Spontaneous Bacterial Peritonitis In Cirrhosis Research Articles

A Study of Spontaneous Bacterial Peritonitis in Cirrhosis of Liver with Ascites at a Tertiary Care Hospital in North India: Prevalence, Clinical, and Microbiological Profile

Background and Objectives: In patients with chronic liver disease and ascites, spontaneous bacterial peritonitis (SBP) is a common complication. This can progress gradually and subtly or go undiagnosed until signs start to show. Early diagnosis is essential for effective treatment and the prevention of subsequent episodes because the mortality rate following a single episode varies from 20% to 40%. The goal was to study the incidence, clinical profile, and microbiological characteristics of SBP and its variants in people with liver cirrhosis and ascites. Materials and Methods: This observational study was done on 104 cirrhotic patients with ascites admitted at a tertiary care hospital. Basic demographics, symptoms, and clinical signs of patients were recorded. Diagnostic paracentesis was done aseptically and immediately sent for ascitic fluid cytology, biochemistry, and culture. Bacterial examination and antibiotic sensitivity tests were carried out by standard microbiological techniques. Results: Out of a total of 104 cirrhotic patients, 28 (26.9%) were diagnosed with SBP. Alcohol was the most common etiological factor, followed by hepatitis C infection. Among the SBP patients, the most common presentation was culture-negative neutrocytic ascites (71.4%), followed by classical SBP (17.8%), then mono bacterial non neutrocytic bacterascites MNB (10.7%). Among the symptoms, the most common was abdominal distension, followed by icterus, pedal edema, and abdominal pain. Majority of the patients belonged to Child–Pugh’s Grade C. Of 28 cases of SBP, 8 were culture positive. Gram-negative isolates were predominant (75%) and Escherichia coli were the most common isolate. Interpretation and Conclusion: The prevalence of SBP in cirrhotic patients was 26.9%, and Gram-negative isolates were predominant. Ascitic fluid culture and susceptibility testing can lead to accurate diagnosis of SBP and can guide for treatment as resistance to antibiotics is common.

The factors associated with the trend in incidence of Bacteraemia and associated mortality over 30 years

BackgroundStudies have reported increased incidence of BSI over the past decades and indicate that it is necessary to investigate the causes. The aim of this study was to determine the factors affecting trends in the incidence of bacteraemias and associated mortality.MethodsWe conducted a retrospective cohort study assessing prospectively collected data of all clinically significant bacteraemias between 1991 and 2020 in a 450-bed hospital. We determined the evolution of bacteraemia-associated incidence, adjusted 30-day mortality and performed multivariable logistic regression to compare the evolution of variables associated with mortality between 5-year periods.Results6777 episodes were included, 59.7% males, age 66.5 ± 18.2, 39.4% ≥ 75 years. The incidence total increased: 43.8/100,000/year in 1991–1995 to 205 in 2016–2020; community-acquired bacteraemia (24.9 to 139) and hospital-acquired (0.36/1000 inpatients-days to 1.09). Bacteraemia with source in vascular catheter, urinary and biliary tract increased. The 30-day mortality rate of patients was 1179/6777 (17.4%) in the whole series and population-adjusted mortality incidence increased from 11.4/100,000 in 1991–1996 to 28.4 in 2016–2020 (RR 2.49, 95% CI 2.01–3.08). Mortality was higher in men (18.2% vs 16.3%) and those over 74 years (22.2% vs 14.3%). Appropriate empirical antimicrobial treatment improved (66.5% to 73.1%), 30-day mortality of patients decreased from 26.1 to 13.9%. When comparing the evolution of the factors associated with mortality between 1991 and 1996 vs 2016–2020, the frequency of some variables associated with higher mortality increased: male sex (OR 1.38, 95% CI 1.10–1,74), age (OR 1.02, 1.01–10.3), immunosuppressive treatment (OR 3.1, 2.09–4.6), polymicrobial bacteraemia (OR 1.76, 1.12–2.79), and others decreased: severe sepsis/septic shock (OR 0.70, 0.52–0.93), spontaneous bacterial peritonitis in cirrhosis (OR 0.06, 0.02–0.23), endocarditis (OR 0.54, 0.35–0.83); on the other hand, the frequency of factors associated with lower mortality increased: urinary (OR 1.67, 95% CI 1.23–2.27) and bile tract source (OR 1.59, 1.04–2.43), and adequate empirical treatment (OR 1.42, 95% CI 1.10–1.83).ConclusionsThe incidence of bacteraemia increased due to more elderly, co-morbid patients undergoing procedures and more device related bacteraemia. The percentage of mortality decreased because adequate empirical treatment improved, decreased spontaneous bacterial peritonitis in cirrhosis and endocarditis, and increased bacteraemia of urinary and biliary tract source.

