Indwelling Peritoneal Drains Increase the Risk of Spontaneous Bacterial Peritonitis (SBP) in Cirrhotic Patients with Refractory Ascites: ACG/AstraZeneca Fellow Award

Abstract

Purpose: The prevalence of SBP in hospitalized cirrhotic patients with ascites is 10-30%. Treatment options for hospitalized patients with large ascites include intermittent large volume paracenteses versus indwelling drain placement. The latter option has been discouraged due to a perceived increased risk of infection. No prior data has evaluated the risk of developing SBP in patients with indwelling drains. Our goal was to evaluate the risk of SBP with indwelling peritoneal drain placement in a cohort of patients with end stage liver disease (ESLD). Methods: We conducted a retrospective review of patients with ESLD and refractory ascites who had indwelling peritoneal drains placed for at least 3 days at an academic medical center between 1999-2009. Patients with malignant ascites were excluded. SBP was defined as ascitic PMNs >250/mmˆ3. Cell counts were done at initial drain placement and 24 and 48 hours later. Univariate analysis was performed to assess the association between baseline characteristics of cirrhotic patients, markers of synthetic liver function, and the development of SBP. Covariates identified as potentially significant through univariate analyses (p<0.20) were analyzed by multivariate logistic regression. Results: A total of 190 drain placements occurred during the study period. 39% of subjects were diagnosed with SBP during this time (17.9% were diagnosed at initial drain placement and the other 21.1% developed SBP within 48 hours of drain placement). There was a statistically significant increase in the occurrence of SBP in patients with hepatitis C cirrhosis (P=0.004) versus other etiologies of liver disease. In addition, those patients with radiographic or endoscopic evidence of varices or collaterals had an increased risk of SBP (25.4% vs 9.6%, p=0.02). There was no significant association between the diagnosis of SBP and gender, race, total fluid protein, serum-ascites albumin gradient (SAAG), development of encephalopathy, or markers of synthetic liver function. Conclusion: Similar to historic controls, 17.9% of our patients had SBP on initial paracentesis. In addition, there was an increased risk of developing SBP within 48 hours of indwelling peritoneal drain placement in our study population. The presence of hepatitis C or varices/collaterals was associated with a significantly increased risk of SBP. Based on this data, we do not recommend the placement of indwelling peritoneal catheters for the treatment of refractory ascites.