5,557

Spontaneous Bacterial Peritonitis among Cirrhotic Patients in Upper Egypt: Clinical and Bacterial Profiles

Nahed A Makhlouf1, Mohamed Ahmed Ghaliony2, Salma Adel El-Dakhli3, Ahmed Mohammed Abu Elfatth4, Amal A Mahmoud5

1 MD, Professor, Tropical Medicine & Gastroenterology Department, Faculty of Medicine, Assiut University, Assiut 71515, Egypt;
2 MD, Assistant Professor of Tropical Medicine and Gastroenterology, Faculty of Medicine, Assiut University, 71515, Egypt;
3 Specialist in Emergency Department, Assiut University Hospital;
4 MSc, Master degree in Tropical Medicine and Gastroenterology, Assistant Lecturer, Faculty of Medicine, Assiut University, 71515, Egypt;
5 MD, Assistant Professor, Department of Clinical Pathology, Faculty of Medicine, Assiut University, Assiut 71515, Egypt.

Conflict-of-interest statement: The author(s) declare(s) that there is no conflict of interest regarding the publication of this paper.

Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http: //creativecommons.org/licenses/by-nc/4.0/

Correspondence to: Nahed A Makhlouf, MD, Professor, Tropical Medicine & Gastroenterology Department, Faculty of Medicine, Assiut University, Assiut 71515, Egypt.
Email: nahedmak@yahoo.com / nahed.mak@aun.edu.eg
Fax: +20-88-2354130

Received: August 10, 2019
Revised: November 2, 2019
Accepted: November 21, 2019
Published online: December 21, 2019

ABSTRACT

Background: Spontaneous bacterial peritonitis (SBP) and its variants represent fatal and serious complications in cirrhosis patients with ascites. However, few detailed data are available regarding the clinical and bacteriological feature of SBP in our Locality. This work aimed to determine the predictors and variants of SBP, and the bacterial pathogens.

Methods: We prospectively analyzed clinical characteristics and bacteriological profiles of 150 cirrhotic patients with ascites.

Results: 53 (35.3%) patients had SBP. 29 (54.7%) patients found to be classical type, 19 (35.8%) patients found to be CNNA, and 5 (9.4%) patients found to have bacterascites. Patients with SBP have higher bilirubin, CRP, INR, MELD score, Child score, and turbid ascites while those with no SBP had significantly higher serum albumin and total proteins. The predictors for SBP were previous history of SBP (OR = 4.56, 95%CI = 1.22- 3.33; p = 0.02) and low albumin in the ascitic fluid (OR= 2.34, 95%CI = 2.01- 4.01; p = 0.03). The most frequently isolated organisms in the 34 patients who have positive culture were E. coli (41.1%) and Staph. aureus (35.3%) followed by Streptococcus (11.7%), Pseudomonas (5.9%) and Pneumococci (5.9%). In the current study, the frequency of gram positive organisms in combination was 52.9% (18/34).

Conclusion: SBP is a serious complication that occurred in cirrhotic patients with ascites so, early empirical antibiotic is a key strategy in improving the prognosis in these patients. The frequency of gram positive organisms in SBP is increasing. It is essential to perform periodic epidemiological and bacteriological surveillance to adapt treatment recommendations.

Key words: SBP; Cirrhosis; Bacterial Profiles

© 2019 The Author(s). Published by ACT Publishing Group Ltd. All rights reserved.

Makhlouf NA, Ghaliony MA, El-Dakhli SA, Abu Elfatth AM, Mahmoud AA. Spontaneous Bacterial Peritonitis among Cirrhotic Patients in Upper Egypt: Clinical and Bacterial Profiles. Journal of Gastroenterology and Hepatology Research 2019; 8(6): 3014-3019 Available from: URL: http://www.ghrnet.org/index.php/joghr/article/view/2754

INTRODUCTION

Bacterial infections in patients with liver cirrhosis are major complication of cirrhosis where 25%-46% of hospitalizations in cirrhotic patients owe to bacterial infection and so, bacterial infections will be associated with acute decompensation events with high morbidity and mortality in such patients[1].

