Ascitic Fluid Total Protein Research Articles

64-Year-Old Woman With Diarrhea and Increased Abdominal Girth

64-year-old woman presented to our institution for evaluation of diarrhea and increasing abdominal girth. She had a 1-month history of postprandial diarrhea unrelated to the type of foods she consumed. Her stool was watery, with no evidence of gastrointestinal bleeding. Concurrently, she also noted increasing abdominal girth requiring new pants with a larger waist size. She had no abdominal pain, nausea/vomiting, flushing, light-headedness, or constitutional symptoms. Her medical history was notable for a previous stroke with a mild residual right hand tremor. She was a lifetime nonsmoker, had no history of illicit drug use, and drank alcohol rarely. She had no history of recent travel, infectious exposures, new medications, or herbal supplement intake. Her blood pressure was 136/83 mm Hg, and herheart rate was 98beats/min.Heroxygensaturation was 95% while she breathed room air, and her respiratory rate was 18 breaths/min. Her temperature was 36.9C. Her mental status was normal. Her abdomen was soft, nontender, and mildly distended with hyperactive bowel sounds. Shifting dullness with a fluid wave was present. 1. Which one of the following is the most appropriate diagnostic approach to evaluate the patient’s abdominal symptoms? a. Paracentesis b. Colonoscopy c. Clostridium difficile toxicology screen or polymerase chain reaction d. Serology testing for transglutaminase antibody e. Abdominal radiography

84-Year-Old Man With Night Sweats, Weight Loss, and Diarrhea

An 84-year-old man with a history of coronary artery disease, hypertension, hyperlipidemia, ischemic stroke, and gastroesophageal reflux disease presented to the outpatient gastroenterology clinic with a 3-month history of night sweats, generalized weakness, nausea, vomiting, nonbloody postprandial diarrhea, and an 18-kg weight loss. He also reported a recent rash and daily morning stiffness in his fingers and knees lasting up to about 30 minutes. He denied alcohol or intravenous drug abuse. Previously, he had been taking several medications, but all had been recently discontinued because of the persistent diarrhea. On examination, the patient had normal vital signs. He appeared cachectic, with a distended abdomen with flank dullness but no pain on palpation. The joints of his fingers and knees were tender to palpation, and soft tissue swelling was evident. No other abnormalities were found on examination of the head, ears, eyes, nose and throat, skin, and lymphatic, cardiac, respiratory, and thyroid systems. A computed tomographic (CT) scan of the abdomen and pelvis obtained 1 month previously at another institution revealed abdominal and pelvic ascites and mildly prominent aortocaval and periportal lymph nodes. A positron emission tomographic/CT scan also obtained at another facility did not suggest malignancy.

Bacteriologic study of cirrhotic patients with non-neutrocytic ascites.

We aimed for detection of bacterial DNA (bactDNA) in spontaneous bacterial peritonitis (SBP) by polymerase chain reaction (PCR) and its prognostic relevance in cirrhotic patients with culture-negative non-neutrocytic ascites (CNNNA). approximately 60% of patients with spontaneous bacterial peritonitis (SBP) are ascites culture negative. Of each 77 patients with cirrhosis and ascites, two samples including blood and ascitic fluid (AF) were taken. Blood samples were obtained for routine biochemical study and PMN count. AF samples were used for biochemical analysis and aerobic and anaerobic culture. BactDNA was detected by polymerase chain reaction (PCR) using bacterial universal 16srRNA gene primer. Of all AF samples, 3 (3.9%) were positive for bacterial culture (one streptococcus α hemolytic and two E.coli). The mean number of PMN in AF was 63. BactDNA was detected in 33 (42.9%) of 77 of samples (group A) and bactDNA was absent in 41 (53.2%) of samples (group B). Blood WBC, prothrombin time, LDH, serum total protein, AF WBC, serum albumin, AF albumin, AF total protein, serum total bilirubin, AST, ALT and BUN were not statically different among group A and B. Hepatitis B, 41(45%), was the most frequent cause of cirrhosis. Hepatitis B is the common cause of cirrhosis in Iranian cirrhotic patients. Also, current study showed that high number of Iranian cirrhotic patients with CNNNA carries bactDNA in their AF. The clinical findings as well as clinical laboratory data in patients with CNNNA are independent to bactDNA status in their ascitic fluid.

