spontaneous bacterial peritonitis

generation cephalosporin. Nosocomial spontaneous bacterial peritonitis often caused by Gram-positive bacteria and multi-resistant pathogens can also be expected thus carbapenem should be the choice of the empiric treatment. An- tibiotic prophylaxis should be considered. Norfloxacin is used most commonly, but changes are expected due to in- crease in quinolone resistance. As a primary prophylaxis, a short-term antibiotic treatment is recommended after gastrointestinal bleeding for 5 days, while long-term prophylaxis is for patients with low ascites protein, and advanced disease (400 mg/day). Secondary prophylaxis is recommended for all patients recovered from spontaneous bacterial peritonitis. Due to increasing antibiotic use of antibiotics prophylaxis is debated to some degree.

Liver cirrhosis is one of the commonest conditions which leads to a significant morbidity, multiple hospitalisation and mortality throughout the world. Spontaneous Bacterial Peritonitis (SBP) is one of the prevalent conditions associated with liver cirrhosis and as cites increasing its mortality several folds. These patients are prone to multiple infections owing to subdued immune response. This is due to deficient complement system, and diminished activity of neutrophilic and reticuloendothelial systems. This poor immune system leads to development of SBP and also responsible for its recurrence. The risk rises with previous episode of SBP, low ascitic fluid protein concentration (less than 1.5g/dL), high serum bilirubin (above 2.5 mg/dL) along with impaired renal functions and with gastrointestinal hemorrhage. The most common microbes found in the ascitic fluid are gram-negative aerobic bacteria and most common isolates are Escherichia coli (E. coli), Klebsiella pneumoniae and the pneumococci. Third generation cephalosporins are the first line agent to treat SBP. Other antimicrobial agents are amoxicillin/clavulanate, ciprofloxacin etc. Prophylactic therapy play a crucial role in decreasing the chances of infection and themorbidity and morbidity associated with this condition. The prophylactic antimicrobial therapy aims to decrease the bacterial contamination of the gut and prevent the seepage of bacteria from the gut to the ascitic fluid. Norfloxacin is most commonly prescribed antimicrobial therapy as lifelong prophylaxis in SBP. Trimethoprim- Sulfamethoxazole is yet another alternative. In view of such high recurrence and morbidity, early diagnosis, treatment and prophylaxis play a crucial role in determining the prognosis of SBP.

PROPHYLAXIS Prevention of bacterial infection should be considered in patients with liver disorders, who are at a high risk. General measures that have been proposed to reduce the incidence of infections in cirrhotics include discontinuing alcohol intake, reducing the length of hospitalization, avoiding unnecessary instrumentation (especially bladder and IV catheters), improving the nutritional status and treating the complications of cirrhosis such as ascites formation and GI haemorrhage. Because, enteric aerobic gram-negative bacteria are the most frequently isolated bacteria in spontaneous bacterial peritonitis, selective intestinal decontamination (SID) has been proposed as a method for the prevention. SID consists of inhibition of the problematic gram- negative flora of the gut with preservation of commensal bacteria. Anaerobes comprise more than 99% of the gut flora and their presence is very important in preventing intestinal colonistation, overgrowth and subsequent extra–intestinal dissemination of pathogenic bacteria. Randomised clinical trials have demonstrated efficacy of SID in preventing gram negative bacterial infection in neutropenic patients without overgrowth of resistant bacteria or significant side effect.

2 Nootan Pharmaceutical, Barotiwala, Baddi, (HP) 174103 ABSTRACT Spontaneous bacterial peritonitis (SBP) is a frequent and severe complication in cirrhotic patients with ascites. To describe spontaneous bacterial peritonitis (SBP) in the context of currently accepted criteria for diagnosis, treatment and prevention. A review of SBP and its associated etiopathogenic factors is presented. Numerous studies on mechanisms of disease, bacteriology, epidemiology, diagnostic markers, and current guidelines for its diagnosis, treatment and prevention are discussed. Peritonitis in patients with ascites in the absence of secondary causes, such as perforation of a viscus, occurs primarily in patients with end-stage liver disease. Enteric organisms, mainly gram- negative bacilli, probably translocate to regional lymph nodes to produce bacteremia and seeding of ascitic fluid. Signs and symptoms of peritonitis are usually subtle. The ascitic fluid polymorphonuclear leukocyte count is the best determinant for early diagnosis and treatment of SBP. Third-generation cephalosporins such as cefotaxime are considered the drugs of choice for treatment, whereas quinolones such as norfloxacin are used to decrease recurrence. Despite increased awareness, early diagnosis, and prompt and effective antimicrobial therapy, SBP recurs frequently and is associated with a high mortality rate. Patients with SBP should be assessed for candidacy for liver transplantation.

