BACKGROUND Edwardsiella tarda(E.tarda)belongs to the family Enterobacteriaceae and is generally seen to cause infections mainly in fish,but is also capable of infecting humans.Extraintestinal infections occur in patie...BACKGROUND Edwardsiella tarda(E.tarda)belongs to the family Enterobacteriaceae and is generally seen to cause infections mainly in fish,but is also capable of infecting humans.Extraintestinal infections occur in patients with certain risk factors,including immunocompromised status.We recently diagnosed a case of spontaneous bacterial peritonitis(SBP)due to E.tarda in an immuno-compromised dialysis patient.CASE SUMMARY Patient was a 55-year-old male,with a history of diabetic nephropathy being treated with hemodialysis three times a week.He was referred to our hospital due to an increased volume of ascites,and blood examination revealed increased inflammatory reaction.At our emergency department,he developed fever,disturbance of consciousness,abdominal distension,and abdomen-wide pain.In addition,a dialysis shunt was confirmed in his right forearm,and the shunt site showed no signs of inflammation.No wounds were confirmed on or in his body.A blood examination revealed increased values of white blood cells,C-reactive protein,and creatinine.Plain chest and abdominal computed tomography scanning revealed increased ascites volume.Abdominal paracentesis was performed and a Gram stain revealed Gramnegative bacillus.These findings prompted diagnosis of SBP.The patient was admitted and treated with cefmetazole,causing fever resolution and symptom improvements.Later,E.tarda was identified in ascites culture.The patient improved with decreased inflammatory response and was discharged on the 12th day of hospitalization.The antibiotic was terminated after 14 days of treatment.SBP in this case may have developed from chronic renal failure and diabetes mellitus.CONCLUSION We report the first known case of SBP due to E.tarda in an immuno-compromised dialysis patient.展开更多
Spontaneous bacterial peritonitis(SBP)is a common complication of liver failure.It is an acute bacterial infection of the ascitic fluid in patients with liver cirrhosis.SBP presents a significant challenge for hepatol...Spontaneous bacterial peritonitis(SBP)is a common complication of liver failure.It is an acute bacterial infection of the ascitic fluid in patients with liver cirrhosis.SBP presents a significant challenge for hepatologists owing to its associated complications.While diagnostic paracentesis with polymorphonuclear count is highly accurate,it can be troublesome for some patients as it is an invasive procedure with associated risks.Several studies have proposed new diagnostic methods to improve current practices,many of which remain invasive.Although some serum tests show promise in the diagnosis of SBP,the results are still preliminary.Recent advancements in artificial intelligence and machine learning have introduced predictive models and scoring systems for diagnosis.However,these models still lack sufficient sensitivity,specificity,and the ability to effe-ctively assess treatment response.展开更多
Rationale:Fereydounia(F.)khargensis is a novel yeast species identified in 2014 from environmental samples and has emerged as a rare pathogen causing human infections.Patient concerns:A 61-year-old male with end-stage...Rationale:Fereydounia(F.)khargensis is a novel yeast species identified in 2014 from environmental samples and has emerged as a rare pathogen causing human infections.Patient concerns:A 61-year-old male with end-stage renal failure on continuous ambulatory peritoneal dialysis,who presented with generalized abdominal pain,turbid dialysate and fever.Diagnosis:Peritoneal fluid culture revealed the presence of yeast cells.F.khargensis was identified by polymerase chain reaction method.Interventions:Removal of Tenckhoff catheter and intravenous fluconazole.Outcomes:He succumbed after two weeks of hospitalization.Lessons:This case report highlights the significance of a rare fungal pathogen,F.khargensis,which has been implicated in the mortality of an immunocompromised patient.Due to its rarity,F.khargensis poses significant challenges associated with its identification and has profound implications for clinical practice.展开更多
BACKGROUND Individuals with liver cirrhosis(LC)are likely to experience multiple infectious processes due to the immune dysfunction caused by the disease.Our hypothesis is that this group of patients is predisposed to...BACKGROUND Individuals with liver cirrhosis(LC)are likely to experience multiple infectious processes due to the immune dysfunction caused by the disease.Our hypothesis is that this group of patients is predisposed to fungal infections.To date,the incidence of spontaneous fungal peritonitis(SFP)has not been determined in Mexico;this endeavor is of great importance because many patients may be suffering from this condition without receiving targeted treatment,which may increase mortality.AIM To report the incidence of SFP in patients presenting with decompensated LC with ascites.METHODS This was a prospective,single-center,descriptive,observational and crosssectional study where patients presenting with decompensated LC with ascites were evaluated from November 2023 to May 2024 in Mexico City.Fungal cultures of ascites were performed and the samples kept in an incubator for 10 days to 14 days,and molecular tests(the API 20 C AUX test)were used for molecular characterization.RESULTS Of the 48 patients included,54.2%were women,77.1%had a comorbidity,47.9%had LC secondary to metabolic dysfunction,43.8%were classified as Child-Pugh C with a model for end-stage liver disease 3.0 median score of 22,and 10.4%were in secondary prophylaxis for spontaneous bacterial peritonitis(SBP).Only four patients had positive cultures where Candida parapsilosis and Candida albicans were isolated,with two of the four patients being positive for Rhodotorula minuta;an SBP incidence of 8.3%was thus calculated.Chronic kidney disease[P=0.012 and relative risk(RR)=15]and secondary prophylaxis for SBP(P=0.049 with RR=8.6)were statistically significant and associated with a high mortality risk(P=0.001 with RR=33).CONCLUSION The presence of infection of fungal origin in ascites in patients presenting with cirrhosis increases short-and medium-term mortality;therefore,it is recommended that fungal culture tests are performed in those patients who visit the emergency room or experience continuous admission with acute decompensation and no bacteria identified in ascites cultures,and even more so in patients with chronic kidney disease and a history of antibiotic use as prophylaxis for SBP.Further studies are needed for the identification of clinical and biochemical data that can help to define SFP so that its presence may be assessed without the need to wait for a positive fungal culture.Thus,treatment may be initiated early in the hope of having a positive impact on the prognosis in this group of patients.展开更多
BACKGROUND Refractory ascites(RA)and spontaneous bacterial peritonitis(SBP)are severe complications of decompensated cirrhosis,contributing to high morbidity and mortality.RA develops when ascites persists despite max...BACKGROUND Refractory ascites(RA)and spontaneous bacterial peritonitis(SBP)are severe complications of decompensated cirrhosis,contributing to high morbidity and mortality.RA develops when ascites persists despite maximum diuretic therapy,while SBP arises from bacterial translocation and immune dysfunction in cirrhotic patients with ascites.Identifying key risk factors associated with these conditions is crucial for early intervention and improved patient outcomes.AIM To assess clinical and biochemical predictors of RA and SBP in a cohort of hospitalized patients with cirrhotic ascites.METHODS A retrospective chart review was conducted on patients with cirrhotic ascites diagnosed with RA or SBP at University Medical Center,El Paso,from July 1,2013 to December 31,2023.Patient demographics,clinical history,laboratory parameters,ascitic fluid analysis,and cirrhosis severity scores[Model for End-Stage Liver Disease-Sodium(MELD-Na)and Child-Pugh]were recorded.Statistical analyses,including multivariate logistic regression,were performed to identify independent predictors of RA and SBP,with a significance threshold of P<0.05.RESULTS A total of 179 patients were included,with a mean age of 59.08±13.04 years,predominantly male(55.9%)and Hispanic(98.3%).The most common etiology of cirrhosis was alcohol-related liver disease(45.3%),and most patients had Grade III ascites(95.5%).Among them,115(64.2%)had RA,and 57(31.8%)had SBP.RA was significantly associated with abnormal serum potassium levels[odds ratio(OR)=2.27,95%CI:1.06–4.84,P=0.034],while SBP was independently predicted by gastrointestinal bleeding(OR=2.59,95%CI:1.18–5.64,P=0.017)and thrombocytopenia(platelet count<50000;OR=3.27,95%CI:1.08–9.88,P=0.035).CONCLUSION RA and SBP are major complications of cirrhosis,with electrolyte imbalances and coagulopathy playing key roles in their development.Our study confirms that abnormal potassium levels significantly predict RA,while gastrointestinal bleeding and thrombocytopenia are strong predictors of SBP.These findings emphasize the need for early risk stratification and targeted management strategies to improve outcomes in high-risk cirrhotic patients,particularly in minority populations with limited healthcare access.Further prospective studies are warranted to validate these results and explore potential interventions to reduce RA and SBP incidence.展开更多
