Predictors of fifty days in-hospital mortality in decompensated cirrhosis patients with spontaneous bacterial peritonitis

Role of IL-6, TNF-α and VCAM-1 as predictors of renal impairment in patients with spontaneous bacterial peritonitis

BACKGROUND

Multiple mechanisms may contribute to the occurrence of renal impairment (RI) in patients with spontaneous bacterial peritonitis (SBP). One such mechanism is systemic inflammatory response syndrome, which involves the release of pro-inflammatory cytokines (tumour necrosis factor [TNF]-α, interleukin [IL]-6 and vascular cell adhesion molecule [VCAM]-1). The goal of this research was to evaluate the role of IL-6, TNF-α and VCAM-1 as potential predictors of RI and mortality in cirrhotic patients with SBP.

METHODS

This study included 90 cirrhotic patients with SBP, divided into two equal groups: group A was patients without RI and group B was patients with RI. Based on mortality outcomes, the patients were further categorized into group 1 (recovery, n=70) and group 2 (death, n=20). TNF-α, IL-6 and VCAM-1 serum levels were measured using enzyme-linked immunosorbent assay.

RESULTS

RI occurred in 50% (45/90) of the study population. Among the 90 patients, 10 (11.1%) had elevated IL-6 levels, 8 (8.9%) had elevated TNF-α levels and 6 (6.7%) had elevated VCAM-1 levels. There were no significant variations in cytokine levels between groups A and B. With an area under the curve of 0.5, the three cytokines showed comparable sensitivity and specificity as predictors of RI.

CONCLUSIONS

The use of TNF-α, IL-6 and VCAM-1 as predictive markers for RI and mortality in SBP patients is not recommended, as these biomarkers demonstrated limited diagnostic value.

Predictors of in-hospital mortality among cirrhotic patients in Ethiopia: A multicenter retrospective study

BACKGROUND

In Ethiopia, cirrhosis is the 6th leading cause of death and is responsible for high hospitalization and mortality rates. However, until now, factors affecting in-hospital mortality of patients with liver cirrhosis are poorly understood. This study assessed the predictors of in-hospital mortality among cirrhotic patients in Ethiopia.

METHODS

A retrospective cross-sectional study using data collected from the electronic medical records of patients who were admitted for complications of liver cirrhosis between January 1, 2023, and March 31, 2024, in the medical wards of Adera Medical Center, St. Paul's Hospital Millennium Medical College, and Tikur Anbessa Specialized Hospital. Frequency and cross-tabulation were used for descriptive statistics. Predictor variables with a p-value <0.25 in bivariate analyses were included in the logistic regression.

RESULTS

Of the 299 patients included in the final analysis, the majority (79.6%) were males, and the median age of the study participants was 45 (IQR, 36-56) years. Hepatitis B virus (32.1%) was the most common etiology, followed by alcohol (30.1%) and hepatitis C virus (13.4%). Ascites (69.2%), upper gastrointestinal bleeding (50.5%), and hepatic encephalopathy (44.8%) were the most common forms of presentation. The in-hospital mortality rate was 25.4%. West Haven grade III or IV hepatic encephalopathy (AOR: 12.0; 95% CI 2.33-61.63; P < 0.01), hepatocellular carcinoma (AOR: 9.05; 95% CI 2.18-37.14; P: 0.01), history of previous admission within one year period (AOR: 6.80; 95% CI 2.18-21.18; P < 0.01), acute kidney injury (AOR: 6.47; 95% CI 1.77-23.64; P < 0.01), and model for end-stage liver disease - sodium score (AOR: 1.17; 95% CI 1.05-1.30; P: 0.02), were found to be predictors of in-hospital mortality.

CONCLUSION

In-hospital mortality of cirrhotic patients is high in Ethiopia. West Haven grade III or IV hepatic encephalopathy is the leading cause of mortality. Hence, prompt identification and management of hepatic encephalopathy and its precipitant at an earlier stage is crucial for better treatment outcomes and survival.

Predictors of Mortality in Patients with Spontaneous Bacterial Peritonitis

Introduction

Despite treatment with antibiotic therapy, spontaneous bacterial peritonitis (SBP) accounts for approximately 20-40% mortality in hospitalized patients. The data is scarce regarding mortality predictors in SBP. Recently, multiple factors have been studied for effectiveness in prognosis prediction in SBP. Therefore, in this study, our main objective was to evaluate the mortality predictors in SBP.

Materials and methods

This prospective observational study was conducted at the Department of Hepatogastroenterology, from January 2022 to June 2023. All the patients aged between 18 and 65 years having decompensated chronic liver disease and diagnosed with SBP were enrolled in the study. The excluded population comprised of those who were on hemodialysis, those having history of any solid organ malignancy or transplantation or patients suffering from infections such as those caused by human immunodeficiency virus (HIV) or infections other than SBP. These patients were followed during the hospital stay and after the discharge monthly for 3 months and then at 6 months to assess mortality.

Results

A total of 142 cirrhotic patients having SBP were enrolled in the study. Among them, most of them were males [98 (69%)]. Viral hepatitis (65.4%) was the most common cause of cirrhosis in studied population. On univariate analysis, serum total leukocyte count (TLC), international normalized ratio (INR), ascitic TLC, ascitic neutrophils, ascitic lactate, ascitic LDH, CTP score, MELD-Na were significantly higher while serum albumin was significantly lower in the patients who died as compared to those who survived. However, on multivariate cox regression analysis, high serum TLC (p = 0.013), ascitic fluid lactate (p < 0.001) along with high CTP (p = 0.041) and MELD-Na score (p = 0.037) at presentation were the factors that were identified as an independent poor prognostic factors in SBP population.