Aim of the work: To compare the level of ascitic fluid C3 concentration in cirrhotic patients with and without spontaneous bacterial peritonitis to determine its possible protective role against acquiring infection. Methods: This is a prospective case-control study in which we recruited 45 cirrhotic patients pre- senting with ascites, of which 25 showed evidence of SBP. All patients had diagnostic paracentesis, received the appropriate treatment, discharged and followed-up monthly for 3 months, with ascitic fluid C3 measurement. Ascitic fluid C3 was compared between both groups at baseline and for three successive reading over 3 months. It was also compared in the same patients group over this interval and correlated with other AF parameters at baseline reading.

Asterixis, a finding in hepatic encephalopathy is caused due to the inability to maintain the posture. An extensor plantar in the Babinski’s response and constructional apraxia are some of the vague physical examination finding. The mainstay of treatment is treating the cause or the precipitating factor. Spontaneous Bacterial Peritonitis is considered to be one of the precipitating feature of hepatic encephalopathy along with other infections like urinary tract infection and pneumonia. Low protein was considered to be part of treatment. But that idea was not that deep rooted. As per new guidelines plant or dairy proteins are considered for the disease as for their favourable protein – calorie ratio. Non absorbable disaccharides like lactulose or lactitol improves the condition as they help in reducing the pH of the stools along with induction of catharsis. In unconscious patients, lactulose can be given as enema to avoid aspiration pneumonia.

Garcia-Tsao, G. (2004). Spontaneous bacterial peritonitis: a his- torical perspective. J Hepatol. 41, 522-7. Gerli, G., Locatelli, G.F., Mongiat, R., Zenoni, L., Agostoni, A. and G. Moschini (1992). Erythrocyte antioxidant activity, se- rum ceruloplasmin and trace element levels in subjects with alcoholic liver disease. Am J Clin Path. 97, 614-8. Guarner, C., Soriano, G., Tomas, A., Bulbena, O., Novella, M.T.

CONCLUSION In the light of above discussion, it can be said that SBP is one of the common complication of cirrhosis of liver with ascites. Poorly managed Spontaneous Bacterial Peritonitis (SBP) may lead to high mortality and morbidity. Diagnostic paracentesis should be advised to all cirrhotic patients with ascites. Ascitic fluid analysis

There are certain additional factors in favor of BT in cirrhosis; the intestinal bacterial overgrowth, the alterations of the intestinal mucosal barrier and the de- ficiencies of the local immune response [7]. The diagnosis of SBP usually fulfilled with either positive ascitic fluid culture, or a polymorph nuclear leukocyte (PMNL) count of >250 cells/μL, or both, in addition to symptoms/signs of spontaneous bacterial peritonitis [8]. Risk Factors of SBP include decompensated cirrhosis and history of SBP [9]. Patients with low complement level have a greatest risk for SBP and those who have low pro- tein levels in the ascitic fluid (<1 g/dL) have a 10-fold higher risk of developing SBP [3]. The association between gastrointestinal bleeding and bacterial infec- tion, that is believed to be related to invasive diagnostic or therapeutic proce- dures, increase bacterial translocation, depression of the reticuloendothelial sys- tem functions caused by hypovolemia and shrinkage of complement levels, that may predispose bleeding patients with cirrhosis to bacteremia [10].