Spontaneous bacterial peritonitis (SBP) is an acute bacterial infection of the ascitic fluid with no an obvious surgically-treatable source. SBP is suspected with presence of manifestations as fever, abdominal pain, or disturbed mental status in patients with cirrhosis and ascites[2].

SBP is considered one of most frequent bacterial infection that occurs in patients with cirrhosis. About 7% and 30% of hospitalized patients with cirrhosis and ascites will develop SBP, representing one of their main complications. Cirrhotic patients with ascites had poor prognosis with development of SBP where acute kidney injury, acute-on-chronic liver failure, and death occur in such patients as much as 54%, 60%, and 40% of the patients, respectively[3].

Additionally, recurrence of SBP is a major problem facing those patients where it reaches up to 70% if no prophylaxis is implemented. For this reason universal secondary antibiotic prophylaxis is recommended, since it decreases the probability of recurrence to 20% with survival improvement[4].

The main action to prevent the majority of complications secondary to SBE is prompt and appropriate empirical antibiotic therapy must be received as early as possible on suspicious of SBP to cover the most commonly isolated bacteria. Based on previous studies, gram-negative bacteria, mainly Enterobacteriaceae, were major accused organisms of SBP and so, third generation cephalosporin are the first empirical line of antibiotics to treat SBP[5].

However, major changes in the bacteriology of infections in patients with cirrhosis occurred over the last few decades with an increasing prevalence of gram-positive, quinolone-resistant, and multidrug-resistant bacteria[2]. A rising prevalence of gram-positive bacteria was reported over the past years in North America, South America, and Europe representing at present 48%-62% of the isolated organisms. The most frequent gram positive isolates are Streptococcus spp., Enterococcus spp., and Staphylococcus spp[6].

Aim of the work: This work was designed to assess the frequency of SBP in patients with liver cirrhosis and ascites in our locality, determine its predictors and identify the bacterial pathogens and their sensitivity pattern to find out the optimal antibiotic choice.

METHODS

Setting and study design

The current study was prospectively performed on 150 patients in the Department of Tropical Medicine & Gastroenterology at Al-Rajhi Liver Hospital, Assiut University in the period between June 2016 and June 2017. After obtaining institute's Ethics committee approval and valid written informed consent, patients were enrolled in the study.

All patients with liver cirrhosis and ascites admitted during the mentioned period were included in our study. Patients who refused to give consent, patients with a documented evidence of intra-abdominal source of infection or patients with ascites due to non-hepatic causes like nephrotic syndrome and congestive cardiac failure were excluded.

We recorded clinical and demographic data (age, sex, symptoms, signs….etc.), disease manifestations (jaundice, ascites, lower limb edema…etc), and laboratory findings (liver function tests, blood urea nitrogen, serum creatinine, international randomized ration, C-reactive protein and complete count), and disease severity based on Child and MELD scores. Abdominal ultrasonography was performed for all patients with a special focus on the liver, spleen and kidney in terms of size and echogenicity, degree of ascites and nature (clear or turbid), presence or absence of bands of adhesion and the presence or absence of Hepacocellular carcinoma (HCC).

Ascitic fluid study

Ascitic fluid samples were extracted at the patient's bedside by aseptic manipulation where about 3 ml of ascitic fluid was used in plain tube for measurement of protein and albumin. Another 2 ml of fluid collected in tubes containing EDTA anticoagulant were used for White blood cell count (WBCs) and Polymorphonulear leucocyte count (PMNL) by automated counter. Ascitic fluid cultured on blood broth (modified culture method and antibiotic sensitivity tests were done in cases of positive growth).

The bacteriologic examination for ascitic fluid was performed using the modified culture method[7]. Briefly, inoculation of 10 mL of the ascitic fluid into blood culture bottles was done. The bottles were kept under both anaerobic and aerobic conditions at 37 0C for about 5 days in BACTEC 9050 automatic blood culture system (Becton-Dickinson Diagnostic Systems, MD, USA). Each bottle was tested every 10 min by the BACTEC instrument. Positive bottles for bacteria were removed from the BACTEC system. Gram staining and sub-culture were done to identify the microorganism.