Spontaneous bacterial peritonitis is a complication of ascitic patients with end-stage liver disease(ESLD); spontaneous fungal peritonitis(SFP) is a complication of ESLD less known and described. ESLD is associated to...Spontaneous bacterial peritonitis is a complication of ascitic patients with end-stage liver disease(ESLD); spontaneous fungal peritonitis(SFP) is a complication of ESLD less known and described. ESLD is associated to immunodepression and the resulting increased susceptibility to infections. Recent perspectives of the management of the critically ill patient with ESLD do not specify the rate of isolation of fungi in critically ill patients,not even the antifungals used for the prophylaxis,neither optimal treatment. We reviewed,in order to focus the epidemiology,characteristics,and,considering the high mortality rate of SFP,the use of optimal empirical antifungal therapy the current literature.展开更多
AIM： To verify the validity of the International Ascites Club guidelines for treatment of spontaneous bacterial peritonitis （SBP） in clinical practice. METHODS： All SBP episodes occurring in a group of consecutive...AIM： To verify the validity of the International Ascites Club guidelines for treatment of spontaneous bacterial peritonitis （SBP） in clinical practice. METHODS： All SBP episodes occurring in a group of consecutive cirrhotics were managed accordingly and included in the study. SBP was diagnosed when the ascitic fluid polymorphonuclear （PIN） cell count was 〉 250 cells/mm^3, and empirically treated with cefotaxime. RESULTS： Thirty-eight SBP episodes occurred in 32 cirrhotics （22 men/20 women; mean age： 58.6 ＋ 22.2 years）. Prevalence of SBP, in our population, was 27%. Ascitic fluid culture was positive in nine （24%） cases only. Eleven episodes were nosocomial and 71% community-acquired. Treatment with cefotaxime was successful in 59% of cases, while 41% of episodes required a modification of the initial antibiotic therapy because of a less-than 25% decrease in ascitic PMN count at 48 h. Change of antibiotic therapy led to the resolution of infection in 87% of episodes. Among the cases with positive culture, the initial antibiotic therapy with cefotaxime failed at a percentage （44%） similar to that of the whole series. In these cases, the isolated organisms were either resistant or with an inherent insufficient susceptibility to cefotaxime. CONCLUSION： In clinical practice, ascitic PMN count is a valid tool for starting a prompt antibiotic treatment andevaluating its efficacy. The initial treatment with cefotaxime failed more frequently than expected. An increase in healthcare-related infections with antibiotic-resistant pathogens may explain this finding. A different first-line antibiotic treatment should be investigated.展开更多
Spontaneous bacterial(SBP) and spontaneous fungal peritonitis(SFP) can be a life-threatening infection in patients with liver cirrhosis(LC) and ascites. One of the possible mechanisms of developing SBP is bacterial tr...Spontaneous bacterial(SBP) and spontaneous fungal peritonitis(SFP) can be a life-threatening infection in patients with liver cirrhosis(LC) and ascites. One of the possible mechanisms of developing SBP is bacterial translocation. Although the number of polymorphonuclear cells in the culture of ascitic fluid is diagnostic for SBP, secondary bacterial peritonitis is necessary to exclude. The severity of underlying liver dysfunction is predictive of developing SBP; moreover, renal impairment and infections caused by multidrug-resistant(MDR) organism are associated with a fatal prognosis of SBP. SBP is treated by antimicrobials, but initial empirical treatment may not succeed because of the presence of MDR organisms, particularly in nosocomial infections. Antibiotic prophylaxis is recommended for patients with LC at a high risk of developing SBP, gastrointestinal bleeding, or a previous episode of SBP, but the increase in the risk of developing an infection caused by MDR organisms is a serious concern globally. Less is known about SFP in patients with LC, but the severity of underlying liver dysfunction may increase the hospital mortality. SFP mortality has been reported to be higher than that of SBP partially because the difficulty of early differentiation between SFP and SBP induces delayed antifungal therapy for SFP.展开更多
AIM:To investigate the performance and diagnostic accuracy of interferon-gamma(IFN-γ) for tuberculous peritonitis(TBP) by meta-analysis.METHODS:A systematic search of English language studies was performed.We searche...AIM:To investigate the performance and diagnostic accuracy of interferon-gamma(IFN-γ) for tuberculous peritonitis(TBP) by meta-analysis.METHODS:A systematic search of English language studies was performed.We searched the following electronic databases:MEDLINE,EMBASE,Web of Science,BIOSIS,LILACS and the Cochrane Library.The Standards for Reporting Diagnostic Accuracy initiative and Quality Assessment for Studies of Diagnostic Accuracy tool were used to assess the methodological quality of the studies.Sensitivity,specificity,and other measures of the accuracy of IFN-γ concentration in the diagnosis of peritoneal effusion were pooled using random-effects models.Receiver operating characteristic(ROC) curves were applied to summarize overall test performance.Two reviewers independently judged study eligibility while screening the citations.RESULTS:Six studies met the inclusion criteria.The average inter-rater agreement between the two reviewers for items in the quality checklist was 0.92.Analysis of IFN-γ level for TBP diagnosis yielded a summary estimate:sensitivity,0.93(95%CI,0.87-0.97);specificity,0.99(95%CI,0.97-1.00);positive likelihood ratio(PLR),41.49(95%CI,18.80-91.55);negative likelihood ratio(NLR),0.11(95%CI,0.06-0.19);and diagnostic odds ratio(DOR),678.02(95%CI,209.91-2190.09).χ 2 values of the sensitivity,specificity,PLR,NLR and DOR were 5.66(P = 0.3407),6.37(P = 0.2715),1.38(P = 0.9265),5.46(P = 0.3621) and 1.42(P = 0.9220),respectively.The summary receiver ROC curve was positioned near the desirable upper left corner and the maximum joint sensitivity and specificity was 0.97.The area under the curve was 0.99.The evaluation of publication bias was not significant(P = 0.922).CONCLUSION:IFN-γ may be a sensitive and specific marker for the accurate diagnosis of TBP.The level of IFN-γ may contribute to the accurate differentiation of tuberculosis(TB) ascites from non-TB ascites.展开更多
Since its initial description in 1964,research hastransformed spontaneous bacterial peritonitis (SBP)from a feared disease (with reported mortality of 90%)to a treatable complication of decompensated cirrhosis,albeit ...Since its initial description in 1964,research hastransformed spontaneous bacterial peritonitis (SBP)from a feared disease (with reported mortality of 90%)to a treatable complication of decompensated cirrhosis,albeit with steady prevalence and a high recurrencerate. Bacterial translocation,the key mechanism in thepathogenesis of SBP,is only possible because of theconcurrent failure of defensive mechanisms in cirrhosis.Variants of SBP should be treated. Leucocyte esterasereagent strips have managed to shorten the 'tap-to-shot' time,while future studies should look into theircombined use with ascitic fluid pH. Third generationcephalosporins are the antibiotic of choice becausethey have a number of advantages. Renal dysfunctionhas been shown to be an independent predictor ofmortality in patients with SBP. Albumin is felt to reducethe risk of renal impairment by improving effectiveintravascular volume,and by helping to bind pro-inflammatory molecules. Following a single episodeof SBP,patients should have long-term antibioticprophylaxis and be considered for liver transplantation.展开更多
