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Cazacu SM, Zlatian OM, Plesea EL, Vacariu AI, Cimpoeru M, Rogoveanu I, Bigea CC, Iordache S. Predominant Gram-Positive Etiology May Be Associated with a Lower Mortality Rate but with Higher Antibiotic Resistance in Spontaneous Bacterial Peritonitis: A 7-Year Study in a Tertiary Center in Romania. Life (Basel) 2025; 15:855. [PMID: 40566508 PMCID: PMC12194169 DOI: 10.3390/life15060855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2025] [Revised: 05/19/2025] [Accepted: 05/21/2025] [Indexed: 06/28/2025] Open
Abstract
(1) Background: Spontaneous bacterial peritonitis (SBP) is associated with a 20% mortality and is mainly caused by Gram-negative bacteria (GNB); Gram-positive bacteria (GPB) were predominant in some areas; and increased antibiotic resistance was recorded. (2) Methods: A retrospective study was performed between 2018 and 2024. The type of isolated strains, antibiotic susceptibility, and mortality (in-hospital; 30-day; 90-day; and 1-year) were estimated; multivariate analyses evaluated predictive factors for in-hospital mortality risk. (3) Results: 45 culture-positive SBP, 28 culture-negative SBP, 6 bacterascites, and 670 control ascites were diagnosed; GPB represented 60%; two Candida peritonitis and 11 polymicrobial peritonitis (21.6%) were noted (without surgery; peritoneal dialysis; or tegumentary lesion). High resistance rates to cephalosporins and quinolones, and high carbapenem resistance for nosocomial GNB were recorded. A low resistance rate to Tigecycline was noted in all infection types; GPB was susceptible to Linezolid and Vancomycin; and GNB was susceptible to Aztreonam and Colistin. In-hospital mortality was 26.7% (40% for GNB-SBP; 20% for GPB-SBP), similar to culture-negative SBP (21.3%), and higher than in the control group (9%); long-term mortality remained higher. (4) Conclusions: microbial changes to GPB etiology and increasing resistance were noted, but with a lower mortality compared to GNB; higher mortality rates up to 1 year for culture-positive and culture-negative SBP were recorded.
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Affiliation(s)
- Sergiu Marian Cazacu
- Gastroenterology Department, University of Medicine and Pharmacy Craiova, Petru Rares Street no 2-4, 200349 Craiova, Romania; (S.M.C.); (I.R.); (S.I.)
| | - Ovidiu Mircea Zlatian
- Microbiology Department, University of Medicine and Pharmacy Craiova, Petru Rares Street no 2-4, 200349 Craiova, Romania;
| | - Elena Leocadia Plesea
- Microbiology Department, University of Medicine and Pharmacy Craiova, Petru Rares Street no 2-4, 200349 Craiova, Romania;
| | - Alexandru Ioan Vacariu
- Doctoral School, University of Medicine and Pharmacy Craiova, Petru Rares Street no 2-4, 200349 Craiova, Romania;
| | - Mihai Cimpoeru
- Emergency Clinic Hospital Craiova, 200642 Craiova, Romania;
| | - Ion Rogoveanu
- Gastroenterology Department, University of Medicine and Pharmacy Craiova, Petru Rares Street no 2-4, 200349 Craiova, Romania; (S.M.C.); (I.R.); (S.I.)
| | - Camelia Cristiana Bigea
- Microbiology Department, University of Medicine and Pharmacy Craiova, Petru Rares Street no 2-4, 200349 Craiova, Romania;
| | - Sevastita Iordache
- Gastroenterology Department, University of Medicine and Pharmacy Craiova, Petru Rares Street no 2-4, 200349 Craiova, Romania; (S.M.C.); (I.R.); (S.I.)
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Silpa C, Alomar T, Wong RJ. Temporal Trends of Fungal Infections in Cirrhotic Patients: A Retrospective Cohort Study 2016-2020. J Clin Exp Hepatol 2025; 15:102469. [PMID: 39850933 PMCID: PMC11750545 DOI: 10.1016/j.jceh.2024.102469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 11/27/2024] [Indexed: 01/25/2025] Open
Abstract
Background Patients with cirrhosis are susceptible to infections due to abnormalities in humoral and cell-mediated immunity. Fungal infections are associated with delayed diagnosis and high mortality rates, emphasizing the importance of performing fungal cultures and maintaining elevated levels of suspicion in this patient population. Methods This retrospective cohort study analyzes cirrhotic patients readmitted with bacterial and fungal infections and investigates outcomes, including in-hospital mortality and hospital resource utilization. Data was acquired from the Nationwide Readmission Database (NRD) from 2016 to 2020. Total hospital costs were calculated using HCUP Cost-to-Charge Ratio files and adjusted for inflation based on the Consumer Price Index (CPI) for medical care services in the U.S., with 2020 as the reference year. The NRD dataset lacks details like ascitic fluid cell counts, antifungal/antibacterial drugs used, and treatment responses, limiting the clinical insights that can be derived. Results The study analyzed 393,195 index hospitalizations. Among these, 102,505 account for 30-day and 157,079 account for 90-day readmissions. The 30-day and 90-day readmissions for spontaneous bacterial peritonitis (SBP) are 8478 and 15,690 respectively. The 30-day and 90-day readmissions for spontaneous fungal peritonitis (SFP) are 3106 and 5798 respectively. The mean age of patients was 57.9 years (standard deviation between 57.7 and 58.1). The mean length of stay (LOS) for SBP at 30 days is 9.4 days, while SFP has ranged from 14.9 to 32.3 days for various fungal infections. Aspergilloses have the longest LOS among SFP. There is an increased rate of mortality as well as hospital charges with SFP compared to SBP (P < 0.001). The 30-day index admission total charges for SBP are $42,258 and SFP are $51,739. The 30-day readmission total charges for SBP are 64, 266 and for SFP 89,913. Conclusions There is increased mortality, LOS, and hospital costs for SFP compared to SBP. It is important to consider SFP in the diagnostic workup for patients who do not respond to antibiotics. Early recognition and administration of antifungals can be associated with improved outcomes.
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Affiliation(s)
- Choday Silpa
- Creighton University School of Medicine-Phoenix Health Sciences Campus, Phoenix, AZ, United States
| | - Talal Alomar
- Creighton University School of Medicine-Phoenix Health Sciences Campus, Phoenix, AZ, United States
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Juncu S, Minea H, Lungu A, Jucan A, Avram R, Buzuleac AM, Cojocariu C, Diaconu LS, Stanciu C, Trifan A, Sîngeap AM. Fluoroquinolones for the Prophylaxis of Spontaneous Bacterial Peritonitis in Patients with Liver Cirrhosis: Are They Losing Ground? Life (Basel) 2025; 15:586. [PMID: 40283141 PMCID: PMC12028953 DOI: 10.3390/life15040586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2025] [Revised: 03/24/2025] [Accepted: 03/31/2025] [Indexed: 04/29/2025] Open
Abstract
Spontaneous bacterial peritonitis (SBP) is the most common bacterial infection in cirrhotic patients. Historically, the bacterial spectrum was dominated by Gram-negative bacteria. However, recent studies showed that fluoroquinolone (FQ)-based prophylaxis promotes the intestinal overgrowth of Gram-positive bacteria and contributes to the selection of quinolone-resistant Gram-negative bacteria, increasing multidrug-resistant (MDR) organism infections. FQ resistance rates reach up to nearly one-third in community-acquired cases and 50% in hospital-acquired cases, raising concerns about FQ efficacy. Moreover, rare but serious side effects further limit FQ use. Predictive factors of FQ treatment failure have been identified, guiding management strategies. Rifaximin has emerged as a promising alternative for SBP prophylaxis, with encouraging results. This review aims to explore the shifting role of FQ-based SBP prophylaxis, focusing on the emerging concerns, side effects, and alternative strategies. While norfloxacin remains a first-line prophylactic in cirrhotic patients with low ascitic protein levels, its efficacy appears to be reduced in those with advanced liver failure or additional risk factors for MDR organisms. In these subgroups, alternative prophylactics, such as trimethoprim-sulfamethoxazole or rifaximin, may be preferable. We propose a risk-stratification approach to guide treatment selection, with further studies needed to refine these criteria.
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Affiliation(s)
- Simona Juncu
- Department of Gastroenterology, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Universitatii Street No. 16, 700115 Iasi, Romania; (S.J.); (A.L.); (A.J.); (R.A.); (A.-M.B.); (C.C.); (C.S.); (A.T.); (A.-M.S.)
- Institute of Gastroenterology and Hepatology, “St. Spiridon” Emergency County Hospital, Bd. Independentei No. 1, 700111 Iasi, Romania
| | - Horia Minea
- Department of Gastroenterology, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Universitatii Street No. 16, 700115 Iasi, Romania; (S.J.); (A.L.); (A.J.); (R.A.); (A.-M.B.); (C.C.); (C.S.); (A.T.); (A.-M.S.)
- Institute of Gastroenterology and Hepatology, “St. Spiridon” Emergency County Hospital, Bd. Independentei No. 1, 700111 Iasi, Romania
| | - Andreea Lungu
- Department of Gastroenterology, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Universitatii Street No. 16, 700115 Iasi, Romania; (S.J.); (A.L.); (A.J.); (R.A.); (A.-M.B.); (C.C.); (C.S.); (A.T.); (A.-M.S.)
- Institute of Gastroenterology and Hepatology, “St. Spiridon” Emergency County Hospital, Bd. Independentei No. 1, 700111 Iasi, Romania
| | - Alina Jucan
- Department of Gastroenterology, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Universitatii Street No. 16, 700115 Iasi, Romania; (S.J.); (A.L.); (A.J.); (R.A.); (A.-M.B.); (C.C.); (C.S.); (A.T.); (A.-M.S.)
- Institute of Gastroenterology and Hepatology, “St. Spiridon” Emergency County Hospital, Bd. Independentei No. 1, 700111 Iasi, Romania
| | - Raluca Avram
- Department of Gastroenterology, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Universitatii Street No. 16, 700115 Iasi, Romania; (S.J.); (A.L.); (A.J.); (R.A.); (A.-M.B.); (C.C.); (C.S.); (A.T.); (A.-M.S.)
- Institute of Gastroenterology and Hepatology, “St. Spiridon” Emergency County Hospital, Bd. Independentei No. 1, 700111 Iasi, Romania
| | - Ana-Maria Buzuleac
- Department of Gastroenterology, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Universitatii Street No. 16, 700115 Iasi, Romania; (S.J.); (A.L.); (A.J.); (R.A.); (A.-M.B.); (C.C.); (C.S.); (A.T.); (A.-M.S.)
- Institute of Gastroenterology and Hepatology, “St. Spiridon” Emergency County Hospital, Bd. Independentei No. 1, 700111 Iasi, Romania
| | - Camelia Cojocariu
- Department of Gastroenterology, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Universitatii Street No. 16, 700115 Iasi, Romania; (S.J.); (A.L.); (A.J.); (R.A.); (A.-M.B.); (C.C.); (C.S.); (A.T.); (A.-M.S.)
- Institute of Gastroenterology and Hepatology, “St. Spiridon” Emergency County Hospital, Bd. Independentei No. 1, 700111 Iasi, Romania
| | - Laura Sorina Diaconu
- Department of Internal Medicine and Gastroenterology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Internal Medicine and Gastroenterology, University Emergency Hospital, 050098 Bucharest, Romania
| | - Carol Stanciu
- Department of Gastroenterology, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Universitatii Street No. 16, 700115 Iasi, Romania; (S.J.); (A.L.); (A.J.); (R.A.); (A.-M.B.); (C.C.); (C.S.); (A.T.); (A.-M.S.)
- Institute of Gastroenterology and Hepatology, “St. Spiridon” Emergency County Hospital, Bd. Independentei No. 1, 700111 Iasi, Romania
| | - Anca Trifan
- Department of Gastroenterology, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Universitatii Street No. 16, 700115 Iasi, Romania; (S.J.); (A.L.); (A.J.); (R.A.); (A.-M.B.); (C.C.); (C.S.); (A.T.); (A.-M.S.)
- Institute of Gastroenterology and Hepatology, “St. Spiridon” Emergency County Hospital, Bd. Independentei No. 1, 700111 Iasi, Romania
| | - Ana-Maria Sîngeap
- Department of Gastroenterology, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Universitatii Street No. 16, 700115 Iasi, Romania; (S.J.); (A.L.); (A.J.); (R.A.); (A.-M.B.); (C.C.); (C.S.); (A.T.); (A.-M.S.)
- Institute of Gastroenterology and Hepatology, “St. Spiridon” Emergency County Hospital, Bd. Independentei No. 1, 700111 Iasi, Romania
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Mahmud N, Salinas Parra N, Hecht AL, Kaplan DE, Serper M. Distribution of culture-positive microorganisms varies with severity of liver disease in patients hospitalized with SBP. Hepatol Commun 2025; 9:e0655. [PMID: 39899683 DOI: 10.1097/hc9.0000000000000655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2024] [Accepted: 01/08/2025] [Indexed: 02/05/2025] Open
Affiliation(s)
- Nadim Mahmud
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology & Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Natalia Salinas Parra
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Aaron L Hecht
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David E Kaplan
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marina Serper
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Yan F, Peng X, Yang X, Yuan L, Zheng X, Yang Y. Predictive Factors and Nomogram for Spontaneous Bacterial Peritonitis in Decompensated Cirrhosis Among the Elderly. J Inflamm Res 2024; 17:10901-10911. [PMID: 39687773 PMCID: PMC11648538 DOI: 10.2147/jir.s484629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2024] [Accepted: 11/28/2024] [Indexed: 12/18/2024] Open
Abstract
Background and Aims Spontaneous bacterial peritonitis (SBP) represents a significant complication in the decompensated phase of cirrhosis. The challenges in treating SBP and the associated mortality rates are markedly elevated in elderly individuals. Timely detection and intervention for SBP are imperative. We aimed to develop a predictive tool for the occurrence of SBP in elderly individuals with decompensated cirrhosis (DC). Methods Elderly patients diagnosed with DC were enrolled from Chengdu Fifth People's Hospital in China, spanning from January 1, 2015, to September 31, 2023. Among the patients, 337 were assigned to the training cohort, while 145 were designated to the validation cohort. A multivariate logistic regression analysis was performed to identify significant predictors and to develop a nomogram for predicting the occurrence of SBP. To evaluate the model's discrimination and calibration, a bootstrap method with 1000 resamples was utilized. Results Findings from the multivariate logistic regression analysis indicated that constipation (odds ratio [OR] 2.09, 95% confidence interval [CI] 1.25-3.49, P=0.005), ascites (OR 2.84, 95% CI 1.64-4.92, P<0.001), Child-Pugh-Turcotte (CPT) score (OR 4.80, 95% CI 1.69-13.60, P=0.003), and high sensitivity C-reactive protein (hs-CRP) (OR 2.96, 95% CI 1.54-5.45, P=0.001) were significant independent predictors for the occurrence of SBP in elderly individuals with DC. The generated nomogram showed an area under the curve of 0.779 for the training cohort and 0.817 for the validation cohort. The nomogram's calibration curve nearly matched the perfect diagonal line, and decision curve analysis showed an improved net benefit for the model. Subsequent validation further corroborated the reliability of the predictive nomogram. Conclusion In conclusion, the nomogram, incorporating variables such as constipation, ascites, CPT score, and hs-CRP, effectively predicted the occurrence of SBP in elderly patients with DC, underscoring its substantial clinical applicability.