Diagnosis of SPB

According to ascitic fluid PMNL count and ascitic fluid culture, the following variants were defined[8]: (1) Classical spontaneous bacterial peritonitis variant: In which PMNL count in ascitic fluid was equal to or more than 250/mm3 and ascitic fluid culture was positive; (2) Culture negative neutrocytic ascites variant: In which ascitic fluid culture was negative and diagnosis was based on PMNL count in ascitic fluid was equal to or more than 250/mm3; (3) Bacterascites variant: In which ascitic fluid culture was positive but PMNL count in ascitic fluid was less than 250/mm3.

Empirical antibiotic therapy

Cefotaxime was used as an empirical therapy in all patients with ascitic PMN count ≥ 250 cells/μL, without waiting results of culture. Also, it was used in bacterascites patients with signs of systemic inflammation. Otherwise, those patients required a second paracentesis and patients in whom the repeat PMN count is ≥ 250/μL would be treated for SBP. Based on results of culture and sensitivity, cefotaxime should be changed[9].

Ethics & Consents

The study was approved by the Faculty's ethics committee and permission was obtained from the ethics committee who was assured that confidentiality would be maintained and ethical principles would be followed. A background about the study and its reason was explained, and the targeted population was encouraged to participate without any undue pressure, and a written consent was taken from each participant.

Statistical Analysis

Data was collected and analyzed using SPSS (Statistical Package for the Social Science, version 20, IBM, and Armonk, New York). Continuous data were expressed in form of mean ± SD or median (range) while nominal data were expressed in form of frequency (percentage). Chi²-test was used to compare the nominal data of different groups in the study while student t-test was used to compare the mean of different groups. Multivariate regression analysis was used to determine the risk factors of SBP in patients with liver cirrhosis and ascites. P value was significant if < 0.05.

RESULTS

One hundred and fifty patients with liver cirrhosis and ascites were enrolled in the study, out of them 53 (35.3%) patients developed SBP based on clinical evaluation, and ascitic fluid analysis. We compared both groups with SBP (53) and without (97). It was noticed that the majority of both groups were males. It was noticed that, previous history of SBP, abdominal pain and abdominal tenderness were significantly higher in SBP group. 66% of patients who developed SBP had suspicious of BP a time of admission. Other baseline data are shown in table 1.

Table 2 shows that bilirubin, CRP, INR, MELD score, Child score, and turbid ascites were significantly higher in those patients with SBP while those with no SBP had significantly higher serum albumin and total proteins. By multivariate regression analysis, the current study showed that the predictors for SBP in patients with liver cirrhosis and ascites were previous history of SBP (OR = 4.56, 95% CI = 1.22- 3.33; p = 0.02) and low albumin in the ascitic fluid (OR = 2.34, 95% CI = 2.01- 4.01; p = 0.03) (Table 3).

Out of those patients with SBP, 48 (90.6%) patients had PMNL in the ascitic fluid ≥ 250 /mm3 while 34 (64%) patients of them had positive growth on culture. The most frequently isolated organisms were E. coli (41.1%) and Staph. aureus (35.3%) followed by Streptococcus (11.7%), Pseudomonas (5.9%) and Pneumococci (5.9%). The frequency of Gram positive organisms in combination was 52.9% (18/34). As regards sensitivity tests; all isolated organisms were sensitive to Cefotaximie (3rd generation cephalosporin). Staph.aureus was also sensitive to trimethoprim-sulfamethoxazole, E.coli was sensitive to Tazobactm, and pneumococcus was sensitive to fluroquinolones (Figure 1).

The most frequent variant was classical SBP (54.7%) followed by culture-negative neutrocytic ascites (35.9%) and monomicrobial non-neutrocytic bacterascites (9.4%) (Table 4).

