Administration Of Antimicrobial Therapy Research Articles

Predicting in-hospital mortality in pneumonia-associated septic shock patients using a classification and regression tree: a nested cohort study

BackgroundPneumonia complicated by septic shock is associated with significant morbidity and mortality. Classification and regression tree methodology is an intuitive method for predicting clinical outcomes using binary splits. We aimed to improve the prediction of in-hospital mortality in patients with pneumonia and septic shock using decision tree analysis.MethodsClassification and regression tree models were applied to all patients with pneumonia-associated septic shock in the international, multicenter Cooperative Antimicrobial Therapy of Septic Shock database between 1996 and 2015. The association between clinical factors (time to appropriate antimicrobial therapy, severity of illness) and in-hospital mortality was evaluated. Accuracy in predicting clinical outcomes, sensitivity, specificity, and area under receiver operating curve of the final model was evaluated in training (n = 2111) and testing datasets (n = 2111).ResultsThe study cohort contained 4222 patients, and in-hospital mortality was 51%. The mean time from onset of shock to administration of appropriate antimicrobials was significantly higher for patients who died (17.2 h) compared to those who survived (5.0 h). In the training dataset (n = 2111), a tree model using Acute Physiology and Chronic Health Evaluation II Score, lactate, age, and time to appropriate antimicrobial therapy yielded accuracy of 73% and area under the receiver operating curve 0.75. The testing dataset (n = 2111) had accuracy of 69% and area under the receiver operating curve 0.72.ConclusionsOverall mortality (51%) in patients with pneumonia complicated by septic shock is high. Increased time to administration of antimicrobial therapy, Acute Physiology and Chronic Health Evaluation II Score, serum lactate, and age were associated with increased in-hospital mortality. Classification and regression tree methodology offers a simple prognostic model with good performance in predicting in-hospital mortality.

Sepsis in children: Initial assessment and treatment

Severe sepsis is the leading cause of mortality among children aged under the age of 5 years. The four main causes of sepsis in children are pneumonia, malaria, measles and diarrhoea. Preventing sepsis is extremely important and immunization of children and regular hand hygiene proved to be very efficient and cost effective in avoiding the development of diseases that may lead to sepsis. Clinical symptoms of all stadiums of sepsis in children are often non specific, but early diagnosis is extremely important. The initial treatment of sepsis in children has to be adjusted to the developmental stadium, age, the capacity of its immune system and the likely cause of infection. In studies on children early administration of antimicrobial therapy proved to be efficient. Early management of septic shock should consist of rapid boluses of crystalloids and 5% albumin solutions and administration of vasoactive medications until hemodynamic stability is achieved.

Oral Parenteral Antimicrobial Therapy Administration in a Homeless Population: Erratum

Oral Parenteral Antimicrobial Therapy Administration in a Homeless Population: Erratum

Implementation of “CODE SEPSIS” for septic patients at Al Wakra Hospital: A practice improvement initiative

Introduction: Sepsis is a major cause of hospitalization with a high mortality rate. Early recognition and management of sepsis have shown to improve mortality outcomes. A proactive alert system for improving the response of the interdisciplinary team may decrease the time to intervention and improve patient outcomes. Objective: The study evaluated the impact of an early alert system, “CODE SEPSIS”, on adherence to the sepsis management bundle and time to intervention among patients at risk for sepsis. Method: Patients presenting to the Emergency Department (ED) and meeting two or more criteria on the sepsis screening tool were intended to trigger an overhead alert known as CODE SEPSIS, which was activated based on the physician's decision. Data were retrospectively collected over a 3-month period for all hospitalized adult patients with confirmed sepsis (age above 18 years). We evaluated the time from ED presentation to diagnostic and treatment interventions. A data collection tool was designed to record information. Results: A total of 36 sepsis patients were identified, among which 18 were classified as CODE SEPSIS and 18 were classified as non-CODE SEPSIS. We found that the CODE SEPSIS group showed greater improvement than the non-CODE SEPSIS group from ED presentation to intravenous catheter insertion (37.3 to 31.5 minutes, 15.6%), fluid administration (41 to 39 minutes, 4.9%), microbiological workup (91 to 33 minutes, 63.7%), lactate level (69 to 66 minutes, 4.3%), prescribing antimicrobial therapy (92 to 44 minutes, 52%), and administration of antimicrobial therapy (88 to 46 minutes, 47.7%). Patients in the non-CODE SEPSIS group showed a 1-day decrease in length of hospital stay. Conclusion: The CODE SEPSIS alert system developed at Al Wakra Hospital promoted early and standardized management among patients at risk for sepsis, which may lead to improved patient outcomes.

