalN/TNF-alpha injection. On the contrary, the Z-FA.FMK pretreatment before D-GalN/TNF-alpha blocked these effects. Based on these findings, we suggest that Z-FA.FMK might act as a proliferative mediator which is controlled by IL-1beta through NF-kappaB and oxidative stress in duodenal epithelial cells of D-GalN/TNF-alpha-administered mice.

Usefulness of reagent strips for checking cure in spontaneous bacterial peritonitis after short-course treatment

BACKGROUND

The usefulness of reagent strips to check cure of spontaneous bacterial peritonitis have not been evaluated to date.

AIM

To assess the usefulness of ascitic fluid analysis by means of reagent strips to check cure after a 5-day antibiotic course.

METHODS

We prospectively included all cirrhotic patients diagnosed with spontaneous bacterial peritonitis. On day 5, conventional and reagent strip ascitic fluid analyses were performed.

RESULTS

Fifty-three episodes of spontaneous bacterial peritonitis in 51 cirrhotic patients were included. Five patients died before the fifth day and in two patients, the control paracentesis yielded no ascitic fluid. In nine out of 46 cases (19.6%), spontaneous bacterial peritonitis had not resolved by day 5. In 32 out of 33 cases in which the ascitic fluid polymorphonuclear count was <250/microL at day five, the reagent strips was negative. The negative predictive value of the reagent strip at fifth day was 97% and the LR- 0.13.

CONCLUSIONS

Almost 20% of episodes of spontaneous bacterial peritonitis do not resolve with a short-course of antibiotic treatment. In view of the high negative predictive value and low likelihood ratio for a negative test, reagent strips analysis may be an alternative to conventional cytology if a 5-day antibiotic therapy is planned.

The roles of tumor necrosis factor-alpha in colon tight junction protein expression and intestinal mucosa structure in a mouse model of acute liver failure

Background

Spontaneous bacterial peritonitis (SBP) is a common clinical disease and one of the most severe complications of acute liver failure (ALF). Although the mechanism responsible for SBP is unclear, cytokines play an important role. The aim of this study was to investigate the effects of tumor necrosis factor-alpha (TNF-α) on the structure of the intestinal mucosa and the expression of tight junction (Zona Occludens 1; ZO-1) protein in a mouse model of ALF.

Methods

We induced ALF using D-galactosamine/lipopolysaccharide (GalN/LPS) or GalN/TNF-α and assessed the results using transmission electron microscopy, immunohistochemistry, Western blotting, ELISA and real-time quantitative PCR. The effects of administration of anti-TNF-α IgG antibody or anti-TNF-α R1 antibody before administration of GalN/LPS or GalN/TNF-α, respectively, on TNF-α were also assessed.

Results

Morphological abnormalities in the intestinal mucosa of ALF mice were positively correlated with serum TNF-α level. Electron microscopic analysis revealed tight junction (TJ) disruptions, epithelial cell swelling, and atrophy of intestinal villi. Gut bacteria invaded the body at sites where TJ disruptions occurred. Expression of ZO-1 mRNA was significantly decreased in both ALF models, as was the level of ZO-1 protein. Prophylactic treatment with either anti-TNF-α IgG antibody or anti-tumor necrosis factor-a receptor1 (anti-TNF-α R1) antibody prevented changes in intestinal tissue ultrastructure and ZO-1 expression.

Conclusion

TNF-α affects the structure of the intestinal mucosa, decreases expression of ZO-1, and affects the morphology of the colon in a mouse model of ALF. It also may participate in the pathophysiological mechanism of SBP complicated to ALF.

The roles of tumor necrosis factor-alpha in colon tight junction protein expression and intestinal mucosa structure in a mouse model of acute liver failure

BACKGROUND

Spontaneous bacterial peritonitis (SBP) is a common clinical disease and one of the most severe complications of acute liver failure (ALF). Although the mechanism responsible for SBP is unclear, cytokines play an important role. The aim of this study was to investigate the effects of tumor necrosis factor-alpha (TNF-alpha) on the structure of the intestinal mucosa and the expression of tight junction (Zona Occludens 1; ZO-1) protein in a mouse model of ALF.

METHODS

We induced ALF using D-galactosamine/lipopolysaccharide (GalN/LPS) or GalN/TNF-alpha and assessed the results using transmission electron microscopy, immunohistochemistry, Western blotting, ELISA and real-time quantitative PCR. The effects of administration of anti-TNF-alpha IgG antibody or anti-TNF-alpha R1 antibody before administration of GalN/LPS or GalN/TNF-alpha, respectively, on TNF-alpha were also assessed.

