Management Of Spontaneous Bacterial Peritonitis Research Articles

Just the facts: Evaluation and management of spontaneous bacterial peritonitis.

Just the facts: Evaluation and management of spontaneous bacterial peritonitis.

Prediction of In-Hospital Mortality in Spontaneous Bacterial Peritonitis Patients with Advanced Liver Disease

Introduction: Bacterial infections are known reason for morbidity and mortality in hospitalized patients with cirrhosis among which Spontaneous bacterial peritonitis (SBP) is most common, accounts for around 20% to 30% mortality rate. Objective: To evaluate the frequency of in-hospital mortality in SBP patients. Study Design: Descriptive case series. Setting: Asian Institute of Medical Sciences Hospital Hyderabad. Duration: From 1st January 2019 to 30th June 2019. Material and Methods: Adult patients diagnosed to have spontaneous bacterial peritonitis and followed for outcome. Results: 223 patients of spontaneous bacterial peritonitis I,e 165 (74%) male and 58 (26%) female fulfilling the inclusion criteria were enrolled in study. Mean age obtained was 47.56 ± 13.069 years and Hepatitis C with most common etiology for CLD was 128 (57.4%) followed by Hepatitis B 26 (11.7%), Hepatitis B + D 30 (13.5 %) and Alcohol 8 (3.6 %). Hepatocellular carcinoma in 70 (31.4 %) only. CTP (Child-Turcot-Pugh) score and MELD (Model for End-stage Liver Disease) score used to access stage of cirrhosis. 38 (17 %) patients with CTP class B and 185 (83 %) with CTP class C. The mean MELD score of all patients found to be 23.09 ± 15.686. Among 223 patients, in-hospital mortality was observed in 61 (27.4%), 115 (51.6%) were discharged with improvement and rest 47 (21.1%) discharged with no improvement. Practical Implication: This study's findings underscore the need for early detection and aggressive management of Spontaneous Bacterial Peritonitis in patients with advanced liver disease, especially those with CTP Class C and high MELD scores, to reduce the high in-hospital mortality rate. Conclusion: Significantly high in-hospital mortality was found to be associated with SBP, with CTP Class C, High MELD Score, increased creatinine, bilirubin, PT, INR and decreased albumin especially in females. Keywords: Cirrhosis; In-hospital mortality; Spontaneous bacterial peritonitis

Role of Albumin in Spontaneous Bacterial Peritonitis: Indications, Side-Effects and Outcome

The most prevalent bacterial infection in cirrhotic patients is spontaneous bacterial peritonitis. Hospitalized patients with cirrhosis and ascites have an incidence that ranges between 10% and 30%, making it one of their primary complications. Since it may lead to kidney failure, hepatic encephalopathy, gastrointestinal bleeding, hypervolemic hyponatremia, the development of acute or chronic liver failure, systemic sepsis, so the outcomes in patients with spontaneous bacterial peritonitis are poor. Early antibiotic treatment is essential for bacterial spontaneous peritonitis. It is advised to utilize albumin in addition to antibiotics for some high-risk patients who have spontaneous bacterial peritonitis. The purpose of this research is to review the available information about the role of albumin in spontaneous bacterial peritonitis: indications, side-effects and outcome. Albumin is a plasma volume expander and is responsible for decreasing inflammatory response mediators such nitric oxide and the proinflammatory cytokines tumour necrosis factor-alpha and interleukin-6 because of this property it has a beneficial role in spontaneous bacterial peritonitis. Intravenous albumin administration has also been demonstrated to enhance systemic hemodynamic and renal function among spontaneous bacterial peritonitis patients. This effect is mediated by both an increase in cardiac function and a decrease in arterial vasodilatation Albumin along with the antibiotics is safe and effective in management of spontaneous bacterial peritonitis. It reduces the risk of renal complications and mortality. Although further research for standardizing the dosage and duration of albumin is needed.

Intravenous albumin for spontaneous bacterial peritonitis and renal dysfunction in patients with cirrhosis-short review

Current clinical guidelines for albumin use in decompensated cirrhosis recommend the use of intravenous albumin infusions for management of ascites-related symptoms and paracentesis (removal of ascitic fluid) and for the management of spontaneous bacterial peritonitis (SBP), renal dysfunction and variceal bleeding. Routine albumin use is not recommended for the management of non-SBP infections. The aim of this review is to improve our understanding of the effects of albumin use in cirrhosis by reviewing the currently available and quantifying the effectiveness of intravenous albumin therapy to prevent specific cirrhosis complications, spontaneous bacterial peritonitis (SBP) and renal dysfunction. Long-term albumin administration to patients with decompensated cirrhosis improves survival, prevents complications, eases the management of ascites and reduces hospitalizations, thus being cost-effective. However, variant results indicate that further investigations are needed, aiming at confirming the beneficial effects of albumin, clarifying its optimal dosage and administration schedule and identify patients who would benefit most from long-term albumin administration.

