Secondary Bacterial Peritonitis Research Articles

Comparative Analysis of Demographic and Clinical Findings in Spontaneous, Peritoneal Dialysis-Related, and Secondary Bacterial Peritonitis.

Background This study aims to contribute to peritonitis management strategies by comparing the demographic, clinical, and laboratory characteristics of patients diagnosed with spontaneous bacterial peritonitis (SBP), peritoneal dialysis-related peritonitis (PDrP), and secondary peritonitis. Methods This study included 86 patients diagnosed with peritonitis between 2016 and 2022. Patients were categorized and compared as SBP, PDrP, and secondary peritonitis. Results SBP was diagnosed in 36% of patients, secondary peritonitis in 36% and PDrP in 28%. The mean age of patients with PDrP is 43.71 ± 14.74, which is significantly lower compared to those with SBP and secondary peritonitis (p<0.001). Patients with hypertension (HT), chronic kidney disease (CKD), and those undergoing dialysis most commonly have PDrP whereas those without HT, without CKD, and not undergoing dialysis are most often diagnosed with secondary peritonitis (p=0.002, p<0.001, p<0.001). In peritoneal fluid cultures, the growth of Gram-positive bacteria was most commonly identified in patients with PDrP, while the growth of Gram-negative bacteria was most frequently seen in patients with secondary peritonitis (p=0.018). CRP levels and sedimentation rates were found to be higher in patients with secondary peritonitis (p<0.001, p=0.003). Conclusion The distinct characteristics observed across different types of peritonitis underscore the importance of tailored approaches to diagnosis and treatment. Parameters such as CRP levels, sedimentation rates, and patient age could serve as valuable indicators in discerning between various types of peritonitis. When selecting empirical antibiotic therapy, it's crucial to consider coverage for Gram-positive pathogens in cases of PDrP and Gram-negative pathogens in secondary peritonitis.

Giant hepatic hemangioma in a patient with cirrhosis: challenging to manage.

Giant hepatic hemangiomas are occasional in patients with cirrhosis. It remains a challenge to decide on the need for treatment and choose the most appropriate intervention. A 62-year-old woman was recently diagnosed with cirrhosis and complained of upper abdominal fullness, reduction in oral food intake, and weight loss of 6 kg over the last three years. Upper digestive endoscopy evidenced thin-caliber esophageal varices and significant extrinsic compression of the lesser gastric curvature. Abdominal computed tomography revealed an exophytic tumor in the left hepatic lobe, measuring 11.5 cm, which had progressive centripetal contrast enhancement from the arterial phase, compatible with hepatic hemangioma. Serum tumor markers were negative, and her liver function was unimpaired. The patient underwent surgical resection (non-anatomical hepatectomy of segments II and III) which had no immediate complications, and the histopathological evaluation confirmed cavernous hepatic hemangioma. Two weeks later, she was admitted to the emergency room with jaundice, signs of hepatic encephalopathy, and moderate ascites, and was further diagnosed with secondary bacterial peritonitis. As no perforations, abscesses, or fistulas were observed on subsequent imaging tests, clinical management was successfully carried out. This case highlights that giant hepatic hemangiomas may be symptomatic and warrant treatment. In the setting of cirrhosis and portal hypertension, physicians should be aware of the risk of hepatic decompensation following surgical resection, even in patients with Child-Pugh class A.

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.

Intraabdominal Urokinase for the Treatment of Secondary Bacterial Peritonitis in Cirrhosis.

Bacterial peritonitis with loculated ascites in patients with liver cirrhosis can be a therapeutic challenge. We present the case of a patient with liver cirrhosis undergoing pre-transplant evaluation, diagnosed with bacterial peritonitis secondary to urgent surgical intervention Imaging studies identified markedly loculated ascites, with a poor response despite broad-spectrum antibiotic therapy. The use of intraabdominal urokinase was a safe and effective adjuvant treatment for the resolution of this complication.

