Ascitic Fluid Infection Research Articles

Comparison of clinical characteristics and outcomes of spontaneous bacterial peritonitis and culture negative neutrocytic ascites

Objective: Ascitic fluid infections (AFI) in cirrhotic patients can be classified into two groups: spontaneous bacterial peritonitis (SBP) and culture-negative neutrocytic ascites (CNNA). The aim of this study was to compare the clinical characteristics and outcomes of the two groups of patients with AFI.Methods: We retrospectively reviewed the medical records of cirrhotic patients with AFI. We evaluated demographic data, clinical presentations of AFI, laboratory findings, liver function, and mortality rates.Results: Between January 2005 and December 2014, 533 patients with AFI were evaluated; 259 (48.6%) had SBP and 274 (51.4%) CNNA. Ascites neutrophil count (4410/mm3 versus 1046/mm3, p < .001) and the blood culture positive rate (38.1% versus 20.1%, p < .001) were higher in the SBP group, which also had a higher MELD score (24.29 versus 22.05, p = .004). Seven-day mortality was higher in the SBP group (9.4% versus 4.5%, p = .027) but there was no significant difference in 30-day (22.1% versus 17.5%) or 90-day mortality rate (36.1% versus 36.4%).Conclusions: Patients in the SBP group had a higher MELD score, ascites neutrophil count, and positive blood culture rate. Although seven-day mortality rate was higher in the SBP group, the 30-day and 90-day mortality rates were similar in the two groups.

56-Year-Old-Man With Fever, Altered Mental Status, and Abdominal Pain

56-Year-Old-Man With Fever, Altered Mental Status, and Abdominal Pain

Clinical profile of ascites in children at tertiary care hospital, North Karnataka

Introduction: Ascites is a common clinical problem in children with liver and renal disease. The peripheral arterial vasodilation hypothesis is mostly accepted as the patho-physiological basis of ascites. The most important complication is spontaneous ascitic fluid infection in the form of spontaneous bacterial peritonitis (SBP) and its variants. Objective: To know the incidence, etiology, associated clinical co-morbidities & the outcome (morbidity & mortality) of the hospitalized children with ascites. Materials and Methods: After informed written consent from parents/ guardian, 102 children admitted with ascites irrespective of primary diagnosis were studied at department of Pediatrics, S. Nijalingappa Medical College, Bagalkot. The study was a prospective study and subjects were enrolled consecutively. Detailed history, complete physical examination & routine investigations were done in all patients and were recorded in predesigned proforma. A detailed etiological workup was done. Results: The most common symptoms were abdominal distension (100%), facial puffiness (62.74%), pedal edema (46.08%), & generalized swelling (35.29 %). The most common signs were facial puffiness in 62.74%, pedal edema in 46.07% & anasarca in 35.29% the most common etiology of ascites was dengue fever, followed by nephrotic syndrome. Of the 102 children with ascites, 2 expired (Gaucher’s disease & Wilson’s disease). Conclusion: Prompt and early diagnosis and appropriate management of ascites is warranted to prevent related morbidity and mortality in children.

Label-free bimodal waveguide immunosensor for rapid diagnosis of bacterial infections in cirrhotic patients

Spontaneous bacterial peritonitis is an acute bacterial infection of ascitic fluid; it has a high incidence in cirrhotic patients and it is associated with high mortality. In such a situation, early diagnosis and treatment is crucial for the survival of the patient. However, bacterial analysis in ascitic fluid is currently based on culture methods, which are time-consuming and laborious. We report here the application of a photonic interferometer biosensor based on a bimodal waveguide (BiMW) for the rapid and label-free detection of bacteria directly in ascitic fluid. The device consists of a straight waveguide in which two modes of the same polarization interfere while interacting with the external medium through their evanescent fields. A bimolecular event occurring on the sensor area of the device (e.g. capturing bacteria) will differently affect each light mode, inducing a variation in the phase of the light exiting at the output of the waveguide. In this work, we demonstrate the quantitative detection of Bacillus cereus in buffer medium and Escherichia coli in undiluted ascitic fluid from cirrhotic patients. In the case of Bacillus cereus detection, the device was able to specifically detect bacteria at relevant concentrations in 12.5min and in the case of Escherichia coli detection, the analysis time was 25min. Extrapolation of the data demonstrated that the detection limits of the biosensor could reach few bacteria per milliliter. Based on the results obtained, we consider that the BiMW biosensor is positioned as a promising new clinical tool for user-friendly, cost-effective and real-time microbiological analysis.