Spontaneous Bacterial Peritonitis and Secondary Bacterial Peritonitis—a Comprehensive Review

Spontaneous bacterial peritonitis (SBP) and secondary bacterial peritonitis are life-threatening complications of cirrhosis if not recognized immediately and managed appropriately. SBP occurs in ~ 3.5 to 10% of patients with cirrhosis and ascites, whereas secondary bacterial peritonitis occurs in 5%. Prompt recognition of SBP variants is vital for tailoring therapy to decrease mortality rate from 90 to 20%. Our objective is to provide an update on the recent publications to elucidate the variants of SBP and provide a management algorithm for the potentially life-threatening complications of cirrhosis. The general guidelines for the management of spontaneous bacterial peritonitis are mostly unchanged, but there are newer data regarding trends in bacteriology and pathogens and newer prophylactic strategies. Spontaneous fungal peritonitis, spontaneous bacterial empyema, and secondary bacterial peritonitis can be clinically challenging if not diagnosed promptly. Nutrition is an under-recognized but important aspect of the management of ascites and SBP prevention. Emerging options for the management of diuretic refractory ascites and infection management are discussed in detail. Early diagnosis and treatment of SBP and secondary bacterial peritonitis are usually associated with good outcomes, but mortality remains as high as 40%. There is a higher risk of other decompensating cirrhotic events after the initial episode of SBP or secondary bacterial peritonitis that portends poor prognosis. The emphasis should be to identify the precipitating cause and focus on the modifiable risk factors to improve outcomes and survival. Newer strategies for SBP prophylaxis and ascites management appear promising until liver transplantation. Personalized approach is crucial to improve the morbidity, quality of life, and mortality in every patient with decompensated cirrhosis.

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

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

Emergency Management of Spontaneous Bacterial Peritonitis - A Clinical Review.

Spontaneous bacterial peritonitis (SBP) has a high mortality rate; early antimicrobial therapy is essential for improving patient outcomes. Given that cirrhotic patients are often coagulopathic, the perceived risk of bleeding may prevent providers from performing a paracentesis and ruling out this potentially deadly disease.We examine the pathophysiology and risk factors for SBP, and current guidelines for its diagnosis and treatment. We then review the time-sensitive nature of performing a paracentesis, and the current controversies and contraindications for performing this procedure in patients at risk for SBP.Cirrhotic patients with ascites and clinical suspicion for SBP—abdominal pain or tenderness, fever or altered mental status—should have a diagnostic paracentesis. Although most patients with cirrhosis and liver dysfunction will have prolonged prothrombin time, paracentesis is not contraindicated. Limited data support platelet administration prior to paracentesis if <40,000-50,000/μL. Timely antimicrobial therapy includes a third-generation cephalosporin for community-acquired infection; nosocomial infections should be treated empirically with a carbapenem or with piperacillin-tazobactam, or based on local susceptibility testing. Patients with gastrointestinal (GI) hemorrhage should receive ceftriaxone prophylactically for GI hemorrhage.SBP has a high mortality rate. Early diagnosis and antimicrobial therapy are essential for improving patient outcomes. Cirrhotic patients with ascites with clinical suspicion for SBP, abdominal pain or tenderness, altered mental status or fever should have a diagnostic paracentesis performed prior to admission unless platelets <40,000-50,000/μL.

Current Trends in the Management of Spontaneous Bacterial Peritonitis

Spontaneous bacterial peritonitis is a life-threatening infection that is a leading cause of mortality among patients with decompensated cirrhosis. In this article, we present current trends in the management of spontaneous bacterial peritonitis (SBP), highlighting treatment failure rates of traditional regimens and ways in which to address such challenges. Despite available management guidelines, there are data to support that these guidelines are often not adhered to, e.g., performing a diagnostic paracentesis at the time of hospital admission in a patient with ascites. Management of SBP is now further complicated by resistant organisms and an increasing prevalence of nosocomial and healthcare-associated infections. Effective treatment of SBP requires careful consideration of patient risk factors, local antibiotic resistance patterns, and clinical presentation.

