Ascitic Fluid Infection Research Articles

Enhancing the accuracy and effectiveness of diagnosis of spontaneous bacterial peritonitis in cirrhotic patients: A machine learning approach utilizing clinical and laboratory data

PurposeSpontaneous bacterial peritonitis (SBP) is a bacterial infection of ascitic fluid that develops naturally, without being triggered by any surgical conditions or procedures, and is a common complication of cirrhosis. With a potential mortality rate of 40 ​%, accurate diagnosis and prompt initiation of appropriate antibiotic therapy are crucial for optimizing patient outcomes and preventing life-threatening complications. This study aimed to expand the use of computational models to improve the diagnostic accuracy of SBP in cirrhotic patients by incorporating a broader range of data, including clinical variables and laboratory values. Patients and methodsWe employed 5 machine learning classification methods - Decision Tree, Support Vector Machine, Naive Bayes, K-Nearest Neighbor, and Random Forest, utilizing a variety of demographic, clinical, and laboratory features and biomarkers. ResultsAscitic fluid markers, including white blood cell (WBC) count, lactate dehydrogenase (LDH), total protein, and polymorphonuclear cells (PMN), significantly differentiated between SBP and non-SBP patients. The Random Forest model demonstrated the highest overall accuracy at 86 ​%, while the Naive Bayes model achieved the highest sensitivity at 72 ​%. Utilizing 10 key features instead of the full feature set improved model performance, notably enhancing specificity and accuracy. ConclusionOur analysis highlights the potential of machine learning to enhance the accuracy of SBP diagnosis in cirrhotic patients. Integrating these models into clinical workflows could substantially improve patient outcomes. To achieve this, ongoing multidisciplinary research is crucial. Ensuring model interpretability, continuous monitoring, and rigorous validation will be essential for the successful implementation of real-time clinical decision support systems.

Variants of Ascitic Fluid Bacterial Infections and Clinical Outcomes in Patients with Liver Cirrhosis

Background: Ascitic fluid infection (AFI) is the most common bacterial infection in patients with cirrhosis and has several variants, including spontaneous bacterial peritonitis (SBP), bacterascites (BA), and culture-negative neutrocytic ascites (CNNA). Objectives: To date, there has been disagreement about the differences in clinical features and outcomes of these variants of AFI, and there are still few studies in this area. Methods: A cross-sectional study was conducted at a referral hospital from June 2018 to September 2022. All cirrhotic patients with ascites were evaluated for the presence of AFI. Patients with AFI were divided into SBP, BA, and CNNA variants. Non-AFI participants were also evaluated as a comparison group. The outcomes, as well as the clinical and laboratory characteristics of the variants of AFI, were compared. Kaplan-Meier curves and Cox regression analysis were used for survival analysis. Results: A total of 466 patients were studied, of which 132 (28.33%) were in the AFI group and 334 (71.67%) were in the non-AFI group. In the AFI group, 64 (48.48%) had SBP, 43 (32.58%) had CNNA, and 25 (18.94%) had BA. The most common bacteria causing AFI was Escherichia coli. SBP (HR 2.43; 95% CI 1.36 - 4.36; P = 0.003) significantly increased the risk of mortality, while CNNA and BA did not significantly increase this risk. The presence of hepatic encephalopathy and female gender also significantly increased the risk of mortality. Conclusions: The mortality risk was higher in patients with SBP compared to other types of AFI. This study also showed differences in clinical characteristics and laboratory parameters among the three types of AFI. Further research is recommended.