Usefulness of serum ascites cholesterol gradient (SACG), total protein (TP) ratio and serum ascites albumin gradient (SAAG) in differentiating tuberculous ascites and cirrhotic ascites

Background: Differential diagnosis of ascites is a common clinical problem and is usually done by Serum Ascites Albumin Gradient (SAAG).However many other markers can also be utilized for the same. Aims & Objective: This study was carried out to evaluate the diagnostic efficiency of ascitic fluid cholesterol, serum ascites albumin gradient (SAAG) , Total protein Ratio and serum ascites cholesterol gradient (Chol gradient/ SACG) in differentiating cirrhotic and tuberculous ascites. Material and Methods: The study included 48 patients admitted in St John’s Medical Hospital, Bangalore, out of which 25 patients were diagnosed with tuberculous ascites and 23 patients were diagnosed with cirrhotic ascites. Serum and ascitic fluid (AF) albumin, Total protein (TP) and Cholesterol (Chol) were estimated. The SAAG, TP ratio, Serum ascites cholesterol gradient (SACG) were calculated. Significance was assessed at 5% level of significance. Cohen’s d effect size has been computed and discrimination function analysis is done to determine the percentage of correct classification between cirrhotic and tubercular ascites. Results: SAAG showed a sensitivity and specificity of 100% and 95.6% at cut off of >1.1g/dl TP ratio at a cut off > 0.5 showed sensitivity100% and specificity98% specificity. Ascitic fluid Cholesterol is high in the tuberculous group and showed sensitivity and specificity of at a cut off value of 100% and 95.5%. Ascitic fluid TP showed a sensitivity and specificity of 100% and 96% at a cut off value of

The Role of Rifaximin in the Primary Prophylaxis of Spontaneous Bacterial Peritonitis in Patients With Liver Cirrhosis

Primary prophylaxis of spontaneous bacterial peritonitis (SBP) may provide a survival advantage in cirrhotic patients with ascites and has become an integral part of clinical practice. Rifaximin is a poorly absorbable antibiotic with a broad spectrum of antibacterial action and has low risk of introducing bacterial resistance. To determine whether rifaximin is associated with decreasing the risk of SBP and improving transplant-free survival in cirrhotic patients with ascites. The medical records of all adult patients with liver cirrhosis and large ascites justifying paracentesis evaluated in our clinic (2003 to 2007) were reviewed. Patients were stratified into 2 groups by the use of rifaximin. Patients were excluded if they had received another antibiotic for SBP prophylaxis or had a history of SBP before rifaximin therapy. A total of 404 patients were included, of whom 49 (12%) received rifaximin. The rifaximin and nonrifaximin groups were comparable with regards to age, sex, and race. The median follow-up time was 4.2 [1.0, 17.1] months. During this time period, 89% of patients on rifaximin remained SBP free compared with 68% of those not on rifaximin (P=0.002). After adjusting for Model of End-Stage Liver Disease score, Child-Pugh score, serum sodium, and ascitic fluid total protein, there was a 72% reduction in the rate of SBP in the rifaximin group (hazard ratio=0.28; 95% confidence interval, 0.11-0.71; P=0.007). The group treated with rifaximin also demonstrated a transplant-free survival benefit compared with those not on rifaximin (72% vs. 57%, P=0.045). Intestinal decontamination with rifaximin may prevent SBP in cirrhotic patients with ascites. Prospective randomized controlled trials are needed to confirm this finding.

The risk factors of liver cirrhosis complicated with spontaneous bacterial peritonitis

Objective To explore the risk factors of liver cirrhosis complicated with spontaneous bacterial peritonitis ( SBP ).Methods 350 patients with liver cirrhosis were divided into SBP group ( 145 patients ) and non-SBP group ( 205 patients ).The age,sex,course of disease,history of SBP and diabetes,upper gastrointestinal bleeding,ascitic fluid total protein,time to occurrence of ascites,and levels of platelet,C-reactive protein,and serum total bilirubin were compared between the two groups.Results There were significant differences between the two groups in level of ascitic fluid total protein,history of SBP and diabetes,serum total bilirubin,gastrointestinal bleeding,and time to occurrence of ascites ( P ＜ 0.05 ).Conclusions Ascitic fluid total protein and other factors are closely associated with liver cirrhosis complicated with peritonitis,to which should be paid more attention.Prevention and treatment should be administered correctly. Key words: Liver cirrhosis; Peritonitis; 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.

