Ascitic Fluid Culture Research Articles

Spontaneous bacterial peritonitis caused by Aeromonas caviae in a patient with cirrhosis.

Spontaneous bacterial peritonitis (SBP) is a common complication of cirrhosis. Based on our current understanding of SBP, the most common etiologies for SBP in cirrhosis are Enterobacter and Streptococcal species. Th e Aeromonas species are ubiquitous in fresh or sea water. Aeromonas caviae is never identified as etiology in cases of SBP. A patient, who had a history of liver cirrhosis related to chronic hepatitis B virus infection for 1 year, presented with diarrhea. He had diarrhea 1 week later returned from coastal city. He was hospitalized and treated with norfloxacin after 7 days of severe symptoms, including fever, abdominal distention, and diarrhea. Analysis of the ascitic specimen revealed a white-cell count of 4.42 × 109 cells/L with 88% neutrophils. Analysis of stool specimen showed a white-cell count of 60 cells per high-power field. Th e patient started the injection of cefriaxone at a dose of 4 g/d. However, the situation was not improved. Th ree days later, stool and ascitic fluid culture showed positive for Aeromonas caviae. Antibiotic susceptibility testing revealed that imipenem, meropenem, amikacin, and cefoperazone-sulbactam were highly sensitive to the Aeromonas caviae. However, the bacilli resisted to ceftriaxone, ceftazidime, ampicillin-sulbactam, levofloxacin, and sulfamethoxazole. Ceftriaxone was then switched to imipenem. The patient was fully recovered 14 days later. Aeromonas caviae is a rare pathogen of SBP in cirrhosis. It resists to third-generation of cephalosporin and fluroquinolone, which are of frequently used dependent on clinical experience. It needs a special attention.

Clinical, laboratory and bacterial profile of Spontaneous Bacterial Peritonitis in Chronic Liver Disease patients.

To determine the clinical and laboratory features, bacterial profile and antibiotic sensitivity pattern of Spontaneous Bacterial Peritonitis (SBP) in Chronic Liver Disease (CLD) patients presenting at a tertiary care hospital of Karachi. Cross-sectional study. PMRC Centre for Gastroenterology and Hepatology and Jinnah Postgraduate Medical Centre, Karachi, from April 2010 to March 2012. CLD patients with ascites were recruited from PMRC Centre for Gastroenterology and Hepatology and Jinnah Postgraduate Medical Centre, Karachi. Basic demographics, symptoms and clinical signs of patients were recorded. Patients with the history of antibiotic use within last 3 days or any intra-abdominal source of infection were excluded. Diagnostic paracentesis was done for ascitic fluid detailed report (D/R) and culture. Blood sample was collected for total leukocyte count, serum proteins and billirubin levels. Out of a total 152 CLD patients, 38 (25%) were diagnosed with SBP. Eight (24.2%) patients presented with classical SBP, 20 (52.6%) had culture negative neutrocytic ascites and 10 (26%) had bacterascites. Fever, abdominal tenderness and constipation were common in SBP patients. Ascitic fluid culture was positive in 19 (50%) patients. E. coli (65%) was the predominant pathogen followed by Enterococcus species (15%). Resistance was high against cephalosporins (78%) and fluoroquinolones (69.6%) and least against amikacin (13%) and meropenem (12%). Ascitic fluid D/R and culture together can lead to the accurate diagnosis of SBP and can guide for the right antibiotic choice as resistance to commonly prescribed antibiotic is common in such patients.

