Spontaneous Bacterial Peritonitis In Cirrhotic Patients 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.

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

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

Cirrhotic patients on proton pump inhibitors are at a twofold risk of spontaneous bacterial peritonitis independently of gastrointestinal bleeding: a population-based retrospective study.

Recent findings suggest that cirrhotic patients on proton pump inhibitors (PPIs) are at a higher risk for developing spontaneous bacterial peritonitis (SBP) than non-PPI users. We aimed to identify whether PPI use is an independent risk factor for the development of SBP among cirrhotic patients in the United States (US). We enrolled a retrospective cohort using a validated multicenter database. Patients with a SNOMED-CT diagnosis of "cirrhosis" between 1999 and 2022 were identified. All patients below 18 years of age were excluded. We calculated the prevalence of individuals using PPIs in the total US population and in cirrhotic patients from 1999 to date, and the incidence of SBP in the past year. Finally, we constructed a multivariate regression model, controlling for multiple covariates. The final analysis included 377,420 patients. The 20-year-period prevalence of SBP in patients with cirrhosis was 3.54% and the prevalence of patients using PPIs in the US population was 12,000 per 100,000 people (12.00%). The 1-year incidence of SBP in cirrhotic patients using PPIs was 2500 per 100,000 people. After accounting for confounders, the risk of SBP was higher among males, patients with a diagnosis of gastrointestinal bleeding, and those using β-blockers and PPIs. To date, this is the largest cohort used to examine the prevalence of SBP among cirrhotic patients in the US. PPI use and hepatic encephalopathy offered the highest risk for the development of SBP, independently of gastrointestinal bleeding. Focusing on judicious PPI use should be encouraged among cirrhotic patients.

Proton Pump Inhibitors Use and Increased Risk of Spontaneous Bacterial Peritonitis in Cirrhotic Patients: A Retrospective Cohort Analysis.

BackgroundSince their introduction in the early 1980s, proton pump inhibitors (PPIs) have been used worldwide for a broad range of indications. Unfortunately, however, PPIs have become overly prescribed by healthcare providers, sometimes in the absence of clear indications. Although PPIs were initially presumed to have an excellent safety profile, emerging studies have shed light on the association between their long-term use and a myriad of side effects, including the possibility of an increased risk of spontaneous bacterial peritonitis (SBP). Data available to date regarding the association between PPI use and SBP development in cirrhotic patients is conflicting. While some observational studies provide no association between PPI use in cirrhotic patients and an increased risk of SBP development, many others support this association. As a result of the conflicting conclusions from case controls, cohorts, and meta-analyses, we aimed to carry out this retrospective cohort analysis of data from cirrhotic patients included in the electronic medical record-based commercial database, EXPLORYS (IMB-WATSON, Cleveland, Ohio). Our aim was to evaluate for a possible association between PPIs use and the risk of SBP development in cirrhotic patients and to compare the prevalence of SBP development between cirrhotic patients who were actively using PPIs and those who were not.MethodsA retrospective cohort analysis with chart review was conducted on patients with cirrhosis who were included in the electronic medical record-based commercial database, EXPLORYS (IMB-WATSON, Cleveland, Ohio). Using this database, records were reviewed between December 2017 and 2020. Included patients were adults aged 30 to 79 years with a Systematized Nomenclature of Medicine-Clinical Terms (SNOMED-CT) diagnosis of liver cirrhosis. Included patients with a SNOMED-CT diagnosis of liver cirrhosis were divided into two groups: the first group included all cirrhotic patients who did not use PPIs and the second group included all cirrhotic patients who were on PPIs at home.ResultsIn our analysis, SBP occurred in 1.7% (1,860 patients) of the included cirrhotic patients whether they were actively taking PPIs or not. Among the 40,670 cirrhotic patients who were on PPIs at home, 1,350 (3.3%) patients developed SBP. On multivariate analysis, PPI use was the strongest predictor for SBP in cirrhotic patients (odds ratio (OR) = 4.24; 95% confidence interval (CI): 3.83 - 4.7, P value < 0.0001), with cirrhotic patients taking PPIs being 4.24 more likely to develop SBP than those not on PPIs. In addition, PPI use, history of bleeding varices, age, race, and gender were found to be independent predicting factors for SBP, in descending order of importance.ConclusionsOur retrospective cohort analysis has shown that the use of PPIs in patients with liver cirrhosis is an independent predicting risk factor for SBP development. It solidified the argument that cirrhotic patients receiving this form of therapy seem to have a higher risk of developing SBP. In the setting of the emerging evidence that PPIs might impose health risks in cirrhotic patients, further studies are needed to settle the current debate between supporters and opponents of this proposition. In addition, future studies may help clarify the relationship between the occurrence of SBP in cirrhotic patients and the type, dose, and duration of PPIs used. We recommend that unless it is clearly indicated, PPI therapy should be avoided or administered with caution in patients with cirrhosis.

