History Of Spontaneous Bacterial Peritonitis Research Articles

Case study: autoimmune hepatitis with cirrhosis and pancytopenia since 7 weeks’ gestation

Abstract Objectives Autoimmune hepatitis (AIH) is a chronic inflammatory disease of unknown etiology and AIH in pregnancy is associated with many adverse maternal and fetal outcomes. The purpose of this report is to share insight into management of AIH-induced pancytopenia unresponsive to steroids and transfusions. Case presentation A 29-year-old G4P0121 female with history of spontaneous bacterial peritonitis (SBP) and severe pancytopenia secondary to AIH was found to be incidentally pregnant at 7 weeks gestation. Despite multiple blood transfusions and steroids, her pancytopenia was unresponsive to therapy. At 33 weeks, she underwent primary cesarean section for persistent category II fetal heart tracing and delivered a viable infant. Delivery was complicated by hemorrhage requiring multiple blood products. Postpartum course was complicated by sepsis secondary to urinary tract infection, and decompensated cirrhosis with hepatic encephalopathy and coagulopathy. Both fetus and mother have recovered well 3 months post-delivery. Conclusions This case highlights the challenges in management of AIH in pregnancy, particularly the difficulty in treating severe unresponsive pancytopenia as well as balancing the need for immunosuppression with the increased risk of infection that may lead to sequelae such as SBP and puerperal sepsis.

Impact of Prophylactic Norfloxacin in Multidrug Resistant Bacterial Infections in the Early Liver Posttransplant Period

Norfloxacin is indicated as primary or secondary prophylaxis for spontaneous bacterial peritonitis in patients with cirrhosis. A history of spontaneous bacterial peritonitis favors colonization by multidrug-resistant bacteria. Infections caused by these bacteria increase morbidity and mortality after transplant. We investigated prophylactic norfloxacin as a risk factor for multidrug-resistant bacterial infections in the early posttransplant period. This prospective cohort study included all adult liver recipients in 2 centers between 2015 and 2016. Recipients were classified into 2 groups according to whether or not they received prophylactic norfloxacin pretransplant. Data collection from liver recipients included pretransplant and first month after transplant clinical and microbiological data. Demographic and clinical data of corresponding donors were also collected. We included 157 liver recipients: 54 (34.6%) received norfloxacin and 103 (65.6%) did not received norfloxacin. There were 63 postoperative infections in 47 recipients (29.9%); 17/63 (27%) were multidrug- resistant bacterial infections. The urinary tract was the most commonly affected site (10/17 episodes, 58.8%), and Klebsiella pneumoniae was the microorganism most often isolated (8/17, 47.1%). Incidence of multidrug-resistant bacterial infection was higher in the norfloxacin group (22.2% vs 4.9%; relative risk = 5.6, 95% CI, 1.85-16.89; P = .001).This association was significant after controlling for most confounding factors, including pretransplant vasoactive support (P = .03), Model for End-Stage Liver Disease score (P = .01), previous spontaneous bacterial peritonitis (P = .02), chronic renal impairment (P = .005), number of packed red blood cells (P = .004), use of antilymphocyte globulin as induction (P = .006), and hepatocellular carcinoma (P = .02), but not pre- transplant antibiotic treatment (P = .06). For recipients who have received prophylactic norfloxacin, clinicians should be aware of the high risk of multidrug-resistant bacterial infections during the first month after liver transplant.

Evaluation of the current guidelines for antibacterial therapy strategies in patients with cirrhosis or liver failure

