Diagnosis, treatment and prevention of spontaneous bacterial peritonitis

Spontaneous bacterial peritonitis (SBP) is a frequent complication in cirrhotic patients with ascites. Diagnosis of SBP is established by a polymorphonuclear cell count in ascitic fluid > or =250 cells/mm(3). The organism responsible for the infection is isolated in 60-70% of the cases. The remaining cases are considered to have a variant of SBP (culture-negative SBP) and are treated in the same way as those with a positive culture. The SBP resolution rate ranges between 70 and 90%, and hospital survival between 50 and 70%. An early diagnosis and the use of a more adequate antibiotic therapy are the most probable reasons for the improvement in prognosis for SBP in recent decades. Despite the resolution of the infection, SBP may trigger severe complications such as renal impairment, gastrointestinal bleeding and accentuation of hepatic insufficiency which are responsible for the associated mortality. Patients recovering from an episode of SBP should be considered as potential candidates for liver transplantation.     

肝硬化伴院内感染自发性腹膜炎肾功能的变化与预后的关系

探讨肝硬化腹水患者院内感染自发性腹膜炎（SBP）后肾功能的变化及其与预后的关系。观察162例院内感染SBP患者肾功能的变化，分析肾功能损害（RI）的演变过程与死亡率的关系。结果显示有SBP的患者肾功能损害（SBP－RI）发生率明显高于无SBP患者肾功能损害发生率（P＜0．05），63例发生SBP－RI的患者中，进展型SBP－RI占36．51％，稳定型SBR－RI占33．33％，一过型SBP－RI占30．16％，进展型和稳定型SBP－RI死亡率（73．91％、42．86％）显著高于无SBP－RI者（16．16％），一过型SBP－RI（15．79％）不增加死亡率。引起SBP－RI的主要原因是感染，它的高死亡率与肾损害程度直接相关。     

Rapid diagnosis of spontaneous bacterial peritonitis by use of reagent strips

We studied the use of reagent strips for diagnosis of spontaneous bacterial peritonitis (SBP) in cirrhotic patients with ascites. A reagent strip for leukocyte esterase designed for the testing of urine with a colorimetric 5-grade scale (0 to 4) was used to evaluate ascitic fluid in 228 nonselected paracentesis performed in 128 cirrhotic patients. We diagnosed 52 SBP and 5 secondary bacterial peritonitis by means of polymorphonuclear cell count and classical criteria. When we considered positive a reagent strip result of 3 or 4, sensitivity was 89% (51 of 57), specificity was 99% (170 of 171), and positive predictive value was 98%. When we considered positive a reagent strip result of 2 or more, sensitivity was 96% (55 of 57), specificity was 89% (152 of 171), and negative predictive value was 99%. In conclusion, the use of reagent strips is a rapid, easy to use, and inexpensive tool for diagnosis of ascitic fluid infection. A positive result should be an indication for empirical antibiotic therapy, and a negative result may be useful as a screening test to exclude SBP.     

Usefulness of urine strip test in the rapid diagnosis of spontaneous bacterial peritonitis.

PURPOSE: Rapid and accurate diagnosis of spontaneous bacterial peritonitis (SBP) is mandatory for timely treatment in cirrhotic patients. The purpose of this study was to assess the usefulness of two different reagent strips, the UriSCAN and the Multistix10SG, for the rapid bedside diagnosis of SBP. METHODS: A total of 75 paracenteses in 53 cirrhotic patients with ascites were performed. All ascitic fluid was analyzed with the two reagent strips, and compared with the manual cell count with differential and ascitic fluid culture. SBP was defined as an ascitic polymorphonuclear cell count > or =250/mm3. RESULTS: SBP was diagnosed in 18 of the 75 samples. If we considered the positive UriSCAN result of 2 or more, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were all 100%. When we considered the positive UriSCAN result of 3, the sensitivity, specificity, PPV, and NPV were 67%, 100%, 100%, and 89%, respectively. When we considered the positive Multistix10SG result of 3, the sensitivity, specificity, PPV, and NPV were 50%, 100%, 100%, and 87%, respectively. CONCLUSION: Urine reagent strip might be useful for rapid and accurate diagnosis of SBP in cirrhotic patients with ascites.     

