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.

Risk factors predicting nosocomial, healthcare-associated and community-acquired infection in spontaneous bacterial peritonitis and survival outcome

Aim of the study

To determine risk factors predicting nosocomial, healthcare-associated and community-acquired infection in spontaneous bacterial peritonitis (SBP) and survival outcome.

Material and methods

This prospective observational study included confirmed cases of cirrhosis with ascites requiring paracentesis, age > 18 years, either gender, any aetiology and Child-Turcotte-Pugh (CTP) stage, with or without cirrhosis-related complications. Patient data included age, gender, co-morbidity, model for end-stage liver disease (MELD) score, CTP score, cirrhosis-related complications, details of previous hospitalization, ascitic tapping and antibiotics instituted. SBP was diagnosed as ascitic fluid polymorphonuclear leucocyte count greater than 250/mm³ (0.25 × 10⁹/l) and/or culture positivity for a single organism. Statistics - chi square test, Mann-Whitney U test, ANOVA, survival plot. A p value < 0.05 was statistically significant.

Results

610 cases fulfilled the criteria for inclusion. 122 (20%) patients had SBP: community-acquired SBP 37 (30.3%), nosocomial SBP 19 (16.5%) and healthcare-associated SBP 66 (54.5%). The majority were men (106; 86%) with median age of 51.5 (27-78) years. A significantly higher percentage of community-acquired SBP belonged to CTP class B. Thirtytwo and 7 patients respectively were blood and ascitic fluid culture positive. Significant nosocomial SBP were blood culture positive (p < 0.02). The most common isolates were E. coli followed by Klebsiella. Survival plot analysis at 3 months showed the worst survival for nosocomial SBP (p = 0.0009).

Conclusions

Prevalence of SBP in our study was 20%, the majority with healthcare-associated SBP belonging to CTP C. Patients with nosocomial SBP had significant bacteremia with high mortality.

A multicenter prospective study of infections related morbidity and mortality in cirrhosis of liver

BACKGROUND AND AIMS

Infections are a common and serious complication among patients with cirrhosis. We assessed the epidemiology, risk factors, and clinical consequences of bacterial infections in cirrhotic patients.

METHODS

In this multicenter prospective study, all patients with cirrhosis of liver with different infections were analyzed. Infections were classified as community-acquired (CA), healthcare-associated (HCA), or hospital-acquired (HA). Site of infection and characteristics of bacteria were recorded; effect on liver function and 30-day survival were evaluated.

RESULTS

One hundred and six out of 420 (25 %) patients with cirrhosis of liver had infection. Infection rate among indoor patients was 37.5 % (92/245) and among outdoor patients was 8 % (14/175). Out of 106 patients, CA, HCA, and HA were seen in 19.8 %, 50 %, and 30.2 %, respectively. Spontaneous bacterial peritonitis (31.1 %), urinary tract infections (22.6 %), and pneumonia and cellulitis (11.3 % each) were common infections. Gram-negative bacteria (54 %) were more common than Gram-positive cocci (46 %). Multidrug resistant (MDR) organisms were seen in 41.7 % of patients. Most of the MDR organisms were seen in HCA and HA patients. The degree of liver impairment was significantly more severe in patients with infection. Independent predictor of infection was high Child-Turcott-Pugh (CTP) class (p = 0.006, Child B vs. A (odds ratio (OR) 3.04 95 % CI = 1.63 to 5.68) and Child C vs. A (OR 4.17 95 % CI = 2.12 to 8.19). Overall in-hospital mortality was 7.6 %. Patients with infection had increased mortality at 30-day follow up compared to those without infection (23.5 % vs. 2.2 %; p<0.001).

CONCLUSIONS

Infections are one of the important causes of morbidity and mortality in patients with cirrhosis of liver. The most frequent infections are HCA and HA. Infection predisposes to deterioration of liver function and increases mortality. Cirrhotic patients should be monitored closely for infections especially those with Child class B and C.