Spontaneous bacterial peritonitis

BACKGROUND: Since the beginning of the eighties systematic investigations broadened our knowledge about the clinical picture of spontaneous bacterial peritonitis very much. Important insights into epidemiology, pathogenesis, symptomatology, diagnosis and therapy of this disease, which is a frequent complication in patients with cirrhosis of the liver and ascites, could be gained. Actual research work primarily deals with questions of therapy and prophylaxis. AIM: Aim of this review is a comprehensive presentation of the different aspects of this disease on the basis of the present literature. CONCLUSIONS: As on the one side the clinical symptoms may be very little and on the other side the prognosis is very bad, it is extremely important to take this entity into the differential considerations to make an early diagnosis and to start an adequate therapy early.     

Spontaneous bacterial peritonitis in liver failure

Cirrhosis of the liver results from a variety of mechanisms that cause progressive hepatic injury. It is the sixth leading cause of death in all patients between the ages of 35 and 55. This study attempts to correlate the morbidity and mortality of spontaneous bacterial peritonitis in liver failure patients to numerous etiologic and clinical variables. A retrospective review of 26 patients with spontaneous bacterial peritonitis associated with chronic liver disease was performed in a university hospital. Demographics (age and gender), clinical variables (etiology of liver failure, Child's classification, prior history of ascites, fever, abdominal pain, encephalopathy, and upper gastrointestinal hemorrhage), and laboratory variables (ascitic polymorphonuclearcyte count and cultures, serum albumin, bilirubin, creatinine, and prothrombin time) were studied. All of the patients had Child's C liver disease. Mortality rate was 46 per cent. Alcohol (46%) and hepatitis (30%) were the most common etiologies. Escherichia coli and Klebsiella pneumoniae were the most common culture isolates. All of the infections were monomicrobial. The only significant predictor of mortality (P < 0.05) in this study was the peritoneal fluid polymorphonuclear (PMN) cell count. PMN count >1000 PMN/mm3 was associated with a mortality of 88 per cent. Few patients with spontaneous bacterial peritonitis are ultimately transplanted.     

Spontaneous bacterial peritonitis associated with acute viral hepatitis

Spontaneous bacterial peritonitis (SBP) occurs most frequently in patients with cirrhosis and preexistent ascites; SBP has not been previously recognized in association with acute liver disease. We report two patients with acute hepatitis B infection who developed SBP. Patient 1 had Streptococcus pneumoniae peritonitis and bacteremia, but did not have ascites until after the peritoneal infection was evident. Subsequent liver biopsy and follow-up studies confirmed the clinical diagnosis of acute hepatitis. Patient 2 had submassive hepatic necrosis due to hepatitis B and developed ascites before Streptococcus fecalis SBP. Although the association of SBP with acute hepatic injury is rare, these two patients illustrate that the syndrome of SBP does occur with acute liver disease.     

Spontaneous bacterial peritonitis in the cirrhotic patient

Spontaneous bacterial peritonitis in cirrhotic patients is a severe complication which frequently decompensate the underlying disease and which is associated, even in our days, to a 50% mortality. Hence, the relevance of an adequate exploration, as weil as an early treatment. The acknowledge of several variants, as are the concepts of bacterascites and neutrocytic ascites with negative culture required the use of updated diagnostic criteria. In addition to the already known clinical and bacteriological characteristics of the ascitic fluid infection, we have also intended to review new aspects of this entity referred to in the literature published in the past years, as are the followings; study of possible predictive factors of this complication and factors which have an influence on its mortality, in order to be able to implement the most adequate preventive its mortality, in order to be able to implement the most adequate preventive its mortality, in order to be able to implement the most adequate preventive and curative therapeutics.     

Laparoscopically guided peritoneal insertion in ventriculoperitoneal shunts

A technique of laparoscopically guided insertion of the peritoneal end of ventriculoperitoneal shunts is described. Eleven consecutive cases were done in this manner. There were no failures in inserting the peritoneal end of the ventriculoperitoneal shunt catheter. By way of comparison, 11 previous cases were reviewed. These were done through standard open methods. There were two failures in the open technique group. One of the failures was the result of insertion of the peritoneal end into the subcutaneous layer in an extremely obese patient. It is our belief that this technique deserves consideration when a ventriculoperitoneal shunt is contemplated in adults.     

