Culture-negative Neutrocytic Ascites Research Articles

Procalcitonin in Diagnosis of Spontaneous Bacterial Peritonitis and Culture Negative Neutrocytic Ascites in patients with Liver Cirrhosis

Procalcitonin in Diagnosis of Spontaneous Bacterial Peritonitis and Culture Negative Neutrocytic Ascites in patients with Liver Cirrhosis

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.

MICROBIOLOGICAL PROFILE OF SPONTANEOUS BACTERIAL PERITONITIS IN PATIENTS WITH CIRRHOSIS OF LIVER IN SOUTHERN ASSAM.

Liver cirrhosis is a common disorder which can have a wide range of aetiologies. Anatomically, it is characterised as a widespread process of nodule formation and fibrosis in the liver. Without any obvious intra-abdominal source of infection, spontaneous bacterial peritonitis (SBP) is characterised by infection of the previously sterile ascitic fluid (AF). SBP is a primary cause of death in decompensated liver disease and requires quick identification and care. In recent years, Assam has seen an increase in the prevalence of alcoholic liver disease and associated complications. Aims and Objectives: This study was undertaken with an idea to evaluate the significance of AF analysis with AF culture and sensitivity to determine microbiological profile and prognosis in cirrhotic patients with SBP in this region. Materials and Methods: Patients admitted with liver cirrhosis with ascites were studied during the period from June 2021 to May 2022. All patients included in the study were confirmed liver cirrhosis by ultrasound. Basic demographics, symptoms and clinical signs of patients were recorded. Patients with the history of antibiotic use within last 3 days or any intraabdominal source of infection were excluded. Diagnostic paracentesis was done for ascitic fluid detailed report and culture. Out of 100 SBP patients, 60 (60%) had culture negative neutrocytic ascites and 40 (40%) had Results: bacterascites. Fever, abdominal tenderness and constipation were common in SBP patients. Ascitic fluid culture was positive in 26 (52%) patients. E. coli (28%) was the predominant pathogen followed by Klebsiella species (8%), Staphylococcus aureus (2%) and acetinobacter (2%). 33 (82.5%) cases showed sensitivity to cefotaxim. In rest 17.5% cases, organism is mildly sensitive or resistant to 3rd generation cephalosporins

Clinical, Laboratory and Bacterial Profile of Spontaneous Bacterial Peritonitis in Vietnamese Patients with Liver Cirrhosis.

AimTo determine several clinical and laboratory features as well as the bacterial profile of spontaneous bacterial peritonitis (SBP) in 58 Vietnamese patients admitted to a single center due to liver cirrhosis.MethodsWe retrospectively analyzed bacteriological, clinical and laboratory characteristics of patients with SBP admitted to the Gastroenterology and Hepatology Center from July 2019 to July 2020.ResultsOut of a total 58 SBP patients, 41 (70.9%) had culture-negative neutrocytic ascites. The majority of patients experienced abdominal pain (93,1%) and large ascites (65,5%). Gram-negative bacteria formed the main pathogens (14/17). Escherichia coli (9/17) was the predominant cause followed by Burkholderia cepacia (2/17). Antibiotic sensitivity rate of E. coli for third generation cephalosporin was low but high for aminoglycoside and carbapenem antibiotics. The resistance of E. coli was significant against fluoroquinolones (100%). All 3 cases of gram-positive bacteria were sensitive to vancomycin.ConclusionOur study reported the bacteriological and clinical characteristics of patients with SBP and compared these findings between two groups: positive ascitic fluid culture and negative fluid culture. Ascitic fluid culture can guide for the right antibiotic choice since resistance to commonly prescribed antibiotics is common in SBP patients.

Spontaneous Ascitic Fluid Infection: Are we Experiencing an Epidemiological shift in Causative Organisms?