The Role of Serum Procalcitonin Levels in Predicting Ascitic Fluid Infection in Ascitic Patients Admitted to Zagazig University Hospital in 2014.

30Apr 2016 The Role of Serum Procalcitonin Levels in Predicting Ascitic Fluid Infection in Ascitic Patients Admitted to Zagazig University Hospital in 2014. Alaa A. Farag and Hany Abd Elmalik Labib. Internal Medicine Department, Faculty of Medicine, Zagazig University, Egypt. Clinical Pathology Department, Faculty of Medicine, Zagazig University, Egypt.

Prevalence and Short Term Outcome of Spontaneous Bacterial Peritonitis of Known Chronic Liver Disease Patients

Spontaneous bacterial peritonitis (SBP) is an infection of ascitic fluid occurring in the absence of a contiguous source of infection characterized by symptoms of fever, abdominal pain, rebound tenderness, encephalopathy. It may develope in hospitalized patients and mortality rate is significantly high. To determine the prevalence of SBP in chronic liver disease with ascites and to establish that SBP is the cause of higher mortality than non SBP, a prospective longitudinal study was carried out in patients attending in the inpatient Department of Gastroenterology of Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorder Hospital(BIRDEM), Bangabandhu Sheikh Mujib Medical University(BSMMU), Dhaka Medical College Hospital(DMCH), Dhaka from March 2010 to September 2010. Among the 60 patients the most common age group was the 46-55 years. In physical finding below average body build was found in 48 (80.0%) cases. Malnutrition was found in 48(80.0%) cases. Per abdominal finding liver was not palpable in 54 (90.0%) cases. Shifting dullness was found in 59 (98.3%) cases. Fluid thrill was detected in 57 (95.0%) cases. It was found that SBP were developed in 11(18.3%) cases and remaining 49(81.7%) case were non SBP, which were higher than SBP. Organism of culture of ascitic fluid in SBP patients (n=11) were E. coli and Pseudomoas spp found in 2(18.2%) cases, the rest 6(54.5%) cases shows no growth. Among 11 SBP patients improvement occurred in 5(45.5%) cases and the rest 6(54.5%) cases died p value &lt;.001. SBP is medical emergency, prompt management and prophylactic antibiotics are essential to reduce mortality.Medicine Today 2015 Vol.27(1): 15-19

Observations on a Giant Sigmoid Volvulus with Unusual Clinical Presentation and Challenging Postoperative Course: Case Report

Introduction: The present report describes a case of a giant sigmoid volvulus (SV) where acute respiratory distress was associated with toxic megacolon. Clinical features, surgical treatment and postoperative course deserved our attention and discussion. Presentation of Case: A 67-year-old man with psychiatric disturbances was admitted to our Department with severe respiratory distress due to an enormous abdominal distension caused by a sigmoid volvulus. Endoscopic derotation was unsuccessful and surgery immediately performed. After a wide colonic resection the patient underwent a prolonged treatment in the Intensive Care Unit. Death occurred 34 days after the operation for secondary infection of peritoneal effusion. Discussion: Main clinical features of SV pertain to abdominal compartment while in the present case acute respiratory distress was the prominent symptom; in the same time the severity of the case was due to the association of high abdominal pressure together with a toxic megacolon. Postoperative treatment consisted in ventilatory support, with a progressive shift from asssisted to spontaneous ventilation; repeated sessions of haemodialysis were necessary to manage renal failure up to recovery of the urine output. Bacterial trans location due to toxic megacolon was responsible of late infection of ascitic fluid. In spite of multiple antibiotic association according to bacterial cultures, intra-abdominal abscesses eventually developed causing fatal outcome 34 days after the first intervention. Conclusion: Severe clinical presentation required a prolonged and demanding postoperative course which was focused on the recovery of respiratory, cardiac and renal function even if fatal outcome was due to septic complications. Suspicion of late infection of ascitic fluid could arise from persistently high values of inflammation indexes and drive to an earlier drainage of the abdominal abscesses.

