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A Case of a Large Intraabdominal Abscess in a Patient with Cirrhosis Misdiagnosed as Spontaneous Bacterial Peritonitis. Case Reports Hepatol 2022; 2022:5951115. [PMID: 36246017 PMCID: PMC9556249 DOI: 10.1155/2022/5951115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 08/15/2022] [Indexed: 11/17/2022] Open
Abstract
Spontaneous bacterial peritonitis is a known complication of patients with decompensated cirrhosis and ascites. It is differentiated from secondary bacterial peritonitis by the absence of an intraabdominal source of infection. We present a 56-year-old man with alcoholic cirrhosis who underwent multiple paracenteses that yielded fluid with progressively increasing neutrophil counts and several different organisms, recurring despite numerous treatments for SBP. Eventually, a computed tomography (CT) of the abdomen and the pelvis revealed a large intraabdominal abscess (22 × 13 cm) treated with an ultrasound-guided drain and IV antibiotics. Recurrent episodes of SBP despite appropriate antibiotics should raise suspicion for secondary bacterial peritonitis. It is crucial to differentiate SBP from secondary bacterial peritonitis as the mortality of the latter is much higher without prompt treatment. Appropriate antibiotic regimens, prompt surgical treatment, and postoperative care are crucial to improving clinical outcomes in these patients.
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Skusa C, Skusa R, Wohlfarth M, Warnke P, Podbielski A, Bath K, Groß J, Schafmayer C, Frickmann H, Weber MA, Hahn A, Meinel FG. Imaging and Clinical Parameters for Distinction between Infected and Non-Infected Fluid Collections in CT: Prospective Study Using Extended Microbiological Approach. Diagnostics (Basel) 2022; 12:diagnostics12020493. [PMID: 35204585 PMCID: PMC8870876 DOI: 10.3390/diagnostics12020493] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/05/2022] [Accepted: 02/08/2022] [Indexed: 12/14/2022] Open
Abstract
The aim of this investigation was to evaluate predictive CT imaging features and clinical parameters to distinguish infected from sterile fluid collections. Detection of infectious agents by advanced microbiological analysis was used as the reference standard. From April 2018 to October 2019, all patients undergoing CT-guided drainages were prospectively enrolled, if drainage material volume was at least 5 mL. Univariate analysis revealed attenuation (p = 0.001), entrapped gas (p < 0.001), fat stranding (p < 0.001), wall thickness (p < 0.001) and enhancement (p < 0.001) as imaging biomarkers and procalcitonin (p = 0.003) as clinical predictive parameters for infected fluid collections. On multivariate analysis, attenuation > 10 HU (p = 0.038), presence of entrapped gas (p = 0.027) and wall enhancement (p = 0.028) were independent parameters for distinguishing between infected and non-infected fluids. Gas entrapment had high specificity (93%) but low sensitivity (48%), while wall enhancement had high sensitivity (91%) but low specificity (50%). CT attenuation > 10 HU showed intermediate sensitivity (74%) and specificity (70%). Evaluation of the published proposed scoring systems did not improve diagnostic accuracy over independent predictors in our study. In conclusion, this prospective study confirmed that CT attenuation > 10 HU, entrapped gas and wall enhancement are the key imaging features to distinguish infected from sterile fluid collections on CT.
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Affiliation(s)
- Christopher Skusa
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, Rostock University Medical Center, 18057 Rostock, Germany; (M.W.); (K.B.); (M.-A.W.); (F.G.M.)
- Correspondence: ; Tel.: +49-381-4949201
| | - Romy Skusa
- Institute of Medical Microbiology, Virology and Hygiene, Rostock University Medical Center, 18057 Rostock, Germany; (R.S.); (P.W.); (A.P.); (H.F.); (A.H.)
| | - Moritz Wohlfarth
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, Rostock University Medical Center, 18057 Rostock, Germany; (M.W.); (K.B.); (M.-A.W.); (F.G.M.)
| | - Philipp Warnke
- Institute of Medical Microbiology, Virology and Hygiene, Rostock University Medical Center, 18057 Rostock, Germany; (R.S.); (P.W.); (A.P.); (H.F.); (A.H.)
| | - Andreas Podbielski
- Institute of Medical Microbiology, Virology and Hygiene, Rostock University Medical Center, 18057 Rostock, Germany; (R.S.); (P.W.); (A.P.); (H.F.); (A.H.)
| | - Kristina Bath
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, Rostock University Medical Center, 18057 Rostock, Germany; (M.W.); (K.B.); (M.-A.W.); (F.G.M.)
| | - Justus Groß
- Department of General, Visceral, Vascular, Thoracic and Transplantation Surgery, Rostock University Medical Center, 18057 Rostock, Germany; (J.G.); (C.S.)
| | - Clemens Schafmayer
- Department of General, Visceral, Vascular, Thoracic and Transplantation Surgery, Rostock University Medical Center, 18057 Rostock, Germany; (J.G.); (C.S.)
| | - Hagen Frickmann
- Institute of Medical Microbiology, Virology and Hygiene, Rostock University Medical Center, 18057 Rostock, Germany; (R.S.); (P.W.); (A.P.); (H.F.); (A.H.)
- Department of Microbiology and Hospital Hygiene, Bundeswehr Hospital Hamburg, 20359 Hamburg, Germany
| | - Marc-André Weber
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, Rostock University Medical Center, 18057 Rostock, Germany; (M.W.); (K.B.); (M.-A.W.); (F.G.M.)
| | - Andreas Hahn
- Institute of Medical Microbiology, Virology and Hygiene, Rostock University Medical Center, 18057 Rostock, Germany; (R.S.); (P.W.); (A.P.); (H.F.); (A.H.)
| | - Felix G. Meinel
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, Rostock University Medical Center, 18057 Rostock, Germany; (M.W.); (K.B.); (M.-A.W.); (F.G.M.)
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Spontaneous bacterial peritonitis caused by Edwardsiella tarda: A case report. Int J Surg Case Rep 2020; 75:422-425. [PMID: 33002853 PMCID: PMC7527672 DOI: 10.1016/j.ijscr.2020.09.126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 09/17/2020] [Accepted: 09/18/2020] [Indexed: 11/21/2022] Open
Abstract
Case of spontaneous bacterial peritonitis associated with E. tarda infection. The patient had Child–Pugh A cirrhosis secondary to hepatitis C virus infection. Surgical findings included redness and thickening of the cecal wall. Purulent ascites without intestinal contents was observed. E. tarda infection has a poor prognosis in patients with underlying disease. Introduction Edwardsiella tarda is a member of the Enterobacteriaceae family of gram-negative bacilli isolated from animals. Gastroenteritis is the most common manifestation of E. tarda infection. However, extraintestinal infections can occur in immunocompromised hosts as well as patients with hepatobiliary disease, malignancy, and/or diabetes mellites. The prognosis of sepsis caused by E. tarda is extremely poor, with a mortality rate of 38%. Here we report the occurrence of spontaneous bacterial peritonitis associated with E. tarda infection. Presentation of case An 87-year-old man with Child–Pugh A cirrhosis secondary to hepatitis C virus infection presented with diarrhea and sudden-onset pain in the abdomen. On arrival, guarding and rebound tenderness were observed over the entire abdomen. Computed tomography revealed circumferential thickening of the cecum and a small volume of ascites in the pelvic cavity. A diagnosis of peritonitis was made, and surgery was performed. Surgical findings included redness and thickening of the cecal wall and purulent ascites without intestinal contents. Peritoneal fluid culture revealed E. tarda as the sole pathogen. The abdominal cavity was washed, a drain was placed in the pelvic cavity, and postoperative intravenous antibiotic therapy was initiated. The postoperative course was uneventful. Discussion E. tarda infection in the presence of an underlying disease such as hepatobiliary disease, malignancy, and/or diabetes mellitus has a poor prognosis. Conclusion Although E. tarda infection is extremely rare, it is a life-threatening illness that can cause intestinal and extraintestinal infections. If necessary, early surgical intervention should be considered for cases of extraintestinal infection.
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Karagozian R, Bhardwaj G, Wakefield DB, Verna EC. Acute kidney injury is associated with higher mortality and healthcare costs in hospitalized patients with cirrhosis. Ann Hepatol 2020; 18:730-735. [PMID: 31175020 DOI: 10.1016/j.aohep.2019.03.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Revised: 03/09/2019] [Accepted: 02/09/2019] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES AKI is known to be associated with increased risk of mortality, however limited information is available on how AKI impacts healthcare costs and resource utilization in hospitalized patients with cirrhosis. Previous studies have had variable definitions of AKI, resulting in inconsistent reporting of the true impact of AKI in patients with cirrhosis. METHODS Data from the Nationwide Inpatient Sample (NIS) which contains data from 44 states and 4378 hospitals, accounting for over 7 million discharges were analyzed. The inclusion data were all discharges in the 2012 NIS dataset with a discharge diagnosis of cirrhosis. RESULTS A total of 32,605 patients were included in the analysis, incidence of AKI was 12.12% in patients with cirrhosis. Crude mortality was much higher for patients with cirrhosis and AKI (14.9% vs. 1.8%, OR 9.42, p<0.001) than for patients without AKI. In addition, mean LOS was longer (8.5 vs. 4.3 days, p<0.001) and median total hospital charges were higher for patients with AKI ($43,939 vs. $22,270, p<0.001). In multivariate logistic regression, controlling for covariates and mortality risk score, sepsis, ascites and SBP were predictors of AKI. CONCLUSIONS AKI is relatively common in hospitalized patients with cirrhosis. Presence of AKI results in significantly higher inpatient mortality as well as LOS and resource utilization. Median hospitalization cost was twice as high in AKI patients. Early identification of patients at high risk for AKI should be implemented to reduce mortality and contain costs. Prognosis could be enhanced by utilizing biomarkers which could rapidly detect AKI.
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Affiliation(s)
- Raffi Karagozian
- Tufts Medical Center, Tufts University School of Medicine, Boston, MA, United States.
| | - Gaurav Bhardwaj
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Dorothy B Wakefield
- Center for Public Health and Health Policy, UConn Health, Farmington, CT, United States; St Francis Hospital & Medical Center, Hartford, CT, United States
| | - Elizabeth C Verna
- New York Presbyterian-Columbia University Medical Center, New York, NY, United States
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Scarpellini E, Fagoonee S, Rinninella E, Rasetti C, Aquila I, Larussa T, Ricci P, Luzza F, Abenavoli L. Gut Microbiota and Liver Interaction through Immune System Cross-Talk: A Comprehensive Review at the Time of the SARS-CoV-2 Pandemic. J Clin Med 2020; 9:2488. [PMID: 32756323 PMCID: PMC7464500 DOI: 10.3390/jcm9082488] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 07/23/2020] [Accepted: 07/28/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND AIMS The gut microbiota is a complex ecosystem containing bacteria, viruses, fungi, yeasts and other single-celled organisms. It is involved in the development and maintenance of both innate and systemic immunity of the body. Emerging evidence has shown its role in liver diseases through the immune system cross-talk. We review herein literature data regarding the triangular interaction between gut microbiota, immune system and liver in health and disease. METHODS We conducted a search on the main medical databases for original articles, reviews, meta-analyses, randomized clinical trials and case series using the following keywords and acronyms and their associations: gut microbiota, microbiome, gut virome, immunity, gastrointestinal-associated lymphoid tissue (GALT), non-alcoholic fatty liver disease (NAFLD), non-alcoholic steato-hepatitis (NASH), alcoholic liver disease, liver cirrhosis, hepatocellular carcinoma. RESULTS The gut microbiota consists of microorganisms that educate our systemic immunity through GALT and non-GALT interactions. The latter maintain health but are also involved in the pathophysiology and in the outcome of several liver diseases, particularly those with metabolic, toxic or immune-mediated etiology. In this context, gut virome has an emerging role in liver diseases and needs to be further investigated, especially due to the link reported between severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection and hepatic dysfunctions. CONCLUSIONS Changes in gut microbiota composition and alterations in the immune system response are involved in the pathogenesis of metabolic and immune-mediated liver diseases.