Table 1 Demographic data of the studied patients.
  SBP (n= 53)No SBP (n= 97)P value
Age (years)57.26 ± 14.1555.72 ± 14.140.52
Sex 0.3
Male37 (69.8%)53 (54.6%) 
Female 16 (30.2%)44 (45.4%) 
Residence 0.32
Rural41 (77.4%)70 (72.2%) 
Urban 12 (12.6%)27 (27.8%) 
Comorbidities0.23
No.35 (66%)68 (70.2%) 
Diabetes mellitus11 (21%)15 (15.4%) 
Hypertension4 (7.5%)10 (10.3%) 
Cardiac disease2 (3.7%)4 (4.1%) 
Chronic kidney disease1 (1.8%)0(0%) 
Previous history of SBP21 (39.6%)4 (4.1%)0.03
Abdominal pain 39 (73.6%)49 (50.5%)0.01
Abdominal tenderness 35 (66%)46 (47.4%)0.04
Fever 29 (54.7%)15 (15.5%)0.02
Causes of admission0.04
Suspected SBP35 (66%)0(0%) 
Hematemesis6 (11.3%)45 (46.4%) 
Hepatic encephalopathy2 (3.8%)30 (30.9%) 
Suspected HRS 10 (18.9%) 22 (22.7%) 
Continuous data were expressed in the form of mean (SD) while nominal data in the form of frequency (percentage). P value was significant if < 0.05. SBP: spontaneous bacterial peritonitis; HRS: hepatorenal syndrome

Table 2 Baseline Laboratory and Sonographic Data in both Groups.
Data SBP (n= 53) No SBP (n= 97)P value
Liver function tests
Bilirubin (µmol/l)81.24 ± 21.8741.06 ± 10.980.02
Direct bilirubin (µmol/l)57.5 ± 12.1326.98 ± 8.990.01
Serum albumin (mg/dl)21.20 ± 7.3525.10 ± 5.700.03
Alanine transaminase (U/l)52.09 ± 10.1154.68 ± 13.220.46
Aspartate transaminase (U/L)63.01 ± 17.1366.01 ± 12.670.99
Total protein (mg/dl)65.70 ± 12.4871.96 ± 10.680.03
Kidney function tests
Blood urea nitrogen (mg/dl)15.16 ± 4.099.98 ± 3.020.09
Serum creatinine (mg/dl)1.51 ± 0.541.34 ± 0.650.07
Complete blood picture
Total leucocytic count (x106/ml)9.53 ± 2.708.39 ± 1.730.13
Hemoglobin (g/dl)9.63 ± 1.839.93 ± 1.710.59
Platelets (x106/ml)120.64 ± 35.21113.11 ± 22.980.21
International normalization ratio2.01 ± 0.791.46 ± 0.290.03
Serum electrolytes
Sodium (µmol/l)132.1 ± 5.04136.33 ± 6.650.09
Potassium (µmol/l)4.03 ± 0.953.87 ± 0.630.45
C- reactive protein (mg/dl)45.87 ± 11.0832.10 ± 12.860.03
MELD score 17.24 ± 1.3615.11 ± 1.030.03
Grades of ascites0.9
Mild12 (22.6%)24 (24.7%) 
Moderate30 (56.6%)55 (56.7%) 
Marked 11 (20.8%)18 (18.6%) 
Characteristics of ascites0.02
Clear25 (47.2%)61 (62.9%) 
Turbid 28 (52.8%)36 (37.1%) 
Child classification
B7 (13.2%)46 (47.4%)0.01
C46 (86.8%)51 (52.6%) 
Child score 11.98 ± 2.249.80 ± 1.870.01
Continuous data were expressed in the form of mean (SD) while nominal data in form of frequency (percentage). P value was significant if < 0.05. SBP: spontaneous bacterial peritonitis; MELD: model for end stage liver disease

Table 3 Predictors of SBP in patients with LC and ascites.
Variables Odd's ratio95% confidence intervalP value
Abdominal pain 1.980.40- 1.200.35
Fever 1.020.04- 0.180.21
Previous SBP4.561.22- 3.220.02
Suspected SBP at admission 1.340.09- 1.220.52
Total bilirubin3.022.11- 2.230.21
Total proteins1.221.22- 2.330.67
Prothrombin time 1.230.98- 1.230.36
High C reactive protein 0.991.02- 2.010.45
Low albumin in the ascitic fluid2.342.01- 4.010.03
Child C class1.230.34- 0.990.56
MELD score1.941.01- 2.090.33
P value was significant if< 0.05. MELD: model for end stage liver disease; LC: liver cirrhosis

Table 4 Variants of ascitic fluid infection in the current study.
VariantsAscitic fluid analysisN= 53
Classical SBPPositive culture with PMNL ≥ 250 cell/mm329 (54.7%)
CNNANegative culture with PMNL ≥ 250 cell/mm319 (35.9%)
MNBPositive culture with PMNL < 250 cell/mm35 (9.4%)
Data was expressed in the form of frequency (percentage). SBP, spontaneous bacterial peritonitis; CNNA, culture-negative neutrocytic ascites; MNB, monomicrobial non-neutrocytic bacterascites

Figure 1 Type of isolated organism in patients with SBP and positive culture.