AIM: To investigate the microbiological characteristics and drug resistance in liver cirrhosis patients with spontaneous peritonitis.METHODS: We analyzed the data of patients with liver cirrhosis and abdominal infecti...AIM: To investigate the microbiological characteristics and drug resistance in liver cirrhosis patients with spontaneous peritonitis.METHODS: We analyzed the data of patients with liver cirrhosis and abdominal infection at the First Affiliated Hospital of Zhejiang University between January 2011 and December 2013. Pathogens present in the ascites were identified,and their sensitivity to various antibiotics was determined. RESULTS: We isolated 306 pathogenic bacteria from 288 cases: In 178 cases,the infection was caused by gram-negative strains(58.2%); in 85 cases,grampositive strains(27.8%); in 9 cases,fungi(2.9%); and in 16 cases,more than one pathogen. The main pathogens were Escherichia coli(E. coli)(24.2%),Klebsiella pneumoniae(18.9%),Enterococcus spp.(11.1%),and Staphylococcus aureus(7.5%). Of the 306 isolated pathogens,99 caused nosocomial infections and 207 caused community-acquired andother infections. The E. coli and K. pneumoniae strains produced more extended-spectrum β-lactamases in cases of nosocomial infections than non-nosocomial infections(62.5% vs 38%,P < 0.013; 36.8% vs 12.8%,P < 0.034,respectively). The sensitivity to individual antibiotics differed between nosocomial and non-nosocomial infections: Piperacillin/tazobactam was significantly more effective against non-nosocomial E. coli infections(4% vs 20.8%,P < 0.021). Nitrofurantoin had stronger antibacterial activity against Enterococcus species causing non-nosocomial infections(36.4% vs 86.3%,P < 0.009).CONCLUSION: The majority of pathogens that cause abdominal infection in patients with liver cirrhosis are gram-negative,and drug resistance is significantly higher in nosocomial infections than in non-nosocomial infections.展开更多
AIM:To evaluate effective alternative antibiotics in treatment of cefotaxime-resistant spontaneous bacterial peritonitis.METHODS:One hundred cirrhotic patients with spontaneous bacterial peritonitis [ascitic fluid pol...AIM:To evaluate effective alternative antibiotics in treatment of cefotaxime-resistant spontaneous bacterial peritonitis.METHODS:One hundred cirrhotic patients with spontaneous bacterial peritonitis [ascitic fluid polymorphonuclear cell count(PMNLs) ≥ 250 cells/mm 3 at admission] were empirically treated with cefotaxime sodium 2 g/12 h and volume expansion by intravenous human albumin.All patients were subjected to history taking,complete examination,laboratory tests(including a complete blood cell count,prothrombin time,biochemical tests of liver and kidney function,and fresh urine sediment),chest X-ray,a diagnostic abdominal paracentesis,and the sample subjected to total and differential cell count,chemical examination,aerobic and anaerobic cultures.Patients were divided after 2 d by a second ascitic PMNL count into group Ⅰ;patients sensitive to cefotaxime(n = 81),group Ⅱ(n = 19);cases resistant to cefotaxime(less than 25% decrease in ascitic PMNL count).Patients of group Ⅱ were randomly assigned into meropenem(n = 11) or levofloxacin(n = 8) subgroups.All patients performed an end of treatment ascitic PMNL count.Patients were considered improved when:PMNLs decreased to < 250 cells/mm 3,no growth in previously positive culture cases,and improved clinical manifestations with at least 5 d of antibiotic therapy.RESULTS:Age,sex,and Child classes showed no significant difference between group Ⅰ and group Ⅱ.Fever and abdominal pain were the most frequent manifestations and were reported in 82.7% and 80.2% of patients in group Ⅰ and in 94.7% and 84.2% of patients in group Ⅱ,respectively.Patients in group Ⅱ had a more severe ascitic inflammatory response than group Ⅰ and this was demonstrated by more ascitic lactate dehydrogenase(LDH) [median:540 IU/L(range:150-1200 IU/L) vs median:240 IU/L(range:180-500 IU/L),P = 0.000] and PMNL [median:15 000 cell/mm 3(range:957-23 822 cell/mm 3) vs 3400 cell/mm 3(range:695-26 400 cell/mm 3),P = 0.000] counts.Ascitic fluid culture was positive in 32% of cases.Cefotaxime failed in 19% of patients;of these patients,11(100%) responded to meropenem and 6(75%) responded to levofloxacin.Two patients with failed levofloxacin therapy were treated according to the in vitro culture and sensitivity(one case was treated with vancomycin and one case was treated with ampicillin/sulbactam).In group Ⅱ the meropenem subgroup had higher LDH(range:108-860 IU/L vs 120-491 IU/L,P = 0.042) and PMNL counts(range:957-23 822 cell/mm 3 vs 957-15 222 cell/mm 3,P = 0.000) at initiation of the alternative antibiotic therapy;there was no significant difference in the studied parameters between patients responsive to meropenem and patients responsive to levofloxacin at the end of therapy(mean ± SD:316.01 ± 104.03PMNLs/mm 3 vs 265.63 ± 69.61 PMNLs/mm 3,P = 0.307).The isolated organisms found in group Ⅱ were;enterococci,acinetobacter,expanded-spectrum β-lactamase producing Escherichia coli,β-lactamase producing Enterobacter and Staphylococcus aureus.CONCLUSION:Empirical treatment with cefotaxime is effective in 81% of cases;meropenem is effective in cefotaxime-resistant cases.展开更多
Ascites remain the commonest complication of decompensated cirrhosis. Spontaneous bacterial peritonitis (SBP) is defined as the infection of ascitic fluid (AF) in the absence of a contiguous source of infection and/or...Ascites remain the commonest complication of decompensated cirrhosis. Spontaneous bacterial peritonitis (SBP) is defined as the infection of ascitic fluid (AF) in the absence of a contiguous source of infection and/or an intraabdominal inflammatory focus. An AF polymorphonuclear (PMN) leucocyte count ≥ 250/mm 3 -irrespective of the AF culture resultis universally accepted nowadays as the best surrogate marker for diagnosing SBP. Frequently the results of the manual or automated PMN count do not reach the hands of the responsible medical personnel in a timely manner. However, this is a crucial step in SBP management. Since 2000, 26 studies (most of them published as full papers) have checked the validity of using leukocyte esterase reagent strips (LERS) in SBP diagnosis. LERS appear to have low sensitivity for SBP, some LERS types more than others. On the other hand, though, LERS have consistently given a high negative predictive value (> 95% in the majority of the studies) and this supports the use of LERS as a preliminary screening tool for SBP diagnosis. Finally, an AF-tailored dipstick has been developed. Within the proper setting, it is set to become the mainstream process for handling AF samples.展开更多
AIM: To evaluate acute cholecystitis, complicated by peritonitis, acute phase response and immunological status in patients treated by laparoscopic or open approach. METHODS: From January 2002 to May 2012, we conducte...AIM: To evaluate acute cholecystitis, complicated by peritonitis, acute phase response and immunological status in patients treated by laparoscopic or open approach. METHODS: From January 2002 to May 2012, we conducted a prospective randomized study on 45 consecutive patients (27 women, 18 men; mean age 58 years). These subjects were taken from a total of 681 patients who were hospitalised presenting similar preoperative findings: acute upper abdominal pain with tenderness, involuntary guarding under the right hypochondrium and/or in the flank; fever higher than 38 ℃, leukocytosis greater than 10 × 10 9 /L or both, and ultrasonographic evidence of calculous cholecystitis possibly complicated by peritonitis. These patients had undergone cholecystectomy for acute calculous cholecystitis,complicated by bile peritonitis. Randomly, 23 patients were assigned to laparoscopic cholecystectomy (LC), and 22 patients to open cholecystectomy (OC). Blood samples were collected from all patients before operation and at days 1, 3 and 6 after surgery. Serum bacteraemia, endotoxaemia, white blood cells (WBCs), WBC subpopulations, human leukocyte antigen-DR (HLA-DR), neutrophil elastase, interleukin-1 (IL-1) and IL-6, and C-reactive protein (CRP) were measured at 0, 30, 60, 90, 120 and 180 min, at 4, 6, 12, 24 h, and then daily (8 A.M.) until post-operative day 6.RESULTS: The two groups were comparable in the severity of peritoneal contamination as indicated by the viable bacterial count (open group = 90% of positive cultures vs laparoscopic group = 87%) and endotoxin level (open group = 33.21 ± 6.32 pg/mL vs laparoscopic group = 35.02 ± 7.23 pg/mL). Four subjects in the OC group (18.1%) and 1 subject (4.3%) in the LC group (P < 0.05) developed intra-abdominal abscess. Severe leukocytosis (range 15.8-19.6/mL) was observed only after OC but not after LC, mostly due to an increase in neutrophils (days 1 and 3, P < 0.05). This value returned