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.     

Coagulative and fibrinolytic activation in cerebrospinal fluid and plasma after subarachnoid hemorrhage

OBJECTIVE: Intrathecal fibrinolytic therapy has been used as one of the anticerebral vasospasm (VS) preventative therapies in patients with subarachnoid hemorrhage (SAH). However, the changes in coagulation and fibrinolysis in the blood and cerebrospinal fluid (CSF) after SAH remain unknown. METHODS: Fifty patients with SAH caused by ruptured cerebral aneurysms were studied postoperatively to detect the serial changes of the thrombin-antithrombin III complex, active plasminogen activator inhibitor (PAI)-1, and tissue plasminogen activator (tPA)-PAI complex (tPA-PAI) activities in the plasma and CSF collected from cisternal drainage catheters. RESULTS: The CSF levels of all parameters and plasma PAI-1 levels were significantly higher in patients with severe SAH than in those with mild SAH. There was no relationship between the CSF and plasma levels of these parameters (except the CSF levels of tPA-PAI) and the initial neurological statuses. The CSF PAI-1 levels increased to greater than 20 ng/ml near the time of the occurrence of cerebral VS, whereas they remained below 20 ng/ml in patients without VS. The CSF tPA-PAI levels showed the highest peak near the time of VS remission. The CSF PAI-1 and tPA-PAI levels were significantly lower in patients with good outcomes than in those with poor outcomes. CONCLUSION: Both the coagulative and fibrinolytic systems were activated in the CSF and plasma after SAH in correlating to the amount of SAH clot. The intrathecal administration of fibrinolytic agents should be started early after surgery, before CSF PAI-1 levels increase, for patients with severe SAH. Patients with CSF PAI-1 levels greater than 20 ng/ml experienced high incidence of VS and poor outcomes.     

Paradoxical conditioning of the plasma copper and corticosterone responses to bacterial endotoxin

The cascade of physiologic mechanisms in response to infection, the acute phase response, is recognized as having a major role in host defense. Two such responses are an increase in plasma copper and activation of the hypothalamic-pituitary-adrenal axis, which are consistently reported to occur during bacterial infection. We aimed to determine whether the alterations in plasma copper and corticosterone were conditionable using the conditioned taste aversion paradigm. The regime involved the pairing of a novel-tasting saccharine solution (the conditioned stimulus) with lipopolysaccharide (the unconditioned stimulus). Seven days after the initial pairing of these stimuli (the test day), the saccharine solution was represented. Animals exposed to this condition displayed a significant decrease in plasma copper levels. In addition, these rats experienced a reduction in plasma corticosterone that was time dependent. Paradoxically, the conditioned response of both these variables were in a direction contrary to that reported during bacterial infection. These results suggest that some acute phase responses may condition as a rebound response, or in an opposing trend to that occurring as the initial reaction.     

Biochemical analysis of peritoneal fluid in patients with and without bacterial infection

PURPOSE: The maximum preload torque of implant prosthetic retaining screws from four manufacturers and of two alloy types was measured to determine one index of interchangeability of intersystem components. MATERIALS AND METHODS: Implant prosthetic retaining screws from four manufacturers (3i Implant Innovations Inc, West Palm Beach, FL; Impla-Med Inc, Sunrise, FL; Nobelpharma USA Inc, Chicago, IL; and Implant Support Systems Inc, Irvine, CA) and of two metal types (gold and titanium) were investigated using an in vitro simulation model. Five screws of each type were tightened down against a gold cylinder using a Tohnichi BTG-6 torque gauge (Tohnichi American Corporation, Northbrook, IL) until fracture occurred. RESULTS: The 3i Implant Innovations gold and the Nobelpharma gold were not significantly different. The 3i Implant Innovations titanium and the Impla-Med gold were able to withstand less preload torque than the 3i Implant Innovations gold and the Nobelpharma gold. The Implant Support Systems titanium was able to withstand significantly more preload torque than all of the other screws. CONCLUSIONS: Interchanging implant prosthetic retaining screws could introduce new and unknown variables that may affect the long-term survival of implant fixtures and/or the implant prostheses.     

In vitro culture of human peritoneal fluid cells

The author has studied the behaviour of cells from human ascitic fluid in long-term culture (5-6 months). Three cellular types are described with different morphological features, namely the cellular shape, the fashion in which the cell spreads on the glass, the nucleocytoplasmic ratio, the chromatin appearance and the abundance of mitochondria. The three cellular types can phagocytose, but each one in a different way. The first one phagocytoses exclusively erythrocytes 'by contact' without emission of pseudopods; the second one phagocytoses degenerating nucleated cells in the same way as the first; the third type phagocytoses degenerating nucleated cells by emission of long pseudopods. The origin of these three cellular types is discussed; it is felt that they are transformed mesothelial cells. According to this study, it cannot be excluded, especially for the second and the third type, that they are histiocytes coming from serous membranes. The life in vitro of the three cellular types is depending upon the composition of nourishing medium. Cells can divide by mitosis only during the first 10 - 15 days of culture (mitotic index 0.1-3.0(0/00). Nuclear amitosis, nucleolus expulsion into cytoplasm and cytoplasmatic DNA synthesis can be observed in healthy cells.     