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. This is a retrospective observational study that aims to determine bacterial etiology, susceptibility patterns of SAI, and its correlation with model for end-stage liver disease-sodium (MELD-Na) and Child-Turcotte-Pugh (CTP) score. The present study was conducted on 274 consecutive cases admitted in Bombay Hospital and Medical Research Centre, Mumbai, India. Cases of cirrhosis (irrespective of etiology) with ascites between the ages of 18-85 years were included in this study. Ascitic fluid of every patient was aspirated under all aseptic measures and was sent for biochemical, culture, and cytological analysis. Of the 274 patients studied, 34 (12.4%) patients were diagnosed to have SAI. Culture-negative neutrocytic ascites (CNNA) was present in 27 patients, spontaneous bacterial peritonitis (SBP) was present in six patients, and monomicrobial bacteriascites was seen in one patient. Mean age of patients enrolled was 56.05 ± 2.47 years. Eighty-two percent were males and 18% were females. Alcohol (45.45%) was the leading cause of cirrhosis followed by nonalcoholic steatohepatitis (NASH) related cirrhosis (26.47.7%) and hepatitis C virus (HCV) related cirrhosis (11.46%) and cryptogenic cirrhosis (8.82%). Average MELD-Na score was 25 and the CTP class C was most common. Klebsiella pneumoniae was the most commonly isolated organism followed by Escherichia coli. The various factors that predispose to development of SBP include low ascitic fluid protein concentration, a high level of serum bilirubin, deranged serum creatinine, high Child-Pugh score, and high MELD-Na score. Ascitic fluid analysis remains the single most important test for identifying and assessing a course of SBP. Early diagnosis and treatment will reduce the mortality rate in these patients.

Poor Oral Hygiene Predicts the Presence of Ascitic Fluid Infection in Patients with Decompensated Cirrhosis

Background: Ascitic fluid infection [AFI] is one of the important complications of cirrhosis which has poor prognosis. It may be classified as Spontaneous Bacterial Peritonitis (SBP), culture negative neutrocytic ascites (CNNA) or bacteriascites. Bacterial translocation from GI tract is considered to be the most important mechanism that leads to development of AFI. Poor oral hygiene may cause subclinical or persistent infections in cirrhotic patients may act as independent risk factor for adverse outcomes in cirrhotic patients including AFI. Aim:To assess the correlation between AFI in patients with decompensated cirrhosis having poor oral hygiene. Methods: All in patients of cirrhosis with ascites were examined for ascitic fluid analysis including total protein, albumin, glucose, PMN count. Fluid was also inoculated at bedside for cultures. Oral hygiene was examined for all patients by using the dental mirror. OHI-S was calculated after calculating calculus and Debris index to determine good /poor oral hygiene. Results: A total 200 patients of decompensated cirrhosis were enrolled in the study. With mean age of 50.9 + 9.85. There were 78 % males with a mean BMI of 18.9 + 1.9. Alcohol was the major cause of cirrhosis (72%). Mean MELD and CTP were 18.6+7.43 and 10.2 +1.28 . Mean OHI- S was 1.8+1.07. AFI was found in 28%, SBP and CNNA27% was found in 1% and 27 % respectively. On univariate analysis CTP, MELD, BMI, Haemoglobin, Serum protein and Albumin significantly associated with poor oral hygiene (P < 0.001). Poor oral hygiene was found in 59.6 % in patients with AFI compared to 16.9 % in patients without SBP/CNNA (P < 0.001). S – OHI so predicted presence of AFI with a AUROC of 0.83. Conclusion: We suggest screening for oral hygiene in all patients of decompensated cirrhosis as it may be a harbinger of ascitic fluid infection.

Culture negative neutrocytic ascites versus culture positive spontaneous bacterial peritonitis; Is there a Difference; A Multi-Centric Study