A study of bacteriological profile of ascitic fluid in suspected clinical cases of spontaneous bacterial peritonitis at a tertiary care hospital in India

Background: Spontaneous bacterial peritonitis (SBP) is the development of a monomicrobial infection of ascitic fluid in the absence of any contiguous source of infection. It occurs most commonly in conjunction with cirrhosis of the liver and alcoholic liver diseases. Majority of the SBP cases are caused by gram-negative organisms, mostly Escherichia coli. Objective: To isolate the various bacteriological agents from ascitic fluid from clinically suspected cases of SBP and to determine their antibiotic sensitivity pattern. Materials and Methods: In this study, 217 ascitic fluid samples from clinically suspected cases of SBP were collected from December 2011 to November 2012. Ascitic fluid was collected by bedside tapping in blood culture bottle aseptically and immediately sent to a microbiology laboratory, Sir T Hospital, Bhavnagar, Gujarat, for microbiological examination. Bacterial examination and antibiotic sensitivity tests were carried out by standard microbiological techniques. Results: Of 217 clinically suspected cases of SBP, 71 (43.80%) had ascitic fluid polymorphonuclear cells (PMN) count ≥ 250/mm3. Among 71 cases, 31 (43.6%) cases were culture positive and 40 (56.4%) cases were culture-negative neutrocytic ascites. From 31 culture-positive cases, E. coli was isolated from 17 (54.9%) cases; Klebsiella spp. was isolated from 5 (16.2%) cases; Staphylococcus aureus was isolated from 6 (19.3%) cases; and Pseudomonas aeruginosa was isolated from 3 (9.6%) cases. All isolates were sensitive to cefotaxime and ceftriaxone. Conclusion: If diagnosed early, SBP can be treated with high success rate, thus ascitic fluid laboratory analysis including culture of all suspected patients will help in improving prognosis of the patients.

Infections in Cirrhotics: Types, Microbiological Spectrum and Risk Factors—5-Year Cohort Study

Cirrhosis is an immunocompromised state that leads to various infections, with an estimated 30% mortality. Pakistan already has a high morbidity and mortality related to complications of cirrhosis. Where the data on infection among cirrhotics is scanty, this study aimed to determine the frequency, microbiological spectrum and various risk factors of infections in cirrhosis of liver. This is a prospective cohort study conducted at a tertiary care hospital. The microbiological spectrum and frequency of infections was determined in cirrhotics. Various risk factors for infection among cirrhotics were evaluated like upper gastrointestinal bleed, use of proton pump inhibitors, malnutrition and severity of cirrhosis. Out of eleven hundred and forty-one patients with cirrhosis of liver, four hundred and ninety (42.94%) patients had infections. All kinds of infections like peritoneal, respiratory, urinary tract and skin were present in cirrhosis of liver where ascitic fluid infections (AFI) were the commonest i.e. 44.89%. The risk factors for bacterial infections among patients with cirrhosis of liver were upper gastrointestinal bleeding (odd ratio = 4.57, p = 0.0001), use of proton pump inhibitors (odd ratio = 2.57, p = 0.0001), degree of malnutrition (odd ratio = 10.34, p = 0.0001) and severity of cirrhosis (odd ratio = 12.99, p = 0.000). All types of infections occurred with varying frequency in cirrhosis of liver. Upper gastrointestinal bleeding, severity of cirrhosis, use of high dose proton pump inhibitors and severe malnutrition are important risk factors for infections among cirrhotics.

New Markers to Explore Spontaneous Bacterial Peritonitis

Spontaneous Bacterial Peritonitis (SBP) is an ascitic fluid infection without a definitive, surgically treatable, intraabdominal source, accounting for 10 to 30% of cirrhotic patients with ascites. To explore new methods of diagnosing Spontaneous Bacterial Peritonitis (SBP), we prospectively studied 19 Acute-on-Chronic Hepatitis B Liver Failure (ACHBLF) patients with or without Spontaneous Bacterial Peritonitis and 17 Hepatitis B Virus (HBV)-related Liver Decompensated Cirrhosis patients with or without Spontaneous Bacterial Peritonitis. Patients were separated into two groups: SBP group (n=14), non SBP group (n=22). A paracentesis of ascetic fluid was performed. The levels of 40 cytokines in ascetic fluid were measured by using RayBio® Human Cytokine Antibody Array. The results indicated that the levels of RANTES, EOTAXIN EOTAXIN-2, IL-1βand MIP-1αwere higher in the ascitic fluid of the SBP group. An increase in cytokine production in the ascitic fluid of patients with SBP may provide new markers to diagnose SBP more easily and accurately.

