Spontaneous bacterial peritonitis(SBP) is the most common infection in end-stage liver disease patients.SBP is defined as an ascitic fluid infection with a polymorphonuclear leucocyte count ≥ 250/mm^3 without an evid...Spontaneous bacterial peritonitis(SBP) is the most common infection in end-stage liver disease patients.SBP is defined as an ascitic fluid infection with a polymorphonuclear leucocyte count ≥ 250/mm^3 without an evident intra-abdominal surgically treatable source.Several mechanisms contribute to SBP occurrence,including translocation of gut bacteria and their products,reduced intestinal motility provoking bacterial overgrowth,alteration of the gut's barrier function and local immune responses.Historically,Gram-negative enteric bacteria have been the main causative agents of SBP,thereby guiding the empirical therapeutic choice.However,over the last decade,a worryingly increasing prevalence of Gram-positive and multi-drug resistant(MDR) SBP has been seen.Recently,the microbiological spectrum of SBP seems to have changed in Europe due to a high prevalence of Gram-positive bacteria(48%-62%).The overall proportion of MDR bacteria is up to 22%-73% of cases.Consequently,empirical therapy based on thirdgeneration cephalosporins or amoxicillin/clavulanic acid,can no longer be considered the standard of care,as these drugs are associated with poor outcomes.Theaim of this review is to describe,with an epidemiological focus,the evidence behind this rise in Gram-positive and MDR SBP from 2000 to present,and illustrate potential targeted therapeutic strategies.An appropriate treatment protocol should include daptomycin plus ceftaroline and meropenem,with prompt stepdown to a narrower spectrum when cultures and sensitivity data are available in order to reduce both cost and potential antibiotic resistance development.展开更多
BACKGROUNDSpontaneous bacterial peritonitis (SBP) is a detrimental infection of the asciticfluid in liver cirrhosis patients, with high mortality and morbidity. Earlydiagnosis and timely antibiotic administration have...BACKGROUNDSpontaneous bacterial peritonitis (SBP) is a detrimental infection of the asciticfluid in liver cirrhosis patients, with high mortality and morbidity. Earlydiagnosis and timely antibiotic administration have successfully decreased themortality rate to 20%-25%. However, many patients cannot be diagnosed in theearly stages due to the absence of classical SBP symptoms. Early diagnosis ofasymptomatic SBP remains a great challenge in the clinic.AIMTo establish a multivariate predictive model for early diagnosis of asymptomaticSBP using positive microbial cultures from liver cirrhosis patients with ascites.METHODSA total of 98 asymptomatic SBP patients and 98 ascites liver cirrhosis patients withnegative microbial cultures were included in the case and control groups,respectively. Multiple linear stepwise regression analysis was performed toidentify potential indicators for asymptomatic SBP diagnosis. The diagnosticperformance of the model was estimated using the receiver operatingcharacteristic curve.RESULTSPatients in the case group were more likely to have advanced disease stages,cirrhosis related-complications, worsened hematology and ascites, and higher mortality. Based on multivariate analysis, the predictive model was as follows: y (P) = 0.018 + 0.312 × MELD (model of end-stage liver disease) + 0.263 × PMN(ascites polymorphonuclear) + 0.184 × N (blood neutrophil percentage) + 0.233 ×HCC (hepatocellular carcinoma) + 0.189 × renal dysfunction. The area under thecurve value of the established model was 0.872, revealing its high diagnosticpotential. The diagnostic sensitivity was 73.5% (72/98), the specificity was 86.7%(85/98), and the diagnostic efficacy was 80.1%.CONCLUSIONOur predictive model is based on the MELD score, polymorphonuclear cells,blood N, hepatocellular carcinoma, and renal dysfunction. This model mayimprove the early diagnosis of asymptomatic SBP.展开更多
AIM To investigate whether the use of proton pump inhibitors(PPIs) increases the incidence of spontaneous bacterial peritonitis(SBP) in patients with cirrhosis and ascites.METHODS An historical cohort study was carrie...AIM To investigate whether the use of proton pump inhibitors(PPIs) increases the incidence of spontaneous bacterial peritonitis(SBP) in patients with cirrhosis and ascites.METHODS An historical cohort study was carried out in cirrhotic outpatients with ascites followed in a specialized clinic at a tertiary hospital in Southern Brazil. Patient charts were reviewed to collect information on the variables of interest as the use of PPIs. Primary outcome was defined as development of SBP during the study period. SBP was diagnosed based on ascitic fluid polymorphonuclear cell count ≥ 250 cells/mm3 without evidence of an intraabdominal, surgically treatable source of infection.RESULTS Of 738 cirrhotic patients, 582(58.2% male) were enrolled, with mean age of 53.6 ± 12 years. Hepatitis C virus infection(36.2%) and alcohol abuse(25.6%) were the main etiologies of cirrhosis. The presence of ascites was detected in 299(51.4%) patients during the development of the study. Nineteen patients with previous diagnosis of SBP undergoing secondary prophylaxis and 22 patients with insufficient PPI data were further excluded. Of 258 patients with ascites, 151 used PPIs, and 34 developed SBP(22.5%). Among 107 non-users of PPIs, 23 developed SBP(21.5%)(HR = 1.44, 95%CI: 0.85-2.47, P = 0.176). The median follow-up time of patients using PPI was 27 mo vs 32 mo for non-users. Univariate analysis of the risk factors associated with the development of SBP revealed a significant association of SPB with the severity of liver disease according to the Child-Turcotte-Pugh(CTP) score. Multivariate analysis confirmed that CTP score was the only independent variable influencing the occurrence of SBP. Survival at 60 mo(Kaplan-Meier analysis) was similar in users and non-users of PPI, independently of the presence of SBP(58.4% vs 62.7% respectively, P = 0.66). For patients with SBP, survival at 60 mo was 55.1%, vs 61.7% in patients without SBP(P = 0.34). CONCLUSION In conclusion, the rate of SBP was not significantly different in users or non-users of PPIs in this cohort of cirrhotic with ascites.展开更多
BACKGROUND Spontaneous bacterial peritonitis(SBP)is an important prognostic factor for outcomes in patients with cirrhosis.Antibiotic prophylaxis is recommended in patients at high risk for developing SBP,but the choi...BACKGROUND Spontaneous bacterial peritonitis(SBP)is an important prognostic factor for outcomes in patients with cirrhosis.Antibiotic prophylaxis is recommended in patients at high risk for developing SBP,but the choice of antibiotics remains unclear.AIM To evaluate the efficacy of various antibiotics for prophylaxis of SBP based on randomized control trials(RCTs).METHODS Electronic databases were searched through November 2018 for RCTs evaluating the efficacy of therapies for primary or secondary prophylaxis of SBP.The primary outcome was the development of SBP.Sensitivity analyses limited to studies of primary or secondary prophylaxis and studies reported after 2010 were performed.The secondary outcome was the risk of all-cause mortality or transplant.The outcomes were assessed by rank of therapies based on network meta-analyses.Individual meta-analyses were also performed.RESULTS Thirteen RCTs(1742 patients)including norfloxacin,ciprofloxacin,rifaximin,trimethoprim-sulfamethoxazole(TMP-SMX),or placebo/no comparator were identified.Individual meta-analyses showed superiority of rifaximin over norfloxacin as well as norfloxacin and TMP-SMX over placebo.Network metaanalysis demonstrated the rank of efficacy in reducing the risk of SBP as:Rifaximin,ciprofloxacin,TMP-SMX,norfloxacin,and placebo/no comparator.Rifaximin ranked highest in sensitivity analyses limited to studies of primary or secondary prophylaxis and studies reported after 2010.Similarly,rifaximin ranked highest in reducing the risk of death/transplant.CONCLUSION The present comprehensive network meta-analysis provides RCT based evidence for superior efficacy of rifaximin compared to other antibiotics for the prophylaxis of SBP and reducing risk of death/transplant.Further RCTs are warranted to confirm our findings.展开更多