Background: There are two variants of spontaneous bacterial peritonitis (SBP) include, culture negative neutrocytic ascites (CNNA) and culture positive SBP. Some suggested that, the clinical presentation of two variants is nearly similar, however, other reported that, patients with culture positive have a more severe course and higher mortality than CNNA. The aim of this study is to determine the clinical characteristics and predictors of CNNA in comparison to culture positive SBP. Materials and methods: This study included 300 consecutive patients with HCV related cirrhotic ascites. All patients underwent abdominal paracentesis and the ascitic fluid was processed for cell count and culture. Clinical and laboratory parameters of these patients were recorded at index admission.. Results: Out of 300 patients included in the study, 150 patients had SBP. Among the 150 patients with SBP, 100 patients were culture positive SBP (culture positive SBP with ascitic fluid PMNL ≥250 cells/m3) and 50 patients were CNNA (culture negative SBP with ascitic fluid PMNL ≥250 cells/m3). Compared to patients with culture positive SBP, patients with CNNA showed, a significant decrease as regards, fever, prevalence of DM, hepatic encephalopathy, platelets, blood PMNL and ascetic PMNL. Logistic regression analysis demonstrated that, decreased platelets count, blood PMNL and ascetic PMNL were independent predictor factors for CNNA. Conclusion: Patients with CNNA have a lower incidence of fever, prevalence of diabetes mellitus, hepatic encephalopathy, blood PMNL and ascetic PMNL versus culture positive SBP. Independent predictors of culture negative SBP are decreased platelets, blood PMNL and ascetic PMNL.

Variants of Ascitic Fluid Bacterial Infection in Children with Chronic Liver Disease in a tertiary care hospital in Bangladesh

Introduction: Ascitic fluid bacterial infection is an infection of preexisting ascites in the absence of abdominal source. Ascitic fluid bacterial infection may presents in both symptomatic and asymptomatic children with chronic liver disease (CLD). Culture negative neutrocytic ascites(CNNA) is the commonest type of infection in children with CLD. Objective: To observe the variants of ascitic fluid bacterial infection in children with CLD. Methods: Thirty five consecutive children with clinical features suggestive of CLD, aged between 2-14 years of both sexes with clinically detected ascites and admitted at the Department of Paediatric Gastroenterology and Nutrition, Bangabandhu Sheikh Mujib Medical University (BSMMU) from January 2013 through June 2013 were enrolled in this cross sectional study. Children who had features of ascitic fluid infection like l fever, abdominal pain with tenderness were categorized as symptomatic and children who had no features of ascitic fluid infection were categorized as asymptomatic children. Demographic, clinical, haematological, biochemical and ascitic fluid study were done for both symptomatic and asymptomatic children. Variants of ascitic fluid bacterial infection was identified by ascitic fluid polymorphonuclear leucocyte count and culture report. Results: Among 35 children, majority 17 (48.6%) were between 6-10 years of age group with male predominance. About 12 (34.3%) were symptomatic and among the symptomatic children 7 (58.4%) were infected and 5 (41.6%) were non-infected, 16 (45.7%) had culture negative neutrocytic ascites (CNNA) variant of ascitic fluid bacterial infection as evident by ascitic fluid polymorphonuclear leucocyte count of  250/mm3 and negative culture report. Mean ascitic fluid polymorphonuclear neutrophil count was 515177.82/HPF among infected children and 85.4770.60/HPF among non-infected children, which is statistically significant (p-0.001). Wilson’s disease was the commonest 11(30) cause of the ...

Antibiotic susceptibility of asymptomatic spontaneous bacterial peritonitis in decompensated liver cirrhosis: A prospective study

Background and aim Asymp to matic spontaneous bacterial peritonitis (SBP) is rare but has similar variants to symptomatic SBP. Our aim is to determine the antibiotic susceptibility in asymptomatic SBP. Patients and methods Patients with decompensated liver cirrhosis were included in our study. Ascitic fluid analysis for polymorphonuclear count, as well as culture was done at baseline and 48 h after antibiotic initiation if polymorphonuclear count more than or equal to 250/mm3 and/or positive culture. Cefotaxime was used empirically, whereas in bacterascites, initial antibiotic was based on the culture. Results A total of 70 patients were included. Approximately 15.7% had asymptomatic SBP. Overall, 9% of patients with asymptomatic SBP were classic SBP, culture-negative neutrocytic ascites (CNNA) in 54.5%, and bacteriascites in 36.4%. Classic SBP and five cases of CNNA were cefotaxime sensitive. The resistant case in CNNA responded to meropenem. Bacterascites was cefotaxime resistant and sensitive to ciprofloxacin and piperacillin-tazobactam. The overall resistance to cefotaxime was 45.5%. Conclusion CNNA is predominant in asymptomatic SBP with high resistance to third-generation cephalosporin which requires antibiotic susceptibility to be identified before therapy.