Hemorrhagic complications of paracentesis: a systematic review of the literature.

Introduction. Large volume paracentesis is considered a safe procedure carrying minimal risk of complications and rarely causing morbidity or mortality. The most common complications of the procedure are ascitic fluid leakage, hemorrhage, infection, and perforation. The purpose of this study was to evaluate all hemorrhagic complications and their outcomes and to identify any common variables. Methods. A literature search for all reported hemorrhagic complications following paracentesis was conducted. A total of 61 patients were identified. Data of interest were extracted and analyzed. The primary outcome of the study was 30-day mortality, with secondary endpoints being achievement of hemostasis after intervention and mortality based on type of intervention. Results. 90% of the patients undergoing paracentesis had underlying cirrhosis. Three types of hemorrhagic complications were identified: abdominal wall hematomas (52%), hemoperitoneum (41%), and pseudoaneurysm (7%). Forty percent of the patients underwent either a surgical (35%) or an IR guided intervention (65%). Patients undergoing a surgical intervention had a significantly higher rate of mortality at day 30 compared to those undergoing IR intervention. Conclusion. Abdominal wall hematomas and hemoperitoneum are the most common hemorrhagic complications of paracentesis. Transcatheter coiling and embolization appear to be superior to both open and laparoscopic surgery in treatment of these complications.

Spontaneous ascitic fluid infection in liver cirrhosis: bacteriological profile and response to antibiotic therapy

Spontaneous ascitic fluid infection (SAI) is common in cirrhotic patients leading to significant morbidity and mortality. Third-generation cephalosporins are currently recommended as first-line therapy. We conducted a prospective study to determine bacterial etiology, susceptibility patterns, and clinical epidemiology including 1-month mortality of SAIs among patients with cirrhosis. Records of 600 patients with suspected SAI over a 4-year period were analyzed. Empirical cefotaxime/ceftriaxone was initiated in patients who had a neutrophil count >250/mm(3). Treatment failure was defined by absence of clinical improvement and/or significant decrease in neutrophil count of ascites (<25 % of base line value) by 72 h of therapy. Seventy patients (11.6 %) had SAI, including 40 (57.1 %) culture-negative neutrocytic ascites (CNNA), 25 (35.8 %) spontaneous bacterial peritonitis (SBP), and five (7 %) monomicrobial non-neutrocytic bacterascites (MNB). Gram-negative bacilli (Klebsiella and E. coli) were the commonest organisms. The overall response rate to ceftriaxone was 62.8 % (44/70). Among culture-positive patients (SBP and MNB), sensitivity rates to ceftriaxone was 50 %, while it was 53.3 % for quinolones, 70 % for piperacillin-tazobactam, and 93.3 % for cefoperazone-sulbactam combination. Thirty-day mortality was lower for CNNA compared to SBP (20 % vs. 40 %, p < 0.001) and for patients with response compared to no response to first antibiotic (11.3 % vs. 53.8 %, p < 0.001). The response of SAI to third-generation cephalosporins was low at our center. Cefoperazone-sulbactam could be a better alternative choice.

Mean platelet volume is a useful indicator of systemic inflammation in cirrhotic patients with ascitic fluid infection

Aim. Ascitic fluid infection (AFI) consists primarily of two variants, namely, culture-negative neutrocytic ascites and spontaneous bacterial peritonitis (SBP). Mean platelet volume (MPV) has begun to be used as a simple and inexpensive indicator of inflammation in some diseases. We aimed to analyse whether platelet size alterations would be useful in predicting AFI in cirrhotic patients.Material and methods. A total of 135 patients with ascites due to cirrhosis and 55 control subjects were enrolled in this study. According to ascitic fluid analysis, 58 patients were considered to have AFI. MPV and inflammatory parameter values were determined for all study participants. The ability of MPV values to predict AFI in cirrhotic patients was analysed using receiver operator characteristic (ROC) curve analysis.Results. A statistically significant increase in MPV levels was observed in cirrhotic patients with AFI compared to cirrhotic patients without AFI and healthy controls (p < 0.001). A statistically significant increase was observed in the AFI group with respect to MPV, C-reactive protein (CRP) and white blood cell (WBC) levels. ROC curve analysis suggested that the optimum MPV level cut-off point for cirrhotic patients with AFI was 8.45, with a sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of 70.7%, 67.5%, 75.4% and 62.1%, respectively (area under curve: 0.768).Conclusion. Our study shows that MPV is increased in cirrhotic patients with AFI. MPV measurement can considered to be an accurate diagnostic test in predicting AFI, possibly due to an ongoing systemic inflammatory response.