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Affiliation(s)
- Fang Yan
- Geriatric Diseases Institute of Chengdu, Department of Geriatrics, Chengdu Fifth People’s Hospital (The Second Clinical Medical College, Affiliated Fifth People’s Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, People’s Republic of China
- Center for Medicine Research and Translation, Chengdu Fifth People’s Hospital (The Second Clinical Medical College, Affiliated Fifth People’s Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, People’s Republic of China
| | - Xiaoxia Peng
- Geriatric Diseases Institute of Chengdu, Department of Geriatrics, Chengdu Fifth People’s Hospital (The Second Clinical Medical College, Affiliated Fifth People’s Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, People’s Republic of China
| | - Xingyao Yang
- Geriatric Diseases Institute of Chengdu, Department of Orthopedics, Chengdu Fifth People’s Hospital (The Second Clinical Medical College, Affiliated Fifth People’s Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, People’s Republic of China
| | - Li Yuan
- Department of Clinical Laboratory, Chengdu Fifth People’s Hospital (The Second Clinical Medical College, Affiliated Fifth People’s Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, Sichuan Province, People’s Republic of China
| | - Xiaomei Zheng
- Geriatric Diseases Institute of Chengdu, Department of Geriatrics, Chengdu Fifth People’s Hospital (The Second Clinical Medical College, Affiliated Fifth People’s Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, People’s Republic of China
| | - Yongxue Yang
- Geriatric Diseases Institute of Chengdu, Department of Geriatrics, Chengdu Fifth People’s Hospital (The Second Clinical Medical College, Affiliated Fifth People’s Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, People’s Republic of China
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Kamath SD, Kumar U, Sarkar N, Shrivastava V. Quadruple Complication in a Patient With Liver Cirrhosis: A Diagnostic Conundrum. Cureus 2024; 16:e64953. [PMID: 39161516 PMCID: PMC11331002 DOI: 10.7759/cureus.64953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2024] [Indexed: 08/21/2024] Open
Abstract
The incidence of bacterial infections is high in patients with liver cirrhosis (LC) due to compromised immune systems. They are associated with acute hepatic decompensation, multiorgan dysfunction, high morbidity, and mortality and account for 25-46% of all hospitalizations. The mortality rate is about 30% after one month and increases to 63% at one-year follow-up. While spontaneous bacterial peritonitis (SBP), urinary tract infections, soft tissue infections, and respiratory tract infections (pneumonia) are some of the common infections, SBP accounts for 25-31% of the cases and is the most frequent bacterial infection. Impaired activity of the phagocytes of the reticuloendothelial system, decreased production of the complement, and bacteria gaining access into the systemic circulation through the porto-systemic shunts are some of the causes of high-risk bacterial infection in patients with LC. The diagnosis of bacterial infection may be challenging as the typical symptoms like fever may not always be evident. We present a very challenging, middle-aged patient of cirrhosis with diabetes mellitus (DM) who presented with infections at multiple sites like SBP due to Serratia ficaria, multiple pyemic liver abscesses, left peri-nephric abscess with septicaemia, further complicated by portal vein thrombosis - all during single hospital admission. SBP was unique in the sense that no case of SBP due to Serratia ficaria has been published in the literature to date. The stormy clinical course, management, and outcome of the patient are described here.
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Affiliation(s)
| | - Umesh Kumar
- General Medicine, Tata Main Hospital, Jamshedpur, IND
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Chen T, Chen G, Wang G, Treeprasertsuk S, Lesmana CRA, Lin HC, Al-Mahtab M, Chawla YK, Tan SS, Kao JH, Yuen MF, Lee GH, Alcantara-Payawal D, Nakayama N, Abbas Z, Jafri W, Kim DJ, Choudhury A, Mahiwall R, Hou J, Hamid S, Jia J, Bajaj JS, Wang F, Sarin SK, Ning Q. Expert consensus on the diagnosis and treatment of end-stage liver disease complicated by infections. Hepatol Int 2024; 18:817-832. [PMID: 38460060 DOI: 10.1007/s12072-023-10637-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 12/22/2023] [Indexed: 03/11/2024]
Abstract
End-stage liver disease (ESLD) is a life-threatening clinical syndrome and when complicated with infection the mortality is markedly increased. In patients with ESLD, bacterial or fungal infection can induce or aggravate the occurrence or progression of liver decompensation. Consequently, infections are among the most common complications of disease deterioration. There is an overwhelming need for standardized protocols for early diagnosis and appropriate management for patients with ESLD complicated by infections. Asia Pacific region has the largest number of ESLD patients, due to hepatitis B and the growing population of alcohol and NAFLD. Concomitant infections not only add to organ failure and high mortality but also to financial and healthcare burdens. This consensus document assembled up-to-date knowledge and experience from colleagues across the Asia-Pacific region, providing data on the principles as well as evidence-based current working protocols and practices for the diagnosis and treatment of patients with ESLD complicated by infections.
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Affiliation(s)
- Tao Chen
- State Key Laboratory for Diagnosis and Treatment of Severe Zoonotic Infectious Diseases, Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095, Jiefang Avenue, Wuhan, 430030, P.R. China
| | - Guang Chen
- State Key Laboratory for Diagnosis and Treatment of Severe Zoonotic Infectious Diseases, Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095, Jiefang Avenue, Wuhan, 430030, P.R. China
| | - Guiqiang Wang
- Department of Infectious Disease, Center for Liver Disease, Peking University First Hospital, Beijing, China
| | - Sombat Treeprasertsuk
- Department of Medicine, Division of Gastroenterology, Faculty of Medicine, Chulalongkorn University, and Thai Red Cross, Bangkok, Thailand
| | - Cosmas Rinaldi Adithya Lesmana
- Internal Medicine, Hepatobiliary Division, Dr. Captor Mangunkusumo National General Hospital, Universitas Indonesia, Jakarta, DKI, Indonesia
| | - Han-Chieh Lin
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Mamun Al-Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Yogesh K Chawla
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | - Soek-Siam Tan
- Department of Hepatology, Hospital Selayang, Selangor Darul Ehsan, Malaysia
| | - Jia-Horng Kao
- Graduate Institute of Clinical Medicine and Hepatitis Research Center, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Man-Fung Yuen
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | - Guan-Huei Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | | | - Nobuaki Nakayama
- Department of Gastroenterology & Hepatology, Saitama Medical University, Saitama, Japan
| | - Zaigham Abbas
- Department of Medicine, Ziauddin University Hospital, Karachi, Pakistan
| | - Wasim Jafri
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Dong-Joon Kim
- Department of Internal Medicine, Chuncheon Sacred Heart Hospital of Hallym University Medical Center, Chuncheon, Korea
| | - Ashok Choudhury
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rakhi Mahiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Jinlin Hou
- Guangdong Provincial Key Laboratory of Viral Hepatitis Research, Guangdong Provincial Clinical Research Center for Viral Hepatitis, Key Laboratory of Infectious Diseases Research in South China, Ministry of Education, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Saeed Hamid
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Jidong Jia
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - J S Bajaj
- Department of Medicine, Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, VA, USA
| | - Fusheng Wang
- Senior Department of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, National Clinical Research Center for Infectious Diseases, Beijing, China
| | - Shiv K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Qin Ning
- State Key Laboratory for Diagnosis and Treatment of Severe Zoonotic Infectious Diseases, Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095, Jiefang Avenue, Wuhan, 430030, P.R. China.
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Pischke S, Ashouri MM, Peters U, Shiprov A, Schulze Zur Wiesch J, Sterneck M, Fischer F, Huebener P, Mader M, Fischer L, Fründt T, Aarabi G, Beikler T. High incidence of periodontitis in patients with ascitic decompensated cirrhosis. World J Hepatol 2023; 15:1325-1332. [PMID: 38223419 PMCID: PMC10784813 DOI: 10.4254/wjh.v15.i12.1325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 09/27/2023] [Accepted: 12/06/2023] [Indexed: 12/25/2023] Open
Abstract
BACKGROUND Periodontitis has been associated with various liver diseases. However, the relevance of periodontitis in the progression of decompensated cirrhosis remains inconclusive. In particular, it is unclear whether the common periodontitis pathogens, Porphyromonas gingivalis (P. gingivalis) and Actinobacillus actinomycetemcomitans (A. actinomycetemcomitans), can be detected not only in the oral mucosa but also in ascites and stool. AIM To investigate the significance of periodontitis, P. gingivalis, and A. actinomycetemcomitans in cirrhosis patients with ascitic decompensation. METHODS This prospective study was conducted at the University Hospital Hamburg-Eppendorf, a tertiary center in Northern Germany. A cohort of 27 patients with ascitic decompensated liver cirrhosis underwent dental examinations to assess the association between periodontitis and various clinical parameters of cirrhosis, as well as patient outcomes. PCR was used to test gingival samples, ascites, and stool for the presence of P. gingivalis and A. actinomycetemcomitans. Gingival samples were collected by probing the deepest gum pocket of a sextant and wiping them on a cotton swab. RESULTS Periodontitis was diagnosed in 22 out of 27 (82%) ascite patients, which is significantly more common than in a control cohort of 100 unselected patients (59%, P = 0.04). P. gingivalis was detected in the gingiva of six patients, and one of them also had P. gingivalis in their stool. However, P. gingivalis was not found in the ascites of any patient. Five out of six patients with P. gingivalis had periodontitis (83%). A. actinomycetemcomitans was not detected in any sample. Patients without periodontitis had a significantly higher mortality rate compared to those with periodontitis, and survival (Kaplan-Meier analysis) was longer in patients with periodontitis (P = 0.02). Transplant-free survival was also more common in patients with periodontitis compared to those without (63% vs 0%, P = 0.02). CONCLUSION Decompensated cirrhotic patients frequently suffer from periodontitis. However, there was no evidence of the translocation of P. gingivalis or A. actinomycetemcomitans into ascites. The survival of cirrhotic patients with periodontitis was not reduced.
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Affiliation(s)
- Sven Pischke
- First Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg 20246, Germany.
| | - Mohamad Motee Ashouri
- First Department of Medicine, University Hospital Hamburg-Eppendorf, Hamburg 20246, Germany
- Periodontics, Preventive and Restorative Dentistry, University Hospital Hamburg-Eppendorf, Hamburg 20246, Germany
| | - Ulrike Peters
- Department of Periodontics, Preventive and Restorative Dentistry, University Medical Center Hamburg-Eppendorf, Hamburg 20246, Germany
| | - Anita Shiprov
- First Department of Medicine, University Hospital Hamburg-Eppendorf, Hamburg 20246, Germany
- Periodontics, Preventive and Restorative Dentistry, University Hospital Hamburg-Eppendorf, Hamburg 20246, Germany
| | | | - Martina Sterneck
- First Department of Medicine, University Hospital Hamburg-Eppendorf, Hamburg 20246, Germany
| | - Frank Fischer
- Department of Periodontics, Preventive and Restorative Dentistry, University Medical Center Hamburg-Eppendorf, Hamburg 20246, Germany
| | - Peter Huebener
- First Department of Medicine, University Hospital Hamburg-Eppendorf, Hamburg 20246, Germany
| | - Maria Mader
- First Department of Medicine, University Hospital Hamburg-Eppendorf, Hamburg 20246, Germany
| | - Lutz Fischer
- Department of Visceral Transplantation, University Hospital Hamburg-Eppendorf, Hamburg 20246, Germany
| | - Thorben Fründt
- First Department of Medicine, University Hospital Hamburg-Eppendorf, Hamburg 20246, Germany
| | - G Aarabi
- Department of Periodontics, Preventive and Restorative Dentistry, University Medical Center Hamburg-Eppendorf, Hamburg 20246, Germany
| | - Thomas Beikler
- Department of Periodontics, Preventive and Restorative Dentistry, University Medical Center Hamburg-Eppendorf, Hamburg 20246, Germany
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9
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Varda B, Alani M, Ahmed S. A Rare Case of Spontaneous Fungal Peritonitis Caused by Candida lusitaniae in a Patient With Necrotizing Pancreatitis. Cureus 2023; 15:e40237. [PMID: 37435273 PMCID: PMC10332884 DOI: 10.7759/cureus.40237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2023] [Indexed: 07/13/2023] Open
Abstract
Candida lusitaniae is a rare cause of peritonitis most commonly associated with peritoneal dialysis patients. Pancreatitis is one possible cause of ascites with a low serum ascites albumin gradient. Herein, we present a case of spontaneous fungal peritonitis caused by Candida lusitaniae in a patient with necrotizing pancreatitis. The patient was treated with antifungal medication, while her pancreatitis was managed endoscopically with necrosectomy. She improved clinically and was discharged in stable condition.