Diagnosis of spontaneous bacterial peritonitis in cirrhotic patients by use of two reagent strips

OBJECTIVE: Spontaneous bacterial peritonitis (SBP) is one of the potentially life-threatening complications in ascitic cirrhotic patients with a mortality rate ranging between 30 and 50%. The improved survival might be explained by a more rapid diagnosis and treatment. The aim of our study was to assess the utility of two reagent strips, the Multistix test and the Combur(2) test LN, for the rapid diagnosis of SBP. METHODS: Thirty-one unselected consecutive cirrhotic patients with ascites were included and a total of 100 paracenteses were performed. All ascitic fluid was analysed with the two reagent strips, leucocyte and polymorphonuclear (PMN) leucocyte cell count and blood-bottle culture if the strips were positive. The strips were considered positive if the colour turned to purple: i.e. grade 3 or 4 for the Multistix test and 2 or 3 for the Combur(2) test LN on a colorimetric scale. RESULTS: We diagnosed nine infections of which four were SBP defined by PMN > or = 250 cells/mm(3) and a positive culture in ascitic fluid and five were culture negative neutrocytic ascites (PMN > or = 250 cells/mm(3) and a negative culture). The results of the two strips were concordant and were negative in only one SBP. The sensitivity, specificity, positive and negative predictive values of these two strips were 89%, 100%, 100% and 99%, respectively. CONCLUSIONS: These reagent strips are very sensitive and specific for the diagnosis of SBP, allowing immediate commencement of empirical antibiotic therapy. These strips should be used for the diagnosis of SBP, especially on an emergency basis.     

Culture-negative neutrocytic ascites: a less severe variant of spontaneous bacterial peritonitis

The clinical signs and symptoms, the biological data and the prognosis of 38 cirrhotic patients with culture-positive spontaneous bacterial peritonitis and 15 cirrhotic patients with culture-negative neutrocytic ascites were compared. The diagnosis of culture-negative neutrocytic ascites was based on the following criteria: an ascitic fluid polymorphonuclear count greater than 250/mm3, a negative ascitic fluid culture and the absence of previous antibiotic therapy and intraabdominal source of infection. All patients were treated by antibiotic therapy. There were no differences in clinical signs and symptoms and Pugh grading between the two groups of patients. Serum creatinine and prevalence of positive-blood culture were higher in spontaneous bacterial peritonitis. Patients with culture-positive spontaneous bacterial peritonitis had a higher ascitic fluid polymorphonuclear count and a lower ascitic fluid pH. Mortality was higher in patients with culture-positive spontaneous bacterial peritonitis than in patients with culture-negative neutrocytic ascites (relative risk: 2.6, p less than 0.01): cumulative mortality was, respectively, 50% and 20% at 1 months, 61% and 33% at 6 months, 75% and 41% at 1 year. The higher mortality observed in patients with culture-positive spontaneous bacterial peritonitis persisted after hospitalization (relative risk: 3, p less than 0.03). Our results suggest that culture-negative neutrocytic ascites is a less severe variant of spontaneous bacterial peritonitis.     

Accuracy of the automated cell counters for management of spontaneous bacterial peritonitis

AIM： To evaluate the accuracy of automated blood cell counters for ascitic polymorphonuclear （PMN） determination for： （1） diagnosis, （2） efficacy of the ongoing antibiotic therapy, and （3） resolution of spontaneous bacterial peritonitis （SBP）.
METHODS： One hundred and twelve ascitic fluid samples were collected from 52 consecutive cirrhotic patients, 16 of them with SBP. The agreement between the manual and the automated method for PMN count was assessed. The sensitivity/specificity and the positive/negative predictive value of the automated blood cell counter were also calculated by considering the manual method as the ＂gold standard＂ RESULTS： The mean ＋ SD of the difference between manual and automated measurements was 7.8 4- 58 cells/ram3, while the limits of agreement were ＋124 cells/mm3 [95% confidence interval （CI）： ＋145 to ＋103] and -108 cells/mm3 （95% CI： -87 to -129）. The automated cell counter had a sensitivity of 100% and a specificity of 97.7% in diagnosing SBP, and a sensitivity of 91% and a specificity of 100% for the efficacy of the ongoing antibiotic therapy. The two methods showed a complete agreement for the resolution of infection.
CONCLUSION： Automated cell counters not only have a good diagnostic accuracy, but are also very effectivein monitoring the antibiotic treatment in patients with SBP. Because of their quicker performance, they should replace the manual counting for PMN determination in the ascitic fluid of patients with SBP.     

Evaluation of leukocyte esterase and nitrite strip tests to detect spontaneous bacterial peritonitis in cirrhotic patients

AIM： To investigate the diagnostic efficacy of leukocyte esterase and nitrite reagent strips for bedside diagnosis of spontaneous bacterial peritonitis （SBP）. METHODS： A total of 63 consecutive patients with cirrhotic ascites （38 male, 25 female） tested between April 2005 and July 2006 were included in the study. Bedside reagent strip testing was performed on ascitic fluid and the results compared to manual cell counting and ascitic fluid culture. SBP was defined as having a polymorphonuclear ascites count of ≥ 250/mm^3. RESULTS： Fifteen samples showed SBP. The sensitivity, specificity, positive and negative predictive values of the leukocyte esterase reagent strips were; 93%, 100%, 100%, and 98%, respectively. The sensitivity, specificity, positive and negative predictive value of the nitrite reagent strips were 13%, 93%, 40%, and 77%, respectively. The combination of leukocyte esterase and nitrite reagents strips did not yield statistically significant effects on diagnostic accuracy. CONCLUSION： Leukocyte esterase reagent strips may provide a rapid, bedside diagnostic test for SBP.     