Conclusion

Cirrhotic patients with SBP are at increased risk of mortality. In our study we observed that high prognostic scores such as CTP and MELD-Na at presentation along with increased white blood cell counts and high ascitic fluid lactate levels at presentation are the potential and reliable predictors of mortality in SBP patients.

How to cite this article

Kumar D, Kumar V, Khan RTY, et al. Predictors of Mortality in Patients with Spontaneous Bacterial Peritonitis. Euroasian J Hepato-Gastroenterol 2024;14(2):125-128.

Critical care outcomes in decompensated cirrhosis: a United States national inpatient sample cross-sectional study

BACKGROUND

Prior assessments of critical care outcomes in patients with cirrhosis have shown conflicting results. We aimed to provide nationwide generalizable results of critical care outcomes in patients with decompensated cirrhosis.

METHODS

This is a retrospective study using the National Inpatient Sample from 2016 to 2019. Adults with cirrhosis who required respiratory intubation, central venous catheter placement or both (n = 12,945) with principal diagnoses including: esophageal variceal hemorrhage (EVH, 24%), hepatic encephalopathy (58%), hepatorenal syndrome (HRS, 14%) or spontaneous bacterial peritonitis (4%) were included. A comparison cohort of patients without cirrhosis requiring intubation or central line placement for any principal diagnosis was included.

RESULTS

Those with cirrhosis were younger (mean 58 vs. 63 years, p < 0.001) and more likely to be male (62% vs. 54%, p < 0.001). In-hospital mortality was higher in the cirrhosis cohort (33.1% vs. 26.6%, p < 0.001) and ranged from 26.7% in EVH to 50.6% HRS. Mortality when renal replacement therapy was utilized (n = 1580, 12.2%) was 46.5% in the cirrhosis cohort, compared to 32.3% in other hospitalizations (p < 0.001), and was lowest in EVH (25.7%) and highest in HRS (51.5%). Mortality when cardiopulmonary resuscitation was used was increased in the cirrhosis cohort (88.0% vs. 72.1%, p < 0.001) and highest in HRS (95.7%).

CONCLUSIONS

One-third of patients with cirrhosis requiring critical care did not survive to discharge in this U.S. nationwide assessment. While outcomes were worse than in patients without cirrhosis, the results do suggest better outcomes compared to previous studies.

Clinical Significance of Ascitic Fluid Polymorphonuclear Leukocyte Percentage in Patients With Cirrhosis Without Spontaneous Bacterial Peritonitis

INTRODUCTION

Absolute polymorphonuclear leukocyte (PMN) count (PMN-C) ≥250 cells/mm 3 in ascites is the diagnostic hallmark of spontaneous bacterial peritonitis (SBP) and is associated with high morbidity and mortality. However, the clinical significance of ascitic PMN percentage (PMN-%) and PMN-C in the absence of SBP as additional biomarkers for mortality and future incidence of SBP has not been determined.

METHODS

This retrospective cohort included adults with cirrhosis undergoing first-recorded paracentesis with initial PMN-C < 250 cells/mm 3 at 2 tertiary medical centers between 2015 and 2020. Patients with prior SBP were excluded. Outcomes were death and SBP development. Cox regression estimated hazard ratios (HRs) for risk of death and SBP development and Akaike information criterion to compare model fit.

RESULTS

Three hundred eighty-four adults (73% male, median age 58 years, 67% with alcohol-associated cirrhosis, median PMN-C 14 cells/mm 3 [interquartile range 5-34], and median PMN-% 10% [interquartile range 4-20]) were included in this study. Univariate risk of death increased 10% per 25-unit increase in PMN-C (95% confidence interval 1.01-1.21, P = 0.03) and 19% per 10-unit increase in PMN-% (95% confidence interval 1.06-1.33, P = 0.003) with PMN-% demonstrating better model fit in assessing mortality risk (Akaike information criterion: 1,044 vs 1,048, respectively). In models adjusted for age, chronic hepatitis C virus infection, and Model for End-Stage Liver Disease-Sodium, PMN-% was associated with risk of death (PMN-% 10%-29%, HR 1.17, P = 0.50; PMN-% ≥ 30% group, HR 1.94, P = 0.03; vs PMN-% < 10%) and SBP development (PMN-% 10%-29%, HR 1.68, P = 0.07; PMN-% ≥ 30%, HR 3.48, P < 0.001; vs PMN-% < 10%).

DISCUSSION

Our results suggest PMN-% at first paracentesis represents a better biomarker compared with PMN-C for assessing risk of death and future SBP development in patients with PMN-C < 250 cells/mm 3 .

Management of sepsis in a cirrhotic patient admitted to the intensive care unit: A systematic literature review

BACKGROUND

Sepsis is a severe medical condition that occurs when the body's immune system overreacts to an infection, leading to life-threatening organ dysfunction. The "Third international consensus definitions for sepsis and septic shock (Sepsis-3)" defines sepsis as an increase in sequential organ failure assessment score of 2 points or more, with a mortality rate above 10%. Sepsis is a leading cause of intensive care unit (ICU) admissions, and patients with underlying conditions such as cirrhosis have a higher risk of poor outcomes. Therefore, it is critical to recognize and manage sepsis promptly by administering fluids, vasopressors, steroids, and antibiotics, and identifying and treating the source of infection.

AIM

To conduct a systematic review and meta-analysis of existing literature on the management of sepsis in cirrhotic patients admitted to the ICU and compare the management of sepsis between cirrhotic and non-cirrhotic patients in the ICU.

METHODS

This study is a systematic literature review that followed the PRISMA statement's standardized search method. The search for relevant studies was conducted across multiple databases, including PubMed, Embase, Base, and Cochrane, using predefined search terms. One reviewer conducted the initial search, and the eligibility criteria were applied to the titles and abstracts of the retrieved articles. The selected articles were then evaluated based on the research objectives to ensure relevance to the study's aims.

