Bacterial Peritonitis In Cirrhosis Research Articles

Intraabdominal Urokinase for the Treatment of Secondary Bacterial Peritonitis in Cirrhosis.

Bacterial peritonitis with loculated ascites in patients with liver cirrhosis can be a therapeutic challenge. We present the case of a patient with liver cirrhosis undergoing pre-transplant evaluation, diagnosed with bacterial peritonitis secondary to urgent surgical intervention Imaging studies identified markedly loculated ascites, with a poor response despite broad-spectrum antibiotic therapy. The use of intraabdominal urokinase was a safe and effective adjuvant treatment for the resolution of this complication.

A Study of Spontaneous Bacterial Peritonitis in Cirrhosis of Liver with Ascites at a Tertiary Care Hospital in North India: Prevalence, Clinical, and Microbiological Profile

Background and Objectives: In patients with chronic liver disease and ascites, spontaneous bacterial peritonitis (SBP) is a common complication. This can progress gradually and subtly or go undiagnosed until signs start to show. Early diagnosis is essential for effective treatment and the prevention of subsequent episodes because the mortality rate following a single episode varies from 20% to 40%. The goal was to study the incidence, clinical profile, and microbiological characteristics of SBP and its variants in people with liver cirrhosis and ascites. Materials and Methods: This observational study was done on 104 cirrhotic patients with ascites admitted at a tertiary care hospital. Basic demographics, symptoms, and clinical signs of patients were recorded. Diagnostic paracentesis was done aseptically and immediately sent for ascitic fluid cytology, biochemistry, and culture. Bacterial examination and antibiotic sensitivity tests were carried out by standard microbiological techniques. Results: Out of a total of 104 cirrhotic patients, 28 (26.9%) were diagnosed with SBP. Alcohol was the most common etiological factor, followed by hepatitis C infection. Among the SBP patients, the most common presentation was culture-negative neutrocytic ascites (71.4%), followed by classical SBP (17.8%), then mono bacterial non neutrocytic bacterascites MNB (10.7%). Among the symptoms, the most common was abdominal distension, followed by icterus, pedal edema, and abdominal pain. Majority of the patients belonged to Child–Pugh’s Grade C. Of 28 cases of SBP, 8 were culture positive. Gram-negative isolates were predominant (75%) and Escherichia coli were the most common isolate. Interpretation and Conclusion: The prevalence of SBP in cirrhotic patients was 26.9%, and Gram-negative isolates were predominant. Ascitic fluid culture and susceptibility testing can lead to accurate diagnosis of SBP and can guide for treatment as resistance to antibiotics is common.

The factors associated with the trend in incidence of Bacteraemia and associated mortality over 30 years