Biochemical analysis of ascitic (peritoneal) fluid: what should we measure?

Ascitic fluid samples are frequently sent to the laboratory for analysis. Although the underlying cause of the ascites is often thought to be clinically obvious, it is important to establish a definitive diagnosis. The value of a cell count and bacterial culture of the ascitic fluid is not disputed, but the role of biochemical testing is less clear. The use of ascitic fluid total protein to try to classify ascitic fluids as either an exudate or a transudate has contributed to this. The use of the physiologically based serum ascites albumin gradient to differentiate ascites caused by portal hypertension from other causes provides a better diagnostic approach. We recommend that the serum ascites albumin gradient is performed by laboratories as the first-line test and that interpretative reports are provided. Additional testing should be restricted to specific diagnostic queries and requires close collaboration between the laboratory and the clinician.

Proteomic evidence of bacterial peptide translocation in afebrile patients with cirrhosis and ascites

Bacterial translocation in patients with cirrhosis induces a marked proinflammatory activity that may be different against viable bacteria or bacterial products. The aim of this study is to identify new markers of bacterial translocation by investigating bacterial-driven peptides and correlate their presence with the inflammatory response. Patients with cirrhosis and ascites were included. An analysis by two-dimensional polyacrylamide gel electrophoresis of ascitic fluid total protein from patients (n = 47) and from frequently detected bacterial strains was performed. Two-dimensional maps were digitally compared. The identification of possible markers was performed by mass spectrometry. TNF-alpha, IFN-gamma, IL-12, nitric oxide, and proteins of the complement and lipopolysaccharide-binding protein levels were measured in ascitic fluid samples of patients by enzyme-linked immunosorbent assay. Patients were distributed according to the presence (group I, n = 16) and absence (group II, n = 31) of serum and ascitic fluid bacterial DNA. Among clinical and analytical differences between groups, only mean arterial pressure was significantly higher in patients from group II. Identified bacterial peptides were associated with bacterial protection against immune defenses and included glyceraldehyde-3-phosphate dehydrogenase A, Porin OmpC, and HSP60. Eight patients from group I also showed bacterial peptides, whereas none from group II did. All studied mediators of immune activation were significantly higher in patients with bacterial DNA than in patients without bacterial DNA. TNF-alpha, IFN-gamma, and proteins of the complement were significantly increased in patients with bacterial peptides versus those without bacterial peptides. Bacterial peptide translocation is present in the ascitic fluid of a subgroup of patients with advanced cirrhosis and is associated with an increased immune response.

Potential Preventability of Spontaneous Bacterial Peritonitis: Study of Adherence Practices of AASLD Guidelines on Antibiotic Prophylaxis for SBP at a University Hospital