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Affiliation(s)
- Emidio Scarpellini
- Internal Medicine Unit, “Madonna del Soccorso” General Hospital, San Benedetto del, 63074 Tronto, Italy;
- Department of Biomedical Sciences, KU Leuven, Gasthuisberg University Hospital, TARGID, 3000 Leuven, Belgium
| | - Sharmila Fagoonee
- Institute for Biostructure and Bioimaging, National Research Council, Molecular Biotechnology Center, 10121 Turin, Italy;
| | - Emanuele Rinninella
- Nephrology and Urology Department, Gastroenterology, Endocrinology, Fondazione Policlinico A, Clinical Nutrition Unit, Gemelli IRCCS, 00168 Rome, Italy;
- Institute of Medical Pathology, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Carlo Rasetti
- Internal Medicine Unit, “Madonna del Soccorso” General Hospital, San Benedetto del, 63074 Tronto, Italy;
| | - Isabella Aquila
- Institute of Legal Medicine and Department of Surgical and Medical Sciences, University “Magna Graecia” of Catanzaro (UMG), 88100 Viale Europa, Italy; (I.A.); (P.R.)
| | - Tiziana Larussa
- Department of Health Sciences, University “Magna Græcia”, 88100 Catanzaro, Italy; (T.L.); (F.L.)
| | - Pietrantonio Ricci
- Institute of Legal Medicine and Department of Surgical and Medical Sciences, University “Magna Graecia” of Catanzaro (UMG), 88100 Viale Europa, Italy; (I.A.); (P.R.)
| | - Francesco Luzza
- Department of Health Sciences, University “Magna Græcia”, 88100 Catanzaro, Italy; (T.L.); (F.L.)
| | - Ludovico Abenavoli
- Department of Health Sciences, University “Magna Græcia”, 88100 Catanzaro, Italy; (T.L.); (F.L.)
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Kirplani PD, Qadar LT, Ochani RK, Memon ZA, Tahir SA, Imran K, Kumar Seetlani N, Abbasi A, Kumar M, Ali P. Recognition of Antibiotic Resistance in Spontaneous Bacterial Peritonitis Caused by Escherichia coli in Liver Cirrhotic Patients in Civil Hospital Karachi. Cureus 2019; 11:e5284. [PMID: 31576274 PMCID: PMC6764645 DOI: 10.7759/cureus.5284] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Introduction Spontaneous bacterial peritonitis (SBP) is the most common life-threatening infection in patients with ascites due to liver cirrhosis. The infection is most commonly caused by the bacterium Escherichia coli, commonly referred to as E. coli. Over the past few years, the incidence of antimicrobial resistance against E. coli has risen drastically, leading to increased morbidity and mortality. Methods This cross-sectional study was conducted to determine the pattern of resistance using variations of antibiotics against E. coli, to prevent its empirical usage and initiate an appropriate target antibiotic therapy. The data were collected from May 2017 to October 2017 and included a total of 184 patients. The patients had previously been diagnosed with chronic liver disease and had presented with E. coli-induced SBP in the medicine wards at Civil Hospital, Karachi, which is the largest tertiary care hospital in the city. All participants underwent diagnostic paracentesis, and the ascitic fluid samples were sent to labs for culture and sensitivity to antibiotics. Results The sample population consisted of 184 participants, of which two-thirds (63.6%; n=117/184) of the population consisted of males. The mean age of the participants was 47.6±10.7 years. More than half of the patients had hepatitis C (54.9%; n=101/184) while the remaining were diagnosed with hepatitis B (45.1%; n=83/184). The ascitic fluid showed varying percentages of resistance for drugs, with no resistance to imipenem and meropenem while ciprofloxacin showed the highest resistance in eradicating the bacterium, E. coli. Additionally, a statistical correlation was tested between drug resistance and factors like age, gender, duration of liver disease, and duration of ascites. Ciprofloxacin and tetracycline showed a positive correlation between the resistance of these drugs and the age, gender, and duration of chronic liver disease in the participants while trimethoprim/sulfamethoxazole, amoxicillin/clavulanic acid, and piperacillin/tazobactam showed a positive association with the duration of ascites. Conclusion A rapid diligent intervention of cirrhotic patients with complicated ascites is crucial to alleviate patient mortality. Due to the rising bacterial resistance, primarily, epidemiological patterns should be assessed and analyzed in our regional hospitals, and then, antibiotics should be prescribed meticulously.
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Affiliation(s)
| | - Laila Tul Qadar
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | | | - Zahid Ali Memon
- Surgery, Civil Hospital Karachi, Dow University of Health Sciences, Karachi, PAK
| | - Syeda Anjala Tahir
- Internal Medicine, Civil Hospital Karachi, Dow University of Health Sciences, Karachi, PAK
| | - Khalid Imran
- Internal Medicine: Gastroenterology, Civil Hospital Karachi, Dow University of Health Sciences, Karachi, PAK
| | - Naresh Kumar Seetlani
- Internal Medicine: Infectious Disease, Civil Hospital Karachi, Dow University of Health Sciences, Karachi, PAK
| | - Amanullah Abbasi
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Mahaish Kumar
- Internal Medicine, Aga Khan University Hospital, Karachi, PAK
| | - Piyar Ali
- Internal Medicine, Civil Hospital Karachi, Dow University of Health Sciences, Karachi, PAK
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Fiore M, Maraolo AE, Leone S, Gentile I, Cuomo A, Schiavone V, Bimonte S, Pace MC, Cascella M. Spontaneous peritonitis in critically ill cirrhotic patients: a diagnostic algorithm for clinicians and future perspectives. Ther Clin Risk Manag 2017; 13:1409-1414. [PMID: 29081656 PMCID: PMC5652902 DOI: 10.2147/tcrm.s144262] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Spontaneous peritonitis (SP) is the most common infection among decompensated end-stage liver disease patients. SP is the infection of ascitic fluid (neutrophil ascitic count ≥250/mL) without an alternative focus of abdominal infection. According to the causative agent, clinicians can make the diagnosis of spontaneous bacterial peritonitis or spontaneous fungal peritonitis. The mortality rate is very high, ranging from one-fifth of the patients with spontaneous bacterial peritonitis to four-fifths of the patients with spontaneous fungal peritonitis. An immediate and accurate diagnosis can improve the outcome in end-stage liver disease patients. The aim of this work is to provide physicians with a practical diagnostic guidance for SP diagnosis according to current evidence, in order to improve the management of cirrhotic patients with infected ascitic fluid.
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Affiliation(s)
- Marco Fiore
- Department of Anaesthesiological, Surgical and Emergency Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Alberto Enrico Maraolo
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - Sebastiano Leone
- Division of Infectious Diseases, “San Giuseppe Moscati” Hospital, Avellino, Italy
| | - Ivan Gentile
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - Arturo Cuomo
- Division of Anesthesia, Department of Anesthesia and Pain Medicine, Istituto Nazionale Tumori – IRCCS – Fondazione G. Pascale, Naples, Italy
| | - Vincenzo Schiavone
- Division of Anesthesia and Intensive Care, Hospital “Pineta Grande”, Castel Volturno, Italy
| | - Sabrina Bimonte
- Division of Anesthesia, Department of Anesthesia and Pain Medicine, Istituto Nazionale Tumori – IRCCS – Fondazione G. Pascale, Naples, Italy
| | - Maria Caterina Pace
- Department of Anaesthesiological, Surgical and Emergency Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Marco Cascella
- Division of Anesthesia, Department of Anesthesia and Pain Medicine, Istituto Nazionale Tumori – IRCCS – Fondazione G. Pascale, Naples, Italy
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Sun LY, Yang YS, Qu W, Zhu ZJ, Wei L, Ye ZS, Zhang JR, Sun XY, Zeng ZG. Gut microbiota of liver transplantation recipients. Sci Rep 2017. [PMID: 28630433 PMCID: PMC5476624 DOI: 10.1038/s41598-017-03476-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The characteristics of intestinal microbial communities may be affected by changes in the pathophysiology of patients with end-stage liver disease. Here, we focused on the characteristics of intestinal fecal microbial communities in post-liver transplantation (LT) patients in comparison with those in the same individuals pre-LT and in healthy individuals. The fecal microbial communities were analyzed via MiSeq-PE250 sequencing of the V4 region of 16S ribosomal RNA and were then compared between groups. We found that the gut microbiota of patients with severe liver disease who were awaiting LT was significantly different from that of healthy controls, as represented by the first principal component (p = 0.0066). Additionally, the second principal component represented a significant difference in the gut microbiota of patients between pre-LT and post-LT surgery (p = 0.03125). After LT, there was a significant decrease in the abundance of certain microbial species, such as Actinobacillus, Escherichia, and Shigella, and a significant increase in the abundance of other microbial species, such as Micromonosporaceae, Desulfobacterales, the Sarcina genus of Eubacteriaceae, and Akkermansia. Based on KEGG profiles, 15 functional modules were enriched and 21 functional modules were less represented in the post-LT samples compared with the pre-LT samples. Our study demonstrates that fecal microbial communities were significantly altered by LT.
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Affiliation(s)
- Li-Ying Sun
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yun-Sheng Yang
- Institute of Digestive Diseases, Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, China.
| | - Wei Qu
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhi-Jun Zhu
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lin Wei
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhi-Sheng Ye
- Institute of Developmental Biology and Molecular Medicine, Fudan University, Shanghai, China
| | - Jian-Rui Zhang
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Xiao-Ye Sun
- Tianjin First Central Hospital, Tianjin, China
| | - Zhi-Gui Zeng
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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Aguirre Valadez JM, Rivera-Espinosa L, Méndez-Guerrero O, Chávez-Pacheco JL, García Juárez I, Torre A. Intestinal permeability in a patient with liver cirrhosis. Ther Clin Risk Manag 2016; 12:1729-1748. [PMID: 27920543 PMCID: PMC5125722 DOI: 10.2147/tcrm.s115902] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Liver cirrhosis is a worldwide public health problem, and patients with this disease are at high risk of developing complications, bacterial translocation from the intestinal lumen to the mesenteric nodes, and systemic circulation, resulting in the development of severe complications related to high mortality rate. The intestinal barrier is a structure with a physical and biochemical activity to maintain balance between the external environment, including bacteria and their products, and the internal environment. Patients with liver cirrhosis develop a series of alterations in different components of the intestinal barrier directly associated with the severity of liver disease that finally increased intestinal permeability. A "leaky gut" is an effect produced by damaged intestinal barrier; alterations in the function of tight junction proteins are related to bacterial translocation and their products. Instead, increasing serum proinflammatory cytokines and hemodynamics modification, which results in the appearance of complications of liver cirrhosis such as hepatic encephalopathy, variceal hemorrhage, bacterial spontaneous peritonitis, and hepatorenal syndrome. The intestinal microbiota plays a fundamental role in maintaining the proper function of the intestinal barrier; bacterial overgrowth and dysbiosis are two phenomena often present in people with liver cirrhosis favoring bacterial translocation. Increased intestinal permeability has an important role in the genesis of these complications, and treating it could be the base for prevention and partial treatment of these complications.
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Affiliation(s)
| | | | - Osvely Méndez-Guerrero
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición”Salvador Zubirán
| | | | - Ignacio García Juárez
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición”Salvador Zubirán
| | - Aldo Torre
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición”Salvador Zubirán
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Bal CK, Daman R, Bhatia V. Predictors of fifty days in-hospital mortality in decompensated cirrhosis patients with spontaneous bacterial peritonitis. World J Hepatol 2016; 8:566-72. [PMID: 27134704 PMCID: PMC4840162 DOI: 10.4254/wjh.v8.i12.566] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 02/28/2016] [Accepted: 04/07/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To determine the predictors of 50 d in-hospital mortality in decompensated cirrhosis patients with spontaneous bacterial peritonitis (SBP). METHODS Two hundred and eighteen patients admitted to an intensive care unit in a tertiary care hospital between June 2013 and June 2014 with the diagnosis of SBP (during hospitalization) and cirrhosis were retrospectively analysed. SBP was diagnosed by abdominal paracentesis in the presence of polymorphonuclear cell count ≥ 250 cells/mm(3) in the peritoneal fluid. Student's t test, multivariate logistic regression, cox proportional hazard ratio (HR), receiver operating characteristics (ROC) curves and Kaplan-Meier survival analysis were utilized for statistical analysis. Predictive abilities of several variables identified by multivariate analysis were compared using the area under ROC curve. P < 0.05 were considered statistical significant. RESULTS The 50 d in-hospital mortality rate attributable to SBP is 43.11% (n = 94). Median survival duration for those who died was 9 d. In univariate analysis acute kidney injury (AKI), hepatic encephalopathy, septic shock, serum bilirubin, international normalized ratio, aspartate transaminase, and model for end-stage liver disease - sodium (MELD-Na) were significantly associated with in - hospital mortality in patients with SBP (P ≤ 0.001). Multivariate cox proportional regression analysis showed AKI (HR = 2.16, 95%CI: 1.36-3.42, P = 0.001) septic shock (HR = 1.73, 95%CI: 1.05-2.83, P = 0.029) MELD-Na (HR = 1.06, 95%CI: 1.02-1.09, P ≤ 0.001) was significantly associated with 50 d in-hospital mortality. The prognostic accuracy for AKI, MELD-Na and septic shock was 77%, 74% and 71% respectively associated with 50 d in-hospital mortality in SBP patients. CONCLUSION AKI, MELD-Na and septic shock were predictors of 50 d in-hospital mortality in decompensated cirrhosis patients with SBP.