BackgroundStudies have reported increased incidence of BSI over the past decades and indicate that it is necessary to investigate the causes. The aim of this study was to determine the factors affecting trends in the incidence of bacteraemias and associated mortality.MethodsWe conducted a retrospective cohort study assessing prospectively collected data of all clinically significant bacteraemias between 1991 and 2020 in a 450-bed hospital. We determined the evolution of bacteraemia-associated incidence, adjusted 30-day mortality and performed multivariable logistic regression to compare the evolution of variables associated with mortality between 5-year periods.Results6777 episodes were included, 59.7% males, age 66.5 ± 18.2, 39.4% ≥ 75 years. The incidence total increased: 43.8/100,000/year in 1991–1995 to 205 in 2016–2020; community-acquired bacteraemia (24.9 to 139) and hospital-acquired (0.36/1000 inpatients-days to 1.09). Bacteraemia with source in vascular catheter, urinary and biliary tract increased. The 30-day mortality rate of patients was 1179/6777 (17.4%) in the whole series and population-adjusted mortality incidence increased from 11.4/100,000 in 1991–1996 to 28.4 in 2016–2020 (RR 2.49, 95% CI 2.01–3.08). Mortality was higher in men (18.2% vs 16.3%) and those over 74 years (22.2% vs 14.3%). Appropriate empirical antimicrobial treatment improved (66.5% to 73.1%), 30-day mortality of patients decreased from 26.1 to 13.9%. When comparing the evolution of the factors associated with mortality between 1991 and 1996 vs 2016–2020, the frequency of some variables associated with higher mortality increased: male sex (OR 1.38, 95% CI 1.10–1,74), age (OR 1.02, 1.01–10.3), immunosuppressive treatment (OR 3.1, 2.09–4.6), polymicrobial bacteraemia (OR 1.76, 1.12–2.79), and others decreased: severe sepsis/septic shock (OR 0.70, 0.52–0.93), spontaneous bacterial peritonitis in cirrhosis (OR 0.06, 0.02–0.23), endocarditis (OR 0.54, 0.35–0.83); on the other hand, the frequency of factors associated with lower mortality increased: urinary (OR 1.67, 95% CI 1.23–2.27) and bile tract source (OR 1.59, 1.04–2.43), and adequate empirical treatment (OR 1.42, 95% CI 1.10–1.83).ConclusionsThe incidence of bacteraemia increased due to more elderly, co-morbid patients undergoing procedures and more device related bacteraemia. The percentage of mortality decreased because adequate empirical treatment improved, decreased spontaneous bacterial peritonitis in cirrhosis and endocarditis, and increased bacteraemia of urinary and biliary tract source.

STUDY OF PROGNOSTIC INDICATORS IN PATIENTS WITH CIRRHOSIS OF LIVER WITH ASCITIS AND SPONTANEOUS BACTERIAL PERITONITIS

Spontaneous bacterial peritonitis(SBP) is dened as ascitic uid infection in the absence of any obvious intraabdominal source of infection. The mortality rate is approximately 30-50% The objective of this study is to study predictors of mortality on patients with spontaneous bacterial peritonitis in cirrhosis of liver patients. Methods: Fifty patients diagnosed with cirrhosis of liver reporting to ACSR GGH, Nellore were included in the study. SBPwas diagnosed based on ascitic uid ascitic uid PMN count >250. Serial ascitic uid cell count was done at 24 hours, 48 hours and 5 days.The results were compared between survivors and non survivors. Results: Male: female ratio was 2:1.Study showed 42% mortality. TLC above 11000/mm3,total bilirubin above > 4 mg/dl, serum creatinine >1.5 were associated with increased mortality .Interpretation & Conclusion: Ascitic uid PMN count > 600 at the time of diagnosis, 700 at 24 hrs, 450 at 48 hrs was associated with poor prognosis. AProgressive fall in serial ascitic uid cell PMN count was associated with good prognosis

ASEPTIC: primary antibiotic prophylaxis using co-trimoxazole to prevent SpontanEous bacterial PeritoniTIs in Cirrhosis—study protocol for an interventional randomised controlled trial

BackgroundBacterial infection is a major cause of mortality in patients with cirrhosis. Spontaneous bacterial peritonitis (SBP) is a serious and common infection in patients with cirrhosis and ascites. Secondary prophylactic antibiotic therapy has been shown to improve outcomes after an episode of SBP but primary prophylaxis to prevent the first episode of SBP remains contentious. The aim of this trial is to assess whether primary antibiotic prophylaxis with co-trimoxazole improves overall survival compared to placebo in adults with cirrhosis and ascites.MethodsThe ASEPTIC trial is a multicentre, placebo-controlled, double-blinded, randomised controlled trial (RCT) in England, Scotland, and Wales. Patients aged 18 years and older with cirrhosis and ascites requiring diuretic treatment or paracentesis, and no current or previous episodes of SBP, are eligible, subject to exclusion criteria. The trial aims to recruit 432 patients from at least 30 sites. Patients will be randomised in a 1:1 ratio to receive either oral co-trimoxazole 960 mg or an identical placebo once daily for 18 months, with 6 monthly follow-up visits thereafter (with a maximum possible follow-up period of 48 months, and a minimum of 18 months). The primary outcome is overall survival. Secondary outcomes include the time to the first incidence of SBP, hospital admission rates, incidence of other infections (including Clostridium difficile) and antimicrobial resistance, patients’ health-related quality of life, health and social care resource use, incidence of cirrhosis-related decompensation events, liver transplantation, and treatment-related serious adverse events.DiscussionThis trial will investigate the efficacy, safety, and cost-effectiveness of co-trimoxazole for patients with liver cirrhosis and ascites to determine whether this strategy improves clinical outcomes. Given there are no treatments that improve survival in decompensated cirrhosis outside of liver transplant, if the trial has a positive outcome, we anticipate widespread adoption of primary antibiotic prophylaxis.Trial registrationClinicalTrials.gov NCT043955365. Registered on 18 April 2020. Research ethical approval was granted by the Research Ethics Committee (South Central – Oxford B; REC 19/SC/0311) and the Medicines and Healthcare products Regulatory Agency (MHRA).