Purpose: Antibiotic prophylaxis can reduce the incidence of the first episode and of recurrence of spontaneous bacterial peritonitis (SBP) in high risk cirrhotic patients. However, recent available data suggest that SBP prophylaxis may be underused. It is unclear how many cases of cirrhosis that develop SBP might actually be prevented through encouraging antibiotic prophylaxis. The aim of this study is to determine the number of “preventable” cases of SBP and adherence to standard guideline of use of antibiotic prophylaxis. Methods: We reviewed the medical records of patients diagnosed with SBP between Jan 2004 and Feb 2009 at a university hospital. SBP was defined as ≥250 PMN/ml in the ascitic fluid (AF). AASLD Guidelines (2004) for SBP prophylaxis include prior SBP; gastrointestinal (GI) hemorrhage; AF protein concentration ≤lg/dL or serum bilirubin ≥2.5mg/dL. “Preventable (P) SBP” is defined as SBP occurring where prophylaxis was indicated but was not administered. “Non-preventable (NP) SBP” is defined as SBP that occurred despite proper adherence to the guidelines. “Spontaneous (S) SBP” were those cases of SBP occurring in the absence of a documented indication for prophylaxis. Results: A total of 259 cirrhotics underwent paracentesis. 29 patients fulfilled inclusion criteria. 230 patients were excluded due to (1) AF PMN<250 cell/ ml (n=173), (2) received antibiotics for another indication (n=5), (3) immunocompromised (n=6), and (4) incomplete AF analysis (n=46). 62% of 29 patients were considered “P-SBP” [Child-Pugh (CP) Class B (n=4, 22%); C (n=14, 77%)]. One (3%) patient was considered “NP-SBP” and 10 (34%) were defined “S-SBP” [CP Class B (n=5, 50%); C (n=5, 55%)]. Of the P-SBP, the overlooked indications for prophylaxis were serum bilirubin ≥2.5mg/dL (38%), GI hemorrhage (33%), AF total protein<lg/dl (16%), and prior SBP (11%), respectively. 77% of the P-SBP were community-acquired; 22% nosocomial. Extra-peritoneal infection occurred in 6/18 (33%) patients with P-SBP [bacteremia 4, UTI 1 and pneumonia 1]. In-hospital mortality in the P-SBP was 16% (n=3). Only 33% (8/16) of patients in all groups who survived SBP received long-term outpatient prophylaxis after discharge. Conclusion: Majority of SBP could be prevented by adhering to the AASLD guidelines. Serum bilirubin ≥2.5 mg/dL and GI hemorrhage are the most frequently overlooked indications for SBP prophylaxis. Studies identifying the reasons for non-adherence to guidelines and developing interventions to increase utilization are warranted.

Study on ascitic fluid protein level in cirrhotic patients with spontaneous bacterial peritonitis

Complement 3 is an important component of ascitic fluid total protein, which offers local defence against infection of the ascitic fluid. Hepatic synthesis of complement 3 as well as other proteins and their concentrations in ascitic fluid is significantly reduced in patients with advanced cirrhosis. The level of protein in ascitic fluid in cirrhotic patients with spontaneous bacterial peritonitis was compared with that in patients without spontaneous bacterial peritonitis. Ascitic fluid protein level in spontaneous bacterial peritonitis (n=15) was 1.1 +/- 0.3 g/dL whereas it was 1.5 +/- 0.5 g/dL in patients without spontaneous bacterial peritonitis (n=15). In conclusion, this study suggests that, ascitic fluid protein level is significantly (p = 0.008) reduced in cirrhotic patients who develop spontaneous bacterial peritonitis.