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Affiliation(s)
- Bianca Varda
- Internal Medicine, St. Joseph's Hospital and Medical Center, Phoenix, USA
- Internal Medicine, Loyola University Medical Center, Chicago, USA
| | | | - Shifat Ahmed
- Gastroenterology, Creighton University School of Medicine, St. Joseph's Hospital and Medical Center, Phoenix, USA
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10
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Long B, Gottlieb M. Emergency medicine updates: Spontaneous bacterial peritonitis. Am J Emerg Med 2023; 70:84-89. [PMID: 37244043 DOI: 10.1016/j.ajem.2023.05.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/11/2023] [Accepted: 05/12/2023] [Indexed: 05/29/2023] Open
Abstract
INTRODUCTION Spontaneous bacterial peritonitis (SBP) is a common infection in patients with cirrhosis and ascites and is associated with significant risk of mortality. Therefore, it is important for emergency medicine clinicians to be aware of the current evidence regarding the diagnosis and management of this condition. OBJECTIVE This paper evaluates key evidence-based updates concerning SBP for the emergency clinician. DISCUSSION SBP is commonly due to Gram-negative bacteria, but infections due to Gram-positive bacteria and multidrug resistant bacteria are increasing. The typical presentation of SBP includes abdominal pain, worsening ascites, fever, or altered mental status in a patient with known liver disease; however, some patients may be asymptomatic or present with only mild symptoms. Paracentesis is the diagnostic modality of choice and should be performed in any patient with ascites and concern for SBP or upper gastrointestinal bleeding, or in those being admitted for a complication of cirrhosis. Ultrasound should be used to optimize the procedure. An ascites absolute neutrophil count (ANC) ≥ 250 cells/mm3 is diagnostic of SBP. Ascitic fluid should be placed in blood culture bottles to improve the culture yield. Leukocyte esterase reagent strips can be used for rapid diagnosis if available. While many patients will demonstrate coagulation panel abnormalities, routine transfusion is not recommended. Management traditionally includes a third-generation cephalosporin, but specific patient populations may require more broad-spectrum coverage with a carbapenem or piperacillin-tazobactam. Albumin infusion is associated with reduced risk of renal impairment and mortality. CONCLUSIONS An understanding of literature updates can improve the care of patients with suspected SBP.
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Affiliation(s)
- Brit Long
- SAUSHEC, Emergency Medicine, Brooke Army Medical Center, United States of America.
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States of America
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11
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Boustany A, Rahhal R, Onwuzo S, Almomani A, Boustany T, Kumar P, hitawala A, Asaad I. Cirrhotic patients on proton pump inhibitors are at a twofold risk of spontaneous bacterial peritonitis independently of gastrointestinal bleeding: a population-based retrospective study. Ann Gastroenterol 2023; 36:327-332. [PMID: 37144010 PMCID: PMC10152803 DOI: 10.20524/aog.2023.0794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 01/30/2023] [Indexed: 05/06/2023] Open
Abstract
Background 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). Methods 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. Results 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. Conclusions 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.
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Affiliation(s)
- Antoine Boustany
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA (Antoine Boustany, Somtochukwu Onwuzo, Ashraf Almomani, Prabhat Kumar, Imad Asaad)
| | - Romy Rahhal
- School of Medicine, Saint Joseph University of Beirut, Beirut, Lebanon (Romy Rahhal)
| | - Somtochukwu Onwuzo
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA (Antoine Boustany, Somtochukwu Onwuzo, Ashraf Almomani, Prabhat Kumar, Imad Asaad)
| | - Ashraf Almomani
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA (Antoine Boustany, Somtochukwu Onwuzo, Ashraf Almomani, Prabhat Kumar, Imad Asaad)
| | - Tara Boustany
- School of Pharmacy, University of Paris-Saclay, Paris, France (Tara Boustany)
| | - Prabhat Kumar
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA (Antoine Boustany, Somtochukwu Onwuzo, Ashraf Almomani, Prabhat Kumar, Imad Asaad)
| | - Asif hitawala
- Liver Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases/National Institutes of Health, Bethesda, USA (Asif hitawala)
| | - Imad Asaad
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA (Antoine Boustany, Somtochukwu Onwuzo, Ashraf Almomani, Prabhat Kumar, Imad Asaad)
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12
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Lee CH, Kang HJ, Yu SY, Seo SY, Kim SH, Kim SW, Lee SO, Lee ST, Kim IH. Initial treatment response and short-term mortality of spontaneous bacterial peritonitis in cirrhotic patients with hepatocellular carcinoma. Sci Rep 2023; 13:6067. [PMID: 37055466 PMCID: PMC10101952 DOI: 10.1038/s41598-023-32006-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 03/21/2023] [Indexed: 04/15/2023] Open
Abstract
This study aimed to investigate the initial treatment response and short-term mortality of spontaneous bacterial peritonitis (SBP) in cirrhotic patients with hepatocellular carcinoma (HCC) compared with those without HCC. A total of 245 patients with liver cirrhosis diagnosed with SBP between January 2004 and December 2020 were included. Of these, 107 (43.7%) were diagnosed with HCC. Overall, the rates of initial treatment failure, 7-day and 30-day mortality were 91 (37.1%), 42 (17.1%), and 89 (36.3%), respectively. While the baseline CTP score, MELD score, culture-positive rate, and rates of antibiotic resistance did not differ between both groups, patients with HCC had a higher rate of initial treatment failure than those without HCC patients (52.3% vs. 25.4%, P < 0.001). Similarly, 30-day mortality was also significantly higher in patients with HCC (53.3% vs. 23.2%, P < 0.001). In the multivariate analysis, HCC, renal impairment, CTP grade C, and antibiotic resistance were independent factors for initial treatment failure. Furthermore, HCC, hepatic encephalopathy, MELD score, and initial treatment failure were independent risk factors for 30-day mortality, with statistically significant poor survival outcomes in patients with HCC (P < 0.001). In conclusion, HCC is an independent risk factor for initial treatment failure and high short-term mortality in patients with cirrhosis with SBP. It has been suggested that more attentive therapeutic strategies are required to improve the prognosis of patients with HCC and SBP.
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Affiliation(s)
- Chang Hun Lee
- Department of Internal Medicine, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonbuk National University Medical School and Hospital, Geonjiro 20, Dukjin-Gu, Jeonju, Jeonbuk, 54907, South Korea
| | - Hye Jin Kang
- Department of Internal Medicine, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonbuk National University Medical School and Hospital, Geonjiro 20, Dukjin-Gu, Jeonju, Jeonbuk, 54907, South Korea
| | - Song Yi Yu
- Department of Internal Medicine, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonbuk National University Medical School and Hospital, Geonjiro 20, Dukjin-Gu, Jeonju, Jeonbuk, 54907, South Korea
| | - Seung Young Seo
- Department of Internal Medicine, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonbuk National University Medical School and Hospital, Geonjiro 20, Dukjin-Gu, Jeonju, Jeonbuk, 54907, South Korea
| | - Seong Hun Kim
- Department of Internal Medicine, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonbuk National University Medical School and Hospital, Geonjiro 20, Dukjin-Gu, Jeonju, Jeonbuk, 54907, South Korea
| | - Sang Wook Kim
- Department of Internal Medicine, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonbuk National University Medical School and Hospital, Geonjiro 20, Dukjin-Gu, Jeonju, Jeonbuk, 54907, South Korea
| | - Seung Ok Lee
- Department of Internal Medicine, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonbuk National University Medical School and Hospital, Geonjiro 20, Dukjin-Gu, Jeonju, Jeonbuk, 54907, South Korea
| | - Soo Teik Lee
- Department of Internal Medicine, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonbuk National University Medical School and Hospital, Geonjiro 20, Dukjin-Gu, Jeonju, Jeonbuk, 54907, South Korea
| | - In Hee Kim
- Department of Internal Medicine, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonbuk National University Medical School and Hospital, Geonjiro 20, Dukjin-Gu, Jeonju, Jeonbuk, 54907, South Korea.
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13
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Mid-Infrared Spectroscopy as a New Tool for Ruling Out Spontaneous Bacterial Peritonitis: A Proof-of-Concept Study. Biomedicines 2023; 11:biomedicines11030838. [PMID: 36979817 PMCID: PMC10045833 DOI: 10.3390/biomedicines11030838] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 03/01/2023] [Accepted: 03/06/2023] [Indexed: 03/12/2023] Open
Abstract
Background and aims: A highly sensitive and specific point-of-care method for diagnosing spontaneous bacterial peritonitis (SBP) is currently lacking. The objective of the present study is to evaluate the diagnostic value of a rapid, easy-to-use, mid-infrared fiber evanescent wave spectroscopy (MIR-FEWS) method for ruling out SBP. Patients and Methods: Cirrhotic patients (n = 256) at five centers in France were included for suspected SBP or for the scheduled evacuation of ascites fluid. The mid-infrared spectrum of 7 µL of an ascites fluid sample was recorded using a MIR-FEWS system. To define a model for the diagnosis of SBP, the patients were divided into a calibration group (n = 170) and a validation group (n = 86). Results: Most of the patients were male (71%). The mean age was 60.25 years. Alcohol-related liver disease was the most common cause of cirrhosis. SBP was observed in 18% of the patients. For the diagnosis of SBP in the calibration and validation groups, respectively, the model gave areas under the receiver operating characteristic curves of 0.87 and 0.89, sensitivities of 90% and 87%, specificities of 78% and 80%, positive predictive values of 48% and 50%, negative predictive values of 97% and 96%, positive likelihood ratio of 4.09 and 4.35, negative likelihood ratio of 0.13 and 0.16, Youden index of 0.68 and 0.67, and correct classification rates of 80% and 81%. Conclusion: The results of this proof-of-concept study show that MIR-FEWS is a highly sensitive diagnostic method for ruling out SBP. The method warrants further investigation.
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14
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Abudeif A, Elbadry MI, Ahmed NM. Validation of the diagnostic accuracy of neutrophil to lymphocyte ratio (NLR) and mean platelet volume (MPV) in cirrhotic patients with spontaneous bacterial peritonitis. EGYPTIAN LIVER JOURNAL 2023. [DOI: 10.1186/s43066-023-00245-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023] Open
Abstract
Abstract
Background
Spontaneous bacterial peritonitis (SBP) is a significant complication among cirrhotic patients with ascites and is associated with high mortality. Early diagnosis and treatment of SBP are crucial, as they are associated with better outcomes and lower mortality. The neutrophil-to-lymphocyte ratio (NLR) and mean platelet volume (MPV) are routine, inexpensive, easily measured markers readily obtained from a complete blood count (CBC). Several studies have addressed the diagnostic role of NLR and MPV in patients with SBP but with different cutoff values, sensitivity, and specificity. Therefore, we conducted this study to validate the clinical utility of NLR and MPV in diagnosing SBP.
Methods
This study included 332 cirrhotic patients with ascites who were admitted to Sohag University Hospitals in Egypt between April 2020 and April 2022. Of these patients, 117 had SBP, and 215 did not. Both NLR and MPV were measured in all patients, and the ability of NLR and MPV to diagnose SBP was assessed using the receiver operator characteristic (ROC) curve analysis.
Results
NLR and MPV were significantly elevated in patients with SBP compared to those without SBP (P < 0.001). At a cutoff value of 5.6, the sensitivity and specificity of the NLR in detecting SBP were 78% and 81%, respectively. In contrast, MPV, at a cutoff value of 8.8 fL, had a sensitivity of 62% and a specificity of 63%. The combination of NLR and MPV did not provide significant additional diagnostic value beyond only using NLR.
Conclusion
Although NLR and MPV allow the detection of SBP, the NLR has higher clinical utility and is superior to MPV in diagnosing SBP.
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15
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Secondary peritonitis in a patient with cirrhosis involving Hyphopichia burtonii, an emerging fungal pathogen. IDCases 2023; 31:e01730. [PMID: 36911872 PMCID: PMC9996382 DOI: 10.1016/j.idcr.2023.e01730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/18/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023] Open
Abstract
We present a case where Hyphopichia burtonii, a yeast, speciated from peritoneal fluid in a cirrhotic patient with secondary peritonitis. The patient, a man in his 60s with decompensated cirrhosis, was admitted for an upper gastrointestinal (GI) bleed. On admission, he was treated empirically for spontaneous bacterial peritonitis (SBP) but failed to improve with antibiotics. Serial paracenteses revealed polymicrobial peritonitis and rising peritoneal polymorphonuclear leukocytes (PMNs). These findings raised concerns for secondary peritonitis, prompting an abdominal computed tomography (CT) scan which revealed ischemic bowel. Among the peritoneal microbiota isolated, Hyphopichia burtonii predominated. Hyphopichia burtonii has only recently been reported as a human pathogen, previously it had only reported as a pathogen in bats[1,2].
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16
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Yoon YK, Moon C, Kim J, Heo ST, Lee MS, Lee S, Kwon KT, Kim SW, Korean Society for Antimicrobial Therapy, Korean Society of Infectious Diseases. Korean Guidelines for Use of Antibiotics for Intra-abdominal Infections in Adults. Infect Chemother 2022; 54:812-853. [PMID: 36596690 PMCID: PMC9840951 DOI: 10.3947/ic.2022.0156] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022] Open
Abstract
The guidelines are intended to provide practical information for the correct use of antibiotics for intra-abdominal infections in Korea. With the aim of realizing evidence-based treatment, these guidelines for the use of antibiotics were written to help clinicians find answers to key clinical questions that arise in the course of patient care, using the latest research results based on systematic literature review. The guidelines were prepared in consideration of the data on the causative pathogens of intra-abdominal infections in Korea, the antibiotic susceptibility of the causative pathogens, and the antibiotics available in Korea.