Frequency of Spontaneous Bacterial Peritonitis in Cirrhosis of Liver in Department of Medicine at People Medical College Hospital Nawabshah Pakistan

Introduction: Bacterial Infections in cirrhosis of liver is one of the main complications with increase mortality rate. Infection of ascitic fluid in cirrhosis of liver was introduced by Conn and fessel [2], termed as spontaneous bacterial peritonitis.
 Objective: To determine the frequency of Spontaneous Bacterial Peritonitis (SBP) in patients presenting with cirrhosis of liver.
 Methodology: It is a descriptive cross-sectional study which was performed in the Medicine Ward at People’s Medical College Hospital Nawabshah Pakistan from 1st June 2018 to 31 July 2020. Total 100 admitted patients were selected for this study, male patient were 58 and female patient were 42. Consent was taken from the patients and their relatives. Primary and secondary outcomes measured. All the patients with diagnosis of cirrhosis of liver were included for this study, ascites due to other causes and patients on antibiotic therapy were excluded from this study. Ascitic fluid aspirated for culture and DR. Blood CP, Urea, Creatinine, LFT and PT was performed.
 Results: Among these 100 patients 13 were culture positive raised ascites PMN, 17 were culture negative raised ascites PMN. E. coli was detected in majority of the culture positive patients. 70 patients presented with sterile ascites. SBP patients presented with fever, abdominal pain, jaundice, Encephalopathy and raised prothrombin time.
 Conclusion: SBP common complication of cirrhosis associated with high mortality. All cirrhotic Patients admitted in medical wards with history of abdominal pain, fever and Encephalopathy, diagnostic paracentesis is compulsory. Early management with intravascular expansion with albumin and antibiotics with good prognosis mortality can be reduced.