Neutrophil Gelatinase-Associated Lipocalin (NGAL): An Early Dual Biomarker in Diagnosis of Ascitic Fluid Infection and Acute Kidney Injury in Liver Cirrhosis in a Tertiary Centre, Egypt

Background: This study aimed to evaluate the ascitic Neutrophil gelatinase-associated lipocalin (NGAL) as a diagnostic biomarker for bacterial translocation or bactDNA translocation in ascites of cirrhotic patients and to evaluate the urinary NGAL for identifying renal dysfunction in patients with liver cirrhosis.&#x0D; Methods: This study included 44 patients with ascites. Study participants were divided into two groups. Group (1) had 22 patients with neutrocytic ascites and/or positive ascitic fluid (AF) culture while group (2) included 22 patients with culture negative non neutrocytic ascites (CNNNA), recruited as controls. AF and urine samples were collected from all studied participants. ELISA kit was used for measurement of NGAL levels in AF and urine. DNA extraction and PCR were done.&#x0D; Results: Values of NGAL in ascitic fluid were statistically significantly higher in bactDNA positive group. At cutoff 143.9 ng/ml, ascites NGAL had 86.4% sensitivity, 45.5% specificity, 61.3% positive predictive value (PPV) and 76.9% negative predictive value (NPV). When comparing ascites NGAL between bactDNA positive and negative group, NGAL has a sensitivity of 86.2% and a specificity of 46.7%, PPV of 75.8%, NPV of 63.6%. As for urine NGAL, patients with AKI had statistically significant higher levels of NGAL. Urine NGAL achieved sensitivity of 77.3%, specificity of 50%, PPV of 60.7%, NPV of 68.75%.&#x0D; Conclusion: Early and accurate diagnosis of BT or bactDNA translocation can be aided by utilizing NGAL especially in ruling out infection in those reported to have negative culture results, besides, it can help in early detection of complication of cirrhosis and infection especially AKI helping in the improving the prognosis of cirrhotic patients. It is an advantage that a single marker can detect both infection and kidney injury.

Lymphocyte to Monocyte Ratio and C-Reactive Protein Combination as the Best Simple Predictor of Treatment Response in Cirrhotic Patients With Culture Negative Neutrocytic Ascites

Objectives:The aim of this study was to evaluate the most ideal inflammatory markers for treatment response and to determine a cutoff value that could predict response to treatment for culture negative neutrocytic ascite (CNNA) patients.Methods:This is a retrospective cross-sectional case-controlled study. Patients with CNNA were evaluated by taking ascites fluid sampling at the beginning and on the 5th day of treatment. Neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), and neutrophil-to-monocyte ratio were calculated.Results:Of the 123 cases with cirrhotic ascites disease, 59 were CCNA and 64 were the control group without ascite-fluid infection. There were statistically significant differences for blood monocyte count, NLR (p<0.01), LMR, and C-reactive protein (CRP) (p<0.001) between two groups. Patients in the CNNA group were compared before and after treatment among themselves for the treatment response. There was statistically significant difference in mean platelet volume, monocyte, LMR, and CRP (p<0.05) between two groups. After receiver operator characteristics curve analysis, the best cutoff value for monocyte was <0.64 × 103/μL (sensitivity 49.2%, specificity 74.6%, positive predictive value [PPV] 65.9%, and negative predictive value [NPV] 59.5%) (p<0.01), for LMR was ≥1.7 (sensitivity 76.3%, specificity 78%, PPV 77.6%, and NPV 76.7%), and for CRP was ≤18 mg/L (sensitivity 91.5% specificity 57.6%, PPV 68.4%, and NPV 87.2%) (p<0.001). When LMR and CRP were used together, sensitivity (86.5%), specificity (83.1%), PPV (83.6%), and NPV (86%) were found to be statistically significantly higher (p<0.001).Conclusion:Our results showed that in cirrhotic patients with CNNA, combined LMR + CRP can be used as a novel, low cost and non-invasive test to predict treatment response.

