Spontaneous Bacterial Peritonitis among Cirrhotic Patients: Prevalence, Clinical Characteristics, and Outcomes

(1) Background: Spontaneous bacterial peritonitis (SBP) is a feared complication of liver cirrhosis. We investigated the prevalence of SBP, positive ascitic fluid cultures, and risk factors for mortality. (2) Methods: A retrospective analysis of all patients with cirrhosis hospitalized or in follow-up in a single center between 1996 and 2020. The clinical data, long-term complications, and mortality of SBP patients were compared with those of non-SBP patients. Ascitic fluid positive culture was compared with those without growth. (3) Results: We included 1035 cirrhotic patients, of which 173 (16.7%) developed SBP. Ascitic fluid culture growth was found in 47.4% of the SBP cases, with Escherichia coli bacteria detected in 38%, 24.4% grew ESBL-producing bacteria, and 14.5% displayed multidrug resistance. In a Cox regression model, SBP, male sex, prolonged INR at diagnosis, and hepatocellular carcinoma were found to be risk factors for mortality in cirrhotic patients. The long-term all-cause mortality was 60% in non-SBP and 90% in SBP patients. (4) Conclusions: Only a minority of cirrhotic patients developed SBP, 47.4% of which had positive ascitic fluid cultures with high antibiotic resistance. Growth of ESBL and multidrug resistant organisms is becoming more frequent in the clinical setting, reaching SBP mortality of 90%.

A nurse-led day-case gastroenterology service in the emergency department

The incidence of liver disease has been steadily increasing, and patients with severe, symptomatic ascites need paracentesis (drainage) of the ascitic fluid for management. The authors and colleagues have previously developed a nurse-led and nurse-managed day-case gastroenterology service that provides paracentesis and other treatments, such as blood transfusion and specialist biologic infusions to patients with inflammatory bowel disease (IBD) and other gastroenterological conditions. This article describes the development of a similar novel nurse-led day-case service within the emergency department (ED) to provide a front-door urgent service for patients attending ED and needing paracentesis/infusions. It also reflects on the journey to developing this service, as well as the challenges faced during to the COVID-19 pandemic.

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

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

Prevalence and Risk Factors for Unsuspected Spontaneous Ascitic Fluid Infection in Cirrhotics Undergoing Therapeutic Paracentesis in an Outpatient Clinic

Background and Aim: Ascites is a common complication of liver cirrhosis, making patients more vulnerable to infectious diseases such as spontaneous bacterial peritonitis. There hasn't been much research done on infectious ascitic fluid in asymptomatic patients. The purpose of the study was to find out the infectious asymptomatic ascitic fluid incidence and risk factors in liver cirrhotic patients. Materials and Methods: This cross-sectional study was conducted on 76 cirrhotic patients who underwent therapeutic paracentesis between September 2020 and February 2021 in an outpatient department of Jinnah Medical College, Peshawar. An 18-G catheter was used to collect ascitic fluid under strict aseptic conditions. Total and differential leucocyte counts, as well as total protein and albumin levels, were measured. The fluid was injected for bacterial culture of aerobic type and anaerobic blood culture bottles (10 mL each) under strict aseptic conditions. Individuals with abdominal pain, recent gastrointestinal bleeding, fever, SBP previous history, hepatic encephalopathy, impaired renal function, and treatment with antibodies were excluded. Written informed consent and ethical approval were taken prior to study conduction. Demographic details, liver disease severity, and etiology were noted along with laboratory technique-based biochemical tests, ascitic fluid count, and culture. SPSS version 20 was used for data analysis. Results: A total of 192 paracenteses were done on 76 liver cirrhosis patients with an average of 2.53 per patient. The overall mean age was 43.65±8.7 years. Of the total 76 patients, 55 (72.4%) were male and 21 (27.6%) were female. The ascites duration for study inclusion was 3 to12 months. Hepatitis B, fatty liver disease, hepatitis C, and drugs were the major causes of cirrhosis among study patients. The prevalence of Hepatitis B, fatty liver disease, hepatitis C, and drugs was 27 (35.5), 23 (30.3%), 11 (14.5%), and 15 (19.7%) respectively. The hepatic encephalopathy and variceal bleeding history were present in 16 (33.3%) and 32 (66.7%) respectively in a total of 48 (63.2%) cirrhosis patients. The class C and child Pugh class had 23 (30.3%) and 53 (69.7%) respectively. Null mortality was found in patients due to infection caused by spontaneous ascitic fluid. Conclusion: Our study found that hepatitis B, fatty liver disease, hepatitis C, and drugs were the major causes of cirrhosis. Asymptomatic ascitic fluid infection was extremely rare in cirrhotic patients who attended an outpatient clinic and underwent therapeutic paracentesis. Additionally, our study found that the peritoneal fluid asymptomatic spontaneous infection is rare among cirrhotic patients undergoing outpatient base therapeutic paracentesis. Further investigation for ascitic fluid analysis's role in such infection without treatment is to be carried out. Keywords: Ascitic fluid; Cirrhosis; Infection; Therapeutic paracentesis; Spontaneous bacterial peritonitis