HYPHOPICHIA BURTONII: A NOVEL PATHOGEN IN SECONDARY PERITONITIS

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: We present a case of secondary peritonitis (SP) due to intestinal infarction from bowel ischemia in a patient with decompensated alcoholic cirrhosis. Differing from spontaneous bacterial peritonitis (SBP) based on presence of a surgically treatable abdominal infectious source, SP is less common than SBP and carries a 3-fold higher risk of in-hospital death (1). CASE PRESENTATION: A 63 year-old man with decompensated alcoholic cirrhosis and a ventral hernia presented to an outside hospital with altered mental status and gastrointestinal bleeding. On hospital day (HD) 1, he underwent esophagogastroduodenoscopy with variceal banding and was treated empirically with piperacillin/tazobactam. On HD 3, paracentesis showed: WBC 4,046 mm3, 96% PMNs, culture positive for Klebsiella pneumoniae and Enterobacter cloacae resistant to piperacillin/tazobactam; he was transitioned to meropenem. He underwent 8.3L paracentesis on HD 7, and was transferred to our hospital on HD 9 for liver transplant evaluation. On arrival, he had stable vitals, West Haven grade III encephalopathy, a ventral hernia, and large ascites without tenderness to palpation. Pertinent labs: WBC 25,600 mm3, Na 156, BUN 78, and Cr 2.07 and MELD-Na of 24. On HD 10, repeat 4.0L paracentesis revealed: WBC 11,385 mm3, 95% PMNs, with cultures growing Candida guilliermondii. Micafungin was initiated and meropenem continued. On HD 13, due to worsening mental status and septic shock, he was transferred to the ICU and intubated. Pertinent labs: WBC 26,800 mm3, Na 140, BUN 98, and Cr 4.09. Repeat paracentesis yielded 2.2L of frank pus, with WBC 18,975 mm3 (no differential), microscopy showed mixed microbiota with budding yeast and gram positive cocci in pairs and chains. Micafungin was continued and daptomycin initiated. CT scan demonstrated ischemic and perforated bowel within the hernia. Despite aggressive measures, he died on HD 14. Among the peritoneal microbiota isolated, Hyphopichia burtonii predominated, speciating 6 days after death. DISCUSSION: To our knowledge, this case of SP due to intestinal infarction represents the first report of Hyphopichia burtonii as a human pathogen. The mixed microbiota on HD 13 raised concerned for SP, prompting a CT scan which revealed intestinal infarction. Notably, our patient exhibited every key sign of SP: polymicrobial peritonitis, a poor response to antibiotics, uptrending PMNs on serial paracenteses, and abnormal imaging findings (2). Hyphopichia burtonii is a species of yeast known as a bread and dairy mold, and part of flora of cured meat. Hyphopichia burtonii has only been reported as the cause of cutaneous mycosis in a bat (3). CONCLUSIONS: We present a case of secondary peritonitis involving Hyphopichia burtonii, a yeast not previously known to be a human pathogen. Reference #1: Lu MLR, et al. Infected ascites: Distinguishing secondary peritonitis from spontaneous bacterial peritonitis in a cirrhotic patient with classic symptoms. IDCases. 2017;8:29-31. Published 2017 Feb 28. doi:10.1016/j.idcr.2017.02.010 Reference #2: Soriano G, et al. Secondary bacterial peritonitis in cirrhosis: a retrospective study of clinical and analytical characteristics, diagnosis and management. J Hepatol. 2010;52(1):39-44. doi:10.1016/j.jhep.2009.10.012 Reference #3: Simpson, V. R., et al (2013). Cutaneous mycosis in a Barbastelle bat (Barbastella barbastellus) caused by Hyphopichia burtonii. Journal of Veterinary Diagnostic Investigation, 25(4), 551–554. https://doi.org/10.1177/1040638713493780 DISCLOSURES: No relevant relationships by Shira Abeles, source=Web Response No relevant relationships by Amy Bellinghausen, source=Web Response No relevant relationships by Erica Feldman, source=Web Response No relevant relationships by Biren Kamdar, source=Web Response No relevant relationships by Irine Vodkin, source=Web Response

Recurrence of spontaneous bacterial peritonitis in cirrhosis: novel predictors.

Recurrence of spontaneous bacterial peritonitis (SBP) is still a matter of debate. We conducted this study to evaluate the probable factors that predict the recurrence of SBP in patients who recovered from the first episode of SBP and the long-term outcomes of SBP recurrence. One hundred twenty-four patients diagnosed with liver cirrhosis, SBP and did not receive secondary prophylaxis either with norfloxacin or other antibiotics were included in this prospective cohort pilot study. Clinical, biochemical and ascitic fluid analysis parameters were evaluated. Ascitic fluid interferon-γ-induced protein (IP-10), calprotectin, interleukin-6 and tumor necrosis factor-α were measured by ELISA. Of these, 76 patients survived with an in-hospital mortality rate of 38.7%. The survivors were classified into two groups according to recurrence and nonrecurrence of SBP and survival time, clinical parameters and cause of death were investigated. Thirty-one participants had one or more attacks of SBP, with a recurrence rate of 40.8% within one-year follow-up. Before discharge, multivariate analysis showed that ascitic IP-10 (≥1220 pg/ml), ascitic calprotectin (≥550 ng/ml), serum albumin (≤2.5 g/dl), nonuse of prophylactic β-blockers and use of proton-pump inhibitors (PPIs) were the independent variables in predicting recurrent SBP. Sepsis-related organ failure was the most common etiology of mortality in the recurrent SBP group within 3 and 6 months. Increased ascitic calprotectin and IP-10, hypoalbuminemia, nonuse of prophylactic β-blockers and use of PPI were independently associated with increased SBP recurrence rate. Sepsis-related organ failure was the most common etiology of mortality.