Prevalence of Spontaneous Bacterial Peritonitis in Cirrhotic Patients with Ascites and Its Pattern in Aswan University Hospital

Background: Spontaneous bacterial peritonitis (SBP) is the most common infection and a lethal complication in patients with liver cirrhosis and ascites. It has high mortality and recurrence rates and poor long-term prognosis. Objective: This study was done to determine the prevalence of spontaneous bacterial peritonitis and its variants in patients of liver cirrhosis with ascites. Patients and Methods: This was a prospective, randomized, cross-sectional clinical study, included 100 adult patients of decompensated liver cirrhosis with ascites in Aswan University Hospital during the period from January 2019 to December 2019. Results: Diagnosis of SBP is based on ascitic fluid analysis as well as culture and sensitivity. The diagnostic criteria are PMNL > 250/mm³ and or positive culture. Mean of age of patients was 63.06 ± 9.67 years old. Majority of patients were males (63%) and 37 % were females. In Our study, 62% of patients were diagnosed SBP. Classic SBP in 30.6%, Culture Negative Neutrocytic Ascites (CNNA) in 59.7% and MNB in 9.7% of patients. Of 25 patients who have positive culture ascetic fluid, 60% were positive for gram-negative bacteria predominantly E. coli. Conclusion: Spontaneous Bacteria Peritonitis is the most common and life-threatening infection in patients who have liver cirrhosis and ascites. It is diagnosed by a) Ascitic fluid PMNL > 250/mm³. b) Positive ascetic fluid culture. c) Both a and b. It is found that SBP has recently increased in prevalence with predominantly causative organism gram negative E Coli.

Difficult-to-treat ascitic fluid infection is a predictor of transplant-free survival in childhood decompensated chronic liver disease.

To study the clinico-bacteriological profile of ascitic fluid infection (AFI) and its impact on outcome in childhood chronic liver disease (CLD). It was a retrospective study on pediatric CLD patientsrequiring an ascitic tap. Logistic regression was performed to study the predictive factors for AFI. Two hundredand fifty-two (30.9%) of 814 children with CLD underwentascitic tap on suspicion of AFI of whom 79 (31.3%) had AFI, culture negative neutrocytic ascites being the commonest. Younger age (p = 0.002), male gender (p = 0.007), new onset/rapid increase in ascites (p = 0.032), fever (p = 0.012), and blood total leukocyte count (TLC)(p = 0.001) were found to be independently associated with AFI. Twenty-three children had positive ascitic fluid culture: 15 Gram negative; 11 (52.3%) were multidrug resistant organism. Hepatic encephalopathy (HE) (p = 0.001), Model for End-stage Liver Disease/Pediatric End-stage Liver Disease (MELD/PELD) (p < 0.0005), and difficult-to-treat AFI (p = 0.007) were found to be independently associated with death and or LT. Children with ascites should undergoa diagnostic paracentesis in presence of fever, increasing or new-onset ascites, and/or increased TLC. Death or liver transplant are more likely due to advanced liver disease (high PELD /HE) and in those with difficult-to-treat AFI.

Prevalence of Spontaneous Bacterial Peritonitis in Cirrhotic Patients with Ascites and Its Pattern in Aswan University Hospital

Background: Spontaneous bacterial peritonitis (SBP) is the most common infection and a lethal complication in patients with liver cirrhosis and ascites. It has high mortality and recurrence rates and poor long-term prognosis. Objective: This study was done to determine the prevalence of spontaneous bacterial peritonitis and its variants in patients of liver cirrhosis with ascites. Patients and Methods: This was a prospective, randomized, cross-sectional clinical study, included 100 adult patients of decompensated liver cirrhosis with ascites in Aswan University Hospital during the period from January 2019 to December 2019. Results: Diagnosis of SBP is based on ascitic fluid analysis as well as culture and sensitivity. The diagnostic criteria are PMNL > 250/mm³ and or positive culture. Mean of age of patients was 63.06 ± 9.67 years old. Majority of patients were males (63%) and 37 % were females. In Our study, 62% of patients were diagnosed SBP. Classic SBP in 30.6%, Culture Negative Neutrocytic Ascites (CNNA) in 59.7% and MNB in 9.7% of patients. Of 25 patients who have positive culture ascetic fluid, 60% were positive for gram-negative bacteria predominantly E. coli. Conclusion: Spontaneous Bacteria Peritonitis is the most common and life-threatening infection in patients who have liver cirrhosis and ascites. It is diagnosed by a) Ascitic fluid PMNL > 250/mm³. b) Positive ascetic fluid culture. c) Both a and b. It is found that SBP has recently increased in prevalence with predominantly causative organism gram negative E Coli.