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Affiliation(s)
- Chinmaya Kumar Bal
- Chinmaya Kumar Bal, Ripu Daman, Vikram Bhatia, Department of Hepatology, Institute of Liver and Biliary Science, New Delhi 110070, India
| | - Ripu Daman
- Chinmaya Kumar Bal, Ripu Daman, Vikram Bhatia, Department of Hepatology, Institute of Liver and Biliary Science, New Delhi 110070, India
| | - Vikram Bhatia
- Chinmaya Kumar Bal, Ripu Daman, Vikram Bhatia, Department of Hepatology, Institute of Liver and Biliary Science, New Delhi 110070, India
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Kim JH, Jeon YD, Jung IY, Ahn MY, Ahn HW, Ahn JY, Ku NS, Han SH, Choi JY, Ahn SH, Song YG, Han KH, Kim JM. Predictive Factors of Spontaneous Bacterial Peritonitis Caused by Gram-Positive Bacteria in Patients With Cirrhosis. Medicine (Baltimore) 2016; 95:e3489. [PMID: 27124049 PMCID: PMC4998712 DOI: 10.1097/md.0000000000003489] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Revised: 03/15/2016] [Accepted: 03/31/2016] [Indexed: 12/13/2022] Open
Abstract
Spontaneous bacterial peritonitis (SBP) in patients with cirrhosis is typically caused by gram-negative bacteria. However, the number of SBP cases due to gram-positive bacteria is steadily increasing. To date, little is known about the predictive factors involved in SBP infections.We performed a retrospective cohort study of patients (>18 years) with SBP due to gram-positive and -negative bacteria who were enrolled from January 2006 to December 2013 at Severance Hospital in Seoul, Korea where the incidences of hepatitis B virus associated chronic liver disease, cirrhosis, and hepatocellular carcinoma are high. Only the 1st SBP episode for each patient within the study period was included in our analysis.We identified 77 patients with cirrhosis and SBP. Of these, 27 patients (35%) had gram-positive bacterial infections and 50 patients (65%) had gram-negative bacterial infections. Our univariate analysis revealed that an early stage of cirrhosis (P = 0.004), lower creatinine level (P = 0.011), lower Sequential Organ Failure Assessment (SOFA) score (P = 0.001), lower Model for End-Stage Liver Disease score (P = 0.005), and use of systemic antibiotics within 30 days before SBP diagnosis (P = 0.03) were significantly associated with gram-positive bacterial infections. Our multivariate analysis indicated that the use of systemic antibiotics within 30 days before SBP diagnosis (odds ratio, 3.94; 95% CI, 1.11-13.96; P = 0.033) and a lower SOFA score (odds ratio, 0.56; 95% CI, 0.37-0.86; P = 0.007) were independent predictive factors of SBP caused by gram-positive bacterial infections in patients with cirrhosis. However, we did not observe a statistically significant difference in the 28-day mortality between the gram-positive and -negative bacterial infection groups (40.7% vs 46.0%, respectively; P = 0.407).In this study, the incidence rate of SBP caused by gram-positive bacteria in patients with cirrhosis was similar to the rates reported in recently published studies. Furthermore, the use of systemic antibiotics within 30 days before SBP diagnosis and a lower SOFA score were significantly associated with SBP caused by gram-positive bacteria in patients with cirrhosis.
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Affiliation(s)
- Jung Ho Kim
- From the Department of Internal Medicine (JHK, YDJ, IYJ, MYA, HWA, JYA, NSK, SHH, JYC, SHA, YGS, KHH, JMK); and AIDS Research Institute, Severance Hospital (YDJ, MYA, HWA, JYA, NSK, SHH, JYC, YGS, JMK), Yonsei University College of Medicine, Seoul, Republic of Korea
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Vaikunthanathan T, Safinia N, Lombardi G, Lechler RI. Microbiota, immunity and the liver. Immunol Lett 2016; 171:36-49. [PMID: 26835593 DOI: 10.1016/j.imlet.2016.01.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 01/24/2016] [Accepted: 01/27/2016] [Indexed: 12/18/2022]
Abstract
The gut harbors a complex community of over 100 trillion microbial cells known to exist in symbiotic harmony with the host influencing human physiology, metabolism, nutrition and immune function. It is now widely accepted that perturbations of this close partnership results in the pathogenesis of several major diseases with increasing evidence highlighting their role outside of the intestinal tract. The intimate proximity and circulatory loop of the liver and the gut has attracted significant attention regarding the role of the microbiota in the development and progression of liver disease. Here we give an overview of the interaction between the microbiota and the immune system and focus on their convincing role in both the propagation and treatment of liver disease.
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Affiliation(s)
- T Vaikunthanathan
- MRC Centre for Transplantation, Division of Transplantation Immunology & Mucosal Biology, King's College London, 5th Floor, Tower Wing, Guy's Hospital, Great Maze Pond, London SE1 9RT, United Kingdom.
| | - N Safinia
- MRC Centre for Transplantation, Division of Transplantation Immunology & Mucosal Biology, King's College London, 5th Floor, Tower Wing, Guy's Hospital, Great Maze Pond, London SE1 9RT, United Kingdom.
| | - G Lombardi
- MRC Centre for Transplantation, Division of Transplantation Immunology & Mucosal Biology, King's College London, 5th Floor, Tower Wing, Guy's Hospital, Great Maze Pond, London SE1 9RT, United Kingdom.
| | - R I Lechler
- MRC Centre for Transplantation, Division of Transplantation Immunology & Mucosal Biology, King's College London, 5th Floor, Tower Wing, Guy's Hospital, Great Maze Pond, London SE1 9RT, United Kingdom.
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Gómez-Hurtado I, Such J, Francés R. Microbiome and bacterial translocation in cirrhosis. GASTROENTEROLOGIA Y HEPATOLOGIA 2016; 39:687-696. [PMID: 26775042 DOI: 10.1016/j.gastrohep.2015.10.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 10/20/2015] [Accepted: 10/22/2015] [Indexed: 02/06/2023]
Abstract
Qualitative and quantitative changes in gut microbiota play a very important role in cirrhosis. Humans harbour around 100 quintillion gut bacteria, thus representing around 10 times more microbial cells than eukaryotic ones. The gastrointestinal tract is the largest surface area in the body and it is subject to constant exposure to these living microorganisms. The existing symbiosis, proven by the lack of proinflammatory response against commensal bacteria, implies the presence of clearly defined communication lines that contribute to the maintenance of homeostasis of the host. Therefore, alterations of gut flora seem to play a role in the pathogenesis and progress of multiple liver and gastrointestinal diseases. This has made its selective modification into an area of high therapeutic interest. Bacterial translocation is defined as the migration of bacteria or bacterial products from the intestines to the mesenteric lymph nodes. It follows that alteration in gut microbiota have shown importance, at least to some extent, in the pathogenesis of several complications arising from terminal liver disease, such as hepatic encephalopathy, portal hypertension and spontaneous bacterial peritonitis. This review sums up, firstly, how liver disease can alter the common composition of gut microbiota, and secondly, how this alteration contributes to the development of complications in cirrhosis.
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Affiliation(s)
- Isabel Gómez-Hurtado
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, España
| | - José Such
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, España; Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dabi, Emiratos Árabes Unidos
| | - Rubén Francés
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, España; Departamento de Medicina Clínica, Universidad Miguel Hernández, San Juan de Alicante, Alicante, España.
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Wu CH, Chen TH, Lin CY, Chiu CH, Su MY, Chiu CT. Analysis of ascitic fluid lactoferrin levels in the diagnosis of spontaneous bacterial peritonitis after systemic antibiotic treatment. ADVANCES IN DIGESTIVE MEDICINE 2015. [DOI: 10.1016/j.aidm.2014.06.010] [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: 11/25/2022]
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Sánchez E, Soriano G, Mirelis B, Gonzalez B, Nieto JC, Vidal S, Guarner-Argente C, Juárez C, Monés J, Guarner C. Effect of long-term acid gastric inhibition on bacterial translocation in cirrhotic rats. Eur J Gastroenterol Hepatol 2015; 27:570-576. [PMID: 25822866 DOI: 10.1097/meg.0000000000000319] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Bacterial translocation (BT) related to intestinal bacterial overgrowth (IBO) plays an important role in the pathogenesis of bacterial infections in cirrhosis. Inhibition of acid gastric secretion promotes IBO and might favor BT. We evaluated the effect of long-term inhibition of acid gastric secretion on BT in cirrhotic rats. METHODS Cirrhotic rats with and without ascites induced by oral CCl4 and controls were randomized to treatment with a daily subcutaneous injection of placebo, ranitidine (50 mg/kg), or pantoprazole (8 mg/kg) during 2 weeks. Continuous pH-metry was performed for 2 h before and at the end of treatment; thereafter, a laparotomy to obtain samples of blood, mesenteric lymph nodes, ascites, spleen, liver, and cecal stools was performed. RESULTS Ranitidine and pantoprazole increased gastric pH as compared with placebo (P<0.001). However, antisecretory drugs increased the incidence of BT only in ascitic rats treated with ranitidine (P<0.05) or pantoprazole (P=0.07) when compared with placebo-treated ascitic rats or cirrhotic rats without ascites treated with the same drug. Cirrhotic ascitic rats treated with pantoprazole showed a trend toward an increased incidence of IBO (P=0.08), a higher ileal malondialdehyde level (P<0.01), and an increased production of tumor necrosis factor-α (P<0.05). CONCLUSION Although inhibition of acid gastric secretion increased gastric pH in all animals, the incidence of BT increased only in ascitic rats, and it was associated with a trend toward an increase in IBO incidence, a higher ileal malondialdehyde level, and an increased production of serum tumor necrosis factor-α. Therefore, antisecretory drugs should be carefully administered to cirrhotic ascitic patients.
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Affiliation(s)
- Elisabet Sánchez
- Departments of aGastroenterology, Liver Unit bMicrobiology cImmunology, Hospital de la Santa Creu i Sant Pau dInstitut d´Investigacions Biomédiques de Sant Pau (IIB) eUniversitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Barcelona fCentro de Investigación Biomédica en Red en el Área temática de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
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Chugh K, Agrawal Y, Goyal V, Khatri V, Kumar P. Diagnosing bacterial peritonitis made easy by use of leukocyte esterase dipsticks. Int J Crit Illn Inj Sci 2015; 5:32-7. [PMID: 25810962 PMCID: PMC4366826 DOI: 10.4103/2229-5151.152337] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Spontaneous bacterial peritonitis (SBP) requires rapid diagnosis for the initiation of antibiotics. Its diagnosis is usually based on manual examination of ascitic fluid (AF) having long reporting time. AF infection is diagnosed when the fluid polymorphonuclear leukocyte (PMNL) concentration ≥250 cells/mm(3). AIMS AND OBJECTIVES Aim was to evaluate the diagnostic utility of leukocyte esterase (LE) reagent strip for rapid diagnosis of SBP in patients who underwent abdominal paracentesis and to calculate the sensitivity, specificity, positive, and negative predictive values. MATERIALS AND METHODS The study was carried out on 103 patients with ascites. Cell count of AF as determined by colorimetric scale of Multistix 10 SG reagent strip was compared with counting chamber method (PMNL count ≥250 cells/mm(3) was considered positive). RESULTS AND OBSERVATIONS Of the 103 patients SBP was diagnosed in 20 patients, 83 patients were negative for SBP by manual cell count. The sensitivity and specificity of the LE test for detecting neutrocytic SBP taking grade 2 as cut off were 95% and 96.4% respectively, with a positive predictive value of 86.4% and a negative predictive value of 98.8%. Diagnostic accuracy of LE test was 96.1%. DISCUSSION There was a good correlation between the reagent strip result and PMNL count. The LE strip test is based on the esterase activity of activated granulocytes which reacts with an ester-releasing hydroxyphenylpyrrole causing a colour change in the azo dye of reagent strip. It is a very sensitive and specific method for the prompt detection of elevated PMNL count, and represents a convenient, inexpensive, simple, and bedside method for diagnosis of SBP. A negative LE test result excludes SBP with a high degree of certainty.