RESULTS

The study findings indicate that cirrhotic patients are more susceptible to infections, resulting in higher mortality rates ranging from 18% to 60%. Early identification of the infection source followed by timely administration of antibiotics, vasopressors, and corticosteroids has been shown to improve patient outcomes. Procalcitonin is a useful biomarker for diagnosing infections in cirrhotic patients. Moreover, presepsin and resistin have been found to be reliable markers of bacterial infection in patients with decompensated liver cirrhosis, with similar diagnostic performance compared to procalcitonin.

CONCLUSION

This review highlights the importance of early detection and management of infections in cirrhosis patients to reduce mortality. Therefore, early detection of infection using procalcitonin test and other biomarker as presepsin and resistin, associated with early management with antibiotics, fluids, vasopressors and low dose corticosteroids might reduce the mortality associated with sepsis in cirrhotic patients.

Emergency medicine updates: Spontaneous bacterial peritonitis

INTRODUCTION

Spontaneous bacterial peritonitis (SBP) is a common infection in patients with cirrhosis and ascites and is associated with significant risk of mortality. Therefore, it is important for emergency medicine clinicians to be aware of the current evidence regarding the diagnosis and management of this condition.

OBJECTIVE

This paper evaluates key evidence-based updates concerning SBP for the emergency clinician.

DISCUSSION

SBP is commonly due to Gram-negative bacteria, but infections due to Gram-positive bacteria and multidrug resistant bacteria are increasing. The typical presentation of SBP includes abdominal pain, worsening ascites, fever, or altered mental status in a patient with known liver disease; however, some patients may be asymptomatic or present with only mild symptoms. Paracentesis is the diagnostic modality of choice and should be performed in any patient with ascites and concern for SBP or upper gastrointestinal bleeding, or in those being admitted for a complication of cirrhosis. Ultrasound should be used to optimize the procedure. An ascites absolute neutrophil count (ANC) ≥ 250 cells/mm³ is diagnostic of SBP. Ascitic fluid should be placed in blood culture bottles to improve the culture yield. Leukocyte esterase reagent strips can be used for rapid diagnosis if available. While many patients will demonstrate coagulation panel abnormalities, routine transfusion is not recommended. Management traditionally includes a third-generation cephalosporin, but specific patient populations may require more broad-spectrum coverage with a carbapenem or piperacillin-tazobactam. Albumin infusion is associated with reduced risk of renal impairment and mortality.

CONCLUSIONS

An understanding of literature updates can improve the care of patients with suspected SBP.

Initial treatment response and short-term mortality of spontaneous bacterial peritonitis in cirrhotic patients with hepatocellular carcinoma

This study aimed to investigate the initial treatment response and short-term mortality of spontaneous bacterial peritonitis (SBP) in cirrhotic patients with hepatocellular carcinoma (HCC) compared with those without HCC. A total of 245 patients with liver cirrhosis diagnosed with SBP between January 2004 and December 2020 were included. Of these, 107 (43.7%) were diagnosed with HCC. Overall, the rates of initial treatment failure, 7-day and 30-day mortality were 91 (37.1%), 42 (17.1%), and 89 (36.3%), respectively. While the baseline CTP score, MELD score, culture-positive rate, and rates of antibiotic resistance did not differ between both groups, patients with HCC had a higher rate of initial treatment failure than those without HCC patients (52.3% vs. 25.4%, P < 0.001). Similarly, 30-day mortality was also significantly higher in patients with HCC (53.3% vs. 23.2%, P < 0.001). In the multivariate analysis, HCC, renal impairment, CTP grade C, and antibiotic resistance were independent factors for initial treatment failure. Furthermore, HCC, hepatic encephalopathy, MELD score, and initial treatment failure were independent risk factors for 30-day mortality, with statistically significant poor survival outcomes in patients with HCC (P < 0.001). In conclusion, HCC is an independent risk factor for initial treatment failure and high short-term mortality in patients with cirrhosis with SBP. It has been suggested that more attentive therapeutic strategies are required to improve the prognosis of patients with HCC and SBP.

The Usefulness of Mayo End-stage Liver Disease (MELD) and MELD-Sodium (MELD-Na) Scores for Predicting Mortality in Cirrhotic Patients With Spontaneous Bacterial Peritonitis

BACKGROUND

Spontaneous bacterial peritonitis (SBP) is a common infection in patients with cirrhosis and ascites. Currently, the accuracy of the model for end-stage liver disease (MELD) and MELD-sodium (MELD-Na) as prognostic scores in this cohort is unclear. This study aimed to evaluate and compare the accuracy of MELD and MELD-Na for predicting 90-day mortality and determine whether the mortality risk estimates they provide accurately reflect the poor prognosis of patients with SBP Methods: Patients with cirrhosis and SBP were retrospectively identified from ascitic fluid samples sent for microscopy, culture and sensitivity analysis (1/1/18-31/12/20) and a previous audit. MELD and MELD-Na scores at diagnosis were calculated and associations with 90-day mortality were assessed using univariate analysis. Receiver operator characteristic curves were compared, and standardised mortality ratios (SMRs) were calculated by comparing the number of deaths observed to the number predicted by MELD and MELD-Na.

RESULTS

Of the 567 patients identified, 15 patients with cirrhosis and SBP were included. The 90-day mortality rate was 66.7% (10/15). Only concurrent hyponatremia (<135mmol/L) was associated with mortality (6/10 non-survivors vs 0/5 survivors, p=0.04). The difference in MELD and MELD-Na's C-statistic was not significant: 0.66 (95% Cl:0.35-0.98) vs 0.74 (95% Cl:0.47-1.0) respectively (p=0.72). Patients with a MELD-Na >18.5 had significantly higher 90-day mortality than patients with MELD-Na ≤18.5 (88.9% (8/9) vs. 33.3% (2/6), p=0.05). The SMR (95% Cl) for each MELD decile evaluated was 33.3 (0-79.5), 11.1 (0.2-22.0) and 3.4 (0-7.0) for scores ≤9,10-19 and 20-29 respectively. For each MELD-Na tertile, these were: 25 (0-59.6), 5.2 (0.1-10.3) and 2.7 (0.1-8.1) for scores <17,17-26, ≥27 respectively.