STUDY OF PROGNOSTIC INDICATORS IN PATIENTS WITH CIRRHOSIS OF LIVER WITH ASCITIS AND SPONTANEOUS BACTERIAL PERITONITIS

Spontaneous bacterial peritonitis(SBP) is dened as ascitic uid infection in the absence of any obvious intraabdominal source of infection. The mortality rate is approximately 30-50% The objective of this study is to study predictors of mortality on patients with spontaneous bacterial peritonitis in cirrhosis of liver patients. Methods: Fifty patients diagnosed with cirrhosis of liver reporting to ACSR GGH, Nellore were included in the study. SBPwas diagnosed based on ascitic uid ascitic uid PMN count >250. Serial ascitic uid cell count was done at 24 hours, 48 hours and 5 days.The results were compared between survivors and non survivors. Results: Male: female ratio was 2:1.Study showed 42% mortality. TLC above 11000/mm3,total bilirubin above > 4 mg/dl, serum creatinine >1.5 were associated with increased mortality .Interpretation & Conclusion: Ascitic uid PMN count > 600 at the time of diagnosis, 700 at 24 hrs, 450 at 48 hrs was associated with poor prognosis. AProgressive fall in serial ascitic uid cell PMN count was associated with good prognosis

ASEPTIC: primary antibiotic prophylaxis using co-trimoxazole to prevent SpontanEous bacterial PeritoniTIs in Cirrhosis—study protocol for an interventional randomised controlled trial

BackgroundBacterial infection is a major cause of mortality in patients with cirrhosis. Spontaneous bacterial peritonitis (SBP) is a serious and common infection in patients with cirrhosis and ascites. Secondary prophylactic antibiotic therapy has been shown to improve outcomes after an episode of SBP but primary prophylaxis to prevent the first episode of SBP remains contentious. The aim of this trial is to assess whether primary antibiotic prophylaxis with co-trimoxazole improves overall survival compared to placebo in adults with cirrhosis and ascites.MethodsThe ASEPTIC trial is a multicentre, placebo-controlled, double-blinded, randomised controlled trial (RCT) in England, Scotland, and Wales. Patients aged 18 years and older with cirrhosis and ascites requiring diuretic treatment or paracentesis, and no current or previous episodes of SBP, are eligible, subject to exclusion criteria. The trial aims to recruit 432 patients from at least 30 sites. Patients will be randomised in a 1:1 ratio to receive either oral co-trimoxazole 960 mg or an identical placebo once daily for 18 months, with 6 monthly follow-up visits thereafter (with a maximum possible follow-up period of 48 months, and a minimum of 18 months). The primary outcome is overall survival. Secondary outcomes include the time to the first incidence of SBP, hospital admission rates, incidence of other infections (including Clostridium difficile) and antimicrobial resistance, patients’ health-related quality of life, health and social care resource use, incidence of cirrhosis-related decompensation events, liver transplantation, and treatment-related serious adverse events.DiscussionThis trial will investigate the efficacy, safety, and cost-effectiveness of co-trimoxazole for patients with liver cirrhosis and ascites to determine whether this strategy improves clinical outcomes. Given there are no treatments that improve survival in decompensated cirrhosis outside of liver transplant, if the trial has a positive outcome, we anticipate widespread adoption of primary antibiotic prophylaxis.Trial registrationClinicalTrials.gov NCT043955365. Registered on 18 April 2020. Research ethical approval was granted by the Research Ethics Committee (South Central – Oxford B; REC 19/SC/0311) and the Medicines and Healthcare products Regulatory Agency (MHRA).