Application of metagenomic next-generation sequencing in optimizing the diagnosis of ascitic infection in patients with liver cirrhosis

BackgroundMetagenomic next-generation sequencing (mNGS) is an emerging technique for the clinical diagnosis of infectious disease that has rarely been used for the diagnosis of ascites infection in patients with cirrhosis. This study compared mNGS detection with conventional culture methods for the on etiological diagnosis of cirrhotic ascites and evaluated the clinical effect of mNGS.MethodsA total of 109 patients with ascites due to cirrhosis were included in the study. We compared mNGS with conventional culture detection by analyzing the diagnostic results, pathogen species and clinical effects. The influence of mNGS on the diagnosis and management of ascites infection in patients with cirrhosis was also evaluated.ResultsAscites cases were classified into three types: spontaneous bacterial peritonitis (SBP) (16/109, 14.7%), bacterascites (21/109, 19.3%) and sterile ascites (72/109, 66.1%). In addition, 109 patients were assigned to the ascites mNGS-positive group (80/109, 73.4%) or ascites mNGS-negative group (29/109, 26.6%). The percentage of positive mNGS results was significantly greater than that of traditional methods (73.4% vs. 28.4%, P < 0.001). mNGS detected 43 strains of bacteria, 9 strains of fungi and 8 strains of viruses. Fourteen bacterial strains and 3 fungal strains were detected via culture methods. Mycobacteria, viruses, and pneumocystis were detected only by the mNGS method. The mNGS assay produced a greater polymicrobial infection rate than the culture method (55% vs. 16%). Considering the polymorphonuclear neutrophil (PMN) counts, the overall percentage of pathogens detected by the two methods was comparable, with 87.5% (14/16) in the PMN ≥ 250/mm3 group and 72.0% (67/93) in the PMN < 250/mm3 group (P > 0.05). Based on the ascites PMN counts combined with the mNGS assay, 72 patients (66.1%) were diagnosed with ascitic fluid infection (AFI) (including SBP and bacterascites), whereas based on the ascites PMN counts combined with the culture assay, 37 patients (33.9%) were diagnosed with AFI (P < 0.05). In 60 (55.0%) patients, the mNGS assay produced positive clinical effects; 40 (85.7%) patients had their treatment regimen adjusted, and 48 patients were improved. The coincidence rate of the mNGS results and clinical findings was 75.0% (60/80).ConclusionsCompared with conventional culture methods, mNGS can improve the detection rate of ascites pathogens, including bacteria, viruses, and fungi, and has significant advantages in the diagnosis of rare pathogens and pathogens that are difficult to culture; moreover, mNGS may be an effective method for improving the diagnosis of ascites infection in patients with cirrhosis, guiding early antibiotic therapy, and for reducing complications related to abdominal infection. In addition, explaining mNGS results will be challenging, especially for guiding the treatment of infectious diseases.

SPONTANEOUS BACTERIAL PERITONITIS

Spontaneous bacterial peritonitis (SBP) is an infection of ascitic fluid, posing a severe complication in patients with portal hypertension (PH). Hospital mortality rates are exceedingly high, sometimes surpassing 85%. Only timely diagnosis and treatment can mitigate mortality and morbidity levels. Purpose. Through literature analysis and review, demonstrate the necessity, appropriateness, and efficacy of SBP treatment in patients with decompensated portal hypertension. Additionally, highlight the potential development of ascites and subsequent infections, which may not always be linked to liver cirrhosis. Materials and methods. This article conducts a literature review and assesses recommendations, findings from randomized controlled trials, meta-analyses, and other review articles published in databases such as PubMed, Scopus, Web of Science, and Google Scholar between 2000 and 2023. Outcome. Diagnostic paracentesis is recommended for all ascites patients requiring emergency care or hospitalization to ascertain SBP presence. Accurate differentiation between SBP and secondary bacterial peritonitis is crucial, as treatment approaches differ for each condition. Conclusions. Standard SBP treatment entails promptly administering broad-spectrum antibiotics, considering the potential for community-acquired or nosocomial SBP, and factoring in microbial antibiotic resistance. Given SBP's annual mortality rate surpassing 50%, liver transplantation is recommended for SBP survivors.

