Culture-negative Spontaneous Bacterial Peritonitis Research Articles

Profile of spontaneous bacterial peritonitis in non-alcoholic fatty liver disease cirrhosis

Background: Etiology of chronic liver disease (CLD) has an impact on the profile of spontaneous bacterial peritonitis (SBP) in terms of infection acquisition, resistance pattern, and treatment outcome. Aims and Objectives: This study aimed to study infection acquisition, antibiotic resistance pattern, and treatment outcome in patients with non-alcoholic fatty liver disease (NAFLD) cirrhosis with SBP. Materials and Methods: This observational prospective study was carried out in Government Medical College; Srinagar: over a period of 2 years from 2017 onward. We did analysis of patients with NAFLDs cirrhosis. We studied infection acquisition, antibiotic resistance pattern, and treatment outcome in this group of patients. Results: Over 2-year period, 246 patients were enrolled. The mean age of patients was 57.09±13.90 years. Hepatitis B virus and NAFLD were the major etiological contributors to the burden of CLD amounting to 51.20% in Kashmir. SBP was present in 33/57 (57.90%) of NAFLD cirrhosis patients. Child-Turcotte-Pugh Class C was 63.60%. Patients with culture-positive SBP (CP-SBP) were 45.45%. In patients of SBP with etiology other than NAFLD, CP-SBP was 61% whereas culture-negative SBP was 38.77%. Conclusion: In our region, NAFLD is one of the leading contributors to CLD. In this study, the trend toward worse treatment outcome and mortality in the patients with NAFLD SBP was observed.

Neutrophil percentage-to-albumin ratio is a new diagnostic marker for spontaneous bacterial peritonitis: a prospective multicenter study

BackgroundThe neutrophil percentage-to-albumin ratio (NPAR) is a novel measure of systemic inflammation and infection. Low albumin levels increase the risk of infection, while high neutrophil counts indicate the presence of infection. Spontaneous bacterial peritonitis (SBP) is a serious infection in cirrhotic ascites, and the potential of NPAR in diagnosing SBP is not yet established.ObjectiveThe objective of this study is to determine the diagnostic value of NPAR in identifying SBP.PatientsThis prospective multicenter study included 465 patients diagnosed with cirrhotic ascites and SBP according to international guidelines. Demographic, clinical, and laboratory data were collected. The sensitivity and specificity of NPAR values for diagnosing SBP were assessed using the receiver operating characteristic curve.ResultsFor SBP diagnosis in the total cohort, NPAR of > 17 had a sensitivity of 85.71%, specificity of 66.67%, and 95% CI (42.1–99.6). In culture-positive SBP, the NPAR at a cut-off > 5.2 had a sensitivity of 85.71%, specificity of 83.33%, and 95% CI (0.709 to 0.979), while in culture-negative SBP, the NPAR at a cut-off > 2.1 had a sensitivity of 92.86%, specificity of 33.33% and CI (0.367 to 0.764). The multivariate analysis revealed that albumin (OR = 2.78, [1.11;3.98], INR (OR = 0.198, [0.066;0.596], creatinine (OR = 0.292, [0.1; 0.81], CRP (OR = 3.18, [1.239;4.52] total leukocytic count (TLC) (OR = 1.97, [1.878; 2.07], platelets (OR = 2.09, [0.99; 2.31] and neutrophil (OR = 3.43, [1.04;3.89] were significantly associated with higher prediction rates for culture positive SBP.ConclusionsNPAR could be a new, affordable, noninvasive test for diagnosing SBP.