I read with great interest the article by Gbele et al published in issue 44 of World J Gastroenterol 2009.The results of their study indicate that-2518 Monocyte chemotactic protein-1(MCP-1)genotype AA is a risk fact...I read with great interest the article by Gbele et al published in issue 44 of World J Gastroenterol 2009.The results of their study indicate that-2518 Monocyte chemotactic protein-1(MCP-1)genotype AA is a risk factor for spontaneous bacterial peritonitis in patients with alcoholic cirrhosis.However,there are some items that need to be discussed.展开更多
Carbapenem antibiotics were first introduced in the 1980s and have long been considered the most active agents for the treatment of multidrug-resistant gramnegative bacteria.Over the last decade,carbapenem-resistant E...Carbapenem antibiotics were first introduced in the 1980s and have long been considered the most active agents for the treatment of multidrug-resistant gramnegative bacteria.Over the last decade,carbapenem-resistant Enterobacteriaceae(CRE)have emerged as organisms causing spontaneous bacterial peritonitis.Infections caused by CRE have shown a higher mortality rate than those caused by bacteria sensitive to carbapenem antibiotics.Current antibiotic guidelines for the treatment of spontaneous bacterial peritonitis are insufficient,and rapid deescalation of empiric antibiotic treatment is not widely recognized.This review summarizes the molecular characteristics,epidemiology and possible treatment of spontaneous bacterial peritonitis caused by CRE.展开更多
Spontaneous bacterial peritonitis(SBP)is one of the most common complications in patients with end-stage liver disease(ESLD),which increases the risk of short-term mortality.Proton pump inhibitors(PPIs)are frequently ...Spontaneous bacterial peritonitis(SBP)is one of the most common complications in patients with end-stage liver disease(ESLD),which increases the risk of short-term mortality.Proton pump inhibitors(PPIs)are frequently used in patients with ESLD,in which controversies about the risk of PPI treatment in the occurrence of SBP are largely raised and the pathogenic mechanism of PPI-associated SBP remains unclear.We conducted a systematic literature search through PubMed/MEDLINE for publications mainly from 1 January 2000 to 1 January 2021.Our narrative review summarized the adverse effect of specific PPI therapy on the occurrence and prognosis of SBP in cirrhotic patients,described the potential mechanisms by which PPI induces the development of SBP,and discussed the risk factors associated with the development of SBP and the strategy of PPI therapy in cirrhotic patients.Although controversy regarding the association between PPI use and the occurrence of SBP exists,PPIs use should be restricted to patients with clear benefit indications,and be cautious for elderly patients with severe liver damage.展开更多
<b style="line-height:1.5;">Introduction:</b><span style="line-height:1.5;"> Spontaneous bacterial peritonitis (SBP) is among the most common infection</span><span style=...<b style="line-height:1.5;">Introduction:</b><span style="line-height:1.5;"> Spontaneous bacterial peritonitis (SBP) is among the most common infection</span><span style="line-height:1.5;">s</span><span style="line-height:1.5;"> in cirrhotic patients. Data on SBP are rare in Cameroon. This prompted us to carry out this study on patients with decompensated cirrhosis of the liver in Yaounde University Hospital Centre (YUHC). <b>Methods:</b> We carried out a cross-sectional study from December 2015 to June 2016 in three units of YUHC. All patients with decompensated liver cirrhosis were included. Our sampling was consecutive. Diagnosis of cirrhosis was performed, based on clinical, biological and ultrasound criteria. A neutrophil count greater than 250 cell/mm<sup>3</sup> in ascites fluid defined an SBP. Data on socio-demography, clinical presentation, and outcomes were collected. <b>Results:</b> We included 34 decompensated cirrhotic patients (15 males). Patients mean age was 57.5</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">±</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">2 years (SBP positive: 48.7 ± 21.3 versus without SBP: 59.8 ± 19.5, p</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">=</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">0.22). SBP diagnosis was made in 6 (17.7%) patients. Compared to patients with decompensated liver cirrhosis and without SBP, positive SBP patients had a higher pulse rate (p</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">=</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">0.002) and respiratory rate (p</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">=</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">0.02). The patients with SBP were more likely to present these other clinical features: pulse rate >100 (RR: 4.2, [95% CI: 0.7 </span><span style="line-height:1.5;">-</span><span style="line-height:1.5;"> 27.7];p</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">=</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">0.02), presence of jaundice (RR: 3.4, [95% CI: 0.6 </span><span style="line-height:1.5;">-</span><span style="line-height:1.5;"> 21.1];p</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">=</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">0.09), being from female gender (RR: 3.2, [95% CI: 0.5 </span><span style="line-height:1.5;">-</span><span style="line-height:1.5;"> 19.9];</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">p</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">=</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">0.11), advanced liver disease (Child C class) (RR: 2.4, [95% CI: 0.4 </span><span style="line-height:1.5;">-</span><span style="line-height:1.5;"> 14.5], p</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">=</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">0.66), low-plasma albumin (less than 20</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">g/L) (RR: 1.7, [95% CI: 0.8 </span><span style="line-height:1.5;">-</span><span style="line-height:1.5;"> 3.9], p</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">=</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">0.08), respiratory rate</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">> 30 (RR: 1.6, [95% CI: 0.6</span><span style="line-height:1.5;"> -</span><span style="line-height:1.5;"> 3.3], p</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">=</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">0.05) and fever/hypothermia (RR: 1.5, [95% CI: 0.6 </span><span style="line-height:1.5;">-</span><span style="line-height:1.5;"> 3.4];p</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">=</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">0.22). Evolution after a 72-hours antibiotherapy was stationary in four cases and unfavorable in two patients, resulting in death. <b>Conclusion: </b>SBP prevalence was 17.7%. SBP patients were younger, from female sex, tachycardia and polypnea, presenting with fever/hypothermia and signs of advanced liver disease than non-SBP patients. Improvement of our technical platform will be useful to determine the cause of cirrhosis and identify the different germs responsible for SBP.展开更多