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Affiliation(s)
- Young Kyung Yoon
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea.,Korean Society for Antimicrobial Therapy, Seoul, Korea
| | - Chisook Moon
- Korean Society for Antimicrobial Therapy, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, Inje University College of Medicine, Busan, Korea
| | - Jieun Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea.,Korean Society of Infectious Diseases, Seoul, Korea
| | - Sang Taek Heo
- Korean Society of Infectious Diseases, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, Jeju National University College of Medicine, Jeju, Korea
| | - Mi Suk Lee
- Korean Society of Infectious Diseases, Seoul, Korea.,Department of Internal Medicine, Kyung Hee University College of Medicine, Seoul, Korea
| | - Shinwon Lee
- Korean Society of Infectious Diseases, Seoul, Korea.,Department of Internal Medicine, Pusan National University School of Medicine and Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Ki-Tae Kwon
- Korean Society for Antimicrobial Therapy, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Shin-Woo Kim
- Korean Society for Antimicrobial Therapy, Seoul, Korea.,Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
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17
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Patel KP, Korbitz PM, Gallagher JP, Schmidt C, Ingviya T, Manatsathit W. Ascitic calprotectin and lactoferrin for detection of spontaneous bacterial peritonitis: a systematic review and meta-analysis. Transl Gastroenterol Hepatol 2022; 7:37. [PMID: 36300150 PMCID: PMC9468990 DOI: 10.21037/tgh-20-323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 02/26/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Spontaneous bacterial peritonitis (SBP) is a common bacterial infection in cirrhotic patients associated with a high mortality rate. Prompt diagnosis and early antibiotic administration are crucial in minimizing adverse outcomes. Although detection of ≥250 polymorphonuclear leukocytes (PMN) in ascitic fluid is the current gold standard to diagnose SBP, consideration for rapid detection with biomarkers is warranted. METHODS A literature search for studies evaluating ascitic calprotectin and lactoferrin for detection of SBP was performed using PubMed, Embase, Scopus, Google Scholar, Cochrane library, and Clinical Trial Registries. Summary sensitivity, specificity, log diagnostic odds ratio (LDOR), and area under the summary receiver operating curve (AUC) were calculated. RESULTS In total, 12 and 13 studies evaluated ascitic calprotectin and lactoferrin, respectively, for detection of SBP. Summary sensitivity, specificity, and LDOR for calprotectin were 0.942 (95% CI, 0.916, 0.967), 0.860 (95% CI, 0.799, 0.935), and 4.250 (95% CI, 3.504, 4.990), respectively. AUC for calprotectin was 0.91. Summary sensitivity, specificity, and LDOR for lactoferrin were 0.954 (95% CI, 0.930, 0.979), 0.890 (95% CI, 0.836, 0.945), and 4.630 (95% CI, 3.800, 5.452), respectively. AUC for lactoferrin was 0.958. CONCLUSIONS The overall performance of ascitic calprotectin and lactoferrin was substantial, potentially serving as a screening tool or an alternative to manual cell count. However, a variety of manufacturers, cut-off values, and significant heterogeneity between studies should be noted. Point-of-care testing for calprotectin and lactoferrin may resolve disadvantages associated with the current methods. Future studies on this topic are, therefore, needed.
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Affiliation(s)
- Kishan P. Patel
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Parker M. Korbitz
- Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - John P. Gallagher
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Cynthia Schmidt
- McGoogan Library of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Thammasin Ingviya
- Department of Family and Preventive Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
- Medical Data Center for Research and Innovation, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
- Digital Innovation and Data Analytics, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Wuttiporn Manatsathit
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
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18
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Mohamed AA, Salah W, Hassan MB, Eldeeb HH, Adaroas AS, Khattab RA, Abostate HM, Soliman MY, Habba E, Abd-Elsalam S, Abo-Amer YEE. MCP1, CRP and Procalcitonin as Novel Diagnostic Markers in Cirrhotic Patients with Spontaneous Bacterial Peritonitis. THE OPEN BIOMARKERS JOURNAL 2022; 12. [DOI: 10.2174/18753183-v12-e2206270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/16/2022] [Accepted: 04/08/2022] [Indexed: 09/01/2023]
Abstract
Background & Aims:
The aim of the study was to evaluate serum c-reactive protein (CRP), ascitic procalcitonin (PCT) and monocyte chemotactic protein-1 (MCP-1) in the diagnosis of spontaneous bacterial peritonitis (SBP) in cirrhotic patients.
Methods:
A cross-sectional analytic study that included 199 patients with decompensated cirrhosis (101 with SBP and 98 without SBP). Patients were classified according to Child-Pugh criteria. Ascitic PCT and MCP-1 were measured by enzyme-linked immunosorbent assay. Serum CRP, liver and renal functions were assessed.
Results:
Three markers are significantly elevated in SBP patients than those without ascites. Using the ROC curve at AUC 0.883 and a cut-off value of >186 ng/ml, the diagnostic performance of ascitic MCP-1 level was higher than CRP (AUC 0.562) and ascitic fluid procalcitonin (AUC 0.751) in the diagnosis of SBP. The sensitivity and specificity were 86.15% and 79.59% at the cutoff of 186 ng/ml for MCP-1, 65.4 and 75.5 at ≥ 1 ng/ml for PCT, and 52.5 and 64.3, respectively for at 11.2 mg/dl CRP.
Conclusion:
Ascitic MCP-1 has a better diagnostic value with higher sensitivity and specificity in diagnosis SBP compared to CRP and procalcitonin which has higher diagnostic accuracy than CRP. Further studies with a large number will be necessary to evaluate the usefulness of these markers in diagnosis, follow-up and relation to morbidity and mortality of SBP patients.
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Nguyen LC, Lo TTB, La HD, Doan HTN, Le NT. Clinical, Laboratory and Bacterial Profile of Spontaneous Bacterial Peritonitis in Vietnamese Patients with Liver Cirrhosis. Hepat Med 2022; 14:101-109. [PMID: 35936811 PMCID: PMC9348134 DOI: 10.2147/hmer.s369966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 07/21/2022] [Indexed: 11/23/2022] Open
Abstract
Aim Methods Results Conclusion
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Affiliation(s)
- Long Cong Nguyen
- Gastroenterology and Hepatology Center, Bach Mai Hospital, Hanoi, Vietnam
- University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
- Correspondence: Long Cong Nguyen, Institution: Gastroenterology and Hepatology Center, Bach Mai hospital, Hanoi, Vietnam, Email
| | | | - Huong Dieu La
- Gastroenterology and Hepatology Center, Bach Mai Hospital, Hanoi, Vietnam
| | - Ha Thi-Ngoc Doan
- Gastroenterology and Hepatology Center, Bach Mai Hospital, Hanoi, Vietnam
| | - Ngoan Tran Le
- Institute of Research and Development, Duy Tan University, Da Nang, Vietnam
- Department of Public Health, School of Medicine, International University of Health and Welfare, Tochigi, Japan
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20
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Caccamo G, Franzè MS, Saffioti F, Pitrone C, Porcari S, Alibrandi A, Filomia R, Mondello P, Cacciola I, Saitta C, Squadrito G, Raimondo G, Maimone S. Cirrhotic Patients with Bacterial Infection and Negative Cultures Have a More Advanced Disease and an Increased Short-Term Mortality Rate. Dig Dis Sci 2022; 67:2655-2665. [PMID: 34041650 DOI: 10.1007/s10620-021-07047-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 05/09/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND The negative clinical impact of bacterial infections (BI) in patients with cirrhosis is well documented. In cirrhotic patients, failure to isolate the pathogen is a frequent event, occurring in 30-40% of cases. AIM The aim of this study was to compare the clinical characteristics, early (30-day) and short-term (90-day) mortality rates, in a cohort of cirrhotic patients with BI, between those with positive (C-pos) and those with negative (C-neg) microbiological cultures. METHODS We retrospectively enrolled 279 consecutive hospitalized cirrhotic patients with BI. Survival and predictors of 30-day and 90-day mortality were assessed by Kaplan-Meier curves and logistic regression analysis, respectively. RESULTS Cultures tested negative in 108/279 (38.7%) patients. C-neg patients were more frequently males (p = 0.035), had higher Child-Pugh-Turcotte (CPT; p = 0.007) and model for end-stage liver disease-sodium (MELD-Na; p = 0.043) scores, and had more frequently decompensated liver disease (p = 0.04). Mortality rate was higher in C-neg than in C-pos patients, both at 30 days (22.2% versus 11.7%, p = 0.024) and 90 days (46.3% versus 33.3%, p = 0.030). MELD-Na score and non-selective beta-blockers (NSBBs) were independent risk factors for 30-day and 90-day mortality. In particular, the use of NSBBs was independently associated with a lower 30-day and 90-day mortality risk (OR 0.41, CI95% 0.17-0.94, p = 0.040; and OR 0.43, CI95% 0.25-0.75, p = 0.003, respectively). CONCLUSIONS Cirrhotic patients with BI and negative microbiological cultures have significantly higher mortality compared to those with positive cultures. Early mortality and short-term mortality are mainly influenced by the underlying severity of liver disease. In this contest, therapy with NSBBs has a positive impact on short-term survival.
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Affiliation(s)
- Gaia Caccamo
- Division of Medicine and Hepatology, University Hospital of Messina "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy.
- Department of Medical Sciences, University Hospital of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy.
| | - Maria Stella Franzè
- Division of Medicine and Hepatology, University Hospital of Messina "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy
- Department of Medical Sciences, University Hospital of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy
- Department of Clinical and Experimental Medicine, University of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy
| | - Francesca Saffioti
- Department of Gastroenterology and Hepatology, Oxford University Hospitals NHS Foundation Trust, Windmill Road, Heading, Oxford, OX1 HP, UK
| | - Concetta Pitrone
- Division of Medicine and Hepatology, University Hospital of Messina "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy
- Department of Medical Sciences, University Hospital of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy
- Department of Clinical and Experimental Medicine, University of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy
| | - Serena Porcari
- Department of Medical Sciences, University Hospital of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy
- Division of Gastroenterology and Inflammatory Bowel Diseases, University Hospital of Messina, Via Consolare Valeria 1, 98124, Messina, Italy
| | - Angela Alibrandi
- Department of Economics Unit of Statistical and Mathematical Science, University of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy
| | - Roberto Filomia
- Division of Medicine and Hepatology, University Hospital of Messina "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy
- Department of Medical Sciences, University Hospital of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy
| | - Placido Mondello
- Department of Medical Sciences, University Hospital of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy
- Division of Infectious Diseases, University Hospital of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy
| | - Irene Cacciola
- Division of Medicine and Hepatology, University Hospital of Messina "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy
- Department of Medical Sciences, University Hospital of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy
- Department of Clinical and Experimental Medicine, University of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy
| | - Carlo Saitta
- Division of Medicine and Hepatology, University Hospital of Messina "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy
- Department of Medical Sciences, University Hospital of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy
| | - Giovanni Squadrito
- Department of Medical Sciences, University Hospital of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy
- Department of Clinical and Experimental Medicine, University of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy
- Division of Internal Medicine, University Hospital of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy
| | - Giovanni Raimondo
- Division of Medicine and Hepatology, University Hospital of Messina "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy
- Department of Medical Sciences, University Hospital of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy
- Department of Clinical and Experimental Medicine, University of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy
| | - Sergio Maimone
- Division of Medicine and Hepatology, University Hospital of Messina "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy
- Department of Medical Sciences, University Hospital of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy
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Radulescu SM, Guedra Allais M, Le Gal A, Cook S. Medically managed spontaneous bacterial peritonitis and bacteraemia associated with jugular catheter infection in a dog with tetanus. VETERINARY RECORD CASE REPORTS 2022. [DOI: 10.1002/vrc2.354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Sinziana Maria Radulescu
- Department of Clinical Science and Services The Royal Veterinary College University of London Hatfield UK
| | - Miriam Guedra Allais
- Department of Clinical Science and Services The Royal Veterinary College University of London Hatfield UK
| | - Alice Le Gal
- Department of Clinical Science and Services The Royal Veterinary College University of London Hatfield UK
| | - Simon Cook
- Department of Clinical Science and Services The Royal Veterinary College University of London Hatfield UK
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Patel KP, Gallagher JP, Korbitz PM, Schmidt C, Ingviya T, Sempokuya T, Manatsathit W. Performance of Leukocyte Esterase Reagent Strips in the Detection of Spontaneous Bacterial Peritonitis in Cirrhotic Patients: A Systematic Review and Meta-analysis. J Clin Exp Hepatol 2022; 12:519-532. [PMID: 35535110 PMCID: PMC9077197 DOI: 10.1016/j.jceh.2021.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 05/04/2021] [Indexed: 12/12/2022] Open
Abstract
Background Spontaneous bacterial peritonitis (SBP) is a bacterial infection associated with a high mortality rate in cirrhotic patients. The gold standard for the detection of SBP is a manual cell count from ascitic fluid; however, alternative screening methods are under investigation. In particular, leukocyte esterase reagent strips (LERS) has been studied as an alternative method to detect SBP with a low cost and instant turnaround time. Therefore, this study aims to evaluate the performance of LERS in the detection of SBP. Methods A literature search was performed for studies evaluating LERS for the detection of SBP on PubMed, Embase, Scopus, Cochrane, and clinical trial registries. Summary sensitivity, specificity, log diagnostic odds ratio (LDOR), and the area under the summary receiver operating curve (AUC) were calculated according to the respective manufacturer. Results In total, 31 studies were evaluated. The summary sensitivity of Aution Sticks, Combur, Multistix, Periscreen reagent strips was 0.962 (95% confidence interval [CI] 0.926, 0.998), 0.892 (95% CI 0.846, 0.938), 0.806 (95% CI 0.738, 0.874), and 0.939 (95% CI 0.900, 0.979), respectively. The summary specificity of Aution Sticks, Combur, Multistix, and Periscreen reagent strips was 0.940 (95% CI 0.904, 0.976), 0.922 (95% CI 0.874, 0.970), 0.974 (95% CI 0.962, 0.985), and 0.672 (95% CI 0.381, 0.963), respectively. Conclusion LERS appears to have a notable overall performance for the detection of SBP. LERS appeared to be an acceptable alternative to diagnose SBP in facilities without ability to perform cell count. However, there were significant differences in performance between each manufacturer.