Oral Parenteral Antimicrobial Therapy Administration in a Homeless Population.

Outpatient parenteral antimicrobial therapy (OPAT) is increasingly used to treat serious infections. Patients who identify themselves as homeless may receive OPAT less often, and little is known about their treatment outcomes. The purpose of this study was to describe challenges, treatment completion rates, and cost savings of OPAT in homeless patients discharged from a public safety-net hospital.

Antimicrobial Stewardship with Pharmacist Intervention Improves Timeliness of Antimicrobials Across Thirty-three Hospitals in South Africa.

IntroductionEnsuring timely administration of antimicrobials is critical in the management of patients with infections. Mortality increases by 7.6% for every hour of delay in the administration of antimicrobial therapy in patients with sepsis. The time elapsed from the written antibiotic order to actual intravenous administration or ‘hang-time’ can often be several hours due to logistics within the hospital. Our purpose is to evaluate the change in compliance with administering antimicrobials within an hour of prescription after implementation of a national antibiotic stewardship pharmacist-driven hang-time process improvement protocol.MethodsThis was a prospective multicenter study in 33 South African hospitals from 1 July 2013–30 August 2014. Two pilot sites established the mechanism for noninfectious disease pharmacists to make interventions and document hang-time data. Following this, a hang-time compliance assessment was initiated using the tools of healthcare improvement spread methodology. This consisted of five stages and an implementation toolkit was developed. The pharmacist study coordinator was responsible for implementation, the development of an implementation toolkit and real-time coordination of data with monthly feedback to all sites.ResultsA total of 32,985 patients who received intravenous antibiotics were assessed for hang-time compliance with first doses of new antibiotic orders. Over the 60-week period, 21,069 patients received antibiotics within an hour following prescription and were assessed as hang-time compliant. The change in improvement of hang-time compliance following implementation of a pharmacist-driven hang-time process improvement protocol was 41.2% pre-intervention week 1 (164/398) to 78.4% post-intervention week 60 (480/612; P < 0.0001). Pharmacists reviewed and evaluated twice as many patients during the final 4 weeks (1680) compared to the first 4 weeks (834; P < 0.0001).ConclusionNoninfectious disease pharmacists can significantly improve the timely administration of antimicrobials and contribute to low-hanging-fruit antimicrobial stewardship initiatives within a hospital system in a resource-limited country.

Blood cultures in acute surgical admissions.

Obtaining blood cultures prior to the administration of antimicrobial therapy was a key recommendation of the 2012 UK Surviving Sepsis Campaign. Few studies have examined the effect blood cultures have on clinical management and there have been none on acute surgical admissions. This retrospective study sought to evaluate the effect of blood cultures on clinical management in acute surgical admissions. Data on acute surgical patients admitted between 1 January and 31 December 2012 were extracted from hospital records. Patients given intravenous antibiotics within 24 hours of admission were identified. Data collected included antibiotics administered, blood culture results, admission observations and white blood cell count. Case notes were reviewed for patients with positive cultures to establish whether the result led to a change in management. Of 5,887 acute surgical admissions, 1,346 received intravenous antibiotics within 24 hours and 978 sets of blood cultures were taken in 690 patients. The recommended two sets of cultures were obtained in 246 patients (18%). Patients who had blood cultures taken had the same in-hospital mortality as those who had none taken (3.6% vs 3.5%, p=0.97). Blood cultures were positive in 80 cases (11.6%). The presence of systemic inflammatory response syndrome did not increase positivity rates (12.9% vs 10.3%, p=0.28). Overall, cultures altered management in two patients (0.3%). Blood cultures rarely affect clinical management. In order to assess the additional value that blood cultures bring to sepsis management in acute surgical admissions, a prospective randomised trial focusing on outcome is needed.