Value of Different Diagnostic Markers in Spontaneous Bacterial Peritonitis in HCV Egyptian Cirrhotic Patients

Background: Spontaneous bacterial peritonitis (SBP) is a life-threatening infection occurring in 8% - 30% of ascitic cirrhotic patients; different laboratory diagnostics play a pivotal role for rapid and effective management of SBP patients. Polymorphonuclear leucocytic (PMNLs) count in Ascitic fluid (AF) is the mainstay for the diagnosis, whereas the diagnostic role of alternative biomarkers is rather controversial. In many studies, serum lipopolysaccharide binding protein (LBP) was elevated and Complement 3 (C3) level was significantly consumed in AF of SBP patients. Objectives: To evaluate the diagnostic value of serum LBP and AF C3 in HCV-cirrhotics with SBP in relation to other well-established serum and AF markers. Patients and Methods: One hundred and twenty patients with HCV-cirrhosis and ascites were enrolled and consented: 50 patients with non-SBP ascites in group A and 70 ascitic patients diagnosed with SBP according to clinical suspicion and PMLs count in AF ≥ 250 cells/mm3 in group B in addition to 15 healthy individuals considered as a control group. Serum LBP, CBC, kidney and liver function tests, CRP, fasting and 2 h PP blood glucose and HCV antibodies were measured. AF samples were sent for C3 level, culture, PMNLs count, LDH, CRP, total proteins and albumin. Results: In patients with SBP, the level of serum LBP was not significantly high (p > 0.05) with best cut off value at 0.4500 and poor AUC (<0.6) with low sensitivity and specificity (53.3% & 57.7%, respectively). AF C3 was significantly reduced in AF (p < 0.001) with best cut off value at 144.2 and almost excellent AUC (0.889) with good sensitivity and specificity (82% & 84%, respectively). AF culture showed significant difference between both patients groups (p < 0.05) but with low sensitivity (33.3%). Serum and AF CRP and AF PMNLs count were of high significance in SBP diagnosis (p < 0.001). Conclusion: Serum LBP level showed low significance while AF C3 was significantly reduced in patients with SBP. AF culture showed significant difference between both groups but with low sensitivity while serum, AF levels of CRP and AF PMNLs count were highly significant, and the latter is still considered the gold standard for SBP diagnosis.

Toward culture-free Raman spectroscopic identification of pathogens in ascitic fluid.

The identification of pathogens in ascitic fluid is standardly performed by ascitic fluid culture, but this standard procedure often needs several days. Additionally, more than half of the ascitic fluid cultures are negative in case of suspected spontaneous bacterial peritonitis (SBP). It is therefore important to identify and characterize the causing pathogens since not all of them are covered by the empirical antimicrobial therapy. The aim of this study is to show that pathogen identification in ascitic fluid is possible by means of Raman microspectroscopy and chemometrical evaluation with the advantage of strongly increased speed. Therefore, a Raman database containing more than 10000 single-cell Raman spectra of 34 bacterial strains out of 13 different species was built up. The performance of the used statistical model was validated with independent bacterial strains, which were grown in ascitic fluid.

Preparation of monoclonal antibodies against bovine haptoglobin.

Female, 8-week-old BALB/c mice were immunized with purified recombinant proteins of the predicted immunodominant region of bovine haptoglobin (pirBoHp). Two monoclonal antibodies (MAbs), named 1B3 and 6D6, were prepared by conventional B lymphocyte hybridoma technique. Titers of ascitic fluid and cell culture supernatant of MAb 1B3 were 1:9.6 × 10(8) and 1:8.2 × 10(4), respectively, and that of MAb 6D6 were 1:4.4 × 10(5) and 1:1.0 × 10(4), respectively. The subtype of MAbs 1B3 and 6D6 was IgG1κ. In Western blot analysis, MAbs 1B3 and 6D6 could recognize the α-chain of native BoHp from plasma of dairy cows. These data indicated that MAbs 1B3 and 6D6 have a potential use for developing diagnostic reagents of BoHp.