Background and Aims: Spontaneous bacterial peritonitis(SBP) is one of the leading causes of death in patients withliver cirrhosis. We aimed to establish a prognostic model toevaluate the 1-year survival of cirrhosis p...Background and Aims: Spontaneous bacterial peritonitis(SBP) is one of the leading causes of death in patients withliver cirrhosis. We aimed to establish a prognostic model toevaluate the 1-year survival of cirrhosis patients after thefirst episode of SBP. Methods: A prognostic model was developedbased on a retrospective derivation cohort of 309cirrhosis patients with first-ever SBP and was validated in aseparate validation cohort of 141 patients. We used Uno’sconcordance, calibration curve, and decision curve (DCA)analysis to evaluate the discrimination, calibration, and clinicalnet benefit of the model. Results: A total of 59 (19.1%)patients in the derivation cohort and 42 (29.8%) patientsin the validation cohort died over the course of 1 year. Aprognostic model in nomogram form was developed withpredictors including age [hazard ratio (HR): 1.25;95% confidenceinterval (CI): 0.92–1.71], total serum bilirubin (HR:1.66;95% CI: 1.28–2.14), serum sodium (HR: 0.94;95%CI: 0.90–0.98), history of hypertension (HR: 2.52;95% CI:1.44–4.41) and hepatic encephalopathy (HR: 2.06;95%CI: 1.13–3.73). The nomogram had a higher concordance(0.79) compared with the model end-stage liver disease(0.67) or Child-Turcotte-Pugh (0.71) score. The nomogramalso showed acceptable calibration (calibration slope, 1.12;Bier score, 0.15±0.21) and optimal clinical net benefit in thevalidation cohort. Conclusions: This prediction model developedbased on characteristics of first-ever SBP patientsmay benefit the prediction of patients’ 1-year survival.展开更多
Escherichia coli is a prevalent causative pathogen of spontaneous bacterial peritonitis(SBP).In this retrospective study,we investigated the microbiological characteristics and antibiotic susceptibility of E.coli clin...Escherichia coli is a prevalent causative pathogen of spontaneous bacterial peritonitis(SBP).In this retrospective study,we investigated the microbiological characteristics and antibiotic susceptibility of E.coli clinical isolates obtained from liver cirrhosis patients suffering from nosocomial SBP.Our results showed that extended-spectrum b-lactamase(ESBL)-producing E.coli accounted for 47%of the cases,while 62%of the isolates were multi-drug resistant(MDR)pathogens.ESBL-producing and MDR isolates showed high incidences of resistance to third-generation cephalosporins,but they displayed susceptibility to carbapenems,b-lactamase inhibitors,and aminoglycosides.Importantly,liver cirrhosis patients with MDR E.coli SBP showed a significantly higher death rate than patients with non-MDR infections(P=0.021).The 30-day mortality of nosocomial SBP was independently correlated with female gender[odds ratio(OR)=5.200,95%confidence interval(CI)=1.194–22.642],liver failure(OR=9.609,95%CI=1.914–48.225),hepatocellular carcinoma(OR=8.176,95%CI=2.065–32.364),hepatic encephalopathy(OR=8.176,95%CI=2.065–32.364),model of end-stage liver disease score(OR=1.191,95%CI=1.053–1.346),white blood cell count(OR=0.847,95%CI=0.737–0.973),and ascites polymorphonuclear(OR=95.903,95%CI=3.410–2697.356).In conclusion,third-generation cephalosporins may be inappropriate for empiric treatment of nosocomial SBP caused by E.coli,due to the widespread presence of ESBLs and high incidence of MDR pathogens.展开更多
Salmonella typhimurium, a non-typhoidal salmonella, is an unusual cause of spontaneous bacterial peritonitis (SBP). It isusually reported in asymptomatic patients with normal or high ascitic fluid protein levels with ...Salmonella typhimurium, a non-typhoidal salmonella, is an unusual cause of spontaneous bacterial peritonitis (SBP). It isusually reported in asymptomatic patients with normal or high ascitic fluid protein levels with underlying immunosuppression,as high opsonic activity in the ascitic fluid of these patients protects them from the usual organisms causingspontaneous bacterial peritonitis, unless they are exposed to a particularly virulent organism like salmonella. We report acase of culture-proven non-typhoidal salmonella in a patient with decompensated cirrhosis, with low protein and withoutany underlying immunosuppression, and no other source to explain its origin.展开更多
BACKGROUND Spontaneous bacterial empyema(SBE)occurs when a hepatic hydrothorax becomes infected and runs a course similar to spontaneous bacterial peritonitis(SBP).It remains underdiagnosed as patients with cirrhosis ...BACKGROUND Spontaneous bacterial empyema(SBE)occurs when a hepatic hydrothorax becomes infected and runs a course similar to spontaneous bacterial peritonitis(SBP).It remains underdiagnosed as patients with cirrhosis do not routinely undergo diagnostic thoracentesis.Current understanding is limited by small cohorts,while studies reporting its association with ascites/SBP are conflicting.AIM To explore the incidence of SBE,to determine its association with ascites,and to summarize what is known regarding treatment and outcomes for patients with SBE.METHODS Major databases were searched until June 2021.Outcomes include the incidence of SBE in pleural effusions,SBP in peritoneal fluid,and SBE in patients without ascites within our cohort of patients with cirrhosis.We performed a meta-analysis using a randomeffects model with pooled proportions and 95%confidence intervals(CI).We assessed heterogeneity using I^(2)and classic fail-safe to determine bias.RESULTS Eight studies with 8899 cirrhosis patients were included.The median age ranged between 41.2 to 69.7 years.The majority of the patients were Child-Pugh B and C.Mean MELD score was 18.6±8.09.A total of 1334 patients had pleural effusions and the pooled incidence of SBE was 15.6%(CI 12.6-19;I^(2)50).Amongst patients diagnosed with SBE,the most common locations included right(202),left(64),and bilateral(8).Amongst our cohort,a total of 2636 patients had ascites with a pooled incidence of SBP of 22.2%(CI 9.9-42.7;I^(2)97.8).The pooled incidence of SBE in patients with cirrhosis but without concomitant ascites was 9.5%(CI 3.6-22.8;I^(2)82.5).CONCLUSION SBE frequently occurs with concurrent ascites/SBP;our results suggest high incidence rates of SBE even in the absence of ascites.The pleura can be an unrecognized nidus and our findings support the use of diagnostic thoracentesis in patients with decompensated cirrhosis after exclusion of other causes of pleural effusion.Thoracentesis should be considered particularly in patients without ascites and when there is a high suspicion of infection.The need for diagnostic thoracentesis will continue to be important as rates of multi-drug resistant bacterial infections increase and antibiotic susceptibility information is required for adequate treatment.展开更多