Frequency of Spontaneous Bacterial Peritonitis in Cirrhosis of Liver in Department of Medicine at People Medical College Hospital Nawabshah Pakistan

Introduction: Bacterial Infections in cirrhosis of liver is one of the main complications with increase mortality rate. Infection of ascitic fluid in cirrhosis of liver was introduced by Conn and fessel [2], termed as spontaneous bacterial peritonitis.
 Objective: To determine the frequency of Spontaneous Bacterial Peritonitis (SBP) in patients presenting with cirrhosis of liver.
 Methodology: It is a descriptive cross-sectional study which was performed in the Medicine Ward at People’s Medical College Hospital Nawabshah Pakistan from 1st June 2018 to 31 July 2020. Total 100 admitted patients were selected for this study, male patient were 58 and female patient were 42. Consent was taken from the patients and their relatives. Primary and secondary outcomes measured. All the patients with diagnosis of cirrhosis of liver were included for this study, ascites due to other causes and patients on antibiotic therapy were excluded from this study. Ascitic fluid aspirated for culture and DR. Blood CP, Urea, Creatinine, LFT and PT was performed.
 Results: Among these 100 patients 13 were culture positive raised ascites PMN, 17 were culture negative raised ascites PMN. E. coli was detected in majority of the culture positive patients. 70 patients presented with sterile ascites. SBP patients presented with fever, abdominal pain, jaundice, Encephalopathy and raised prothrombin time.
 Conclusion: SBP common complication of cirrhosis associated with high mortality. All cirrhotic Patients admitted in medical wards with history of abdominal pain, fever and Encephalopathy, diagnostic paracentesis is compulsory. Early management with intravascular expansion with albumin and antibiotics with good prognosis mortality can be reduced.

Recurrence of spontaneous bacterial peritonitis in cirrhosis: novel predictors.

Recurrence of spontaneous bacterial peritonitis (SBP) is still a matter of debate. We conducted this study to evaluate the probable factors that predict the recurrence of SBP in patients who recovered from the first episode of SBP and the long-term outcomes of SBP recurrence. One hundred twenty-four patients diagnosed with liver cirrhosis, SBP and did not receive secondary prophylaxis either with norfloxacin or other antibiotics were included in this prospective cohort pilot study. Clinical, biochemical and ascitic fluid analysis parameters were evaluated. Ascitic fluid interferon-γ-induced protein (IP-10), calprotectin, interleukin-6 and tumor necrosis factor-α were measured by ELISA. Of these, 76 patients survived with an in-hospital mortality rate of 38.7%. The survivors were classified into two groups according to recurrence and nonrecurrence of SBP and survival time, clinical parameters and cause of death were investigated. Thirty-one participants had one or more attacks of SBP, with a recurrence rate of 40.8% within one-year follow-up. Before discharge, multivariate analysis showed that ascitic IP-10 (≥1220 pg/ml), ascitic calprotectin (≥550 ng/ml), serum albumin (≤2.5 g/dl), nonuse of prophylactic β-blockers and use of proton-pump inhibitors (PPIs) were the independent variables in predicting recurrent SBP. Sepsis-related organ failure was the most common etiology of mortality in the recurrent SBP group within 3 and 6 months. Increased ascitic calprotectin and IP-10, hypoalbuminemia, nonuse of prophylactic β-blockers and use of PPI were independently associated with increased SBP recurrence rate. Sepsis-related organ failure was the most common etiology of mortality.

Calprotectin as Diagnostic Marker for Hepatic Encephalopathy and Spontaneous Bacterial Peritonitis in Cirrhosis.