Risk Factors Recurrence of Spontaneous Ascitic Fluid Infection (Slai) in Cirrhotic Patients

Risk Factors Recurrence of Spontaneous Ascitic Fluid Infection (Slai) in Cirrhotic Patients

Portal Vein Thrombosis in Patients With Cirrhosis of the Liver: Prevalence and Risk Factors.

Chronic liver disease very often culminates into cirrhosis and its associated complications. One of the serious complications is portal venous thrombosis, which can occur due to a variety of risk factors. One significant factor contributing to portal hypertension is portal vein thrombosis (PVT).In this study, we aimed to investigate the prevalence of PVT among patients with liver cirrhosis in a tertiary hospital and identify the factors associated with this complication. This was a cross-sectional observational study of 93 diagnosed liver cirrhosis patients treated at Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) hospital in southern India between June 2020 and January 2021.A thorough evaluation of the clinical condition of the patients and associated comorbidities was done. The patients then underwent Doppler ultrasound/CECT/MRI to look for PVT and its extent. The collected data were analyzed using Statistical Product and Service Solutions (SPSS, version 24) (IBM SPSS Statistics for Windows, Armonk, NY). Comparison between two proportions was done using two two-tailed Z-test/Fisher's exact tests. Our study found a PVT prevalence of 17.2% in cirrhotic patients, with a higher prevalence of acute PVT than chronic PVT. Ascitic fluid infection, longer duration of cirrhosis, and increased cirrhosis severity were significantly associated with PVT development. We found no significant associations between PVT and gender, hypertension, smoking, diabetes, or the duration of alcohol intake. This study highlights the importance of early screening for PVT using Doppler USG in all patients diagnosed with cirrhosis. Additionally, anticoagulation therapy for acute PVT may be considered in patients without bleeding risks.

A Study on the Bacteriological Profile of Ascitic Fluids and Their Antibiotic Susceptibility Pattern in a Tertiary Care Hospital.

Background Ascitic fluid culture remains an essential step in the management of all patients with ascites, regardless of their presenting complaints. Diagnostic paracentesis should not be delayed or prevent timely administration of antibiotics, particularly in unstable patients. Hence, it is an essential part of the surveillance system of every hospital to perform ascitic fluid culture and assess the antibiotic susceptibility patterns of bacterial isolates. In view of this perspective, the present study was conducted at Chengalpattu Medical College Hospital, Tamil Nadu, India. Objective The aim of the study isto determine the bacterial isolatesof ascitic fluid samples and study their antibiotic susceptibility patterns. Materials and methods Ascitic fluids received in the central laboratory at the Department of Microbiology from various departments were included in this study. Preliminary identification of isolates wasperformed by direct Gram staining, acid-fast staining, and motility testing by the hanging drop method. Within one hour of receiving the samples, they were plated onto blood agar and MacConkey agar media and incubated for 18-24 hours at 37°C for isolation. Growth was checked, and species identification was done based on conventional methods. Antibiotic susceptibility testing was performed using the Kirby-Bauer disk diffusion method. Results In this study, a total of 100 ascitic fluid samples were collected, of which only eight (8%) showed growth. Among the eight isolates, six (75%) were Gram-negative bacilli (GNB). Four (66.66%) of the six GNB wereKlebsiella spp., while the remaining two (33.33%) were Escherichia coli. Both Gram-positive cocci wereStaphylococcus aureus. All the GNB isolates were susceptible to meropenem, piperacillin-tazobactam, and ceftriaxone, with varying susceptibilities to other drugs. Both Gram-positive isolates were found to be methicillin-sensitive Staphylococcus aureus. Conclusion GNB were the predominant organisms in cases of ascitic fluid infection, and they showed 100% susceptibility to carbapenem drugs (especially meropenem),piperacillin-tazobactam, and ceftriaxone.All these drugs can be kept in reserve for serious infections. Amikacin and gentamicin showed promising susceptibility. These drugs can be started empirically with patients on admission before performing culture. Drug adjustments may be later made based on culture reports.