Association Between Proton Pump Inhibitor Therapy and Spontaneous Bacterial Peritonitis Occurrence in Cirrhotic Patients: A Clinical Review.

Spontaneous bacterial peritonitis (SBP) is one of the most common complications in patients with end-stage liver disease (ESLD), which increases the risk of short-term mortality. Proton pump inhibitors (PPIs) are frequently used in patients with ESLD, in which controversies about the risk of PPI treatment in the occurrence of SBP are largely raised and the pathogenic mechanism of PPI-associated SBP remains unclear. We conducted a systematic literature search through PubMed/MEDLINE for publications mainly from 1 January 2000 to 1 January 2021. Our narrative review summarized the adverse effect of specific PPI therapy on the occurrence and prognosis of SBP in cirrhotic patients, described the potential mechanisms by which PPI induces the development of SBP, and discussed the risk factors associated with the development of SBP and the strategy of PPI therapy in cirrhotic patients. Although controversy regarding the association between PPI use and the occurrence of SBP exists, PPIs use should be restricted to patients with clear benefit indications, and be cautious for elderly patients with severe liver damage.

Diagnostic role of procalcitonin serum level in hepatitis C virus-infected patients with spontaneous bacterial peritonitis

ObjectiveWe aimed at the evaluation of the role of quantification of serum procalcitonin (PCT) in the detection of spontaneous bacterial peritonitis (SBP) in hepatitis C-related cirrhosis before and after initiation of antibiotic therapy.BackgroundSBP is a lethal consequence of advanced cirrhosis. The outcome is heavily affected by early detection and treatment. PCT has been evaluated during acute bacterial infections and sepsis.Patients and methodsWe included 60 patients with ascites due to hepatitis C-related cirrhosis, who were divided in two groups: group 1 included 40 naïve patients with SBP, and group 2 included 20 patients with sterile ascites as a control. After history taking and clinical examination, full blood count, liver test profile, and renal functions were done. Moreover, C-reactive protein and erythrocyte sedimentation rate levels were measured. Serum PCT was measured by immunoassay. Diagnostic ascitic sample analysis was done for the polymorphonuclear leukocyte (PMNL) count, albumin levels, and ascetic fluid culture.ResultsSerum PCT was significantly elevated in group 1 before treatment than after treatment, as well as when compared with group 2. There was no statistically significant correlation between the change in the C-reactive protein level and that of the serum PCT before and after treatment in group 1. There is no significant correlation between increases in the serum PCT and the results of bacterial growth of ascetic fluid culture group before and after treatment.ConclusionPCT levels in the serum appear to provide a good diagnostic certainty in the diagnosis of SBP in cirrhotic patients at a cutoff value of 0.17 ng/ml for patients with either culture-positive or negative SBP.

Explainable machine learning model for predicting spontaneous bacterial peritonitis in cirrhotic patients with ascites

Spontaneous bacterial peritonitis (SBP) is a life-threatening complication in patients with cirrhosis. We aimed to develop an explainable machine learning model to achieve the early prediction and outcome interpretation of SBP. We used CatBoost algorithm to construct MODEL-1 with 46 variables. After dimensionality reduction, we constructed MODEL-2. We calculated and compared the sensitivity and negative predictive value (NPV) of MODEL-1 and MODEL-2. Finally, we used the SHAP (SHapley Additive exPlanations) method to provide insights into the model’s outcome or prediction. MODEL-2 (AUROC: 0.822; 95% confidence interval [CI] 0.783–0.856), liked MODEL-1 (AUROC: 0.822; 95% CI 0.784–0.856), could well predict the risk of SBP in cirrhotic ascites patients. The 6 most influential predictive variables were total protein, C-reactive protein, prothrombin activity, cholinesterase, lymphocyte ratio and apolipoprotein A1. For binary classifier, the sensitivity and NPV of MODEL-1 were 0.894 and 0.885, respectively, while for MODEL-2 they were 0.927 and 0.904, respectively. We applied CatBoost algorithm to establish a practical and explainable prediction model for risk of SBP in cirrhotic patients with ascites. We also identified 6 important variables closely related to the occurrence of SBP.