In this editorial,we comment on the article by Liakina V:“Antibiotic resistance in patients with liver cirrhosis:Prevalence and current approach to tackle”(World J Clin Cases 2023,11:7530-7542).In this excellent rev...In this editorial,we comment on the article by Liakina V:“Antibiotic resistance in patients with liver cirrhosis:Prevalence and current approach to tackle”(World J Clin Cases 2023,11:7530-7542).In this excellent review,Liakina presents current data on bacterial complications in patients with cirrhosis.Bacterial infections are the most common complication in patients with liver cirrhosis.We focus specifically on spontaneous bacterial peritonitis(SBP)which is the most repres-entative infectious complication.Liakina V suggested starting empirically,in all patients with suspected SBP,third-generation cephalosporins when the number of polymorphonuclear leukocytes(PMNs)in ascites is greater than 250/mm^(3).This statement creates some doubts in our clinical practice so we discuss on the unsolved pitfalls of diagnosis and treatment that are often encountered in patients with ascitic fluid infections,especially on bacterascites that is defined as ascitic bacterial growth with PMNs below 250/mm^(3).The severity of liver disease and overall prognosis are highly comparable for patients with bacterascites and SBP in some recent well-conducted studies.Furthermore,we present a brief analysis of the prevalence of antibiotic-resistant isolates with an introduction of currently approved antibiotic drug options to treat ascitic fluid infections avoiding antibiotic resistance.In light of the most recent epidemiological data,third-generation cephalosporins should not be considered as an empirical antibiotic treatment of choice for ascitic fluid infections.展开更多
Patients with cirrhosis show an increased susceptibility to infection due to disease-related immune-dysfunction.Bacterial infection therefore represents a common,often detrimental event in patients with advanced liver...Patients with cirrhosis show an increased susceptibility to infection due to disease-related immune-dysfunction.Bacterial infection therefore represents a common,often detrimental event in patients with advanced liver disease,since it can worsen portal hypertension and impair the function of hepatic and extrahepatic organs.Among pharmacological strategies to prevent infection,antibiotic prophylaxis remains the first-choice,especially in high-risk groups,such as patients with acute variceal bleeding,low ascitic fluid proteins,and prior episodes of spontaneous bacterial peritonitis.Nevertheless,antibiotic prophylaxis has to deal with the changing bacterial epidemiology in cirrhosis,with increased rates of gram-positive bacteria and multidrug resistant rods,warnings about quinolonesrelated side effects,and low prescription adherence.Short-term antibiotic prophylaxis is applied in many other settings during hospitalization,such as before interventional or surgical procedures,but often without knowledge of local bacterial epidemiology and without strict adherence to antimicrobial stewardship.This paper offers a detailed overview on the application of antibiotic prophylaxis in cirrhosis,according to the current evidence.展开更多
Mortality in cirrhosis is mostly associated with the development of clinical decompensation,characterized by ascites,hepatic encephalopathy,variceal bleeding,or jaundice.Therefore,it is important to prevent and manage...Mortality in cirrhosis is mostly associated with the development of clinical decompensation,characterized by ascites,hepatic encephalopathy,variceal bleeding,or jaundice.Therefore,it is important to prevent and manage such complications.Traditionally,the pathophysiology of decompensated cirrhosis was explained by the peripheral arterial vasodilation hypothesis,but it is currently understood that decompensation might also be driven by a systemic inflammatory state(the systemic inflammation hypothesis).Considering its oncotic and nononcotic properties,albumin has been thoroughly evaluated in the prevention and management of several of these decompensating events.There are formal evidence-based recommendations from international medical societies proposing that albumin be administered in individuals with cirrhosis undergoing large-volume paracentesis,patients with spontaneous bacterial peritonitis,those with acute kidney injury(even before the etiological diagnosis),and those with hepatorenal syndrome.Moreover,there are a few randomized controlled trials and meta-analyses suggesting a possible role for albumin infusion in patients with cirrhosis and ascites(long-term albumin administration),individuals with hepatic encephalopathy,and those with acute-on-chronic liver failure undergoing modest-volume paracentesis.Further studies are necessary to elucidate whether albumin administration also benefits patients with cirrhosis and other complications,such as individuals with extraperitoneal infections,those hospitalized with decompensated cirrhosis and hypoalbuminemia,and patients with hyponatremia.展开更多
Decompensated cirrhosis is characterized by chronic inflammation and severe portal hypertension leading to systemic circulatory dysfunction.Albumin infusion has been widely used in decompensated cirrhosis in patients ...Decompensated cirrhosis is characterized by chronic inflammation and severe portal hypertension leading to systemic circulatory dysfunction.Albumin infusion has been widely used in decompensated cirrhosis in patients with spontaneous bacterial peritonitis,large-volume paracentesis and hepatorenal syndrome.Emerging data suggest long-term albumin infusion has both oncotic and non-oncotic properties which may improve the clinical outcomes in decompensated cirrhosis patients.We review the current literature on both the established and potential role of albumin,and specifically address the controversies of long-term albumin infusion in decompensated cirrhosis patients.展开更多
BACKGROUND Ascites is one of the most common complications of cirrhosis,placing a significant burden on the healthcare system.Data regarding the optimal time of paracentesis and outcomes among patients with cirrhosis ...BACKGROUND Ascites is one of the most common complications of cirrhosis,placing a significant burden on the healthcare system.Data regarding the optimal time of paracentesis and outcomes among patients with cirrhosis and ascites are scarce.AIM To assess the outcomes of patients who underwent paracentesis within 12 h after admission compared to patients who underwent paracentesis later than 12 h.METHODS The study included 185 patients with cirrhosis and ascites who underwent paracentesis.The early paracentesis group was defined as paracentesis performed<12 h after admission(65 patients)and the delayed paracentesis group was defined as paracentesis performed>12 h after admission(120 patients).Newonset complications of cirrhosis,length of hospital stay,weekday or weekend admission,in-hospital mortality rate,and 90-d readmission rates were assessed and compared between the groups.RESULTS Significantly more patients in the delayed paracentesis group than in the early paracentesis group developed hepatic encephalopathy(45%vs 21.5%,P<0.01),hepato-renal syndrome(21.6%vs 9.2%,P=0.03)and infections(25%vs 10.7%,P=0.02)during hospitalization.There were no statistically significant differences in the occurrence of spontaneous bacterial peritonitis and upper gastrointestinal bleeding between the two groups.Length of stay was shorter in the early paracentesis group than in the delayed paracentesis group(6.7 d vs 12.2 d)and inhospital mortality was lower among patients in the early paracentesis group.Patients in the delayed paracentesis group had a higher risk of developing complications during hospitalization.CONCLUSION Early paracentesis(within 12 h after admission)could be a new inpatient quality metric among patients hospitalized with cirrhosis and ascites as it is associated with fewer complications of cirrhosis,lower in-hospital mortality and shorter length of stay.展开更多
The management of patients with cirrhosis is complex and subject to ever-evolving literature and recommendations.In the most recent Japanese practice guidelines for liver cirrhosis(1),Yoshiji et al.provide a number of...The management of patients with cirrhosis is complex and subject to ever-evolving literature and recommendations.In the most recent Japanese practice guidelines for liver cirrhosis(1),Yoshiji et al.provide a number of key updates to guidance based on evidence reflective of practice in Japan that are worth emphasizing.展开更多