1999. Cefpodoxime for Spontaneous Bacterial Peritonitis Prophylaxis: Incidence of Breakthrough Infection

Abstract Background Guidelines recommend use of fluoroquinolones and sulfamethoxazole-trimethoprim (SMX-TMP) for spontaneous bacterial peritonitis (SBP) prophylaxis based on data demonstrating a decrease in one-year incidence of SBP. Our institution frequently utilizes cefpodoxime for its favorable safety profile despite the lack of robust clinical experience. We sought to compare rates of breakthrough SBP with the use of cefpodoxime compared to previously reported incidence rates with the use of SMX-TMP and fluoroquinolones. Methods This is an IRB-approved, retrospective, single-center cohort analysis. The electronic medical record at the Hospital of the University of Pennsylvania was utilized to identify cirrhotic patients newly started on cefpodoxime for SBP prophylaxis from March 1, 2016, to December 31, 2020. The primary endpoint was the incidence of breakthrough infections within 1 year in patients who received cefpodoxime for primary or secondary SBP prophylaxis. Secondary endpoints included 1-year all-cause mortality and any microbiologic data from suspected or confirmed SBP during the study timeframe. Descriptive statistics were utilized to analyze baseline characteristics and collected data points. Results Overall, 90 patients met inclusion criteria within our timeframe. The study population consisted of mostly men (65.6%) with a mean age of 59 years. The majority of patients were taking cefpodoxime for primary prophylaxis (66.7%). A large proportion of the patients also had diabetes (44.4%). Alcohol use (53.3%) was the most common cause of cirrhosis, and the mean MELD score was 20.3. Breakthrough SBP occurred in 4 (4.4%) out of 90 patients within 1 year of cefpodoxime initiation. Of the 19 patients who completed a full year of cefpodoxime, 1 (5.2%) patient experienced breakthrough SBP. Microbiologic data was significant for the growth of Citrobacter spp., Streptococcus spp., Enterococcus spp., and Candida glabrata. One patient experienced culture-negative SBP. All-cause mortality at one year in our study was 41.1%. Conclusion Cefpodoxime is a viable option for primary or secondary prophylaxis of SBP based on comparable rates of breakthrough infection. Cefpodoxime does not frequently appear to encourage colonization and infection with resistant gram-negative pathogens. Disclosures All Authors: No reported disclosures.

Spontaneous Bacterial Peritonitis in Cirrhotic Patients: A Shift in the Microbial Pattern? A Retrospective Analysis

Introduction: Over the last decade, a shift in the spontaneous bacterial peritonitis (SBP) microbial pattern toward an increasing incidence of gram-positive and multidrug-resistant (MDR) bacteria has been reported. Systematic surveillance of the local microbiological scenario and antibiotic resistance is crucial to SBP treatment success. The main objective of this study was to evaluate the microbiological profile and bacterial resistance of SBP pathogens in a Portuguese cohort to allow selection of the most appropriate empirical antibiotics. Methods: This is a single-center retrospective study including 63 adult cirrhotic patients with culture-positive SBP. Patients were identified using a hospital general diagnostic database and searching for all SBP events (neutrophil count in ascitic fluid ≥250/mm³) from January 1, 2012, to December 31, 2017. Patients were excluded if they had culture-negative SBP, secondary peritonitis, peritoneal dialysis, a liver transplant, or immunodeficiency. The site of SBP acquisition was classified as nosocomial if it was diagnosed 48 h or longer after hospitalization or as nonnosocomial if it was diagnosed within the first 48 h. MDR bacteria were those with an acquired resistance to at least 1 agent in 3 or more antimicrobial categories. All statistical analyses were carried out using IBM SPSS Statistics software version 22 (IBM, New York, USA). Results: The study cohort comprised 53 (84.1%) men. The mean age of the patients was 60.6 ± 11.2 years. Alcohol was the most common etiology (88.9%) and most patients had advanced liver cirrhosis (87.1%, Child C). Gram-negative bacteria were slightly more frequent than gram-positive bacteria (56.9 vs. 43.1%). Escherichia coli was the most common pathogen (33.8%). Nineteen (31.7%) bacteria were classified as MDR. Resistance to third-generation cephalosporins, quinolones, piperacillin-tazobactam, and carbapenems was found in 31.7, 35, 26.7, and 18.3% of the cases, respectively. The rates of gram-positive bacteria were similar between nosocomial and nonnosocomial episodes (45 vs. 42.2%; p = 0.835). MDR bacteria were more common in the nosocomial group (50 vs. 23.8%; p = 0.046). Resistance to third-generation cephalosporins (50 vs. 23.8%; p = 0.046), piperacillin-tazobactam (44.4 vs. 19.1%; p = 0.041), and carbapenems (33.3 vs. 11.9%; p = 0.049) occurred more frequently in nosocomial episodes. Resistance to first-line antibiotic occurred in 29.3% of the patients, being more common in the nosocomial group (44.4 vs. 22.5%; p = 0.089). Conclusion: Although gram-negative bacteria remain the most common causative microorganisms, our results emphasize the shift in SBP microbiological etiology, as almost half of the isolated microorganisms were gram positive. The emergence of bacteria resistant to traditionally recommended empirical antibiotics underlines the importance of basing this choice on local flora and antibiotic susceptibility data, allowing a more rational and successful use of antibiotics.