Clinical profile and outcome of ascites and spontaneous bacterial peritonitis (SBP) in cirrhotics study

Objectives: A prospective of cirrhotic patients with ascites in terms of clinical profile, prevalence and outcome. Methods: All inpatients during 2 years (2006–2008) with cirrhotic ascites were included. Laboratory workup, diagnostic ascitic paracentesis was performed on admission. Ascitic fluid was tested for total cell count, differential count, albumin, total protein and inoculated in blood culture bottles (BacT/ALERT) R AF at bedside. For ease of analysis CNNA and classic SBP were included in a broad group as spontaneous bacterial peritonitis. All patients with ascitic fluid infection were initially treated with 2nd or 3rd generation cephalosporins or penicillin derivatives or fluoroquinolones empirically and later modified as per culture sensitivity. Primary end points included discharge or death. Statistical analysis was done using Student t test, Chi-square/Fisher Exact. Results: Out of 179 most were between 30-70 years with a mean age of 54 with 80% males. Main etiology of cirrhosis was ethanol (69%). Abdominal distension was the commonest presenting symptom followed by fever, abdominal pain, and encephalopathy. In our study 31% had SBP. Abdominal pain and fever were significantly associated with SBP. Culture positivity rate was 80%. Majority was due to E. coli (63%). SBP was significantly associated with higher creatinine, total WBC count (blood), SAAG, lower serum albumin, serum sodium and ascitic fluid proteins. Common complications other than SBP were shock, acute renal failure (37%) and encephalopathy. Mortality rate was 4.5%. Patients with SBP had higher Child's class and MELD scores. Conclusion: This study underlines effectiveness of bedside inoculation of ascitic fluid into blood culture bottles results in better yield. Patients presenting with abdominal pain, fever or encephalopathy, high blood counts, high creatinine, low sodium, low ascitic fluid protein should be suspected of having SBP.

The Role of Serum Procalcitonin Levels in Predicting Ascitic Fluid Infection in Hospitalized Cirrhotic and Non-cirrhotic Patients

Objective: To determine the role of serum procalcitonin levels in predicting ascites infection in hospitalized cirrhotic and non-cirrhotic patients.Methods: A total of 101 patients (mean age: 63.4±1.3, 66.3% were males) hospitalized due to cirrhosis (n=88) or malignancy related (n=13) ascites were included in this study. Spontaneous bacterial peritonitis (SBP, 19.8%), culture-negative SBP (38.6%), bacterascites (4.9%), sterile ascites (23.8%) and malign ascites (12.9%) groups were compared in terms of procalcitonin levels in predicting ascites infection. Receiver operating characteristic (ROC) curves were used to evaluate the diagnostic performance of procalcitonin levels and predicting outcome of procalcitonin levels was compared with C-reactive protein (CRP).Results: Culture positivity was determined in 26.7% of overall population. Serum procalcitonin levels were determined to be significantly higher in patients with positive bacterial culture in ascitic fluid compared to patients without culture positivity (median (min-max): 4.1 (0.2-36.4) vs. 0.4 (0.04-15.8), p<0.001). Using ROC analysis, a serum procalcitonin level of <0.61 ng/mL in SBP (area under curve (AUC): 0.981, CI 95%: 0.000-1.000, p<0.001), <0.225 ng/mL in culture-negative SBP (AUC: 0.743, CI 95%: 0.619-0.867, p<0.001), <0.42 ng/mL in SBP and culture-negative SBP patients (AUC: 0.824, CI 95%: 0.732-0.916, p<0.001), and <1.12 ng/mL in bacterascites (AUC: 0.837, CI 95%: 0.000-1.000, p=0.019) were determined to accurately rule out the diagnosis of bacterial peritonitis. Predictive power of serum procalcitonin levels in SBP + culture-negative SBP group (AUCs: 0.824 vs 0.622, p=0.004, Fig 4), culture-positive SBP (AUCs: 0.981 vs 0.777, p=0.006, Fig 5) and (although less powerfull) in culture-negative SBP (AUCs: 0.743 vs 0.543, p=0.02, Fig 6) were found significantly higher than CRP.Conclusion: According to our findings determination of serum procalcitonin levels seems to provide satisfactory diagnostic accuracy in differentiating bacterial infections in hospitalized patients with liver cirrhosis related ascites.