The Role of Ascitic Fluid Viscosity in the Differential Diagnosis of Ascites

Ascites is defined as the pathological accumulation of fluid in the peritoneal cavity. It is the most common complication of cirrhosis, which is also the most common cause of ascites. Viscosity is a measure of the resistance of a fluid to deform under shear stress. Plasma viscosity is influenced by the concentration of plasma proteins and lipoproteins, with the major contribution from fibrinogen. To our knowledge, the viscosity of ascitic fluid has not yet been studied. To evaluate the role of ascitic fluid viscosity in discriminating between ascites due to portal hypertension-related and nonportal hypertension-related causes, and to compare results with the serum-ascites albumin gradient (SAAG). The present study involved 142 patients with ascites presenting with diverse medical problems. Serum total protein, albumin, glucose, lactate dehydrogenase (LDH) levels and complete blood count were obtained for all subjects. Paracentesis was performed routinely on admission and all ascitic fluid samples were evaluated by manual cell count with differential, ascitic fluid culture and biochemistry (total protein, albumin, glucose and LDH). Cultures of ascitic fluid were performed at bedside in all patients using blood culture bottles. Ascitic fluid viscosity was measured in a commercially available cone and plate viscometer. Of the 142 patients studied, 34 (24%) had an SAAG of 11 gL or less, whereas 108 (76%) had an SAAG of greater than 11 gL. Sex and mean age did not differ significantly between the two groups (P>0.05). Serum total protein, albumin, glucose, LDH levels, leukocyte count, ascitic fluid glucose levels and ascitic fluid leukocyte counts were similar in both groups, with no statistically significant relationship detected (P>0.05). However, the mean (+/-SD) ascitic fluid total protein (0.0172+/-0.1104 gL versus 0.043+/-0.011 gL), albumin (0.0104+/-0.0064 gL versus 0.0276+/-0.0069 gL) and LDH (102.76+/-80.95 UL versus 885.71+/-199.93 UL) were found to be higher in patients with an SAAG of 11 gL or less than in those with an SAAG of greater than 11 gL (P<0.001). The mean ascitic fluid viscosities were 0.86+/-0.12 centipoise (cP) and 1.22+/-0.25 cP in patients with an SAAG greater than 11 gL and an SAAG of 11 gL or less, respectively (P<0.001). Although ascitic fluid infection was detected in 35 patients (24.6%) (19 patients with spontaneous bacterial peritonitis, seven patients with culture-negative neutrocytic ascites, three patients with monobacterial non-neutrocytic bacterascites and six patients with secondary bacterial peritonitis), no significant effect on ascitic fluid viscosity was detected. Multiple linear regression analysis revealed that ascitic fluid total protein, albumin and LDH levels were independent predictors of ascitic fluid viscosity (P<0.001). The sensitivity, specificity, and positive and negative predictive values of ascitic fluid viscosity for the discrimination between ascites due to portal hypertension-related and nonportal hypertension-related causes according to the SAAG were determined by receiver operating characteristic analysis. Regarding the cut-off value of 1.03 cP, ascitic fluid viscosity measurement had a high sensitivity, specificity (98% and 80%, respectively), and positive and negative predictive value (79% and 94%, respectively) for the etiological discrimination of ascites. The measurement of ascitic fluid viscosity correlates significantly with SAAG values. In view of its simplicity, low cost, small sample volume requirement and allowance for measurement in previously frozen samples, measurement of ascites viscosity could be useful for the accurate and rapid classification of ascites.

Spontaneous Bacterial Peritonitis.

Spontaneous bacterial peritonitis (SBP) is the prototypical ascitic fluid infection occurring in patients with advanced liver disease and ascites. The key to successful treatment of SBP is a knowledge of appropriate antibiotic regimens and an understanding of the setting in which infection develops, particularly those individuals at high risk for infection. A high index of suspicion should lead to early diagnostic paracentesis and ascitic fluid analysis. Treatment of SBP involves the use of non-nephrotoxic broad-spectrum antibiotics expected to cover the typical bacterial flora associated with SBP. SBP typically involves infection with a single organism, with Escherichia coli, Klebsiella spp, and Streptococcus spp responsible for nearly three fourths of cases. The treatment of choice is cefotaxime 2 g given intravenously every 8 hours for a total of 5 days. The antibiotic regimen is adjusted based on the results of ascitic fluid cultures. Other antibiotic regimens for SBP are less well studied. Given the significant morbidity and mortality rates associated with SBP, efforts to prevent its development and recurrence with antibiotic prophylaxis are warranted. The most extensively studied form of prophylaxis involves selective intestinal decontamination (SID) with the oral fluoroquinolone norfloxacin. Individuals with low-protein ascites (ascitic fluid total protein < 1g/dL) benefit from SID with norfloxacin 400 mg daily during times of hospitalization. Long-term primary prophylaxis during outpatient management of individuals awaiting liver transplantation with severe ascites and advanced liver failure should also be considered. Patients with cirrhosis and upper gastrointestinal bleeding should receive norfloxacin 400 mg twice daily for 1 week following their bleed. Those individuals surviving an episode of SBP should be treated with norfloxacin 400 mg daily until the risk of SBP is removed by definitive resolution of the ascites or liver transplantation surgery. Although the infection-related mortality associated with SBP has decreased to less than 10%, hospitalization-related mortality remains as high as 30% as a result of the severe underlying liver disease in which the infection arises and the marked generation of cytokines and nitric oxide resulting from the infection. Recently, the simultaneous administration of intravenous albumin and antibiotics for SBP has been shown to result in the decreased development of azotemia and hospitalization-related mortality. Further improvement in the outcomes of SBP will require treatments targeting this cytokine cascade rather than the development of more potent antibiotics.