DISCUSSION

We studied 150 patients; 90 males and 60 females. Ascitic fluid samples were obtained from all patients for ascitic fluid analysis, including (PMNL count, total protein and albumin), and bed side culture on blood broth.

Out of them, 53 (35.3%) patients are actually having SBP based on clinical data, and ascitic fluid chemical analysis and culture. In contrast to this result, Bibi et al[10] (2015) revealed that out of the total 152 patients, 38 (25%) patients had SBP but our results were nearly similar to that obtained by Mohammad et al[11] (2016) where 54 (31%) patients out of 176 studied patients were diagnosed as SBP.

Riggio et al[12] (2008) stated that automated cell counter should replace the manual counting for PMNL in the ascitic fluid due to the accuracy and rapid differential counts of leukocytes.

Makhlouf et al[13] (2018) studied 87 cirrhotic patients with ascites (HCV related) from April 2015 to September 2015, and found that 49 (56.3%) patients were defined as SBP which was higher than in the current study. This may be attributed to early recognition and management of risk factors for SBP.

Prior history of SBP in the current study was significantly higher in those with SBP when compared to those without SBP (35.8% versus 4.1%; p = 0.03). Our results were in contrast to the study of Mohammad et al[11] (2016) which showed that only 14 (26%) patients from 54 SBP cases had previous episodes.

Frequency of abdominal pain and tenderness, in our study, were significantly higher in those patients with SBP (73.6% and 66% respectively) in comparison to those with no SBP (50.5% and 47.4% respectively) (p < 0.05). Also, fever was significantly higher in those with SBP (54.7%) in comparison to those with no SBP (15.5%, p = 0.02). Similarly, Makhlouf et al[13] (2018) found that SBP cases had higher percentage of abdominal pain (89.9%), fever (65.3%) and abdominal tenderness (55.1%) than non SBP cases.

Many studies either local or international said SBP had wide, highly variable and non-specific presentation and some patients often being asymptomatic and hence diagnostic paracentesis to confirm the diagnosis is recommended[14]. It is important to point out that SBP may be asymptomatic, particularly in outpatients[15].

In the current study, patients with SBP had significantly higher bilirubin, C- reactive protein, Child score and MELD score and significantly lower serum albumin and total proteins. These results were consistent to that obtained by Huang et al[16] (2011) as regarding bilirubin level, Child score and MELD score, but El-Gendy et al[17] (2014) showed that, there was no significant difference between SBP and non SBP groups as regard to CRP mean value.

Makhlouf et al[13] (2018) found significant difference between both groups regarding total serum bilirubin, and CRP where these values were higher in SBP cases (p value = 0.037, p value = 0.001) respectively. In the current study, frequency of Child C class was significantly higher in patients with SBP which was consistent with the results obtained from the study of Schwabl et al[18] (2015).

We found that ascitic fluid proteins and albumin were significantly lower in those patients with SBP in comparison to those with no SBP. Similarly, Novella et al[19] (1997) found ascitic fluid protein was significantly lower in SBP patients. Also, our study showed similar result to that obtained by Verma et al[20] (2017) who reported that patients with spontaneous bacterial peritonitis were found to have significantly lower ascitic fluid albumin in comparison to patients with sterile cirrhotic ascites.

Out of 53 patients who diagnosed as SBP in this work: 48 (90.6%) patients had ascitic fluid PMNL ≥ 250 cell/ml and in remaining 5 (9.4%) patients had ascitic fluid PMNL < 250 cell/ml. In the present study, from 53 patients who were diagnosed as SBP, there were 29 (54.7%) patients found to be classical type, 19 (35.8%) patients found to be CNNA, and 5(9.4%) patients found to have bacterascites.