to the normal range within 3-4 d after LC and 5-7 d after OC. Other WBC types and lymphocyte subpopulations showed no significant variation. On the first day after surgery, a statistically significant difference was observed in HLA-DR expression between LC (13.0 ± 5.2) and OC (6.0 ± 4.2) (P < 0.05). A statistically significant change in plasma elastase concentration was recorded post-operatively at days 1, 3, and 6 in patients from the OC group when compared to the LC group (P < 0.05). In the OC group, the serum levels of IL-1 and IL-6 began to increase considerably from the first to the sixth hour after surgery. In the LC group, the increase of serum IL-1 and IL-6 levels was delayed and the peak values were notably lower than those in the OC group. Significant differences between the groups, for these two cytokines, were observed from the second to the twenty-fourth hour (P < 0.05) after surgery. The mean values of serum CRP in the LC group on post-operative days (1 and 3) were also lower than those in the OC group (P < 0.05). Systemic concentration of endotoxin was higher in the OC group at all intra-operative sampling times, but reached significance only when the gallbladder was removed (OC group = 36.81 ± 6.4 ρg/mLvs LC group = 16.74 ± 4.1 ρg/mL, P < 0.05). One hour after surgery, microbiological analysis of blood cultures detected 7 different bacterial species after laparotomy, and 4 species after laparoscopy (P < 0.05). CONCLUSION: OC increased the incidence of bacteraemia, endotoxaemia and systemic inflammation compared with LC and caused lower transient immunological defense, leading to enhanced sepsis in the patients examined.展开更多
AIM: To evaluate the epidemiology and outcomes of culture-positive spontaneous bacterial peritonitis (SBP) and spontaneous bacteremia (SB) in decompensated cirrhosis.METHODS: We prospectively collected clinical, labor...AIM: To evaluate the epidemiology and outcomes of culture-positive spontaneous bacterial peritonitis (SBP) and spontaneous bacteremia (SB) in decompensated cirrhosis.METHODS: We prospectively collected clinical, laboratory characteristics, type of administered antibiotic, susceptibility and resistance of bacteria to antibiotics in one hundred thirty cases (68.5% males) with positive ascitic fluid and/or blood cultures during the period from January 1, 2012 to May 30, 2014. All patients with SBP had polymorphonuclear cell count in ascitic fluid > 250/mm<sup>3</sup>. In patients with SB a thorough study did not reveal any other cause of bacteremia. The patients were followed-up for a 30-d period following diagnosis of the infection. The final outcome of the patients was recorded in the end of follow-up and comparison among 3 groups of patients according to the pattern of drug resistance was performed.RESULTS: Gram-positive-cocci (GPC) were found in half of the cases. The most prevalent organisms in a descending order were Escherichia coli (33), Enterococcus spp (30), Streptococcus spp (25), Klebsiella pneumonia (16), S. aureus (8), Pseudomanas aeruginosa (5), other Gram-negative-bacteria (GNB) (11) and anaerobes (2). Overall, 20.8% of isolates were multidrug-resistant (MDR) and 10% extensively drug-resistant (XDR). Health-care-associated (HCA) and/or nosocomial infections were present in 100% of MDR/XDR and in 65.5% of non-DR cases. Meropenem was the empirically prescribed antibiotic in HCA/nosocomial infections showing a drug-resistance rate of 30.7% while third generation cephalosporins of 43.8%. Meropenem was ineffective on both XDR bacteria and Enterococcus faecium (E. faecium). All but one XDR were susceptible to colistin while all GPC (including E. faecium) and the 86% of GNB to tigecycline. Overall 30-d mortality was 37.7% (69.2% for XDR and 34.2% for the rest of the patients) (log rank, P = 0.015). In multivariate analysis, factors adversely affecting outcome included XDR infection (HR = 2.263, 95%CI: 1.005-5.095, P = 0.049), creatinine (HR = 1.125, 95%CI: 1.024-1.236, P = 0.015) and INR (HR =1.553, 95%CI: 1.106-2.180, P = 0.011).CONCLUSION: XDR bacteria are an independent life-threatening factor in SBP/SB. Strategies aiming at restricting antibiotic overuse and rapid identification of the responsible bacteria could help improve survival.展开更多
Diagnosis of acute arterial mesenteric ischemia in the early stages is now possible using modern computed tomography with intravenous contrast enhancement and imaging in the arterial and/or portal phase.Most patients ...Diagnosis of acute arterial mesenteric ischemia in the early stages is now possible using modern computed tomography with intravenous contrast enhancement and imaging in the arterial and/or portal phase.Most patients have acute superior mesenteric artery(SMA)occlusion,and a large proportion of these patients will develop peritonitis prior to mesenteric revascularization,and explorative laparotomy will therefore be necessary to evaluate the extent and severity of intestinal ischemia,and to perform bowel resections.The establishment of a hybrid operating room in vascular units in hospitals is most important to be able to perform successful intestinal revascularization.This review outlines current frontline surgical strategies to improve survival and minimize bowel morbidity in patients with peritonitis secondary to acute SMA occlusion.Explorative laparotomy needs to be performed first.Curative treatment is based upon intestinal revascularization followed by bowel resection.If no vascular imaging has been carried out,SMA angiography is performed.In case of embolic occlusion of the SMA,open embolectomy is performed followed by angiography.In case of thrombotic occlusion,the occlusive lesion can be recanalized retrograde from an exposed SMA,the guidewire snared from either the femoral or brachial artery,and stented with standard devices from these access sites.Bowel resections and sometimes gall bladder removal due to transmural infarctions are performed at initial laparotomy,leaving definitive bowel reconstructions to a planned second look laparotomy,according to the principles of damage control surgery.Patients with peritonitis secondary to acute SMA occlusion should be managed by both the general and vascular surgeon,and a hybrid revascularization approach is of utmost importance to improve outcomes.展开更多
Sclerosing encapsulating peritonitis (SEP) is a rare cause of intestinal obstruction that is characterized by a thick grayish-white fibrotic membrane encasing the small bowel. SEP can be classified as idiopathic,also ...Sclerosing encapsulating peritonitis (SEP) is a rare cause of intestinal obstruction that is characterized by a thick grayish-white fibrotic membrane encasing the small bowel. SEP can be classified as idiopathic,also known as abdominal cocoon,or secondary. It is difficult to make a definite pre-operative diagnosis. We experienced five cases of abdominal cocoon,and the case files were reviewed retrospectively for the clinical presentation,operative findings and outcome. All the patients presented with acute,subacute and chronic intestinal obstruction. Computed tomography (CT) showed characteristic findings of small bowel loops congregated to the center of the abdomen encased by a soft-tissue density mantle in four cases. Four cases had an uneventful post-operative period,one case received second adhesiolysis due to persistent ileus. The imaging techniques may facilitate pre-operative diagnosis. Surgery is important in the management of SEP.展开更多
This report presents a survey of current knowledge concerning one of the relatively frequent and severe complications of liver cirrhosis and associated ascites-spontaneous bacterial peritonitis. Epidemiology,aetiology...This report presents a survey of current knowledge concerning one of the relatively frequent and severe complications of liver cirrhosis and associated ascites-spontaneous bacterial peritonitis. Epidemiology,aetiology,pathogenesis,clinical manifestation,diagnosis and present possibilities of treatment are discussed.展开更多