Diagnostic value of serum procalcitonin level in the diagnosis of the spontaneous bacterial peritonitis

Introduction: Spontaneous bacterial peritonitis (SBP) is an infectious ascitic fluid with an unknown intraabdominal source. Rapid diagnosis of infection can improve prognosis in cirrhotic patients. Objectives: We aim to determine the diagnostic value of serum procalcitonin (PCT) and C-reactive protein (CRP) in SBP. Patients and Methods: In this cross-sectional study, we included 120 cirrhotic patients with possible diagnosis of SBP asities. Serum and ascitic fluid samples were taken from the patient before initiating antibiotics. The ascitic fluid parameters, serum levels of CRP, PCT and white blood cells were measured and the diagnostic value of the CRP and PCT were evaluated. Results: Of 120 patients, 59.16% had confirmed SBP. PCT with a cutoff of 0.8 ng/mL and CRP with cutoff of 10.5 mg/L had a sensitivity of 90.91% and 86.11% and specificity of 91.5% and 81.25% respectively in diagnosing of SBP. Considering PCT above 0.8 ng/mL and CRP above 10.5 mg/L both, they had the sensitivity and specificity of 96.87% and 83.92% in detecting SBP in cirrhotic patients. Conclusion: Serum PCT and CRP levels could predict SBP in cirrhotic patients while PCT had the most sensitivity and specificity. Considering both parameters, the sensitivity will increase, but the specificity is decreasing. Both PCT and CRP levels could be used as a less invasive method compared to ascites fluid analysis in diagnosing SBP.

Ascitic calprotectin for the diagnosis of spontaneous bacterial peritonitis: a systematic review and meta-analysis

Calprotectin is a promising diagnostic biomarker for spontaneous bacterial peritonitis (SBP) among cirrhotic patients, but published studies report a wide variation of its diagnostic accuracy. We systematically searched six databases for eligible studies (i.e., all original studies that reported ascitic calprotectin as a diagnostic marker for SBP in cirrhotic patients), and assessed their quality with the Quality Assessment of Diagnostic Accuracy Studies-2 tool. We calculated the pooled sensitivity, specificity, positive and negative likelihood ratios (PLR and NLR), and diagnostic odds ratio (DOR) using the bivariate mixed-effect model. We constructed the summary receiver operating characteristic and determined the area under the curve (AUC). We registered the study protocol in PROSPERO (CRD42019125476). Our search retrieved 102 studies, of which 10 were included in the analysis. The overall risk of bias of these studies ranged from low to moderate. There was no heterogeneity from the threshold effect (Spearman correlation coefficient = 0.100, P value = 0.770). The pooled estimates [95% confidence intervals (CIs)] for ascitic calprotectin were as follows: sensitivity 0.91 (95% CI: 0.88-0.94), specificity 0.87 (95% CI: 0.68-0.96), PLR 7.18 (95% CI: 2.52-20.43), NLR 0.10 (95% CI: 0.07-0.15), DOR 71.91 (95% CI: 19.42-266.34), and AUC 0.92 (95% CI: 0.90-0.94). The sensitivity analysis did not detect outliers, and the model had a robust goodness of fit. There was no significant publication bias detected (Deeks test of asymmetry, P value = 0.79). Ascitic calprotectin is a promising diagnostic biomarker for SBP in cirrhotic patients.

Relation between 25-hydroxy vitamin D serum level and spontaneous bacterial peritonitis in patients with liver cirrhosis

<br><b>Background and aim</b><br>Besides its role in calcium metabolism, vitamin D has pleiotropic functions, including immunomodulation, cellular proliferation, and differentiation. Low levels of vitamin D increase the risk for bacterial infections in liver cirrhotic patients, including spontaneous bacterial peritonitis (SBP). This work is conducted to study the relation between serum level of the 25-OH vitamin D and SBP in liver cirrhotic patients.<br><b>Patients and methods</b><br>A total of 90 patients were enrolled in the present study. They were divided into three groups, with 30 patients each: first, patients with compensated liver cirrhosis; second, patients who had decompensated liver cirrhosis without SBP; and third, patients who had decompensated liver cirrhosis with SBP. Different laboratory investigations were carried out, such as liver and kidney functions tests, complete blood count, ascitic neutrophilic count, and serum 25-OH vitamin D level.<br><b>Results</b><br>In the present study, the lowest serum 25-OH vitamin D level was found in patients with decompensated liver cirrhosis with SBP, with a highly significant difference between the studied groups.<br><b>Conclusion</b><br>Increased incidence of infections with SBP in cirrhotic patients might be linked to vitamin D deficiency. We recommend vitamin D supplementation to lower the risk of SBP in these cases and thereby mortality rate.<br>