BackgroundBacterial infections are common complications in patients with cirrhosis or liver failure and are correlated with high mortality. Clinical practice guideline (CPG) is a reference used to help clinicians make decisions. This systematic appraisal aimed to evaluate the methodological quality and summarize the recommendations of reported CPGs in these patients.MethodsWe systematically searched CPGs published from 2008 to 2019. The methodological quality of the included CPGs was assessed using the AGREE II instrument. We extracted and compared recommendations for prophylactic and empirical treatment strategies.ResultsFourteen CPGs with a median overall score of 56.3% were included. The highest domain score was Clarity of Presentation (domain 4, 85.4%), and the lowest was for Stakeholder Involvement (domain 2, 31.3%). Three CPGs had an overall score above 80%, and 6 CPGs had a score above 90% in domain 4. Prophylaxis should be strictly limited to patients with varicose bleeding, low ascites protein levels and a history of spontaneous bacterial peritonitis. Fluoroquinolones (norfloxacin and ciprofloxacin), third-generation cephalosporins (G3) (ceftriaxone and cefotaxime) and trimethoprim–sulfamethoxazole (SXT) are recommended for preventing infections in patients with cirrhosis or liver failure. G3, β-lactam/β-lactamase inhibitor combinations (BLBLIs) and carbapenems are recommended as the first choice in empirical treatment according to local epidemiology of bacterial resistance.ConclusionsThe methodological quality of CPGs focused on patients with cirrhosis or liver failure evaluated by the AGREE II instrument is generally poor. Three CPGs that were considered applicable without modification and 6 CPGs that scored above 90% in domain 4 should also be paid more attention to by healthcare practitioners. Regarding recommendations, norfloxacin, ciprofloxacin, ceftriaxone, cefotaxime, and SXT are recommended for prophylactic treatment appropriately. G3, BLBLIs, and carbapenems are recommended for use in empirical treatment strategies.

An encapsulated bulky abdominal abscess due to amoeba

We report a rare case of amebiasis associated with an intraabdominal abscess without colitis, an intestinal perforation, or other extraintestinal amebiasis. A patient was admitted with cirrhosis and a history of spontaneous bacterial peritonitis (SBP) and was found to have a high C-reactive protein (CRP) level. Dynamic CT and ultrasound echo findings showed an intraabdominal abscess. No intestinal lesions or extraintestinal lesions other than the intraabdominal abscess were observed. Blood cultures and puncture fluid cultures were negative for bacteria. However, microscopic examination of the puncture fluid showed a cystic form of amoeba, leading to a diagnosis of an amoeba abscess. The abscess disappeared after 10days of oral treatment with metronidazole. When an abdominal abscess is seen in an immunocompromised patient such as a cirrhotic patient, amoeba infection should be considered as a possible diagnosis.

Antibiotic prophylaxis to prevent spontaneous bacterial peritonitis in people with liver cirrhosis: a network meta-analysis.

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To compare the benefits and harms of different prophylactic antibiotic treatments for prevention of spontaneous bacterial peritonitis in people with liver cirrhosis.

Morbidity and mortality after transjugular intrahepatic portosystemic shunt placement in patients with cirrhosis.

Transjugular intrahepatic portosystemic shunt (TIPS) is adopted to treat refractory complications of portal hypertension, such as variceal bleeding and ascites. This study aimed to assess predictors of hepatic encephalopathy (HE) development and cumulative transplant-free survival after TIPS placement in patients with cirrhosis complicated by refractory ascites and major gastroesophageal bleeding. Sixty-three cirrhotic patients who underwent TIPS positioning as a secondary prophylaxis of major upper gastroesophageal bleeding (N=30) or to control refractory ascites (N=33) were enrolled. After a median follow-up of 26 months following TIPS insertion, only 1/30 (3.3%) patients developed reoccurrence of bleeding. Complete control of refractory ascites was recorded in 19/23 (82.6%) patients. Within the first month after TIPS placement, 34/63 (53.9%) patients developed clinically significant HE, which was associated with the baseline presence of type 2 hepatorenal syndrome (P=0.022). At the end of 90 months of follow-up, 35 (55.6%) patients were alive, 12 (19.0%) patients underwent liver transplantation, and 16 (25.4%) patients died. Independent predictors of transplant-free survival were a model for end-stage liver disease score up to 15 (P<0.001), the absence of a history of spontaneous bacterial peritonitis (P=0.010) pre-TIPS, and no HE within 1 month post-TIPS (P=0.040). TIPS insertion can be considered a safe and effective treatment in patients with cirrhosis and severe complications of portal hypertension that are not manageable with standard treatments. Interestingly, if confirmed in future studies, the history of spontaneous bacterial peritonitis pre-TIPS could be added to the model for end-stage liver disease score as a strong baseline predictor of post-TIPS mortality.

Predicting packed red blood cell transfusion in living donor liver transplantation: A retrospective analysis.