Hemophagocytic Syndrome Associated with Scrub Typhus: A Case Report from North East India

Scrub typhus infection is an important aetiology of acute undifferentiated fever in south-east Asia and India. Haemophagocytic Lymphohistiocytosis (HLH) (haemophagocytic syndrome) is a potentially fatal hyper inflammatory syndrome that is characterized by histiocyte proliferation and haemophagocytosis. We describe a case of Haemphagocytic syndrome secondary to scrub typhus which presented with fever, rash, pancytopenia, epistaxis and haematuria who responded dramatically with respect to haematological parameters and clinically following prompt antimicrobial therapy. Scrub typhus with hemophagocytic syndrome can be complicated by multiorgan failure. Patients with scrub typhus usually have an excellent response to treatment; therefore, early diagnosis and prompt administration of antimicrobial therapy may prevent the development of serious complications.

A cluster of fulminant Clostridium difficile colitis in an intensive care unit in Italy

We describe, for the first time, a cluster of lethal fulminant health-care associated Clostridium difficile (CD) colitis in Italy, observed in the intensive care unit (ICU) of an Italian tertiary care hospital in Rome. For all cases the cause of ICU admission was CD-related septic shock. Three out of seven patients were residents in a long-term care facility in Rome, and the others had been transferred to the ICU from different medical wards of the same hospital. Five patients died within 96 h of ICU admission. Because of a clinical deterioration after 4 days of adequate antibiotic therapy, two patients underwent subtotal colectomy: both of them died within 30 days of surgical intervention. In four cases, ribotyping assay was performed and ribotype 027 was recognized. This high mortality rate could be attributable to three findings: the extent of disease severity induced by the strain 027, the delay in antimicrobial therapy administration, and the lack of efficacy of the standard antibiotic treatment for fulminant CD colitis compared to an earlier surgical approach. In order to contain a CD infection epidemic, control and surveillance measures should be implemented, and empirical therapy should be administered. Because of potential 027 ribotype CD spread in Italy, CDI should be regarded with a high index of suspicion in all patients presenting with shock and signs or symptoms suggesting abdominal disease, and an early surgical approach should be considered.

A Case Report of Scrub Typhus-Associated Hemophagocytic Syndrome and a Review of Literature

A 34-year-old woman presented with septic shock, disseminated intravascular coagulation (DIC), and multiorgan dysfunction with a 1-week history of fever, abdominal pain in the right upper quadrant, and dull pain in the right flank. Physical and laboratory data showed cytopenia (thrombocytopenia and anemia), splenomegaly, hyperferritinemia, hypofibrinogenemia, and an elevated level of interleukin-2 receptor (soluble CD25). Bone marrow examinations disclosed hypercellular marrow with increased infiltration of histiocytes with hemophagocytosis. This diagnosis was confirmed by positive Weil-Felix test results (Proteus mirabilis OX-K titer, 1:80), the presence of IgG and IgM antibodies, and positive PCR results for Orientia tsutsugamushi. The patient developed a severe intracranial hemorrhage 3 days after admission and expired due to systemic inflammatory response syndrome with DIC and multiorgan failure on the 13th day of hospitalization. Scrub typhus with hemophagocytic syndrome can be complicated by DIC and multiorgan failure. Patients with scrub typhus usually have an excellent response to treatment; therefore, early diagnosis and prompt administration of antimicrobial therapy may prevent the development of serious complications.

Gonococcal Endocarditis in a 47-year-old Japanese Man

A 47-year-old sexually active Japanese man was admitted with a persistent fever and weight loss. A physical examination revealed a cardiac murmur. A transthoracic echocardiogram was nondiagnostic, although blood cultures grew Neisseria gonorrhoeae. Gonococcal endocarditis was diagnosed based on the modified Duke criteria. The administration of antimicrobial therapy resulted in an adequate initial resolution; however, two months after completing the therapy, the patient developed cardiac failure. Severe aortic regurgitation was identified, and the patient underwent emergent aortic valve replacement. Despite the rarity of gonococcal endocarditis, this disease should nevertheless be considered in patients presenting with a fever, cardiac murmur and a consistent sexual history.