Small intestine dysmotility and bacterial overgrowth in cirrhotic patients with spontaneous bacterial peritonitis

Patients with bacterial overgrowth of the small intestine developed spontaneous bacterial peritonitis (SBP) more frequently than patients without bacterial overgrowth of the small intestine. The objective of this study was to determine whether the incidences of small intestine dysmotility and bacterial overgrowth are higher in cirrhotic patients with a history of SBP than in cirrhotic patients without SBP. Forty cirrhotic patients were enrolled in this study. There were 20 patients with a history of SBP and 20 patients without a history of SBP. Small intestine bacterial overgrowth was diagnosed by breath hydrogen test. Small intestine motility was recorded, by a 3-channel solid-state manometric catheter, for 24 hours. There were no statistical differences in age or sex between the two groups. The Child-Pugh scores in the SBP group were higher than in the non-SBP group (10.5 +/- 2.1 vs. 8.1 +/- 1.9, P < .01). The incidence of bacterial overgrowth of the small intestine was higher in the SBP group than in the non-SBP group (70% vs. 20%, P < .01). The amplitude and duration of migrating motor complex (MMC) activity fronts, as well as the number of clusters per hour, were similar in both groups. However, the frequency of MMC activity fronts was higher in the non-SBP group than in the SBP group (4.8 +/- 2.3/24 hours vs. 3.5 +/- 1.2/24 hours, P < .05). In addition, the MMC velocity was significantly higher in the non-SBP group (8.3 +/- 2.6 vs. 5.3 +/- 2.1 cm/min, P < .01). The incidence of bacterial overgrowth of the small intestine was higher in cirrhotic patients with history of SBP than in those without SBP. Small intestine motility dysfunction was more severe in cirrhotic patients with history of SBP. Impaired motility of the small intestine, causing bacterial overgrowth of the small intestine, may be one of the explanations for recurrent SBP in cirrhotic patients.     

Spontaneous bacterial peritonitis: clinical study, microbiological findings and clinical course

One hundred and forty-four episodes of spontaneous bacterial peritonitis (SBP) treated in our service between July 1988 and September 1995 were studied retrospectively to assess the clinical presentation, microbiological findings, possible pathogens, treatment and course. Ascites, abdominal pain and fever were the most common symptoms. Only 3.5% of cases were asymptomatic. The outcome was fatal in 12 (8.33%). Among the factors analyzed, only a prothrombin time of less than 35% correlated significantly with a higher mortality rate (60% and 8.33%, respectively; p < 0.01). Ascitic fluid culture was positive in 43.05% of cases; significant differences existed between these patients and those with negative ascitic fluid culture with respect to clinical findings or course. Gram-negative microorganisms were those most frequently isolated (48.38%). Treatment was initiated within 12 hours in 77.7% of the patients, between 12 and 72 hours in 11.8% and later in 10.41%. Intravenous cefotaxime was administered in 86.1% of cases and other drugs or drug combinations in only 13.9%; the mortality rate was much lower with cefotaxime (2.4% vs 45%; p < 0.01).     

Antibiotic concentrations in ascitic fluid of patients with ascites and bacterial peritonitis

Thirty-six paired specimens of serum and ascitic fluid from 21 patients with peritonitis and ascites, most with sponetaneous bacterial peritonitis and alcoholic cirrhosis, were assayed for antibiotic content. Antibiotics assayed and number of determinations were gentamicin, 14; tobramycin, 7; ampicillin, 5; clindamycin, 3; penicillin G, 2; cephalothin, 2; chloramphenico, 2; and cefazolin, 1. In 31 pared specimens the ascitic fluid antibiotic concentration was about one half or more of the simultaneous serum level and in 17 assays exceeded 90% of the serum level. All antibiotics studied penetrated ascitic fluid equally well. Clinical response to antibiotic therapy was good in 12 of 16 patients with culture-proven bacterial peritonitis. Antibiotic levels in ascitic fluid exceeded the minimal inhibitory concentration of the infecting organisms in all but one patient who responded. Direct intraperitoneal instillation of antibiotics does not appear to be necessary routinely; however, there may be an initial lag of several hours before antibiotic concentrations is ascites achieve therapeutic levels.     