Bibi et al[10] (2015) found out of the 38 patients who developed SBP, classical type was present in 8 (21%) patients, CNNA was found in 20 (52.6%), and 10 (21.3%) patients were found to have bacterascites.

The difference between the current study and previous studies could be attributed to the different culture techniques as Pawar et al[21] (1994) has reported a significant association between the culture technique and culture positivity ratio. Also, we used the modified culture method through enrichment in blood culture bottles by immediately placing up to 10 mL of the peritoneal fluid into each blood culture bottle (10 mL/bottle maximum) which may be responsible for the increased detection rate of the causative organism[7].

The most frequent accused organism in the 34 patient who have positive culture in the present study was Escherichia coli where it occurred in 14 (41.1%) patients and was sensitive to Cefotaxime and Tazobactum, followed by Staph.aureus that occurred in 12 (35.3%) patients and was sensitive to Cefotaxime and Septrin followed by Streptococcus (11.7%), Pseudomonas (5.9%) and Pneumococci (5.9%). The other cases that had negative culture, their diagnosis was according to ascitic fluids PMNL count which was equal to or above 250 cell/mm3 where 19 (35.8%) patient, met this criteria and this called culture negative neutrocytic ascites (CNNA) and they were given Cefotaxime.

In the study of Kawale & his co-workers (2017)[22], the ascitic fluid culture was positive in 27 (54%), CNNA was seen in 23 (46%). E coli (40%) was the most commonly found organism in ascitic fluid, followed by streptococcus pneumoniae (8%), Klebsiella (4%), and anaerobe was seen in 2% cases. Mohammad & collaeges (2010)[23] reported that E-coli were isolated from (61.55%) and Streptococci in (15.38%).

In a study done by Tsung & co-workers (2013)[24], they reported that Escherichia coli were detected in (12 of the 47 cases, 25.5%), Klebsiella species (9 cases, 19.1%) and Streptococcus species (9 cases, 19.1%) and the remaining were CNNA.

High rates of resistance against Cephalosporins and Fluoroquinolones were reported from previous studies but international data still suggests a higher sensitivity to these drugs[25].

In the current study, the frequency of gram positive organisms in combination was 52.9% (18/34). Similarly, Alexopoulou et al[26] (2013) reported that gram-positive cocci (GPC) were found to be the most frequent cause in culture-positive SBP in (55%) and a variety of drug - resistant microorganisms have emerged.

In conclusion, SBP is one of the most serious complications that occurred in cirrhotic patients with ascites so, early empirical antibiotic therapy is a key strategy in improving the prognosis in these patients. Primary and secondary spontaneous bacterial peritonitis prophylaxis have proven to be effective, but should be used with caution to reduce the risk of bacterial resistance development. The frequency of gram positive organisms in SBP is increasing. It is essential to perform periodic epidemiological and bacteriological surveillance to adapt treatment recommendations.

Acknowledgment

The research team would like to thank staff members and laboratory Technicians at the Department of Clinical Pathology for their assistance and doing all the routine laboratory work related to this study. The authors would like to thank Health Care Workers at Tropical Medicine and Gastroenterology Department at Al-Rajhi Liver Hospital for their help during the study.

REFERENCES

1. Arvaniti V, D'Amico G, Fede G, Manousou P, Tsochatzis E, Pleguezuelo M, Burroughs AK. Infections in Patients With Cirrhosis Increase Mortality Four-Fold and Should Be Used in Determining Prognosis. Gastroenterology. 2010; 139(4): 1246-56.e5. [PMID: 20558165]; [DOI: 10.1053/j.gastro.2010.06.019]

2. Fernández J, Acevedo J, Castro M, Garcia O, de Lope CR, Roca D, Pavesi M, Sola E, Moreira L, Silva A, Seva-Pereira T, Corradi F, Mensa J, Ginès P, Arroyo V. Prevalence and risk factors of infections by multiresistant bacteria in cirrhosis: A prospective study. Hepatology. 2012; 55(5): 1551-61. [PMID: 22183941]; [DOI: 10.1002/hep.25532]

3. Marciano S, Díaz JM, Dirchwolf M, Gadano A. Spontaneous bacterial peritonitis in patients with cirrhosis: incidence, outcomes, and treatment strategies. Hepat Med. 2019; 11: 13-22. [PMID: 30666172]; [PMCID: PMC6336019]; [DOI: 10.2147/HMER.S164250]

4. Sreenivasulu V, Bheemasenachari M. Study of prevalence of spontaneous bacterial peritonitis in cirrhosis of liver with ascites. J Evol Med Dent Sci. 2016; 5(44): 2720-4.