RESULTS

Morphological abnormalities in the intestinal mucosa of ALF mice were positively correlated with serum TNF-alpha level. Electron microscopic analysis revealed tight junction (TJ) disruptions, epithelial cell swelling, and atrophy of intestinal villi. Gut bacteria invaded the body at sites where TJ disruptions occurred. Expression of ZO-1 mRNA was significantly decreased in both ALF models, as was the level of ZO-1 protein. Prophylactic treatment with either anti-TNF-alpha IgG antibody or anti-tumor necrosis factor-a receptor1 (anti-TNF-alpha R1) antibody prevented changes in intestinal tissue ultrastructure and ZO-1 expression.

CONCLUSION

TNF-alpha affects the structure of the intestinal mucosa, decreases expression of ZO-1, and affects the morphology of the colon in a mouse model of ALF. It also may participate in the pathophysiological mechanism of SBP complicated to ALF.

Aeromonas spontaneous bacterial peritonitis: a highly fatal infectious disease in patients with advanced liver cirrhosis

BACKGROUND/PURPOSE

Aeromonas infections, rarely reported in Western countries, are not uncommon infectious diseases in Taiwan. The clinical manifestations and prognostic factors of Aeromonas spontaneous bacterial peritonitis (SBP) in patients with liver cirrhosis were investigated.

METHODS

We reviewed the medical charts and microbiological records of liver cirrhosis patients with Aeromonas SBP between January 1990 and December 2005, in a medical center in southern Taiwan.

RESULTS

Thirty-one liver cirrhosis patients developed Aeromonas SBP within a 16-year period. The majority (26, 84%) had concurrent Aeromonas bacteremia. A. sobria (55%) and A. hydrophila (45%) were the causative species. The predominant clinical manifestations included fever (84%), abdominal pain (74%), hypotension on admission (48%), altered mental status (45%), and acute renal failure (42%). Gram-negative bacilli were found in Gram staining of ascitic fluids in 27% of 26 patients, while aeromonads were isolated from ascitic fluids in 55% of 31 patients. The yield rate of ascitic fluid cultures decreased greatly, if paracentesis was performed at > 3 hours after the administration of antimicrobial therapy. All but one patient received in-vitro-active antimicrobial agents within 48 hours, but the all-cause mortality rate was 56%. Initial high Pitt's bacteremia score was independently associated with a fatal outcome in multivariate analysis.

CONCLUSION

Aeromonas SBP is a fatal disease, and must be included in the differential diagnosis of SBP in patients with advanced liver cirrhosis in endemic areas.

Genetic background of Escherichia coli isolates from patients with spontaneous bacterial peritonitis: relationship with host factors and prognosis

Spontaneous bacterial peritonitis (SBP) is a severe complication in patients with cirrhosis and ascites. It is predominantly caused by Escherichia coli. The phylogenetic group and virulence genotype of E. coli isolates causing SBP were investigated, and the association of these characteristics with host factors and prognosis was examined. Seventy-six episodes of E. coli SBP that occurred over a 9-year period were studied. The phylogenetic group of the isolates and the presence of 36 virulence factor genes were investigated. The influence of bacterial and host factors on in-hospital mortality was assessed by multiple logistic regression. Phylogenetic groups A, B1, B2 and D were found in 26%, 4%, 46% and 24% of the isolates, respectively. Virulence factor genes were more frequent in B2 isolates than in non-B2 isolates (mean virulence score 15.4 vs. 7.3, p <10(-4)). Ciprofloxacin resistance was significantly associated with non-B2 groups and a low virulence score. Host factors independently associated with a shift from B2 to non-B2 isolates were norfloxacin prophylaxis (OR 13.01, p 0.0213) and prothrombin ratio (OR 1.04 for a 10% decrease, p 0.0211). The model for end-stage liver disease (MELD) score (OR 1.83, p 0.0007) and hospital-acquired SBP (OR 4.13, p 0.0247) were independent predictors of in-hospital mortality. In contrast, outcome was not influenced by the phylogenetic group or the virulence profile. These findings indicate that the characteristics of E. coli isolates causing SBP vary with the severity of liver disease and with fluoroquinolone prophylaxis. Host factors are more important than bacterial factors in predicting in-hospital mortality.

Amplification of bacterial DNA does not distinguish patients with ascitic fluid infection from those colonized by bacteria

OBJECTIVE

To evaluate 16S ribosomal RNA (rRNA) gene amplification to diagnose spontaneous bacterial peritonitis (SBP).