Calprotectin is a well-established marker for intestinal inflammation, mainly in inflammatory bowel disease, and represents one of the most studied biomarkers in stool samples. Apart from its important diagnostic role in inflammatory bowel disease, there are few studies showing that calprotectin can also be used as a diagnostic tool in patients suffering from hepatic encephalopathy (HE) and spontaneous bacterial peritonitis (SBP) in cirrhosis. Since calprotectin concentration in the human stool or in ascites is elevated at an early stage of inflammation, it might serve as an early screening tool for patients suffering from cirrhosis who are at risk to develop these conditions. As detection and monitoring of HE and SBP may be unclear and resource-intensive, identification of valid new markers of disease activity is necessary. In this review, we summarize the current knowledge of calprotectin as a diagnostic biomarker in cirrhosis, indicating that it is a highly promising diagnostic surrogate marker to screen for the presence of HE and SBP. To screen cirrhotic patients for SBP, calprotectin should be assessed in ascitic fluid while it should be measured in feces when screening for HE. However, the value of calprotectin in managing individual patients must be considered in the specific clinical context.

Effect of acute kidney injury on long-term outcomes of spontaneous bacterial peritonitis in cirrhotic patients using the International Club of Ascites-acute kidney injury criteria.

This study aimed to investigate the effect of acute kidney injury (AKI) on long-term mortality of spontaneous bacterial peritonitis (SBP) in cirrhotic patients using International Club of Ascites (ICA)-AKI criteria. A total of 157 cirrhotic patients with a first episode of SBP between 2007 and 2016 were analyzed. We investigated the long-term mortality with related risk factors of SBP in cirrhosis including the ICA-AKI criteria. The ICA-AKI stage at SBP diagnosis is evaluated by stages 0-3. Stage progression was defined as a progression of AKI to a higher stage. The ICA-AKI stage at the diagnosis of SBP was stage 0 in 91 (58%), stage 1 in 33 (21%), stage 2 in 19 (12%), and stage 3 in 14 patients (9%). Stage progression within 48h after SBP diagnosis was noted in 18 patients (12%). Multivariable analysis showed that the risk factors for overall survival were age ≥60years (hazard ratio [HR] 1.74, P=0.029), serum sodium ≤130mmol/L (HR 1.3, P=0.017), ICA-AKI stage 1 (HR 2.51, P=0.003), ICA-AKI stage 2 or 3 (HR 3.36, P<0.001), and stage progression at 48h after SBP diagnosis (HR 2.57, P=0.004). The differences in overall survival using the ICA-AKI in patients without AKI using the conventional criteria were significantly different (P=0.019). Acute kidney injury and its progression are significant risk factors for mortality in cirrhotic patients with SBP. The application of the ICA-AKI criteria is important and advantageous for early evaluation and intervention for a better prognosis in cirrhotic patients with SBP.

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

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

Genetic variants of TRAF6 modulate peritoneal immunity and the risk of spontaneous bacterial peritonitis in cirrhosis: A combined prospective-retrospective study

Alterations of the innate immunity contribute to the development of spontaneous bacterial peritonitis (SBP) in liver cirrhosis. Given its role in immune signaling, antimicrobial function, and macrophage differentiation, we hypothesized that genetic polymorphisms of TRAF6 modulate the risk of SBP. Thus, we determined theTRAF6 haplotype in 432 patients with cirrhosis and ascites using the haplotype-tagging single nucleotide polymorphisms rs331457 and rs5030419. In addition, peritoneal macrophages were immunomagnetically isolated and characterized. Overall, 122 (28%) patients had an episode of SBP. In the combined prospective-retrospective analysis the frequency of SBP differed between the four haplotypes (P = 0.014) and was the highest in 102 patients carrying the rs331457 but not the rs5030419 variant, when compared to other haplotypes (odds ratio 1.95 [1.22–3.12]) or to the wild-type (odds ratio 1.71 [1.04–2.82]). This association was confirmed in multivariate logistic regression (adjusted odds ratio 2.00 [1.24–3.22]) and in prospective sensitivity analysis (hazard ratio 2.09 [1.08–4.07]; P = 0.03). The risk haplotype was associated with lower concentrations of the immune activation marker soluble CD87 in ascitic fluid and with a decreased expression of IL-6 and CXCL8 in isolated peritoneal macrophages. In conclusion, genetic polymorphisms of TRAF6 are associated with decreased peritoneal immune activation and an increased risk of SBP.