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Affiliation(s)
- Kishan P. Patel
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - John P. Gallagher
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Parker M. Korbitz
- Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Cynthia Schmidt
- McGoogan Library of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Thammasin Ingviya
- Department of Family and Preventive Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
- Medical Data Center for Research and Innovations, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Tomoki Sempokuya
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Wuttiporn Manatsathit
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
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Xiang S, Tan J, Tan C, Xu Q, Wen Y, Wang T, Yang C, Zhao W. Establishment and Validation of a Non-Invasive Diagnostic Nomogram to Identify Spontaneous Bacterial Peritonitis in Patients With Decompensated Cirrhosis. Front Med (Lausanne) 2022; 8:797363. [PMID: 35174183 PMCID: PMC8842661 DOI: 10.3389/fmed.2021.797363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 12/20/2021] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Spontaneous bacterial peritonitis (SBP) is a common and life-threatening infection in patients with decompensated cirrhosis (DC), and it is accompanied with high mortality and morbidity. However, early diagnosis of spontaneous bacterial peritonitis (SBP) is not possible because of the lack of typical symptoms or the low patient compliance and positivity rate of the ascites puncture test. We aimed to establish and validate a non-invasive diagnostic nomogram to identify SBP in patients with DC. METHOD Data were collected from 4,607 patients with DC from July 2015 to December 2019 in two tertiary hospitals in Chongqing, China (A and B). Patients with DC were divided into the SBP group (995 cases) and the non-SBP group (3,612 cases) depending on whether the patients had SBP during hospitalization. About 70% (2,685 cases) of patients in hospital A were randomly selected as the traindata, and the remaining 30% (1,152 cases) were used as the internal validation set. Patients in hospital B (770 cases) were used as the external validation set. The univariate analysis and least absolute shrinkage and selection operator (LASSO) regression were used to screen variables, and logistic regression was used to determine independent predictors to construct a nomogram to identify patients with SBP. Area under curve (AUC), calibration curve, and dynamic component analysis (DCA) were carried out to determine the effectiveness of the nomogram. RESULT The nomogram was composed of seven variables, namely, mean red blood cell hemoglobin concentration (odds ratio [OR] = 1.010, 95% CI: 1.004-1.016), prothrombin time (OR = 1.038, 95% CI: 1.015-1.063), lymphocyte percentage (OR = 0.955, 95% CI: 0.943-0.967), prealbumin (OR = 0.990, 95% CI: 0.987-0.993), total bilirubin (OR = 1.003 95% CI: 1.002-1.004), abnormal C-reactive protein (CRP) level (OR = 1.395, 95% CI: 1.107-1.755), and abnormal procalcitonin levels (OR = 1.975 95% CI: 1.522-2.556). Good discrimination of the model was observed in the internal and external validation sets (AUC = 0.800 and 0.745, respectively). The calibration curve result indicated that the nomogram was well-calibrated. The DCA curve of the nomogram presented good clinical application ability. CONCLUSION This study identified the independent risk factors of SBP in patients with DC and used them to construct a nomogram, which may provide clinical reference information for the diagnosis of SBP in patients with DC.
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Affiliation(s)
- Shoushu Xiang
- College of Medical Informatics, Chongqing Medical University, Chongqing, China
| | - Juntao Tan
- Department of Medical Administration, People's Hospital of Chongqing Banan District, Chongqing, China
| | - Chao Tan
- Cancer Hospital, Chongqing University, Chongqing, China
| | - Qian Xu
- College of Medical Informatics, Chongqing Medical University, Chongqing, China
| | - Yuanjiu Wen
- Department of General Medicine, Army Medical University (Third Military Medical University), Chongqing, China
| | - Tiantian Wang
- College of Medical Informatics, Chongqing Medical University, Chongqing, China
| | - Chen Yang
- Medical Data Science Academy, Chongqing Medical University, Chongqing, China
| | - Wenlong Zhao
- College of Medical Informatics, Chongqing Medical University, Chongqing, China
- Medical Data Science Academy, Chongqing Medical University, Chongqing, China
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Diagnostic Potential of Calprotectin for Spontaneous Bacterial Peritonitis in Patients Withliver Cirrhosis and Ascites. Pril (Makedon Akad Nauk Umet Odd Med Nauki) 2021; 42:97-106. [PMID: 35032370 DOI: 10.2478/prilozi-2021-0040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The development of spontaneous bacterial peritonitis (SBP) is a serious and life-threatening condition in patients with cirrhosis and ascites. The aim of this study was to determine the diagnostic potential of calprotectin in ascites, for SBP in patients with liver cirrhosis and ascites before and after antibiotic treatment and to compare the mean values of calprotectin in ascites in patients with and without SBP. This prospective-observational study was comprised of 70 patients with cirrhosis and ascites, divided into two groups, the SBP and the non-SBP group. Quantitative measurements of calprotectin in ascites was completed with the Quantum Blue Calprotectin Ascites test (LF-ASC25), using the Quantum Blue Reader. The average value of calprotectin in the SBP group was 1.5 ± 0.40 μg / mL, and in the non-SBP group it was lower (0.4 ± 0.30). The difference between the mean values was statistically significant with p <0.05. The mean value of calprotectin in ascites before therapy among the SBP group was 1.5 ± 0.4, and after antibiotic therapy, the value decreased significantly to 1.0 ± 0.6; the difference between the mean values was statistically significant with p <0.05. ROC analysis indicated that calprotectin contributed to the diagnosis of SBP with a 94.3% sensitivity rating (to correctly identify positives), and the specificity was 62.5%, which corresponded to the value of 0.275. Our research confirmed that ascitic calprotectin was a good predictor, and is significantly associated with the occurrence of SBP in patients with liver cirrhosis. By monitoring the value of calprotectin in ascites on the 7th day of antibiotic treatment, the effectiveness of antibiotic treatment in patients with SBP can be determined.
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25
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Elzouki AN, Hamad A, Almasri H, Ata M, Ashour A, Othman M, Badi A, Errayes M, Zahid M, Danjuma M. Predictors of Short-Term Mortality Following First Episode of Spontaneous Bacterial Peritonitis in Hospitalized Cirrhotic Patients. Cureus 2021; 13:e18999. [PMID: 34853741 PMCID: PMC8609112 DOI: 10.7759/cureus.18999] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2021] [Indexed: 11/25/2022] Open
Abstract
Background and aims Spontaneous bacterial peritonitis (SBP) is an important cause of morbidity and mortality in patients with cirrhosis. This study aimed to identify the factors impacting morbidity and short-term mortality in a cohort of patients with cirrhosis following an index episode of SBP. Methods In a retrospective study of hospitalized cirrhotic cohort, 333 patient records were reviewed. Demographic, clinical, and laboratory, as well as radiological characteristics of the patient population were analyzed on day 1 of admission. The diagnosis of cirrhosis was based on the combination of laboratory, clinical, and radiological features. The diagnosis of SBP was established by abdominal paracentesis in the presence of cellular, biochemical, and microbiological features consistent with SBP. All independent variables were analyzed to generate a predictive model of mortality by using the Cox proportional hazards regression analysis (adjusted for age and gender). Results A total of 61 cirrhotic patients with ascites and a first episode of SBP were identified. The overall mortality among hospitalized patients was 19.7% and was associated with longer length of stay (12.6 vs. 7.6 days; p=0.01). Patient cohorts with multiple antibiotic resistant bacteria as a cause of SBP had a significantly higher mortality compared to those with other bacterial phenotypes (p=0.03). Multivariate analyses showed that a model for end-stage liver disease (MELD) score (hazard ratio [HR]=1.29; 95% CI: 1.10 to 1.92; p=0.023), Child-Turcotte-Pugh score (HR=1.23; 95% CI: 1.05 to 1.82; p=0.027), and acute kidney injury (HR=2.09; 95% CI: 1.41 to 3.47; p=0.01) were the predictors of mortality from SBP. Conclusion SBP predicts in-hospital mortality in cirrhotic patients. In addition to multiple antibiotic resistant bacteria, thresholds of both hepatic and renal injury independently predict adverse outcomes.
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Affiliation(s)
- Abdel-Naser Elzouki
- Internal Medicine, Hamad Medical Corporation, Doha, QAT.,Internal Medicine, College of Medicine, Qatar University, Doha, QAT.,Internal Medicine, Weill Cornel Medical College, Doha, QAT
| | | | | | - Mohamed Ata
- Internal Medicine, Hamad Medical Corporation, Doha, QAT
| | - Anas Ashour
- Internal Medicine, Hamad Medical Corporation, Doha, QAT
| | - Muftah Othman
- Internal Medicine, Hamad Medical Corporation, Doha, QAT
| | - Ahmad Badi
- Internal Medicine, Hamad Medical Corporation, Doha, QAT
| | - Mehdi Errayes
- Internal Medicine, Hamad Medical Corporation, Doha, QAT
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Maslennikov R, Ivashkin V, Efremova I, Poluektova E, Shirokova E. Gut-liver axis in cirrhosis: Are hemodynamic changes a missing link? World J Clin Cases 2021; 9:9320-9332. [PMID: 34877269 PMCID: PMC8610853 DOI: 10.12998/wjcc.v9.i31.9320] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/03/2021] [Accepted: 09/07/2021] [Indexed: 02/06/2023] Open
Abstract
Recent evidence suggests that the condition of the gut and its microbiota greatly influence the course of liver disease, especially cirrhosis. This introduces the concept of the gut-liver axis, which can be imagined as a chain connected by several links. Gut dysbiosis, small intestinal bacterial overgrowth, and intestinal barrier alteration lead to bacterial translocation, resulting in systemic inflammation. Systemic inflammation further causes vasodilation, arterial hypotension, and hyperdynamic circulation, leading to the aggravation of portal hypertension, which contributes to the development of complications of cirrhosis, resulting in a poorer prognosis. The majority of the data underlying this model were obtained initially from animal experiments, and most of these correlations were further reproduced in studies including patients with cirrhosis. However, despite the published data on the relationship of the disorders of the gut microbiota with the complications of cirrhosis and the proposed pathogenetic role of hemodynamic disorders in their development, the direct relations between gut dysbiosis and hemodynamic changes in this disease are poorly studied. They remain a missing link in the gut-liver axis and a challenge for future research.
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Affiliation(s)
- Roman Maslennikov
- Department of Internal Medicine, Gastroenterology and Hepatology, Sechenov University, Moscow 119435, Russia
- The Interregional Public Organization "Scientific Community for the Promotion of the Clinical Study of the Human Microbiome", Moscow 119435, Russia
- Department of Internal Medicine, Consultative and Diagnostic Center of the Moscow City Health Department, Moscow 107564, Russia
| | - Vladimir Ivashkin
- Department of Internal Medicine, Gastroenterology and Hepatology, Sechenov University, Moscow 119435, Russia
| | - Irina Efremova
- Department of Internal Medicine, Gastroenterology and Hepatology, Sechenov University, Moscow 119435, Russia
| | - Elena Poluektova
- Department of Internal Medicine, Gastroenterology and Hepatology, Sechenov University, Moscow 119435, Russia
- The Interregional Public Organization "Scientific Community for the Promotion of the Clinical Study of the Human Microbiome", Moscow 119435, Russia
| | - Elena Shirokova
- Department of Internal Medicine, Gastroenterology and Hepatology, Sechenov University, Moscow 119435, Russia
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Huang SF, Huang CC, Chou KT, Chan YJ, Yang YY, Wang FD. Chronic Pulmonary Aspergillosis: Disease Severity Using Image Analysis and Correlation with Systemic Proinflammation and Predictors of Clinical Outcome. J Fungi (Basel) 2021; 7:jof7100842. [PMID: 34682263 PMCID: PMC8537715 DOI: 10.3390/jof7100842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 10/02/2021] [Accepted: 10/03/2021] [Indexed: 02/07/2023] Open
Abstract
(1) Background: The presentation of chronic pulmonary aspergillosis (CPA) ranges from single granuloma to fibrosis in the affected lung. CPA can be divided into five categories according to European Respirology Society (ERS) guidance but is usually assessed by clinical physicians. Computer-based quantitative lung parenchyma analysis in CPA and its correlation with clinical manifestations, systemic inflammation, and angiogenesis have never been investigated. (2) Method: Forty-nine patients with CPA and 36 controls were prospectively enrolled. Pulmonary function tests (forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and FEV1/FCV) and biomarkers in the peripheral blood (the chemokines interleukin (IL)-1B, IL-6, IL-10, IL-8, CRP, ESR, MMP1, MMP7, MMP8, TNF-α, calprotectin, SDF-1α, and VEGFA) were measured before antifungal treatment. The disease severity was categorized into mild, moderate, and severe based on chest computed tomography (CT) images. The oxygen demand and overall mortality until the end of the study were recorded. Quantitative parenchyma analysis was performed using the free software 3Dslicer. (3) Results: The results of quantitative parenchyma analysis concorded with the visual severity from the chest CT, oxygen demand, FVC, and FEV1 in the study subjects. The decrease in kurtosis and skewness of the lung density histograms on CT, increase in high attenuation area (HAA), and reduced lung volume were significantly correlated with increases in the PMN %, CRP, IL-1B, SDF-1α, MMP1, and Calprotectin in peripheral blood in the multivariable regression analysis. TNF-α and IL-1B at study entry and the CPA severity from either a visual method or computer-based evaluation were predictors of long-term mortality. (4) Conclusion: The computer-based parenchyma analysis in CPA agreed with the categorization on a visual basis and was associated with the clinical outcomes, chemokines, and systemic proinflammation profiles.