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Affiliation(s)
- Kiran Chugh
- Department of Biochemistry, Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Yuthika Agrawal
- Department of Biochemistry, Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Vipin Goyal
- Department of Chest and TB, Shree Guru Gobind Singh Tricentenary Medical College, Budhera, Gurgaon, Haryana, India
| | - Vinod Khatri
- Department of Medicine, Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Pradeep Kumar
- Department of Medicine, Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
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Gómez-Hurtado I, Such J, Sanz Y, Francés R. Gut microbiota-related complications in cirrhosis. World J Gastroenterol 2014; 20:15624-15631. [PMID: 25400446 PMCID: PMC4229527 DOI: 10.3748/wjg.v20.i42.15624] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 05/19/2014] [Indexed: 02/06/2023] Open
Abstract
Gut microbiota plays an important role in cirrhosis. The liver is constantly challenged with commensal bacteria and their products arriving through the portal vein in the so-called gut-liver axis. Bacterial translocation from the intestinal lumen through the intestinal wall and to mesenteric lymph nodes is facilitated by intestinal bacterial overgrowth, impairment in the permeability of the intestinal mucosal barrier, and deficiencies in local host immune defences. Deranged clearance of endogenous bacteria from portal and systemic circulation turns the gut into the major source of bacterial-related complications. Liver function may therefore be affected by alterations in the composition of the intestinal microbiota and a role for commensal flora has been evidenced in the pathogenesis of several complications arising in end-stage liver disease such as hepatic encephalopathy, splanchnic arterial vasodilatation and spontaneous bacterial peritonitis. The use of antibiotics is the main therapeutic pipeline in the management of these bacteria-related complications. However, other strategies aimed at preserving intestinal homeostasis through the use of pre-, pro- or symbiotic formulations are being studied in the last years. In this review, the role of intestinal microbiota in the development of the most frequent complications arising in cirrhosis and the different clinical and experimental studies conducted to prevent or improve these complications by modifying the gut microbiota composition are summarized.
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Diagnosis of spontaneous bacterial peritonitis and an in situ hybridization approach to detect an "unidentified" pathogen. Int J Hepatol 2014. [PMID: 25132996 DOI: 10.1155/2014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Spontaneous bacterial peritonitis (SBP) is a frequent and severe complication in cirrhotic patients with ascites. Although identifying the pathogen(s) plays a major role in the management of infectious diseases, ascitic fluid cultures often show negative results in patients with clinical signs and symptoms of SBP, and ascitic fluid cell analyses are the gold standard method for diagnosing SBP. SBP is generally diagnosed based on an increased number of polymorphonuclear neutrophils in the ascitic fluid (>250/mm(3)), and the identification of the causal pathogen may not be given consideration. We newly developed an in situ hybridization (ISH) method to provide early and direct evidence of bacterial infection in ascites in patients with SBP. This paper will review the diagnosis of SBP, including our novel approach with ISH method to detect bacterial DNA in SBP ascitic fluid.
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Enomoto H, Inoue SI, Matsuhisa A, Nishiguchi S. Diagnosis of spontaneous bacterial peritonitis and an in situ hybridization approach to detect an "unidentified" pathogen. Int J Hepatol 2014; 2014:634617. [PMID: 25132996 PMCID: PMC4123576 DOI: 10.1155/2014/634617] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 07/01/2014] [Accepted: 07/04/2014] [Indexed: 01/19/2023] Open
Abstract
Spontaneous bacterial peritonitis (SBP) is a frequent and severe complication in cirrhotic patients with ascites. Although identifying the pathogen(s) plays a major role in the management of infectious diseases, ascitic fluid cultures often show negative results in patients with clinical signs and symptoms of SBP, and ascitic fluid cell analyses are the gold standard method for diagnosing SBP. SBP is generally diagnosed based on an increased number of polymorphonuclear neutrophils in the ascitic fluid (>250/mm(3)), and the identification of the causal pathogen may not be given consideration. We newly developed an in situ hybridization (ISH) method to provide early and direct evidence of bacterial infection in ascites in patients with SBP. This paper will review the diagnosis of SBP, including our novel approach with ISH method to detect bacterial DNA in SBP ascitic fluid.
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Affiliation(s)
- Hirayuki Enomoto
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Mukogawacho 1-1, Nishinomiya, Hyogo 663-8501, Japan
| | - Shin-ichi Inoue
- Research & Development Center, Fuso Pharmaceutical Industries, Ltd., Morinomiya 2-3-30, Joto-ku, Osaka 536-8523, Japan
| | - Akio Matsuhisa
- Research & Development Center, Fuso Pharmaceutical Industries, Ltd., Morinomiya 2-3-30, Joto-ku, Osaka 536-8523, Japan
| | - Shuhei Nishiguchi
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Mukogawacho 1-1, Nishinomiya, Hyogo 663-8501, Japan
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Baijal R, Amarapurkar D, Praveen Kumar HR, Kulkarni S, Shah N, Doshi S, Gupta D, Jain M, Patel N, Kamani P, Issar SK, Dharod M, Shah A, Chandnani M, Gautam S. A multicenter prospective study of infections related morbidity and mortality in cirrhosis of liver. Indian J Gastroenterol 2014; 33:336-42. [PMID: 24879611 DOI: 10.1007/s12664-014-0461-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2013] [Accepted: 03/30/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Infections are a common and serious complication among patients with cirrhosis. We assessed the epidemiology, risk factors, and clinical consequences of bacterial infections in cirrhotic patients. METHODS In this multicenter prospective study, all patients with cirrhosis of liver with different infections were analyzed. Infections were classified as community-acquired (CA), healthcare-associated (HCA), or hospital-acquired (HA). Site of infection and characteristics of bacteria were recorded; effect on liver function and 30-day survival were evaluated. RESULTS One hundred and six out of 420 (25 %) patients with cirrhosis of liver had infection. Infection rate among indoor patients was 37.5 % (92/245) and among outdoor patients was 8 % (14/175). Out of 106 patients, CA, HCA, and HA were seen in 19.8 %, 50 %, and 30.2 %, respectively. Spontaneous bacterial peritonitis (31.1 %), urinary tract infections (22.6 %), and pneumonia and cellulitis (11.3 % each) were common infections. Gram-negative bacteria (54 %) were more common than Gram-positive cocci (46 %). Multidrug resistant (MDR) organisms were seen in 41.7 % of patients. Most of the MDR organisms were seen in HCA and HA patients. The degree of liver impairment was significantly more severe in patients with infection. Independent predictor of infection was high Child-Turcott-Pugh (CTP) class (p = 0.006, Child B vs. A (odds ratio (OR) 3.04 95 % CI = 1.63 to 5.68) and Child C vs. A (OR 4.17 95 % CI = 2.12 to 8.19). Overall in-hospital mortality was 7.6 %. Patients with infection had increased mortality at 30-day follow up compared to those without infection (23.5 % vs. 2.2 %; p<0.001). CONCLUSIONS Infections are one of the important causes of morbidity and mortality in patients with cirrhosis of liver. The most frequent infections are HCA and HA. Infection predisposes to deterioration of liver function and increases mortality. Cirrhotic patients should be monitored closely for infections especially those with Child class B and C.
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Affiliation(s)
- Rajiv Baijal
- Department of Gastroenterology, Jagjivan Ram Hospital, Maratha Mandir Marg, Mumbai Central, Mumbai, 400 008, India
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Khilji MF. Primary Peritonitis-A Forgotten Entity. European J Pediatr Surg Rep 2014; 3:27-9. [PMID: 26171311 PMCID: PMC4487121 DOI: 10.1055/s-0034-1374544] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 02/25/2014] [Indexed: 11/15/2022] Open
Abstract
Primary peritonitis is a rare phenomenon in modern antibiotic era. A case of pediatric primary peritonitis is presented here, in which a child presented with complaints of abdominal pain, vomiting for one day. Abdominal examination showed marked tenderness and guarding, diagnosis of appendicitis was made and laparoscopic appendectomy done. Later, ascitic fluid analysis and appendix histopathology proved it to be a case of primary peritonitis.
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Thiele GB, da Silva OM, Fayad L, Lazzarotto C, Ferreira MDA, Marconcini ML, Dantas-Corrêa EB, Schiavon LDL, Narciso-Schiavon JL. Clinical and laboratorial features of spontaneous bacterial peritonitis in southern Brazil. SAO PAULO MED J 2014; 132:205-210. [PMID: 25055065 PMCID: PMC10496729 DOI: 10.1590/1516-3180.2014.1324698] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 08/07/2013] [Accepted: 08/15/2013] [Indexed: 12/21/2022] Open
Abstract
CONTEXT AND OBJECTIVE Spontaneous bacterial peritonitis (SBP) is a severe complication that occurs in 8-27% of hospitalized patients with liver cirrhosis and ascites, with high mortality rates. This study aimed to identify the clinical characteristics associated with SBP. DESIGN AND SETTING Cross-sectional study, conducted in a public university. METHODS The study consecutively included individuals with liver cirrhosis and ascites between September 2009 and March 2012. Forty-five patients were included: mean age 53.2 ± 12.3 years, 82.2% male, 73.8% Caucasian, mean Model of End-stage Liver Disease (MELD) score of 19.5 ± 7.2, and 33.3% with SBP. The subjects were divided into two groups: SBP and controls. RESULTS Comparison between individuals with SBP and controls showed that those with SBP had lower mean prothrombin activity time (36.1 ± 16.0% versus 47.1 ± 17.2%; P = 0.044) and lower median serum-ascites albumin gradient (SAAG) (1.2 versus 1.7, P = 0.045). There was a tendency towards higher mean MELD in the SBP group, not significant (22.2 ± 7.6 versus 17.9 ± 6.7; P = 0.067). There was a strong positive correlation between the neutrophil count in ascitic fluid and serum leukocyte count (r = 0.501; P = 0.001) and a negative correlation between the neutrophil count in ascitic fluid with prothrombin activity time (r = -0.385; P = 0.011). CONCLUSION A few characteristics are associated with the presence of SBP, especially liver dysfunction, SAAG and peripheral leukocytosis.
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Affiliation(s)
- Gabriela Bicca Thiele
- Medical Student. Universidade Federal de Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
| | - Otávio Marcos da Silva
- Medical Student. Universidade Federal de Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
| | - Leonardo Fayad
- MD. Resident in Gastroenterology, Núcleo de Estudos em Gastroenterologia e Hepatologia (NEGH), Universidade Federal de Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
| | - César Lazzarotto
- MD, MSc. Resident in Gastroenterology, Núcleo de Estudos em Gastroenterologia e Hepatologia (NEGH), Universidade Federal de Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
| | | | - Maíra Luciana Marconcini
- Medical Student. Universidade Federal de Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
| | - Esther Buzaglo Dantas-Corrêa
- MD, PhD. Adjunct Professor in Gastroenterology, Núcleo de Estudos em Gastroenterologia e Hepatologia (NEGH), Universidade Federal de Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
| | - Leonardo de Lucca Schiavon
- MD, PhD. Adjunct Professor in Gastroenterology, Núcleo de Estudos em Gastroenterologia e Hepatologia (NEGH), Universidade Federal de Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
| | - Janaína Luz Narciso-Schiavon
- MD, PhD. Adjunct Professor in Gastroenterology, Núcleo de Estudos em Gastroenterologia e Hepatologia (NEGH), Universidade Federal de Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
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Henao-Mejia J, Elinav E, Thaiss CA, Licona-Limon P, Flavell RA. Role of the intestinal microbiome in liver disease. J Autoimmun 2013; 46:66-73. [PMID: 24075647 DOI: 10.1016/j.jaut.2013.07.001] [Citation(s) in RCA: 130] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Accepted: 07/02/2013] [Indexed: 02/06/2023]
Abstract
The liver integrates metabolic outcomes with nutrient intake while preventing harmful signals derived from the gut to spread throughout the body. Direct blood influx from the gastrointestinal tract through the portal vein makes the liver a critical firewall equipped with a broad array of immune cells and innate immune receptors that recognize microbial-derived products, microorganisms, toxins and food antigens that have breached the intestinal barrier. An overwhelming amount of evidence obtained in the last decade indicates that the intestinal microbiota is a key component of a wide variety of physiological processes, and alterations in the delicate balance that represents the intestinal bacterial communities are now considered important determinants of metabolic syndrome and immunopathologies. Moreover, it is now evident that the interaction between the innate immune system and the intestinal microbiota during obesity or autoimmunity promotes chronic liver disease progression and therefore it might lead to novel and individualized therapeutic approaches. In this review, we discuss a growing body of evidence that highlights the central relationship between the immune system, the microbiome, and chronic liver disease initiation and progression.