PATIENTS AND METHODS

According to a retrospective protocol, 31 patients with portal hypertensive ascites (serum to ascites albumin gradient > or = 1.1 g/dL) were studied. Ascitic fluid was analyzed as follows: Gram stain, aerobic and anaerobic cultures, polymorphonuclear cell count, and biochemical tests. Bacterial DNA was detected by polymerase chain reaction.

RESULTS

There were 8 episodes of SBP and 4 episodes of bacterascites (BA). Culture was positive in 4 of 8 cases of SBP and bacterial DNA was positive in 7 of 8 cases of SBP. Bacterial DNA was positive in 3 of 4 cases of BA and in 8 of 28 cases of culture-negative non-neutrocytic ascites (CNNNA). The PELD score, serum to albumin ascites gradient, and mortality showed no statistical difference between patients with CNNNA and the result of the bacterial DNA analysis.

CONCLUSIONS

Although the 16S rRNA gene amplification was better than culture to diagnose SBP, bacterial DNA does not seem to allow a distinction between ascites infection and ascites colonization.

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.

Long-term clinical outcome of large volume paracentesis with intravenous albumin in patients with spontaneous bacterial peritonitis: a randomized prospective study

BACKGROUND AND AIM

Large volume paracentesis (LVP) with plasma volume expansion has been used for tense or refractory ascites. However, still in question is whether it is safe and effective for the treatment of spontaneous bacterial peritonitis (SBP). We addressed this issue and conducted a study to assess safety and long-term outcome of LVP in cirrhotic patients with SBP.

METHODS

Forty-two randomly assigned cirrhotic patients with SBP were classified into two groups; Group 1 included 21 patients who were treated with LVP and intravenous albumin; and Group 2 included 21 patients who were treated with diuretics and intravenous albumin.

RESULTS

The overall cumulative survival rate was poor in patients with SBP (42.5% and 22.5% at 6 and 12 months, respectively). At 7 days after treatment, the blood tests were similar between the two groups. In the ascitic fluid, the white blood cell counts decreased significantly and the protein concentrations tended to increase in both groups. In-hospital days, resolution rate of SBP, and in-hospital mortality rate were similar between the two groups. Although complication rates tended to be slightly higher in Group 1, long-term cumulative survivals were similar between Group 1 and Group 2. LVP was effective in removing abdominal discomfort in patients with tense ascites without serious complication.

CONCLUSIONS

LVP with intravenous albumin was as effective as diuretics with intravenous albumin for the treatment of SBP with similar mortality. LVP with intravenous albumin might be feasible for the treatment of tense or refractory ascites in cirrhotic patients with SBP.

Tumor necrosis factor-alpha induces apoptosis of enterocytes in mice with fulminant hepatic failure

AIM: To explore the alterations of intestinal mucosa morphology, and the effects of tumor necrosis factor α (TNFα) on enterocyte apoptosis in mice with fulminant hepatic failure (FHF).

METHODS: Liver damage was induced by lipopolysaccharide (LPS)/TNF-α in D-galactosamine (GalN) sensitized BALB/c mice. There were 40 mice in normal saline (NS)-treated group, 40 mice in LPS-treated group, 40 mice in GalN-treated group, 120 mice in GalN/ LPS-treated group and 120 mice in GalN/ TNFα-treated group. Each group was divided into five subgroups of eight mice each. Serum samples and liver, intestinal tissues were respectively obtained at 2, 6, 9, 12 and 24 h after administration. Anti-TNFα monoclonal antibody was injected intravenously into GalN/LPS-treated mice. Serum TNFα levels were determined by enzyme-linked immunosorbent assays (ELISA). Serum ALT levels were determined using an automatic analyzer. The intestinal tissues were studied under light microscope and electron microscope at 2, 6, 9, 12 and 24 h in mice with fulminant hepatic failure, respectively. Enterocyte apoptosis was determined by terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL) method. The expression of tumor necrosis factor receptor 1 (TNFR1) in intestinal tissue was tested by immunohistochemistry Envision Two Steps.