BACTERIOLOGY OF SPONTANEOUS BACTERIAL PERITONITIS

Cirrhosis is a major cause of mortality worldwide and is the most common non neoplastic cause ofdeath among hepatobiliary and digestive diseases. Ascites is often among the first signs of de-compensation in patientswith chronic liver disease. Spontaneous Bacterial Peritonitis (SBP) (with out any source of infection) occurs in 30% ofpatients with ascites. Common causative organisms include escherichia coli, pneumococcus, Klebsiella and anaerobes.It has a 25% mortality and recurs in 70% of patients within a year. Objective: To determine the pathological agentscausing SBP in patients with liver cirrhosis. Design: Descriptive study. Setting: Medical Ward Allied and K.M. HospitalsFaisalabad. Period: From 17 Nov 2004 to 15 May 2005. Patients &amp; Materials. Fifty patients of either sex havingcirrhosis of liver and ascites were included according to the criteria i.e ascitic fluid leukocyte count of &gt;500 cells/L or&gt;250 PMN, while results of bacterial cultures of ascitic fluid were pending. Results: Out of 50 patients, 27 (54%) weremales and 23 (46%) females. Mean age of whole the population was found to be 51±12.49) yrs. Classical spontaneousbacterial peritonitis was present in 27 patients and Culture Negative Neutrocytic Ascites (CNNA) in 23(46%) patients.Out of 50 patients, 27(54%) samples of ascitic fluid showed positive culture reports. E Coli was isolated in 9(18%)cases. Klebsiella pneumoniae in 6(12%), streptococcus pneumoniae 4(8%), staphylococcus aureus 2(4%),pseudomonas aeruginosa 2(4%). Acinobacter 2(4%) and proteus mirabilis 2(4%). E.Coli is the commonest organismfollowed by klebsiella pneumoniae.

973 Utility of Gram Stain in the Diagnosis and Management of Spontaneous Bacterial Peritonitis: Promoting High Value Care

INTRODUCTION: The diagnostic criteria for spontaneous bacterial peritonitis (SBP) and culture negative neutrocytic ascites depends largely on neutrophil counts of more than 250 cells / mm3. A positive ascitic fluid culture makes the diagnosis of SBP versus CNNA. In general clinical practice gram stain (GS) and culture are routinely sent for suspected SBP. The yield of microbe from ascitic fluid is low possibly because SBP and CNNA are known to happen with very small concentrations of bacteria, whereas bacterial loads as high as 10^5 organisms/ml are required for a positive GS. The aim of this study was to determine the utility of GS in the diagnosis and management of suspected SBP as an impetus to decrease overall burden of healthcare cost and unnecessary testing. METHODS: We retrospectively reviewed patients with ascites and cirrhosis, who underwent paracentesis with body fluid analysis at a large tertiary care hospital in a 1-year period. Patients were identified using institutional procedural codes and ICD 9 and ICD 10 codes for ascites and cirrhosis. We included all adult patients with cirrhosis who had underwent paracentesis in 2017 and had both a culture and a GS sent for analysis. We excluded patients who had any evidence of recent or current source of intra-abdominal infection or had partial labs sent. Variables of interest were date of ascitic fluid studies sent, date of GS results, date of culture results, date of initiation of empiric antibiotics and the date and name of the second antibiotic used. Descriptive statistics were used to analyze data. Costs for GS, culture and body fluid cell count &amp; differential were obtained from the coding and reimbursement department. RESULTS: 767 patients underwent ascitic fluid testing in our study period. 43 had a positive GS (5.6%). 21 of these had SBP (PMN &gt; 250 and positive culture), one patient had CNNA (PMN &gt; 250 and no culture growth), 20 patients had bacteracitis (PMN &lt; 250 and positive culture) and one patient had PMNs &lt; 250 and no culture growth. Management was changed in 3 cases (0.4%) based on GS alone (Table 1). In one of these patients, therapy was changed again after the culture grew a different organism. Total healthcare cost calculated to be at least $36,672 each year at our center based on $48 per ascitic fluid gram stain sample alone. CONCLUSION: Carrying out GS on all ascitic fluid samples is not cost effective and rarely leads to changes in management.