CONCLUSION

In a small cohort of patients with cirrhosis and SBP, the MELD's accuracy in predicting 90-day mortality was limited. MELD-Na's accuracy was higher but not significantly. Both scores consistently underestimated participants' mortality, therefore future studies could evaluate the accuracy of alternative prognostic scores in this patient group.

Retrospective Investigation of Factors Affecting Mortality in Spontaneous Bacterial Peritonitis

Background

Spontaneous bacterial peritonitis (SBP) is an important reason for mortality in cirrhosis. This study aimed to identify the factors associated with mortality in SBP.

Materials and methods

A total of 69 patients with cirrhosis and 74 with SBP attacks that occurred in this group were assessed. Demographic data, symptoms at admission, comorbidities, laboratory parameters, treatment protocols, causes of cirrhosis, scoring characteristics, cirrhosis complications, and mortality were analyzed.

Results

Model for end-stage liver disease (MELD; p = 0.001), sodium-MELD (p = 0.001), and Child-Pugh-Turcotte (CTP) (p < 0.001) scores were correlated with mortality in patients with SBP episodes. Hepatorenal syndrome (p = 0.001) and esophageal variceal bleeding (p < 0.001) related to mortality. Serum lactate dehydrogenase (LDH) (p = 0.007), serum leukocyte (p = 0.017), and serum hemoglobin (p = 0.010) values had a statistically significant effect on mortality in multivariate regression analysis.

Discussion

The mortality rate can be reduced by identifying factors influencing death in patients with SBP episodes.

How to cite this article

Ocak T, Gülten M. Retrospective Investigation of Factors Affecting Mortality in Spontaneous Bacterial Peritonitis. Euroasian J Hepato-Gastroenterol 2023;13(1):5-9.

Plasma Proteomic Analysis Identified Proteins Associated with Faulty Neutrophils Functionality in Decompensated Cirrhosis Patients with Sepsis

Decompensated cirrhosis (DC) is susceptible to infections and sepsis. Neutrophils and monocytes provide the first line of defense to encounter infection. We aimed to evaluate proteins related to neutrophils functionality in sepsis. 70 (DC), 40 with sepsis, 30 without (w/o) sepsis and 15 healthy controls (HC) plasma was analyzed for proteomic analysis, cytokine bead array, endotoxin, cell free DNA and whole blood cells were analyzed for nCD64-mHLADR index, neutrophils-monocytes, functionality and QRT-PCR. nCD64-mHLADR index was significantly increased (p < 0.0001) with decreased HLA-DR expression on total monocytes in sepsis (p = 0.045). Phagocytic activity of both neutrophils and monocytes were significantly decreased in sepsis (p = 0.002 and p = 0.0003). Sepsis plasma stimulated healthy neutrophils, showed significant increase in NETs (neutrophil extracellular traps) and cell free DNA (p = 0.049 and p = 0.04) compared to w/o sepsis and HC. Proteomic analysis revealed upregulated- DNAJC13, TMSB4X, GPI, GSTP1, PNP, ANPEP, COTL1, GCA, APOA1 and PGAM1 while downregulated- AHSG, DEFA1,SERPINA3, MPO, MMRN1and PROS1 proteins (FC > 1.5; p < 0.05) associated to neutrophil activation and autophagy in sepsis. Proteins such as DNAJC13, GPI, GSTP1, PNP, ANPEP, COTL1, PGAM1, PROS1, MPO, SERPINA3 and MMRN1 showed positive correlation with neutrophils activity and number, oxidative burst activity and clinical parameters such as MELD, MELD Na and Bilirubin. Proteomic analysis revealed that faulty functionality of neutrophils may be due to the autophagy proteins i.e., DNAJC13, AHSG, TMSB4X, PROS1 and SERPINA3, which can be used as therapeutic targets in decompensated cirrhosis patients with sepsis.

Development and Validation of a Prognostic Model for One-year Survival of Cirrhosis Patients with First-ever Spontaneous Bacterial Peritonitis

BACKGROUND AND AIMS

Spontaneous bacterial peritonitis (SBP) is one of the leading causes of death in patients with liver cirrhosis. We aimed to establish a prognostic model to evaluate the 1-year survival of cirrhosis patients after the first episode of SBP.

METHODS

A prognostic model was developed based on a retrospective derivation cohort of 309 cirrhosis patients with first-ever SBP and was validated in a separate validation cohort of 141 patients. We used Uno's concordance, calibration curve, and decision curve (DCA) analysis to evaluate the discrimination, calibration, and clinical net benefit of the model.

RESULTS

A total of 59 (19.1%) patients in the derivation cohort and 42 (29.8%) patients in the validation cohort died over the course of 1 year. A prognostic model in nomogram form was developed with predictors including age [hazard ratio (HR): 1.25; 95% confidence interval (CI): 0.92-1.71], total serum bilirubin (HR: 1.66; 95% CI: 1.28-2.14), serum sodium (HR: 0.94; 95% CI: 0.90-0.98), history of hypertension (HR: 2.52; 95% CI: 1.44-4.41) and hepatic encephalopathy (HR: 2.06; 95% CI: 1.13-3.73). The nomogram had a higher concordance (0.79) compared with the model end-stage liver disease (0.67) or Child-Turcotte-Pugh (0.71) score. The nomogram also showed acceptable calibration (calibration slope, 1.12; Bier score, 0.15±0.21) and optimal clinical net benefit in the validation cohort.