SPONTANEOUS BACTERIAL PERITONITIS;

Objectives: To determine the frequency of culture positive (SBP) and culture negative spontaneous bacterial peritonitis (neutrocytic ascites) in cirrhotic population. Period: The six months (November 08th 2012 to May 07th 2013). Study Design: Descriptive cross-sectional study. Setting: Department of Gastroenterology at Liaquat National Hospital. Total 107 patients of liver cirrhosis with ascites admitted in our hospital. All the specific patients had ascitic fluid DR and C/S were enrolled and evaluated. Patient’s information was recorded on proforma and analyzed by using SPSS-20.0. Results: SBP was detected in 10 7 patients aged between 18 and 67 years included in study. Out of 107 patients with SBP 23 (21.5%) were culture positive while 84 (78.5%) were culture negative. In the culture positive group,19 (82.6%) were male and 4 (17.4%) were female while in culture negative group 46 (54.76%) were male and 38 (45.24%) were female. The ascitic fluid mean total leukocyte count in patients with culture positive ascites was 5140.39 /mm3 and in culture negative ascites was 2654.26 / mm3. The ascitic fluid mean neutrophils count in subjects with culture positive ascites was 75.57% and in culture negative ascites was 76.02%. The ascitic fluid mean lymphocyte count in individuals had culture positive ascites was 26.09 % and in subjects had culture negative ascites was 23.97%. Conclusion: Frequency of culture negative ascites is greater than culture positive ascites in SBP. The ascitic fluid mean total leucocyte count for culture positive ascites is greater than culture negative ascites. Mortality is high in culture positive ascites.

Evidence of Significant Ceftriaxone and Quinolone Resistance in Cirrhotics with Spontaneous Bacterial Peritonitis

There are few studies addressing the impact of cephalosporin and quinolone resistance on hospital length of stay and mortality in spontaneous bacterial peritonitis (SBP). We aim to describe the shifting epidemiology of SBP at our institution and its impact on clinical outcomes. We performed a single-center retrospective cohort study of all cases of SBP from 2005 to 2015 at a transplant center. Cases were identified using hospital billing data. Patient data were confirmed using the electronic medical record. Univariate and multivariate logistic regression and Cox proportional hazards models were used to identify factors that were associated with prolonged hospital length of stay and reduced survival. Culture-positive cases (N = 56) were compared to culture-negative cases (N = 104). Subpopulation analysis of the culture-positive cases compared ceftriaxone-resistant (N = 25) to ceftriaxone-susceptible (N = 31) cases. We identified 160 cases of SBP (56 culture positive and 104 culture negative; 21 nosocomial, 79 hospital associated, and 60 community acquired). Forty-five percent (N = 25 total, 13 hospital associated and 6 nosocomial) of bacterial isolates were resistant to ceftriaxone, with 37.5% (N = 21) being gram positive, including 8 methicillin-resistant staphylococcus and 6 vancomycin-resistant enterococcus. Multivariate analysis identified hospital-associated SBP, age, alcoholic cirrhosis, and MELD-Na score as variables associated with worse survival (P < 0.05), with a trend toward worse survival in culture-positive cases (P = 0.123). Only MELD-Na was associated with prolonged length of stay. The burden of resistant pathogens causing SBP is significant, notably in hospital-associated SBP. Culture-positive SBP may represent a higher risk group compared to culture-negative SBP.