Culture Negative Neutrocytic Ascites and Mortality Risk in Cirrhotic Patients: A Systematic Review

Introduction: Spontaneous bacterial peritonitis (SBP) increases the mortality of patients with cirrhosis and ascites. It is controversial if culture negative neutrocytic ascites (CNNA) has similar clinical course and prognosis than SBP. We therefore performed a systematic review to determine the association of CNNA and overall mortality in patients with cirrhosis. Methods: Multiple electronic databases, including EMBASE and MEDLINE, were searched from inception through May 2014. We reviewed relevant prospective observational studies of adult cirrhotic patients with CNNA, defined as a polymorphonuclear ascitic fluid cell count of 250 cells/mm3 or more, with negative culture of ascitic fluid. We reviewed only studies that performed survival analyses and reported in-hospital or 30 days mortality. Two authors performed data extraction independently, and a third investigator resolved any conflicts. Results: Eight prospective cohort studies met inclusion criteria. A total of 455 patients were included in the analysis, 240 in the CNNA group, and 215 in the SBP group. The median age of patients was 49 years (68% male), with a median follow-up of 365 days. Mean MELD score was 20 in CNNA group and 21.3 in SBP group (p>0.05). All patients received antibiotics. SBP was associated with higher in-hospital (40.2% vs. 19.9%; p< 0.0001), 1-month (39.4% vs. 18.5%; p<0.0001), and 6-month (50% vs. 63.3%; p=0.04) mortality rates compared with the CNNA group. There was no difference in mortality between both groups at 12 months of follow-up (63.1% vs. 67.5%; p=0.45). Conclusion: In this systematic review, the in-hospital, 1-month and 6-month mortality rates were significantly lower in cirrhotic patients with CNNA than SBP. Despite the paucity of literature comparing the outcomes between these 2 variants, current AASLD guidelines identify both conditions to have a similar high risk of mortality. However, further large, well-conducted trials are needed to clarify the clinical course, management, and prognostic role of CNNA in cirrhotic patients.

A Unique Case of Disseminated Cryptococcosis in the Setting of Hepatitis C Cirrhosis

Introduction: Cryptococcus neoformans can be pathogenic in immuno-compromised hosts and in patients with chronic organ failure. Cryptococcal peritonitis is a rare manifestation of cryptococcosis. Although several cases of spontaneous cryptococcal peritonitis have been reported, their clinical characteristics remain ill-defined. Case Report: A 63-year-old male with hepatitis C cirrhosis presented with worsening ascites without constitutional or focal abdominal symptoms. Physical examination revealed stable vital signs, mild jaundice, and obvious ascites. Large-volume paracentesis revealed WBC of 510/mm3 with lymphocytic predominance (33%) and segmented neutrophils (17%). Serum-ascites albumin gradient (SAAG) was 1.5 g/L. Concomitant blood and ascitic fluid cultures grew Cryptococcus neoformans. HIV screening was negative. Cerebrospinal fluid (CSF) was positive for Cryptococcus antigen. He was treated with liposomal amphotericin-B, flucytosine, and cefepime, and developed renal failure that required hemodialysis. Subsequently, the infection was cleared from the blood stream, peritoneal fluid, and CSF, but he continued to deteriorate clinically with multi-organ failure. He eventually died because of respiratory failure. Conclusion: Spontaneous cryptococcal peritonitis in patients with liver cirrhosis may be an indicator of disseminated Cryptococcosis. Routine examination of ascitic fluid India ink preparation and/or serum cryptococcal antigen in these patients should be considered, especially when there is ascitic fluid with lymphocyte predominance. Clinical awareness of this entity may lead to early diagnosis and timely treatment.

Surveillance for infectious complications in pediatric acute liver failure - a prospective study.

To prospectively evaluate infectious complications (IC) in pediatric acute liver failure (PALF) by employing surveillance cultures. From 2011 to 2013, children with PALF in a tertiary care centre received a standard protocolised management. Prophylactic parenteral antibiotics were used without antifungals. Surveillance cultures of blood, urine, ascites and tracheal aspirates were sent. Biochemical and clinical parameters and outcomes were compared between children with and without IC. Of the 29 children with PALF admitted during the study period (median age 36 mo, range 12-90 mo), 13.8 % had blood stream infections (BSI) at admission. Organisms were isolated in 8.8 % (12/136) of the blood cultures, 13.7 % (11/80) of the urine cultures, 30.8 % (8/26) of the tracheal aspirates and 7.1 % (1/14) of the ascitic fluid cultures. Gram negative bacteriae (n = 17) were the commonest, followed by fungi (n = 13) and gram positive bacteriae (n = 2). Klebsiella pneumoniae and Candida nonalbicans group were the commonest bacteria and fungi respectively. After admission, fungal BSI and urinary tract infections were diagnosed at a median time of 4 d (range 3-8 d) and 3.5 d (range 3-6 d) respectively. ICs were not associated with other complications and increased mortality but with longer hospital and pediatric intensive care unit (PICU) stay. In this study BSI was a common finding at admission in PALF. Inspite of prophylactic antibiotics, break through gram negative bacterial and fungal ICs were common. Empirical treatment of IC should include broad spectrum antibiotics. Fungal IC occurred beyond 48 h. Prophylactic antifungals at admission may be considered to decrease their frequency. IC prolongs PICU and hospital stay.