Background and Aims:Blood transfusion is unpredictable in liver transplantation and is associated with increased patient morbidity, mortality and cost. This retrospective analysis was conducted to detect factors which could predict intraoperative transfusion of more than four units of packed red blood cells (PRBCs) during elective living donor liver transplantation (LDLT).Methods:This was a single-centre retrospective study. Demographic, clinical and intraoperative data of 258 adult patients who underwent LDLT from March 2009 to January 2015 were analysed. Univariate and multivariate regression model was used to identify factors responsible for transfusion of more than four PRBCs (defined as massive transfusion [MT]).Results:On univariate regression analysis, preoperative factors like aetiology of liver disease, hypertension, history of spontaneous bacterial peritonitis, low haemoglobin and fibrinogen, high serum bilirubin, high blood urea and creatinine, high model for end-stage liver disease score, portal venous thrombosis, increased duration of surgery and anhepatic phase as well as increased use of other blood products were found to be significantly associated with MT. Multivariate logistic regression analysis revealed that the only independent factor associated with MT was the number of units of fresh frozen plasma transfused (odds ratio = 1.54 [95% CI (1.12–2.12)]).Conclusion:Many factors are responsible for the need for transfusion during LDLT. Preoperative factors alone do not accurately and consistently predict the need for MT as in our study. It is important to be prepared for need for MT during each transplant.

Role of Rifaximin in Spontaneous Bacterial Peritonitis Prevention.

Cirrhosis affects millions of people around the world and is associated with increased morbidity and mortality. Spontaneous bacterial peritonitis (SBP) is a common complication of liver disease with cirrhosis and accounts for up to 30% of infections in patients with cirrhosis. Patients with a history of SBP and those deemed to be at high risk often are prescribed antibiotics to reduce the incidence of SBP. Fluoroquinolones and sulfamethoxazole-trimethoprim are commonly used antibiotics for long-term prevention for these specified populations; however, these antibiotics are associated with several adverse effects and interactions that may be harmful to patients. In addition, resistance development may decrease the efficacy of SBP treatment and prophylaxis. Given these limitations, rifaximin, a nonabsorbable, broad-spectrum antibiotic that is used for hepatic encephalopathy, may serve as a prophylactic alternative to conventional therapy. This review discusses guideline-recommended therapy and the evidence for using rifaximin for SBP prophylaxis.

Rifaximin for the prevention of spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis: a systematic review and meta-analysis.

Prophylactic antibiotics have been recommended in patients with a previous history of spontaneous bacterial peritonitis (SBP). Recently, there has been interest in the use of rifaximin for the prevention of SBP and hepatorenal syndrome (HRS). We conducted a meta-analysis to evaluate this association of rifaximin. We searched several databases from inception through 24 January 2017, to identify comparative studies evaluating the effect of rifaximin on the occurrence of SBP and HRS. We performed predetermined subgroup analyses based on the type of control group, design of the study, and type of prophylaxis. Pooled odds ratios (ORs) were calculated using a random effects model. We included 13 studies with 1703 patients in the meta-analysis of SBP prevention. Pooled OR [95% confidence interval (CI)] was 0.40 (95% CI: 0.22-0.73) (I=58%). On sensitivity analysis, adjusted OR was 0.29 (95% CI: 0.20-0.44) (I=0%). The results of the subgroup analysis based on type of control was as follows: in the quinolone group, pooled OR was 0.42 (95% CI: 0.14-1.25) (I=55%), and in the no antibiotic group, pooled OR was 0.40 (95% CI: 0.18-0.86) (I=64%). However, with sensitivity analysis, benefit of rifaximin was demonstrable; pooled ORs were 0.32 (95% CI: 0.17-0.63) (I=0%) and 0.28 (95% CI: 0.17-0.45) (I=0%) for the comparison with quinolones and no antibiotics, respectively. Pooled OR based on randomized controlled trials was 0.41 (95% CI: 0.22-0.75) (I=13%). For the prevention of HRS, the pooled OR was 0.25 (95% CI: 0.13-0.50) (I=0%). Rifaximin has a protective effect against the development of SBP in cirrhosis. However, the quality of the evidence as per the GRADE framework was very low. Rifaximin appeared effective for the prevention of HRS.