STUDY OF MEAN PLATELET VOLUME VERSUS LEUCOCYTE ESTERASE AS A MARKER IN DIAGNOSIS OF SPONTANEOUS BACTERIAL PERITONITIS

Background: Spontaneous bacterial peritonitis (SBP) is a severe and frequent complication of cirrhosis with a high mortality rate. Early diagnosis and treatment of SBP is necessary for survival. Objective: To study the mean platelet volume (MPV) versus leucocyte esterase as a marker in diagnosis of decompensated cirrhotic patients with spontaneous bacterial peritonitis. Patients and methods: A total of 200 patients with decompensated liver cirrhosis and ascites, were admitted to the Department of Gastroenterology and Hepatology in Nasser Institute, and were enrolled in this study between January 2016 and October 2017. Patients were divided into two equal groups; group (I) was diagnosed non SBP and group (II) was diagnosed SBP. All patients underwent abdominal paracentesis, and the ascitic fluid was processed for cell count, leukocyte esterase reagent strip test (LERS) (URIT 10V) and culture. All patients underwent assessment of MPV in CBC. Results: Diagnostic performance of mean platelet volume showed that we can use MPV as a good diagnostic marker for SBP with sensitivity 75 %, specificity 99% and accuracy 93.2 %. The best cut off value for discriminating patients with SBP from patients without SBP was 9.2 fl. The test of ascetic fluid by leukocyte esterase reagent strips showed that specificity = 93% , sensitivity = 80%, positive predictive value (PPV) = 92%, negative predictive value (NPV) =82.3% and accuracy = 86.5%. Conclusion: MPV and LERS can be used as a good marker in diagnosis of SBP in cirrhotic patients with ascites.

STUDY OF MEAN PLATELET VOLUME VERSUS LEUCOCYTE ESTERASE AS A MARKER IN DIAGNOSIS OF SPONTANEOUS BACTERIAL PERITONITIS

Background: Spontaneous bacterial peritonitis (SBP) is a severe and frequent complication of cirrhosis with a high mortality rate. Early diagnosis and treatment of SBP is necessary for survival. Objective: To study the mean platelet volume (MPV) versus leucocyte esterase as a marker in diagnosis of decompensated cirrhotic patients with spontaneous bacterial peritonitis. Patients and methods: A total of 200 patients with decompensated liver cirrhosis and ascites, were admitted to the Department of Gastroenterology and Hepatology in Nasser Institute, and were enrolled in this study between January 2016 and October 2017. Patients were divided into two equal groups; group (I) was diagnosed non SBP and group (II) was diagnosed SBP. All patients underwent abdominal paracentesis, and the ascitic fluid was processed for cell count, leukocyte esterase reagent strip test (LERS) (URIT 10V) and culture. All patients underwent assessment of MPV in CBC. Results: Diagnostic performance of mean platelet volume showed that we can use MPV as a good diagnostic marker for SBP with sensitivity 75 %, specificity 99% and accuracy 93.2 %. The best cut off value for discriminating patients with SBP from patients without SBP was 9.2 fl. The test of ascetic fluid by leukocyte esterase reagent strips showed that specificity = 93% , sensitivity = 80%, positive predictive value (PPV) = 92%, negative predictive value (NPV) =82.3% and accuracy = 86.5%. Conclusion: MPV and LERS can be used as a good marker in diagnosis of SBP in cirrhotic patients with ascites.