Background:Albumin is a critical component in the standard therapeutic approach to acute renal failure(ARF)and spontaneous bacterial peritonitis(SBP)in the setting of ascites.However,data regarding the safety and mini...Background:Albumin is a critical component in the standard therapeutic approach to acute renal failure(ARF)and spontaneous bacterial peritonitis(SBP)in the setting of ascites.However,data regarding the safety and minimumeffective dose are limited.Methods:We conducted a retrospective review of patients with decompensated cirrhosis who received albumin within the first 48 hours of hospitalization at Beth Israel Deaconess Medical Center between 2010 and 2013.Outcomes included 90-day risk of death or transplantation(primary)and(secondary)complications of albumin infusion(length of stay(LOS)and need for critical care),all adjusted for comorbidity and severity of illness.Results:We included 169 patients with ARF and 88 patients with SBP.The optimal doses of albumin for a survival benefit were found to be 87.5 g and 100 g in the ARF and SBP cohorts,respectively.The odds ratio(OR)for the 90-day risk of death or liver transplantation associated with the optimal loading dose was 0.36(95%CI:0.17-0.76,P=0.008)and 0.28(95%CI:0.07-0.97,P=0.04)for the ARF and SBP cohorts,respectively.This effect persisted for patients with ARF who had neither hepatorenal syndrome(HRS)nor SBP(OR:0.13,95%CI:0.007-0.79,P=0.02).LOS(beta coefficient per log albumin dose:1.69;95%CI:0.14-3.24,P=0.03)and risk of critical care(OR/g albumin:1.03;95%CI:1.01-1.05,P=0.01)were also dose dependent.Conclusion:Albumin has a dose-dependent effect on both survival and complications in patients with cirrhosis with ARF(HRS and otherwise)and/or SBP.展开更多
文摘Spontaneous bacterial peritonitis(SBP) is the most common infection in end-stage liver disease patients.SBP is defined as an ascitic fluid infection with a polymorphonuclear leucocyte count ≥ 250/mm^3 without an evident intra-abdominal surgically treatable source.Several mechanisms contribute to SBP occurrence,including translocation of gut bacteria and their products,reduced intestinal motility provoking bacterial overgrowth,alteration of the gut's barrier function and local immune responses.Historically,Gram-negative enteric bacteria have been the main causative agents of SBP,thereby guiding the empirical therapeutic choice.However,over the last decade,a worryingly increasing prevalence of Gram-positive and multi-drug resistant(MDR) SBP has been seen.Recently,the microbiological spectrum of SBP seems to have changed in Europe due to a high prevalence of Gram-positive bacteria(48%-62%).The overall proportion of MDR bacteria is up to 22%-73% of cases.Consequently,empirical therapy based on thirdgeneration cephalosporins or amoxicillin/clavulanic acid,can no longer be considered the standard of care,as these drugs are associated with poor outcomes.Theaim of this review is to describe,with an epidemiological focus,the evidence behind this rise in Gram-positive and MDR SBP from 2000 to present,and illustrate potential targeted therapeutic strategies.An appropriate treatment protocol should include daptomycin plus ceftaroline and meropenem,with prompt stepdown to a narrower spectrum when cultures and sensitivity data are available in order to reduce both cost and potential antibiotic resistance development.
基金Supported by the Digestive Medical Coordinated Development Center of Beijing Municipal Administration,No.XXZ0403.
文摘BACKGROUNDSpontaneous bacterial peritonitis (SBP) is a detrimental infection of the asciticfluid in liver cirrhosis patients, with high mortality and morbidity. Earlydiagnosis and timely antibiotic administration have successfully decreased themortality rate to 20%-25%. However, many patients cannot be diagnosed in theearly stages due to the absence of classical SBP symptoms. Early diagnosis ofasymptomatic SBP remains a great challenge in the clinic.AIMTo establish a multivariate predictive model for early diagnosis of asymptomaticSBP using positive microbial cultures from liver cirrhosis patients with ascites.METHODSA total of 98 asymptomatic SBP patients and 98 ascites liver cirrhosis patients withnegative microbial cultures were included in the case and control groups,respectively. Multiple linear stepwise regression analysis was performed toidentify potential indicators for asymptomatic SBP diagnosis. The diagnosticperformance of the model was estimated using the receiver operatingcharacteristic curve.RESULTSPatients in the case group were more likely to have advanced disease stages,cirrhosis related-complications, worsened hematology and ascites, and higher mortality. Based on multivariate analysis, the predictive model was as follows: y (P) = 0.018 + 0.312 × MELD (model of end-stage liver disease) + 0.263 × PMN(ascites polymorphonuclear) + 0.184 × N (blood neutrophil percentage) + 0.233 ×HCC (hepatocellular carcinoma) + 0.189 × renal dysfunction. The area under thecurve value of the established model was 0.872, revealing its high diagnosticpotential. The diagnostic sensitivity was 73.5% (72/98), the specificity was 86.7%(85/98), and the diagnostic efficacy was 80.1%.CONCLUSIONOur predictive model is based on the MELD score, polymorphonuclear cells,blood N, hepatocellular carcinoma, and renal dysfunction. This model mayimprove the early diagnosis of asymptomatic SBP.
文摘AIM To investigate whether the use of proton pump inhibitors(PPIs) increases the incidence of spontaneous bacterial peritonitis(SBP) in patients with cirrhosis and ascites.METHODS An historical cohort study was carried out in cirrhotic outpatients with ascites followed in a specialized clinic at a tertiary hospital in Southern Brazil. Patient charts were reviewed to collect information on the variables of interest as the use of PPIs. Primary outcome was defined as development of SBP during the study period. SBP was diagnosed based on ascitic fluid polymorphonuclear cell count ≥ 250 cells/mm3 without evidence of an intraabdominal, surgically treatable source of infection.RESULTS Of 738 cirrhotic patients, 582(58.2% male) were enrolled, with mean age of 53.6 ± 12 years. Hepatitis C virus infection(36.2%) and alcohol abuse(25.6%) were the main etiologies of cirrhosis. The presence of ascites was detected in 299(51.4%) patients during the development of the study. Nineteen patients with previous diagnosis of SBP undergoing secondary prophylaxis and 22 patients with insufficient PPI data were further excluded. Of 258 patients with ascites, 151 used PPIs, and 34 developed SBP(22.5%). Among 107 non-users of PPIs, 23 developed SBP(21.5%)(HR = 1.44, 95%CI: 0.85-2.47, P = 0.176). The median follow-up time of patients using PPI was 27 mo vs 32 mo for non-users. Univariate analysis of the risk factors associated with the development of SBP revealed a significant association of SPB with the severity of liver disease according to the Child-Turcotte-Pugh(CTP) score. Multivariate analysis confirmed that CTP score was the only independent variable influencing the occurrence of SBP. Survival at 60 mo(Kaplan-Meier analysis) was similar in users and non-users of PPI, independently of the presence of SBP(58.4% vs 62.7% respectively, P = 0.66). For patients with SBP, survival at 60 mo was 55.1%, vs 61.7% in patients without SBP(P = 0.34). CONCLUSION In conclusion, the rate of SBP was not significantly different in users or non-users of PPIs in this cohort of cirrhotic with ascites.