Fluorescence in-situ hybridization as a novel technique for rapid and sensitive detection of ascitic fluid infection

Fluorescence in-situ hybridization as a novel technique for rapid and sensitive detection of ascitic fluid infection

Evaluation of different therapeutic approaches for spontaneous bacterial peritonitis

Background and study aimsSpontaneous bacterial peritonitis (SBP) is a significant cause of mortality in cirrhosis. Reducing toxic burden of infected ascitic fluid through paracentesis needs further studies as adjunctive therapy of SBP. We aimed to evaluate different therapies for SBP. Patients and methodsThirty-six cirrhotic ascitic patients with SBP were examined and classified according to treatment modality (5–7days) into: Group A received cefotaxime, group B received cefotaxime and albumin 1.5g/kg body weight within 6h of SBP being diagnosed and 1g/kg body weight on day 3, group C received cefotaxime and paracentesis with volume dependent albumin infusion. Control group of 12 cirrhotic ascitic patients free from SBP were included. Routine laboratory tests, ascitic fluid analysis for leucocytes and culture were done, inflammatory mediators such as nitric oxide and tumour necrosis factor alpha were measured in serum and ascitic fluid. Duplex-Doppler assessment of portal flow volume and renal resistive index, Echocardiography to measure end diastolic and end systolic volumes, stroke volume and cardiac output were done. Tests were carried out before and after therapy. ResultsTreatment response was assessed by, cardiac haemodynamics, portaland renal flow and NO and TNF. All studied parameters; laboratory, cardiac, Doppler exhibited a significant improvement in group B in contrast to the other groups as demonstrated by post therapy reduction of (blood and ascitic fluid WBCs & PNLS, serum and ascitic NO & TNF and renal resistive index), elevation of (serum albumin and portal flow volume) and improvement of cardiac haemodynamic. ConclusionTreatment of spontaneous bacterial peritonitis by cefotaxime and body weight based albumin infusion gave most favourable results compared to other regimens. Postulation of removing toxic burden through paracentesis has not been confirmed.

Emergence of spontaneous bacterial peritonitis due to enterococci – risk factors and outcome in a 12‐year retrospective study

Third-generation cephalosporins (TGC) constitute the empirical first-line therapy for spontaneous bacterial peritonitis (SBP). Hospitalisation, invasive procedures and use of antibiotics may challenge this concept due to an increase in enterococci and other TGC-resistant microorganisms. To determine prevalence, risk factors and outcome of ascitic fluid infections caused by enterococci. All independent episodes of culture-positive ascitic fluid between 2000 and 2011 in a German tertiary centre were analysed retrospectively. Out of 244 positive ascitic fluid cultures, 90 episodes of monomicrobial SBP and 25 episodes of monomicrobial bacterascites (BA) in patients with decompensated cirrhosis were identified. Enterococcus spp. were isolated in 32 (28%) episodes. We noticed a profound increase in the frequency of enterococcal infection over the study period from 11% to 35% (P = 0.007). Univariate risk factors for enterococcal SBP/BA included nosocomial infection (OR = 4.56; 95% CI 1.90-10.97), previous use of antibiotics (OR = 5.63; 95% CI 1.81-17.49) and recent gastrointestinal endoscopy (OR = 3.17; 95% CI 1.33-7.54). Nosocomial infection (OR = 3.29; P = 0.011) and recent antibiotic therapy (OR = 3.88; P = 0.025) remained independent risk factors for enterococcal infection in multivariate logistic regression and these factors contributed also to the model when only SBP cases were considered. In subjects with monomicrobial SBP who were treated with TGC or ciprofloxacin, the probability of 90-day survival was 12% in enterococcal infection compared to 50% in non-enterococcal SBP (P = 0.022 in log-rank test). Because of the increasing prevalence of enterococcal spontaneous bacterial peritonitis and its poor prognosis when treated inappropriately, clinicians should consider empirical therapy with anti-enterococcal antibiotics for patients with risk factors.