Ascitic fluid infection in children with liver disease: time to change empirical antibiotic policy.

Recent years have shown a rise in occurrence of multidrug resistant ascitic fluid infection (AFI) including resistant to third generation cephalosporins. Our aim was to find the prevalence, antibiotics resistance and outcome of AFI in children with liver disease. Children (≤ 18years) with liver disease-related ascites were prospectively enrolled from April 2015 to October 2017. Based on the results of ascitic fluid examination and culture, patients were classified as having AFI [spontaneous bacterial peritonitis (SBP), culture negative neutrocytic ascites (CNNA) and monomicrobial non-neutrocytic bacterascites (MNB)] and no-AFI. AFI diagnosed after 48h of index hospitalization was considered as nosocomial. We enrolled 194 children with a median age of 85 [2-216] months. Chronic liver disease was the commonest etiology (153, 79%). AFI was present in 60 (31%) children [SBP (n = 13), CNNA (n = 39), MNB (n = 8)] of which 53% were nosocomial and resulted in high in-hospital mortality. Gram-negative bacilli dominated the ascitic fluid culture (12/21, 57%) and 10/12 (83%) of them were extended spectrum beta-lactamases (ESBL) producers. Six (60%) ESBL producers were sensitive to cefoperazone-sulbactam and 70% to carbapenems. Child-Pugh-Turcotte (CPT) score of ≥ 11 independently determined in-hospital mortality in children with AFI. AFI was found in 31% children with liver disease and almost half of them were nosocomial resulting in high mortality. ESBL producing Gram-negative bacteria were the most frequently isolated organisms. Cefoperazone-sulbactam or carbapenems may be useful empirical antibiotics in nosocomial setting. Children with AFI and CPT score ≥ 11 should be evaluated for liver transplantation.

Analysis of patients with suspected diagnosis of spontaneous bacterial peritonitis in the emergency department

Aim: In this study, we aimed to determine the epidemiological characteristics, microbiological and laboratory parameters of the patients diagnosed with spontaneous bacterial peritonitis (SBP) in the tertiary emergency department and to determine the in-hospital mortality rates. Material and Methods: A total of 294 patients who met these criteria and whose data were fully accessible from the hospital information management system included in the study. Demographic data such as age, gender, cirrhosis etiology, laboratory results and in-hospital mortality were recorded on the study form previously prepared. Child-Pugh and model for end stage liver disease (MELD) scores were calculated according to the formulas. Results: The mean age of the patients was 49 ± 17 years (mean ± SD) and 212 (72.1%) were male. When the patients were examined in terms of the etiology of cirrhosis; the most common cause was viral hepatitis with 53.4% (n: 157), followed by alcoholic hepatitis with 28.4% (n: 83). In terms of Child-Pugh grades, 45.2% (n: 132) of the patients were Child-Pugh grade C. In acid fluid analysis; there were 57 (19.3%) patients in SBP group, 45 (15.3%) patients in the culture negative neutrocytic ascites group and 192 (65.4%) patients in monomicrobial bacterascites group. Conclusion: Since the first admission address of these patients are mostly ED, especially emergency physicians should always keep this diagnosis in mind for such patients.