Hepatic vena cava syndrome: a common cause of liver cirrhosis in children in Nepal.

Disease of hepatic portion of the inferior vena cava (IVC) now renamed hepatic vena cava syndrome (HVCS) is an insidious onset chronic disease characterized by recurrent acute exacerbations and development of cavo-caval collaterals. In adults it is complicated by high incidence of liver cirrhosis. Aim of this study was to assess the incidence of liver cirrhosis in children with HVCS and discuss its pathogenesis. One hundred and seventy eight children with HVCS were followed up with ultrasonography (USG), routine hematology and liver tests. During acute exacerbations, cultures of blood and ascitic fluid for aerobic microorganisms were also done. Diagnosis of liver cirrhosis was based on transformation of the liver parenchymal echo-texture from normal to uniformly coarse with rounded edges in follow-up USG It was confirmed by direct inspection of the liver or by biopsy in six. The duration from disease onset to detection of liver cirrhosis was also assessed. HVCS was seen in children from poor socio-economic background. Forty nine patients (27.5%) developed liver cirrhosis within a few months to a few years of onset of the disease. Development of cirrhosis was related to frequency or severity of acute exacerbations and not to duration of illness or severity of the caval lesion. The cause of cirrhosis in HVCS was the ischemic injury of the hepatocytes and sinusoids following thrombosis of the IVC and/or intra-hepatic veins during severe acute episodes or exacerbations precipitated by bacterial infection. Since such acute exacerbations are amenable to medical treatment, HVCS may be a cause of preventable liver cirrhosis in developing countries.

Evolving epidemiology and antimicrobial resistance in spontaneous bacterial peritonitis: a two-year observational study.

BackgroundCurrent recommendations for empirical antimicrobial therapy in spontaneous bacterial peritonitis (SBP) are based on quite old trials. Since microbial epidemiology and the management of patients have changed, whether these recommendations are still appropriate must be confirmed.MethodsAn observational study that exhaustively collected the clinical and biological data associated with positive ascitic fluid cultures was conducted in four French university hospitals in 2010–2011.ResultsTwo hundred and sixty-eight documented positive cultures were observed in 190 cirrhotic patients (median age 61.5 years, 58.5% Child score C). Of these, 57 were classified as confirmed SBP and 140 as confirmed bacterascites. The predominant flora was Gram-positive cocci, whatever the situation (SBP, bacterascites, nosocomial/health-care related or not). Enteroccocci (27.7% E. faecium) were isolated in 24% of the episodes, and in 48% from patients receiving quinolone prophylaxis. E. coli were susceptible to amoxicillin-clavulanate and to third-generation cephalosporins in 62.5% and 89.5% of cases, respectively. No single antibiotic allowed antimicrobial coverage of more than 60%. Only combinations such as amoxicillin + third-generation cephalosporin or cotrimoxazole allowed coverage close to 75-80% in non-nosocomial episodes. Combinations based on broader spectrum antibiotics should be considered for empirical therapy of nosocomial infections.ConclusionsOur study confirmed the changing spectrum of pathogens in SBP and bacterascites, and the need for more complex antibiotic strategies than those previously recommended. Our findings also underline the need for new clinical trials conducted in the current epidemiological context.