Does ascitic fluid lactoferrin has a role in the diagnosis and follow up of spontaneous bacterial peritonitis in hepatitis C virus cirrhotic patients

Background Polymorphonuclear leukocyte (PMNL) count in the ascitic fluid (AF) is the gold standard method for the diagnosis of spontaneous bacterial peritonitis (SBP). Its measurement is routinely performed by traditional manual counting which is operator dependent and false-negative results may occur due to lysis of the leukocyte during transport. Aims The aims of the study were to assess the accuracy of AF lactoferrin and the best cutoff value for the diagnosis of SBP and also to compare its level before and after treatment to be used as a marker for follow up. Patients and methods The present study included 150 Egyptian patients with hepatitis C virus-related liver cirrhosis and ascites. The cases were divided into 100 patients with SBP and 50 patients with no SBP based on an elevated AF PMNL count of greater than or equal to 250 cells/mm3, ascitic samples were examined for PMNL count, culture, chemistry, and lactoferrin concentration in non-SBP patients and in SBP patients before and after systemic antibiotic treatment. Results AF lactoferrin concentration is significantly higher in SBP patients than in non-SBP patients with a cutoff value of 75.55 ng/ml, significantly higher in culture positive than in culture-negative SBP patients and its concentration is decreased significantly in SBP patients after systemic antibiotic therapy. Conclusion Elevated AF lactoferrin levels in cirrhotic patients are reliable for the diagnosis and follow up of SBP after systemic antibiotic therapy. The level of AF lactoferrin level is higher in resistant cases of SBP than the cases that respond to systemic antibiotic treatment.

Microbiology and resistance in first episodes of spontaneous bacterial peritonitis: implications for management and prognosis.

International guidelines for antibiotic treatment of spontaneous bacterial peritonitis (SBP) are based on studies conducted decades ago and do not reflect regional differences of bacterial epidemiology. We retrospectively analyzed epidemiology of agents, antibiotic resistance patterns, and survival in liver cirrhosis patients with their first episode of SBP during the years 2007-2013. Of the 311 patients included, 114 patients had a positive ascites culture, and 197 had an ascitic neutrophil count >250 μL. Gram-positive bacteria (47.8%) were more frequently found than Gram-negatives (44.9%), fungi in 7.2%. Enterobacter spp. (40.6%), Enterococcus spp. (26.1%), and Staphylcoccus spp. (13.8%) were the most frequently isolated agents. Third-generation cephalosporins covered 70.2% of non-nosocomial and 56.3% of nosocomial-acquired SBP cases.When SBP was diagnosed by a positive ascitic culture, survival was highly significantly reduced (mean: 13.9 ± 2.9 months; 95% confidence interval [CI]: 8.1-19.8) compared with culture-negative SBP patients (mean: 44.1 ± 5.4 months; 95% CI: 33.4-54.9; P = 0.000). Along with model of end-stage liver disease score and intensive care unit contact, a positive ascites culture remained an independent risk factor associated with poor survival (odds ratio: 1.49; 95% CI: 1.09-2.03) in multivariate analysis; piperacillin/tazobactam proved to be an adequate antibiotic for nosocomial and non-nosocomial SBP in 85.1% and 92.5%, respectively. SBP infection with Enterococcus spp. was associated with poor patient survival (P = 0.048). Third-generation cephalosporins have poor microbial coverage for treatment of SBP. Current guidelines need to adapt for the emerging number of Gram-positive infectious agents in SBP patients.