The impact of direct inoculation of ascites into blood culture bottles on ascites culture positivity

Abstract Objective: Assess whether direct inoculation of ascites into blood culture bottles would improve ascites culture yield. Design: Pre-post-study. Setting: The study was performed at a quaternary academic medical center in Houston, Texas, including all inpatient and emergency department encounters. Patients: Ascites cultures collected from November 2020 to December 2022 were reviewed and screened for spontaneous bacterial peritonitis. Patients were excluded if a prior ascites culture from the same patient was already included in the study or if there was evidence of secondary bacterial peritonitis. Intervention: In the pre-intervention period, ascites cultures were collected into a sterile container and inoculated onto/into solid and liquid media. In the post-intervention period, ascites cultures were instead directly inoculated into bioMérieux© blood culture bottles at the bedside. Results: 114 patients met inclusion and exclusion criteria, 61 pre-intervention and 53 post-intervention. Overall ascites culture positivity was 15.8% (18/114), 11.5% (7/61) pre-intervention vs 20.8% (11/53) post-intervention. After adjusting for confounders, the intervention had a trend toward a significant effect on ascites culture positivity (P = 0.077). No significant differences were seen in time to positivity, hospital length of stay, or 30-day readmission. Conclusions: Direct inoculation of ascitic fluid into blood culture bottles led to a small increase in culture yield but lacked statistical significance. This lack of significance may be due to the study being underpowered. Further studies are required to investigate if this is due to procedural inefficiencies (eg, inadequate inoculation volumes) or pragmatic clinical practice considerations (ie, high rates of pre-culture antibiotics).

Secondary Bacterial Peritonitis and Pelvic Abscess Complicating Recurrent Pyogenic Cholangitis

Secondary Bacterial Peritonitis and Pelvic Abscess Complicating Recurrent Pyogenic Cholangitis

329. Bedside Inoculation of Blood Culture Bottles Does Not Improve Ascites Culture Positivity Rate in Spontaneous Bacterial Peritonitis

Abstract Background Prior research demonstrates increased positivity rate for ascites cultures in spontaneous bacterial peritonitis (SBP) when directly inoculated into blood culture bottles at bedside, versus the “conventional method” - transportation of ascitic fluid in a sealed syringe to the laboratory, centrifuging, and plating on Chocolate, Blood, and MacConkey’s agars and in a Schaedler broth. We hypothesized that collection of ascites via direct inoculation into blood culture bottles would improve ascites culture positivity rate in SBP when compared to prior methods. Methods In November of 2021, our institution implemented a policy in which all ascites cultures were directly inoculated into blood culture bottles at bedside. We retrospectively reviewed all ascites cultures collected from May of 2021 through April of 2022, including all cultures with an absolute neutrophil count of greater than 250 cells/mm3. We excluded all samples from patients with secondary bacterial peritonitis and all samples collected in November. If a patient had multiple samples that met inclusion criteria, only the first was included for analysis. Our primary outcome was positivity rate of cultures pre- and post-implementation of this new policy. Results 1375 ascites cultures were collected. Of these, 52 met our inclusion criteria. These patients were on average 58 years old (range 33-74), 50% female, with a median MELD of 25.5 (range 8-40). The conventional method was positive in 7/37 (18.9%) cultures, and direct inoculation of blood cultures in 1/15 (6.67%), p = .27. Conclusion As opposed to the previous literature, we detected no difference in positivity rate between the conventional method of ascites culture compared to direct inoculation of blood cultures at the bedside. This difference from prior literature may be due to differences in time to inoculation, our smaller sample size, or overfilling of the bottles during inoculation. Disclosures All Authors: No reported disclosures.