5. Liver EAftSot. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. Journal of hepatology. 2018; 69(2): 406-60. [PMID: 29653741]; [DOI: 10.1016/j.jhep.2018.03.024]

6. Fiore M, Maraolo AE, Gentile I, Borgia G, Leone S, Sansone P, Passavanti MB, Aurilio C, Pace MC. Current concepts and future strategies in the antimicrobial therapy of emerging Gram-positive spontaneous bacterial peritonitis. World journal of hepatology. 2017; 9(30): 1166. [PMID: 29109849]; [PMCID: PMC5666303]; [DOI: 10.4254/wjh.v9.i30.1166]

7. Akcam FZ, Yayli G, Uskun E, Kaya O, Demir C. Evaluation of the Bactec microbial detection system for culturing miscellaneous sterile body fluids. Research in microbiology. 2006; 157(5): 433-6. [PMID: 16364602]; [DOI: 10.1016/j.resmic.2005.10.005]

8. Liver EAFTSOT. EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. Journal of Hepatology. 2010; 53(3): 397. [PMID: 20633946]; [DOI: 10.1016/j.jhep.2010.05.004

9. Ning N-z, Li T, Zhang J-l, Qu F, Huang J, Liu X, Li Z, Geng W, Fu JL, Huan W, Zhang SY, Bao CM, Wang H. Clinical and bacteriological features and prognosis of ascitic fluid infection in Chinese patients with cirrhosis. BMC infectious diseases. 2018; 18(1): 253. [PMID: 29866104]; [PMCID: PMC5987451]; [DOI: 10.1186/s12879-018-3101-1]

10. Bibi S, Ahmed W, Arif A, Khan F, Alam SE. Clinical, laboratory and bacterial profile of spontaneous bacterial peritonitis in chronic liver disease patients. J Coll Physicians Surg Pak. 2015; 25(2): 95-9. [PMID: 25703750]; [DOI: 02.2015/JCPSP.9599]

11. Mohammad AN, Yousef LM, Mohamed HS. Prevalence and predictors of spontaneous bacterial peritonitis: does low zinc level play any role? Al-Azhar Assiut Medical Journal. 2016; 14(1): 37.

12. Riggio O, Angeloni S, Parente A, Leboffe C, Pinto G, Aronne T, et al. Accuracy of the automated cell counters for management of spontaneous bacterial peritonitis. World journal of gastroenterology: WJG. 2008; 14(37): 5689. [PMID: 18837085]; [PMCID: PMC2748203]; [DOI: 10.3748/wjg.14.5689]

13. Makhlouf NA, Morsy KH, Mahmoud AA, Hassaballa AE. Diagnostic Value of Ascitic Fluid Lactoferrin, Calprotectin, and Calprotectin to Albumin Ratio in Spontaneous Bacterial Peritonitis. International Journal of Current Microbiology and Applied Sciences. 2018; 7(2): 2618-31.

14. Căruntu FA, Benea L. Spontaneous bacterial peritonitis: pathogenesis, diagnosis, treatment. J Gastrointestin Liver Dis. 2006; 15(1): 51-6. [PMID: 16680233]

15. Nousbaum JB, Cadranel JF, Nahon P, Khac EN, Moreau R, Thévenot T, Silvain C, Bureau C, Nouel O, Pilette C, Paupard T, Vanbiervliet G, Oberti F, Davion T, Jouannaud V, Roche B, Bernard PH, Beaulieu S, Danne O, Thabut D, Chagneau-Derrode C, de Lédinghen V, Mathurin P, Pauwels A, Bronowicki JP, Habersetzer F, Abergel A, Audigier JC, Sapey T, Grangé JD, Tran A; Club Francophone pour l'Etude de l'Hypertension Portale; Association Nationale des Hépato-Gastroentérologues des Hôpitaux Généraux de France. Diagnostic accuracy of the Multistix 8 SG reagent strip in diagnosis of spontaneous bacterial peritonitis. Hepatology. 2007; 45(5): 1275-81. [PMID: 17464969]; [DOI: 10.1002/hep.21588]