Association of gastric acid suppressants with the development of spontaneous bacterial peritonitis in cirrhotic patients with ascites

AbstractThe study aimed to characterize the association of gastric acid suppressants (GAS) with the development of spontaneous bacterial peritonitis (SBP) in cirrhotic patients with ascites. A retrospective case controlled study from January 2013 to December 2017 at Cheng‐Ching General Hospital was conducted. We included patients with a diagnosis of liver cirrhosis with ascites, divided into those with and without SBP. SBP was defined by ascitic fluid polymorphonuclear cell level. GAS users were patients who received GAS daily for more than 7 days in the 90 days before admission. Of 229 cirrhotic patients enrolled, 60 had SBP and 169 did not. The groups differed significantly in albumin (P = .045) and total bilirubin (P = .016) levels; in international normalized ratio (P = .007) and proton pump inhibitor (PPI) use (P = .021); but not in histamine‐2 receptor antagonist (H2RA) use. Multivariate analysis identified PPI use as the only independent risk factor for SBP development (odds ratio 2.101, 95% confidence interval 1.122‐3.935, P = .02). PPIs but not H2RAs may increase the incidence of SBP in cirrhotic patients with ascites. Prescribing PPIs in cirrhotic patients should be done carefully, for the minimal effective treatment duration.

The association between pre hospital use of proton pump inhibitors and spontaneous bacterial peritonitis in patients presenting with liver cirrhosis.

Objectives: To determine the association between pre hospital use of proton pump inhibitors and spontaneous bacterial peritonitis in patients presenting with liver cirrhosis. Study Design: Case control study. Setting: Department of Gastroenterology at Liaquat National Hospital Karachi. Period: Six months (From 1st – March-2017 to 31st – August-2017). Material and Methods: There were 120 patients with cirrhosis were included in this study. Sixty patients were cases with spontaneous bacterial peritonitis (SBP) and 60 patients were control without spontaneous bacterial peritonitis. All patients were interviewed for pre hospital intake of PPI (as per operational definition). All the data was entered on predesigned proforma (attached). Results: The average age of the patients was 42.47±9.87 years. Rate of PPI use was significantly higher among cases with SBP (46.7%) as compared to the patients without SBP (23.3%). Conclusion: In conclusion, PPI use (acid suppression) was associated with the development of SBP in cirrhotic patients with ascites. We recommend that PPI indications in cirrhotic patients should be frequently re-evaluated with particular attention devoted to duration of use, especially following endoscopic variceal ligation (EVL).

2410 Unusual Cause of Ascites in Liver Cirrhosis: Peritoneal Tuberculosis

INTRODUCTION: Peritoneal tuberculosis is a rare disease with increasing incidence in recent years, especially in patients with immunocompromised state. Tuberculous peritonitis (TBP) in cirrhotic patients can mimic spontaneous bacterial peritonitis (SBP) and infrequently considered in differential diagnosis, resulting in delayed diagnosis and mortality. We present a case of TBP in a patient with cirrhosis. CASE DESCRIPTION/METHODS: 37-year-old man with history of alcoholic cirrhosis and alcohol abuse presented with gradually worsening abdominal distension for 3-6 months and abdominal pain for 2 days. Patient had pulmonary tuberculosis 20 years ago for which he received multi-drug regimen for 6 months. On presentation, vitals were stable and he had epigastric tenderness. Labs revealed AST - 61 U/L and normal CBC. CT abdomen showed moderate ascites with thin peripheral enhancement suggestive of peritonitis. He was started on empiric antibiotics for presumed SBP. Paracentesis removed 1.4 L of straw colored fluid with WBC 791 cells/L with lymphocytes (94%), SAAG-0.4 g/dl, negative gram stain, ascitic fluid culture and cytology showed benign mesothelial cells and small mature lymphocytes. Given continued low-grade fever upto 100.4 F and lymphocytic predominance in the ascitic fluid, serum Quantiferon gold was done which came back positive. A laparoscopic peritoneal biopsy revealed exudates, loculated ascites and biopsy showed granulomatous inflammation with caseous necrosis confirming Mycobacterium tuberculosis. Patient was started on Ethambutol, Isoniazid, Pyrazinamide and Rifampin for 2 months followed by isoniazid and Rifampin for 4 months. DISCUSSION: Tuberculous peritonitis should be considered as differential diagnosis, in addition to SBP in cirrhotic patients who presents with ascites and abdominal pain. Similar to SBP, TBP in patients with cirrhosis presents with nonspecific signs and symptoms including abdominal distension, fever and abdominal pain. However, treatment of TBP and SBP differs vastly. TBP should be considered with the following criteria: cirrhotic patients with Child Pugh B; TB identified at additional sites; lymphopenia in the peripheral blood; ascitic protein &gt;25 g/l; lymphocytes predominance in ascites; ascitic ADA activity &gt;27 U/l; and ascitic LDH &gt;90 U/l. Treatment of TBP with anti-tuberculosis drugs for atleast 6 months with 4-drug regimen for initial 2 months followed by two-drug regimen. 20%–40% of patients with TBP presents with an acute abdomen and need surgical intervention.