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Introduction: The 2012 Surviving Sepsis Campaign Guidelines recommend collection of cultures prior to administration of antimicrobial therapy. Timeliness to obtaining cultures is pressured by the recommendation to administer antimicrobials within one hour of sepsis recognition. Feasibility of obtaining cultures during this time is challenged by competing care priorities, phlebotomy skill level, and patient-associated phlebotomy access variables. The purpose of this initiative was to evaluate the impact of an algorithm that standardized workflow to obtain cultures and included escalation to obtain phlebotomy assistance on the time from order to collection of culture samples. Methods: A survey of current practices and perceived barriers to culture collection was conducted. Baseline and post-intervention data regarding time intervals from culture order to collection were collected. A blood culture collection algorithm was developed and implemented. Staff education on the importance of identifying the causative pathogen and risks of delayed antimicrobial therapy in severe sepsis was completed via multiple methods including culture case reviews. Case reviews included staff interviews to assess barriers when greater than 60 minutes for collection. Results: Survey results revealed variable practice in culture attempts and assistance requests. Primary barriers reported were difficult vascular access, competing care priorities, and miscommunication of order urgency. Review revealed the new electronic order for blood culture default was set to routine rather than stat. Pre-intervention review of 66 collections revealed a mean collection time of 87 ± 101 minutes for routine orders and a mean collection time 117 ± 149 minutes for stat orders. Post-intervention chart review of 43 collections revealed a decrease in stat order collection times to 59 ± 67 minutes. Adjuncts such as ultrasound were identified as potential aids to improve culture phlebotomy timeliness. Conclusions: A standardized algorithm for blood culture collection including criteria for escalation for assistance can facilitate compliance with SSC Guideline care bundle elements.

Vancomycin-resistant Enterococcus outbreak in a neonatal intensive care unit: Epidemiology, molecular analysis and risk factors

Vancomycin-resistant Enterococcus faecium (VRE) may cause outbreaks in neonatal intensive care units (NICU). We describe a biphasic VRE outbreak and identify risk factors for VRE acquisition. After the occurrence of 2 cases of VRE infections in a 44-bed NICU, a bundle of interventions was implemented that included active surveillance cultures for VRE, enhanced infection control measures, and audits on antimicrobial use, from June to December 2008. Analysis was performed using polymerase chain reaction and pulse-field gel electrophoresis techniques. A case-control study was conducted to identify risk factors. Among 253 neonates screened, 101 (39.9%) were found to be colonized with VRE. During the first 9 weeks of the study period, 59 new cases were detected. Molecular analysis showed 1 predominant clone. During weeks 10-12, no new cases of VRE colonization were detected; however, at week 13, just when the outbreak appeared to be over, a second wave occurred, with 42 new cases and multiple clones detected. Multivariate analysis identified administration of antimicrobial therapy for late-onset neonatal sepsis and hospitalization during the first month of this outbreak as significant risk factors for VRE colonization. Both a high prevalence of VRE colonization and antimicrobial use promoted the transmission of VRE during this biphasic outbreak. Adherence to infection control measures and antimicrobial stewardship policies are of utmost importance.

Epidemiological characteristics of nosocomial diarrhea caused by Clostridium difficile in a tertiary level hospital in Serbia

Among the most important causes of diarrhea in modern hospitals is Clostridium difficile (C. difficile). A wide spectrum of diseases caused by this bacterium is now known as C. difficile associated disease (CDAD). The development of CDAD is usually preceded by the administration of antimicrobial therapy and fecal-oral infections with C. difficile. Over the last years epidemiology of CDAD has significantly changed. Recently, a hypervirulent BI/NAP1/027 strain, the cause of severe epidemics in North America and Western Europe, has been identified. The aim of this study was to identify risk factors for CDAD in patients operated on at the Military Medical Academy (MMA). The study included all patients who underwent surgery at the MMA during 2010. Nested case-control study design was used. The subjects were divided into groups of operated patients with and without CDAD. The patients were under prospective follow-up, while their data were collected using a questionnaire during a routine epidemiological control. During 2010 the incidence rate of CDAD was 3.3 per 10,000 hospital days. Univariate regression analysis showed that the length of administration of one or two antibiotics, as well as concurrent administration of two antibiotics, were far more frequently observed in the patients with than in the patients without CDAD. Independent risk factor for the development of CDAD was the length of the administration of one antibiotic. Reduction in the incidence rate of CDAD can be achieved by using reliable measures of prevention and control; the rational use of antibiotics, early diagnosis and therapy of infected patients, contact isolation of infected persons, proper disinfection, and continued education of medical and nonmedical personnel.