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Affiliation(s)
- Jorge Henao-Mejia
- Department of Immunobiology, Yale University School of Medicine, CT 06520, USA
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Hwang SY, Yu SJ, Lee JH, Kim JS, Yoon JW, Kim YJ, Yoon JH, Kim EC, Lee HS. Spontaneous fungal peritonitis: a severe complication in patients with advanced liver cirrhosis. Eur J Clin Microbiol Infect Dis 2013; 33:259-64. [DOI: 10.1007/s10096-013-1953-2] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 08/06/2013] [Indexed: 02/06/2023]
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El-Kersh K, Rawasia WF, Chaddha U, Guardiola J. Rarity revisited: cryptococcal peritonitis. BMJ Case Rep 2013; 2013:bcr-2013-009099. [PMID: 23845672 DOI: 10.1136/bcr-2013-009099] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Cryptococcal peritonitis is a rare disease. Although the respiratory tract is considered to be the usual port of entry for the organism, the gastrointestinal tract can also serve as the potential site of entry. Here, we present a case of cryptococcal peritonitis that developed in an HIV-negative patient with underlying liver cirrhosis. We reviewed the literature and a total of 61 cases of cryptococcal peritonitis were identified. Liver cirrhosis, HIV/AIDS and end-stage renal disease on continuous ambulatory peritoneal dialysis were the major risk factors for developing crytococcal peritonitis.
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Affiliation(s)
- Karim El-Kersh
- Department of Pulmonary, Critical Care & Sleep Medicine, University of Louisville, Louisville, Kentucky, USA.
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Tsung PC, Ryu SH, Cha IH, Cho HW, Kim JN, Kim YS, Moon JS. Predictive factors that influence the survival rates in liver cirrhosis patients with spontaneous bacterial peritonitis. Clin Mol Hepatol 2013; 19:131-9. [PMID: 23837137 PMCID: PMC3701845 DOI: 10.3350/cmh.2013.19.2.131] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Revised: 02/23/2013] [Accepted: 02/27/2013] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND/AIMS Spontaneous bacterial peritonitis (SBP) has been known to greatly influence the survival rate of patients with liver cirrhosis. However, the factors that affect the survival rate in patients with SBP need to be clarified. METHODS This study enrolled 95 liver cirrhosis patients diagnosed with SBP. The laboratory findings of their serum and ascitic fluid were examined and the characteristics of the isolated microorganisms in their peritoneal fluid were analyzed. RESULTS The proportion of patients with culture-positive SBP was 41.1%, and 47 microorganisms were isolated from the ascitic fluid. The proportions of cultured bacteria that were Gram negative and Gram positive were 57.4% and 40.4%, respectively. The proportions of Escherichia coli, Klebsiella species, and Streptococcus species were 25.5%, 19.1%, and 19.1%, respectively. Enterococcus species represented 12.8% of the microorganisms cultured. The overall survival rates at 6, 12, and 24 months were 44.5%, 37.4%, and 32.2%, respectively. There was no relationship between the bacterial factors and the survival rate in SBP. Multivariate analysis revealed that the presence of hepatocellular carcinoma (HCC; P=0.001), higher serum bilirubin levels (≥3 mg/dL, P=0.002), a prolonged serum prothrombin time (i.e., international normalized ratio >2.3, P<0.001), renal dysfunction (creatinine >1.3 mg/dL, P<0.001), and lower glucose levels in the ascitic fluid (<50 mg/dL, P<0.001) were independent predictive factors of overall survival rate. CONCLUSIONS HCC, higher serum bilirubin levels, a prolonged serum prothrombin time, renal dysfunction, and lower ascitic glucose levels are associated with higher mortality rates in cirrhotic patients with SBP.
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Affiliation(s)
- Pei Chuan Tsung
- Division of Gastroenterology, Department of Internal Medicine, Inje University Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
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Diagnostic value of lactoferrin ascitic fluid levels in spontaneous bacterial peritonitis. EGYPTIAN LIVER JOURNAL 2013. [DOI: 10.1097/01.elx.0000427108.01923.3d] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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Abstract
Recent evidence indicates that the intestinal microflora plays a critical role in physiological and pathological processes; in particular, it is now considered a key determinant of immune pathologies and metabolic syndrome. Receiving the majority of its blood supply from the portal vein, the liver represents the first line of defense against food antigens, toxins, microbial-derived products, and microorganisms. Moreover, the liver is critically positioned to integrate metabolic outcomes with nutrient intake. To accomplish this function, the liver is equipped with a broad array of immune networks. It is now evident that, during pathological processes associated with obesity, alcohol-intake, or autoimmunity, the interaction between these immune cell populations and the intestinal microbiota promotes chronic liver disease progression and therefore they represent a novel therapeutic target. Herein, we highlight recent studies that have shed new light on the relationship between the microbiome, the innate immune system, and chronic liver disease progression.
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Poca M, Concepción M, Casas M, Alvarez-Urturi C, Gordillo J, Hernández-Gea V, Román E, Guarner-Argente C, Gich I, Soriano G, Guarner C. Role of albumin treatment in patients with spontaneous bacterial peritonitis. Clin Gastroenterol Hepatol 2012; 10:309-15. [PMID: 22094025 DOI: 10.1016/j.cgh.2011.11.012] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Revised: 10/04/2011] [Accepted: 11/02/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Intravenous administration of albumin decreases the incidence of renal failure and mortality among patients with spontaneous bacterial peritonitis (SBP). However, it is unclear whether it should be given to all patients with SBP; we evaluated its efficacy. METHODS We analyzed data from all episodes of SBP (n = 216) during a 7-year period that occurred in a nonselected series of 167 patients with cirrhosis. Low-risk episodes (urea <11 mmol/L and bilirubin <68 μmol/L) were not treated with albumin, whereas high-risk episodes (urea >11 mmol/L and/or bilirubin >68 μmol/L) were or were not given albumin at the discretion of the attending physician. RESULTS Sixty-four episodes of SBP (29.6%) were low risk and not treated with albumin, whereas 152 (70.4%) were high risk; 73 of these (48%) were treated with albumin and 79 (52%) were not. Renal failure before SBP resolution was less frequent after low-risk episodes than high-risk episodes (4.7% versus 25.6%; P = .001), in-hospital mortality was lower (3.1% versus 38.2%; P < .001), and the 3-month probability of survival was higher (93% versus 53%; P < .001). In an analysis of only the high-risk group, patients who received albumin had lower in-hospital mortality than those not treated with albumin (28.8% versus 46.8%; P = .02) and a greater 3-month probability of survival (62% versus 45%; P = .01). CONCLUSIONS Albumin therapy increases survival of patients who have high-risk episodes of SBP, although it does not seem to be necessary for patients with low risk of death.
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Affiliation(s)
- Maria Poca
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Institut d'Investigacions Biomèdiques Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
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Biecker E. Diagnosis and therapy of ascites in liver cirrhosis. World J Gastroenterol 2011; 17:1237-48. [PMID: 21455322 PMCID: PMC3068258 DOI: 10.3748/wjg.v17.i10.1237] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2010] [Revised: 12/22/2010] [Accepted: 12/29/2010] [Indexed: 02/06/2023] Open
Abstract
Ascites is one of the major complications of liver cirrhosis and is associated with a poor prognosis. It is important to distinguish noncirrhotic from cirrhotic causes of ascites to guide therapy in patients with noncirrhotic ascites. Mild to moderate ascites is treated by salt restriction and diuretic therapy. The diuretic of choice is spironolactone. A combination treatment with furosemide might be necessary in patients who do not respond to spironolactone alone. Tense ascites is treated by paracentesis, followed by albumin infusion and diuretic therapy. Treatment options for refractory ascites include repeated paracentesis and transjugular intrahepatic portosystemic shunt placement in patients with a preserved liver function. Potential complications of ascites are spontaneous bacterial peritonitis (SBP) and hepatorenal syndrome (HRS). SBP is diagnosed by an ascitic neutrophil count > 250 cells/mm3 and is treated with antibiotics. Patients who survive a first episode of SBP or with a low protein concentration in the ascitic fluid require an antibiotic prophylaxis. The prognosis of untreated HRS type 1 is grave. Treatment consists of a combination of terlipressin and albumin. Hemodialysis might serve in selected patients as a bridging therapy to liver transplantation. Liver transplantation should be considered in all patients with ascites and liver cirrhosis.
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Gómez-Hurtado I, Zapater P, Bellot P, Pascual S, Pérez-Mateo M, Such J, Francés R. Interleukin-10-mediated heme oxygenase 1-induced underlying mechanism in inflammatory down-regulation by norfloxacin in cirrhosis. Hepatology 2011; 53:935-44. [PMID: 21374664 DOI: 10.1002/hep.24102] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
UNLABELLED Patients with cirrhosis receiving norfloxacin show a restored inflammatory balance that likely prevents clinical complications derived from an excessive proinflammatory response to bacterial product challenges. This study sought to investigate associated inflammatory control mechanisms established in patients with cirrhosis receiving norfloxacin. A total of 62 patients with cirrhosis and ascites in different clinical conditions were considered. Blood samples were collected and intracellular and serum norfloxacin were measured. Inflammatory mediators were evaluated at messenger RNA and protein levels. Neutrophils from all patients were cultured with lipopolysaccharide (LPS) and anti-interleukin-10 (anti-IL-10) monoclonal antibody in different conditions. IL-10 and heme oxygenase-1 (HO-1) were up-regulated in patients receiving norfloxacin and correlated with norfloxacin in a concentration-dependent manner, whereas proinflammatory inducible nitric oxide synthase, cyclooxygenase-2, and nuclear factor-κB behaved inversely. Higher IL-10 levels correlated with lower white blood cell count and higher mean arterial pressure. No correlations were found between IL-10 and disease clinical scores or liver function markers in blood. Neutrophilic in vitro assays showed that the effect of LPS on proinflammatory mediator levels in the presence of norfloxacin was abrogated by significantly increasing IL-10 and HO-1 expression. After stimulation with LPS plus anti-IL-10, proinflammatory mediators were dramatically increased in patients receiving norfloxacin, and increasing intracellular norfloxacin concentrations did not decrease the expression levels of these proinflammatory molecules. Unblocking IL-10 restored proinflammatory mediator and HO-1 expression to previously observed levels in response to LPS stimulation. CONCLUSION Although the described association does not necessarily mean causality, an IL-10-mediated HO-1-induced anti-inflammatory mechanism is present in patients with cirrhosis receiving norfloxacin, that is directly associated with cell-modulating events in these patients.