Spontaneous pneumoperitoneum without peritonitis

We report one case of spontaneum pneumoperitoneum without peritonitis in a male newborn was admitted in Infantil Robert Reid Cabral Hospital. Many radiological studies were carried out. Its treatment was conservative. The child had excellent evolution. We recommend this treatment for all the patient who has the same features.     

Laparoscopic surgery in children with ventriculoperitoneal shunts: effect of pneumoperitoneum on intracranial pressure--preliminary experience

Toxic disease in livestock caused by the shrubs Baccharis coridifolia and Baccharis artemisioides is very common in Argentina. The toxicity of Argentinian and Brazilian B. coridifolia plants and of Argentinian B. artemisioides was investigated. The toxicogenic capacity of 15 endothyte isolates of Ceratopicnidium baccharidicola from B. coridifolia was determined. Roridins and verrucarins were analyzed by thin-layer chromatography using a modified Jarvis method. One-hundred per cent of Argentinian B. coridifolia plants were positive for roridins (RA and RE) and verrucarins (VA and VJ), 16.2% for RD and 2.7% for RH. All of the Brazilian B. coridifolia plants were positive only for roridins. In B. artemisioides plants, RA, RE and RD were present in higher concentrations than VA and VJ, and all of them were more concentrated than in B. coridifolia. One-third of the endophyte isolates were toxicogenic for the same roridins and verrucarins, but in very low concentrations. This is the first report of macrocyclic trichothecenes in B. artemisioides, and a new report of B. coridifolia macrocyclic trichothecenes in Argentina.     

Therapy of spontaneous bacterial peritonitis

The outcome of untreated spontaneous bacterial peritonitis (SBP) is fatal. In the onset of SBP clinical manifestations may be subtle, therefore every patient with hepatogenic ascites has to be examined for SBP at admission. If polynuclear cell count in ascitic fluid exceeds 250/microliter, antibiotic therapy has to begin immediately, until irreversible complications develop. Aerobic gram-negative bacilli of the normal intestinal flora are responsible for most cases of SBP, followed by gram-positive organisms and anaerobes. Antibiotic agents with extended spectrum, such as third-generation cephalosporins are considered the drugs of choice for SBP. In severe cases combination with metronidazole is recommended. As soon as repeated paracenteses show polynuclear cells beyond 250/microliter, the antibiotic therapy can be stopped. Selective decontamination of the gut with norfloxacin is effective to prevent SBP in high-risk patients. Trimethoprim-sulfamethoxazole is superior due to its activity even against gram-positive organisms. Overall prognosis of patients with SBP, however, is determined mainly to complications specific for cirrhosis, e.g. variceal bleeding, coma etc.     