G363(P) Infectious complications in biliary atresia; a single centre experience

Objectives To evaluate incidence and timing of cholangitis and spontaneous bacterial peritonitis (SBP) in Biliary Atresia (BA), after Kasai Porto-enterostomy (KP), prior to liver transplantation (LT). Methods A single-centre retrospective analysis, comprising 78 patients (36M:42F) who underwent KP between 2008–2010. Results Cholangitis followed in 38/78 (48%) patients; median number of episodes 2 (range: 1, 5). Median age for first episode was 5.6 months (2, 72.5). Six patients showed dilated biliary radicles on ultrasound. Organisms were isolated from blood cultures in six patients; E-coli (n = 2), Staphylococcus Aureus, Klebsiella, Streptococcus Pneumonia and Pseudomonas. 27/38 (71%) cholangitic patients underwent LT, 10 are alive with their native liver and one died. Ascites developed in 29/78 (37%) patients, at median age 6.5 months (3.1, 66). Ascitic taps were performed in 41% (12/29), due to respiratory distress with fever (5/12) or without fever (7/12) at median age 7.4 months (3.2, 22.8). 16/17 patients that did not have ascitic taps underwent LT at a median age 17.2 months (7.4, 79.7) and one died whilst listed for LT. Timing of tap was at the onset of ascites in six patients and at a median time of 2 months (0.1, 4.6) from onset of ascites in the remaining six patients. Four patients fulfilled criteria for SBP diagnosis; 3 culture-negative (wcc >250 mm 3 ), one bacteri-ascites (wcc 3 ; gram-positive cocci, gram-negative rods). No culture-positive SBP was identified. One culture-negative SBP revealed Streptococcus Pneumoniae in blood cultures. Five patients that underwent ascitic taps previously had cholangitis. Antibiotics were already commenced in 8/12 patients pre-tap. Raised plasma wcc (>17 mm 3 ) was identified in SBP (3/4) and non-SBP (3/8) patients. All SBP patients underwent LT at a median age 10.5 months (7.1, 16.1). Non-SBP patients underwent LT (n = 4), are alive with native liver (n = 1) or died (n = 3; all listed for LT). Conclusion Cholangitis and SBP occurred in 48% and 5% of BA patients respectively; cholangitis episodes presented earlier. Few cases revealed positive bacterial cultures. Definition of paediatric SBP needs to account for pre-culture antibiotic use. New molecular techniques should be sought to aid diagnosis. LT is a successful outcome for cholangitis, SBP and non-SBP ascites.

Susceptibility to spontaneous bacterial peritonitis ‐ are genetics the future?