16. Huang CH, Lin CY, Sheen IS, Chen WT, Lin TN, Ho YP, Chiu CT. Recurrence of spontaneous bacterial peritonitis in cirrhotic patients non-prophylactically treated with norfloxacin: serum albumin as an easy but reliable predictive factor. Liver International. 2011; 31(2): 184-91. [PMID: 21143367]; [DOI: 10.1111/j.1478-3231.2010.02377.x]

17. El-Gendy NA, Tawfeek NA, Saleh RA, Radwan EE, Ahmad EE, Mohammed RA. Diagnosis of spontaneous bacterial peritonitis. The Egyptian Journal of Internal Medicine. 2014; 26(2): 53.

18. Schwabl P, Bucsics T, Soucek K, Mandorfer M, Bota S, Blacky A, Hirschl AM, Ferlitsch A, Trauner M, Peck-Radosavljevic M. Risk factors for development of spontaneous bacterial peritonitis and subsequent mortality in cirrhotic patients with ascites. Liver International. 2015; 35(9): 2121-8. [PMID: 25644943]; [DOI: 10.1111/liv.12795]

19. Novella M, Sola R, Soriano G, Andreu M, Gana J, Ortiz J, Coll S, Sàbat M, Vila MC, Guarner C, Vilardell F. Continuous versus inpatient prophylaxis of the first episode of spontaneous bacterial peritonitis with norfloxacin. Hepatology. 1997; 25(3): 532-6. [PMID: 9049193]; [DOI: 10.1002/hep.510250306]

20. Verma RK, Giri R, Agarwal M, Srivastava V. To study the relation between spontaneous bacterial peritonitis and serum ascitis albumin gradient in chronic liver disease patients. International Journal of Research in Medical Sciences. 2017; 5(8): 3654.

21. Pawar G, Gupta M, Satija V. Evaluation of culture techniques for detection of spontaneous bacterial peritonitis in cirrhotic ascites. Indian journal of gastroenterology: official journal of the Indian Society of Gastroenterology. 1994; 13(4): 139-40.

22. Kawale JB, Rawat KJ. Study of etiology, clinical profile and predictive factors of spontaneous bacterial peritonitis in cirrhosis of liver. International Journal of Research in Medical Sciences. 2017; 5(6): 2326.

23. Mohammad T, Ali A. Noor-ul-iman, Yield of ascetic fluid culture in SBP in Cirrhosis. J Med Sci. 2010; 18(1): 59-62.

24. Tsung PC, Ryu SH, Cha IH, Cho HW, Kim JN, Kim YS, et al. Predictive factors that influence the survival rates in liver cirrhosis patients with spontaneous bacterial peritonitis. Clinical and molecular hepatology. 2013; 19(2): 131. [PMID: 23837137]; [PMCID: PMC3701845]; [DOI: 10.3350/cmh.2013.19.2.131]

25. Kim SU, Chon YE, Lee CK, Park JY, Kim DY, Han KH, Chon CY, Kim S, Jung KS, Ahn SH. Spontaneous bacterial peritonitis in patients with hepatitis B virus-related liver cirrhosis: community-acquired versus nosocomial. Yonsei medical journal. 2012; 53(2): 328-36. [PMID: 22318820]; [PMCID: PMC3282968]; [DOI: 10.3349/ymj.2012.53.2.328]

26. Alexopoulou A, Papadopoulos N, Eliopoulos DG, Alexaki A, Tsiriga A, Toutouza M, Pectasides D. Increasing frequency of gram-positive cocci and gram-negative multidrug-resistant bacteria in spontaneous bacterial peritonitis. Liver International. 2013; 33(7): 975-81. [PMID: 23522099]; [DOI: 10.1111/liv.12152]

Refbacks

  • There are currently no refbacks.


Creative Commons License
This work is licensed under a Creative Commons Attribution 3.0 License.