Ancillary tests to improve the accuracy of laparoscopy in the diagnosis of tuberculous peritonitis

It has been suggested in your journal that laparoscopy and biopsy should be deployed to diagnose tuberculous peritonitis.1 In 1993, the World Health Organization took an unprecedented step and declared tuberculosis (TB) a global emergency.2 The prevalence of extrapulmonary TB is rising, possibly related to coinfection with HIV. In patients with extrapulmonary TB, the abdomen is involved in 11% of patients.2 Tuberculous peritonitis is believed to exhibit a female predominance; other causes of abdominal pain may delay diagnosis. Over a 2-year period, we carried out a prospective study of 92 patients admitted to the Government Medical College at Srinagar with the clinical suspicion of abdominal TB. Of these patients, 50 were subsequently proven by biopsy to have peritoneal TB. All the patients underwent the following diagnostic tests after a thorough clinical examination: erythrocyte sedimentation rate (ESR); Mantoux test; ascitic fluid analysis for adenosine deaminase (ADA) levels, Ziehl–Neelsen staining and culture of mycobacterium tubercle bacilli (MTB); and contrast enhanced computed tomography (CT) of the abdomen. We then undertook diagnostic laparoscopy. Features of a positive laparoscopy included thickened peritoneum, adhesions and peritoneal tubercles, which were biopsied (Fig. 1). Our patients were mainly young adults from rural areas, with a slight female predominance. Patients presented with fever (50%), weigh loss (40%), aneroxia (74%), malaise/pain (80%), diarrhea (10%), vomiting (40%) and constipation (25%). Physical signs were palor (74%), tender abdomen (70%), abdominal distension (50%), abdominal mass (20%), ascitis (15%) and lymphadenopathy (8%). The Mantoux test was positive in 23 patients (46%). Anaemia was present in 84% of patients and the ESR was high in 90%. Fig. 1 Adhesions between the colon and the parietal peritoneum in a patient with tuberculous peritonitis. Diagnostic laparoscopy was positive in 46 of 50 patients with biopsy-proven peritoneal TB, with a sensitivity of 92%. Contrast enhanced CT of the abdomen detected 30 of 50 cases of abdominal TB with a sensitivity of 60% and specificity of 71.42%. Ziehl–Neelsen staining for MTB of ascitic fluid was positive in only 2 patients (4%) and culture for MTB was positive in 8 cases (16%), whereas ascitic fluid polymerase chain reation (PCR) for TB increased the sensitivity to 83.33%. Ascitic fluid analysis for ADA (> 33 U/L) showed a sensitivity and specificity of 100% and 96%, respectively. Diagnostic laparoscopy was falsely positive in 10 of 42 patients who did not have TB peritonitis. Difficulties in the diagnosis of TB peritonitis owe to its nonspecific associated clinical features, unhelpful laboratory tests and a high level of false-negative tests (i.e., Mantoux test, Ziehl–Neelsen staining and culture of ascitic fluid and false-negative imaging). High levels of ascitic ADA is associated with TB peritonitis.3 Ascitic fluid was found clinically in only 15% of our patients, but may be available at the time of operation. Histopathology of peritoneal lesions is appropriate for diagnosing TB and to rule out other diseases, such as cancer. In the past, this required laparotomy4 even though the potential for laparoscopy was known before the advent of video laparoscopy.5 We agree with the previous report1 on the value of laparoscopy, but we found a false-positive rate of 18%. We suggest that the laparoscopic diagnosis of TB peritonitis be confirmed by histopathology of peritoneal lesions or ascitic fluid analysis for ADA greater than 33 U/L, depending on the local availability of these tests.