Building Effective Quality Improvement Programs for Liver Disease: A Systematic Review of Quality Improvement Initiatives.

Quality indicators are the measurable components of clinical standards. Data are limited about the design and impact of interventions to improve quality indicators for patients with chronic liver disease. A systematic review of PubMed, Web of Science, and conference proceedings was performed to find reports of quality improvement (QI) interventions. Data regarding the several indicators were collected. The search focused on vaccination against hepatitis A or hepatitis B virus, management of spontaneous bacterial peritonitis, screening for varices, management of acute variceal hemorrhage, hepatocellular carcinoma screening, and 30-day readmissions. Fifteen studies reported on the results of QI interventions. Ten focused on specific quality indicators (1 specific to vaccination, 2 spontaneous bacterial peritonitis, 3 gastrointestinal bleeding, and 4 hepatocellular carcinoma screening); 5 focused on clinical outcomes. Most studies used a pre-post study design. Interventions included checklists, educational conferences, electronic decision supports, nurse coordinators, and systematic changes to facilitate specialist co-management. Successful interventions optimized clinical workflow, closed knowledge gaps among frontline providers, created forced functions in the electronic ordering system, added dedicated staff to manage specific indicators, and provided viable alternatives to hospitalization to reduce readmission. Unsuccessful interventions included case management, phone calls, and home visits to reduce readmissions, checklists, and educational programs. Past experience with QI provides generalizable rules for successful future interventions aimed at improved quality indicator adherence and patient outcomes.

Infectious Considerations in the Pre-Transplant Evaluation of Cirrhotic Patients Awaiting Orthotopic Liver Transplantation

The incidence of end-stage liver disease (ESLD) is increasing and many of these patients may be considered for orthotopic liver transplantation. As patients with ESLD are at risk of a number of infections, infectious disease physicians should be aware of the management of these infections in order to provide optimal patient care and ensure transplantation success. We present a review of the literature pertaining to infectious disease considerations in the liver transplant candidate. It highlights several topics with recent developments including the management of hepatitis C virus infection prior to transplantation, treatment of hepatitis B virus infection, colonization and infection with multidrug resistant organisms, and management of spontaneous bacterial peritonitis.

Improving the management of spontaneous bacterial peritonitis in cirrhotic patients: assessment of an intervention in trainee doctors

Spontaneous bacterial peritonitis (SBP) in cirrhotic patients is a serious complication associated with a high mortality rate. A baseline audit of the acute medical take (AMT) at Northwick Park suggested a lack of awareness regarding management. A questionnaire based on contemporary SBP guidelines was circulated to all trainee doctors (FY1 to SpR). Ascitic fluid testing requests were analysed over a six-month period. The electronic requesting system was updated to include prompts and direct links to Trust SBP guidelines, and a one-hour lecture to all members of the AMT, supported by an educational booklet on SBP, was performed. Re-audit was carried out six months post-intervention, the AMT completed a second questionnaire and ascitic fluid testing requests were re-audited. In comparable pre- and post-intervention AMT cohorts, a clinical and educational intervention led to a significant improvement in understanding of when to investigate (p≤0.001), samples (p = 0.002) and containers (p≤0.001) required, urgency of obtaining results (p≤0.001), and initiation of treatment for suspected SBP (p = 0.007). Significantly more ascitic samples were sent, with specific suspicion of SBP more readily documented, crucial to expediting laboratory processing. Targeted education and production of a clinical algorithm has significantly improved the management of patients with SBP.

PTU-088 Variation in Practice of Management of Spontaneous Bacterial Peritonitis (SBP)

IntroductionSpontaneous Bacterial Peritonitis (SBP) is the most frequent and life-threatening infection in patients with liver cirrhosis, requiring prompt recognition and treatment. Clinical practise guidelines on management of SBP were released...

S1848 A Kidney Function Determined Treatment Algorithm for Administration of Albumin in the Management of Spontaneous Bacterial Peritonitis (SBP)