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Affiliation(s)
- Isabel Gómez-Hurtado
- Hepatic Unit and Clinical Pharmacology Service, Hospital General Universitario de Alicante, Universidad Miguel Hernández, Elche, Alicante, Spain
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Soriano G, Esparcia O, Montemayor M, Guarner-Argente C, Pericas R, Torras X, Calvo N, Román E, Navarro F, Guarner C, Coll P. Bacterial DNA in the diagnosis of spontaneous bacterial peritonitis. Aliment Pharmacol Ther 2011; 33:275-84. [PMID: 21083594 DOI: 10.1111/j.1365-2036.2010.04506.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Despite inoculation into blood culture bottles, ascitic fluid culture is negative in 50% of cases of spontaneous bacterial peritonitis (SBP). AIM To determine whether 16S rDNA gene detection by real-time polymerase chain reaction (PCR) and sequencing increases the efficacy of culture in microbiological diagnosis of spontaneous bacterial peritonitis. METHODS We prospectively included 55 consecutive spontaneous bacterial peritonitis episodes in cirrhotic patients, 20 cirrhotic patients with sterile ascites and 27 patients with neoplasic ascites. Ascitic fluid was inoculated into blood culture bottles at the bedside and tested for bacterial DNA by real-time PCR and sequencing of 16S rDNA gene. RESULTS Bacterial DNA was detected in 23/25 (92%) culture-positive SBP, 16/30 (53%) culture-negative SBP (P = 0.002 with respect to culture-positive SBP), 12/20 (60%) sterile ascites (P = 0.01 with respect to culture-positive SBP) and 0/27 neoplasic ascites (P < 0.001 with respect to other groups). Sequencing identified to genus or species level 12 culture-positive SBP, six culture-negative SBP and six sterile ascites. In the remaining cases with positive PCR, sequencing did not yield a definitive bacterial identification. CONCLUSIONS Bacterial DNA was not detected in almost half the culture-negative spontaneous bacterial peritonitis episodes. Methodology used in the present study did not always allow identification of amplified bacterial DNA.
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Affiliation(s)
- G Soriano
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Institut d'Investigacions Biomèdiques Sant Pau, Spain.
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Reginato TJB, Oliveira MJA, Moreira LC, Lamanna A, Acencio MMP, Antonangelo L. Characteristics of ascitic fluid from patients with suspected spontaneous bacterial peritonitis in emergency units at a tertiary hospital. SAO PAULO MED J 2011; 129:315-9. [PMID: 22069130 PMCID: PMC10868938 DOI: 10.1590/s1516-31802011000500006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2010] [Revised: 01/10/2011] [Accepted: 04/15/2011] [Indexed: 12/20/2022] Open
Abstract
CONTEXT AND OBJECTIVE Spontaneous bacterial peritonitis (SBP) is a complication of ascites, especially in cirrhosis. Ascitic fluid with 250 or more neutrophils/mm³ is an acceptable criterion for diagnosis, even when bacterial fluid cultures are negative. The aims here were to estimate SBP frequency among emergency room patients based on cellular criteria and evaluate the biochemical profile of these fluids. DESIGN AND SETTING Retrospective study at a public tertiary hospital. METHODS Laboratory records of patients with ascites attended in emergency rooms between November 2001 and November 2006, from whom ascitic fluid samples were sent to the laboratory due to suspected SBP, were evaluated. The 691 samples included were divided into group A (presumed SBP: ≥ 250 neutrophils/mm³; n = 219; 31.7%) and group B (no presumed SBP: < 250 neutrophils/mm³; n = 472; 68.3%). Patients' sex and age; ascitic fluid characteristics (numbers of neutrophils, leukocytes and nucleated cells); bacteriological characteristics; and protein, lactate dehydrogenase, adenosine deaminase and glucose concentrations were evaluated. RESULTS Among group A cultured samples, 63 (33.8%) had positive bacterial cultures with growth of pathogens commonly associated with SBP. In total, the group A samples showed higher lactate dehydrogenase levels than seen in the group B samples. The latter presented predominance of lymphocytes and macrophages. CONCLUSION Among the ascitic fluid samples with clinically suspected SBP, 31.7% fulfilled the cellular diagnostic criteria. Positive bacterial isolation was found in 33.8% of the cultured samples from the presumed SBP group.
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Affiliation(s)
| | - Marcelo José Andrade Oliveira
- MD. Clinical Pathologist, Clinical Laboratory, Department of Pathology, LIM 03, Hospital das Clínicas (HC), Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil.
| | - Luiz César Moreira
- BSc. Biologist. Clinical Laboratory, Department of Pathology, LIM 03, Hospital das Clínicas (HC), Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil.
| | - Antonieta Lamanna
- BSc. Biologist. Clinical Laboratory, Department of Pathology, LIM 03, Hospital das Clínicas (HC), Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil.
| | | | - Leila Antonangelo
- MD, PhD. Clinical Pathologist and Professor, Clinical Laboratory, Department of Pathology, LIM 03, Hospital das Clínicas (HC), Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil.
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Bittencourt PL, Farias AQ, Strauss E, Mattos AAD. Variceal bleeding: consensus meeting report from the Brazilian Society of Hepatology. ARQUIVOS DE GASTROENTEROLOGIA 2010; 47:202-16. [PMID: 20721469 DOI: 10.1590/s0004-28032010000200017] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2009] [Accepted: 08/17/2009] [Indexed: 02/06/2023]
Abstract
In the last decades, several improvements in the management of variceal bleeding have resulted in a significant decrease in morbidity and mortality of patients with cirrhosis and bleeding varices. Progress in the multidisciplinary approach to these patients has led to a better management of this disease by critical care physicians, hepatologists, gastroenterologists, endoscopists, radiologists and surgeons. In this respect, the Brazilian Society of Hepatology has, recently, sponsored a consensus meeting in order to draw evidence-based recommendations on the management of these difficult-to-treat subjects. An organizing committee comprised of four people was elected by the Governing Board and was responsible to invite 27 researchers from distinct regions of the country to make a systematic review of the subject and to present topics related to variceal bleeding, including prevention, diagnosis, management and treatment, according to evidence-based medicine. After the meeting, all participants met together for discussion of the topics and the elaboration of the aforementioned recommendations. The organizing committee was responsible for writing the final document. The meeting was held at Salvador, May 6th, 2009 and the present manuscript is the summary of the systematic review that was presented during the meeting, organized in topics, followed by the recommendations of the Brazilian Society of Hepatology.
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Abstract
BACKGROUND In patients with cirrhosis, bacterial DNA has been found in ascites reflecting bacterial translocation. However, the clinical relevance of this finding is ill-defined especially compared with the standard diagnostics for detection of spontaneous bacterial peritonitis (SBP). Furthermore, other DNA tests have not been sufficiently evaluated. PATIENTS AND METHODS We prospectively included 151 patients with cirrhosis and ascites admitted to our department. The patients were evaluated for diagnosis of SBP (polymorphonuclear count > 250 cells/mm) or finding of bacterascites, defined by positive bacterial culture from ascites. To detect bacterial species of bacterial DNA fragments in ascites, broad-range polymerase chain reaction and nucleotide sequencing analysis with the LightCycler SeptiFast Kit Mgrade were performed. Routine parameters were correlated with these findings. RESULTS Eighteen of 151 patients (12%) had SBP according to the classic definition. Bacterial DNA was detected in five of these 18 patients (3%), whereas in 13 patients (9%), bacterial DNA was detected without standard SBP. Seven patients (5%) had culture-positive SBP, only in two of them bacterial DNA was detected. In multivariate analysis, C-reactive protein (P = 0.000), white blood cell count (P = 0.019), and lactic acid dehydrogenase in ascites (P = 0.000) were independently associated with SBP. In the DNA-positive ascites group, none of the assessed parameters was significantly associated with the bacterial DNA positivity. CONCLUSION We found no correlation between detection of bacterial DNA in ascites and SBP (polymorphonuclear count > 250/mm). In contrast to the patients with bacterial DNA in ascites, patients with SBP showed clinical signs of infection. This study provides no evidence that detection of bacterial DNA in ascites of patients with liver cirrhosis is of clinical or diagnostic relevance when using the panel of LightCycler SeptiFast Kit Mgrade.
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Abstract
Spontaneous bacterial peritonitis (SBP) is one of the most serious complications occurring in cirrhotic patients with ascites. Therefore, an effective therapy is always required starting immediately after diagnosis. There are three aims of therapy: (1) to eradicate the bacterial strain responsible of the infection; (2) to prevent renal failure; and (3) to prevent SBP recurrence. The first end point is achievable by means of a large-spectrum antibiotic therapy. Empirical antibiotic therapy can be started with a third-generation cephalosporin, amoxicillin-clavulanate or a quinolone. The effectiveness of antibiotics should be verified by determining the percent reduction of polymorphonuclear cells count in the ascitic fluid. If bacteria result to be resistant to the empirical therapy, a further antibiotic must be given according to the in vitro bacterial susceptibility. In most cases, a 5-day antibiotic therapy is enough to eradicate the bacterial strain. Severe renal failure occurs in about 30% of patients with SBP, independently of the response to antibiotics, and it is associated with elevated mortality. The early administration of large amount of human albumin showed to be able to reduce the episodes of renal failure and to improve survival. After the resolution of an episode of SBP, the recurrence is frequent. Therefore, an intestinal decontamination with oral norfloxacin has been shown to significantly reduce this risk and is widely practised. However, such a long-term prophylaxis, as well as the current increased use of invasive procedures, favours the increase of bacterial infections, including SBP, contracted during the hospitalization (nosocomial infections) and sustained by multi-resistant bacteria. This involves the necessity to use a different strategy of antibiotic prophylaxis as well as a more strict surveillance of patients at risk.
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Affiliation(s)
- Francesco Salerno
- Department of Internal Medicine, Policlinico IRCCS San Donato, Università di Milano, Via Morandi, 30, 20097, San Donato Milanese, Italy.
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EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol 2010; 53:397-417. [PMID: 20633946 DOI: 10.1016/j.jhep.2010.05.004] [Citation(s) in RCA: 1126] [Impact Index Per Article: 75.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2010] [Accepted: 05/25/2010] [Indexed: 02/07/2023]
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Pereg D, Kotliroff A, Gadoth N, Hadary R, Lishner M, Kitay-Cohen Y. Probiotics for patients with compensated liver cirrhosis: a double-blind placebo-controlled study. Nutrition 2010; 27:177-81. [PMID: 20452184 DOI: 10.1016/j.nut.2010.01.006] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2009] [Revised: 12/15/2009] [Accepted: 01/10/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND Gut flora is related to the major complications of liver cirrhosis including hepatic encephalopathy, spontaneous bacterial peritonitis, and variceal bleeding. Prior studies have reported a beneficial effect of gut flora modification with probiotic bacteria in patients with minimal hepatic encephalopathy. We aimed to study the effect of probiotics on clinical and laboratory parameters of patients with compensated cirrhosis. METHODS A double-blind placebo-controlled study that included patients with liver cirrhosis and at least one major complication of cirrhosis in the past, clinical evidence of portal hypertension, or decreased hepatic synthetic function. Participants were randomly assigned to receive probiotic capsules containing Lactobacillus acidophilus, Lactobacillus bulgaricus, Bifidobacterium lactis, and Streptococcus thermophiles or placebo for a period of 6 mo. RESULTS A total of 36 patients were available for final analysis (distributed equally between the probiotic and placebo groups). The administration of probiotics was not associated with significant differences in either clinical or laboratory parameters between the two groups. Because the lack of a beneficial effect may be related to the compensated liver disease of patients, we conducted a subanalysis of patients with baseline ammonia levels > 50 mmol/L. In this subgroup, the administration of probiotics appeared to significantly reduce the ammonia levels starting after 1 mo of treatment. However, this effect diminished and lost its significance following comparison to the placebo group. CONCLUSIONS Our study did not show a significant beneficial effect of probiotic supplementation in patients with compensated liver cirrhosis. Nevertheless, it points toward a possible positive effect of probiotics in patients with above normal baseline ammonia levels. This issue requires further investigation in larger cohorts.
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Affiliation(s)
- David Pereg
- Department of Internal Medicine A, Meir Medical Center, Kfar-Saba, Israel.