Spontaneous bacterial peritonitis(SBP) is a frequent, life-threatening bacterial infection in patients with liver cirrhosis and ascites. Portal hypertension leads to increased bacterial translocation from the intestin...Spontaneous bacterial peritonitis(SBP) is a frequent, life-threatening bacterial infection in patients with liver cirrhosis and ascites. Portal hypertension leads to increased bacterial translocation from the intestine. Failure to eliminate invading pathogens due to immune defects associated with advanced liver disease on the background of genetic predisposition may result in SBP. The efficacy of antibiotic treatment and prophylaxis has declined due to the spread of multi-resistant bacteria. Patients with nosocomial SBP and with prior antibiotictreatment are at a particularly high risk for infection with resistant bacteria. Therefore, it is important to adapt empirical treatment to these risk factors and to the local resistance profile. Rifaximin, an oral, nonabsorbable antibiotic, has been proposed to prevent SBP, but may be useful only in a subset of patients. Since novel antibiotic classes are lacking, we have to develop prophylactic strategies which do not induce bacterial resistance. Farnesoid X receptor agonists may be a candidate, but so far, clinical studies are not available. New diagnostic tests which can be carried out quickly at the patient's site and provide additional prognostic information would be helpful. Furthermore, we need tools to predict antibiotic resistance in order to tailor first-line antibiotic treatment of spontaneous bacterial peritonitis to the individual patient and to reduce mortality.展开更多
Spontaneous bacterial peritonitis(SBP) is the most typical infection observed in cirrhosis patients. SBP is responsible for an in-hospital mortality rate of approximately 32%. Recently, pattern changes in the bacteria...Spontaneous bacterial peritonitis(SBP) is the most typical infection observed in cirrhosis patients. SBP is responsible for an in-hospital mortality rate of approximately 32%. Recently, pattern changes in the bacterial flora of cirrhosis patients have been observed, and an increase in the prevalence of infections caused by multi-resistant bacteria has been noted. The wide-scale use of quinolones in the prophylaxis of SBP has promoted flora modifications and resulted in the development of bacterial resistance. The efficacy of traditionally recommended therapy has been low in nosocomial infections(up to 40%), and multi-resistance has been observed in up to 22% of isolated germs in nosocomial SBP. For this reason, the use of a broad empirical spectrum antibiotic has been suggested in these situations. The distinction between community-acquired infectious episodes, healthcare-associated infections, or nosocomial infections, and the identification of risk factors for multi-resistant germs can aid in the decision-making process regarding the empirical choice of antibiotic therapy. Broad-spectrum antimicrobial agents, such as carbapenems with or without glycopeptides or piperacillin-tazobactam, should be considered for the initial treatment not only of nosocomial infections but also of healthcare-associated infections when the risk factors or severity signs for multi-resistant bacteria are apparent. The use of cephalosporins should be restricted to community-acquired infections.展开更多
文摘BACKGROUND Edwardsiella tarda(E.tarda)belongs to the family Enterobacteriaceae and is generally seen to cause infections mainly in fish,but is also capable of infecting humans.Extraintestinal infections occur in patients with certain risk factors,including immunocompromised status.We recently diagnosed a case of spontaneous bacterial peritonitis(SBP)due to E.tarda in an immuno-compromised dialysis patient.CASE SUMMARY Patient was a 55-year-old male,with a history of diabetic nephropathy being treated with hemodialysis three times a week.He was referred to our hospital due to an increased volume of ascites,and blood examination revealed increased inflammatory reaction.At our emergency department,he developed fever,disturbance of consciousness,abdominal distension,and abdomen-wide pain.In addition,a dialysis shunt was confirmed in his right forearm,and the shunt site showed no signs of inflammation.No wounds were confirmed on or in his body.A blood examination revealed increased values of white blood cells,C-reactive protein,and creatinine.Plain chest and abdominal computed tomography scanning revealed increased ascites volume.Abdominal paracentesis was performed and a Gram stain revealed Gramnegative bacillus.These findings prompted diagnosis of SBP.The patient was admitted and treated with cefmetazole,causing fever resolution and symptom improvements.Later,E.tarda was identified in ascites culture.The patient improved with decreased inflammatory response and was discharged on the 12th day of hospitalization.The antibiotic was terminated after 14 days of treatment.SBP in this case may have developed from chronic renal failure and diabetes mellitus.CONCLUSION We report the first known case of SBP due to E.tarda in an immuno-compromised dialysis patient.
文摘Spontaneous bacterial peritonitis(SBP)is a common complication of liver failure.It is an acute bacterial infection of the ascitic fluid in patients with liver cirrhosis.SBP presents a significant challenge for hepatologists owing to its associated complications.While diagnostic paracentesis with polymorphonuclear count is highly accurate,it can be troublesome for some patients as it is an invasive procedure with associated risks.Several studies have proposed new diagnostic methods to improve current practices,many of which remain invasive.Although some serum tests show promise in the diagnosis of SBP,the results are still preliminary.Recent advancements in artificial intelligence and machine learning have introduced predictive models and scoring systems for diagnosis.However,these models still lack sufficient sensitivity,specificity,and the ability to effe-ctively assess treatment response.
文摘Rationale:Fereydounia(F.)khargensis is a novel yeast species identified in 2014 from environmental samples and has emerged as a rare pathogen causing human infections.Patient concerns:A 61-year-old male with end-stage renal failure on continuous ambulatory peritoneal dialysis,who presented with generalized abdominal pain,turbid dialysate and fever.Diagnosis:Peritoneal fluid culture revealed the presence of yeast cells.F.khargensis was identified by polymerase chain reaction method.Interventions:Removal of Tenckhoff catheter and intravenous fluconazole.Outcomes:He succumbed after two weeks of hospitalization.Lessons:This case report highlights the significance of a rare fungal pathogen,F.khargensis,which has been implicated in the mortality of an immunocompromised patient.Due to its rarity,F.khargensis poses significant challenges associated with its identification and has profound implications for clinical practice.
文摘BACKGROUND Individuals with liver cirrhosis(LC)are likely to experience multiple infectious processes due to the immune dysfunction caused by the disease.Our hypothesis is that this group of patients is predisposed to fungal infections.To date,the incidence of spontaneous fungal peritonitis(SFP)has not been determined in Mexico;this endeavor is of great importance because many patients may be suffering from this condition without receiving targeted treatment,which may increase mortality.AIM To report the incidence of SFP in patients presenting with decompensated LC with ascites.METHODS This was a prospective,single-center,descriptive,observational and crosssectional study where patients presenting with decompensated LC with ascites were evaluated from November 2023 to May 2024 in Mexico City.Fungal cultures of ascites were performed and the samples kept in an incubator for 10 days to 14 days,and molecular tests(the API 20 C AUX test)were used for molecular characterization.RESULTS Of the 48 patients included,54.2%were women,77.1%had a comorbidity,47.9%had LC secondary to metabolic dysfunction,43.8%were classified as Child-Pugh C with a model for end-stage liver disease 3.0 median score of 22,and 10.4%were in secondary prophylaxis for spontaneous bacterial peritonitis(SBP).Only four patients had positive cultures where Candida parapsilosis and Candida albicans were isolated,with two of the four patients being positive for Rhodotorula minuta;an SBP incidence of 8.3%was thus calculated.Chronic kidney disease[P=0.012 and relative risk(RR)=15]and secondary prophylaxis for SBP(P=0.049 with RR=8.6)were statistically significant and associated with a high mortality risk(P=0.001 with RR=33).CONCLUSION The presence of infection of fungal origin in ascites in patients presenting with cirrhosis increases short-and medium-term mortality;therefore,it is recommended that fungal culture tests are performed in those patients who visit the emergency room or experience continuous admission with acute decompensation and no bacteria identified in ascites cultures,and even more so in patients with chronic kidney disease and a history of antibiotic use as prophylaxis for SBP.Further studies are needed for the identification of clinical and biochemical data that can help to define SFP so that its presence may be assessed without the need to wait for a positive fungal culture.Thus,treatment may be initiated early in the hope of having a positive impact on the prognosis in this group of patients.