Spontaneous Bacterial Peritonitis in Decompensated Liver Cirrhosis—A Literature Review

Background: Spontaneous bacterial peritonitis (SBP) is defined as a bacterial infection of the ascitic fluid without a surgically treatable intra-abdominal infection source. SBP is a common, severe complication in cirrhosis patients with ascites, and if left untreated, in-hospital mortality may exceed 90%. However, the incidence of SBP has been lowered to approx. 20% through early diagnosis and antibiotic therapy. Clinical awareness, prompt diagnosis, and immediate treatment are advised when caring for these patients to reduce mortality and morbidity. Aim: To discuss important issues comprising types of SBP, pathogenesis, bacteriology, including the emergence of multidrug-resistant (MDR) microorganisms, prompt diagnosis, risk factors, prognosis, treatment strategies, as well as recurrence prevention through antibiotic prophylaxis until liver transplantation and future trends in treating and preventing SBP in detail. Methods: This article is a literature review and appraisal of guidelines, randomized controlled trials, meta-analyses, and other review articles found on PubMed from between 1977 and 2022. Results: There are three types of SBP. Bacterial translocation from GI tract is the most common source of SBP. Therefore, two thirds of SBP cases were caused by Gram-negative bacilli, of which Escherichia coli is the most frequently isolated pathogen. However, a trend of Gram-positive cocci associated SBP has been demonstrated in recent years, possibly related to more invasive procedures and long-term quinolone prophylaxis. A diagnostic paracentesis should be performed in all patients with cirrhosis and ascites who require emergency room care or hospitalization, who demonstrate or report consistent signs/symptoms in order to confirm evidence of SBP. Distinguishing SBP from secondary bacterial peritonitis is essential because the conditions require different therapeutic strategies. The standard treatment for SBP is prompt broad-spectrum antibiotic administration and should be tailored according to community-acquired SBP, healthcare-associated or nosocomial SBP infections and local resistance profile. Albumin supplementation, especially in patients with renal impairment, is also beneficial. Selective intestinal decontamination is associated with a reduced risk of bacterial infection and mortality in high-risk group. Conclusions: The standard treatment for SBP is prompt broad-spectrum antibiotic administration and should be tailored according to community-acquired SBP, healthcare-associated or nosocomial SBP infections and local resistance profile. Since the one-year overall mortality rates for SBP range from 53.9 to 78%, liver transplantation should be seriously considered for SBP survivors who are good candidates for transplantation. Further development of non-antibiotic strategies based on pathogenic mechanisms are also urgently needed.

O026 Post-operative mortality following planned versus on-demand relaparotomy for secondary bacterial peritonitis: a literature review

Abstract Introduction Post-operative peritonitis is a life-threatening complication of surgical care, whereby early relaparotomy is paramount in diagnosing and controlling the infective source. Currently, there are no clear guidelines on surgical strategies for re-laparotomy. This study aimed to evaluate the current evidence on the mortality rates and length of hospital admission associated with planned (PR) versus on-demand re-laparotomy (ODR) in patients with secondary peritonitis. Methods Literature review was conducted using Ovid MEDLINE and PubMed to identify English-language papers directly comparing ODR and PR in adults over 18 years. Case reports, reviews and papers including individuals with peritonitis post-pancreatitis or abdominothoracic surgery were excluded. Eight of the 154 studies identified met inclusion criteria following abstract screening. Results No significant difference was found between post-operative mortality in PR and ODR for patients with secondary peritonitis (mean mortality rates 30.0% and 31.7% respectively). ODR was shown to have better overall outcomes in avoiding unnecessary surgeries, reducing infection-related complications and length of ITU admissions. ODR is favoured provided there is no operation delay. However, in patients with extensive peritonitis and high APACHE-II scores, PR is preferred to effectively control infection source. Conclusion Literature analysis shows there is still much debate regarding whether PR or ODR is favoured for post-operative peritonitis. Further randomised control-trials across multiple international centres are required to improve the evidence base for future surgical practice. Take-home message Mortality and complication rates are comparable following planned and on-demand re-laparotomy in patients with post-operative peritonitis. Further international research is required to construct evidence-based guidelines for re-laparotomy and improve our future care for critically unwell surgical patients.