CONCLUSIONS

This prediction model developed based on characteristics of first-ever SBP patients may benefit the prediction of patients' 1-year survival.

Spontaneous bacterial peritonitis mortality trends of cirrhotic patients in the last decade in Constanta County

Spontaneous bacterial peritonitis (SBP) is a complication of liver cirrhosis with an increased in-hospital mortality rate. For this reason, the aim of the present study was to examine the main predictors of mortality in order to be able to identify high-risk patients in time and to guide the optimal treatment for prognosis improvement. We retrospectively collected demographic, clinical, laboratory and treatment data as well as data regarding length of stay and cost of hospitalization from 72 patients diagnosed with SBP between January 2010 and December 2019 in the Emergency Clinical Hospital St. Apostle Andrew, Constanta, Romania. Patients were divided into two groups: Those who survived and those who died. Logistic regression was used to identify a possible association between these factors and the increased risk of mortality. Univariate analysis revealed that clinical factors (fever, chills, and hepatic encephalopathy), biological factors such as serum and ascites leukocyte value, polymorphonuclear percentage (PMN), erythrocyte sedimentation rate (ESR) value, previous SBP episodes, and the presence of complications such as acute kidney injury (AKI), sepsis, and systemic inflammatory response syndrome (SIRS) were significantly associated with in-hospital mortality in patients with SBP. Multivariate analysis revealed that SIRS (P=0.0010) and fever (P=0.0258) were significantly associated with in-hospital mortality in patients with SBP. Findings of the present study suggest that, SIRS and fever were independent predictive factors of mortality in cirrhotic patients with SBP.

A retrospective analysis of cases of Spontaneous Bacterial Peritonitis in cirrhosis patients

Background & aims

Spontaneous Bacterial Peritonitis (SBP) is an infection in patients with cirrhosis and carries significant mortality. The management of SBP is evolving with the rise of multidrug resistant organisms. Our aim was to perform a retrospective analysis to determine if identification of bacteria in culture could aid in prognosis and provide information regarding optimal treatment.

Methods

We analyzed our 10-year experience of SBP in a single academic center (Northwestern Memorial Hospital). We obtained information regarding SBP prophylaxis, culture data and resistance patterns of bacteria, choice/duration of inpatient antibiotics, and key laboratory measurements and determined outcomes including mortality, hospital duration, and ICU stay.

Results

Patients with SBP had a 17.8% mortality and had culture positive SBP 34.4% of the time. Antimicrobial resistance was seen in 21.3% of cases and trended towards worsening mortality, with worsened mortality associated with first line use of piperacillin-tazobactam (p = 0.0001). Patients on SBP prophylaxis who developed SBP had improved mortality (p<0.0001) unless there was a positive culture, in which case patients had worsened mortality (p = 0.019). Patient with a higher PMN counts after repeat paracentesis had higher mortality (p = 0.02).

Conclusions

Our results show that SBP continues to be a morbid and deadly condition and identification of an organism is key in treatment. The standard initial antibiotic for SBP may need to be modified to reflect emerging resistant pathogens and gram-positive organisms. Further, antibiotic prophylaxis should be utilized only in select cases to prevent development of resistance.

Lymphocyte-To-Monocyte Ratio as the Best Simple Predictor of Bacterial Infection in Patients with Liver Cirrhosis

Background and aim: The aim of this study was to assess the diagnostic performance of new morphology-related indices and Child–Turcotte–Pugh (CTP) and Model for End-Stage Liver Disease (MELD) scores during hospitalization in predicting the onset of bacterial infection in patients with liver cirrhosis. Material and methods: A total of 171 patients (56.9% males; median age 59 years; total number of hospitalizations 209) with liver cirrhosis were included in this observational study. The diagnosis of cirrhosis was made on the basis of clinical, biochemical, ultrasonic, histological, and endoscopic findings. The neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), modified aspartate aminotransferase-to-platelet ratio index (APRI), aspartate aminotransferase-to-alanine aminotransferase ratio (AAR), Fibrosis-4 index (FIB-4), platelet-to-lymphocyte ratio (PLR), neutrophil-to-monocyte ratio (NMR), and CTP and MELD scores were calculated for the cases of patients with cirrhosis. Results: Bacterial infection was diagnosed in 60 of the 209 (28.7%) hospitalizations of patients with cirrhosis. The most common infections were urinary tract infection (UTI), followed by pneumonia and sepsis. The more severe the liver failure, the greater the bacterial infection prevalence and mortality. Patients with decompensated liver cirrhosis were infected more often than subjects with compensated cirrhosis (50.0% vs. 12.9%, p = 0.003). The calculated MELD score, CTP, NLR, LMR, AAR, monocyte count, and C-reactive protein (CRP) concentration were also related to the bacterial infection prevalence, and mortality areas under the curve (AUC) were 0.629, 0.687, 0.606, 0.715, 0.610, 0.648, and 0.685, respectively. The combined model with two variables (LMR and CTP) had the best AUC of 0.757. The most common bacteria isolated from patients with UTI were Escherichia coli, Enterococcus faecalis, and Klebsiella pneumonia. Gram-negative bacteria were also responsible for spontaneous bacterial peritonitis (SBP), and together with gram-positive streptococci and staphylococci, these microorganisms were isolated from blood cultures of patients with sepsis. Significant differences were found between CTP classification, MELD score, NLR, LMR, AAR, CRP, and PLR in patients with cirrhosis with, or without, bacterial infection. Conclusions: Bacterial infection prevalence is relatively high in patients with liver cirrhosis. Although all analyzed scores, including the LMR, NLR, aspartate aminotransferase (AST)/alanine aminotransferase (ALT), CRP, CTP, and MELD, allowed the prediction of bacterial occurrence, the LMR had the highest clinical utility, according to the area under the curve (AUC) and odds ratio (OR).