Su1526 Proton Pump Inhibitors and Risk of Spontaneous Bacterial Peritonitis in Cirrhosis: An Updated Meta-Analysis

Su1526 Proton Pump Inhibitors and Risk of Spontaneous Bacterial Peritonitis in Cirrhosis: An Updated Meta-Analysis

Management of uninfected and infected ascites in cirrhosis.

Ascites is the most frequent complication of patients with cirrhosis. Ascites is related to increased renal sodium retention as a result of increased activity of the renin-angiotensin-aldosterone system in response to marked vasodilation of the splanchnic circulation. Management of uncomplicated ascites is based on a low-sodium diet and diuretics. However, approximately 10% of patients develop refractory ascites during follow-up, which is associated with a poor prognosis. The treatment of choice in patients with refractory ascites is large-volume paracentesis associated with intravenous albumin. Moreover, patients who develop refractory ascites should be considered as candidates for liver transplantation. Patients with ascites are all at risk of developing spontaneous bacterial peritonitis (SBP). SBP is a common infection in patients with cirrhosis with a risk of mortality of 20%. Empirical antibiotics are the treatment of choice in patients with SBP but differ depending on the acquisition site of infection, because nosocomial infections have a higher risk of being caused by multiresistant bacteria. In addition to antibiotic treatment, all patients with SBP should also receive intravenous albumin. This review summarizes the management of uninfected ascites and SBP in cirrhosis.

A quick screening model for symptomatic bacterascites in cirrhosis

Background:Diagnosis of spontaneous bacterial peritonitis in cirrhosis can be made when a patient has an ascites polymorphonuclear leukocyte count ≥250/mm3. However, symptomatic bacterascites, which is a variant of spontaneous bacterial peritonitis with signs of infection but an ascites polymorphonuclear leukocyte count <250/mm3, cannot be confirmed until the time-consuming ascites culture becomes positive. Currently, early indicators for symptomatic bacterascites remain undetermined.Aims:To develop a quick screening model for early detection of symptomatic bacterascites in cirrhosis.Materials and Methods:Data on patients with cirrhotic ascites from two hospitals (from 2010 to 2014) were collected retrospectively. Patients with symptomatic bacterascites were enrolled in the case group and compared with patients without any infection in the control group. Logistic regression analysis was used to build a model for screening symptomatic bacterascites, and a receiver operating characteristics curve was used to assess the model.Results:In total, 103 patients were enrolled in the case group and 204 patients were enrolled in the control group. A screening model was constructed based on body temperature, abdominal tenderness, blood neutrophil percentage, blood total bilirubin, prothrombin time, and ascites nucleated leukocyte count. The area under the receiver operating characteristic curve was 0.939; a screening score of 0.328 was the best cutoff value.Conclusion:Patients with suspected symptomatic bacterascites can be quickly screened according to the developed model, and a screening score ≥0.328 indicates symptomatic bacterascites.

The Negative Prognostic Impact of a First Ever Episode of Spontaneous Bacterial Peritonitis in Cirrhosis and Ascites.