Spontaneous bacterial peritonitis (SBP) is a common complication in cirrhotic patients with ascites 1. Several pathogenic mechanisms are currently discussed. Bacterial translocation – the migration of intestinal bacteria through the intestinal wall to mesenteric lymph nodes and other sites such as the ascitic fluid – is considered the most relevant 2. Factors facilitating bacterial translocation in patients with cirrhosis are complex: overgrowth of microorganisms, change of the microbiome, impaired intestinal motility, structural changes because of portal hypertension with increased permeability, alteration of the intestinal bile salt pattern, defects in local mucosal defence factors such as antimicrobial peptides as well as impairment of the innate and acquired immunity 3. To achieve a local defence against invading microorganisms, cells of the intestinal mucosa express a number of so-called pattern recognition receptors which detect microbial components and initiate several response mechanisms. Thus, nucleotide-binding oligomerization domain 2 (NOD) receptor expression has been found in intestinal epithelial cells, especially Paneth cells. Three single nucleotide polymorphisms (SNP) in the NOD2/CARD15 gene (R702W, G908R, L1007fs) have been identified. This results in a defective activation of NF-kB and secretion of antimicrobial peptides as a response to bacterial cell wall products in patients with Crohn's disease 4-6. Genetic variants in NOD2 are also considered to be risk factors for the development of graft-vs-host-disease (GvHD) after allogenic stem cell transplantation 7 and seem to be one of the predictors for impaired in-hospital-survival in patients with sepsis 8. Furthermore, a recent report showed an association between NOD2 gene variants and an increased rate of SBP together with impaired survival in a cohort of patients with cirrhosis 10. In this issue of Liver International, Bruns and co-workers suggest that NOD2 gene variants facilitate the development of SBP in cirrhotic patients with ascites 9. They investigated 175 prospectively characterized, consecutive patients with cirrhosis and ascites who underwent diagnostic paracentesis in two German centres. The three most common NOD2/CARD15 variants (see above) were determined by TaqMan PCR. In 9/32 (28%) patients with NOD2 variants SBP was diagnosed as compared to 20/143 (14%) of patients with wild type. The association with SBP was most pronounced when bacteria were detectable in the ascitic fluid. Yet, contrary to the above-mentioned previous study 10, there was no association of NOD2 variants with culture-negative SBP (OR 1.6, P = 0.493). Multivariate analysis identified a previous SBP episode, a higher MELD score and presence of NOD2 risk variants as independent risk factors for SBP. After adjusting for MELD score and age, presence of NOD2 risk variants was an independent predictor of death in patients without hepatocellular carcinoma (HR 1.89, P = 0.045). However, association with shorter survival was overall only marginal, contrary to data from the previous work 10. An interesting new aspect of the present study was the finding that patients with NOD2 variants had more often a history of recent variceal bleeding (P = 0.052). This supports the hypothesis that infections trigger bleeding from portal hypertension and may be prevented by antibiotics. These findings together with the recently published ones are the first to report a strong impact of a NOD2 variant on SBP suggesting a major role of NOD2 coding variants as a new genetic factor determining the outcome of SBP in cirrhotic patients. This also indicates a major role for impaired barrier function and bacterial translocation in the pathomechanism of SBP. In future, prospective studies in large series of patients should be carried out and additional genetic polymorphisms should be evaluated. What conclusions can be drawn from this study together with an earlier similar evaluation 10?

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

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

Bacterial DNA in the diagnosis of spontaneous bacterial peritonitis

Despite inoculation into blood culture bottles, ascitic fluid culture is negative in 50% of cases of spontaneous bacterial peritonitis (SBP). To determine whether 16S rDNA gene detection by real-time polymerase chain reaction (PCR) and sequencing increases the efficacy of culture in microbiological diagnosis of spontaneous bacterial peritonitis. We prospectively included 55 consecutive spontaneous bacterial peritonitis episodes in cirrhotic patients, 20 cirrhotic patients with sterile ascites and 27 patients with neoplasic ascites. Ascitic fluid was inoculated into blood culture bottles at the bedside and tested for bacterial DNA by real-time PCR and sequencing of 16S rDNA gene. Bacterial DNA was detected in 23/25 (92%) culture-positive SBP, 16/30 (53%) culture-negative SBP (P = 0.002 with respect to culture-positive SBP), 12/20 (60%) sterile ascites (P = 0.01 with respect to culture-positive SBP) and 0/27 neoplasic ascites (P < 0.001 with respect to other groups). Sequencing identified to genus or species level 12 culture-positive SBP, six culture-negative SBP and six sterile ascites. In the remaining cases with positive PCR, sequencing did not yield a definitive bacterial identification. Bacterial DNA was not detected in almost half the culture-negative spontaneous bacterial peritonitis episodes. Methodology used in the present study did not always allow identification of amplified bacterial DNA.