RESULTS: Gut mucosa was morphologically normal at all time points in all groups, but typical apoptotic cells could be seen in all experimental groups under electron micro-scope. Apoptosis rate of gut mucosal epithelial cells were significantly increased at 6, 9 and 12 h, peaked at 12 h in mice with fulminant hepatic failure. TNFα induced apoptosis of enterocytes in mice with FHF. The integrated OD (IOD) levels of TNFα receptor 1 protein expressed in the intestine of mice with GalN/LPS and GalN/ TNFα-induced FHF at 2, 6, 9, 12 and 24 h after GalN/LPS and GalN/TNFα administration were 169.54±52.62/905.79±111.84, 11350.67±2133.26/28160.37±4601.67, 25781.00±2277.75/122352.30±49412.40, 5241.53±3007.24/49157.93±9804.88, 7086.13±1031.15/3283.45±127.67, respectively, compared with those in control groups (with NS, LPS and GalN administration, respectively). IOD level of TNFR1 changed significantly at 6, 9 and 12 h after GalN/LPS and GalN/TNFα administration. The expression of TNFR1 protein was significantly higher at 9 h after GalN/LPS and GalN/TNFα administration than that in control groups. Protein expression of TNFR1 was positively correlated with enterocyte apoptosis.

CONCLUSION: TNFα can induce apoptosis of enterocytes in mice with FHF. Anti-TNFα IgG can inhibit this role.

Infected and noninfected ascites in pediatric patients

OBJECTIVES

To determine the prevalence of spontaneous bacterial peritonitis, ascites with bacterial infection and noninfected ascites in pediatric patients with portal hypertensive ascites and to compare the clinical and laboratory features of infected and noninfected ascites.

METHODS

Forty-one episodes of portal hypertensive ascites (serum-ascites albumin gradient >1.1 g/dL) in 31 patients were studied. Median age was 2.9 years. Twenty-four (77.4%) patients were cirrhotic and 20 (83.3%) were classified as Child-Pugh C. Median pediatric end-stage liver disease score was 18.5. The following ascites features were assessed: polymorphonuclear neutrophil cell count, cytology, pH, concentration of glucose, lactic dehydrogenase, total protein and albumin, Gram stain and bacteriological culture. Blood was sampled for complete blood count, coagulation studies, liver and renal function tests. Groups were compared by Mann-Whitney and chi tests (P < 0.05).

RESULTS

Noninfected ascites were observed in 29 of 41 samples, spontaneous bacterial peritonitis in eight of 41 and ascites with bacterial infection in four of 41. The most prevalent clinical features were fever, voluminous ascites and encephalopathy, but there were no significant differences in the clinical features of the groups. All patients with infected ascites were cirrhotic. There was no statistical difference in Child-Pugh or pediatric end-stage liver disease status between patients with infected and noninfected ascites. Culture of ascetic fluid was positive in four of eight cases of spontaneous bacterial peritonitis. Gram-negative rods were the most prevalent bacteria cultured. Except for serum albumin, no statistical differences in biochemical markers were observed between patients with infected and noninfected ascites.

CONCLUSIONS

The prevalence of infected ascites was 29.2%. With the exception of serum albumin, there were no differences in the clinical and biochemical features of patients with infected ascites and noninfected ascites.

Effect of TNF-α on tight junctions between the epithelial cells of intestinal mucosal barrier

AIM: To investigate the effect of TNF-α on tight junctions between the epithelial cells of the intestinal mucosal barrier.

METHODS: Colon cancer cell line (CaCo-2) was cultured. The localizations of zonula occluden-1 (ZO-1) in CaCo-2 epithelial cells were detected by immunofluorescence after exposure to TNF-α (0, 50, 100 and 200 mg/L) for 24 h and the TNF-α treatment with 100 mg/L for 0, 4, 8 and 24 h. The expression level of ZO-1 was analyzed by semi-quantitative reverse transcriptase-PCR after exposure to TNF-α with the above time and concentration.

RESULTS: Different expression levels of ZO-1 depended on different time and concentration of TNF-α treated on CaCo-2 epithelial cells. The integrity of tight junctions was disrupted and the expression level of ZO-1 decreased after treatment with TNF-α. The intensity of the immunofluorescent signal was less intensive after exposure to TNF-α 100 and 200 mg/L than that to 0 and 50 mg/L. The intensity of the immunofluorescent signal was less intensive after exposure to TNF-α 100 mg/L for 24 hours than those for 0 h, 4 h and 8 h. The RT-PCR results showed that after CaCo-2 cells were treated for 24h with the indicated concentrations (0, 50, 100 and 200 mg/L) of TNF-α and the TNF-α treatment with 100 mg/L for 0 h, 4 h, 8 h and 24 h, the expression levels of ZO-1 mRNA in CaCo-2 cells were decreased by TNF-α with 100 mg/L for 24 h, as compared with control (P < 0.01).

CONCLUSION: Tight junctions between the epithelial cells of the intestinal mucosal barrier can be destroyed by TNF-α, and decreased expression level of ZO-1 induced by TNF-α is one of the most important molecular mechanisms.

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.