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Khan J, Pikkarainen P, Karvonen AL, Mäkelä T, Peräaho M, Pehkonen E, Collin P. Ascites: aetiology, mortality and the prevalence of spontaneous bacterial peritonitis. Scand J Gastroenterol 2010; 44:970-4. [PMID: 19440927 DOI: 10.1080/00365520902964739] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To assess the aetiology, prognosis and prevalence of spontaneous bacterial peritonitis (SBP) in patients hospitalized for ascites. The validity of an elevated (>11 g/l) serum-ascites albumin gradient (SAAG) in the diagnostic work-up was evaluated. Mortality trends were observed over two periods of time. MATERIAL AND METHODS A total of 231 consecutive patients who underwent diagnostic paracentesis between February 1994 and December 1998 and January 2005 and March 2007 were included in the study. The definition of SBP comprised polymorphonuclear cell count >250/mm(3) without evidence of other intra-abdominal source of infection. SAAG was obtained and the Child-Pugh classification applied. Survival rates were obtained from medical records. RESULTS The most common causes of ascites were alcohol liver cirrhosis (n=143; 62%), malignancy (n=30; 13%), non-alcoholic cirrhosis (n=11; 5%) and malignancy with cirrhosis (n=11; 5%). The prevalence of SBP in cirrhosis was 6.7% (95% CI 2.8-10.5%). Overall mortality rates at 1 month, 6 months and 1 year were 22%, 40% and 48%, respectively, and remained unchanged between the intervals. Patients with grade C liver disease had higher 1-month (26% versus 6%), and 6-month (44% versus 27%) mortality rates than grade B patients, but commensurate 1-year mortality (49% versus 47%). SAAG was >or=11 g/l in 85% of patients with obvious portal hypertension and in 30% with malignancy, ascites albumin level <or=9 g/l in 69% and 20%, respectively. CONCLUSIONS Mortality in patients with ascites was high. The occurrence of SBP was relatively low in our series, with a high proportion of alcoholic cirrhosis. SAAG was inaccurate in differentiating ascites caused by portal hypertension or malignancy.
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Affiliation(s)
- Jahangir Khan
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital and Medical School, University of Tampere, Tampere, Finland
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Balagopal SK, Sainu A, Thomas V. Evaluation of leucocyte esterase reagent strip test for the rapid bedside diagnosis of spontaneous bacterial peritonitis. Indian J Gastroenterol 2010; 29:74-7. [PMID: 20443105 DOI: 10.1007/s12664-010-0017-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2009] [Revised: 11/17/2009] [Accepted: 11/19/2009] [Indexed: 02/04/2023]
Abstract
BACKGROUND Spontaneous bacterial peritonitis (SBP) is a common serious complication of cirrhosis, and carries a high morbidity and mortality. Rapid diagnosis and prompt treatment of this condition may improve survival of such patients. OBJECTIVE To validate the diagnostic efficacy of a leukocyte esterase reagent (LER) strip test for rapid, bedside diagnosis of SBP. METHODS We prospectively studied 175 patients with liver cirrhosis and ascites [mean age 48 (SD 16.4) years; 146 men] between August 2007 and December 2008. Alcohol was the most common (124 of 175; 70.8%) cause of liver cirrhosis. All patients underwent abdominal paracentesis, and the ascitic fluid was processed for cell count, LER strip (Magistik 10) test and culture. Two different cut-offs for calling the LER strip test positive were tried, namely when the color turned light blue [grade 2: >125 polymorphonuclear leucocytes (PMNL)/microL] or it turned purple (grade 3: >500 PMNL/microL). Sensitivity, specificity, positive predictive value, negative predictive value were calculated, using PMN count by microscopy exceeding 250 PMNL/microL. RESULTS LER strip using the more stringent purple-color cut off to diagnose SBP had a sensitivity of 92% and specificity of 100%. The corresponding figures using the light-blue color cut-off were 97% and 89%, respectively. CONCLUSIONS LER strip testing of ascitic fluid is a rapid, cheap and sensitive bed side tool for the diagnosis of SBP.
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Soriano G, Castellote J, Alvarez C, Girbau A, Gordillo J, Baliellas C, Casas M, Pons C, Román EM, Maisterra S, Xiol X, Guarner C. Secondary bacterial peritonitis in cirrhosis: a retrospective study of clinical and analytical characteristics, diagnosis and management. J Hepatol 2010; 52:39-44. [PMID: 19897273 DOI: 10.1016/j.jhep.2009.10.012] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2009] [Revised: 07/11/2009] [Accepted: 08/20/2009] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Secondary bacterial peritonitis in cirrhotic patients is an uncommon entity that has been little reported. Our aim is to analyse the frequency, clinical characteristics, treatment and prognosis of patients with secondary peritonitis in comparison to those of patients with spontaneous bacterial peritonitis (SBP). METHODS Retrospective analysis of 24 cirrhotic patients with secondary peritonitis compared with 106 SBP episodes. RESULTS Secondary peritonitis represented 4.5% of all peritonitis in cirrhotic patients. Patients with secondary peritonitis showed a significantly more severe local inflammatory response than patients with SBP. Considering diagnosis of secondary peritonitis, the sensitivity of Runyon's criteria was 66.6% and specificity 89.7%, Runyon's criteria and/or polymicrobial ascitic fluid culture were present in 95.6%, and abdominal computed tomography was diagnostic in 85% of patients in whom diagnosis was confirmed by surgery or autopsy. Mortality during hospitalization was higher in patients with secondary peritonitis than in those with SBP (16/24, 66.6% vs. 28/106, 26.4%) (p<0.001). There was a trend to lower mortality in secondary peritonitis patients who underwent surgery (7/13, 53.8%) than in those who received medical treatment only (9/11, 81.8%) (p=0.21). Considering surgically treated patients, the time between diagnostic paracentesis and surgery was shorter in survivors than in non-survivors (3.2+/-2.4 vs. 7.2+/-6.1 days, p=0.31). CONCLUSIONS Secondary peritonitis is an infrequent complication in cirrhotic patients but mortality is high. A low threshold of suspicion on the basis of Runyon's criteria and microbiological data, together with an aggressive approach that includes prompt abdominal computed tomography and early surgical evaluation, could improve prognosis in these patients.
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Affiliation(s)
- Germán Soriano
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Sant Antoni Maria Claret, 167, 08025 Barcelona, Spain.
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Zapater P, Caño R, Llanos L, Ruiz-Alcaraz AJ, Pascual S, Barquero C, Moreu R, Bellot P, Horga JF, Muñoz C, Pérez J, García-Peñarrubia P, Pérez-Mateo M, Such J, Francés R. Norfloxacin modulates the inflammatory response and directly affects neutrophils in patients with decompensated cirrhosis. Gastroenterology 2009; 137:1669-79.e1. [PMID: 19660462 DOI: 10.1053/j.gastro.2009.07.058] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2008] [Revised: 06/12/2009] [Accepted: 07/14/2009] [Indexed: 01/27/2023]
Abstract
BACKGROUND & AIMS Patients with cirrhosis undergoing selective intestinal decontamination with norfloxacin show a reduction in serum cytokine levels, probably because of a combined effect of norfloxacin on bowel flora and neutrophils. METHODS Thirty-one patients with cirrhosis receiving norfloxacin (400 mg/day) were included. Blood samples were collected at 0.5-4 hours (peak samples group, n = 47) and at 22-24 hours (trough samples group, n = 84) after dose. Fifty-nine ascitic fluid samples were obtained. Single doses of norfloxacin and trimethoprim/sulfamethoxazole were administered to 13 and 5 patients, respectively, (temporal profile group) and samples were collected at 0, 0.5, 1, 1.5, 2, 4, and 24 hours. Norfloxacin, trimethoprim/sulfamethoxazole, cytokines, nitric oxide, expression levels of nuclear factor (NF)-kappaB and inhibitor of NF-kappaB (IkB-alpha), neutrophil oxidative burst, and rate of apoptotic events were determined. RESULTS All samples were bacterial DNA negative and had no significant levels of lipopolysaccharide. Serum and ascitic levels of tumor necrosis factor-alpha, interferon-gamma, interleukin-12, and nitric oxide were significantly lower in peak than in trough samples. A correlation was present between serum norfloxacins concentrations and tumor necrosis factor-alpha (r = -0.68; P < .001), interferon-gamma (r = -0.66; P < .001), interleukin-12 (r = -0.66; P < .001), and nitric oxide (r = -0.68; P < .001). Serum norfloxacin's highest concentrations (1 +/- 0.5 microg/mL) were achieved at 1-2 hours and concurred in time with the lower levels of cytokines and nitric oxide. Intracellular norfloxacin's highest levels (2 +/- 1 microg/mL/10(7) cells) were observed at 2 hours and concurred with a lower NF-kappaB expression, a reduced anion superoxide generation, and apoptotic rate in response to phorbol myristate acetate. Trimethoprim/sulfamethoxazole did not significantly modulate cytokine expression. CONCLUSIONS Norfloxacin but not trimethoprim/sulfamethoxazole modulates inflammatory response and directly affects neutrophils in patients with cirrhosis.
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Affiliation(s)
- Pedro Zapater
- Sección de Farmacología Clínica, Hospital General Universitario, Alicante, and Universidad Miguel Hernández, Elche, Spain
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Heo J, Seo YS, Yim HJ, Hahn T, Park SH, Ahn SH, Park JY, Park JY, Kim MY, Park SK, Cho M, Um SH, Han KH, Kim HS, Baik SK, Kim BI, Cho SH. Clinical features and prognosis of spontaneous bacterial peritonitis in korean patients with liver cirrhosis: a multicenter retrospective study. Gut Liver 2009; 3:197-204. [PMID: 20431746 PMCID: PMC2852707 DOI: 10.5009/gnl.2009.3.3.197] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2009] [Accepted: 06/21/2009] [Indexed: 12/18/2022] Open
Abstract
Background/Aims Although early recognition and treatment with effective antibiotics have lead to improvements in the prognosis of patients with spontaneous bacterial peritonitis (SBP), it remains to be a serious complication in cirrhotic patients. This study was designed to evaluate the clinical manifestations and prognosis of patients with liver cirrhosis and SBP in Korea. Methods This was a multicenter retrospective study examining 157 episodes of SBP in 145 patients with cirrhosis. SBP was diagnosed based on a polymorphonuclear cell count in ascitic fluid of >250 cells/mm3 in the absence of data compatible with secondary peritonitis. Results The mean age of the cohort was 56 years, and 121 (77%) of the 157 episodes of SBP occurred in men. Microorganisms were isolated in 66 episodes (42%): Gram-negative bacteria in 54 (81.8%), Gram-positive in 11 (16.7%), and Candida in 1. Isolated Gram-negative organisms were resistant to third-generation cephalosporin in 6 cases (17%), to ciprofloxacin in 11 (20.8%), and to penicillin in 33 (62.3%). The treatment failure and in-hospital mortality rates were 12.1% and 21%, respectively. A high Model of End-Stage Liver Disease (MELD) score, SBP caused by extended-spectrum β-lactamase-producing organisms, and hepatocellular carcinoma were independent prognostic factors of high in-hospital mortality. Conclusions SBP remains to be a serious complication with high in-hospital mortality, especially in patients with a high MELD score.
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Affiliation(s)
- Jeong Heo
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, Korea
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El-Naggar MM, Khalil ESAM, El-Daker MAM, Salama MF. Bacterial DNA and its consequences in patients with cirrhosis and culture-negative, non-neutrocytic ascites. J Med Microbiol 2009; 57:1533-1538. [PMID: 19018026 DOI: 10.1099/jmm.0.2008/001867-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The detection of bacterial DNA in serum and ascitic fluid (AF) from patients with liver cirrhosis and ascites is interpreted as molecular evidence of intestinal bacterial translocation (BT) and considered sufficient to activate the cellular immune response leading to greater cytokine synthesis. We studied 34 patients with liver cirrhosis and culture-negative, non-neutrocytic ascites [22 patients without bacterial DNA (group I) and 12 patients with bacterial DNA (group II)]. History and clinical examination were done with the following investigations at first admission and followed up for 24 weeks: serum and AF tumour necrosis factor-alpha (TNF-alpha), AF polymorphonuclear leukocytes, AF cultivation and detection of blood and AF bacterial DNA. Serum and AF TNF-alpha were significantly higher in patients with bacterial DNA compared to those without bacterial DNA at first admission [54.5+/-22.56 vs 35.2+/-17.97 pg ml(-1) (P=0.02) and 123.2+/-49.32 vs 82.6+/-29.58 pg ml(-1) (P <0.005), respectively]. These changes became highly significant at the end of follow-up of both groups [119.3+/-27.19 vs 40.2+/-16.08 pg ml(-1) (P <0.001) and 518.8+/-91.11 vs 97.6+/-17.81 pg ml(-1) (P <0.001), respectively]. In group II, there was a significant increase in serum and AF TNF-alpha at the end of follow-up compared to at first admission (P <0.001). The relative risk of death, hepatorenal syndrome (HRS) and spontaneous bacterial peritonitis (SBP) was higher in patients with bacterial DNA compared to those without bacterial DNA. We conclude that cirrhotic patients with culture-negative, non-neutrocytic ascites and bacterial DNA have a significantly higher level of serum and AF TNF-alpha and higher risk of HRS, SBP and mortality compared to those without bacterial DNA, suggesting that bacterial DNA and TNF-alpha are implicated in these complications of liver cirrhosis.