Calprotectin as Diagnostic Marker for Hepatic Encephalopathy and Spontaneous Bacterial Peritonitis in Cirrhosis.

Calprotectin is a well-established marker for intestinal inflammation, mainly in inflammatory bowel disease, and represents one of the most studied biomarkers in stool samples. Apart from its important diagnostic role in inflammatory bowel disease, there are few studies showing that calprotectin can also be used as a diagnostic tool in patients suffering from hepatic encephalopathy (HE) and spontaneous bacterial peritonitis (SBP) in cirrhosis. Since calprotectin concentration in the human stool or in ascites is elevated at an early stage of inflammation, it might serve as an early screening tool for patients suffering from cirrhosis who are at risk to develop these conditions. As detection and monitoring of HE and SBP may be unclear and resource-intensive, identification of valid new markers of disease activity is necessary. In this review, we summarize the current knowledge of calprotectin as a diagnostic biomarker in cirrhosis, indicating that it is a highly promising diagnostic surrogate marker to screen for the presence of HE and SBP. To screen cirrhotic patients for SBP, calprotectin should be assessed in ascitic fluid while it should be measured in feces when screening for HE. However, the value of calprotectin in managing individual patients must be considered in the specific clinical context.

Genetic variants of TRAF6 modulate peritoneal immunity and the risk of spontaneous bacterial peritonitis in cirrhosis: A combined prospective-retrospective study

Alterations of the innate immunity contribute to the development of spontaneous bacterial peritonitis (SBP) in liver cirrhosis. Given its role in immune signaling, antimicrobial function, and macrophage differentiation, we hypothesized that genetic polymorphisms of TRAF6 modulate the risk of SBP. Thus, we determined theTRAF6 haplotype in 432 patients with cirrhosis and ascites using the haplotype-tagging single nucleotide polymorphisms rs331457 and rs5030419. In addition, peritoneal macrophages were immunomagnetically isolated and characterized. Overall, 122 (28%) patients had an episode of SBP. In the combined prospective-retrospective analysis the frequency of SBP differed between the four haplotypes (P = 0.014) and was the highest in 102 patients carrying the rs331457 but not the rs5030419 variant, when compared to other haplotypes (odds ratio 1.95 [1.22–3.12]) or to the wild-type (odds ratio 1.71 [1.04–2.82]). This association was confirmed in multivariate logistic regression (adjusted odds ratio 2.00 [1.24–3.22]) and in prospective sensitivity analysis (hazard ratio 2.09 [1.08–4.07]; P = 0.03). The risk haplotype was associated with lower concentrations of the immune activation marker soluble CD87 in ascitic fluid and with a decreased expression of IL-6 and CXCL8 in isolated peritoneal macrophages. In conclusion, genetic polymorphisms of TRAF6 are associated with decreased peritoneal immune activation and an increased risk of SBP.