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Affiliation(s)
- Shiang-Fen Huang
- Division of Infectious Disease, Department of Medicine, Taipei Veterans General Hospital, Taipei 112201, Taiwan;
- School of Medicine, National Yang-Ming Chiao-Tung University, Taipei 112304, Taiwan;
- Correspondence:
| | - Chia-Chang Huang
- Division of Endocrinology and Metabolism, Department of Medicine, Veterans General Hospital, Taipei 112201, Taiwan;
- Division of Clinical Skills Training, Department of Medical Education, Taipei Veterans General Hospital, Taipei 112201, Taiwan;
| | - Kun-Ta Chou
- School of Medicine, National Yang-Ming Chiao-Tung University, Taipei 112304, Taiwan;
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei 112201, Taiwan
| | - Yu-Jiun Chan
- Division of Microbiology, Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital, Taipei 112201, Taiwan;
| | - Ying-Ying Yang
- Division of Clinical Skills Training, Department of Medical Education, Taipei Veterans General Hospital, Taipei 112201, Taiwan;
- Department of Medicine, Institute of Clinical Medicine, National Yang-Ming Chiao-Tung University, Taipei 112304, Taiwan
| | - Fu-Der Wang
- Division of Infectious Disease, Department of Medicine, Taipei Veterans General Hospital, Taipei 112201, Taiwan;
- School of Medicine, National Yang-Ming Chiao-Tung University, Taipei 112304, Taiwan;
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Pörner D, Von Vietinghoff S, Nattermann J, Strassburg CP, Lutz P. Advances in the pharmacological management of bacterial peritonitis. Expert Opin Pharmacother 2021; 22:1567-1578. [PMID: 33878993 DOI: 10.1080/14656566.2021.1915288] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Bacterial peritonitis is an infection with high mortality if not treated immediately. In the absence of an intraabdominal source of infection, bacterial peritonitis may arise in patients with liver cirrhosis, in patients on peritoneal dialysis (PD) for end-stage renal disease or in patients with tuberculosis. In patients with cirrhosis, bacterial peritonitis may trigger acute on chronic liver failure with substantial mortality despite optimal treatment. In patients on PD, peritonitis may make continuation of PD impossible, necessitating the switch to hemodialysis.Areas covered: Recovery from peritonitis and prevention of complications depend on timely pharmacological management. Challenges are the broad microbiological spectrum with growing rates of antimicrobial resistance, the underlying chronic liver or kidney failure and high rates of relapse. The authors provide a review of predisposing conditions, diagnosis, and prevention of bacterial peritonitis with a particular focus on the pharmacological management.Expert opinion: Diagnosis of the type of bacterial peritonitis is essential to pharmacological management. In patients with spontaneous bacterial peritonitis, broad-spectrum antibiotics should be given intravenously in conjunction with albumin. In patients on PD, antibiotic therapy should be preferably applied intraperitoneally with empirical coverage of gram-positive and gram-negative bacteria. Secondary peritonitis usually requires surgical or interventional treatment.
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Affiliation(s)
- Daniel Pörner
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, Bonn, Germany
| | - Sibylle Von Vietinghoff
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, Bonn, Germany
| | - Jacob Nattermann
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, Bonn, Germany
- German Center for Infection Research (DZIF), University Hospital Bonn, Venusberg-Campus 1, Bonn, Germany
| | - Christian P Strassburg
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, Bonn, Germany
- German Center for Infection Research (DZIF), University Hospital Bonn, Venusberg-Campus 1, Bonn, Germany
| | - Philipp Lutz
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, Bonn, Germany
- German Center for Infection Research (DZIF), University Hospital Bonn, Venusberg-Campus 1, Bonn, Germany
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Spontaneous bacterial peritonitis: update on diagnosis and treatment. ACTA ACUST UNITED AC 2021; 59:345-350. [PMID: 34182617 DOI: 10.2478/rjim-2021-0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Indexed: 11/21/2022]
Abstract
Spontaneous bacterial peritonitis (SBP) is a common complication in patients with liver cirrhosis, with an increased risk of mortality. For this reason, a diagnostic paracentesis should be performed in all patients with ascites and clinical features with high diagnostic suspicion. Although literature data abound in identifying new diagnostic markers in serum or ascites, they have not yet been validated. The final diagnosis requires the analysis of ascites and the presence of > 250 mm3 neutrophil polymorphonuclear (PMN) in ascites. If previous data showed that the most common microorganisms identified were represented by gram-negative bacteria, we are currently facing an increase in gram-positive bacteria and multi-drug resistant bacteria. Although prompt and effective treatment is required to prevent outcomes, this becomes challenging as first-line therapies may become ineffective leading to worsening prognosis and increased inhospital mortality. In this paper we will make a brief review of existing data on the diagnosis and treatment of SBP.
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Pharmacokinetics and Antifungal Activity of Echinocandins in Ascites Fluid of Critically Ill Patients. Antimicrob Agents Chemother 2021; 65:e0256520. [PMID: 33972242 DOI: 10.1128/aac.02565-20] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The pharmacokinetics and antifungal activity of the echinocandins anidulafungin (AFG), micafungin (MFG), and caspofungin (CAS) were assessed in ascites fluid and plasma of critically ill adults treated for suspected or proven invasive candidiasis. Ascites fluid was obtained from ascites drains or during paracentesis. The antifungal activity of the echinocandins in ascites fluid was assessed by incubation of Candida albicans and Candida glabrata at concentrations of 0.03 to 16.00 μg/ml. In addition, ascites fluid samples obtained from our study patients were inoculated with the same isolates and evaluated for fungal growth. These patient samples had to be spiked with echinocandins to restore the original concentrations because echinocandins had been lost during sterile filtration. In ascites fluid specimens of 29 patients, echinocandin concentrations were below the simultaneous plasma levels. Serial sampling in 20 patients revealed a slower rise and decline of echinocandin concentrations in ascites fluid than in plasma. Proliferation of C. albicans in ascites fluid was slower than in culture medium and growth of C. glabrata was lacking, even in the absence of antifungals. In CAS-spiked ascites fluid samples, fungal CFU counts moderately declined, whereas spiking with AFG or MFG had no relevant effect. In ascites fluid of our study patients, echinocandin concentrations achieved by therapeutic doses did not result in a consistent eradication of C. albicans or C. glabrata. Thus, therapeutic doses of AFG, MFG, or CAS may result in ascites fluid concentrations preventing relevant proliferation of C. albicans and C. glabrata, but do not warrant reliable eradication.
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Lingiah VA, Pyrsopoulos NT. Bacterial Infections in Cirrhotic Patients in a Tertiary Care Hospital. J Clin Transl Hepatol 2021; 9:32-39. [PMID: 33604253 PMCID: PMC7868695 DOI: 10.14218/jcth.2020.00076] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 11/15/2020] [Accepted: 12/05/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND AND AIMS Patients with cirrhosis are immunocompromised and at higher risk of developing infections compared to the general population. The aim of this study was to assess the incidence of infections in cirrhotic patients in a large academic liver center and investigate potential associations between infections, bacteria isolated, therapeutic regimens used, and mortality. METHODS This was a retrospective chart review study, including 192 patients. All patients had a diagnosis of cirrhosis and were admitted to University Hospital. Information collected included demographics, etiology of cirrhosis, identification of bacteria from cultures, multidrug-resistant (MDR) status, antibiotics administered, intensive care unit (ICU) admission, and patient mortality. RESULTS Infections were present in 105 (54.6%) patients, and 60 (31.2%) patients had multiple infections during a hospitalization(s) for infections. A total of 201 infections were identified. Urinary tract infections (UTIs) were the most common infection (37.8%), followed by bacteremia (20.4%), pneumonia (12.9%), spontaneous bacterial peritonitis (SBP) (11.9%), abscess/cellulitis (6.0%), infectious diarrhea (6.0%), and other (5.0%). Escherichia coli was the most common bacteria isolated (13.4%), both among sensitive and MDR infections. MDR bacteria were the cause for 41.3% of all infections isolated. Fungi accounted for 9.5% of infections. 21.9% of patients had decompensation from their infection(s) that required ICU care, and 14.6% of patients died during hospitalization or soon after discharge. CONCLUSIONS The incidence of infections in cirrhotic patients is much higher than in their non-cirrhotic counterparts (54.6%), even higher than prior studies suggest. As many of these infections are caused by MDR bacteria and fungal organisms, stronger empiric antibiotics and antifungals should be considered when initially treating this immunocompromised population. However, once organism sensitivities are discovered, narrowing of antibiotic regimens must occur to maintain good antibiotic stewardship.
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Affiliation(s)
- Vivek A. Lingiah
- Department of Medicine, Division of Gastroenterology and Hepatology, Rutgers University, New Jersey Medical School, Newark, NJ, USA
| | - Nikolaos T. Pyrsopoulos
- Department of Medicine, Division of Gastroenterology and Hepatology, Rutgers University, New Jersey Medical School, Newark, NJ, USA
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Recurrent and Treatment-Unresponsive Spontaneous Bacterial Peritonitis Worsens survival in Decompensated Liver Cirrhosis. J Clin Exp Hepatol 2021; 11:334-342. [PMID: 33994716 PMCID: PMC8103328 DOI: 10.1016/j.jceh.2020.08.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 08/30/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Spontaneous bacterial peritonitis (SBP) remains a major complication of cirrhosis. However, the incidence and the real impact of SBP in determining patient survival rates remain unclear. This study aims to evaluate the incidence and risk factors for SBP development and the role of SBP in predicting transplant-free survival. METHODS Two hundred two consecutive patients underwent 492 paracenteses with biochemical and microbiological analysis of the ascitic fluid. When multiple paracenteses had been performed on a given patient, the first SBP-positive paracentesis or the first paracentesis conducted when none was diagnostic for SBP was included in the study. RESULTS SBP was detected in 28 of 202 (13.9%) patients; in 26 of 28 patients, the neutrophil count in the ascitic fluid was ≥250 cells/μl, and in 15 of 28 patients, the cultures were positive. Variables independently associated with SBP were as follows: a higher model of end-stage liver disease (MELD) score, the serum glucose value, elevated CRP serum levels, and higher potassium serum levels. Overall, the median (range) transplant-free survival was 289 (54-1253) days. One hundred (49.5%) patients died, whereas 35 patients (17.3%) underwent liver transplantation. Independent predictors of death or liver transplantation were a higher MELD score and the development of SBP, especially if it was antibiotic-resistant or recurrent SBP. CONCLUSION The occurrence of SBP is associated with more severe liver dysfunction in conjunction with the presence of inflammation. Unlike the occurrence of SBP per se, failure of first-line antibiotic treatment and SBP recurrence appear to strongly influence the mortality rate.
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Key Words
- ALP, alkaline phosphatase
- ALT, alanine aminotransferase
- AST, aspartate aminotransferase
- BMI, body mass index
- CLIF-SOFA, chronic liver failure-sequential organ failure assessment
- CP, Child-Pugh
- CRP, C-reactive protein
- EPS, hepatic encephalopathy
- HBV, hepatitis B virus
- HCV, hepatitis C virus
- INR, international normalized ratio
- LT, liver transplantation
- MELD, model of end-stage liver disease
- OR, odds ratio
- PLT, platelet
- SBP, Spontaneous bacterial peritonitis
- SIRS, systemic inflammatory response syndrome
- WBC, white blood cell
- antibiotic-resistant infections
- ascites
- gGT, gamma-glutamyl transpeptidase
- liver transplantation
- survival
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Mayr U, Lukas M, Elnegouly M, Vogt C, Bauer U, Ulrich J, Schmid RM, Huber W, Lahmer T. Ascitic Interleukin 6 Is Associated with Poor Outcome and Spontaneous Bacterial Peritonitis: A Validation in Critically Ill Patients with Decompensated Cirrhosis. J Clin Med 2020; 9:jcm9092865. [PMID: 32899730 PMCID: PMC7564827 DOI: 10.3390/jcm9092865] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 08/27/2020] [Accepted: 09/02/2020] [Indexed: 02/08/2023] Open
Abstract
Decompensated cirrhosis predisposes to infectious diseases and acute-on-chronic liver failure (ACLF) in critically ill patients. Infections like spontaneous bacterial peritonitis (SBP) are frequently associated with multi-organ failure and increased mortality. Consequently, reliable predictors of outcome and early diagnostic markers of infection are needed to improve individualized therapy. This study evaluates the prognostic role of ascitic interleukin 6 in 64 patients with cirrhosis admitted to our intensive care unit (ICU). In addition, we analysed the diagnostic ability of ascitic interleukin 6 in a subgroup of 19 patients with SBP. Baseline ascitic interleukin 6 performed well in predicting 3-month mortality in patients with decompensated cirrhosis (area under curve (AUC) = 0.802), as well as in patients fulfilling ACLF-criteria (AUC = 0.807). Ascitic interleukin 6 showed a moderate prognostic advantage compared with common clinical scores and proinflammatory parameters. Moreover, ascitic interleukin 6 had a sufficient diagnostic ability to detect SBP (AUC = 0.901) and was well correlated with ascitic polymorphonuclear neutrophils in SBP (p = 0.002). Interestingly, ascitic interleukin 6 revealed a high predictive value to rule out apparent infections on admission to ICU (AUC = 0.904) and to identify patients with “culture-positive SBP” (AUC = 0.856). Ascitic interleukin 6 is an easily-applicable proinflammatory biomarker with high prognostic and diagnostic relevance in critically ill patients with liver cirrhosis.
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Affiliation(s)
- Ulrich Mayr
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, D-81675 München, Germany; (M.L.); (M.E.); (U.B.); (J.U.); (R.M.S.); (W.H.); (T.L.)
- Correspondence: ; Tel.: +49-89-4140-5226; Fax: +49-89-4140-4742
| | - Marina Lukas
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, D-81675 München, Germany; (M.L.); (M.E.); (U.B.); (J.U.); (R.M.S.); (W.H.); (T.L.)
| | - Mayada Elnegouly
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, D-81675 München, Germany; (M.L.); (M.E.); (U.B.); (J.U.); (R.M.S.); (W.H.); (T.L.)
| | - Christine Vogt
- Institut für Klinische Chemie und Pathobiochemie, Klinikum rechts der Isar, Technische Universität München, D-81675 München, Germany;
| | - Ulrike Bauer
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, D-81675 München, Germany; (M.L.); (M.E.); (U.B.); (J.U.); (R.M.S.); (W.H.); (T.L.)
| | - Joerg Ulrich
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, D-81675 München, Germany; (M.L.); (M.E.); (U.B.); (J.U.); (R.M.S.); (W.H.); (T.L.)
| | - Roland M. Schmid
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, D-81675 München, Germany; (M.L.); (M.E.); (U.B.); (J.U.); (R.M.S.); (W.H.); (T.L.)
| | - Wolfgang Huber
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, D-81675 München, Germany; (M.L.); (M.E.); (U.B.); (J.U.); (R.M.S.); (W.H.); (T.L.)
| | - Tobias Lahmer
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, D-81675 München, Germany; (M.L.); (M.E.); (U.B.); (J.U.); (R.M.S.); (W.H.); (T.L.)