Arginine methylation regulates c-Myc–dependent transcription by altering promoter recruitment of the acetyltransferase p300

Protein arginine methyltransferase 1 (PRMT1) is an essential enzyme controlling about 85% of the total cellular arginine methylation in proteins. We have shown previously that PRMT1 is an important regulator of innate immune responses and that it is required for M2 macrophage differentiation. c-Myc is a transcription factor that is critical in regulating cell proliferation and also regulates the M2 transcriptional program in macrophages. Here, we sought to determine whether c-Myc in myeloid cells is regulated by PRMT1-dependent arginine methylation. We found that PRMT1 activity was necessary for c-Myc binding to the acetyltransferase p300. PRMT1 inhibition decreased p300 recruitment to c-Myc target promoters and increased histone deacetylase 1 (HDAC1) recruitment, thereby decreasing transcription at these sites. Moreover, PRMT1 inhibition blocked c-Myc-mediated induction of several of its target genes, including peroxisome proliferator-activated receptor γ (PPARG) and mannose receptor C-type 1 (MRC1), suggesting that PRMT1 is necessary for c-Myc function in M2 macrophage differentiation. Of note, in primary human blood monocytes, p300-c-Myc binding was strongly correlated with PRMT1 expression, and in liver sections, PRMT1, c-Myc, and M2 macrophage levels were strongly correlated with each other. Both PRMT1 levels and M2 macrophage numbers were significantly lower in livers from individuals with a history of spontaneous bacterial peritonitis, known to have defective cellular immunity. In conclusion, our findings demonstrate that PRMT1 is an important regulator of c-Myc function in myeloid cells. PRMT1 loss in individuals with cirrhosis may contribute to their immune defects.

Relative Adrenal Insufficiency is Associated with the Clinical Outcome in Patients with Stable Decompensated Cirrhosis

BackgroundThe clinical impact of relative adrenal insufficiency (AI) on patients with stable decompensated cirrhosis (DeCi) has not been yet elucidated. AimExplore the association between AI and outcome [death or liver transplantation (LT)] in patients with DeCi. Material and methodsPatients with DeCi presenting no active complication have been included. Clinical and laboratory data, including serum levels of corticosteroid-binding globulin (CBG), interleukin (IL)-1b, IL-6 and tumor necrosis factor (TNFa) were recorded in each participant. Salivary cortisol (SC) and serum total cortisol (STC) were assessed at (T0) and 1 h (T60) after intravenous injection of 250 |ig corticotropin. Results113 consecutive patients were totally tested. Median SC was 3.9 ng/mL and 15.5 ng/mL and median STC was 10.7 ng/dL and 22.7 ng/dL at T0 and T60 respectively. The patients with AI [group 1, n = 34 (30%)] had significantly lower systolic blood pressure (106 ± 12 vs. 113 ± 13 mmHg, p = 0.05), serum sodium (133 ± 7 vs. 137 ± 12 mEq/ L, p = 0.04), HDL (29.9 ± 14 vs. 38.6 ± 18 mg/dL, p = 0.034) and albumin (2.7 ± 0.5 vs. 3.1 ± 0.5 g/dL, p = 0.002), but higher direct bilirubin (median: 1.6 vs. 0.8 mg/dL, p = 0.029) compared to those without AI [group 2, n = 79 (70%)]. Moreover, group 1 patients presented more frequently past history of spontaneous bacterial peritonitis (SBP) [10/34 (29.4%) vs. 6/79 (7.5%), p = 0.002]. AI was significantly associated with death [HR = 2.65, 95% C.I.: 1.55 - 4.52, p = 0.003 over a follow up period of 12 (6-48) months.] ConclusionsThe presence of AI in patients with stable DeCi predispose to obvious clinical implications since it is associated with circulatory dysfunction, previous history of SBP and worse survival.

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

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

Brain Natriuretic Peptide in Liver Cirrhosis and Fatty Liver: Correlation with Cardiac Performance.