Su1526 Proton Pump Inhibitors and Risk of Spontaneous Bacterial Peritonitis in Cirrhosis: An Updated Meta-Analysis

Su1526 Proton Pump Inhibitors and Risk of Spontaneous Bacterial Peritonitis in Cirrhosis: An Updated Meta-Analysis

A quick screening model for symptomatic bacterascites in cirrhosis

Background:Diagnosis of spontaneous bacterial peritonitis in cirrhosis can be made when a patient has an ascites polymorphonuclear leukocyte count ≥250/mm3. However, symptomatic bacterascites, which is a variant of spontaneous bacterial peritonitis with signs of infection but an ascites polymorphonuclear leukocyte count <250/mm3, cannot be confirmed until the time-consuming ascites culture becomes positive. Currently, early indicators for symptomatic bacterascites remain undetermined.Aims:To develop a quick screening model for early detection of symptomatic bacterascites in cirrhosis.Materials and Methods:Data on patients with cirrhotic ascites from two hospitals (from 2010 to 2014) were collected retrospectively. Patients with symptomatic bacterascites were enrolled in the case group and compared with patients without any infection in the control group. Logistic regression analysis was used to build a model for screening symptomatic bacterascites, and a receiver operating characteristics curve was used to assess the model.Results:In total, 103 patients were enrolled in the case group and 204 patients were enrolled in the control group. A screening model was constructed based on body temperature, abdominal tenderness, blood neutrophil percentage, blood total bilirubin, prothrombin time, and ascites nucleated leukocyte count. The area under the receiver operating characteristic curve was 0.939; a screening score of 0.328 was the best cutoff value.Conclusion:Patients with suspected symptomatic bacterascites can be quickly screened according to the developed model, and a screening score ≥0.328 indicates symptomatic bacterascites.

The Negative Prognostic Impact of a First Ever Episode of Spontaneous Bacterial Peritonitis in Cirrhosis and Ascites.

The prognostic impact of the first ever episode of spontaneous bacterial peritonitis (SBP) on patient outcomes is not well described. Our aim was to compare the clinical outcomes of cirrhotic patients with ascites, and with or without a first episode of SBP. Consecutive patients with cirrhosis and ascites were prospectively enrolled. Demographics, liver and renal function, and hemodynamics were documented at baseline, at resolution of SBP, and thereafter at 4 monthly intervals for 12 months. Complications of cirrhosis and survival were noted. Twenty-nine cirrhotic patients with a first ever episode of SBP (group A) and 123 control patients slightly younger but similar in gender who never had SBP (group B) were enrolled. At SBP diagnosis, group A had worse liver and renal function (Model of End-Stage Liver Disease : 21.1±10.6 vs. 14.4±5.0), lower serum sodium concentrations, and a more hyperdynamic circulation compared with group B (all P<0.001). SBP resolution resulted in improvement in all measures to baseline levels. During follow-up, group A required more frequent hospital admissions than group B (58% vs. 43%), developed more cirrhotic complications, including further SBP (31% vs. 3%*), hyponatremia (12% vs. 0.8%*), acute kidney injury (50% vs. 23%*), hepatorenal syndrome type 1 (46% vs. 7%*), liver transplantation (62% vs. 30%*), and had a worse overall 1-year survival (38% vs. 70%*) (*P<0.05). A first SBP episode is commonly followed by multiple complications, and overall worse prognosis. Consideration should be given to assess cirrhotic patients for liver transplant after the first episode of SBP.

Proton pump inhibitor therapy does not increase the incidence of spontaneous bacterial peritonitis in cirrhosis: A multicenter prospective study

Retrospective studies show an association between proton pump inhibitor (PPI) therapy and spontaneous bacterial peritonitis (SBP). We investigate the relationship between PPI and SBP in decompensated cirrhotic patients in a large nationwide prospective study. Seven hundred seventy patients with a diagnosis of decompensated cirrhosis were admitted consecutively in 23 hospitals in Argentina from March 2011 to April 2012; the patients were carefully investigated for PPI consumption in the previous 3 months. In total, 251 patients were excluded because of active gastrointestinal hemorrhage, antibiotic use during the preceding weeks, HIV-positive status and immunosuppressive therapy. Two hundred twenty-six out of 519 patients (43.5%) had received PPI therapy within the last 3 months. In 135 patients, PPIs were administered for longer than 2 weeks. A bacterial infection was shown in 255 patients (49.1%). SBP was diagnosed in 95 patients out of 394 patients with ascites (24.7%). There was no significant difference in the rate of PPI consumption between the infected and the non-infected patients (44.3% vs. 42.8%) or between the SBP patients and the patients with ascites without SBP (46% vs. 42%). In the SBP patients, the duration of PPI administration did not influence the rate of SBP occurrence. The type of bacteria and the origin of SBP infection were similar in the patients with and without PPI. In the current large, multicenter, prospective study, PPI therapy, specifically evaluated at admission of consecutive cirrhotic patients, was not associated with a higher risk of SBP.