文摘BACKGROUND Refractory ascites(RA)and spontaneous bacterial peritonitis(SBP)are severe complications of decompensated cirrhosis,contributing to high morbidity and mortality.RA develops when ascites persists despite maximum diuretic therapy,while SBP arises from bacterial translocation and immune dysfunction in cirrhotic patients with ascites.Identifying key risk factors associated with these conditions is crucial for early intervention and improved patient outcomes.AIM To assess clinical and biochemical predictors of RA and SBP in a cohort of hospitalized patients with cirrhotic ascites.METHODS A retrospective chart review was conducted on patients with cirrhotic ascites diagnosed with RA or SBP at University Medical Center,El Paso,from July 1,2013 to December 31,2023.Patient demographics,clinical history,laboratory parameters,ascitic fluid analysis,and cirrhosis severity scores[Model for End-Stage Liver Disease-Sodium(MELD-Na)and Child-Pugh]were recorded.Statistical analyses,including multivariate logistic regression,were performed to identify independent predictors of RA and SBP,with a significance threshold of P<0.05.RESULTS A total of 179 patients were included,with a mean age of 59.08±13.04 years,predominantly male(55.9%)and Hispanic(98.3%).The most common etiology of cirrhosis was alcohol-related liver disease(45.3%),and most patients had Grade III ascites(95.5%).Among them,115(64.2%)had RA,and 57(31.8%)had SBP.RA was significantly associated with abnormal serum potassium levels[odds ratio(OR)=2.27,95%CI:1.06–4.84,P=0.034],while SBP was independently predicted by gastrointestinal bleeding(OR=2.59,95%CI:1.18–5.64,P=0.017)and thrombocytopenia(platelet count<50000;OR=3.27,95%CI:1.08–9.88,P=0.035).CONCLUSION RA and SBP are major complications of cirrhosis,with electrolyte imbalances and coagulopathy playing key roles in their development.Our study confirms that abnormal potassium levels significantly predict RA,while gastrointestinal bleeding and thrombocytopenia are strong predictors of SBP.These findings emphasize the need for early risk stratification and targeted management strategies to improve outcomes in high-risk cirrhotic patients,particularly in minority populations with limited healthcare access.Further prospective studies are warranted to validate these results and explore potential interventions to reduce RA and SBP incidence.
文摘Spontaneous bacterial peritonitis is a complication of ascitic patients with end-stage liver disease(ESLD); spontaneous fungal peritonitis(SFP) is a complication of ESLD less known and described. ESLD is associated to immunodepression and the resulting increased susceptibility to infections. Recent perspectives of the management of the critically ill patient with ESLD do not specify the rate of isolation of fungi in critically ill patients,not even the antifungals used for the prophylaxis,neither optimal treatment. We reviewed,in order to focus the epidemiology,characteristics,and,considering the high mortality rate of SFP,the use of optimal empirical antifungal therapy the current literature.
文摘AIM： To verify the validity of the International Ascites Club guidelines for treatment of spontaneous bacterial peritonitis （SBP） in clinical practice. METHODS： All SBP episodes occurring in a group of consecutive cirrhotics were managed accordingly and included in the study. SBP was diagnosed when the ascitic fluid polymorphonuclear （PIN） cell count was 〉 250 cells/mm^3, and empirically treated with cefotaxime. RESULTS： Thirty-eight SBP episodes occurred in 32 cirrhotics （22 men/20 women; mean age： 58.6 ＋ 22.2 years）. Prevalence of SBP, in our population, was 27%. Ascitic fluid culture was positive in nine （24%） cases only. Eleven episodes were nosocomial and 71% community-acquired. Treatment with cefotaxime was successful in 59% of cases, while 41% of episodes required a modification of the initial antibiotic therapy because of a less-than 25% decrease in ascitic PMN count at 48 h. Change of antibiotic therapy led to the resolution of infection in 87% of episodes. Among the cases with positive culture, the initial antibiotic therapy with cefotaxime failed at a percentage （44%） similar to that of the whole series. In these cases, the isolated organisms were either resistant or with an inherent insufficient susceptibility to cefotaxime. CONCLUSION： In clinical practice, ascitic PMN count is a valid tool for starting a prompt antibiotic treatment andevaluating its efficacy. The initial treatment with cefotaxime failed more frequently than expected. An increase in healthcare-related infections with antibiotic-resistant pathogens may explain this finding. A different first-line antibiotic treatment should be investigated.
文摘Spontaneous bacterial(SBP) and spontaneous fungal peritonitis(SFP) can be a life-threatening infection in patients with liver cirrhosis(LC) and ascites. One of the possible mechanisms of developing SBP is bacterial translocation. Although the number of polymorphonuclear cells in the culture of ascitic fluid is diagnostic for SBP, secondary bacterial peritonitis is necessary to exclude. The severity of underlying liver dysfunction is predictive of developing SBP; moreover, renal impairment and infections caused by multidrug-resistant(MDR) organism are associated with a fatal prognosis of SBP. SBP is treated by antimicrobials, but initial empirical treatment may not succeed because of the presence of MDR organisms, particularly in nosocomial infections. Antibiotic prophylaxis is recommended for patients with LC at a high risk of developing SBP, gastrointestinal bleeding, or a previous episode of SBP, but the increase in the risk of developing an infection caused by MDR organisms is a serious concern globally. Less is known about SFP in patients with LC, but the severity of underlying liver dysfunction may increase the hospital mortality. SFP mortality has been reported to be higher than that of SBP partially because the difficulty of early differentiation between SFP and SBP induces delayed antifungal therapy for SFP.
文摘AIM:To investigate the performance and diagnostic accuracy of interferon-gamma(IFN-γ) for tuberculous peritonitis(TBP) by meta-analysis.METHODS:A systematic search of English language studies was performed.We searched the following electronic databases:MEDLINE,EMBASE,Web of Science,BIOSIS,LILACS and the Cochrane Library.The Standards for Reporting Diagnostic Accuracy initiative and Quality Assessment for Studies of Diagnostic Accuracy tool were used to assess the methodological quality of the studies.Sensitivity,specificity,and other measures of the accuracy of IFN-γ concentration in the diagnosis of peritoneal effusion were pooled using random-effects models.Receiver operating characteristic(ROC) curves were applied to summarize overall test performance.Two reviewers independently judged study eligibility while screening the citations.RESULTS:Six studies met the inclusion criteria.The average inter-rater agreement between the two reviewers for items in the quality checklist was 0.92.Analysis of IFN-γ level for TBP diagnosis yielded a summary estimate:sensitivity,0.93(95%CI,0.87-0.97);specificity,0.99(95%CI,0.97-1.00);positive likelihood ratio(PLR),41.49(95%CI,18.80-91.55);negative likelihood ratio(NLR),0.11(95%CI,0.06-0.19);and diagnostic odds ratio(DOR),678.02(95%CI,209.91-2190.09).χ 2 values of the sensitivity,specificity,PLR,NLR and DOR were 5.66(P = 0.3407),6.37(P = 0.2715),1.38(P = 0.9265),5.46(P = 0.3621) and 1.42(P = 0.9220),respectively.The summary receiver ROC curve was positioned near the desirable upper left corner and the maximum joint sensitivity and specificity was 0.97.The area under the curve was 0.99.The evaluation of publication bias was not significant(P = 0.922).CONCLUSION:IFN-γ may be a sensitive and specific marker for the accurate diagnosis of TBP.The level of IFN-γ may contribute to the accurate differentiation of tuberculosis(TB) ascites from non-TB ascites.
文摘Since its initial description in 1964,research hastransformed spontaneous bacterial peritonitis (SBP)from a feared disease (with reported mortality of 90%)to a treatable complication of decompensated cirrhosis,albeit with steady prevalence and a high recurrencerate. Bacterial translocation,the key mechanism in thepathogenesis of SBP,is only possible because of theconcurrent failure of defensive mechanisms in cirrhosis.Variants of SBP should be treated. Leucocyte esterasereagent strips have managed to shorten the 'tap-to-shot' time,while future studies should look into theircombined use with ascitic fluid pH. Third generationcephalosporins are the antibiotic of choice becausethey have a number of advantages. Renal dysfunctionhas been shown to be an independent predictor ofmortality in patients with SBP. Albumin is felt to reducethe risk of renal impairment by improving effectiveintravascular volume,and by helping to bind pro-inflammatory molecules. Following a single episodeof SBP,patients should have long-term antibioticprophylaxis and be considered for liver transplantation.