OC-037 Epidemiology and resistance patterns of culture-positive spontaneous bacterial peritonitis in Leeds 2006–2008

Introduction Spontaneous bacterial peritonitis (SBP) is a life threatening infection of ascitic fluid which occurs primarily in patients with pre-existing ascites in the setting of cirrhosis. Risk factors for developing SBP include: prior episode of SBP, gastrointestinal bleeding, ascitic total protein Escherichia coli (70%), Klebsiella species (10%), Proteus species (4%), Enterococcus faecalis (4%) and Pseudomonas species (2%).1 The choice of antimicrobial therapy must take into consideration the increasing frequency of hospital acquired infections, such as Clostridium difficile infection. Aim To identify the local epidemiology and resistance patterns of culture-positive SBP. Methods We retrospectively assessed the culture results of all ascitic fluid samples that grew a single organism in Leeds during the 3 years 2006–2008. Patients case notes were assessed to establish a diagnosis of SBP. An ascitic fluid neutrophil count ≥ 250/mm 3 in patients with liver disease was used to confirm the diagnosis of SBP.12 We excluded culture-negative SBP. Results Single organism positive ascitic cultures were identifed in 42 patients with liver disease and an ascitic fluid neutrophil count ≥250/mm 3 . Mean age 52.1 years, 32/42 male. Underlying liver disease was ALD 35/42, HCV 3/42, PBC 1/42, NAFLD 1/42, Cryptogenic 1/42 and Post transplant 1/42. At the time of diagnosis of SBP the mean ascitic total white cell count 5.25, mean ascitic neutrophil count 4.08, mean serum Na+ 129.6 mmol/l and mean serum creatinine 147 mmol/l. Overall Child score A 0, B 8/42, C 34/42 and mean MELD score 24.1. The isolated organisms were Escherichia coli 15, Klebsiella spp. 7, other coliforms 10, Gram positive organisms 8 (including Enterococcus 2, Corynebacterium spp. 2). The Gram-negative isolates were resistant to a number of antibiotics: ciprofloxacin 38% (13/34), cefuroxime 29% (10/34), amoxycillin 32% (11/34) and tazocin 17% (6/34). The 30-day mortality was 50%. Conclusion Empirical treatment regimes need to take into account local resistance patterns. Ciprofloxacin has been widely used for treatment and prophylaxis in SBP. Resistance has now become a significant problem.

Diagnosis, treatment and prevention of spontaneous bacterial peritonitis

Spontaneous bacterial peritonitis (SBP) is a frequent complication in cirrhotic patients with ascites. Diagnosis of SBP is established by a polymorphonuclear cell count in ascitic fluid ⩾250cells/mm3. The organism responsible for the infection is isolated in 60–70% of the cases. The remaining cases are considered to have a variant of SBP (culture-negative SBP) and are treated in the same way as those with a positive culture. The SBP resolution rate ranges between 70 and 90%, and hospital survival between 50 and 70%. An early diagnosis and the use of a more adequate antibiotic therapy are the most probable reasons for the improvement in prognosis for SBP in recent decades. Despite the resolution of the infection, SBP may trigger severe complications such as renal impairment, gastrointestinal bleeding and accentuation of hepatic insufficiency which are responsible for the associated mortality. Patients recovering from an episode of SBP should be considered as potential candidates for liver transplantation.

Bacterial infections in liver disease.

Most bacterial infections in cirrhotic patients are hospital-acquired. Urinary tract infections, spontaneous bacterial peritonitis (SBP), respiratory tract infections, and bacteremia are the most frequent bacterial infectious complications seen in cirrhotic patients. SBP is the most characteristic infectious complication of cirrhotic patients, and it is defined as the infection of a previously sterile ascitic fluid, with no apparent intra-abdominal source of infection. The incidence of SBP in cirrhotic patients admitted to hospital with ascites has been estimated to range between 7 and 23%. The diagnosis is established on the basis of clinical signs and symptoms and/or a polymorphonuclear cell count in ascitic fluid higher than 250/mm3. This diagnosis is confirmed by a positive culture in approximately 70% of the cases. The remaining 30% are considered culture-negative SBP but are empirically treated with antibiotics because severe peritonitis and death may follow if these patients are not treated. Early diagnosis, the routine use of diagnostic paracentesis in patients admitted to hospital with ascites, and, especially, the use of adequate antibiotics are very important tools in the treatment of SBP. Third-generation cephalosporins are the first-choice antibiotic treatment in SBP, although selected patients with SBP, those with normal renal function and without hepatic encephalopathy, shock, or gastrointestinal bleeding, may be treated with oral quinolones. Selective intestinal decontamination with norfloxacin is safe and useful in the primary and secondary prophylaxis of SBP, although the incidence of quinolone-resistant organisms is increasing and this may be a problem in the future.