ObjectiveThe aims of the present study were to assess the serum BNP level in patients with post hepatitis C liver cirrhosis and patients with fatty liver and to determine the correlation between BNP and the severity of liver disease and cardiac performance.MethodsThe study was conducted on 140 subjects subdivided into 3 groups: group 1 included 60 patients having post hepatitis C virus (HCV) liver cirrhosis; group 2 included 60 patients with nonalcoholic fatty liver disease (NAFLD); and group 3 included 20 healthy volunteers serving as a control group. All patients and volunteers were subjected to full physical examinations, laboratory evaluation of hemoglobin percent, liver and renal function tests, serum electrolytes, cholesterol, triglyceride, HBs antigen, HCV antibody and serum BNP levels, ECG, abdominal ultrasonography, and echocardiography.ResultsThere was a significant increase in the BNP level in cirrhotic patients compared to the other two groups (p = 0.000), and it was correlated with the severity of liver disease assigned as Child’s classification (p = 0.000). Also, there was a significant increase in the BNP level in cirrhotic patients with decompensation components compared to those without decompensation components (p = 0.000), history of hepatic encephalopathy (p = 0.000), history of variceal bleeding (p = 0.000), history of spontaneous bacterial peritonitis (p = 0.000), presence of ascites (p = 0.000) and portal vein diameter > 11 mm in abdominal ultrasound (p = 0.000), and prolonged QTc interval in ECG (p = 0.011). There was a significant increase in serum BNP in patients with cirrhosis with the following echocardiographic findings: IVST > 11 mm, PWT > 11 mm, LA diameter > 40 mm, EF% < 54%, and E/A ratio < 1 compared to those without these echocardiographic findings (p = 0.000).ConclusionBNP level increases in post hepatitis C cirrhotic patients and tends to decrease in fatty liver disease patients, and it is correlated with both the severity of liver disease and the morpho-functional cardiac changes. Given the ever-increasing prevalence of liver cirrhosis and fatty liver disease worldwide, it is important to understand the benefits and limitations of BNP as a heart failure biomarker in hepatic patients, where the relationship between BNP level and myocardial function is complex and is altered by the liver disease.

Spontaneous Bacterial Peritonitis as a Prognostic Marker for Short-Term Post-Liver Transplant Outcome

Background and Aim: Spontaneous Bacterial Peritonitis (SBP) is the most common infection among cirrhotics and is associated with a poor long-term prognosis, making it an indication for liver transplantation (LT). Previous studies showed that despite high Child–Pugh status and model for end-stage liver disease (MELD) score at the time of LT, survival times of patients with SBP before LT are similar to those without SBP. However, prior episodes of SBP may affect post-LT outcome owing to persistent bacteriacites and poor nutritional status. We aimed to determine the short-term outcome of patients who received LT, with and without a history of SBP. Material and methods: This was a retrospective study on patients who underwent live donor liver transplantation in a single center between June 2004 and February 2015. After excluding all patients with renal dysfunction, patients with SBP were compared with other patients who underwent LT. The primary end points were mortality, post-operative hospital stay, and ICU stay. Statistical analysis was performed using SPSS version 16.0. Results: 124 patients were included in the study. The mean MELD was 22.06 and 99.2% were Child–Pugh stage C. 51 patients (41.9%) had at least one episode of SBP prior to LT. The mean hospital and ICU stay post-liver transplantation were found to be similar in both groups. Of the 21 patients who died, 71.4% (n = 15) had SBP as opposed to 28.6% (n = 6) in the patients who survived (P ≤ 0.001). SBP prior to liver transplantation was an indicator of post-operative mortality with a sensitivity of 77.4% and a specificity of 64.1% (Odds ratio of 4.4). Conclusions: The presence of any episode of SBP prior to Liver Transplantation portends a worse short-term post-LT outcome irrespective of MELD score, Child–Pugh status, Type 2 Diabetes Mellitus, and cardiopulmonary comorbidities.

B-type natriuretic peptide and cirrhosis progression.