Clinical efficacy of total laparoscopic splenectomy for portal hypertension and its influence on hepatic hemodynamics and liver function.

The liver hemodynamic changes caused by portal hypertension (PH) are closely related to various complications such as gastroesophageal varices and portosys-temic shunts, which may lead to adverse clinical outcomes in these patients, so it is of great clinical significance to find treatment strategies with favorable clinical efficacy and low risk of complications. To study the clinical efficacy of total laparoscopic splenectomy (TLS) for PH and its influence on hepatic hemodynamics and liver function. Among the 199 PH patients selected from October 2016 to October 2020, 100 patients [observation group (OG)] were treated with TLS, while the remaining 99 [reference group (RG)] were treated with open splenectomy (OS). We observed and compared the clinical efficacy, operation indexes [operative time (OT) and intraoperative bleeding volume], safety (intraperitoneal hemorrhage, ascitic fluid infection, eating disorders, liver insufficiency, and perioperative death), hepatic hemodynamics (diameter, velocity, and flow volume of the portal vein system), and liver function [serum alanine aminotransferase (ALT), serum aspartate aminotransferase (AST), and serum total bilirubin (TBil)] of the two groups. The OT was significantly longer and intraoperative bleeding volume was significantly lesser in the OG than in the RG. Additionally, the overall response rate, postoperative complications rate, and liver function indexes (ALT, AST, and TBil) did not differ significantly between the OG and RG. The hepatic hemodynamics statistics showed that the pre- and postoperative blood vessel diameters in the two cohorts did not differ statistically. Although the postoperative blood velocity and flow volume reduced significantly when compared with the preoperative values, there were no significant inter-group differences. TLS contributes to comparable clinical efficacy, safety, hepatic hemodynamics, and liver function as those of OS in treating PH, with a longer OT but lesser intraoperative blood loss.

Accuracy of leukocyte esterase reagent strip test and platelet indices for early diagnosis of ascitic fluid infection in liver cirrhosis

Background: Spontaneous bacterial peritonitis (SBP) is one of the serious complexities in patients with cirrhosis and ascites. 30-50% of death may occur if it not treated properly. The leucocyte esterase reagent (LER) strip test is a special apparatus for prior detection of neutrophils in the ascetic fluid. The aim of the study was to investigate the diagnostic accuracy of the LER strip test and platelet indices in the early detection of SBP in cirrhotic patients. Methods: This cross-sectional study was carried out in the department of gastrointestinal hepatobiliary and pancreatic disorders (GHPD), BIRDEM, Dhaka, Bangladesh, from January 2018 to October 2019. A total of 110 indoor patients of liver cirrhosis with ascites were enrolled after fulfilment of the inclusion and exclusion criteria with adequate history taking and clinical examination. Results: Out of 110 cases, 68 were male and 42 were female, and among them 23 (20.9%) patients had SBP. LER strip test at grade 4 set as a cut-off value which showed sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy was 91.3%, 90.8%, 70%, 97.5%, and 90% respectively. Mean platelet volume (MPV) and platelet distribution width (PDW) were done by complete blood count, where the MPV cut-off value set as 12.5 fl showed sensitivity, specificity, PPV, NPV, and accuracy were 82.6%, 90.8%, 66%, 96.25%, and 88.18% respectively. PDW cut-off value set on 18.10% revealed sensitivity, specificity, PPV, NPV, accuracy was 82.6%, 83.9%, 50%, 95.71% and 79% respectively. ROC curve was plotted to set the cut-off value by examining sensitivity and specificity. Results were considered statistically significant at p&lt;0.05. Conclusions: This study was undertaken to detect LER strip tests that showed significant results in bedside diagnosis of SBP. Apart from this, a significant increase in MPV and PDW was observed in SBP. So, LER strip tests and platelet indices measurement can be economical and reliable appliances for early diagnosis of SBP.

Ascites and Chronic Liver Disease in Children.