ASCITIC INTERLEUKIN 6 AND SERUM PROCALCITONIN FOR EARLY DETECTION OF SPONTANEOUS BACTERIAL PERITONITIS IN ADVANCED LIVER CIRRHOSIS

Background: Liver cirrhosis is associated with frequent bacterial infections that increase mortality. Spontaneous bacterial peritonitis (SBP) is an important cause of mortality and morbidity in such patients with ascites. A polymorphonuclear (PMN) cell count >250/μl in the ascitic fluid is the current gold standard for diagnosing SBP which is considered a subjective test. Early diagnosis of SBP although vital is difficult in these patients. Interleukin 6 is pro-inflammatory marker that increases earlier in bacterial infection than other inflammatory markers. This is crucial in cirrhotic patients to initiate treatment accordingly.Objective: Evaluate the role of IL 6 together with other inflammatory markers in early diagnosis of SBP and as prognostic markers as well.Patients and methods: The study was conducted on 60 cirrhotic patients with ascites divided into 2 groups. Group I included 30 cirrhotic patients with sterile ascites and group II, 30 patients with SBP. Liver profile, serum creatinine, serum sodium, ascitic IL6 , C-reactive protein, serum pro-calcitonin , and ascitic fluid analysis were done for all patients in both groups. Exclusion criteria included; acute infection, diabetes mellitus, coronary vascular disease, collagen vascular disease and any form of sepsis.Results: Ascitic IL6 mean value was 2171.5(62.2 – 5000) and 342.5(146 – 2567) pg/ml in groups I and II respectively which was significantly higher in group I than among group II patients (P 780 pg/ml and >0.4ng/ml respectively.Conclusion: Ascitic IL6 and serum procalcitonin can be used as a valuable surrogate serum marker for early diagnosis of SBP in cirrhotic patients.

Trends in Hospitalization, Acute Kidney Injury, and Mortality in Patients With Spontaneous Bacterial Peritonitis.

The purpose of our study was to evaluate trends of hospitalization, acute kidney injury (AKI) and mortality in cirrhotic patients with spontaneous bacterial peritonitis (SBP). SBP is a frequent bacterial infection in cirrhotic patients leading to increased morbidity and mortality. A total of 4,840,643 patients hospitalized with cirrhosis from 2005 to 2014 were identified using the Nationwide Inpatient Sample database, of which 115,359 (2.4%) had SBP. We examined annual trends and used multivariable mixed-effects logistic regression analyses to obtain adjusted odds ratios by accounting for hospital level and patient level variables. We identified a striking increase in hospitalizations for SBP in cirrhotic patients (0.45% to 3.12%) and AKI in SBP patients (25.6% to 46.7%) from 2005 to 2014. Inpatient mortality decreased over the study period in patients with SBP (19.1% to 16.1%) and in patients with SBP plus AKI (40.9% to 27.6%). Patients with SBP had a higher inpatient mortality rate than those without SBP [15.5% vs. 6%, adjusted odd ratio (aOR): 2.02, P<0.001]. AKI was 2-fold more prevalent in cirrhotics with SBP than those without SBP (42.8% vs. 17.2%, aOR: 1.91, P<0.001) and concomitant AKI was associated with a 6-fold mortality increase (aOR: 5.84, P<0.001). Cirrhotic patients with SBP had higher hospitalization costs and longer length of stays than patients without SBP. Despite a higher hospitalization rate and prevalence of concomitant AKI, mortality in patients with SBP decreased during the study period. SBP is associated with high likelihood of development of AKI, which in turn, increases mortality.

Associated vitamin D deficiency is a risk factor for the complication of HCV-related liver cirrhosis including hepatic encephalopathy and spontaneous bacterial peritonitis.