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Mattos AA, Wiltgen D, Jotz RF, Dornelles CMR, Fernandes MV, Mattos ÂZ. Spontaneous bacterial peritonitis and extraperitoneal infections in patients with cirrhosis. Ann Hepatol 2020; 19:451-457. [PMID: 32533951 DOI: 10.1016/j.aohep.2020.04.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 03/22/2020] [Accepted: 04/07/2020] [Indexed: 02/04/2023]
Abstract
Infections are a frequent complication and a major cause of death among patients with cirrhosis. The important impact of infections in general and especially spontaneous bacterial peritonitis on the course of disease and prognosis of patients with cirrhosis has been recognized for many years. Nevertheless, such importance has recently increased due to the comprehension of infection as one of the most prominent risk factors for patients to develop acute-on-chronic liver failure. Furthermore, the issue of infections in cirrhosis is a focus of increasing attention because of the spreading of multidrug resistant bacteria, which is an emerging concern among physicians assisting patients with cirrhosis. In the present paper, we will review the current epidemiology of infections in patients with cirrhosis and particularly that of infections caused by resistant bacteria, demonstrating the relevance of the subject. Besides, we will discuss the current recommendations on diagnosis and treatment of different kinds of infections, including spontaneous bacterial peritonitis, and we will highlight the importance of knowing local microbiological profiles and choosing empirical antibiotic therapy wisely. Finally, we will debate the existing evidences regarding the role of volume expansion with albumin in patients with cirrhosis and extraperitoneal infections, and that of antibiotic prophylaxis of spontaneous bacterial peritonitis.
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Affiliation(s)
- Angelo A Mattos
- Federal University of Health Sciences of Porto Alegre, Graduate Program in Medicine: Hepatology, Brazil; Irmandade Santa Casa de Misericórdia de Porto Alegre, Brazil
| | - Denusa Wiltgen
- Irmandade Santa Casa de Misericórdia de Porto Alegre, Brazil; Federal University of Health Sciences of Porto Alegre, Brazil
| | - Raquel F Jotz
- Federal University of Health Sciences of Porto Alegre, Brazil
| | | | | | - Ângelo Z Mattos
- Federal University of Health Sciences of Porto Alegre, Graduate Program in Medicine: Hepatology, Brazil; Irmandade Santa Casa de Misericórdia de Porto Alegre, Brazil.
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Allaire M, Cadranel JF, Nguyen TTN, Garioud A, Zougmore H, Heng R, Perignon C, Ollivier-Hourmand I, Dao T. Management of infections in patients with cirrhosis in the context of increasing therapeutic resistance: A systematic review. Clin Res Hepatol Gastroenterol 2020; 44:264-274. [PMID: 31706985 DOI: 10.1016/j.clinre.2019.10.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 09/23/2019] [Accepted: 10/04/2019] [Indexed: 02/04/2023]
Abstract
Patients with cirrhosis are prone to develop bacterial infections, which consist in one of the major precursors of Acute-on-Chronic Liver Failure (ACLF) and are responsible for a high mortality rate. In recent years, the management of bacterial infections in patients with cirrhosis has become increasingly complicated due to a change in bacterial ecology associated with a higher rate of cocci gram positive bacteria in Europe and America along with the emergence of a multidrug-resistant (MDR) and extensively drug-resistant (XDR) bacteria leading to a decrease in the efficacy of empirical strategies based on the administration of third-generation cephalosporins. MDR and XDR now account for about 40% of the infections worldwide, and up to 70% in India. Among them, the most common ones are extended-spectrum beta-lactamase producing (ESBL-P) bacteria, carbapenem-resistant enterobacteriaceae (CRE), Methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant enterococci (VRE). An early diagnosis associated to an empirical antibiotic adapted to the site of infection and potential bacterial resistance is now crucial in order to improve the chances of survival and contain the resistance phenomenon. Moreover, a fungal infection must always be discussed in these high-risks patients, especially in the absence of clinical improvement under appropriate antibiotic treatment. In this review, we will focus on the emerging threat of MDR and XDR organisms, as well as fungal infections, in order to better adapt the therapeutic management of cirrhotic patients with infections.
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Affiliation(s)
- Manon Allaire
- Service d'hépato-gastro-entérologie et nutrition, CHU Côte de Nacre, 14000 Caen, France; Unité Inserm-U1149, Centre de recherche sur l'inflammation, 75018 Paris, France.
| | - Jean-François Cadranel
- Service d'hépato-gastro-entérologie de nutrition et d'alcoologie, GHPSO, 60100 Creil, France
| | - Thi Thu Nga Nguyen
- Service d'hépato-gastro-entérologie et nutrition, CHU Côte de Nacre, 14000 Caen, France
| | - Armand Garioud
- Service d'hépato-gastro-entérologie de nutrition et d'alcoologie, GHPSO, 60100 Creil, France
| | - Honore Zougmore
- Service d'hépato-gastro-entérologie de nutrition et d'alcoologie, GHPSO, 60100 Creil, France
| | - Ratmony Heng
- Service d'hépato-gastro-entérologie de nutrition et d'alcoologie, GHPSO, 60100 Creil, France
| | - Claire Perignon
- Service d'hépato-gastro-entérologie et nutrition, CHU Côte de Nacre, 14000 Caen, France
| | | | - Thông Dao
- Service d'hépato-gastro-entérologie et nutrition, CHU Côte de Nacre, 14000 Caen, France
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Liu CR, Li YP, Feng DD, Dang SS. Hot topics and difficult problems in diagnosis and treatment of end-stage liver disease with fungal infection. Shijie Huaren Xiaohua Zazhi 2020; 28:203-209. [DOI: 10.11569/wcjd.v28.i6.203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Chen-Rui Liu
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710004, Shaanxi Province, China
| | - Ya-Ping Li
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710004, Shaanxi Province, China
| | - Dan-Dan Feng
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710004, Shaanxi Province, China
| | - Shuang-Suo Dang
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710004, Shaanxi Province, China
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Maraolo AE, Scotto R, Zappulo E, Pinchera B, Schiano Moriello N, Nappa S, Buonomo AR, Gentile I. Novel strategies for the management of bacterial and fungal infections in patients with liver cirrhosis: focus on new antimicrobials. Expert Rev Anti Infect Ther 2020; 18:191-202. [PMID: 32011191 DOI: 10.1080/14787210.2020.1725473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: Liver cirrhosis is a frequent condition caused by different etiologies. Bacterial and fungal infections are common complications, representing an independent prognostic stage in patients with cirrhosis, dramatically worsening their clinical outcomes.Areas covered: The present review article addresses manifold points and to this purpose an inductive literature search of MEDLINE database through PubMed was performed. First, it provides an overview on the mechanisms underlying immune disfunctions in patients with cirrhosis, who are prone to develop infections being at higher risk than the general population. Second, commonest types of bacterial and fungal infections in patients with advanced liver disease are described, focusing on their deleterious impact as decompensating events. Third, the rise of multidrug-resistant (MDR) bacteria and fungi as causative agents of infection in cirrhotic subjects is illustrated. Eventually, the most promising novel therapeutic options against MDR pathogens and fungi are reviewed.Expert opinion: The management of bacterial and fungal infections in patients with cirrhosis is difficult, due to the frequent co-existence of renal impairment, low platelet count and other conditions that limit the antimicrobial choice. New antibacterial and antifungal compounds may overcome this issue by providing a better tolerability profile, along with equal or superior efficacy compared with older drugs.
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Affiliation(s)
- Alberto E Maraolo
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - Riccardo Scotto
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - Emanuela Zappulo
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - Biagio Pinchera
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - Nicola Schiano Moriello
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - Salatore Nappa
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - Antonio Riccardo Buonomo
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - Ivan Gentile
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
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Sasidharan Nair GV, Mathen PG, Pillai MG, Gireesh Kumar KP, Velayudhan KK, Sreekrishnan TP. Initial choice of antibiotic in recurrent spontaneous bacterial peritonitis: A retrospective study. Int J Crit Illn Inj Sci 2019; 9:187-190. [PMID: 31879606 PMCID: PMC6927126 DOI: 10.4103/ijciis.ijciis_49_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 09/05/2019] [Accepted: 10/25/2019] [Indexed: 11/23/2022] Open
Abstract
Context: Spontaneous bacterial peritonitis (SBP) is a commonly encountered infection seen in the setting of ascites secondary to advanced liver disease. Recurrence of SBP is common and is associated with high mortality. This study was designed to recognize a better initial choice of antibiotic in case of recurrent SBP – a third-generation cephalosporin or a carbapenem. Aims: This study aims to determine a better initial choice of antibiotic in case of recurrent SBP and to compare the all-cause mortality among two different groups of patients treated with a third-generation cephalosporin and a carbapenem. Settings and Design: This study was conducted among fifty patients presenting with recurrent SBP visiting the emergency department (ED) at a tertiary care center and who were subsequently admitted in a gastroenterology intensive care unit, during a period of 1 year. Subjects and Methods: This is a retrospective, observational study conducted among patients with chronic liver disease and diagnosed with recurrent SBP visiting the ED at a tertiary care center in South India treated with either of two classes of antibiotics – third-generation cephalosporins or carbapenems, and their outcomes were compared. Recurrence is defined as an episode of SBP after resolution of the first index case of SBP within 1 year. Statistical Analysis Used: Statistical analysis was done using IBM SPSS version 23.0 (SPSS Inc., Chicago, IL, USA). All categorical variables were represented as percentages, and all continuous variables were represented as mean ± standard deviation. To test the statistical significance of the association of categorical variables with the outcome, Chi-square test was used. P <0.05 was considered statistically significant. Results: A total of fifty patients with recurrent SBP were included in the study, of which 44 (88%) patients were male and 6 patients were female (12%). Twenty-nine (58%) patients survived and 21 (42%) patients expired within 28 days. Twenty-seven (54%) patients were treated with third-generation cephalosporins and 23 (46%) were treated with carbapenems. It was observed that mortality was statistically significantly lower among patients treated with carbapenem (P = 0.001). The incidence of acute kidney injury was also lower among patients treated with a carbapenem than patients treated with a third-generation cephalosporin (40.7% vs. 59.25%, respectively). Conclusions: Initiation of a carbapenem significantly reduced the all-cause mortality when compared to a third-generation cephalosporin as an initial antibiotic of choice in recurrent SBP.
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Affiliation(s)
| | - Prannoy George Mathen
- Department of Emergency Medicine and Critical Care, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - M Gopalakrishna Pillai
- Department of Internal Medicine, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - K P Gireesh Kumar
- Department of Emergency Medicine and Critical Care, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - K K Velayudhan
- Department of Internal Medicine, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - T P Sreekrishnan
- Department of Emergency Medicine and Critical Care, Amrita Institute of Medical Sciences, Kochi, Kerala, India
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Gonzalez-Cordero AF, Malavé-Sánchez M, Vergara-Gómez M, Franqui-Rivera H. Spontaneous Fungal Peritonitis. JACC Case Rep 2019; 1:372-375. [PMID: 31840136 PMCID: PMC6908944 DOI: 10.1016/j.jaccas.2019.07.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This report presents a case of spontaneous fungal peritonitis (SFP) in a patient with cardiogenic ascites. Physicians need to be aware of this life-threatening condition because early suspicion of SFP can improve survival. (Level of Difficulty: Intermediate.)
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Huang CH, Pang LT, Xu LC, Ge TT, Xu QM, Chen Z. Risk factors, clinical features, and short-term prognosis of spontaneous fungal peritonitis in cirrhosis: A matched case-control study. World J Clin Cases 2019; 7:2438-2449. [PMID: 31559280 PMCID: PMC6745339 DOI: 10.12998/wjcc.v7.i17.2438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/12/2019] [Accepted: 07/27/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Spontaneous peritonitis is one of the most common infectious complications in cirrhotic patients with ascites. Spontaneous fungal peritonitis (SFP) is a type of spontaneous peritonitis that is a less recognized but devastating complication in end-stage cirrhosis. Although high mortality was previously noted, scant data are available to fully define the factors responsible for the occurrence of SFP and its mortality.
AIM To illustrate the differences between SFP and spontaneous bacterial peritonitis (SBP) and discuss the risk factors for the occurrence of SFP and its short-term mortality.
METHODS We performed a matched case-control study between January 1, 2007 and December 30, 2018. Patients with SFP were included in a case group. Sex-, age-, and time-matched patients with SBP were included in a control group and were further divided into control-1 group (positive bacterial culture) and control-2 group (negative bacterial culture). The clinical features and laboratory parameters, severity models, and prognosis were compared between the case and control groups. Logistic regression analysis was used to determine the risk factors for occurrence, and the Cox regression model was used to identify the predictive factors for short-term mortality of SFP.
RESULTS Patients with SFP exhibited more severe systemic inflammation, higher ascites albumin and polymorphonuclear neutrophils, and a worsened 15-d mortality than patients in the control groups. Antibiotic administration (case vs control-1: OR = 1.063, 95%CI: 1.012-1.115, P = 0.014; case vs control-2: OR = 1.054, 95%CI: 1.014-1.095, P = 0.008) remarkably increased the occurrence of SFP or fungiascites. Hepatorenal syndrome (HR = 5.328, 95%CI: 1.050-18.900) and total bilirubin (μmol/L; HR = 1.005, 95%CI: 1.002-1.008) represented independent predictors of SFP-related early mortality.
CONCLUSION Long-term antibiotic administration increases the incidence of SFP, and hepatorenal syndrome and total bilirubin are closely related to short-term mortality.