Spontaneous bacterial peritonitis: Analysis of treatment and outcome.

Spontaneous bacterial peritonitis occurred on 44 separate occasions in 43 patients during a five year period, including 27 culture positive and 17 probable cases of spontaneous bacterial peritonitis. Alcoholic liver disease was the underlying cause of 72% of cases. Of the 27 culture positive cases, Escherichia coli was the most common isolate (14 cases), followed by Klebsiella pneumoniae (three cases), group G streptococci (three cases), group B streptococci (two cases) and one case each of five other organisms. Bacteremia occurred in 50% of cases and was the same as the peritoneal isolate 88% of the time. The overall mortality rate was 65% (66% culture positive and 60% probable spontaneous bacterial peritonitis). The mean interval between onset of symptoms and death was 10.2±8.6 days in fatal cases. Spontaneous bacterial peritonitis was felt to be a contributing cause of mortality in 70% of fatal cases. Survivors were younger (44±20 years versus 59±13, P<0.05) and less likely to develop renal insufficiency than nonsurvivors (38% versus 73%, P<0.05). Patients who were treated with an aminoglycoside were more likely to develop renal failure compared to those treated with nonaminoglycoside regimens (P<0.05). There was no difference in mortality rate between culture positive and culture negative spontaneous bacterial peritonitis, total peritoneal leukocyte counts, Gram-positive versus Gram-negative organisms, presence of bacteremia, or serum albumin or bilirubin levels. The mortality rate for this disease remains unacceptably high, indicating a need for the development of new strategies in the prevention, diagnosis and management of this disease.

Spontaneous bacterial empyema in cirrhotic patients: Analysis of eleven cases

Eleven episodes of spontaneous bacterial empyema were identified in eight cirrhotic patients with ascites. Criteria for spontaneous bacterial empyema included positive pleural fluid culture or polymorphonuclear cell concentration greater than 500 cells/mm3, evidence of pleural effusion before an infectious episode and transudate characteristics during infection. In five cases, spontaneous bacterial empyema was culture-negative and was associated with spontaneous bacterial peritonitis. Ascitic fluid was culture-negative in two of these cases and culture-positive in three. Blood cultures were negative in all five of these cases. In six cases spontaneous bacterial empyema was culture-positive (Escherichia coli in four, Klebsiella pneumoniae in one and Clostridium perfringens in one). Four of these patients had the same organism in ascites; one had culture-negative spontaneous bacterial peritonitis and one had no infection of ascites. Blood cultures were positive in four of these patients; three died. Death was more frequent in patients with positive cultures than in those with negative ones (p less than 0.05). Patients with hydrothorax are prone to spontaneous bacterial empyema. This infection probably occurs through hematogenous seeding, but transfer of infected ascites from the abdominal cavity through the diaphragm cannot be excluded. Patients with spontaneous bacterial empyema may be asymptomatic or may be seen with fever, chills and dyspnea. Spontaneous bacterial empyema must be differentiated from parapneumonic empyemas. The presence of pleural effusion before the infectious episode, fluid characteristics and the organisms isolated are the clues for differential diagnosis. Treatment includes antibiotics; chest tube insertion probably is not necessary.