Development of ascites in children with chronic liver disease is the most common form of decompensation. It is associated with a poor prognosis and increased risk of mortality. A diagnostic paracentesis should be performed in liver disease patients with- new-onset ascites, at the beginning of each hospital admission and when ascitic fluid infection (AFI) is suspected. The routine analysis includes cell count with differential, bacterial culture, ascitic fluid total protein and albumin. A serum albumin-ascitic fluid albumin gradient of ≥1.1g/dL confirms the diagnosis of portal hypertension. Ascites has been reported in children with non-cirrhotic liver disease like acute viral hepatitis, acute liver failure and extrahepatic portal venous obstruction. The main steps in management of cirrhotic ascites include dietary sodium restriction, diuretics and large-volume paracentesis. Sodium should be restricted to maximum of 2mEq/kg/d (max 90mEq/d) of sodium/day. Oral diuretic therapy comprises of aldosterone antagonists (e.g., spironolactone) with or without loop-diuretics (e.g., furosemide). Once the ascites is mobilized, the diuretics should be gradually tapered to the minimum effective dosage. Tense ascites should be managed with a large-volume paracentesis (LVP) preferably with albumin infusion. Therapeutic options for refractory ascites include recurrent LVP, transjugular intrahepatic porto-systemic shunt and liver transplantation. AFI (fluid neutrophil count ≥250/mm3) is an important complication, and requires prompt antibiotic therapy. Hyponatremia, acute kidney injury, hepatic hydrothorax and hernias are the other complications.

Gut Microbiota and Infectious Complications in Advanced Chronic Liver Disease: Focus on Spontaneous Bacterial Peritonitis.

Liver cirrhosis is a chronic disease that can be complicated by episodes of decompensation such as variceal bleeding, hepatic encephalopathy, ascites, and jaundice, with subsequent increased mortality. Infections are also among the most common complications in cirrhotic patients, mostly due to a defect in immunosurveillance. Among them, one of the most frequent is spontaneous bacterial peritonitis (SBP), defined as the primary infection of ascitic fluid without other abdominal foci. SBP is mainly induced by Gram-negative bacteria living in the intestinal tract, and translocating through the intestinal barrier, which in cirrhotic patients is defective and more permeable. Moreover, in cirrhotic patients, the intestinal microbiota shows an altered composition, poor in beneficial elements and enriched in potentially pathogenic ones. This condition further promotes the development of leaky gut and increases the risk of SBP. The first-line treatment of SBP is antibiotic therapy; however, the antibiotics used have a broad spectrum of action and may adversely affect the composition of the gut microbiota, worsening dysbiosis. For this reason, the future goal is to use new therapeutic agents that act primarily on the gut microbiota, selectively modulating it, or on the intestinal barrier, reducing its permeability. In this review, we aim to describe the reciprocal relationship between gut microbiota and SBP, focusing on pathogenetic aspects but also on new future therapies.

Differentiation of Spontaneous Bacterial Peritonitis from Secondary Peritonitis in Patients with Liver Cirrhosis: Retrospective Multicentre Study

Ascitic fluid infection is a serious complication of liver cirrhosis. The distinction between the more common spontaneous bacterial peritonitis (SBP) and the less common secondary peritonitis in patients with liver cirrhosis is crucial due to the varying treatment approaches. This retrospective multicentre study was conducted in three German hospitals and analysed 532 SBP episodes and 37 secondary peritonitis episodes. Overall, >30 clinical, microbiological, and laboratory parameters were evaluated to identify key differentiation criteria. Microbiological characteristics in ascites followed by severity of illness and clinicopathological parameters in ascites were the most important predictors identified by a random forest model to distinguish between SBP and secondary peritonitis. To establish a point-score model, a least absolute shrinkage and selection operator (LASSO) regression model selected the ten most promising discriminatory features. By aiming at a sensitivity of 95% either to rule out or rule in SBP episodes, two cut-off scores were defined, dividing patients with infected ascites into a low-risk (score ≥ 45) and high-risk group (score < 25) for secondary peritonitis. Overall, the discrimination of secondary peritonitis from SBP remains challenging. Our univariable analyses, random forest model, and LASSO point score may help clinicians with the crucial differentiation between SBP and secondary peritonitis.