Accuracy of serum — Ascites albumin gradient in the aetiological diagnosis of ascites

50 adults with ascites admitted to our hospital were studied. Simultaneous samples of ascitic fluid and blood were collected and subjected to analysis including ascitic fluid total protein and serum ascites albumin gradient. The cut off value of serum-ascites albumin gradient for differentiating between high and low gradient was taken as 1.1 gm% and of ascitic fluid protein for differentiating exudate and transudate as 2.5 gm%. The sensitivity, specificity, positive predictive value and negative predictive value of high gradient and transudative ascites in diagnosing portal hypertension were 94.3%, 60%, 84.6%, 81.8% and 62.9%, 13.3%, 91.7% and 50% respectively. High gradient ascites is a sensitive test in the diagnosis of portal hypertension as a cause of ascites. The exudate-transudate approach has severe limitations in the differential diagnosis of ascites.

This month in Gastroenterology

This month in Gastroenterology

Norfloxacin primary prophylaxis of bacterial infections in cirrhotic patients with ascites

Abstract Background/Aims : Norfloxacin is useful to prevent infections in hospitalized cirrhotic patients with low ascitic fluid protein concentrations. It is also effective in preventing the recurrence of spontaneous bacterial peritonitis. The aim of our study was to determine the efficacy of norfloxacin in the primary prophylaxis of gram-negative bacilli infections in cirrhotic patients with low ascitic fluid protien levels ( Methods: One hundred ans even patients were randomized to receive norfloxacin (400 mg/day; n =53) or placebo ( n =54) for 6 months. The patients had no history of infection since cirrhosis diagnosis and no active infection. Results: The probability of gram-negative infection was significantly lower among patients treated with norfloxacin than among those treated with placebo. Six gram-negative bacilli infections occurred in the placebo group and none in the treatment group. Severe infections (spontaneous bacterial peritonitis, neutrocytic ascites and bacteremia) developed in nine patients in the placebo group (17%) and in one patient in the norfloxacin group (2%; p Conclusions: These data show that primary prophylaxis with norfloxacin for 6 months is effective in the prevention of infections caused by gram-negative bacilli in cirrhotic patients with low ascitic fluid total protein levels.

Norfloxacin primary prophylaxis of bacterial infections in cirrhotic patients with ascites: a double-blind randomized trial

Background/Aims: Norfloxacin is useful to prevent infections in hospitalized cirrhotic patients with low ascitic fluid protein concentrations. It is also effective in preventing the recurrence of spontaneous bacterial peritonitis. The aim of our study was to determine the efficacy of norfloxacin in the primary prophylaxis of gram-negative bacilli infections in cirrhotic patients with low ascitic fluid protien levels (<15 g/l). Methods: One hundred ans even patients were randomized to receive norfloxacin (400 mg/day; n=53) or placebo ( n=54) for 6 months. The patients had no history of infection since cirrhosis diagnosis and no active infection. Results: The probability of gram-negative infection was significantly lower among patients treated with norfloxacin than among those treated with placebo. Six gram-negative bacilli infections occurred in the placebo group and none in the treatment group. Severe infections (spontaneous bacterial peritonitis, neutrocytic ascites and bacteremia) developed in nine patients in the placebo group (17%) and in one patient in the norfloxacin group (2%; p<0.03). There was no between-group difference in the overall rate of infection or in survival. In ten patients from the norfloxacin group, gram-negative bacilli not present in baseline stool cultures were transiently isolated in follow-up cultures. Conclusions: These data show that primary prophylaxis with norfloxacin for 6 months is effective in the prevention of infections caused by gram-negative bacilli in cirrhotic patients with low ascitic fluid total protein levels.