文摘BACKGROUND Spontaneous bacterial peritonitis(SBP)is an important prognostic factor for outcomes in patients with cirrhosis.Antibiotic prophylaxis is recommended in patients at high risk for developing SBP,but the choice of antibiotics remains unclear.AIM To evaluate the efficacy of various antibiotics for prophylaxis of SBP based on randomized control trials(RCTs).METHODS Electronic databases were searched through November 2018 for RCTs evaluating the efficacy of therapies for primary or secondary prophylaxis of SBP.The primary outcome was the development of SBP.Sensitivity analyses limited to studies of primary or secondary prophylaxis and studies reported after 2010 were performed.The secondary outcome was the risk of all-cause mortality or transplant.The outcomes were assessed by rank of therapies based on network meta-analyses.Individual meta-analyses were also performed.RESULTS Thirteen RCTs(1742 patients)including norfloxacin,ciprofloxacin,rifaximin,trimethoprim-sulfamethoxazole(TMP-SMX),or placebo/no comparator were identified.Individual meta-analyses showed superiority of rifaximin over norfloxacin as well as norfloxacin and TMP-SMX over placebo.Network metaanalysis demonstrated the rank of efficacy in reducing the risk of SBP as:Rifaximin,ciprofloxacin,TMP-SMX,norfloxacin,and placebo/no comparator.Rifaximin ranked highest in sensitivity analyses limited to studies of primary or secondary prophylaxis and studies reported after 2010.Similarly,rifaximin ranked highest in reducing the risk of death/transplant.CONCLUSION The present comprehensive network meta-analysis provides RCT based evidence for superior efficacy of rifaximin compared to other antibiotics for the prophylaxis of SBP and reducing risk of death/transplant.Further RCTs are warranted to confirm our findings.
文摘I read with great interest the article by Gbele et al published in issue 44 of World J Gastroenterol 2009.The results of their study indicate that-2518 Monocyte chemotactic protein-1(MCP-1)genotype AA is a risk factor for spontaneous bacterial peritonitis in patients with alcoholic cirrhosis.However,there are some items that need to be discussed.
文摘Carbapenem antibiotics were first introduced in the 1980s and have long been considered the most active agents for the treatment of multidrug-resistant gramnegative bacteria.Over the last decade,carbapenem-resistant Enterobacteriaceae(CRE)have emerged as organisms causing spontaneous bacterial peritonitis.Infections caused by CRE have shown a higher mortality rate than those caused by bacteria sensitive to carbapenem antibiotics.Current antibiotic guidelines for the treatment of spontaneous bacterial peritonitis are insufficient,and rapid deescalation of empiric antibiotic treatment is not widely recognized.This review summarizes the molecular characteristics,epidemiology and possible treatment of spontaneous bacterial peritonitis caused by CRE.
文摘Spontaneous bacterial peritonitis(SBP)is one of the most common complications in patients with end-stage liver disease(ESLD),which increases the risk of short-term mortality.Proton pump inhibitors(PPIs)are frequently used in patients with ESLD,in which controversies about the risk of PPI treatment in the occurrence of SBP are largely raised and the pathogenic mechanism of PPI-associated SBP remains unclear.We conducted a systematic literature search through PubMed/MEDLINE for publications mainly from 1 January 2000 to 1 January 2021.Our narrative review summarized the adverse effect of specific PPI therapy on the occurrence and prognosis of SBP in cirrhotic patients,described the potential mechanisms by which PPI induces the development of SBP,and discussed the risk factors associated with the development of SBP and the strategy of PPI therapy in cirrhotic patients.Although controversy regarding the association between PPI use and the occurrence of SBP exists,PPIs use should be restricted to patients with clear benefit indications,and be cautious for elderly patients with severe liver damage.
文摘<b style="line-height:1.5;">Introduction:</b><span style="line-height:1.5;"> Spontaneous bacterial peritonitis (SBP) is among the most common infection</span><span style="line-height:1.5;">s</span><span style="line-height:1.5;"> in cirrhotic patients. Data on SBP are rare in Cameroon. This prompted us to carry out this study on patients with decompensated cirrhosis of the liver in Yaounde University Hospital Centre (YUHC). <b>Methods:</b> We carried out a cross-sectional study from December 2015 to June 2016 in three units of YUHC. All patients with decompensated liver cirrhosis were included. Our sampling was consecutive. Diagnosis of cirrhosis was performed, based on clinical, biological and ultrasound criteria. A neutrophil count greater than 250 cell/mm<sup>3</sup> in ascites fluid defined an SBP. Data on socio-demography, clinical presentation, and outcomes were collected. <b>Results:</b> We included 34 decompensated cirrhotic patients (15 males). Patients mean age was 57.5</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">±</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">2 years (SBP positive: 48.7 ± 21.3 versus without SBP: 59.8 ± 19.5, p</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">=</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">0.22). SBP diagnosis was made in 6 (17.7%) patients. Compared to patients with decompensated liver cirrhosis and without SBP, positive SBP patients had a higher pulse rate (p</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">=</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">0.002) and respiratory rate (p</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">=</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">0.02). The patients with SBP were more likely to present these other clinical features: pulse rate >100 (RR: 4.2, [95% CI: 0.7 </span><span style="line-height:1.5;">-</span><span style="line-height:1.5;"> 27.7];p</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">=</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">0.02), presence of jaundice (RR: 3.4, [95% CI: 0.6 </span><span style="line-height:1.5;">-</span><span style="line-height:1.5;"> 21.1];p</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">=</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">0.09), being from female gender (RR: 3.2, [95% CI: 0.5 </span><span style="line-height:1.5;">-</span><span style="line-height:1.5;"> 19.9];</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">p</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">=</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">0.11), advanced liver disease (Child C class) (RR: 2.4, [95% CI: 0.4 </span><span style="line-height:1.5;">-</span><span style="line-height:1.5;"> 14.5], p</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">=</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">0.66), low-plasma albumin (less than 20</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">g/L) (RR: 1.7, [95% CI: 0.8 </span><span style="line-height:1.5;">-</span><span style="line-height:1.5;"> 3.9], p</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">=</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">0.08), respiratory rate</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">> 30 (RR: 1.6, [95% CI: 0.6</span><span style="line-height:1.5;"> -</span><span style="line-height:1.5;"> 3.3], p</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">=</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">0.05) and fever/hypothermia (RR: 1.5, [95% CI: 0.6 </span><span style="line-height:1.5;">-</span><span style="line-height:1.5;"> 3.4];p</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">=</span><span style="line-height:1.5;"> </span><span style="line-height:1.5;">0.22). Evolution after a 72-hours antibiotherapy was stationary in four cases and unfavorable in two patients, resulting in death. <b>Conclusion: </b>SBP prevalence was 17.7%. SBP patients were younger, from female sex, tachycardia and polypnea, presenting with fever/hypothermia and signs of advanced liver disease than non-SBP patients. Improvement of our technical platform will be useful to determine the cause of cirrhosis and identify the different germs responsible for SBP.
基金The work was supported by the Capital’s Funds for Health Improvement and Research(No.2020-2-2172)Beijing Hospitals Authority Clinical Medicine Development of Special Funding Support(No.ZYLX202127)the Fund of Beijing Science&Technology Development of TCM(No.JJ2018-44).