Rarer adverse effect of clozapine

Introduction: Clozapine is an atypical anti-psychotic drug widely used in the treatment of schizophrenia. It reduces suicidal ideations in schizophrenics and hence the mortality. Agranulocytosis is one among the most known serious complication of this drug. However, it can also cause life-threatening complications like necrotizing enterocolitis. Case Report: We report a case of a 31-year-old male with past history of schizophrenia and seizure disorder on 300 mg clozapine and phenytoin 300 mg daily for 10 years. He was admitted for the evaluation of altered sensorium. Blood routine investigations and radioimaging were normal. Electroencephalogram (EEG) showed non-convulsive status epilepticus which was managed with anti-epileptic drugs. His sensorium did not improve. He started to develop fever and loose stools, later developed abdominal distension and pain. On evaluation it was found to have ischemic colitis with secondary bacterial peritonitis. Clozapine was stopped, managed conservatively. The patient recovered completely. Conclusion: Clozapine can cause seizures. The anti-cholinergic effect of this drug can induce focal intestinal necrosis, which when unrecognized progress to transmural ischemia and perforation. Such cases need surgical intervention and is associated with high mortality. A high index of suspicion for early diagnosis, prompt correction of risk factors and early intervention prevents mortality.

Macroscopic and histopathological features of acute peritoneal infection in diabetic and euglycemic Wistar rats.

Impact of the secondary peritoneal infections on the peritoneal morphology in diabetic population remains unclear. To study the histopathological changes of the peritoneum due to secondary bacterial peritonitis in diabetic rats in compari-son to the normoglycemic animals. 13 adult male Wistar rats were divided into 2 groups: control (n = 3) and experimental (n = 10). The latter was subdivided into non-diabetic (n = 5) and diabetic (n = 5). T1DM and peritonitis were induced through the single intraperitoneal injec-tion of Streptozotocin (60 mg/kg) and intraperitoneal injection of 2 ml of the faecal matter, respectively. Macroscopic findings of diabetic rat peritoneum included significant accumulation of the exudate in the peritoneal cavity and presence of intraintestinal adhesions and abscesses. Morphology of the peritonium presented with diffuse, profound degenerative and inflammatory lesions involving the subjacent tissues. In contrast, the underlying muscular layer of the non-diabetic rats remained intact. Natural course of the peritoneal infection in diabetic rats (48 hours) is characterised by diffuse severe peritonitis with inter-intestinal abscess formation and more profound subadjacent tissue involvement in comparison with non-diabetic rats.

Microbial spectrum and antibiotic sensitivity in cirrhotic patients with spontaneous bacterial peritonitis

Objective: There are reports of changing microbial profile of ascitic fluid in spontaneous bacterial peritonitis (SBP) and developing resistance of these bacteria to commonly used antibiotics. This study was done to determine the micro-organism causing SBP and their sensitivity to various antibiotics. Setting and Methods: This observational study was done in Medical department of Sheikh Zayed Medical College/Hospital, Rahim Yar Khan from March to November 2019. Thirty five cirrhotic patients with ascites admitted in ward for various reasons and having positive ascitic fluid culture were included in the study. Exclusion criteria was presence of secondary bacterial peritonitis. Ten ml of ascitic fluid was inoculated in blood culture bottle and sent immediately to hospital laboratory. Results: The mean age of these 35 patients was 48.94 ± 13.51 years with a range of 19 to 80 years. Twenty (57.1 %) patients were male and 15 (42.9 %) were female. Bacteria that had caused SBP were E.coli (62.9 %), staph aureus (11.4 %), klebsiella (8.6 %), streptococci (8.6 %), gram positive cocci (5.7 %) and pseudomonas aeruginosa (2.8 %). Imipenem had high sensitivity rate (100 %) along with amikacin (82.9 %) and cefoperazone-sulbactam (68.6 %). Sensitivity of these organisms to other commonly used antibiotics were: ciprofloxacin 57.1 %, ofloxacin 40 %, norfloxacin 37.1 %, ceftazidime 34.3 %, ceftriaxone 31.4 % and piperacillin-tazobactam 25.7 %. Conclusion: We found that E.coli was the commonest bacteria causing SBP, and ceftriaxone and ciprofloxacin have significantly high resistance rate in these patients. Key words: cirrhosis, ascitic fluid, spontaneous bacterial peritonitis, antibiotic sensitivity