The prognostic impact of the first ever episode of spontaneous bacterial peritonitis (SBP) on patient outcomes is not well described. Our aim was to compare the clinical outcomes of cirrhotic patients with ascites, and with or without a first episode of SBP. Consecutive patients with cirrhosis and ascites were prospectively enrolled. Demographics, liver and renal function, and hemodynamics were documented at baseline, at resolution of SBP, and thereafter at 4 monthly intervals for 12 months. Complications of cirrhosis and survival were noted. Twenty-nine cirrhotic patients with a first ever episode of SBP (group A) and 123 control patients slightly younger but similar in gender who never had SBP (group B) were enrolled. At SBP diagnosis, group A had worse liver and renal function (Model of End-Stage Liver Disease : 21.1±10.6 vs. 14.4±5.0), lower serum sodium concentrations, and a more hyperdynamic circulation compared with group B (all P<0.001). SBP resolution resulted in improvement in all measures to baseline levels. During follow-up, group A required more frequent hospital admissions than group B (58% vs. 43%), developed more cirrhotic complications, including further SBP (31% vs. 3%*), hyponatremia (12% vs. 0.8%*), acute kidney injury (50% vs. 23%*), hepatorenal syndrome type 1 (46% vs. 7%*), liver transplantation (62% vs. 30%*), and had a worse overall 1-year survival (38% vs. 70%*) (*P<0.05). A first SBP episode is commonly followed by multiple complications, and overall worse prognosis. Consideration should be given to assess cirrhotic patients for liver transplant after the first episode of SBP.

Spontaneous bacterial peritonitis caused by Aeromonas caviae in a patient with cirrhosis.

Spontaneous bacterial peritonitis (SBP) is a common complication of cirrhosis. Based on our current understanding of SBP, the most common etiologies for SBP in cirrhosis are Enterobacter and Streptococcal species. Th e Aeromonas species are ubiquitous in fresh or sea water. Aeromonas caviae is never identified as etiology in cases of SBP. A patient, who had a history of liver cirrhosis related to chronic hepatitis B virus infection for 1 year, presented with diarrhea. He had diarrhea 1 week later returned from coastal city. He was hospitalized and treated with norfloxacin after 7 days of severe symptoms, including fever, abdominal distention, and diarrhea. Analysis of the ascitic specimen revealed a white-cell count of 4.42 × 109 cells/L with 88% neutrophils. Analysis of stool specimen showed a white-cell count of 60 cells per high-power field. Th e patient started the injection of cefriaxone at a dose of 4 g/d. However, the situation was not improved. Th ree days later, stool and ascitic fluid culture showed positive for Aeromonas caviae. Antibiotic susceptibility testing revealed that imipenem, meropenem, amikacin, and cefoperazone-sulbactam were highly sensitive to the Aeromonas caviae. However, the bacilli resisted to ceftriaxone, ceftazidime, ampicillin-sulbactam, levofloxacin, and sulfamethoxazole. Ceftriaxone was then switched to imipenem. The patient was fully recovered 14 days later. Aeromonas caviae is a rare pathogen of SBP in cirrhosis. It resists to third-generation of cephalosporin and fluroquinolone, which are of frequently used dependent on clinical experience. It needs a special attention.

Proton pump inhibitor therapy does not increase the incidence of spontaneous bacterial peritonitis in cirrhosis: A multicenter prospective study

Retrospective studies show an association between proton pump inhibitor (PPI) therapy and spontaneous bacterial peritonitis (SBP). We investigate the relationship between PPI and SBP in decompensated cirrhotic patients in a large nationwide prospective study. Seven hundred seventy patients with a diagnosis of decompensated cirrhosis were admitted consecutively in 23 hospitals in Argentina from March 2011 to April 2012; the patients were carefully investigated for PPI consumption in the previous 3 months. In total, 251 patients were excluded because of active gastrointestinal hemorrhage, antibiotic use during the preceding weeks, HIV-positive status and immunosuppressive therapy. Two hundred twenty-six out of 519 patients (43.5%) had received PPI therapy within the last 3 months. In 135 patients, PPIs were administered for longer than 2 weeks. A bacterial infection was shown in 255 patients (49.1%). SBP was diagnosed in 95 patients out of 394 patients with ascites (24.7%). There was no significant difference in the rate of PPI consumption between the infected and the non-infected patients (44.3% vs. 42.8%) or between the SBP patients and the patients with ascites without SBP (46% vs. 42%). In the SBP patients, the duration of PPI administration did not influence the rate of SBP occurrence. The type of bacteria and the origin of SBP infection were similar in the patients with and without PPI. In the current large, multicenter, prospective study, PPI therapy, specifically evaluated at admission of consecutive cirrhotic patients, was not associated with a higher risk of SBP.