Next- and Third-Generation Sequencing Outperforms Culture-Based Methods in the Diagnosis of Ascitic Fluid Bacterial Infections of ICU Patients

Objectives: Infections of the ascitic fluid are serious conditions that require rapid diagnosis and treatment. Ascites is often accompanied by other critical pathologies such as gastrointestinal bleeding and bowel perforation, and infection increases the risk of mortality in intensive care patients. Owing to a relatively low success rate of conventional culture methods in identifying the responsible pathogens, new methods may be helpful to guide antimicrobial therapy and to refine empirical regimens. Here, we aim to assess outcomes and to identify responsible pathogens in ascitic fluid infections, in order to improve patients’ care and to guide empirical therapy. Methods: Between October 2019 and March 2021, we prospectively collected 50 ascitic fluid samples from ICU patients with suspected infection. Beside standard culture-based microbiology methods, excess fluid underwent DNA isolation and was analyzed by next- and third-generation sequencing (NGS) methods. Results: NGS-based methods had higher sensitivity in detecting additional pathogenic bacteria such as E. faecalis and Klebsiella in 33 out of 50 (66%) ascitic fluid samples compared with culture-based methods (26%). Anaerobic bacteria were especially identified by sequencing-based methods in 28 samples (56%), in comparison with only three samples in culture. Analysis of clinical data showed a correlation between sequencing results and various clinical parameters such as peritonitis and hospitalization outcomes. Conclusions: Our results show that, in ascitic fluid infections, NGS-based methods have a higher sensitivity for the identification of clinically relevant pathogens than standard microbiological culture diagnostics, especially in detecting hard-to-culture anaerobic bacteria. Patients with such infections may benefit from the use of NGS methods by the possibility of earlier and better targeted antimicrobial therapy, which has the potential to lower the high morbidity and mortality in critically ill patients with ascitic bacterial infection.

Diagnostic utility of measuring lactate dehydrogenase levels and its isoenzyme activities for the evaluation of malignancy in feline pleural effusion and ascitic fluid

Lactate dehydrogenase (LDH) isoenzymes may be useful in the differential diagnosis of pleural effusion (PE) and ascitic fluid (AF) etiologies in cats since tissue damage induces their release, thereby changing the pattern of their activity. The present study aimed to determine the diagnostic utility of measuring LDH levels and its isoenzyme activities in PE or AF in cats with malignancy. We measured LDH levels and its isoenzyme activities in serum, PE, and AF in 29 cats and compared the results between malignant, infectious diseases, and non-malignant, non-infectious diseases. Receiver operating characteristic (ROC) analysis was performed to assess the accuracy of the tests in diagnosing feline malignancy. In PE or AF, significant differences were found in LDH levels and LDH isoenzymes activities among the three groups. The combination of LDH level and LDH-1 activity in PE or AF had the highest area under the ROC (AUC) value of 0.874 for discriminating malignant effusion from non-malignant effusion. The sensitivity and specificity of using the combination of LDH level (cutoff: <2,269 U/L) and LDH-1 activity (cutoff: <4.8%) in PE or AF for predicting malignancy with the highest AUC value were 94.4% and 72.7%, respectively. Our results suggest that the combination of LDH level and LDH-1 activity in PE or AF can potentially diagnose for malignancy. Considering that LDH isoenzymes can be measured inexpensively and easily, LDH tests can be readily accommodated in veterinary clinical practice.