Brain natriuretic peptide (BNP) is used as a marker of cardiac dysfunction to predict heart failure mortality. The significance of the prognostic ability of BNP for liver cirrhosis remains unknown, although the levels of BNP seen in cirrhosis are high. We aimed to determine whether the BNP level is related to the stage of cirrhosis and could serve as a prognostic marker of cirrhosis (predict the 1-year all-cause mortality). We recruited 92 patients at different stages of cirrhosis and 81 controls matched by age and gender for this study. At admission, cardiac physical examination and BNP measurements were performed. Upon discharge, the 89 patients were followed up for 12 months. The median BNP levels of patients with cirrhosis were 167.0 pg/mL, which were significantly higher than those of the control group (167.0 vs 34.8 pg/mL, P = 0.001). Serum BNP levels were positively correlated with the Child score, the grade of esophageal varices, a history of spontaneous bacterial peritonitis, and the presence of ascites and collateral circulation. BNP levels above the median were associated with an increased occurrence of death within 12 months of discharge (log rank P = 0.025), as determined by univariate and multivariate Cox regression analyses. Esophageal varices, large/medium volume ascites, and BNP levels were related to the clinical outcome (P = 0.034, 0.030, and 0.025, respectively). Together, these results suggested that serum BNP levels are significantly correlated with the stage of cirrhosis, suggesting that BNP levels might serve as a significant predictor for 1-year all-cause mortality.

Authors' Response

To the Editor: We thank Dr Sood for his insightful comments and the opportunity to clarify a number of points from our study. We acknowledge that the patients with bacterascites should have been analyzed as a third group, separate from the spontaneous bacterial peritonitis (SBP) or noninfected ascites (NIA) groups, based on the most recent guideline from the European Association for the Study of the Liver published in 2010 (1); however, it is important to note that in our study only 3 paracentesis procedures out of 115 included in the NIA group meet criteria for bacterascites. The C-reactive protein (CRP) values found in those 3 cases were, respectively, 22.6, 6.6, and 8.3 mg/L. To verify whether the inclusion of 3 bacterascites cases in the NIA group had an impact on the CRP cutoff level, we then repeated the statistical analysis, excluding the bacterascites cases. This decision was made because we had a small number of cases in the bacterascites group. In the new receiver operating characteristic curve, the same CRP diagnostic cutoff level of >55.3 mg/dL gives a sensitivity of 78.3% and specificity of 76.8%. Previously the sensitivity and specificity were, respectively, 78.3% and 78%. This finding suggests that the inclusion of the 3 bacterascites cases in the NIA group is unlikely to be the reason for the high CRP cutoff level of >55.3 mg/L found in our study (2). Regarding the high leukocyte level and its relation to SBP found in our study, 2 previous studies (3,4) with a smaller number of patients, also without age-matched groups, did not find any statistically significant difference in the leukocyte level between the 2 groups. Definitely more studies are needed to elucidate this question, and age matching the groups is a very good point that you have raised. We agree that it would have been interesting to know the CRP levels on follow-up, a history of SBP, and use of prophylactic antibiotics, but because our study was retrospective and we did not consistently have these data available in the medical charts, obtaining this information was not possible. Our group is working on a prospective study that hopefully will be able to provide answers to some of these questions and also look at the effects of antipneumococcal vaccination in this group of children.

Risk factors associated with preoperative fecal carriage of extended‐spectrum β‐lactamase‐producing Enterobacteriaceae in liver transplant recipients

The aim of the study was to identify risk factors associated with pre-transplant fecal carriage of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae in liver transplant recipients. Over a 3-year period (January 2009-December 2011), 317 patients who underwent liver transplantation were screened preoperatively for fecal carriage of ESBL-producing Enterobacteriaceae. Risk factors for fecal carriage were investigated by univariate analysis and stepwise logistic regression. Of the 317 patients screened, 50 (15.7%) harbored an ESBL-producing isolate. Previous infection with an ESBL-producing organism had developed during the last 6 months in 20% of fecal carriers versus in none of the non-carriers. Other variables associated with fecal carriage were a model for end-stage liver disease score ≥25, pre-transplant stay in the intensive care unit ≥48 h, hospital stay ≥10 days in the last 6 months, a history of spontaneous bacterial peritonitis (SBP), exposure to a β-lactam agent in the last month, and prophylaxis with norfloxacin. Independent predictors of fecal carriage in the multivariate logistic regression model were exposure to a β-lactam agent in the month preceding transplantation (odds ratio [OR] = 7.8, confidence interval [CI] = 4-15.5, P < 0.001), and a history of SBP (OR = 2.4, CI = 1.1-4.9, P = 0.02). Previous infection with an ESBL-producing isolate, recent exposure to a β-lactam agent, and a history of SBP are risk factors for preoperative fecal carriage of ESBL-producing Enterobacteriaceae in liver transplant recipients. Patients at risk of fecal carriage should receive intraoperative prophylaxis and, when necessary, empiric postoperative antimicrobial treatment that includes coverage for these organisms.