A Rare Case of Pelvic Abscess Due to Spontaneous Non-traumatic Bladder Rupture

Spontaneous bladder rupture is an uncommon and life-threatening urological emergency, and early diagnosis is often challenging. Herein, we report a case of intraperitoneal bladder rupture in an 81-year-old male with neurogenic bladder-the case of intraperitoneal bladder rupture required late laparotomy for pelvic abscess following initial conservative treatment.An eighty-one-year-old male presented to our emergency department with deterioration of consciousness, fever, and hematuria. He denied previous trauma history and had been treated for neurogenic bladder. Physical examination revealed signs of tenderness in the abdomen. A diagnosis of bladder rupture was made based on laboratory examination indicating renal failure and radiological imaging showing urinary ascites. Conservative management with a Foley catheter and antibiotics (meropenem administered 1 g/day) was initiated. On day seven after admission, the patient complained of abdominal pain and fever, and a diagnosis of pelvic abscess based on contrast-enhanced computed tomography and septic peritonitis was made. An emergency exploratory laparotomy for peritoneal drainage was performed. The postoperative course was uneventful, and the patient was discharged on day 29 after admission.Urinary bladder rupture should always be considered as a differential diagnosis in patients presenting with free fluid in the abdomen, peritonitis, reduced urine output, and hematuria. Clinicians should be aware that secondary bacterial peritonitis can occur as a major complication of a ruptured urinary bladder.

S2884 Pelvic Inflammatory Disease as an Unusual Cause of Ascites

Introduction: Pelvic inflammatory disease (PID) is an infection of the upper genital tract, including the uterus, fallopian tubes, and/or ovaries. Neisseria gonorrhea, Chlamydia trachomatis, and Mycoplasma genitalium are the most frequently isolated pathogens. Case Description/Methods: A 25-year-old female presented with an 8-day history of lower abdominal pain associated with fevers, chills, vomiting, and non-bloody diarrhea. Patient denied recent travel, changes in her diet, family history of Inflammatory Bowel Disease. Her abdomen was diffusely tender. Routine laboratory testing was unremarkable. CT scan of the abdomen and pelvis (Figure 1) showed focal small bowel mural thickening, concerning for gastroenteritis. COVID PCR, HIV antigen/antibody, blood cultures, Clostridium difficile toxin and stool pathogen PCR panel were all negative. Patient was presumed to have viral gastroenteritis and was discharged home. She was readmitted two days later for worsening nausea and vomiting. Laboratory testing was significant for WBC 12.7 x 109/L, potassium of 2.8 mEq, INR 1.7, CRP 19.24 mg/dL. A repeat CT abdomen and pelvis (Figure 2) showed a re-demonstration of marked wall thickening of the small bowel most consistent with enteritis, and the development of large loculated ascites in the mid abdomen and pelvis with peritoneal thickening and enhancement. Diagnostic paracentesis showed PMNs 990, RBCs 4000, SAAG < 1.1, total protein 3.7 g/dl, glucose 29 mg/dl, and LDH 1609 U/L. Peritoneal cultures grew Neisseria gonorrhea. Patient was discharged home on a two-week course of IV ceftriaxone, metronidazole and doxycycline with improvement in clinical symptoms. Repeat diagnostic imaging showed interval improvement and resolution of ascites. Discussion: Acute symptomatic PID presents with lower abdominal pain associated with fevers, chills, nausea, vomiting, vaginal discharge and/or intermenstrual bleeding. PID may present with RUQ pain in the setting of liver capsular inflammation, also known as perihepatitis i.e. Fitz-Hugh Curtis Syndrome. Perihepatitis occurs in about 10% of woman with acute PID. However, the development of ascites as a presenting complication of PID is very rare. In this case, the ascites fluid studies were not consistent with portal hypertension with a SAAG < 1.1. In addition, PMNs > 250 cells suggested bacterial peritonitis. Furthermore, per the Runyon’s criteria, this pattern resembled secondary bacterial peritonitis with a total protein >1 g/dL, glucose < 50 mg/dL, and LDH > upper limit of normal serum.Figure 1.: CT abdomen and pelvis on presentation showing small bowel mural thickening and enhancement.Figure 2.: CT abdomen and pelvis on representation showing large volume ascites with continued small bowel mural thickening and enhancement.