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Affiliation(s)
- Mohammed Mahmoud El-Naggar
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | | | | | - Mona Fouda Salama
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Chavez-Tapia NC, Soares-Weiser K, Brezis M, Leibovici L. Antibiotics for spontaneous bacterial peritonitis in cirrhotic patients. Cochrane Database Syst Rev 2009; 2009:CD002232. [PMID: 19160207 PMCID: PMC7100568 DOI: 10.1002/14651858.cd002232.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Spontaneous bacterial peritonitis is a complication of cirrhotic ascites that occurs in the absence of any intra-abdominal, surgically treatable source of infection. Antibiotic therapy is indicated and should be initiated as soon as possible to avoid severe complications that may lead to death. It has been proposed that empirical treatment should cover gram-negative enteric bacteria and gram-positive cocci, responsible for up to 90% of spontaneous bacterial peritonitis cases. OBJECTIVES This review aims to evaluate the beneficial and harmful effects of different types and modes of antibiotic therapy in the treatment of spontaneous bacterial peritonitis in cirrhotic patients. SEARCH STRATEGY We performed electronic searches in The Cochrane Hepato-Biliary Group Controlled Trials Register (July 2008), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 3, 2008), MEDLINE (1950 to July 2008), EMBASE (1980 to July 2008), and Science Citation Index EXPANDED (1945 to July 2008). In addition, we handsearched the references of all identified studies and contacted the first author of each included trial. SELECTION CRITERIA Randomised studies comparing different types of antibiotics for spontaneous bacterial peritonitis in cirrhotic patients. DATA COLLECTION AND ANALYSIS Data were independently extracted from the trials by at least two authors. Peto odds ratios or average differences, with their 95% confidence intervals, were estimated. MAIN RESULTS This systematic review attempted to summarise evidence from randomised clinical trials on the treatment of spontaneous bacterial peritonitis. Thirteen studies were included; each one of them compared different antibiotics in their experimental and control groups. No meta-analyses could be performed, though data on the main outcomes were collected and analysed separately for each included trial. Currently, the evidence showing that lower dosage or short-term treatment with third generation cephalosporins is as effective as higher dosage or long-term treatment is weak. Oral quinolones could be considered an option for those with less severe manifestations of the disease. AUTHORS' CONCLUSIONS This review provides no clear evidence for the treatment of cirrhotic patients with spontaneous bacterial peritonitis. In practice, third generation cephalosporins have already been established as the standard treatment of spontaneous bacterial peritonitis, and it is clear, that empirical antibiotic therapy should be provided in any case. However, until large, well-conducted trials provide more information, practice will remain based on impression, not evidence.
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Affiliation(s)
- Norberto C Chavez-Tapia
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga #5, Mexico City, Distrito Federal, Mexico, 14000.
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Kim BS, Lee SG, Hwang S, Ahn CS, Kim KH, Moon DB, Ha TY, Song GW, Jung DH. Influence of pretransplantation bacterial and fungal culture positivity on outcome after living donor liver transplantation. Transplant Proc 2009; 41:250-252. [PMID: 19249527 DOI: 10.1016/j.transproceed.2008.10.033] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2008] [Revised: 09/09/2008] [Accepted: 10/29/2008] [Indexed: 01/29/2023]
Abstract
BACKGROUND Bacterial and fungal infections are serious complications in patients with cirrhosis and are among the main causes of morbidity and mortality. The effects of pretransplantation infection on the outcome after orthotopic liver transplantation (OLT), however, have not been fully described. OBJECTIVE To assess the influence of pretransplantation infection on OLT by analyzing the clinical profiles of liver recipients with preexisting bacterial or fungal infection. PATIENTS AND METHODS We retrospectively reviewed the medical records of 223 adult patients who underwent living donor OLT between October 1, 2005, and September 30, 2006. In all patients, routine blood culture, was performed, and in patients with suspected bacterial or fungal infection; sputum, urine, and ascitic fluid cultures were performed. RESULTS Of 223 patients, 37 (16.6%) had a positive culture in one or more samples. Culture-positive and culture-negative groups differed significantly in end-stage liver disease score but showed no differences in Child-Turcotte-Pugh score, existence of spontaneous bacterial peritonitis, hemodialysis, or duration of stay in the intensive care unit or hospital. Six of 37 patients with positive cultures (16.2%) and 4 (2.2%) of 186 patients with negative cultures (2.2%) died during the first 90 days after OLT (P = .007). The causes of death among culture-positive patients were brain edema (n = 2), brain hemorrhage (n = 1), hepatic dysfunction (n = 1), and sepsis (n = 2), whereas all 4 culture-negative patients died of infectious complications. CONCLUSION Prompt OLT accompanied by adequate antibiotic or antifungal therapy may be acceptable in patients with preexisting bacterial or fungal infection unless there are overt manifestations of active infection.
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Affiliation(s)
- B-S Kim
- Department of Surgery, East-West Neo Medical Center, Kyung Hee University College of Medicine, Seoul, Korea
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Kamani L, Mumtaz K, Ahmed US, Ali AW, Jafri W. Outcomes in culture positive and culture negative ascitic fluid infection in patients with viral cirrhosis: cohort study. BMC Gastroenterol 2008; 8:59. [PMID: 19091136 PMCID: PMC2628346 DOI: 10.1186/1471-230x-8-59] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2008] [Accepted: 12/18/2008] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Ascitic fluid infection (AFI) in cirrhotic patients has a high morbidity and mortality. It has two variants namely, spontaneous bacterial peritonitis (SBP) and culture negative neutrocytic ascites (CNNA). The aim of this study was to determine the outcome in cirrhotic patients with culture positive (SBP) and culture negative neutrocytic ascites. METHODS We analyzed 675 consecutive hepatitis B and/or C related cirrhosis patients with ascites admitted in our hospital from November 2005 to December 2007. Of these, 187 patients had AFI; clinical and laboratory parameters of these patients including causes of cirrhosis, Child Turcotte Pugh (CTP) score were recorded. RESULTS Out of 187 patients with AFI, 44 (23.5%) had SBP while 143 (76.4%) had CNNA. Hepatitis C virus (HCV) infection was the most common cause of cirrhosis in 139 (74.3%) patients. Patients with SBP had high CTP score as compared to CNNA (12.52 +/- 1.45 vs. 11.44 +/- 1.66); p < 0.001. Platelets count was low in patients with SBP (101 +/- 53 x 10(9)/L) as compared to CNNA (132 +/- 91 x 10(9)/L), p = 0.005. We found a high creatinine (mg/dl) (1.95 +/- 1.0 vs. 1.44 +/- 0.85), (p = 0.003) and high prothrombin time (PT) in seconds (24.8 +/- 6.6 vs. 22.4 +/- 7.2) (p = 0.04) in SBP as compared to CNNA. More patients with SBP (14/44; 31.8%) had blood culture positivity as compare to CNNA (14/143; 9.8%), p = 0.002. Escherichia. Coli was the commonest organism in blood culture in 15/28 (53.5%) patients. SBP group had a higher mortality (11/44; 25%) as compared to CNNA (12/143; 8.4%), p = 0.003. On multiple logistic regression analysis, creatinine >1.1 mg/dl and positive blood culture were the independent predictors of mortality in patients with SBP. CONCLUSION Patients with SBP have a higher mortality than CNNA. Independent predictors of mortality in SBP are raised serum creatinine and a positive blood culture.
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Affiliation(s)
- Lubna Kamani
- Medicine Department, Aga Khan University Hospital, Karachi, Pakistan.
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Lee JH, Yoon JH, Kim BH, Chung GE, Myung SJ, Kim W, Kim YJ, Kim EC, Lee HS. Enterococcus: not an innocent bystander in cirrhotic patients with spontaneous bacterial peritonitis. Eur J Clin Microbiol Infect Dis 2008; 28:21-6. [PMID: 18612666 DOI: 10.1007/s10096-008-0578-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2008] [Accepted: 06/06/2008] [Indexed: 12/12/2022]
Abstract
Clinicians sometimes experience treatment failure in the initial empirical antibiotics treatment using cephalosporins in cirrhotic patients with spontaneous bacterial peritonitis (SBP). Enterococcus, which is intrinsically resistant to cephalosporins, may be one of the causes of treatment failure. The aim of this study was to evaluate the clinical importance and the clinical characteristics of spontaneous enterococcal peritonitis (SEP). This was a retrospective cohort study of 359 patients with SBP treated in a single tertiary care center in South Korea from January 2000 through December 2004. We evaluated the clinical manifestation and the treatment results of SBP patients with enterococci identified from ascites culture. During the observation period, 13 of 359 patients (3.6%) diagnosed with culture-positive SBP had enterococcal peritonitis. For the initial empirical treatment, third-generation cephalosporins were administered to the 13 patients, ten of whom (76.9%) did not improve in the first 48 h. An in vitro antibiotic sensitivity test showed that the identified enterococci were susceptible to ampicillin plus gentamycin in eight patients (61.5%) and there was no vancomycin-resistant enterococcus. Although antibiotics were changed to antienterococcal antibiotics in 11 patients, only five patients improved. As a result, eight of the 13 patients (61.5%) with enterococcal SBP died during the observation period, and the one-month mortality was significantly higher from enterococcal SBP than from nonenterococcal SBP (P = 0.038). We conclude that enterococcal SBP has poor prognosis and it is reasonable to use antienterococcal antibiotics when enterococcus is identified from ascites culture of patients with liver cirrhosis.
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Affiliation(s)
- J-H Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
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Francés R, Zapater P, González-Navajas JM, Muñoz C, Caño R, Moreu R, Pascual S, Bellot P, Pérez-Mateo M, Such J. Bacterial DNA in patients with cirrhosis and noninfected ascites mimics the soluble immune response established in patients with spontaneous bacterial peritonitis. Hepatology 2008; 47:978-85. [PMID: 18306221 DOI: 10.1002/hep.22083] [Citation(s) in RCA: 123] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
UNLABELLED Bacterial infections and severity of associated inflammatory reaction influence prognosis in patients with advanced cirrhosis. We compared the innate immune response to bacterial DNA (bactDNA) translocation with that caused by viable bacteria translocation in patients with spontaneous bacterial peritonitis and the relationship between the cytokine response and serum levels of bactDNA. The bactDNA translocation was investigated in 226 patients with cirrhosis and noninfected ascites, 22 patients with spontaneous bacterial peritonitis, and 10 patients with ascites receiving continuous norfloxacin. Serum and ascitic fluid tumor necrosis factor alpha, interferon-gamma, interleukin-12, and nitric oxide metabolites were measured via enzyme-linked immunosorbent assay. Bacterial genomic identifications were made via amplification and sequencing of the 16S ribosomal RNA gene and digital quantization with DNA Lab-on-chips. The bactDNA was present in 77 noninfected patients (34%) and in all cases of spontaneous bacterial peritonitis, even in those with culture-negative ascitic fluid. No patient receiving norfloxacin showed bactDNA translocation. Levels of all cytokines were similar in patients with bactDNA translocation or spontaneous bacterial peritonitis and significantly higher than in patients without bactDNA or in those receiving norfloxacin. Serum bactDNA concentration paralleled levels of all cytokines and nitric oxide in a series of patients with bactDNA translocation or spontaneous bacterial peritonitis followed during 72 hours. Antibiotic treatment in the series of patients with spontaneous bacterial peritonitis did not abrogate bactDNA translocation in the short term. CONCLUSION bactDNA translocation-associated cytokine response is indistinguishable from that in patients with spontaneous bacterial peritonitis and is dependent on bactDNA concentration. Norfloxacin abrogates bactDNA translocation and cytokine response.
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Affiliation(s)
- Rubén Francés
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
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