Beta‐blockers in portal hypertension: new developments and controversies

There are many studies investigating the role of non-selective beta-blockers in portal hypertension. Satisfactory reduction in portal pressure is possible in a third to half of patients with propranolol and nadolol, although combining these drugs with nitrates may be more effective. Carvedilol is a more potent agent than propranolol in reducing portal pressure, particularly in non-responders, and is better tolerated. All these drugs have been studied in primary and secondary prophylaxis, sometimes in combination with band ligation and/or nitrates. There is some evidence to support combining these agents with band ligation, despite a lack of survival benefit and increased adverse events. Hemodynamic monitoring can help select non-responders who may benefit from additional therapies such as band ligation, as lack of response is associated with worse outcomes. Propranolol should be used with caution in patients with refractory ascites, although the current evidence is not of sufficient quality to justify not using these drugs in such situations. Beta-blockers have been shown to reduce bacterial translocation and spontaneous bacterial peritonitis in cirrhosis.

Albumin for bacterial infections other than spontaneous bacterial peritonitis in cirrhosis. A randomized, controlled study

Treatment with albumin in patients with cirrhosis and spontaneous bacterial peritonitis (SBP) prevents renal failure and improves survival. Whether albumin has similar beneficial effects in patients with infections other than SBP is unknown. One hundred and ten patients with cirrhosis hospitalized for infections other than SBP were randomly assigned to receive antibiotics plus albumin (1.5 g/kgbw at diagnosis and 1 g/kgbw at day 3) (albumin group; n=56) or antibiotics alone (control group; n=54). The primary end point was survival at 3 months. Secondary end points were effects on renal and circulatory function. The renal function, as evaluated by differences in changes in serum creatinine and estimated glomerular filtration rate between the two groups, improved in patients treated with albumin. The circulatory function improved significantly in patients treated with albumin, but not in those from the control group. There was a trend for a lower frequency of type 1 hepatorenal syndrome in the albumin group compared to the control group (1 vs. 4 patients, respectively; p=n.s.). Probability of survival at 3 months was not significantly different among the two groups. However, when adjusted for factors with independent prognostic value, treatment with albumin was an independent predictive factor of survival. As compared with standard antibiotic therapy alone, treatment with albumin together with antibiotics has beneficial effects on the renal and circulatory function and shows a potential survival benefit. Further studies with large sample sizes should be performed to confirm these findings.

PWE-288 Spontaneous bacterial peritonitis: prevalence on admission to a tertiary centre and subsequent outcome

IntroductionSpontaneous bacterial peritonitis (SBP) is a sinister complication of cirrhosis associated with poor survival (approximately 38% at 1 year1). However, a diagnosis of SBP does not represent, in its own...

Bacterial infections other than spontaneous bacterial peritonitis in cirrhosis

Cirrhotic patients are immunocompromised with a high risk of infection. Proinflammatory cytokines and hemodynamic circulation derangement further facilitate the development of serious consequences of infections. Other than spontaneous bacterial peritonitis, bacteremia and bacterial infections of other organ systems are frequently observed. Gram-negative enteric bacteria are the most common causative organism. Other bacterial infections, such as enterococci, Vibrio spp., Aeromonas spp., Clostridium spp., Listeria monocytogenes, Plesiomonas shigelloides and Mycobacterium tuberculosis are more prevalent and more virulent. Generally, intravenous third generation cephalosporins are recommended as empirical antibiotic therapy. Increased incidences of gram-positive and drug-resistant organisms have been reported, particularly in hospital-acquired infections and in patients receiving quinolones prophylaxis. This review focuses upon epidemiology, microbiology, clinical features and treatment of infections in cirrhosis other than spontaneous bacterial peritonitis, including pathogen-specific and liver disease-specific issues.