Beta‐blockers in portal hypertension: new developments and controversies

There are many studies investigating the role of non-selective beta-blockers in portal hypertension. Satisfactory reduction in portal pressure is possible in a third to half of patients with propranolol and nadolol, although combining these drugs with nitrates may be more effective. Carvedilol is a more potent agent than propranolol in reducing portal pressure, particularly in non-responders, and is better tolerated. All these drugs have been studied in primary and secondary prophylaxis, sometimes in combination with band ligation and/or nitrates. There is some evidence to support combining these agents with band ligation, despite a lack of survival benefit and increased adverse events. Hemodynamic monitoring can help select non-responders who may benefit from additional therapies such as band ligation, as lack of response is associated with worse outcomes. Propranolol should be used with caution in patients with refractory ascites, although the current evidence is not of sufficient quality to justify not using these drugs in such situations. Beta-blockers have been shown to reduce bacterial translocation and spontaneous bacterial peritonitis in cirrhosis.

Albumin for bacterial infections other than spontaneous bacterial peritonitis in cirrhosis. A randomized, controlled study

Treatment with albumin in patients with cirrhosis and spontaneous bacterial peritonitis (SBP) prevents renal failure and improves survival. Whether albumin has similar beneficial effects in patients with infections other than SBP is unknown. One hundred and ten patients with cirrhosis hospitalized for infections other than SBP were randomly assigned to receive antibiotics plus albumin (1.5 g/kgbw at diagnosis and 1 g/kgbw at day 3) (albumin group; n=56) or antibiotics alone (control group; n=54). The primary end point was survival at 3 months. Secondary end points were effects on renal and circulatory function. The renal function, as evaluated by differences in changes in serum creatinine and estimated glomerular filtration rate between the two groups, improved in patients treated with albumin. The circulatory function improved significantly in patients treated with albumin, but not in those from the control group. There was a trend for a lower frequency of type 1 hepatorenal syndrome in the albumin group compared to the control group (1 vs. 4 patients, respectively; p=n.s.). Probability of survival at 3 months was not significantly different among the two groups. However, when adjusted for factors with independent prognostic value, treatment with albumin was an independent predictive factor of survival. As compared with standard antibiotic therapy alone, treatment with albumin together with antibiotics has beneficial effects on the renal and circulatory function and shows a potential survival benefit. Further studies with large sample sizes should be performed to confirm these findings.

PWE-288 Spontaneous bacterial peritonitis: prevalence on admission to a tertiary centre and subsequent outcome

IntroductionSpontaneous bacterial peritonitis (SBP) is a sinister complication of cirrhosis associated with poor survival (approximately 38% at 1 year1). However, a diagnosis of SBP does not represent, in its own...

Bacterial infections other than spontaneous bacterial peritonitis in cirrhosis

Cirrhotic patients are immunocompromised with a high risk of infection. Proinflammatory cytokines and hemodynamic circulation derangement further facilitate the development of serious consequences of infections. Other than spontaneous bacterial peritonitis, bacteremia and bacterial infections of other organ systems are frequently observed. Gram-negative enteric bacteria are the most common causative organism. Other bacterial infections, such as enterococci, Vibrio spp., Aeromonas spp., Clostridium spp., Listeria monocytogenes, Plesiomonas shigelloides and Mycobacterium tuberculosis are more prevalent and more virulent. Generally, intravenous third generation cephalosporins are recommended as empirical antibiotic therapy. Increased incidences of gram-positive and drug-resistant organisms have been reported, particularly in hospital-acquired infections and in patients receiving quinolones prophylaxis. This review focuses upon epidemiology, microbiology, clinical features and treatment of infections in cirrhosis other than spontaneous bacterial peritonitis, including pathogen-specific and liver disease-specific issues.