The influence of vitamin D, 25-hydroxyvitamin D (25(OH)D), deficiency on hepatitis C virus (HCV)-related cirrhosis had been poorly elucidated especially in patients with hepatic encephalopathy (HE) and spontaneous bacterial peritonitis (SBP). We aimed to investigate the association between vitamin D deficiency and the risk of SBP or HE, including the mortality rate. Serum 25(OH)D levels were prospectively determined in 135 patients. Of them, 45 patients had complications with HE and 45 patients had complications with SBP; 45 cirrhotic patients without complication served as the control group. Vitamin D deficiency was defined as 25(OH)D levels < 20ng/ml. Receiver operating characteristic (ROC) and Kaplan-Meier method with log-rank test were used in our statistical analysis. Predictors of survival were determined using Cox regression analysis. Serum 25(OH)D levels were significantly (P < 0.05) lower in the HE and SBP groups than in the control group (6.81 ± 2.75, 7.15 ± 2.10, 16.28 ± 6.60, respectively). Moreover, serum 25(OH)D levels were significantly lower in the high HE grade than in the low grade (P < 0.001). Regarding the SBP group, classic SBP was associated with lower 25(OH)D levels compared to other types (P < 0.001). ROC curve revealed that lower 25(OH)D levels less than 7.1ng/ml and 6.6ng/ml could predict the mortality in SBP and HE patients, respectively, with high sensitivity and specificity. Serum 25(OH)D levels < 5ng/ml were associated with significant higher mortality rate (HR = 2.76, P = 0.001). Lower 25(OH)D levels were associated with HE and SBP in cirrhotic patients. In addition, it may be considered a prognostic parameter for the severity of liver cirrhosis.

Daily Norfloxacin vs. Weekly Ciprofloxacin to Prevent Spontaneous Bacterial Peritonitis: A Randomized Controlled Trial.

For the prevention of spontaneous bacterial peritonitis (SBP) in cirrhotic patients with ascites, norfloxacin 400 mg per day is recommended as a standard regimen. This study aims to investigate whether ciprofloxacin once weekly administration is not inferior to norfloxacin once daily administration for the prevention of SBP. This is an investigator-initiated open-label randomized controlled trial conducted at seven tertiary hospitals in South Korea. Liver cirrhosis patients with ascites were screened, and enrolled in this randomized controlled trial if ascitic protein ≤1.5 g/dL or the presence of history of SBP. Ascitic polymorphonucleated cell count needed to be <250/mm3. Patients were randomly assigned into norfloxacin daily or ciprofloxacin weekly group, and followed-up for 12 months. Primary endpoint was the prevention of SBP. One hundred twenty-four patients met enrollment criteria and were assigned into each group by 1:1 ratio (62:62). Seven patients in the norfloxacin group and five patients in the ciprofloxacin group were lost to follow-up. SBP developed in four patients (4/55) and in three patients (3/57) in each group, respectively (7.3% vs. 5.3%, P = 0.712). The transplant-free survival rates at 1 year were comparable between the groups (72.7% vs. 73.7%, P = 0.970). Incidence of infectious complication, hepatorenal syndrome, hepatic encephalopathy, and variceal bleeding rates were not significantly different (all P = ns). The factors related to survival were models representing underlying liver function. Once weekly ciprofloxacin was as effective as daily norfloxacin for the prevention of SBP in cirrhotic patients with ascites.

Study of platelet indices in cirrhotic patients with spontaneous bacterial peritonitis

Background Ascites are a pathological collection of fluid within the peritoneal cavity and the most common complication of liver cirrhosis. Spontaneous bacterial peritonitis (SBP) is an infection that develops in cirrhotic ascitic patients. Platelets release prothrombotic and proinflammatory agents and participate in the induction and advancement of vascular and inflammatory disorders. Aim The aim of this study was to evaluate platelet indices as noninvasive predictors for the diagnosis of SBP in cirrhotic patients. Patients and methods Patients were divided into the following groups: group I included 52 cirrhotic ascitic patients with SBP; group II included 34 cirrhotic ascitic patients without SBP; group III (the control group) included 20 healthy individuals. A complete blood count analysis was carried out using the Erma PCE-210 hematology analyzer. Platelet count, mean platelet volume (MPV), and platelet distribution width (PDW) of all the participating patients were determined. Results In this study, there were differences in MPV and PDW between the three groups. MPV showed a significant increase in SBP in comparison with ascitic patients and control participants (11.39±1.08, 10.39±1.32, and 9.47±1.29 fl, respectively), with a P value of less than 0.001. Similarly, the PDW was greater in SBP patients compared with those in groups II and III, but with no significant difference (14.14±2.01, 13.96±3.58, and 12.90±3.13, respectively). Conclusion MPV measurement is an inexpensive, fast, and easy to use test that can predict the development of SBP in cirrhotic ascitic patients.