Procalcitonin and macrophage inflammatory protein-1 beta (MIP-1β) in serum and peritoneal fluid of patients with decompensated cirrhosis and spontaneous bacterial peritonitis

PurposeSpontaneous bacterial peritonitis (SBP) is the most frequent infection in patients with cirrhosis causing significant mortality which requires rapid recognition for effective antibiotic therapy, whereas ascitic fluid cultures are frequently negative. The aim of this study was to evaluate the SBP diagnostic efficacy of procalcitonin (PCT) and macrophage inflammatory protein-1 beta (MIP-1β) measured in serum and peritoneal fluid. Material/methodsThirty-two participants with liver cirrhosis and ascites were included into the study (11 females and 21 males, mean age 49.5±11.9 years). The peritoneal fluid and venous blood were collected for routine laboratory examinations and measurements of PCT and MIP-1β. Patients were divided into two groups according to the ascitic absolute polymorphonuclear leukocytes count (≥250mm−3 and <250mm–3). ResultsAscites was sterile in 22 participants and SBP was diagnosed in 10 patients. Serum and ascitic levels of PCT and MIP-1β did not correlate with clinical and routine laboratory parameters. MIP-1β in the ascitic fluid was significantly higher in patients with SBP (213±279pg/ml vs. 66.3±49.8pg/ml; p=0.01). The sensitivity and specificity for diagnosis of SBP with ascitic MIP-1β were 80% and 72.7%, respectively (cut-off value 69.4pg/ml) with AUROC 0.77 (95%CI 0.58–0.96). Serum levels of MIP-1β showed lower diagnostic yield. Serum and ascitic PCT levels were not different in patients with and without SBP. ConclusionsMIP-1β concentration in ascitic fluid may distinguish patients with and without SBP with satisfactory sensitivity and specificity. Chemokines should be further explored for diagnostic use.

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A prospective audit of the use of diagnostic laparoscopy to establish the diagnosis of abdominal tuberculosis

The incidence of abdominal tuberculosis is much higher in an HIV-positive cohort. The use of laparoscopy in the diagnostic work-up of suspected abdominal tuberculosis is underutilized and its use and efficacy in the context of HIV co-infection has never been examined. A prospective clinical audit of the use of diagnostic laparoscopy was conducted in patients with clinically suspected abdominal tuberculosis but histologically or microbiologically unconfirmed tuberculosis at any site. From January 2008 to June 2010, 81 patients underwent diagnostic laparoscopy; 34 were male and 47 were female, with a mean age of 33years, and 77% were HIV-positive. Fifty-five patients (68%) had positive histology or culture for tuberculosis. In 15 patients (19%), histology revealed non-specific inflammation, no pathology was found in one patient, and no specimen was taken from one patient. Eighty percent of peritoneal deposits and 77% of lymph nodes were positive for tuberculosis, whereas 35% of ascitic fluid cultures were positive. In nine patients (11%) an alternative diagnosis was found; nine patients (11%) had conversion to laparotomy. There was no procedure-related death. Nine patients (11%) died during the 2-month follow-up period. Diagnostic laparoscopy avoids the morbidity and mortality of laparotomy in chronically ill patients, and reduces the rate of misdiagnosis of other abdominal conditions and unnecessary long-term therapy. Diagnostic laparoscopy and tissue sampling is a viable and reliable strategy in patients with suspected abdominal tuberculosis.

Diagnosis of spontaneous bacterial peritonitis and an in situ hybridization approach to detect an "unidentified" pathogen.

Spontaneous bacterial peritonitis (SBP) is a frequent and severe complication in cirrhotic patients with ascites. Although identifying the pathogen(s) plays a major role in the management of infectious diseases, ascitic fluid cultures often show negative results in patients with clinical signs and symptoms of SBP, and ascitic fluid cell analyses are the gold standard method for diagnosing SBP. SBP is generally diagnosed based on an increased number of polymorphonuclear neutrophils in the ascitic fluid (>250/mm3), and the identification of the causal pathogen may not be given consideration. We newly developed an in situ hybridization (ISH) method to provide early and direct evidence of bacterial infection in ascites in patients with SBP. This paper will review the diagnosis of SBP, including our novel approach with ISH method to detect bacterial DNA in SBP ascitic fluid.

Spontaneous bacterial peritonitis in Dakar, Senegal: study of 55 patients with cirrhosis.