Changes in human amniotic fluid fibrinolytic inhibitor levels during pregnancy

The amniotic fluid (AF) when incubated with the patient's own plasma diminishes the lytic activity of the plasma. It is suggested that this inhibition is due to the presence of fibrinolytic inhibitors in the AF. The inhibitors rate increases as pregnancy advances. Evaluating these inhibitors in a group of 65 women before and after the 38th week of pregnancy, a higher rate of fibrinolytic inhibitors is found after the 38th week. The said differences are statistically significant. For the moment it does not seem that the increasing of the inhibitors in the last part of pregnancy might be used as a fetal maturity test.     

Nitric oxide production by peritoneal macrophages of cirrhotic rats: a host response against bacterial peritonitis

BACKGROUND & AIMS: Patients and rats with cirrhosis and ascites are prone to develop peritonitis. The aim of this study was to assess whether peritoneal macrophages of cirrhotic rats without peritoneal infection produce nitric oxide and express inducible NO synthase (iNOS). METHODS: NO2- accumulation produced by macrophages from control rats and cirrhotic rats with ascites was determined. iNOS messenger RNA and protein expression were analyzed by Northern and Western blot and immunocytochemical analysis. The in vivo effects of inhibiting iNOS were investigated by giving the specific iNOS inhibitor L-N-(1-iminoethyl)-lysine (L-NIL) or sterile saline to 9 and 7 cirrhotic rats with ascites, respectively. RESULTS: Cirrhotic macrophages produced NO2- that was around fourfold greater than that of control macrophages after 30 hours in culture. Northern and Western blot and immunocytochemical analysis showed the presence of iNOS messenger RNA and protein in macrophages of cirrhotic rats. Ascites cultures were positive in all rats administered L-NIL and negative in those administered saline. CONCLUSIONS: Macrophages of cirrhotic rats produce NO and express iNOS messenger RNA and protein, and these changes are not a consequence of overt bacterial infection. Because iNOS inhibition results in peritoneal infection, these results suggest that iNOS induction in macrophages of cirrhotic rats is a host defense response to prevent bacterial peritonitis.     

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.     

Coagulation/fibrinolytic system and platelet in acute coronary syndrome]

Coagulation/fibrinolytic system and platelet function play roles not only in the onset of acute coronary syndrome (ACS) but also in the development of atherosclerosis, which is a major underlying condition of ACS. In this paper we reviewed the involvement of coagulation/fibrinolytic system and platelet in coronary atherosclerosis and ACS. It is well known that hyperchoresterolemia and diabetes mellitus (DM) are the important risk factor for coronary atherosclerosis and ACS. Both oxidized LDL and advanced glycation endproduct (AGE) activate endothelial cells with down-regulating thrombomodulin and tissue plasminogen activator(t-PA) expression. Moreover the oxidized LDL and AGE up-regulate the expression of tissue factor, and t-PA inhibitor, PAI-1. Thus Ox-LDL and AGE impair the endothelial antithrombotic function and result ACS. These may explain the pathomechanism of coronary sclerosis and ACS. In the atherosclerotic lesion with narrowing the lumen, high shear stress may be occurred. Recent observations suggested that high shear stress induces platelets aggregation named as shear stress induced platelet aggregation (SIPA), which may also have very important role for the pathogenesis in ACS.     

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.     

Coagulation and fibrinolytic properties of peripheral venous blood in chronic ectopic pregnancy

The coagulation and fibrinolytic properties of peripheral venous blood was studied in 10 Black patients with chronic ectopic pregnancy. There were significant elevations of plasma fibrinogen and serum fibrin-fibrinogen degradation products (FDP) and prolongation of the euglobulin lysis time. These features are believed to be compatible with chronic inflammation. No evidence of a haemostatic defect was found.     

Chlamydia trachomatis infection of human mesothelial cells alters proinflammatory, procoagulant, and fibrinolytic responses

In this study we demonstrate the capability of Chlamydia trachomatis to infect cultured human mesothelial cell (MC) monolayers and to induce the production of the proinflammatory cytokines interleukin 1beta (IL-1beta) and IL-8. Seventy-two hours after initial infection, both the procoagulant activity of MC and the activity of the fibrinolytic inhibitor (plasminogen activator inhibitor 1) in the supernatants were enhanced. These findings support the hypothesis that provoked proinflammatory responses contribute to the development of complications after chlamydial infection.     