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Affiliation(s)
- Chun-Hong Huang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Lan-Tian Pang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Li-Chen Xu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Tian-Tian Ge
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Qiao-Mai Xu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Zhi Chen
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
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El Sayed Zeid A, El Sayed Salem P, El Hadidi AS, Ibrahim TG. Vitamin D and LL-37 in cirrhotic patients with culture-positive spontaneous bacterial peritonitis. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2019. [DOI: 10.4103/ejim.ejim_102_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
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Facciorusso A, Antonino M, Orsitto E, Sacco R. Primary and secondary prophylaxis of spontaneous bacterial peritonitis: current state of the art. Expert Rev Gastroenterol Hepatol 2019; 13:751-759. [PMID: 31304804 DOI: 10.1080/17474124.2019.1644167] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 07/12/2019] [Indexed: 02/07/2023]
Abstract
Introduction: Spontaneous bacterial peritonitis represents a frequent and severe complication in cirrhotic patients with ascites. In daily practice, the diagnosis of spontaneous bacterial peritonitis might be challenging in the absence of the typical signs and symptoms of infection such as fever or leukocytosis. Areas covered: Aim of this review is to revise the current state of the art on primary and secondary spontaneous bacterial peritonitis. Literature search in Medline/Pubmed was performed. Expert opinion: Historically, gram-negative bacteria were the most frequent etiologic agents of spontaneous bacterial peritonitis, with Escherichia coli and Klebsiella spp. being the most frequently isolated bacteria. However, major changes in this regard occurred over the last few decades with an increasing prevalence of gram-positive, quinolone-resistant, and multidrug-resistant bacteria. In particular, the increasing prevalence of quinolone-resistant bacteria challenged the prominent role of norfloxacin in spontaneous bacterial peritonitis prevention. Given the high mortality rate and the risk of developing the hepatorenal syndrome, prophylaxis of spontaneous bacterial peritonitis is indicated in three high-risk populations: patients with acute gastrointestinal hemorrhage, patients with low total protein content in ascitic fluid and advanced cirrhosis, and patients with a previous history of spontaneous bacterial peritonitis (secondary prophylaxis).
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Affiliation(s)
- Antonio Facciorusso
- a Department of Medical Sciences, Ospedali Riuniti di Foggia , Foggia , Italy
| | - Matteo Antonino
- a Department of Medical Sciences, Ospedali Riuniti di Foggia , Foggia , Italy
| | - Eugenio Orsitto
- b Department of Radiology, Azienda Ospedaliero-Universitaria Pisana , Pisa , Italy
| | - Rodolfo Sacco
- a Department of Medical Sciences, Ospedali Riuniti di Foggia , Foggia , Italy
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Tariq T, Irfan FB, Farishta M, Dykstra B, Sieloff EM, Desai AP. Spontaneous fungal peritonitis: Micro-organisms, management and mortality in liver cirrhosis-A systematic review. World J Hepatol 2019; 11:596-606. [PMID: 31388401 PMCID: PMC6669191 DOI: 10.4254/wjh.v11.i7.596] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 06/15/2019] [Accepted: 07/05/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Spontaneous peritonitis is an infection of ascitic fluid without a known intra-abdominal source of infection. spontaneous fungal peritonitis (SFP) is a potentially fatal complication of decompensated cirrhosis, defined as fungal infection of ascitic fluid in the presence of ascitic neutrophil count of greater than 250 cells/mL.
AIM To determine the prevalence of fungal pathogens, management and outcomes (mortality) of SFP in critically ill cirrhotic patients.
METHODS Studies were identified using PubMed, EMBASE, Cochrane Central Register of Controlled Trials and Scopus databases until February 2019. Inclusion criteria included intervention trials and observation studies describing the association between SFP and cirrhosis. The primary outcome was in-hospital, 1-mo, and 6-mo mortality rates of SFP in cirrhotic patients. Secondary outcomes were fungal microorganisms identified and in hospital management by anti-fungal medications. The National Heart, Lung and Blood Institute quality assessment tools were used to assess internal validity and risk of bias for each included study.
RESULTS Six observational studies were included in this systematic review. The overall quality of included studies was good. A meta-analysis of results could not be performed because of differences in reporting of outcomes and heterogeneity of the included studies. There were 82 patients with SFP described across all the included studies. Candida species, predominantly Candida albicans was the fungal pathogen in majority of the cases (48%-81.8%) followed by Candida krusei (15%-25%) and Candida glabrata (6.66%-20%). Cryptococcus neoformans (53.3%) was the other major fungal pathogen. Antifungal therapy in SFP patients was utilized in 33.3% to 81.8% cases. The prevalence of in hospital mortality ranged from 33.3% to 100%, whereas 1-mo mortality ranged between 50% to 73.3%.
CONCLUSION This systematic review suggests that SFP in end stage liver disease patient is associated with high mortality both in the hospital and at 1-mo, and that antifungal therapy is currently underutilized.
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Affiliation(s)
- Tooba Tariq
- Department of Internal Medicine, Western Michigan University, Kalamazoo, MI 49008, United States
| | - Furqan B Irfan
- College of Osteopathic Medicine, Michigan State University, WEast Lansing, MI 48824, United States
| | - Mehdi Farishta
- Department of Internal Medicine, Western Michigan University, Kalamazoo, MI 49008, United States
| | - Brian Dykstra
- Department of Pulmonary and Critical Care Medicine, Western Michigan University, Kalamazoo, MI 49008, United States
| | - Eric Martin Sieloff
- Department of Internal Medicine, Western Michigan University, Kalamazoo, MI 49008, United States
| | - Archita P Desai
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN 46202, United States
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Marciano S, Díaz JM, Dirchwolf M, Gadano A. Spontaneous bacterial peritonitis in patients with cirrhosis: incidence, outcomes, and treatment strategies. Hepat Med 2019; 11:13-22. [PMID: 30666172 PMCID: PMC6336019 DOI: 10.2147/hmer.s164250] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Spontaneous bacterial peritonitis is the most frequent bacterial infection in patients with cirrhosis. The reported incidence varies between 7% and 30% in hospitalized patients with cirrhosis and ascites, representing one of their main complications. Outcomes in patients with spontaneous bacterial peritonitis are poor since acute kidney injury, acute-on-chronic liver failure, and death occur in as much as 54%, 60%, and 40% of the patients, respectively, at midterm. Early antibiotic treatment of spontaneous bacterial peritonitis is crucial. However, the landscape of microbiological resistance is continuously changing, with an increasing spread of multidrug-resistant organisms that make its current management more challenging. Thus, the selection of the empirical antibiotic treatment should be guided by the severity and location where the infection was acquired, the risk factors for multidrug-resistant organisms, and the available information on the local expected bacteriology. The use of albumin as a complementary therapy for selected high-risk patients with spontaneous bacterial peritonitis is recommended in addition to antibiotics. Even though antibiotic prophylaxis has proven to be effective to prevent spontaneous bacterial peritonitis, a careful selection of high-risk candidates is crucial to avoid antibiotic overuse. In this article we review the pathogenesis, risk factors, and prognosis of spontaneous bacterial peritonitis, as well as the current evidence regarding its treatment and prophylaxis.
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Affiliation(s)
- Sebastián Marciano
- Liver Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina,
- Department of Research, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina,
| | - Juan Manuel Díaz
- Liver Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina,
| | - Melisa Dirchwolf
- Hepatology Unit, Hospital Privado de Rosario, Santa Fe, Argentina
| | - Adrián Gadano
- Liver Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina,
- Department of Research, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina,
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Maraolo AE, Buonomo AR, Zappulo E, Scotto R, Pinchera B, Gentile I. Unsolved Issues in the Treatment of Spontaneous Peritonitis in Patients with Cirrhosis: Nosocomial Versus Community-acquired Infections and the Role of Fungi. Rev Recent Clin Trials 2019; 14:129-135. [PMID: 30514194 DOI: 10.2174/1574887114666181204102516] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 11/26/2018] [Accepted: 11/27/2018] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Historically, spontaneous bacterial peritonitis (SBP) has represented one of the most frequent and relevant infectious complications of advanced liver disease, and this is still valid today. Nevertheless, in recent years the role of fungi as causative pathogens of primary peritonitis in patients with cirrhosis has become not negligible. Another issue is linked with the traditional distinction, instrumental in therapeutic choice, between community-acquired and nosocomial forms, according to the onset. Between these two categories, another one has been introduced: the so-called "healthcare-associated infections". OBJECTIVE To discuss the most controversial aspects in the management of SBP nowadays in the light of best available evidence. METHODS A review of recent literature through MEDLINE was performed. RESULTS The difference between community-acquired and nosocomial infections is crucial to guide empiric antibiotic therapy, since the site of acquisition impact on the likelihood of multidrug-resistant bacteria as causative agents. Therefore, third-generation cephalosporins cannot be considered the mainstay of treatment in each episode. Furthermore, the distinction between healthcare-associated and nosocomial form seems very subtle, especially in areas wherein antimicrobial resistance is widespread, warranting broad-spectrum antibiotic regimens for both. Finally, spontaneous fungal peritonitis is a not common but actually underestimated entity, linked to high mortality. Especially in patients with septic shock and/or failure of an aggressive antibiotic regimen, the empiric addition of an antifungal agent might be considered. CONCLUSION Spontaneous bacterial peritonitis is one of the most important complications in patients with cirrhosis. A proper empiric therapy is crucial to have a positive outcome. In this respect, a careful assessment of risk factors for multidrug-resistant pathogens is crucial. Likewise important, mostly in nosocomial cases, is not to overlook the probability of a fungal ascitic infection, namely a spontaneous fungal peritonitis.
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Affiliation(s)
- Alberto Enrico Maraolo
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, 80131, Naples, Italy
| | - Antonio Riccardo Buonomo
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, 80131, Naples, Italy
| | - Emanuela Zappulo
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, 80131, Naples, Italy
| | - Riccardo Scotto
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, 80131, Naples, Italy
| | - Biagio Pinchera
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, 80131, Naples, Italy
| | - Ivan Gentile
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, 80131, Naples, Italy
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Righi E. Management of bacterial and fungal infections in end stage liver disease and liver transplantation: Current options and future directions. World J Gastroenterol 2018; 24:4311-4329. [PMID: 30344417 PMCID: PMC6189843 DOI: 10.3748/wjg.v24.i38.4311] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Revised: 09/11/2018] [Accepted: 10/05/2018] [Indexed: 02/06/2023] Open
Abstract
Patients with liver cirrhosis are susceptible to infections due to various mechanisms, including abnormalities of humoral and cell-mediated immunity and occurrence of bacterial translocation from the intestine. Bacterial infections are common and represent a reason for progression to liver failure and increased mortality. Fungal infections, mainly caused by Candida spp., are often associated to delayed diagnosis and high mortality rates. High level of suspicion along with prompt diagnosis and treatment of infections are warranted. Bacterial and fungal infections negatively affect the outcomes of liver transplant candidates and recipients, causing disease progression among patients on the waiting list and increasing mortality, especially in the early post-transplant period. Abdominal, biliary tract, and bloodstream infections caused by Gram-negative bacteria [e.g., Enterobacteriaceae and Pseudomonas aeruginosa (P. aeruginosa)] and Staphylococcus spp. are commonly encountered in liver transplant recipients. Due to frequent exposure to broad-spectrum antibiotics, invasive procedures, and prolonged hospitalizations, these patients are especially at risk of developing infections caused by multidrug resistant bacteria. The increase in antimicrobial resistance hampers the choice of an adequate empiric therapy and warrants the knowledge of the local microbial epidemiology and the implementation of infection control measures. The main characteristics and the management of bacterial and fungal infections in patients with liver cirrhosis and liver transplant recipients are presented.
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Affiliation(s)
- Elda Righi
- Department of Infectious Diseases, Santa Maria della Misericordia University Hospital, Udine 33100, Italy
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Wang H, Li Y, Zhang F, Yang N, Xie N, Mao Y, Li B. Combination of PCT, sNFI and dCHC for the diagnosis of ascites infection in cirrhotic patients. BMC Infect Dis 2018; 18:389. [PMID: 30097024 PMCID: PMC6086035 DOI: 10.1186/s12879-018-3308-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 08/03/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It is difficult to diagnose ascites infection early in cirrhotic patients. The present study was to create and evaluate a new bioscore combined with PCT, sNFI and dCHC in the diagnosis of ascites infection in cirrhotic patients. METHODS Two hundred and fifty-nine consecutive patients were enrolled; of which 51 patients were culture-positive spontaneous bacterial peritonitis (culture-positive SBP) and 58 patients were culture-negative SBP. The efficacy of procalcitonin(PCT), c-reactive protein (CRP), white blood cell (WBC), mean fluorescence intensity of mature neutrophils(sNFI) and difference in hemoglobin concentration between newly formed and mature red blood cells(dCHC) for diagnosing ascites infection was examined. These parameters were used to create a scoring system. The scoring system was analyzed by logistic regression analysis to determine which parameters were statistically different between ascites infection and non-ascites infection patients. Receiver operating characteristic curve (ROC) was used to analyze the diagnostic ability of bioscore for ascites infection. RESULTS In ROC analysis, the area under the curves (AUC) for PCT was 0.852 (95% CI 0.803-0.921, P < 0.001), dCHC 0.837 (95% CI 0.773-0.923, P < 0.001), CRP 0.669 (95% CI 0.610-0.732, P = 0.0624), sNFI 0.838 (95% CI 0.777-0.903, P < 0.001), and WBC 0.624 (95% CI 0.500-0.722, P = 0.0881). Multivariate analysis revealed PCT, dCHC and sNFI to be statistically significant. The combination of these three parameters in the bioscore had an AUC of 0.937 (95% CI 0.901-0.994, P < 0.001). A bioscore of ≥3.40 was considered to be statistically significant in making a positive diagnosis of ascites infection. In different groups of ascites infection, bioscore also shown a high diagnostic value of AUC was 0.947(95% CI 0.882-0.988, P < 0.001) and 0.929 (95% CI 0.869-0.974, P < 0.001) for culture-positive SBP and culture-negative SBP group respectively. CONCLUSION The composite markers of combining PCT, dCHC and sNFI could be a valuable diagnostic score to early diagnose ascites infection in patients with cirrhosis.
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Affiliation(s)
- Han Wang
- Clinical Diagnostic Centre, 302 Military Hospital of China, Beijing, 100039 People’s Republic of China
| | - Yan Li
- Clinical Diagnostic Centre, 302 Military Hospital of China, Beijing, 100039 People’s Republic of China
| | - Fangfang Zhang
- Out-patient department, 302 Military Hospital of China, Beijing, 100039 People’s Republic of China
| | - Ning Yang
- Clinical Diagnostic Centre, 302 Military Hospital of China, Beijing, 100039 People’s Republic of China
| | - Na Xie
- Out-patient department, 302 Military Hospital of China, Beijing, 100039 People’s Republic of China
| | - Yuanli Mao
- Clinical Diagnostic Centre, 302 Military Hospital of China, Beijing, 100039 People’s Republic of China
| | - Boan Li
- Clinical Diagnostic Centre, 302 Military Hospital of China, Beijing, 100039 People’s Republic of China
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