基金Supported by Grants from the National Basic Research Program of China,973 Program,No.2013CB531401
文摘AIM: To investigate the microbiological characteristics and drug resistance in liver cirrhosis patients with spontaneous peritonitis.METHODS: We analyzed the data of patients with liver cirrhosis and abdominal infection at the First Affiliated Hospital of Zhejiang University between January 2011 and December 2013. Pathogens present in the ascites were identified,and their sensitivity to various antibiotics was determined. RESULTS: We isolated 306 pathogenic bacteria from 288 cases: In 178 cases,the infection was caused by gram-negative strains(58.2%); in 85 cases,grampositive strains(27.8%); in 9 cases,fungi(2.9%); and in 16 cases,more than one pathogen. The main pathogens were Escherichia coli(E. coli)(24.2%),Klebsiella pneumoniae(18.9%),Enterococcus spp.(11.1%),and Staphylococcus aureus(7.5%). Of the 306 isolated pathogens,99 caused nosocomial infections and 207 caused community-acquired andother infections. The E. coli and K. pneumoniae strains produced more extended-spectrum β-lactamases in cases of nosocomial infections than non-nosocomial infections(62.5% vs 38%,P < 0.013; 36.8% vs 12.8%,P < 0.034,respectively). The sensitivity to individual antibiotics differed between nosocomial and non-nosocomial infections: Piperacillin/tazobactam was significantly more effective against non-nosocomial E. coli infections(4% vs 20.8%,P < 0.021). Nitrofurantoin had stronger antibacterial activity against Enterococcus species causing non-nosocomial infections(36.4% vs 86.3%,P < 0.009).CONCLUSION: The majority of pathogens that cause abdominal infection in patients with liver cirrhosis are gram-negative,and drug resistance is significantly higher in nosocomial infections than in non-nosocomial infections.
文摘AIM:To evaluate effective alternative antibiotics in treatment of cefotaxime-resistant spontaneous bacterial peritonitis.METHODS:One hundred cirrhotic patients with spontaneous bacterial peritonitis [ascitic fluid polymorphonuclear cell count(PMNLs) ≥ 250 cells/mm 3 at admission] were empirically treated with cefotaxime sodium 2 g/12 h and volume expansion by intravenous human albumin.All patients were subjected to history taking,complete examination,laboratory tests(including a complete blood cell count,prothrombin time,biochemical tests of liver and kidney function,and fresh urine sediment),chest X-ray,a diagnostic abdominal paracentesis,and the sample subjected to total and differential cell count,chemical examination,aerobic and anaerobic cultures.Patients were divided after 2 d by a second ascitic PMNL count into group Ⅰ;patients sensitive to cefotaxime(n = 81),group Ⅱ(n = 19);cases resistant to cefotaxime(less than 25% decrease in ascitic PMNL count).Patients of group Ⅱ were randomly assigned into meropenem(n = 11) or levofloxacin(n = 8) subgroups.All patients performed an end of treatment ascitic PMNL count.Patients were considered improved when:PMNLs decreased to < 250 cells/mm 3,no growth in previously positive culture cases,and improved clinical manifestations with at least 5 d of antibiotic therapy.RESULTS:Age,sex,and Child classes showed no significant difference between group Ⅰ and group Ⅱ.Fever and abdominal pain were the most frequent manifestations and were reported in 82.7% and 80.2% of patients in group Ⅰ and in 94.7% and 84.2% of patients in group Ⅱ,respectively.Patients in group Ⅱ had a more severe ascitic inflammatory response than group Ⅰ and this was demonstrated by more ascitic lactate dehydrogenase(LDH) [median:540 IU/L(range:150-1200 IU/L) vs median:240 IU/L(range:180-500 IU/L),P = 0.000] and PMNL [median:15 000 cell/mm 3(range:957-23 822 cell/mm 3) vs 3400 cell/mm 3(range:695-26 400 cell/mm 3),P = 0.000] counts.Ascitic fluid culture was positive in 32% of cases.Cefotaxime failed in 19% of patients;of these patients,11(100%) responded to meropenem and 6(75%) responded to levofloxacin.Two patients with failed levofloxacin therapy were treated according to the in vitro culture and sensitivity(one case was treated with vancomycin and one case was treated with ampicillin/sulbactam).In group Ⅱ the meropenem subgroup had higher LDH(range:108-860 IU/L vs 120-491 IU/L,P = 0.042) and PMNL counts(range:957-23 822 cell/mm 3 vs 957-15 222 cell/mm 3,P = 0.000) at initiation of the alternative antibiotic therapy;there was no significant difference in the studied parameters between patients responsive to meropenem and patients responsive to levofloxacin at the end of therapy(mean ± SD:316.01 ± 104.03PMNLs/mm 3 vs 265.63 ± 69.61 PMNLs/mm 3,P = 0.307).The isolated organisms found in group Ⅱ were;enterococci,acinetobacter,expanded-spectrum β-lactamase producing Escherichia coli,β-lactamase producing Enterobacter and Staphylococcus aureus.CONCLUSION:Empirical treatment with cefotaxime is effective in 81% of cases;meropenem is effective in cefotaxime-resistant cases.
文摘Ascites remain the commonest complication of decompensated cirrhosis. Spontaneous bacterial peritonitis (SBP) is defined as the infection of ascitic fluid (AF) in the absence of a contiguous source of infection and/or an intraabdominal inflammatory focus. An AF polymorphonuclear (PMN) leucocyte count ≥ 250/mm 3 -irrespective of the AF culture resultis universally accepted nowadays as the best surrogate marker for diagnosing SBP. Frequently the results of the manual or automated PMN count do not reach the hands of the responsible medical personnel in a timely manner. However, this is a crucial step in SBP management. Since 2000, 26 studies (most of them published as full papers) have checked the validity of using leukocyte esterase reagent strips (LERS) in SBP diagnosis. LERS appear to have low sensitivity for SBP, some LERS types more than others. On the other hand, though, LERS have consistently given a high negative predictive value (> 95% in the majority of the studies) and this supports the use of LERS as a preliminary screening tool for SBP diagnosis. Finally, an AF-tailored dipstick has been developed. Within the proper setting, it is set to become the mainstream process for handling AF samples.
文摘AIM: To evaluate acute cholecystitis, complicated by peritonitis, acute phase response and immunological status in patients treated by laparoscopic or open approach. METHODS: From January 2002 to May 2012, we conducted a prospective randomized study on 45 consecutive patients (27 women, 18 men; mean age 58 years). These subjects were taken from a total of 681 patients who were hospitalised presenting similar preoperative findings: acute upper abdominal pain with tenderness, involuntary guarding under the right hypochondrium and/or in the flank; fever higher than 38 ℃, leukocytosis greater than 10 × 10 9 /L or both, and ultrasonographic evidence of calculous cholecystitis possibly complicated by peritonitis. These patients had undergone cholecystectomy for acute calculous cholecystitis,complicated by bile peritonitis. Randomly, 23 patients were assigned to laparoscopic cholecystectomy (LC), and 22 patients to open cholecystectomy (OC). Blood samples were collected from all patients before operation and at days 1, 3 and 6 after surgery. Serum bacteraemia, endotoxaemia, white blood cells (WBCs), WBC subpopulations, human leukocyte antigen-DR (HLA-DR), neutrophil elastase, interleukin-1 (IL-1) and IL-6, and C-reactive protein (CRP) were measured at 0, 30, 60, 90, 120 and 180 min, at 4, 6, 12, 24 h, and then daily (8 A.M.) until post-operative day 6.RESULTS: The two groups were comparable in the severity of peritoneal contamination as indicated by the viable bacterial count (open group = 90% of positive cultures vs laparoscopic group = 87%) and endotoxin level (open group = 33.21 ± 6.32 pg/mL vs laparoscopic group = 35.02 ± 7.23 pg/mL). Four subjects in the OC group (18.1%) and 1 subject (4.3%) in the LC group (P < 0.05) developed intra-abdominal abscess. Severe leukocytosis (range 15.8-19.6/mL) was observed only after OC but not after LC, mostly due to an increase in neutrophils (days 1 and 3, P < 0.05). This value returned to the normal range within 3-4 d after LC and 5-7 d after OC. Other WBC types and lymphocyte subpopulations showed no significant variation. On the first day after surgery, a statistically significant difference was observed in HLA-DR expression between LC (13.0 ± 5.2) and OC (6.0 ± 4.2) (P < 0.05). A statistically significant change in plasma elastase concentration was recorded post-operatively at days 1, 3, and 6 in patients from the OC group when compared to the LC group (P < 0.05). In the OC group, the serum levels of IL-1 and IL-6 began to increase considerably from the first to the sixth hour after surgery. In the LC group, the increase of serum IL-1 and IL-6 levels was delayed and the peak values were notably lower than those in the OC group. Significant differences between the groups, for these two cytokines, were observed from the second to the twenty-fourth hour (P < 0.05) after surgery. The mean values of serum CRP in the LC group on post-operative days (1 and 3) were also lower than those in the OC group (P < 0.05). Systemic concentration of endotoxin was higher in the OC group at all intra-operative sampling times, but reached significance only when the gallbladder was removed (OC group = 36.81 ± 6.4 ρg/mLvs LC group = 16.74 ± 4.1 ρg/mL, P < 0.05). One hour after surgery, microbiological analysis of blood cultures detected 7 different bacterial species after laparotomy, and 4 species after laparoscopy (P < 0.05). CONCLUSION: OC increased the incidence of bacteraemia, endotoxaemia and systemic inflammation compared with LC and caused lower transient immunological defense, leading to enhanced sepsis in the patients examined.