Acute kidney injury in critically ill cirrhotic patients with spontaneous bacterial peritonitis: a comparison of KDIGO and ICA criteria

INTRODUCTION

Acute kidney injury (AKI) is an important independent predictor of mortality in cirrhotic patients with spontaneous bacterial peritonitis (SBP). However, the definition of AKI in cirrhosis has been debated for many years. This study aims to compare the prediction accuracy of Kidney Disease: Improving Global Outcomes (KDIGO) and International Club of Ascites (ICA) criteria for hospital mortality in cirrhotic patients with SBP admitted to the intensive care unit (ICU).

MATERIAL AND METHODS

Two hundred and sixteen cirrhotic patients with SBP consecutively admitted to the ICU during 2010-2017 were retrospectively analyzed. Demographic parameters and clinical variables were collected with case report forms. Risk factors for hospital mortality were identified through a multivariate logistic regression analysis. The predictive value of ICA and KDIGO criteria was analyzed by the area under the receiver operating characteristic curve (AUROC). The primary endpoint was hospital mortality.

RESULTS

Overall hospital mortality in our population was 73.6%. Incidence of AKI was 83.8% and 81.5% according to the KDIGO and ICA classifications respectively, associated with increased in-hospital and 180-day mortality. The AKI was an independent risk factor for hospital mortality. The risk factor of AKI according to KDIGO was greater than that of ICA. The AUROC for in-hospital mortality for ICA and KDIGO was 0.730 and 0.752, respectively. However, the predictive ability of ICA criteria for in-hospital mortality was non-inferior to that of KDIGO criteria (p = 0.123).

CONCLUSIONS

Both ICA and KDIGO criteria were good tools with excellent prediction performance for hospital mortality in cirrhotic patients with SBP admitted to the ICU.

Model for End-Stage Liver Disease Score Predicts Development of First Episode of Spontaneous Bacterial Peritonitis in Patients With Cirrhosis

OBJECTIVE

To examine whether baseline model for end-stage liver disease (MELD) score in patients with cirrhosis and ascites predicts the future development of first spontaneous bacterial peritonitis (SBP) episode.

METHODS

A retrospective case-control study was performed at three academic centers to select patients admitted with first SBP episode (cases) and those with ascites admitted for decompensation without SBP (controls). Medical records from these centers were reviewed between January 1, 2008, and December 31, 2013. Cases and controls were matched (1:2) for age, sex, and race. Conditional logistic recession models were built to determine whether baseline MELD score (within a month before hospitalization) predicts first SBP episode.

RESULTS

Of 697 patients (308, 230, and 159 from centers A, B, and C, respectively), cases and controls were matched in 94%, 89%, and 100% at three respective centers. In the pooled sample, probability of SBP was 11%, 31%, 71%, and 93% at baseline MELD scores less than or equal to 10, from 11 to 20, from 21 to 30, and greater than 30, respectively. Compared with MELD score less than or equal to 10, patients with MELD scores from 11 to 20, 21 to 30, and greater than 30 had six- (3- to 11-), 29- (12- to 69-), and 115- (22- to 598-) folds (95% CI) risk of SBP, respectively. Based on different MELD score cutoff points, MELD score greater than 17 was most accurate in predicting SBP occurrence. Analyzing 315 patients (152 cases) with available data on ascitic fluid protein level controlling for age, sex, and center, MELD score but not ascitic fluid protein associated with first SBP episode with respective odds ratios of 1.20 (1.14 to 1.26) and 0.88 (0.70 to 1.11).

CONCLUSION

Baseline MELD score predicts first SBP episode in patients with cirrhosis and ascites.

Emerging Gram-positive bacteria and drug resistance in cirrhosis patients with spontaneous bacterial peritonitis: A retrospective study

Spontaneous bacterial peritonitis (SBP) is one of the most severe complications in liver cirrhosis (LC) patients with ascites. The aim of the present study was to retrospectively analyze the bacterial spectrum and drug resistance in ascites culture of patients with SBP. A total of 3, 189 patients with ascites were enrolled in the present study, including 912 LC patients, of which 247 had SBP. It was revealed that in the 3, 189 patients, the ratio of SBP exhibited annual increases, especially in 2015, and this trend remained when cases were divided into two groups: Group A (admission, 2011-2013) and Group B (admission, 2014-2016). The 247 SBP patients were then stratified into two groups: Group 1 (admission, 2011-2013) and Group 2 (admission, 2014-2016). The rate of infection with gram-positive bacteria (GPB) was markedly higher in Group 2 compared with Group 1. Over time, GPB and gram-negative bacteria (GNB) were increased, while the increase of GPB was greater than that of GNB. Direct bilirubin and C-reactive protein levels, and the positive rate of ascites culture in Group 2 were greater than in Group 1. Furthermore, marked differences in serological and ascitic indexes or pathogeny, as well as complications between the patients with GPB and GNB infection were observed. The results regarding drug sensitivity revealed that the resistance rate of GPB and GNB to penicillin (ampicillin) was 100%, while the resistance rate to amikacin, imipenem, meropenem and piperacillin/tazobactam was 0% for GNB, and similarly, the resistance rate to vancomycin, teicoplanin, amikacin and linezolid was 0% for GPB. The results suggested that combined use of ampicillin/sulbactam or piperacillin/tazobactam should be selected forempirical therapy. In cases of nosocomial infection, these drugs should be combined with vancomycin, linezolid or teicoplanin when required.

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.

Scoring systems for prediction of mortality in decompensated liver cirrhosis: A meta-analysis of test accuracy

AIM

To compare the accuracy of the scoring systems Child-Turcotte-Pugh (CTP), Model for End-stage Liver Disease score (MELD), MELD-Na, and MELD to Serum Sodium ratio (MESO) to predict the mortality in decompensated liver cirrhosis.