P-124 POST PARACENTESIS COMPLICATIONS IN PATIENTS WITH DIAGNOSIS OF LIVER CIRRHOSIS

Post paracentesis complications are correlated to a high morbidity and mortality rate in patients with a diagnosis of liver cirrhosis, among whom a high incidence of them has been observed after performing this procedure. To identify post paracentesis complications in patients diagnosed with liver cirrhosis in the Department of Internal Medicine of the Roosevelt Hospital from January 1 to December 31, 2018, Guatemala. Cross-sectional descriptive study carried out in patients with a diagnosis of liver cirrhosis who had undergone decompressive / diagnostic paracentesis. The majority of patients were male (70%) with child pug C liver cirrhosis (71%) aged between 40 to 49 years of age (44%), with less than 1 year of diagnosis of liver cirrhosis (64%). Persistent leakage of ascites fluid from the puncture site was the most frequent complication (35%), followed by secondary bacterial peritonitis and hematoma of the abdominal wall at the puncture site (13% and 12% respectively). A third of the patients did not present any complications after the procedure (31%). Alteration in liver function tests (0.0001), decreased platelets and prolonged clotting times (0.001) presented a statistically significant relationship of greater probability of presenting some complication after the procedure, the bilirubin level did not present a statistically significant relationship for complications occur. (0.3). A third of the patients were indicated decompressive paracentesis (48%), of which a higher rate of complications was observed after the procedure (67%). The most frequent complication was the persistent leakage of ascites fluid. Hypoalbuminemia, coagulopathy, and platelet alteration correlate with a higher risk of complications.

EFFICACY OF CIPROFLOXACIN AND CEFOTAXIME IN PATIENTS WITH CIRRHOSIS LIVER PRESENTING WITH SPONTANEOUS BACTERIAL PERITONITIS TO A TERTIARY CARE HOSPITAL

Spontaneous Bacterial Peritonitis (SBP), a known complication of cirrhosis Liver is an acute bacterial infection of the peritoneum. Usually no source of infection is easily identifiable.&#x0D; Objective:&#x0D; To compare the efficacy of Ciprofloxacin and Cefotaxime in Cirrhosis Liver patients with SBP.&#x0D; Material and Methods: This prospective, comparative, single center study was conducted in the Department of Medicine, Khyber Teaching Hospital Peshawar from 1st October 2017 to 31st December 2018. A total of 300 admitted patients having Cirrhosis Liver with SBP were included in this study. The patients were randomized into Group A and Group B. Group A was treated with Intravenous Ciprofloxacin and Group B was treated with Intravenous Cefotaxime given twice daily for a period of 5 days. Diagnostic peritoneal paracentesis was done before the start of the treatment and repeated after 5 days therapy. Patients who were either non cirrhotic or had secondary bacterial peritonitis were excluded from the study.&#x0D; Results: A total of 300 Cirrhosis Liver patients with SBP were studied in two equal randomized groups. Out of these 168 were male and 132 were female. The mean age of patients in study was 51.14±11.9 years. The age ranged between 15-75 years. In Group A, 82 percent responded to ciprofloxacin and in group B, 86 percent responded to cefotaxime.&#x0D; Conclusion:&#x0D; Both intravenous ciprofloxacin and cefotaxime are effective in treating spontaneous bacterial peritonitis in patients with Cirrhosis Liver.&#x0D; Key Words: Ciprofloxacin, Cefotaxime, Spontaneous bacterial peritonitis, Efficacy.