文摘AIM: To evaluate the epidemiology and outcomes of culture-positive spontaneous bacterial peritonitis (SBP) and spontaneous bacteremia (SB) in decompensated cirrhosis.METHODS: We prospectively collected clinical, laboratory characteristics, type of administered antibiotic, susceptibility and resistance of bacteria to antibiotics in one hundred thirty cases (68.5% males) with positive ascitic fluid and/or blood cultures during the period from January 1, 2012 to May 30, 2014. All patients with SBP had polymorphonuclear cell count in ascitic fluid > 250/mm<sup>3</sup>. In patients with SB a thorough study did not reveal any other cause of bacteremia. The patients were followed-up for a 30-d period following diagnosis of the infection. The final outcome of the patients was recorded in the end of follow-up and comparison among 3 groups of patients according to the pattern of drug resistance was performed.RESULTS: Gram-positive-cocci (GPC) were found in half of the cases. The most prevalent organisms in a descending order were Escherichia coli (33), Enterococcus spp (30), Streptococcus spp (25), Klebsiella pneumonia (16), S. aureus (8), Pseudomanas aeruginosa (5), other Gram-negative-bacteria (GNB) (11) and anaerobes (2). Overall, 20.8% of isolates were multidrug-resistant (MDR) and 10% extensively drug-resistant (XDR). Health-care-associated (HCA) and/or nosocomial infections were present in 100% of MDR/XDR and in 65.5% of non-DR cases. Meropenem was the empirically prescribed antibiotic in HCA/nosocomial infections showing a drug-resistance rate of 30.7% while third generation cephalosporins of 43.8%. Meropenem was ineffective on both XDR bacteria and Enterococcus faecium (E. faecium). All but one XDR were susceptible to colistin while all GPC (including E. faecium) and the 86% of GNB to tigecycline. Overall 30-d mortality was 37.7% (69.2% for XDR and 34.2% for the rest of the patients) (log rank, P = 0.015). In multivariate analysis, factors adversely affecting outcome included XDR infection (HR = 2.263, 95%CI: 1.005-5.095, P = 0.049), creatinine (HR = 1.125, 95%CI: 1.024-1.236, P = 0.015) and INR (HR =1.553, 95%CI: 1.106-2.180, P = 0.011).CONCLUSION: XDR bacteria are an independent life-threatening factor in SBP/SB. Strategies aiming at restricting antibiotic overuse and rapid identification of the responsible bacteria could help improve survival.
文摘Diagnosis of acute arterial mesenteric ischemia in the early stages is now possible using modern computed tomography with intravenous contrast enhancement and imaging in the arterial and/or portal phase.Most patients have acute superior mesenteric artery(SMA)occlusion,and a large proportion of these patients will develop peritonitis prior to mesenteric revascularization,and explorative laparotomy will therefore be necessary to evaluate the extent and severity of intestinal ischemia,and to perform bowel resections.The establishment of a hybrid operating room in vascular units in hospitals is most important to be able to perform successful intestinal revascularization.This review outlines current frontline surgical strategies to improve survival and minimize bowel morbidity in patients with peritonitis secondary to acute SMA occlusion.Explorative laparotomy needs to be performed first.Curative treatment is based upon intestinal revascularization followed by bowel resection.If no vascular imaging has been carried out,SMA angiography is performed.In case of embolic occlusion of the SMA,open embolectomy is performed followed by angiography.In case of thrombotic occlusion,the occlusive lesion can be recanalized retrograde from an exposed SMA,the guidewire snared from either the femoral or brachial artery,and stented with standard devices from these access sites.Bowel resections and sometimes gall bladder removal due to transmural infarctions are performed at initial laparotomy,leaving definitive bowel reconstructions to a planned second look laparotomy,according to the principles of damage control surgery.Patients with peritonitis secondary to acute SMA occlusion should be managed by both the general and vascular surgeon,and a hybrid revascularization approach is of utmost importance to improve outcomes.
文摘Sclerosing encapsulating peritonitis (SEP) is a rare cause of intestinal obstruction that is characterized by a thick grayish-white fibrotic membrane encasing the small bowel. SEP can be classified as idiopathic,also known as abdominal cocoon,or secondary. It is difficult to make a definite pre-operative diagnosis. We experienced five cases of abdominal cocoon,and the case files were reviewed retrospectively for the clinical presentation,operative findings and outcome. All the patients presented with acute,subacute and chronic intestinal obstruction. Computed tomography (CT) showed characteristic findings of small bowel loops congregated to the center of the abdomen encased by a soft-tissue density mantle in four cases. Four cases had an uneventful post-operative period,one case received second adhesiolysis due to persistent ileus. The imaging techniques may facilitate pre-operative diagnosis. Surgery is important in the management of SEP.
基金Supported by The research project: NR 9310-3, Internal Grant Agency, Ministry of Health and research grant MSM 6198959223, Ministry of Education, Czech Republic
文摘This report presents a survey of current knowledge concerning one of the relatively frequent and severe complications of liver cirrhosis and associated ascites-spontaneous bacterial peritonitis. Epidemiology,aetiology,pathogenesis,clinical manifestation,diagnosis and present possibilities of treatment are discussed.
文摘Spontaneous bacterial peritonitis(SBP) is a frequent, life-threatening bacterial infection in patients with liver cirrhosis and ascites. Portal hypertension leads to increased bacterial translocation from the intestine. Failure to eliminate invading pathogens due to immune defects associated with advanced liver disease on the background of genetic predisposition may result in SBP. The efficacy of antibiotic treatment and prophylaxis has declined due to the spread of multi-resistant bacteria. Patients with nosocomial SBP and with prior antibiotictreatment are at a particularly high risk for infection with resistant bacteria. Therefore, it is important to adapt empirical treatment to these risk factors and to the local resistance profile. Rifaximin, an oral, nonabsorbable antibiotic, has been proposed to prevent SBP, but may be useful only in a subset of patients. Since novel antibiotic classes are lacking, we have to develop prophylactic strategies which do not induce bacterial resistance. Farnesoid X receptor agonists may be a candidate, but so far, clinical studies are not available. New diagnostic tests which can be carried out quickly at the patient's site and provide additional prognostic information would be helpful. Furthermore, we need tools to predict antibiotic resistance in order to tailor first-line antibiotic treatment of spontaneous bacterial peritonitis to the individual patient and to reduce mortality.
文摘Spontaneous bacterial peritonitis(SBP) is the most typical infection observed in cirrhosis patients. SBP is responsible for an in-hospital mortality rate of approximately 32%. Recently, pattern changes in the bacterial flora of cirrhosis patients have been observed, and an increase in the prevalence of infections caused by multi-resistant bacteria has been noted. The wide-scale use of quinolones in the prophylaxis of SBP has promoted flora modifications and resulted in the development of bacterial resistance. The efficacy of traditionally recommended therapy has been low in nosocomial infections(up to 40%), and multi-resistance has been observed in up to 22% of isolated germs in nosocomial SBP. For this reason, the use of a broad empirical spectrum antibiotic has been suggested in these situations. The distinction between community-acquired infectious episodes, healthcare-associated infections, or nosocomial infections, and the identification of risk factors for multi-resistant germs can aid in the decision-making process regarding the empirical choice of antibiotic therapy. Broad-spectrum antimicrobial agents, such as carbapenems with or without glycopeptides or piperacillin-tazobactam, should be considered for the initial treatment not only of nosocomial infections but also of healthcare-associated infections when the risk factors or severity signs for multi-resistant bacteria are apparent. The use of cephalosporins should be restricted to community-acquired infections.