To report the prevalence of spontaneous bacterial peritonitis (SBP) and its clinical and laboratory features in patients with cirrhosis followed at the Aristide Le Dantec Hospital in Dakar (Senegal). From May through December, 2010, we prospectively included patients with cirrhosis and a first episode of ascites on clinical examination. Diagnostic abdominal paracentesis was performed in all cases to determine the macroscopic appearance of the fluid, protein concentration, and cell count, and to culture the ascitic fluid in a blood culture bottle. SBP was diagnosed when the fluid contained more than 250 polymorphonuclear leukocytes per cubic millimeter of fluid. The data were analyzed with Epi-Info software, version 3.5.2. Comparisons used Fisher's exact and Chi-square tests, with significance set at p < 0.05. The study included 55 patients with cirrhosis, with a mean age of 45 years and a male/female sex ratio of 1.89 (36 men). The prevalence of SBP was 27.3%. Factors significantly associated with SBP were female gender, malnutrition, turbid appearance of the ascites, and neutrophilia. In samples from patients with SBP, the mean protein concentration was 20.7 g/L, the white cell count was 1797/mm(3), and the neutrophil count 1,102/mm(3). Ascitic fluid culture was positive in 20% of the SBP cases (n=3). In Dakar, cirrhosis is found especially in young adults, and the prevalence of SBP in our population was 27.3%. Improved technical equipment would improve the hospital's ability to determine the causes of cirrhosis and identify the various germs responsible for SBP.

Retrospective Investigation of Bacterascites and Spontaneous Bacterial Peritonitis in Liver Cirrhosis Patients Undergoing Paracentesis

Objective: There have been few studies of bacterascites among liver cirrhosis (LC) patients, although spontaneous bacterial peritonitis (SBP) has been well studied. Moreover, there have been no comparative studies of bacterascites and sterile ascites among LC patients. Therefore, we compared the characteristics of bacterascites, SBP, and sterile ascites among LC patients. Methods: Characteristics of bacterascites, SBP, and sterile ascites were retrospectively compared among 476 LC patients with ascites (547 paracentesis procedures, which included laboratory examinations and bacterial cultures of ascitic fluid) in Japan. Result: The frequencies of bacterascites and SBP were 2.6% (14/545) and 6.1% (33/545), respectively. Serum albumin and total protein levels in the ascitic fluid were significantly lower in the bacterascites group than in the sterile ascites group (498/545). However, no significant differences were observed in the Child–Pugh scores, incidence of type І hepatorenal syndrome (HRS), or short-term mortality rates between the bacterascites and sterile ascites groups. However, these parameters were significantly higher in the SBP group than in the sterile ascites group. Conclusion: No significant differences in short-term prognosis were observed among the groups because there appears to be no significant difference in the severity of liver dysfunction associated with underlying LC and the incidence of type І HRS between patients with bacterascites and sterile ascites. However, SBP was associated with a significantly poorer prognosis than sterile ascites.

A novel mAb against a human CD34 peptide reacts with the native protein on CD34+ cells.

‎Human CD34 is a transmembrane glycoprotein which is expressed in human hematopoietic stem ‎cells (HSCs) and the small-‎vessel endothelial cells of a variety of tissues. CD34 plays a critical role as a ‎marker for diagnosis ‎and classification of leukemia. Anti CD34 antibodies are used for isolation and ‎purification ‎of HSCs from bone marrow, peripheral blood and cord blood. To characterize a newly produced monoclonal antibody against a human CD34 peptide. Anti CD34 monoclonal antibody (Clone 2C10-D3) was purified from mouse ascitic fluid and hybridoma cell culture supernatants by affinity chromatography and its immune reactivity was examined by ELISA. The purified antibody was further characterized using Western blot and flow cytometry on TF1 (Human Erythroblast) cell line. ‎ELISA experiment revealed that the antibody recognized CD34 peptide. Western ‎blot analysis on TF1 ‎cell lysate confirmed the reactivity of the antibody with a 42 KDa protein. Blocking the antibody with a saturating concentration of specific CD34 peptide resulted in loss of its activity with TF1 lysate in Western blot. The 2C10-D3 antibody reacted with TF1 cells in flow cytometry in a similar manner to a commercial anti CD34 monoclonal antibody.‎ ‎Our data suggest that the anti CD34 monoclonal antibody (Clone 2C10-D3) is an appropriate antibody to study the CD34+ cells by flow cytometry and Western blot.