Rapid Identification of Genetic Modifications in Bacillus anthracis Using Whole Genome Draft Sequences Generated by 454 Pyrosequencing

BackgroundThe anthrax letter attacks of 2001 highlighted the need for rapid identification of biothreat agents not only for epidemiological surveillance of the intentional outbreak but also for implementing appropriate countermeasures, such as antibiotic treatment, in a timely manner to prevent further casualties. It is clear from the 2001 cases that survival may be markedly improved by administration of antimicrobial therapy during the early symptomatic phase of the illness; i.e., within 3 days of appearance of symptoms. Microbiological detection methods are feasible only for organisms that can be cultured in vitro and cannot detect all genetic modifications with the exception of antibiotic resistance. Currently available immuno or nucleic acid-based rapid detection assays utilize known, organism-specific proteins or genomic DNA signatures respectively. Hence, these assays lack the ability to detect novel natural variations or intentional genetic modifications that circumvent the targets of the detection assays or in the case of a biological attack using an antibiotic resistant or virulence enhanced Bacillus anthracis, to advise on therapeutic treatments.Methodology/Principal FindingsWe show here that the Roche 454-based pyrosequencing can generate whole genome draft sequences of deep and broad enough coverage of a bacterial genome in less than 24 hours. Furthermore, using the unfinished draft sequences, we demonstrate that unbiased identification of known as well as heretofore-unreported genetic modifications that include indels and single nucleotide polymorphisms conferring antibiotic and phage resistances is feasible within the next 12 hours.Conclusions/SignificanceSecond generation sequencing technologies have paved the way for sequence-based rapid identification of both known and previously undocumented genetic modifications in cultured, conventional and newly emerging biothreat agents. Our findings have significant implications in the context of whole genome sequencing-based routine clinical diagnostics as well as epidemiological surveillance of natural disease outbreaks caused by bacterial and viral agents.

Early Antimicrobial Therapy in Severe Sepsis and Septic Shock

The advent of modern antimicrobial therapy following the discovery of penicillin during the 1940s yielded remarkable improvements in the case fatality rates of serious infections, including septic shock. Since then, pathogens have continuously evolved under selective antimicrobial pressure, resulting in a lack of additional significant improvement in clinical effectiveness of antimicrobial therapy of septic shock despite ever more broad-spectrum and potent drugs. In addition, although substantial effort and money were expended on the development of novel nonantimicrobial therapies of sepsis in the past 30years, clinical progress in this regard has been limited. This article explores the possibility that the key to significant improvement in the outcome of septic shock may lie, in great part, with improvements in delivery of existing antimicrobials. Recognizing the role of delays in administration of antimicrobial therapy in the poor outcomes of septic shock is central to this effort.

Impact of the implementation of a sepsis protocol for the management of fluid-refractory septic shock: A single-center, before-and-after study