Macrophages and mesothelial cells in bacterial peritonitis

Research in recent years has examined the mechanisms underlying cellular host defence in the peritoneal cavity. These studies have established that the resident cells of the peritoneal cavity, the peritoneal macrophages (PM phi) and the mesothelial cells (HPMC) contribute to the initiation, amplification and resolution of peritoneal inflammation. Ex vivo measurements of intra-peritoneal inflammatory mediators during peritonitis has elucidated the time courses for the generation of proinflammatory, chemotactic and anti-inflammatory cytokines and have identified that their secretion occurs largely within the peritoneum. These studies provide evidence that both PM phi- and HPMC-derived mediators are directly involved in controlling inflammation. It has been widely accepted that resident PM phi form the first line of defence against peritoneal infection, a more contemporary view would suggest that the direct or indirect (via secreted pro-inflammatory cytokines) interaction between PM phi and HPMC is pivotal to the activation and subsequent amplification of the peritoneum's response to infection. Whilst the site of these interactions is unknown, considerable evidence suggests that it occurs on the surface of the mesothelium, where invading micro-organisms may colonize. In this respect Staphylococcal exoproducts can directly activate HPMC cytokine synthesis. Once the inflammatory response is initiated, recent evidence suggests, that mesothelial cells upon activation by PM phi-derived IL-1 beta and TNF-alpha, are capable of amplifying inflammation and generating signals (via the creation of a gradient of chemotactic cytokines, IL-8, MCP-1 and RANTES) for the recruitment of leukocytes into the peritoneum. This process is also facilitated via the cytokine driven up-regulation of adhesion molecule expression (ICAM-1 and VCAM-1) on HPMC. Much less is understood about the mechanisms by which inflammation is resolved, although the secretion of anti-inflammatory molecules (IL-6, IL-1ra and soluble TNF-p55/75) by receptors by PM phi and HPMC may be important in the process. The existence of a peritoneal cytokine network controlling inflammation is now well established, within this the interaction of PM phi and HPMC appears to play a pivotal role in the hosts response to peritoneal infection.     

Evaluation of the therapeutic effect of pefloxacin in comparison with ampicillin and gentamicin in cirrhotic patients with spontaneous bacterial peritonitis

BACKGROUND/AIMS: Hepatic cirrhosis is a common, chronic disease. Spontaneous bacterial peritonitis (SBP) is a dangerous complication, which must be treated as soon as it has been diagnosed. This usually requires hospitalization of the patient and parenteral antibiotic therapy for 10 to 14 days. The present study was carried out to compare the therapeutic effects of pefloxacin with ampicillin plus gentamicin in the management of SBP. METHODOLOGY: The patients were divided into two groups at random. Group A consisted of nine patients who received parenteral ampicillin plus gentamicin. Group B consisted of thirteen patients who received pefloxacin. RESULTS: 55% of patients in group A and 100% of patients in group B responded to treatment. No major side effects were observed in either of the groups. CONCLUSIONS: Considering the benefits of oral treatment and the low incidence of side effects of pefloxacin we conclude that this regimen should be the treatment of choice for SBP patients, especially when there is a shortage of hospital beds.     

Effectiveness of continuous drainage in diffuse bacterial peritonitis

From 1975 to 1977 we carried out postoperative, continuous peritoneal lavage of th abdomen in 41 patients with diffuse bacterial peritonitis. Although the peritonitis was arrested more frequently and earlier, comparison to 71 patients treated conventionally since 1970 showed an increase of wound complications and a prolongation of hospital stay from 25 to 44 days. The higher frequency of complications led to increased lethality from 42% to 54%. The harm by continuous peritoneal lavage out-weights the advantages, except for stercoraceous peritonitis.     

Cost-analysis of prophylactic antibiotics in spontaneous bacterial peritonitis

BACKGROUND & AIMS: Antibiotic prophylaxis has been shown to decrease the incidence of spontaneous bacterial peritonitis (SBP) in patients with cirrhosis and ascites. The aim of this study was to test whether antibiotic prophylaxis for SBP is cost-effective and to compare the costs associated with different patient groups and treatment strategies. METHODS: A cost-effectiveness analysis was performed using a Markov chain model. The costs incurred during 1-year treatment with prophylactic antibiotics vs. no prophylaxis in patients with cirrhosis and ascites were calculated. The incidence rates of primary and recurrent SBP and the mortality rate of SBP were obtained from the literature. Total direct costs of SBP treatment were determined from the wholesale price of drugs and from disbursements by the Health Care Financing Administration. RESULTS: Norfloxacin prophylaxis resulted in savings between $2216 and $8545 per patient per year, depending on the patient group studied. Trimethoprim-sulfamethoxazole prophylaxis resulted in savings between $2934 and $9251 per patient per year. The groups that benefited most from prophylaxis were patients with an ascitic fluid total protein concentration of < or = 1 g/dL and those with a previous history of SBP. CONCLUSIONS: The use of prophylactic antibiotics to decrease the incidence of SBP is a cost-saving strategy in patients with cirrhosis and ascites.