Predictors of spontaneous bacterial peritonitis in Romanian adults with liver cirrhosis: Focus on the neutrophil-to-lymphocyte ratio.

Spontaneous bacterial peritonitis (SBP) is a severe complication of liver cirrhosis whose diagnosis is based on a polymorphonuclear leukocyte (PMN) value >250 mm3, yet this PMN value cannot identify all existing types. The aim of our study was to determine the clinical and biological factors that were associated with SBP and predict its occurrence, focusing on the neutrophil-to-lymphocyte ratio (NLR) as one of them. Our retrospective study included 216 patients with liver cirrhosis who were hospitalized between December 2019 and January 2010 at the Emergency County Clinical Hospital of 'St. Apostle Andrew' in Constanta, Romania. Demographic, clinical, and laboratory data were collected from patient observation sheets. The patients were divided into two groups: One group of patients with SBP and the other without SBP. The diagnosis of SBP was made when patients presented with PMN >250 mm3 and other causes of secondary bacterial peritonitis were excluded. The mean age of the patients was 61.25±10.67 years, and the alcoholic etiology of liver cirrhosis was most common (44%). Univariate logistic regression analysis showed that there was an association between biological parameters, such as serum white blood cells, total platelet count, total bilirubin, serum albumin, international normalized ratio, creatinine, erythrocyte sedimentation rate (ESR), serum sodium, alkaline reserve, and NLR, and clinical parameters, such us upper gastrointestinal bleeding and cardiac comorbidities in the occurrence of SBP. Multivariate analysis identified ESR and NLR as predictive factors in the occurrence of SBP. The area under the curve (AUC) was 0.916 [P<0.001, 95% confidence interval (CI) 0.870-0.949] for ESR and AUC was 0.963 (P<0.001, 95% CI 0.928-0.984) for NLR, respectively. In conclusion, the combination of these 2 biological parameters is useful in identifying or excluding SBP.

Antibiotic prophylaxis for prevention of spontaneous bacterial peritonitis in liver cirrhosis: systematic review.

Spontaneous bacterial peritonitis is a potentially life-threatening infection in patients with liver cirrhosis and ascites. Its prevention is vital to improve prognosis of cirrhotic patients. The main objective of this systematic review was to evaluate what is the most efficacious and safest antibiotic prophylactic strategy. Studies were located by searching PubMed and Cochrane Central Register of Controlled Trials in The Cochrane Library until February 2019. Randomized controlled trials evaluating primary or secondary spontaneous bacterial peritonitis prophylaxis in cirrhotic patients with ascites were included. The selection of studies was performed in two stages: screening of titles and abstracts, and assessment of the full papers identified as relevant, considering the inclusion criteria. Data were extracted in a standardized way and synthesized qualitatively. Fourteen studies were included. This systematic review demonstrated that daily norfloxacin is effective as a prophylactic antibiotic for the prevention of spontaneous bacterial peritonitis in patients with cirrhosis. Once weekly ciprofloxacin was not inferior to once daily norfloxacin, with good tolerance and no induced resistance. Trimethoprim-sulfamethoxazole and norfloxacin have similar efficacy for primary and secondary prophylaxis of spontaneous bacterial peritonitis, however, trimethoprim-sulfamethoxazole was associated with an increased risk of developing an adverse event. Rifaximin was more effective than norfloxacin in the secondary prophylaxis of spontaneous bacterial peritonitis, with a significant decrease in adverse events and mortality rate. Continuous long-term selective intestinal decontamination with norfloxacin is the most widely used prophylactic strategy in spontaneous bacterial peritonitis, yet other equally effective and safe options are available.