Pleural Fluid Analysis and Clinical Characteristics of Spontaneous Bacterial Pleuritis in Patients with Liver Cirrhosis

Purpose: There are limited published data defining complete pleural fluid analysis in patients with liver cirrhosis and spontaneous bacterial pleuritis. Herein, we sought to examine the laboratory factors associated with this disease, as well as the clinical characteristics of patients who presented with it. Methods: We reviewed the pleural fluid analyses of all patients with liver cirrhosis and hepatic hydrothorax referred for thoracentesis at a single tertiary care center between 2011 and 2013. Spontaneous bacterial pleuritis was defined as pleural fluid absolute neutrocytic cell count (ANC) > 500 cell/mm3 or a positive pleural fluid culture with ANC > 250 cell/mm3 in the absence of a surgically-treatable intrathoracic source of infection. Results: The pleural fluid characteristics in eight patients with spontaneous bacterial pleuritis are listed in the table below. All patients with pleuritis (100%) had exudative pleural effusions by Light's criteria, compared with only two out of 11 (18%) of those without this condition (p<0.001). This yielded a sensitivity of 100% and specificity of 82% as a screening modality. Pleural fluid cultures were positive in only two cases. Only one patient had a prior history of spontaneous bacterial peritonitis (SBP), and none had concurrent SBP. Five patients were on a prophylactic antibiotic prior to presentation. Five patients underwent liver transplantation within six months of diagnosis, and all of them were alive and well to date. Of the three patients who did not undergo transplantation, two died within one year of the diagnosis and the remaining patient was lost to follow-up. Conclusion: Our findings suggest that the diagnosis of exudative pleural effusion using Light's criteria is very sensitive and specific in screening for spontaneous bacterial pleuritis. This is especially useful as our study also found that cultures are frequently negative in this condition. Following infection clearance, liver transplantation provides a favorable outcome.Table

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

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

Sa1033 Oral Nutrition With a High Content of BCAA Improves the Liver Function and Major Symptoms of Decompensated Cirrhotic Patients Unresponsive to BCAA Granules Only

BACKGROUND: Spontaneous bacterial peritonitis (SBP) is a frequent and severe bacterial infection in patients with decompensated cirrhosis and ascites. Most organisms causing SBP are from intestinal microbial flora with Enterobacteriaceae and Escherichia coli being reported the most common organisms. However, studies of small series in recent years reported increasing frequency of SBP caused by Gram -positive bacteria in SBP. AIM: To evaluate microbial characteristics of ascitic fluid in cirrhotic patients with spontaneous bacterial peritonitis. METHODS: Medical records of 236 patients who underwent diagnostic paracentesis from July 1 2006 to July 1 2011 at Hershey Medical Center were reviewed. Pertinent data were collected and analyzed using SAS 1.1 software. RESULTS: One hundred ninety eight patients, age between 18-80 years old who had cirrhosis and ascites were included. The majority of the patients with end stage liver disease had either alcoholic liver disease or viral hepatitis or both. 145 (73.2%) were males and 53 (26.8 %) were females. Mean age was 54.8 years. Total 650 cultures were performed. 153 out of 650 cultures (23.5%) met criteria of spontaneous bacterial peritonitis based on absolute neutrophil count in ascitc fluid >250 cells/mm3. Bacteria grew in 86 cultures. 21 of the 86 cultures grew 2 or more micro-organisms, possible secondary to contamination, were excluded from this analysis. One culture grew candida. Fifty out of 64 (78.1%) cultures grew Gram-positive bacteria and 14/64 (21.9%) cultures grew Gram-negative bacteria. Most common organism isolated was coagulase negative Staphylococcus and the most common Gram-negative organism isolated was Klebsiella. Positive culture result of either Gram-positive or Gram-negative bacteria did not differ in age, MELD score, frequency of paracentesis, etiology of liver disease, or previous history of SBP. CONCLUSION: Our study shows increased frequency of Grampositive bacteria in patients with SBP which is a change in the pattern of SBP compared to current guideline. Larger prospective studies are needed to confirm this finding. The implication of such change is likely to modify treatment strategies particularly when empiric therapy is contemplated.