Neutrocytic Ascites and Clostridium difficile-associated Diarrhea: Should Patients Be Treated Empirically for Spontaneous Bacterial Peritonitis?

Case 1: A 68-year-old woman with cryptogenic cirrhosis presented with new high SAAG neutrocytic ascites (PMN: 421) and Clostridium difficile-associated diarrhea (CDAD). She was treated empirically with oral vancomycin and five days of cefotaxime. Ascitic fluid cultures were negative, and her diarrhea resolved. Case 2: A 58 -year-old woman with hepatitis C cirrhosis presented with high SAAG neutrocytic ascites (PMN: 778) and severe CDAD. She was treated with IV metronidazole and oral vancomycin, as well as cefotaxime. At 48 hours, ascitic fluid cultures were preliminarily negative, and cefotaxime was stopped. Final ascitic fluid cultures remained negative, and she recovered. Discussion: The standard treatment for spontaneous bacterial peritonitis (SBP) is early initiation of antibiotics and albumin after performing a diagnostic paracentesis. However, in CDAD, early discontinuation of broad-spectrum antibiotics is critical. In our two patients, this led to a therapeutic dilemma that required us to consider whether to discontinue antibiotics early in patients undergoing empiric treatment for SBP. Ascites is a common finding in cases of CDAD, up to nearly 80% in some case series (1,2,3,4). The overall specificity of ascites is low, as it may be seen in a variety of conditions (3,4). To our knowledge, this is the first report of a scenario of CDAD in a patient with cirrhosis and ascites with SAAG >1.1, with a high neutrophil count (>250/mL). Conclusion: Cirrhotic patients with CDAD may have culture-negative neutrocytic ascites from colitis alone. Based on our experiences, it may be reasonable to stop empiric treatment of SBP in a patient with high SAAG (>1.1) neutrocytic (>250/mL) ascites, who has confirmed CDAD, if ascitic cultures are negative at 48 hours.

Neutrocytic Ascites and Clostridium difficile-associated Diarrhea: Should Patients Be Treated Empirically for Spontaneous Bacterial Peritonitis?

Case 1: A 68-year-old woman with cryptogenic cirrhosis presented with new high SAAG neutrocytic ascites (PMN: 421) and Clostridium difficile-associated diarrhea (CDAD). She was treated empirically with oral vancomycin and five days of cefotaxime. Ascitic fluid cultures were negative, and her diarrhea resolved. Case 2: A 58-year-old woman with hepatitis C cirrhosis presented with high SAAG neutrocytic ascites (PMN: 778) and severe CDAD. She was treated with iv metronidazole and oral vancomycin, as well as cefotaxime. At 48 hours, ascitic fluid cultures were preliminarily negative, and cefotaxime was stopped. Final ascitic fluid cultures remained negative, and she recovered. The standard treatment for spontaneous bacterial peritonitis (SBP) is early initiation of antibiotics and albumin after performing a diagnostic paracentesis. However, in CDAD, early discontinuation of broad-spectrum antibiotics is critical. In our two patients, this led to a therapeutic dilemma that required us to consider whether to discontinue antibiotics early in patients undergoing empiric treatment for SBP. Ascites is a common finding in cases of CDAD, up to nearly 80% in some case series (1,2,3,4). The overall specificity of ascites is low as it may be seen in a variety of conditions (3,4). To our knowledge, this is the first report of a scenario of CDAD in a patient with cirrhosis and ascites with SAAG >1.1 with a high neutrophil count (>250/mL). Cirrhotic patients with CDAD may have culture-negative neutrocytic ascites from colitis alone. Based on our experiences, it may be reasonable to stop empiric treatment of SBP in a patient with high SAAG (>1.1) neutrocytic (>250/mL) ascites who has confirmed CDAD if ascitic cultures are negative at 48 hours.