Background: Evidence-based guidelines have been published for the acute management of severe sepsis and septic shock. Key goals of institution-driven protocols include timely fluid resuscitation and antibiotic selection, as well as source control. Objective: This study assessed the impact of a sepsis protocol on the timeliness of antibiotic administration, the adequacy of fluid resuscitation, and 28-day mortality in patients with fluid-refractory septic shock. Methods: This was a single-center, before-and-after study (18 months before July 2007 and 18 months after) with prospective data collection evaluating the outcomes of a sepsis protocol in adult patients with fluid-refractory septic shock. All patients received a fluid challenge and antibiotics; those who did not were excluded from this analysis. Preprotocol findings led to the development of the sepsis protocol, which emphasized fluid resuscitation, timely administration of antibiotic therapy, and collection of specimens for culture at the onset of septic shock. In the pre- and postprotocol phases of the study, data were collected prospectively and analyzed for demographic characteristics; Acute Physiology and Chronic Health Evaluation (APACHE) II score; appropriateness of fluid resuscitation; antibiotic use; number of vasopressor, ventilator, and intensive care unit (ICU) days; and 28-day mortality. Outcomes were measured prospectively at any time during the patient's hospital admission. The primary end points were the time to administration of antimicrobial therapy and the appropriateness of fluid resuscitation before and after implementation of the sepsis protocol. Results: A total of 118 patients were included in the analysis: 64 and 54 in the pre- and postprotocol groups, respectively. Patients in the preprotocol group were primarily women (53% [34/64]) and had a mean (SD) age of 61 (15.5) years and a mean APACHE II score of 28 (6.0). Patients in the postprotocol group were primarily men (54% [29/54]) and had a mean age of 52 (18.0) years and a mean APACHE II score of 27 (6.4). Implementation of the sepsis protocol resulted in a greater percentage of patients receiving timely antibiotic therapy (ie, within 4.5 hours of refractory shock; 85% [46/54] vs 56% [36/64]; P = 0.001) and adequate fluid resuscitation (72% [39/54] vs 31% [20/64]; P < 0.001) compared with the preprotocol group. Post hoc analysis found significant decreases in the number of vasopressor days (mean [SD], 3.8 [2.7] to 1.4 [1.5]; P < 0.001), ventilator days (9.1 [12.2] to 2.7 [4.0]; P < 0.001), and ICU days (12.3 [12.6] to 4.9 [3.9]; P < 0.001) in the postprotocol group. In-hospital mortality was not significantly different between the groups (survival 46% [28/61] before vs 54% [33/61] after the protocol). Multivariate analysis for predictors of in-hospital mortality identified an interval between shock and empiric antibiotic administration of >4.5 hours (odds ratio [OR] = 5.54; 95% CI, 1.91–16.07; P < 0.002), vasopressor duration in days (OR = 1.27; 95% CI, 1.01–1.59; P = 0.037), APACHE II score (OR = 1.14; 95% CI, 1.05-1.24; P = 0.003), and type of infection (community vs nosocomial, OR = 0.18; 95% CI, 0.05–0.61; P = 0.006) as significant predictors. The 28-day mortality decreased from 61% (39/64) to 33% (18/54) after implementation of the protocol ( P = 0.004). Conclusion: Implementation of a sepsis protocol emphasizing early administration of antibiotic therapy and adequate fluid resuscitation was associated with improved clinical outcomes and lower 28-day mortality in patients with fluid-refractory septic shock at this institution.

121: Prognosis of Urosepsis Patients Who Are Treated by Inappropriate Initial Antimicrobial Therapy in the Emergency Department

Urosepsis is known to have a better prognosis than other types of sepsis. However, it is not clear whether there is an increase in adverse outcome if there is erroneous initial antimicrobial therapy administration followed later, by a change to appropriate therapy after cultures results become available. We categorized patients with urosepsis into two groups with regard to appropriate and inappropriate initial antibiotic choice and measured the outcome, which included the difference of mortality rate and cost of hospitalization.

Prospective, Randomized Trial of 10 Days versus 30 Days of Antimicrobial Treatment, Including a Short‐Term Course of Parenteral Therapy, for Childhood Septic Arthritis

The standard treatment for septic arthritis in children is antimicrobials for several weeks (initially administered intravenously) and arthrotomy (at least for the hip and shoulder joints). No sufficiently powered study has examined the true need for these treatments. In a randomized, multicenter prospective trial in Finland, children aged 3 months to 15 years who had culture-positive septic arthritis were randomized to receive clindamycin or a first-generation cephalosporin for 10 days or 30 days (intravenously for the first 2-4 days). The number of surgical procedures was kept to a minimum. Illness was monitored with preset criteria. Antimicrobial therapy was discontinued when the clinical response was good and the C-reactive protein level decreased to 20 mg/L. The primary end point was full recovery without need for further administration of antimicrobial therapy because of an osteoarticular indication during the 12 months after therapy. Of the total 130 cases, 88% were caused by Staphylococcus aureus, Haemophilus influenzae, or Streptococcus pyogenes; 63 patients were in the short-term treatment group, and 67 were in the long-term treatment group. The median durations of antimicrobial treatment were 10 days and 30 days, respectively. Surgical procedures that were more extensive than percutaneous joint aspiration were performed for 12% of patients, with no preponderance to hip or shoulder arthritis. Two late-onset infections occurred in 1 child in the long-term treatment group; however, all patients recovered without sequelae. Large doses of well-absorbed antimicrobials for <2 weeks (initially administered intravenously) and only 1 joint aspiration are sufficient for treatment of most cases of childhood septic arthritis, regardless of the infecting pathogen or anatomical site, if the clinical response is good and the C-reactive protein level normalizes shortly after initiation of treatment.

Aeromonas Spontaneous Bacterial Peritonitis: A Highly Fatal Infectious Disease in Patients with Advanced Liver Cirrhosis

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. 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. 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. 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.