The role of prophylactic antibiotics in prevention of spontaneous bacterial peritonitis in compensated liver cirrhosis with upper gastrointestinal bleeding: randomized controlled, clinical trial

Background and aim Acute variceal bleeding is one of the major causes of death in cirrhotic patients. Bacterial infection is one of the common complications with acute variceal bleeding. Using prophylactic antibiotic is controversial in Child–Pugh-A patients with acute variceal bleeding. In this respect, we aimed to assess the impact of using prophylactic antibiotic in Child-A cirrhotic patients presented with upper gastrointestinal bleeding (UGIB) in prevention of spontaneous bacterial peritonitis (SBP). Patient and methods From January 2021 to December 2022, we recruited 68 cirrhotic patients presented with UGIB. We divided our patients into two groups: prophylactic group (34 patients) and control group (34 patients). Clinical evaluation, laboratory investigations, and ultrasound of the abdomen all were done at baseline and followed up for 7 days during admission for signs of bacterial infection, especially SBP (NCT04711122). Results The infections that we encountered were SBP (three cases in the prophylaxis group and seven cases in the control group) and pneumonia (one case in the control group). There was no statistically significant difference between the two groups regarding the incidence of ascitic fluid infection (8.8 vs. 20.6%, P=0.15). There was insignificant difference between both groups as regards hospital stay, blood transfusion, admission to the ICU, and mortality. Conclusion Cirrhotic patients with Child class A who presented with UGIB and received antibiotic prophylaxis did not get benefit regarding the incidence of bacterial infections, mortality, or frequency of admission to the ICU.

S2927 Persistent Spontaneous Bacterial Peritonitis in a Patient With Cardiogenic Ascites

Introduction: Ascites is defined as a collection of more than 25mL of fluid in the peritoneal cavity, most commonly caused by liver cirrhosis. Cardiogenic ascites from heart failure contributes to 5% of cases. Spontaneous bacterial peritonitis (SBP) is a common complication of ascites, defined as an infection of ascitic fluid in the absence of a surgically treatable source. This is more commonly associated with hepatic cirrhosis. Here we present a case of SBP in a patient with cardiogenic ascites. Case Description/Methods: Patient is a 37-year-old male with right sided heart failure secondary to bronchopulmonary dysplasia with no history of liver disease. The patient was found to have dyspnea and anasarca, so he was admitted for heart failure exacerbation. CT of the abdomen showed large volume ascites and hepatomegaly. While being diuresed, 5L of ascitic fluid was removed via paracentesis. Analysis revealed a serum albumin-ascites gradient (SAAG) of 0.7, protein 4.5, absolute neutrophil count (ANC) 948, and negative culture. The patient was then started on ceftriaxone for SBP. An additional 4.5L was removed via paracentesis 3 days later due to worsening ascites. Analysis at that time showed SAAG 0.6, protein 4.2, and ANC 4,808. No cultures were reported. Antibiotics were escalated to piperacillin-tazobactam due to worsening ANC. A third paracentesis was performed 3 days later after reaccumulation of ascites (3.2L) and to assess therapeutic response. Peritoneal fluid analysis revealed SAAG 0.8, protein 3.7, ANC 2,931, and negative culture. At this point, the infectious disease team was consulted, recommending discontinuation of antibiotics and close monitoring. Patient was discharged 6 days later as he was afebrile and without leukocytosis. Discussion: The pathophysiology of SBP is thought to be related to bacterial translocation and impaired immunity, specifically deficiencies in complement protein neutrophil function. This is reflected by low ascites protein. However, SBP is exceedingly rare in cardiogenic ascites with only 8 cases reported. This is likely secondary to the high protein and opsonic character in this type of ascites, developing from elevated intrahepatic pressures and congestive hepatopathy. This composition of ascites fluid yields antimicrobial activity similar to normal peritoneal fluid. Perhaps this was the reason for the patient’s elevated ANC despite negative cultures. Future studies could focus on the role of antibiotics and prophylaxis in these patients.