Background/ Aims: Portal vein thrombosis (PVT) in patients with liver cirrhosis is usually associated with hepatocellualar carcinoma. The pathogenesis of non-malignant PVT in cirrhotics has not been specifically studied and risk factors of PVT in this group of patients are still poorly understood. The aim of this study was to ascertain the prevalence and the significance of hyperhomocyteinemia among other risk factors in the development of PVT in cirrhotic patients. Patients and methods: Fifty two subjects were included in this study. Forty two cirrhotic patients; among them 21 had PVT and 21 had liver cirrhosis without PVT. Ten healthy subjects were included as controls. Plasma levels of homocysteine, antithrombin III, protein C and protein S were measured. Factor V Leiden was determined and methylenetetrahydrofolate reductase (MTHFR) C677T gene mutation was detected. Results: Our results revealed that plasma levels of protein C, protein S and antithrombin III were lower in cirrhotic patients with PVT than in those without PVT and controls. Plasma homocysteine level was higher among cirrhotics with PVT compared to those without PVT and controls. Factor V Leiden was detected only in 10% of controls and in 9.52% of cirrhotics with and without PVT whereas MTHFR gene mutation TT (homozygous) was detected in 23.81% of cirrhotics with PVT and not found in other groups. Conclusion: Heyperhomocyteinemia could be considered as a newly recognized risk factor for PVT in cirrhotic patients and should be routinely measured particularly when the etiology of PVT is unclear. These results could be clinically important due to the readily available therapy of folate, vitamin B6 and B12 supplementation that may reduce homocysteine and prevent further thrombotic complications.

Ascitic fluid analysis for diagnosis and monitoring of spontaneous bacterial peritonitis

Polymorphonuclear (PMN) cell count in the ascitic fluid is essential for the diagnosis and management of spontaneous bacterial peritonitis (SBP). To date, PMN cell count is routinely performed by traditional manual counting. However, this method is time-consuming, costly, and not always timely available. Therefore, considerable efforts have been made in recent years to develop an alternative test for a more rapid diagnosis and monitoring of SBP. The use of urinary reagent strips was proposed to achieve an "instant" bedside diagnosis of SBP. A series of reports evaluated the urine strip test for SBP diagnosis and reported promising results. However, a recent large multicenter study revealed a surprising lack of diagnostic efficacy of the urine screening test for SBP diagnosis. Another method, more recently proposed as an alternative to the manual PMN count, is the measurement of lactoferrin in ascitic fluid, but the data available on the diagnostic value of this test are limited to a single study. However, both urinary reagent strips and ascitic lactoferrin tests are qualitative methods and need, therefore, to be further confirmed by standard cytology of the ascitic fluid. To date, the only quantitative method proposed as a valid alternative to manual PMN counting is automated blood cell counters, commonly used in all laboratories for blood cell counting. Data available in the literature on the diagnostic performance of this method are limited but very promising, and this tool seems to have the potential to replace the manual counting method.

Accuracy of the automated cell counters for management of spontaneous bacterial peritonitis

To evaluate the accuracy of automated blood cell counters for ascitic polymorphonuclear (PMN) determination for: (1) diagnosis, (2) efficacy of the ongoing antibiotic therapy, and (3) resolution of spontaneous bacterial peritonitis (SBP). One hundred and twelve ascitic fluid samples were collected from 52 consecutive cirrhotic patients, 16 of them with SBP. The agreement between the manual and the automated method for PMN count was assessed. The sensitivity/specificity and the positive/negative predictive value of the automated blood cell counter were also calculated by considering the manual method as the "gold standard". The mean +/- SD of the difference between manual and automated measurements was 7.8 +/- 58 cells/mm(3), while the limits of agreement were +124 cells/mm(3) [95% confidence interval (CI): +145 to +103] and -108 cells/mm(3) (95% CI: -87 to -129). The automated cell counter had a sensitivity of 100% and a specificity of 97.7% in diagnosing SBP, and a sensitivity of 91% and a specificity of 100% for the efficacy of the ongoing antibiotic therapy. The two methods showed a complete agreement for the resolution of infection. Automated cell counters not only have a good diagnostic accuracy, but are also very effective in monitoring the antibiotic treatment in patients with SBP. Because of their quicker performance, they should replace the manual counting for PMN determination in the ascitic fluid of patients with SBP.

MANAGEMENT OF ASCITES

The evaluation of ascites includes a directed history, focused physical examination, and diagnostic paracentesis with ascitic fluid analysis. Dietary sodium restriction and oral diuretics are the mainstay of therapy for the majority of patients with cirrhotic ascites. Transjugular intrahepatic portocaval shunt has emerged as the treatment of choice for selected patients with refractory ascites, although serial large-volume paracenteses should be attempted first. Early diagnosis, broad-spectrum antibiotics, and albumin infusion contribute to the successful management of spontaneous bacterial peritonitis (SBP). Referral for liver transplant evaluation should be considered at the first sign of decompensation and should not be delayed until development of ominous clinical features, such as refractory ascites and SBP.