Abstract: Spontaneous bacterial peritonitis is the most frequent bacterial infection in patients with cirrhosis. The reported incidence varies between 7% and 30% in hospitalized patients with cirrhosis and ascites, representing one of their main complications. Outcomes in patients with spontaneous bacterial peritonitis are poor since acute kidney injury, acute-on-chronic liver failure, and death occur in as much as 54%, 60%, and 40% of the patients, respectively, at midterm. Early antibiotic treatment of spontaneous bacterial peritonitis is crucial. However, the landscape of microbiological resistance is continuously changing, with an increasing spread of multidrug-resistant organisms that make its current management more challenging. Thus, the selection of the empirical antibiotic treatment should be guided by the severity and location where the infection was acquired, the risk factors for multidrug-resistant organisms, and the available information on the local expected bacteriology. The use of albumin as a complementary therapy for selected high-risk patients with spontaneous bacterial peritonitis is recommended in addition to antibiotics. Even though antibiotic prophylaxis has proven to be effective to prevent spontane- ous bacterial peritonitis, a careful selection of high-risk candidates is crucial to avoid antibiotic overuse. In this article we review the pathogenesis, risk factors, and prognosis of spontaneous bacterial peritonitis, as well as the current evidence regarding its treatment and prophylaxis.

Copyright © 2015 Neil Gupta et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Henoch-Sch¨onlein purpura (HSP) is a small vessel systemic vasculitis, predominantly affecting children, characterized by a tetrad of manifestations, specifically palpable purpura, arthralgia, abdominal pain, and renal disease. HSP in the adult population is rare, and no case has been described of HSP in liver cirrhosis with spontaneous bacterial peritonitis (SBP). We present the case of a 58- year-old male with liver cirrhosis, who was subsequently diagnosed with SBP and later HSP. In this patient, the diagnosis of HSP was demonstrated clinically by his palpable purpura, diarrhea, hematuria, and abdominal pain and confirmed pathologically by his renal and skin biopsies demonstrating leukocytoclastic vasculitis and IgA complexes. We believe that this is an example of altered IgA processing in cirrhosis leading to the development of IgA immune complexes and ultimately HSP. The patient additionally had SBP, which may have increased his risk for developing HSP given antigen processing by mucosa-associated lymphoid tissues leading to immune complex deposition, which may not have been effectively cleared in the context of his liver disease. The patient unfortunately died of gastrointestinal hemorrhage, which is unclear to be due to his underlying cirrhosis or a gastrointestinal manifestation of HSP itself.

A B S T R A C T Objective: To determine the spontaneous bacterial peritonitis and its common pathogens in HCV Cirrhotic patients. Patients and Methods: This cross-sectional descriptive study was conducted at department of Medicine, Liaquat University Hospital Hyderabad/Jamshoro. This study was carried out for period of six months, i.e. from 1 st March, 2009 to 31 st August, 2009. Patients with liver cirrhosis caused by hepatitis C virus, ranging from 15 to 70 years of age and either gender were included in this study. Ascitic fluid was sent to Diagnostic and Research Laboratory of LUMHS within half hour of collection and ascitic fluid culture was done on blood agar media. TLC count >500-cells/µl or polymorph nuclear leucocyte >250-cells/µl were labelled as SBP positive. Growth positive on different disc was labelled with respect to the positive pathogen. All the data was entered on predesigned proforma.

radiologic findings patients undergoing additional evaluation and liver biopsy. 1 Liver cirrhosis patients were highly susceptible to bacterial infections due to defects in numerous host defense mechanism. 2 Spontaneous bacterial peritonitis (SBP) was commonest infection in cirrhotic patients followed by urinary tract infections (UTIs), pneumonia, and bacteremia. 3 SBP was a commonest infection among patients with cirrhosis and ascites. Apparently, infection can be diagnosed up to 30% of cirrhosis patients with ascites. SBP is associated with significant mortality and morbidity. 3,4 Intestinal bacterial translocation, altered ABSTRACT

In this study, the use of systemic antibiotics within 30 days before SBP diagnosis was an independent predictive factor in patients with cirrhosis and SBP caused by gram-positive bac- terial infections. Innate and adaptive immune dysfunction, also referred to as cirrhosis-associated immune dysfunction syn- drome, is a major component of cirrhosis. 20 Bacterial infections are common and represent important causes of liver-related TABLE 2. Bacteria Isolated From Ascitic Fluid in Patients With Spontaneous Bacterial Peritonitis

Background: Current recommendations for empirical antimicrobial therapy in spontaneous bacterial peritonitis (SBP) are based on quite old trials. Since microbial epidemiology and the management of patients have changed, whether these recommendations are still appropriate must be confirmed. Methods: An observational study that exhaustively collected the clinical and biological data associated with positive ascitic fluid cultures was conducted in four French university hospitals in 2010 – 2011.