文摘Background and Aims: Spontaneous bacterial peritonitis(SBP) is one of the leading causes of death in patients withliver cirrhosis. We aimed to establish a prognostic model toevaluate the 1-year survival of cirrhosis patients after thefirst episode of SBP. Methods: A prognostic model was developedbased on a retrospective derivation cohort of 309cirrhosis patients with first-ever SBP and was validated in aseparate validation cohort of 141 patients. We used Uno’sconcordance, calibration curve, and decision curve (DCA)analysis to evaluate the discrimination, calibration, and clinicalnet benefit of the model. Results: A total of 59 (19.1%)patients in the derivation cohort and 42 (29.8%) patientsin the validation cohort died over the course of 1 year. Aprognostic model in nomogram form was developed withpredictors including age [hazard ratio (HR): 1.25;95% confidenceinterval (CI): 0.92–1.71], total serum bilirubin (HR:1.66;95% CI: 1.28–2.14), serum sodium (HR: 0.94;95%CI: 0.90–0.98), history of hypertension (HR: 2.52;95% CI:1.44–4.41) and hepatic encephalopathy (HR: 2.06;95%CI: 1.13–3.73). The nomogram had a higher concordance(0.79) compared with the model end-stage liver disease(0.67) or Child-Turcotte-Pugh (0.71) score. The nomogramalso showed acceptable calibration (calibration slope, 1.12;Bier score, 0.15±0.21) and optimal clinical net benefit in thevalidation cohort. Conclusions: This prediction model developedbased on characteristics of first-ever SBP patientsmay benefit the prediction of patients’ 1-year survival.
基金the Special Fund of the Digestive Medical Coordinated Development Center of Beijing Municipal Administration(Grant number:XXZ0403).
文摘Escherichia coli is a prevalent causative pathogen of spontaneous bacterial peritonitis(SBP).In this retrospective study,we investigated the microbiological characteristics and antibiotic susceptibility of E.coli clinical isolates obtained from liver cirrhosis patients suffering from nosocomial SBP.Our results showed that extended-spectrum b-lactamase(ESBL)-producing E.coli accounted for 47%of the cases,while 62%of the isolates were multi-drug resistant(MDR)pathogens.ESBL-producing and MDR isolates showed high incidences of resistance to third-generation cephalosporins,but they displayed susceptibility to carbapenems,b-lactamase inhibitors,and aminoglycosides.Importantly,liver cirrhosis patients with MDR E.coli SBP showed a significantly higher death rate than patients with non-MDR infections(P=0.021).The 30-day mortality of nosocomial SBP was independently correlated with female gender[odds ratio(OR)=5.200,95%confidence interval(CI)=1.194–22.642],liver failure(OR=9.609,95%CI=1.914–48.225),hepatocellular carcinoma(OR=8.176,95%CI=2.065–32.364),hepatic encephalopathy(OR=8.176,95%CI=2.065–32.364),model of end-stage liver disease score(OR=1.191,95%CI=1.053–1.346),white blood cell count(OR=0.847,95%CI=0.737–0.973),and ascites polymorphonuclear(OR=95.903,95%CI=3.410–2697.356).In conclusion,third-generation cephalosporins may be inappropriate for empiric treatment of nosocomial SBP caused by E.coli,due to the widespread presence of ESBLs and high incidence of MDR pathogens.
文摘Salmonella typhimurium, a non-typhoidal salmonella, is an unusual cause of spontaneous bacterial peritonitis (SBP). It isusually reported in asymptomatic patients with normal or high ascitic fluid protein levels with underlying immunosuppression,as high opsonic activity in the ascitic fluid of these patients protects them from the usual organisms causingspontaneous bacterial peritonitis, unless they are exposed to a particularly virulent organism like salmonella. We report acase of culture-proven non-typhoidal salmonella in a patient with decompensated cirrhosis, with low protein and withoutany underlying immunosuppression, and no other source to explain its origin.
文摘BACKGROUND Spontaneous bacterial empyema(SBE)occurs when a hepatic hydrothorax becomes infected and runs a course similar to spontaneous bacterial peritonitis(SBP).It remains underdiagnosed as patients with cirrhosis do not routinely undergo diagnostic thoracentesis.Current understanding is limited by small cohorts,while studies reporting its association with ascites/SBP are conflicting.AIM To explore the incidence of SBE,to determine its association with ascites,and to summarize what is known regarding treatment and outcomes for patients with SBE.METHODS Major databases were searched until June 2021.Outcomes include the incidence of SBE in pleural effusions,SBP in peritoneal fluid,and SBE in patients without ascites within our cohort of patients with cirrhosis.We performed a meta-analysis using a randomeffects model with pooled proportions and 95%confidence intervals(CI).We assessed heterogeneity using I^(2)and classic fail-safe to determine bias.RESULTS Eight studies with 8899 cirrhosis patients were included.The median age ranged between 41.2 to 69.7 years.The majority of the patients were Child-Pugh B and C.Mean MELD score was 18.6±8.09.A total of 1334 patients had pleural effusions and the pooled incidence of SBE was 15.6%(CI 12.6-19;I^(2)50).Amongst patients diagnosed with SBE,the most common locations included right(202),left(64),and bilateral(8).Amongst our cohort,a total of 2636 patients had ascites with a pooled incidence of SBP of 22.2%(CI 9.9-42.7;I^(2)97.8).The pooled incidence of SBE in patients with cirrhosis but without concomitant ascites was 9.5%(CI 3.6-22.8;I^(2)82.5).CONCLUSION SBE frequently occurs with concurrent ascites/SBP;our results suggest high incidence rates of SBE even in the absence of ascites.The pleura can be an unrecognized nidus and our findings support the use of diagnostic thoracentesis in patients with decompensated cirrhosis after exclusion of other causes of pleural effusion.Thoracentesis should be considered particularly in patients without ascites and when there is a high suspicion of infection.The need for diagnostic thoracentesis will continue to be important as rates of multi-drug resistant bacterial infections increase and antibiotic susceptibility information is required for adequate treatment.
文摘In this editorial,we comment on the article by Liakina V:“Antibiotic resistance in patients with liver cirrhosis:Prevalence and current approach to tackle”(World J Clin Cases 2023,11:7530-7542).In this excellent review,Liakina presents current data on bacterial complications in patients with cirrhosis.Bacterial infections are the most common complication in patients with liver cirrhosis.We focus specifically on spontaneous bacterial peritonitis(SBP)which is the most repres-entative infectious complication.Liakina V suggested starting empirically,in all patients with suspected SBP,third-generation cephalosporins when the number of polymorphonuclear leukocytes(PMNs)in ascites is greater than 250/mm^(3).This statement creates some doubts in our clinical practice so we discuss on the unsolved pitfalls of diagnosis and treatment that are often encountered in patients with ascitic fluid infections,especially on bacterascites that is defined as ascitic bacterial growth with PMNs below 250/mm^(3).The severity of liver disease and overall prognosis are highly comparable for patients with bacterascites and SBP in some recent well-conducted studies.Furthermore,we present a brief analysis of the prevalence of antibiotic-resistant isolates with an introduction of currently approved antibiotic drug options to treat ascitic fluid infections avoiding antibiotic resistance.In light of the most recent epidemiological data,third-generation cephalosporins should not be considered as an empirical antibiotic treatment of choice for ascitic fluid infections.