Management of Malignant Culture-negative Neutrocytic Ascites

Introduction: Culture-negative neutrocytic ascites (CNNA) is described as having a similar mortality rate and presentation to spontaneous bacterial peritonitis (SBP). Patients with CNNA are treated the same as patients with SBP, although malignant ascitic fluid may have a neutrocytic predominance in the absence of infection. We present a suggestion for the clinical management of malignant CNNA based on the following case. Case: This is a case of a 50-year-old woman with a history of adenocarcinoma of gastric origin with metastasis to peritoneum, who presented with abdominal distension and abdominal pain. She was hemodynamically stable and afebrile on presentation with physical exam significant for a soft, distended, diffusely tender abdomen without rebound. Labs were notable for WBC of 10 with ascitic fluid showing SAAG 15000 cells with 37% granulocytes, 50% malignant cells with negative cultures. CT abdomen with IV and PO contrast showed no evidence of perforation or abscess ruling out secondary bacterial peritonitis. Antibiotics were broadened to eliminate the possibility of an infectious peritonitis untreated with ceftriaxone alone. She was discharged on a seven-day course of broad antimicrobial coverage. Discussion: The management of malignant culture-negative neutrocytic ascites (CNNA) is not clearly outlined in the literature. In the setting of peritoneal carcinomatosis, we propose a modification to the traditional CNNA management strategy to reduce the burden of hospital days and antibiotic courses. Patients with known malignant ascites should be started on broad antimicrobial coverage for empiric treatment of SBP at the outset, with a repeat tap at 3-5 days to allow sufficient culture growth. Antibiotics should be discontinued without further investigation if the following criteria are met: unchanged clinical picture, negative cultures, unchanged or increased neutrophil count on repeat paracentesis, and secondary bacterial peritonitis has been ruled out with imaging.

Portal Hypertensive Duodenopathy in Decompensated Liver Cirrhosis: A Cause of GI Bleeding

Alcoholic cirrhosis and non-alcoholic fatty liver disease on the continuous rise in the United States, there is also a congruent rise in portal hypertension. Far more familiar complications of portal hypertension include esophageal varices, ascites and hepatorenal syndrome. Portal hypertensive duodenopathy is a rare but known consequence of portal hypertension, which serves as a potentially devastating source of gastrointestinal (GI) bleeding. A 46 year old man with a past medical history of Liver Cirrhosis (MELD 24, child pugh class B) complicated by esophageal varices presented with abdominal pain and hematochezia for the past 3 days. He reported worsening ascites and generalized malaise. Patient also reported associated chills, shortness of breath, lightheadedness, and decreased appetite. He undergoes frequent paracentesis for refractory ascites, last presentation 1 month prior. Patient endorsed diet and medication compliance. Physical exam was significant for ascites, generalized abdominal tenderness, and splenomegaly without rebound or guarding. Scant blood noted on rectal exam. Laboratory findings revealed stable hemoglobin of 12.4 g/dL, hematocrit of 36.8 %, platelet of 83 K/UL, leukocytosis of 15.4 K/UL with 78% neutrophils and 16% bands, sodium of 130 mmol/L, ammonia of 83 Umol/L, alanine aminotransferase of 40 U/L, aspartate aminotransferase of 42 U/L and alkaline phosphatase of 127 U/L. INR was 2.02. Diagnostic paracentesis revealed serosanguinous fluid, PMN count of 686 cells/mm3 consistent with culture negative neutrocytic ascites. Blood cultures obtained revealed no growth of organisms. Patient completed course of intravenous (IV) Ceftriaxone therapy. Endoscopy performed revealed erosions, mucosal edema and erythema with minimal oozing of blood in the duodenum. Colonoscopy and video capsule endoscopy revealed no active bleeding. Patient was referred for evaluation for transugular intrahepatic portosystemic shunt (TIPS) amidst significant complications of portal hypertension. Management of portal hypertensive duodenopathy with acute bleeding is same as in patients with other causes of upper GI bleed. Endoscopic thermal coagulation could be effective if bleeding lesions are identified. Clinicians should consider TIPS as a management strategy in patients with other significant complications of portal hypertension.Figure: EGD picture of duodenum with snake skin like picture of portal hypertensive duodenopathy.Figure: EGD picture of duodenum with snake skin like picture of portal hypertensive duodenopathy.Figure: EGD picture of duodenum with snake skin like picture of portal hypertensive duodenopathy.