METHODS

The PubMed, Web of Science, Cochrane Library, EMBASE, and Ovid databases were systematically searched from inception to September 2018 for relevant articles, and we evaluated the quality of the included studies. The accuracy of scoring systems was analyzed with Stata 12 and MetaDiSc 1.4.

RESULTS

Sixteen studies involving 2337 patients were included. The pooled areas under the summary receiver operating characteristic curves (AUROCs) of CTP, MELD, MELD-Na, and MESO to predict mortality were 0.81, 0.78, 0.85, and 0.86, respectively. Within 3 mo, the AUROCs of CTP, MELD, and MELD-Na in predicting mortality were 0.78, 0.76, and 0.89, respectively. The AUROCs of CTP, MELD, and MELD-Na at 3 mo were 0.86, 0.78, and 0.86, respectively. The AUROCs of CTP, MELD, and MELD-Na at 6 mo were 0.91, 0.83, and 0.90, respectively. The AUROCs of CTP, MELD, and MELD-Na at 12 mo were 0.72, 0.75 and 0.84, respectively. In cirrhotic patients with bleeding, the AUROCs of CTP and MELD were 0.76 and 0.88, respectively.

CONCLUSION

MESO has the highest AUROC in all assessed scoring systems. Considering the different time points, MELD-Na has good accuracy in predicting the mortality of decompensated liver cirrhosis. Compared to CTP, MELD is better in predicting variceal bleeding.

Rifaximin has the potential to prevent complications of cirrhosis

BACKGROUND

Cirrhosis-related complications are associated with poor prognosis. With our analyses, we examined the potential benefit of rifaximin in reducing the risk of developing cirrhosis-related complications.

METHODS

Adults with cirrhosis and hepatic encephalopathy (HE) in remission were randomly assigned to receive rifaximin 550 mg twice daily or placebo for 6 months with concomitant lactulose permitted. Post hoc analyses examined time to cirrhosis-related complications (HE, spontaneous bacterial peritonitis (SBP), variceal bleeding, acute kidney injury/hepatorenal syndrome). Subgroup analyses evaluated efficacy for select baseline disease characteristics.

RESULTS

Of patients receiving rifaximin (n = 140) and placebo (n = 159), 53.6% and 49.1%, respectively, had baseline Model for End-Stage Liver Disease (MELD) score ⩾ 12 and international normalized ratio (INR) ⩾ 1.2. Baseline ascites was observed in 36.4% (rifaximin) and 34.6% (placebo) of patients. In patients with MELD score ⩾ 12 and INR ⩾ 1.2, rifaximin reduced the relative risk (RR) of any first complication experienced during trial by 59% [hazard ratio (HR) = 0.41, 95% confidence interval (CI): 0.25-0.67; p < 0.001] versus placebo. For patients with baseline ascites, rifaximin reduced the RR of any first complication experienced during trial by 42% versus placebo (HR = 0.58, 95% CI: 0.34-1.0; p = 0.045). For some subgroups, there was a decrease in RR of complications of SBP, variceal bleeding, and acute kidney injury/hepatorenal syndrome with rifaximin versus placebo, although there were few events reported in the study.

CONCLUSION

Rifaximin may reduce the incidence of cirrhosis-related complications and the recurrence of overt HE.[ClinicalTrials.gov identifier: NCT00298038.].

Mortality from Spontaneous Bacterial Peritonitis Among Hospitalized Patients in the USA

BACKGROUND AND AIM

Spontaneous bacterial peritonitis (SBP) is a serious complication of cirrhosis and is associated with significant morbidity and mortality. In this study, we examined the clinical characteristics and risk factors associated with mortality in hospitalized patients presenting with SBP.

METHODS

The Nationwide Inpatient Sample was queried for all hospitalizations involving SBP from 2006 to 2014 using the International Classification of Disease-9-CM Code. Logistic regression was performed to evaluate the association between SBP mortality and factors such as age, gender, race/ethnicity, and concomitant medical conditions at presentation (e.g., variceal hemorrhage, hepatic encephalopathy, acute renal failure, coagulopathy, and other infections including pneumonia). The lengths of stay (LOS) and total charges were also examined.

RESULTS

From 2006 to 2014, there were 88,167 SBP hospitalizations with 29,963 deaths (17.6% in-hospital mortality). The mean age of patients who died in the hospital was higher (58.2 years vs. 55.8, p < 0.01) than those who survived the admission. Acute alcoholic hepatitis was noted among a higher proportion of patients who died (7.0 vs. 5.9%, p < 0.01), who were also likely to have more medical comorbidities. In multivariable analysis, older age, female gender, hepatic encephalopathy, coagulopathy, variceal hemorrhage, sepsis, pneumonia, and acute kidney injury were associated with increased in-hospital mortality. This group also had longer LOS (11.6 days vs. 9.1, p < 0.01) and higher total charges ($138,273 vs. $73,533, p < 0.01).

CONCLUSION

SBP is associated with significant in-hospital mortality, especially in patients with concurrent risk factors. SBP remains a significant burden to the healthcare system.

Spontaneous bacterial and fungal peritonitis in patients with liver cirrhosis: A literature review

Spontaneous bacterial (SBP) and spontaneous fungal peritonitis (SFP) can be a life-threatening infection in patients with liver cirrhosis (LC) and ascites. One of the possible mechanisms of developing SBP is bacterial translocation. Although the number of polymorphonuclear cells in the culture of ascitic fluid is diagnostic for SBP, secondary bacterial peritonitis is necessary to exclude. The severity of underlying liver dysfunction is predictive of developing SBP; moreover, renal impairment and infections caused by multidrug-resistant (MDR) organism are associated with a fatal prognosis of SBP. SBP is treated by antimicrobials, but initial empirical treatment may not succeed because of the presence of MDR organisms, particularly in nosocomial infections. Antibiotic prophylaxis is recommended for patients with LC at a high risk of developing SBP, gastrointestinal bleeding, or a previous episode of SBP, but the increase in the risk of developing an infection caused by MDR organisms is a serious concern globally. Less is known about SFP in patients with LC, but the severity of underlying liver dysfunction may increase the hospital mortality. SFP mortality has been reported to be higher than that of SBP partially because the difficulty of early differentiation between SFP and SBP induces delayed antifungal therapy for SFP.