Cost-analysis of prophylactic antibiotics in spontaneous bacterial peritonitis

BACKGROUND & AIMS: Antibiotic prophylaxis has been shown to decrease the incidence of spontaneous bacterial peritonitis (SBP) in patients with cirrhosis and ascites. The aim of this study was to test whether antibiotic prophylaxis for SBP is cost-effective and to compare the costs associated with different patient groups and treatment strategies.METHODS: A cost-effectiveness analysis was performed using a Markov chain model. The costs incurred during 1-year treatment with prophylactic antibiotics vs. no prophylaxis in patients with cirrhosis and ascites were calculated. The incidence rates of primary and recurrent SBP and the mortality rate of SBP were obtained from the literature. Total direct costs of SBP treatment were determined from the wholesale price of drugs and from disbursements by the Health Care Financing Administration.RESULTS: Norfloxacin prophylaxis resulted in savings between $2216 and $8545 per patient per year, depending on the patient group studied. Trimethoprim-sulfamethoxazole prophylaxis resulted in savings between $2934 and $9251 per patient per year. The groups that benefited most from prophylaxis were patients with an ascitic fluid total protein concentration of < or = 1 g/dL and those with a previous history of SBP.CONCLUSIONS: The use of prophylactic antibiotics to decrease the incidence of SBP is a cost-saving strategy in patients with cirrhosis and ascites.(Gastroenterology 1997 Oct;113(4):1289-94)

Spontaneous ascitic infection in different cirrhotic groups: prevalence, risk factors and the efficacy of cefotaxime therapy.

To investigate the prevalence of spontaneous ascitic infection (SAI) in different cirrhotic groups, the risk factors for development of SAI, and the efficacy of cefotaxime therapy. A prospective study. In-patient clinic of a university hospital. Eighty cirrhotic patients with ascites were assigned to four groups: hepatitis B or D virus-related 34, alcoholic 18, hepatitis C virus-related 14, miscellaneous 14. Paracentesis was performed on 80 patients during 92 consecutive hospitalizations. Ascitic fluid was cultured by the method of bedside inoculation of blood culture bottles with ascites. The patients with SAI were treated with cefotaxime (2 g, three times daily, intravenously) for 5 days. Frequency of SAI in cirrhotic groups; clinical, bacteriological and biochemical findings of SAI; rate of recovery-from infection. Twenty SAI episodes (22%) were found in 16 patients; 8 episodes were spontaneous bacterial peritonitis, 2 bacterascites, and 10 culture-negative neutrocytic ascites. SAI occurred more frequently in patients with hepatitis B or D virus-related liver cirrhosis (32%) than in the alcoholic (6%, P < 0.05), hepatitis C virus-related (14%) or miscellaneous (14%) cirrhotic groups in multivariate analysis, independent predictive factors associated with the development of SAI are chronic hepatitis B virus infection, ascitic fluid total protein and serum bilirubin. Escherichia coli was obtained in 5 of 10 positive ascitic fluid cultures. Cure of the infection was achieved in 95% of episodes. Hospitalization mortality rate in infected patients was 20%. Spontaneous ascitic infection occurs in approximately 20% of cirrhotic patients hospitalized with ascites. The patients with low ascitic protein concentration, high serum bilirubin level or hepatitis B virus cirrhosis are more predisposed to SAI. Cefotaxime may be an effective first-choice antibiotic for ascitic fluid infection.

Spontaneous bacterial peritonitis.

Spontaneous bacterial peritonitis (SBP) is considered a bacterial infection of ascitic fluid without any intraabdominal, surgically treatable source of infection. Multiple variants of this infection with a different clinical setting and outcome have been described during the past decade. Bacterial translocation from the gut to mesenteric lymph nodes, depressed activity of the reticuloendothelial phagocytic system and decreased antimicrobial capacity of ascitic fluid seem to be the main steps in the pathogenesis of ascitic fluid infection. Diagnosis of ascitic fluid infection is based on clinical suspicion and analysis of ascitic fluid, especially white cell count and culture in blood culture bottles. A low threshold for performing an abdominal paracentesis is the key for an early diagnosis and treatment. A third-generation cephalosporin is the treatment of choice, achieving a cure rate higher than 80%. Nonazotemic patients with nonadvanced, uncomplicated SBP may be treated with oral ofloxacin. Prophylactic selective intestinal decontamination with oral norfloxacin is extremely useful in preventing SBP in patients that are at high risk for developing SBP, such as hospitalized cirrhotic patients with gastrointestinal hemorrhage or low ascitic fluid total protein. Primary or secondary long-term prophylaxis of SBP also decreases the incidence of SBP, but these patients should be carefully observed for detecting possible infections caused by quinolone-resistant organisms. Since long-term prognosis of SBP patients is poor, survivors should be considered for liver transplantation.