Moraxella Peritonitis in a Non-Peritoneal Dialysis Patient

<strong>Background:</strong> Spontaneous Bacterial Peritonitis is a serious complication of ascites in patients with liver cirrhosis. Most commonly, the cause is monomicrobial, the usual suspects being E. Coli, K. pneumoniae, and sometimes, S. pneumoniae. Moraxella, a gram-negative coccobacillus, is a rare cause of secondary bacterial peritonitis in patients undergoing peritoneal dialysis. In this paper, we present a patient with spontaneous bacterial peritonitis, with no history of peritoneal catheterization or peritoneal dialysis, with Moraxella spp. as the causative agent. To the best of our knowledge, this is the only reported case of spontaneous Moraxella peritonitis. <strong>Presentation:</strong> A 63-year-old gentleman, with alcoholic liver cirrhosis and chronic refractory ascites, was referred to the Emergency Room, from the Gastroenterology outpatient clinic, when he presented with the chief complaints of worsening abdominal distension and abdominal discomfort. Leukocytosis was noted and abdominal ultrasound showed moderate ascites. The patient underwent diagnostic and therapeutic paracentesis. The SAAG was calculated to be 0.8 with a total WBC count of 330 cells/mm3 (98% lymphocytes and 2% polymorphs). While the laboratory analysis of the ascitic fluid did not meet the criteria for spontaneous bacterial peritonitis (SBP), the cultures grew Moraxella spp. No other source of infection was identified. The patient was started on Doxycycline and Cefpodoxime for likely spontaneous bacterial peritonitis as sensitivities were not available, and the patient demonstrated clinical improvement, with a decrease in abdominal pain and tenderness, and a decrease in leukocytosis. He was discharged with an outpatient gastroenterology appointment and antibiotics for secondary prophylaxis. <strong>Discussion:</strong> Although rare, there is data to establish Moraxella as an often-encountered pathogen causing peritonitis in peritoneal dialysis patients. However, there is insufficient literature regarding its role in SBP, resulting in delays in establishing a diagnosis and in initiating treatment. A greater understanding of this organism will help further the knowledge of its pathogenicity and help recognize optimal antibiotic choices.

Comparative Evaluation of Various Methods of Drainage of the Abdominal Cavity in Patients with Secondary Bacterial Peritonitis

Background: Secondary peritonitis is a serious complication of all the inflammatory diseases and injuries of the abdominal organs and requires urgent surgical intervention. The mortality rate of patients with secondary bacterial peritonitis (SBP) reaches 70%. In some patients, despite the treatment, secondary peritonitis turns into tertiary peritonitis (TP), which complicates the healing process and aggravates the prognosis. Inadequate drainage of the abdominal cavity is a possible contributing factor to the formation of TP. Aims: A prospective study of the result of surgical treatment of patients with SBP was carried out to improve the results of treatment. Methods. The study included 608 patients with SBP who underwent surgery in a clinical hospital in Russia in 2013-2019. All the patients were divided into groups depending on the method of draining the abdominal cavity and on signs of the purulent process generalization, the marker of which was multiple organ failure. Efficiency of abdominal drainage (by the incidence of TP) and of treatment results (in terms of mortality) were assessed in each group. Results: In patients without signs of the purulent process generalization, drainage of the abdominal cavity with drainage tubes (293 observations) is accompanied by the development of TP in 4.1% of cases and by mortality in 22.9%. If the purulent process is of a generalized nature (315 observations), the incidence of TP increases ten-fold and is 41.9%, and the mortality rate increases 2.7 times and reaches 62.8%. With the generalization of the purulent process, the efficiency of drainage of the abdominal cavity has a significant impact on the results of surgical treatment of patients with SBP. If abdominal drainage is carried out with drainage tubes (129 observations), the incidence of TP is 41.9%, and the mortality rate is 62.8%. Drainage of the abdominal cavity using traditional laparostomy (Bogota bag, 104 cases) is accompanied by the development of TP in 36.5% of cases and mortality in 45.2%. If the abdomen is drained using active laparostomy (VAC-system, 82 observations), the incidence of TP is reduced to 18.3% and mortality to 19.5%. Conclusion. Drainage of the abdominal cavity is the most important stage of surgical intervention in patients with SBP. In cases of the purulent process generalization, drainage of the abdominal cavity in the most effective way– by active laparostomy (VAC-system) will improve the results of treatment of these patients.