Bacterial infections and hepatic encephalopathy in liver cirrhosis-prophylaxis and treatment

Infections are common among patients with liver cirrhosis. They occur more often in cirrhotic patient groups than in the general population and result in higher mortality. One reason for this phenomenon is bacterial translocation from the intestinal lumen that occurs as a consequence of intestinal bacterial overgrowth, increased permeability and decreased motility. The most common infections in cirrhotic patients are spontaneous bacterial peritonitis and urinary tract infections, followed by pneumonia, skin and soft tissue infections. Intestinal bacterial overgrowth is also responsible for hyperammonemia, which leads to hepatic encephalopathy. All of these complications make this group of patients at high risk for mortality. The role of antibiotics in liver cirrhosis is to treat and in some cases to prevent the development of infectious complications. Based on our current knowledge, antibiotic prophylaxis should be administered to patients with gastrointestinal hemorrhage, low ascitic fluid protein concentration combined with liver or renal failure, and spontaneous bacterial peritonitis as a secondary prophylaxis, as well as after hepatic encephalopathy episodes (also as a secondary prophylaxis). In some cases, the use of non-antibiotic prophylaxis can also be considered. Current knowledge of the treatment of infections allows the choice of a preferred antibiotic for empiric therapy depending on the infection location and whether the source of the disease is nosocomial or community-acquired.

Quick chronic liver failure-sequential organ failure assessment: an easy-to-use scoring model for predicting mortality risk in critically ill cirrhosis patients

BACKGROUND AND AIM

Critically ill cirrhosis patients have an increased risk of morbidity and mortality, even after admission to the ICU. Our objectives were to compare the predictive accuracy of model for end-stage liver disease (MELD), MELD-Na, UK model for end-stage liver disease, and chronic liver failure-sequential organ failure assessment (CLIF-SOFA) by the development and validation of an easy-to-use prognostic model [named quick CLIF-SOFA (qCLIF-SOFA)] for early risk prediction in critically ill patients with cirrhosis.

PATIENTS AND METHODS

Overall, 1460 patients were extracted from the MIMIC-III database and enrolled in this study at 30-day and 90-day follow-up. qCLIF-SOFA was developed in the established cohort (n=730) and a performance analysis was completed in the validation cohort (n=730) using area under the receiver operating characteristic curve. Results were compared with CLIF-SOFA.

RESULTS

The performance of CLIF-SOFA was significantly better than that of MELD, MELD-Na, and UK model for end-stage liver disease for predicting both 30-day and 90-day mortality (all P<0.05). qCLIF-SOFA consisted of five independent factors (bilirubin, creatinine, international normalized ratio, mean arterial pressure, and vasopressin) associated with mortality. In the established cohort, CLIF-SOFA and qCLIF-SOFA predicted mortality with area under the receiver operating characteristic curve values of 0.768 versus 0.743 at 30-day, 0.747 versus 0.744 at 90-day, and 0.699 versus 0.706 at 1 year, respectively (all P>0.05). A similar result was observed in the validation cohort (0.735 vs. 0.734 at 30 days, 0.723 vs. 0.737 at 90 days, and 0.682 vs. 0.700 at 1 year, respectively, all P>0.05).

CONCLUSION

The utility of CLIF-SOFA was further shown to predict mortality for critically ill cirrhosis patients. The novel and simpler qCLIF-SOFA model showed comparable accuracy compared with existing CLIF-SOFA for prognostic prediction.

Predictors of fifty days in-hospital mortality in patients with culture negative neutrocytic ascites

Background

Culture negative neutrocytic ascites is a variant of spontaneous bacterial peritonitis. But there are conflicting reports regarding the mortality associated with culture negativeneutrocytic ascites. Therefore we aim to determine the predictors of mortality associated with culture negativeneutrocytic ascites in a larger sample population.

Methods

We analysed 170 patients consecutively admitted to intensive care unit with diagnosis of culture negative neutrocytic ascites. The clinical, laboratory parameters, etiology of liver cirrhosis was determined along with the scores like model for end stage liver disease, child turcotte pugh were recorded.

Results

The 50 day in-hospital mortality rate in culture negative neutrocytic ascites was 39.41% (n = 67). In univariate analysis, means of parameters like total leucocyte count, urea, bilirubin, alanine transaminase, aspartate transaminase, international normalized ratio, acute kidney injury, septic shock, hepatic encephalopathy and model for end stage liver disease were significantly different among survived and those who died (P value ≤0.05). Cox proportional regression model showed the hazard ratio (HR) of acute kidney injury was 2.212 (95% CI: 1.334–3.667), septic shock (HR = 1.895, 95% CI: 1.081–3.323) and model for end stage liver disease (HR = 1.054, 95% CI: 1.020–1.090). Receiver operating characteristics curve showed aspartate aminotransferase (AST) had highest area under the curve 0.761 (95% CI: 0.625–0.785).

Conclusion

Patients with culture negative neutrocytic ascites have a mortality rate comparable to spontaneous bacterial peritonitis. aspartate aminotransferase, alanine aminotransferase (ALT), acute kidney injury (AKI), model for end stage liver disease (MELD) and septic shock are the independent predictors of 50 days in-hospital mortality in culture negative neutrocytic ascites.