Abstract Spontaneous bacterial peritonitis (SBP) in patients with cirrhotic liver disease is a serious complication that contributes to the high morbidity and mortality rate seen in this population. Currently, there is a lack of consensus amongst the research community on the clinical predictors of SBP as well as the risks and benefits of prophylactic antibiotic therapy in these patients. Pharmaco- logical gastric acid suppression (namely with PPIs and H2RAs) are frequently prescribed for these patients, many times without a clear indication, and may contribute to gut bacterial overflow and SBP development. However, this re- mains controversial as there are conflicting findings in SBP prevalence be- tween PPI/H2RA-users and non-users. In addition, studies show recent anti- biotic use, whether for SBP prophylaxis or for another infectious process, ap- pear to be associated with higher rates of SBP and drug-resistant organisms.

Ma, M. (2013) The 22/11 Risk Prediction Model: A Validated Model for Predicting 30-Day Mortality in Patients with Cirrhosis and Spontaneous Bacterial Peritonitis. The American Journal of Gastroenterology, 108, 1473-1479. http://dx.doi.org/10.1038/ajg.2013.204 [28] Yuan, L.Y., Ke, Z.-Q., Wang, M. and Li, Y. (2013) Procalcitonin and C-Reactive Protein in the Diagnosis and Predic- tion of Spontaneous Bacterial Peritonitis Associated with Chronic Severe Hepatitis B. Annals of Laboratory Medicine, 33, 449-454. http://dx.doi.org/10.3343/alm.2013.33.6.449

Spontaneous bacterial peritonitis (SBP) arises from acute bacterial infection of the ascitic fluid. By expanding intravascular volume, intravenous albumin infusion has been shown to prevent renal failure and decrease mortality in patients with SBP. As such, separate clinical guidelines presented by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases (AASLD) recommend that patients with SBP receive albumin, 1,2

ABSTRACT Background: Spontaneous bacterial peritonitis (SBP) is common complication of cirrhosis caused by bacterial translocation. Bacterial colonization and overgrowth may occur in GI tract on suppression of gastric acid secretion. Beta-blockers have been postulated to reduce intestinal permeability. There is no significant Indian study to evaluate association of PPI with SBP in cirrhotic ascites. We aimed to assess the effect of PPI in cirrhotic patients decompensated with ascites.

But the one-year survival rate after recovery from the first episode of SBP is only 30 – 40% [26, 27]. A number of studies have sought to identify prognostic factors in patients with SBP [4, 10, 12, 23, 28, 29]. Consistent with other studies [4, 28, 29], our results show that the Child-Pugh classification, concomitant hepatocellular carcinoma, renal failure presentation and hepatic en- cephalopathy are all significant risk factors for the 30-day mortality associated with SBP. As for nosocomial infections being a prognostic factor for SBP, some diver- gent opinions still exist. In our study, even after adjust- ing for the other prognostic factors associated with mortality, nosocomial SBP (p = 0.044; HR, 1.514; 95% CI, 1.012–2.267) was still identified as an independent risk factor for mortality. This view is consistent with the study findings of Cheong et al, [4] but differs from other studies in Korea [12, 13], which have all highlighted that the acquisition site of infection does not affect the clin- ical outcomes for patients with SBP. Differences in the study populations and variable therapeutic regimens may play a part in this discrepancy. But researchers also think that the high mortality rate for patients with SBP reflects both the presence of infectious diseases and the underlying illness itself. In general, patients with nosoco- mial SBP have more severe underlying illnesses than Table 5 Risk factors for 30-day mortality in patients with spontaneous bacterial peritonitis