Role of liver NK cells and peritoneal macrophages in gamma interferon and interleukin-10 production in experimental bacterial peritonitis in mice

Gamma interferon (IFN-gamma), tumor necrosis factor alpha (TNF-alpha), and interleukin-10 (IL-10) production by liver, spleen, lung, peripheral blood mononuclear cells (MNC), and peritoneal exudate cells (PEC) in experimental bacterial peritonitis was examined by cecum ligation and puncture (CLP) (with an 18-gauge needle) of BALB/c mice. MNC of organs were cultured for 18 h, and cytokine levels in supernatants were examined. Cytokines contained in peritoneal lavage fluid were regarded as those produced by PEC. Only liver MNC and PEC produced substantial amounts of IFN-gamma, and PEC were the main source of IL-10, especially 12 h after CLP. As reflected by the cytokine production by liver MNC and PEC, serum IFN-gamma and IL-10 levels were elevated after CLP. C57BL/6 (B6) mice and BALB/c nude mice showed a similar pattern of cytokine production. TNF-alpha levels in culture supernatants, peritoneal lavage fluid, and sera were not significantly elevated compared to those of sham-operated mice. In vivo depletion of NK cells of B6 mice with anti-asialo GM1 or anti-NK1.1 antibody greatly decreased IFN-gamma levels in liver MNC culture supernatants and sera, suggesting that liver NK cells are IFN-gamma producers. On the other hand, plastic-adherent PEC macrophages are the major IL-10 producers. Mice subjected to a cecum ligation and cut procedure (which have a more severe peritonitis) showed much higher IFN-gamma and IL-10 levels than those subjected to CLP, while mice subjected to CLP with a smaller (22-gauge) needle showed low levels of these cytokines. These findings show that liver NK cells and PEC macrophages are important for the production of proinflammatory and anti-inflammatory cytokines in bacterial peritonitis.     

Failure to cure Mycobacterium gordonae peritonitis associated with continuous ambulatory peritoneal dialysis

Nontuberculous mycobacteria are increasingly recognized as important pathogens in peritonitis associated with continuous ambulatory peritoneal dialysis (CAPD). Mycobacterium gordonae rarely causes human infection and is the least likely mycobacterium to produce clinical infection in CAPD patients. We describe a patient with persistent M. gordonae peritonitis acquired while undergoing CAPD. During 18 months of treatment, clinical improvement occurred but a microbiological cure could not be achieved. Principles of therapy for mycobacterial peritonitis developing during CAPD are reviewed, and potential explanations for our patient's failure to respond to therapy are discussed.     

Pathophysiology of peritoneal fluid eosinophilia in peritoneal dialysis patients

This study deals with the stress distribution in concrete deck slabs on composite steel beams used with integral abutment bridges. The applied loading is composed of one or more side-by-side HS20-44 trucks. The finite-element method is used to analyze two bridge structures with different numbers of beams, beam spacings, and supporting piles. The transverse and longitudinal slab stresses in the deck slab are investigated in the positive and negative bending regions near and away from the integral abutment. The slab stresses in the integral abutment bridges are compared with the corresponding stresses induced in the slab of equivalent jointed bridges. The results indicate that integral abutment bridges distribute the loads in the deck slab more uniformly than their jointed counterparts. The maximum stresses in the transverse direction of the slab can be 25–50% lower in the integral bridges than in their corresponding simply supported ones.     

Effects of wine on plasma fibrinolytic and coagulation systems

Energy expenditure was estimated using the doubly-labelled water (DLW) method in summer in five free-living adult, non-pregnant, non-lactating, red deer (Cervus elaphus) hinds (weight 107.3 (SE 0.9) kg; age 6 (SE 1) years) on lowland pasture under typical farming conditions. Climatic conditions were monitored throughout the experiment. Errors due to 2H losses in CH4 and faeces were calculated from previous estimates of stoichiometries. CH4 production, fractionated water loss, urinary N and O2 consumption were estimated using an iterative approach. The water flux (rH2O) in these animals consuming only fresh grass was 12 (SE 0.5) kg/d, the CO2 production (rCO2) was 1271 (SE 40) litres/d and the mean energy expenditure was 25 (SE 0.8) MJ/d. There were no significant differences in the isotope distribution spaces and flux rates, rH2O, rCO2 or energy expenditure using the multi-point or two-point approaches to calculation. The DLW-derived energy expenditure of 25 MJ/d is approximately 20% higher than the recommended intake of 21 MJ/d for adult hinds kept outdoors (Adam, 1986) and, at 757 kJ/kg0.75 per d, one third higher than the value of 570 kJ/kg0.75 per d for stags penned indoors (Key et al. 1984).     

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.     

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.