Correlation of poor oral hygiene and Ascitic fluid infection in patients with decompensated cirrhosis

Correlation of poor oral hygiene and Ascitic fluid infection in patients with decompensated cirrhosis

Mean Platelet Volume in Cirrhotic Patients with Ascitic Fluid Infection

Introduction: Ascites is the most prevalent clinical symptom of cirrhosis and hepatic decompensation. Patients with cirrhosis are often more likely to get bacterial infections, particularly ascitic fluid infection, which affects 15-20% of people with ascites and cirrhosis Objective: To determine mean platelet volume in cirrhotic patients with ascitic fluid infection. Material and methods: The current study was descriptive and cross-sectional carried out at the department of Medicine Lady Reading Hospital Peshawar for duration of six months from January 2022 to July 2022. From all the patients, a 10cc blood and 20cc ascitic fluid was obtained under aseptic conditions and was sent immediately to hospital diagnostic laboratory for measurement of MPV from blood and Poly-morphonuclear cells in the ascitic fluid. Data analysis was done by employing SPSS version 17. Results: In the current study, male patients were 129(62%) while female patients were 79(38%). The mean age (±SD) in the current study was 42 (±1.88) years. Based on platelet volume, 46(22%) patients had platelet volume range from 7.6- 8.5 fl, 100(48%) patients had platelet volume range 8.6- 9.5 fl, 62(30%) patients had platelet volume range 9.6- 11.5 fl. Mean platelet volume was 9.12 fl with SD ± 1.21. Conclusion: Our study concludes that MPV levels increase significantly in cirhhotic patients with ascitic fluid infection therefore MPV measurement might be thought of as an accurate diagnostic tool for predicting ascitic fluid infection. Keywords: Mean platelet volume; cirrhotic patients; ascitic fluid infection

Ascitic Fluid Calprotectin Level as a Diagnostic Marker of Spontaneous Bacterial Peritonitis in Cirrhotic Patients

Spontaneous bacterial peritonitis (SBP) is the infection of pre-existing ascitic fluid without evidence of a secondary infection.

An evaluation of ascitic calprotectin for diagnosis of ascitic fluid infection in children with cirrhosis

BackgroundThe most common infection in children with the hepatic disease with or without cirrhotic ascites is spontaneous bacterial peritonitis (SBP), which occurs in the absence of an evident intra-abdominal source of infection. The present study aims to assess the value of calprotectin in ascitic fluid in the diagnosis of ascitic fluid infection in children with liver cirrhosis.Materials and methodsIn this cross-section study, 80 children with underlying liver disease who attended the Hepatology and Emergency Department in Shiraz University Hospitals were studied. All the patients were evaluated by a thorough history, clinical examination, laboratory investigations, diagnostic paracentesis with PMNLs count, and Calprotectin, which was measured in 1 mL ascitic fluid by ELISA.ResultsThirty-five patients (43.75%) were diagnosed with ascitic fluid infection. Of these children 6 cases had positive ascitic fluid culture (SBP). Calprotectin was high in AFI patients with a statistically significant difference in AFI patients compared to non-AFI patients. The cut-off levels were 91.55 mg /L and the area under the curve was 0.971. So it can serve as a sensitive and specific diagnostic test for detection of AFI in children with underlying liver disease.ConclusionElevated ascitic calprotectin levels in cirrhotic patients are a diagnostic and reliable marker for the detection of AFI and are considered a surrogate marker for PMN.

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.