Prevalence and risk factors for unsuspected spontaneous ascitic fluid infection in cirrhotics undergoing therapeutic paracentesis in an outpatient clinic

Spontaneous bacterial peritonitis (SBP) has been typically described in hospitalized patients. There are little data on ascitic fluid infection in asymptomatic outpatients. The present study was aimed at determining the prevalence and risk factors for asymptomatic ascitic fluid infection among patients with liver cirrhosis attending an outpatient clinic. Between January 2008 and December 2009, consecutive patients with cirrhosis (n = 110) undergoing therapeutic paracentesis in an outpatient setting were studied. Patients with fever, abdominal pain, hepatic encephalopathy, recent gastrointestinal bleeding, impaired renal function, previous history of SBP and on antibiotic treatment were excluded. Baseline demographic details, and etiology and severity of liver disease were recorded. Ascitic fluid cell count, culture and biochemical tests were done using standard laboratory techniques. The causes of cirrhosis were alcohol (55.5%), hepatitis B (21.8%), hepatitis C (9.1%) and others (13.6%). A total of 278 paracenteses were done in them (average 2.5 [1.1] times per patient). Spontaneous ascitic fluid infection was found in 7 (2.5%) paracentesis, including spontaneous bacterial peritonitis in one (0.4%), monomicrobial nonneutrocytic bacterascites (MNB) in two (0.7%) and culture-negative neutrocytic ascites (CNNA) in four (1.4%). Escherichia coli, Klebsiella spp. and Staphylococcus aureus were grown. There was no difference between cirrhotic outpatients with and without infection in age, gender, alcohol consumption, etiology of cirrhosis, Child-Pugh score, serum albumin and ascitic fluid total protein. There was no death due to spontaneous ascitic fluid infection. Asymptomatic ascitic fluid infection was very infrequent in patients with cirrhosis attending an outpatient clinic and undergoing therapeutic paracentesis.

NOD2 gene variants are a risk factor for culture‐positive spontaneous bacterial peritonitis and monomicrobial bacterascites in cirrhosis

Spontaneous bacterial peritonitis (SBP) is considered as result of bacterial translocation from the gastrointestinal lumen to the mesenteric lymph nodes and subsequent circulation. Variants of the NOD2 gene contribute to bacterial translocation and were associated with SBP in a recent study. We determined common NOD2 variants by TaqMan polymerase chain reaction and analysed the ascitic fluid neutrophil count and bacterial culture results in 175 prospectively characterized hospitalized patients with decompensated cirrhosis who underwent diagnostic paracentesis in two German centres. Ten patients presented with culture-positive SBP, 19 with culture-negative SBP and six had bacterascites. Minor allele frequencies for R702W, G908R and 1007fs in subjects with sterile non-neutrocytic ascites were 3.2, 2.5 and 2.5% respectively. Patients with SBP [odds ratio (OR) 2.7; P=0.036], culture-positive SBP (OR 6.0; P=0.012) and bacterascites (OR 6.0; P=0.050) were more often carriers of NOD2 variants than patients with sterile non-neutrocytic ascites. The mutations 1007fs and G908R were associated with culture-positive SBP (P ≤ 0.005) and R702W with bacterascites (P=0.014). There was no significant association of NOD2 variants with culture-negative SBP (OR 1.6; P=0.493). In logistic regression, previous SBP, a higher model for end-stage liver disease (MELD) score and the presence of a NOD2 variant were independent predictors of ascitic fluid infection. The median survival was insignificantly shorter in patients with NOD2 variants (268 vs. 339 days; P=0.386). In patients without hepatocellular carcinoma at study entry (N=148), NOD2 was a predictor of survival after adjustment for the MELD score and age (hazard ratio 1.89; P=0.045). NOD2 variants increase the risk for culture-positive SBP and bacterascites in cirrhosis and may affect survival.