Risk stratification of spontaneous bacterial peritonitis in cirrhosis with ascites based on classification and regression tree analysis

Risk stratification for spontaneous bacterial peritonitis (SBP) in patients with cirrhosis and ascites helps guide care. Existing prediction models, such as end-stage liver disease (MELD) score, are accurate but controversial in clinical practice. We developed and validated a practical user-friendly bedside tool for SBP risk stratification of patients with cirrhosis and ascites. Using classification and regression tree (CART) analysis, a model was developed for prediction of SBP in cirrhosis with ascites. The CART model was derived on data collected from 676 patients admitted from January 2007 to December 2009 retrospectively, and then was prospectively tested in another independent 198 inpatients between January 2010 and December 2010. The accuracy of CART model was evaluated using the area under the receiver operating characteristic curve. The performance of the model was further validated by comparing its predictive accuracy with that of the MELD score. Furthermore, the model was used to stratify SBP among patients with MELD scores under 15. CART analysis identified four variables for prediction of SBP: creatinine, total bilirubin, prothrombin time and white blood cell count, and three risk groups: low (2.0%), intermediate (27.5-33.3%) and high (60.6-86.4%) risk. The accuracy of CART model (0.881) exceeded that of MELD (0.791). Subjects in the intermediate risk and high risk groups had 22.21-fold (95% confident interval (CI), 9.98-49.45) and 173.50-fold (95% CI, 77.68-634.33) increased risk of SBP, respectively, comparing with the low risk group. Similar results were found when this risk stratification was applied to the validation cohort. Cirrhotic patients with ascites at low, intermediate, and high risk for SBP can be easily identified using CART model, which provides clinicians with a validated, practical bedside tool for SBP risk stratification.

Secondary bacterial peritonitis in cirrhosis: A retrospective study of clinical and analytical characteristics, diagnosis and management

Secondary bacterial peritonitis in cirrhotic patients is an uncommon entity that has been little reported. Our aim is to analyse the frequency, clinical characteristics, treatment and prognosis of patients with secondary peritonitis in comparison to those of patients with spontaneous bacterial peritonitis (SBP). Retrospective analysis of 24 cirrhotic patients with secondary peritonitis compared with 106 SBP episodes. Secondary peritonitis represented 4.5% of all peritonitis in cirrhotic patients. Patients with secondary peritonitis showed a significantly more severe local inflammatory response than patients with SBP. Considering diagnosis of secondary peritonitis, the sensitivity of Runyon's criteria was 66.6% and specificity 89.7%, Runyon's criteria and/or polymicrobial ascitic fluid culture were present in 95.6%, and abdominal computed tomography was diagnostic in 85% of patients in whom diagnosis was confirmed by surgery or autopsy. Mortality during hospitalization was higher in patients with secondary peritonitis than in those with SBP (16/24, 66.6% vs. 28/106, 26.4%) (p<0.001). There was a trend to lower mortality in secondary peritonitis patients who underwent surgery (7/13, 53.8%) than in those who received medical treatment only (9/11, 81.8%) (p=0.21). Considering surgically treated patients, the time between diagnostic paracentesis and surgery was shorter in survivors than in non-survivors (3.2+/-2.4 vs. 7.2+/-6.1 days, p=0.31). Secondary peritonitis is an infrequent complication in cirrhotic patients but mortality is high. A low threshold of suspicion on the basis of Runyon's criteria and microbiological data, together with an aggressive approach that includes prompt abdominal computed tomography and early surgical evaluation, could improve prognosis in these patients.