文摘Patients with cirrhosis show an increased susceptibility to infection due to disease-related immune-dysfunction.Bacterial infection therefore represents a common,often detrimental event in patients with advanced liver disease,since it can worsen portal hypertension and impair the function of hepatic and extrahepatic organs.Among pharmacological strategies to prevent infection,antibiotic prophylaxis remains the first-choice,especially in high-risk groups,such as patients with acute variceal bleeding,low ascitic fluid proteins,and prior episodes of spontaneous bacterial peritonitis.Nevertheless,antibiotic prophylaxis has to deal with the changing bacterial epidemiology in cirrhosis,with increased rates of gram-positive bacteria and multidrug resistant rods,warnings about quinolonesrelated side effects,and low prescription adherence.Short-term antibiotic prophylaxis is applied in many other settings during hospitalization,such as before interventional or surgical procedures,but often without knowledge of local bacterial epidemiology and without strict adherence to antimicrobial stewardship.This paper offers a detailed overview on the application of antibiotic prophylaxis in cirrhosis,according to the current evidence.
文摘Mortality in cirrhosis is mostly associated with the development of clinical decompensation,characterized by ascites,hepatic encephalopathy,variceal bleeding,or jaundice.Therefore,it is important to prevent and manage such complications.Traditionally,the pathophysiology of decompensated cirrhosis was explained by the peripheral arterial vasodilation hypothesis,but it is currently understood that decompensation might also be driven by a systemic inflammatory state(the systemic inflammation hypothesis).Considering its oncotic and nononcotic properties,albumin has been thoroughly evaluated in the prevention and management of several of these decompensating events.There are formal evidence-based recommendations from international medical societies proposing that albumin be administered in individuals with cirrhosis undergoing large-volume paracentesis,patients with spontaneous bacterial peritonitis,those with acute kidney injury(even before the etiological diagnosis),and those with hepatorenal syndrome.Moreover,there are a few randomized controlled trials and meta-analyses suggesting a possible role for albumin infusion in patients with cirrhosis and ascites(long-term albumin administration),individuals with hepatic encephalopathy,and those with acute-on-chronic liver failure undergoing modest-volume paracentesis.Further studies are necessary to elucidate whether albumin administration also benefits patients with cirrhosis and other complications,such as individuals with extraperitoneal infections,those hospitalized with decompensated cirrhosis and hypoalbuminemia,and patients with hyponatremia.
基金Supported by Nurturing Clinician Scientist Scheme Award by SingHealth Duke-NUS Medicine Academic Medicine Programme(Medicine ACP),Changi General Hospital Research Grant.
文摘Decompensated cirrhosis is characterized by chronic inflammation and severe portal hypertension leading to systemic circulatory dysfunction.Albumin infusion has been widely used in decompensated cirrhosis in patients with spontaneous bacterial peritonitis,large-volume paracentesis and hepatorenal syndrome.Emerging data suggest long-term albumin infusion has both oncotic and non-oncotic properties which may improve the clinical outcomes in decompensated cirrhosis patients.We review the current literature on both the established and potential role of albumin,and specifically address the controversies of long-term albumin infusion in decompensated cirrhosis patients.
文摘BACKGROUND Ascites is one of the most common complications of cirrhosis,placing a significant burden on the healthcare system.Data regarding the optimal time of paracentesis and outcomes among patients with cirrhosis and ascites are scarce.AIM To assess the outcomes of patients who underwent paracentesis within 12 h after admission compared to patients who underwent paracentesis later than 12 h.METHODS The study included 185 patients with cirrhosis and ascites who underwent paracentesis.The early paracentesis group was defined as paracentesis performed<12 h after admission(65 patients)and the delayed paracentesis group was defined as paracentesis performed>12 h after admission(120 patients).Newonset complications of cirrhosis,length of hospital stay,weekday or weekend admission,in-hospital mortality rate,and 90-d readmission rates were assessed and compared between the groups.RESULTS Significantly more patients in the delayed paracentesis group than in the early paracentesis group developed hepatic encephalopathy(45%vs 21.5%,P<0.01),hepato-renal syndrome(21.6%vs 9.2%,P=0.03)and infections(25%vs 10.7%,P=0.02)during hospitalization.There were no statistically significant differences in the occurrence of spontaneous bacterial peritonitis and upper gastrointestinal bleeding between the two groups.Length of stay was shorter in the early paracentesis group than in the delayed paracentesis group(6.7 d vs 12.2 d)and inhospital mortality was lower among patients in the early paracentesis group.Patients in the delayed paracentesis group had a higher risk of developing complications during hospitalization.CONCLUSION Early paracentesis(within 12 h after admission)could be a new inpatient quality metric among patients hospitalized with cirrhosis and ascites as it is associated with fewer complications of cirrhosis,lower in-hospital mortality and shorter length of stay.
基金Nadim Mahmud is supported by the National Institute of Diabetes and Digestive and Kidney Diseases(No.K08-DK124577)by American College of Gastroenterology.
文摘The management of patients with cirrhosis is complex and subject to ever-evolving literature and recommendations.In the most recent Japanese practice guidelines for liver cirrhosis(1),Yoshiji et al.provide a number of key updates to guidance based on evidence reflective of practice in Japan that are worth emphasizing.
基金supported by a grant from the Scholars in Medicine office,Harvard Medical School.Dr.Tapper was supported by a grant from the Carl J.Shapiro Institute for Education and Research.The content is solely the responsibility of the authors and does not necessarily represent their funding institutions.
文摘Background:Albumin is a critical component in the standard therapeutic approach to acute renal failure(ARF)and spontaneous bacterial peritonitis(SBP)in the setting of ascites.However,data regarding the safety and minimumeffective dose are limited.Methods:We conducted a retrospective review of patients with decompensated cirrhosis who received albumin within the first 48 hours of hospitalization at Beth Israel Deaconess Medical Center between 2010 and 2013.Outcomes included 90-day risk of death or transplantation(primary)and(secondary)complications of albumin infusion(length of stay(LOS)and need for critical care),all adjusted for comorbidity and severity of illness.Results:We included 169 patients with ARF and 88 patients with SBP.The optimal doses of albumin for a survival benefit were found to be 87.5 g and 100 g in the ARF and SBP cohorts,respectively.The odds ratio(OR)for the 90-day risk of death or liver transplantation associated with the optimal loading dose was 0.36(95%CI:0.17-0.76,P=0.008)and 0.28(95%CI:0.07-0.97,P=0.04)for the ARF and SBP cohorts,respectively.This effect persisted for patients with ARF who had neither hepatorenal syndrome(HRS)nor SBP(OR:0.13,95%CI:0.007-0.79,P=0.02).LOS(beta coefficient per log albumin dose:1.69;95%CI:0.14-3.24,P=0.03)and risk of critical care(OR/g albumin:1.03;95%CI:1.01-1.05,P=0.01)were also dose dependent.Conclusion:Albumin has a dose-dependent effect on both survival and complications in patients with cirrhosis with ARF(HRS and otherwise)and/or SBP.