Polymorphonuclear count in ascitic fluid after laparotomy in cirrhotic patients.

In order to establish whether an ascitic polymorphonuclear count greater than 250/mm3 remains a diagnostic criterion for postoperative bacterial peritonitis, a prospective study of 16 patients with cirrhosis and ascites undergoing hepatectomy (n = 4), portocaval shunt (n = 5) and biliary and digestive surgery (n = 7) was carried out. Sixty-four consecutive specimens of ascitic fluid were obtained through abdominal one-way suction tubes left in situ. In 17 (26%) specimens, ascitic fluid was blood stained and the polymorphonuclear count was unreliable; none of these specimens demonstrated positive ascitic fluid culture. In the remaining 47 specimens the polymorphonuclear count ranged from 5 to 5,920/mm3. Positive ascitic fluid culture was significantly higher in polymorphonuclear > or = 250/mm3 group (5/13: 38%) than in polymorphonuclear < 250/mm3 group (2/34: 6%) (p < 0.02). These results suggest that, as in non-operated cirrhotic patients: (a) polymorphonuclear count should be taken in account in the diagnosis of postoperative bacterial peritonitis; (b) polymorphonuclear count greater than 250/mm3 is a good criterion for the diagnosis of bacterial postoperative peritonitis.     

Activation of the alternative complement pathway in ascitic fluid during spontaneous bacterial peritonitis

We studied complement and immunoglobulin profiles on the serum and ascitic fluid of a patient before and during gram-negative spontaneous bacterial peritonitis (SBP). During the infection, activation of the alternative complement pathway in ascitic fluid was manifested by a 35% reduction in functional activity and depression of both properdin and factor B concentrations to nondetectable levels. Activation of the complement cascade was also demonstrated by a 50% reduction in the C3 concentration and depression of total hemolytic complement. There was no evidence of complement activation of a functionally intact complement system in the ascitic fluid of cirrhotic patients. Complement consumption in ascitic fluid may predispose the cirrhotic to SBP.     

Study on ascitic fluid complement 3 level in cirrhotic patients with spontaneous bacterial peritonitis and without spontaneous bacterial peritonitis

BACKGROUND/AIMS: Ascitic fluid Complement 3 (C3) concentration is the most important factor to offer local defense against infection of ascitic fluid. Hepatic synthesis of Complement 3 and its concentration in ascitic fluid is significantly reduced in patients with advanced cirrhosis. The aim of the study was to assess the level of Complement 3 in ascitic fluid in cirrhotic patients with and without spontaneous bacterial peritonitis (SBP) and to identify the group of cirrhotic ascites at risk of developing METHODOLOGY: A prospective case control study was carried out to compare the level of ascitic fluid Complement 3 concentration in patients with SBP (case-group) and without SBP (control-group). Ascitic fluid Complement 3 level was estimated in 15 patients with SBP (case) and another 15 patients without SBP (control). RESULTS: In the study, ascitic fluid Complement 3 concentration was 7.3+/-4.3 mg/dL in patients with SBP and 16.4+/-11.3 mg/dL in patients who did not develop SBP. CONCLUSIONS: Ascitic fluid Complement 3 level is significantly (P=0.009) reduced in cirrhotic patients who develop SBP.     

Expression of proinflammatory cytokines and their inhibitors during the course of spontaneous bacterial peritonitis

The aim of this work was the evaluation, in cirrhotic patients with noninfected ascites and with spontaneous bacterial peritonitis (SBP), of serum and ascitic fluid levels of proinflammatory cytokines [interleukin (IL) 1-, tumor necrosis factor (TNF-), and IL6] and antiinflammatory compounds [IL10, soluble IL-1 receptor antagonist (sIL-1Ra), soluble receptors of TNF p55 and p75 (sTNFR55 and sTNFR75), and soluble receptor of IL6 (sIL6R)], as well as their relationship with the outcome of the infection in those with SBP. These molecules were assayed by ELISA in noninfected cirrhotic controls (n = 15), patients with SBP (n = 32), and healthy controls (n = 20). Serum levels of IL6 and of the majority of antiinflammatory mediators, sIL1Ra, sTNFR75, and sIL6R, were higher in control cirrhotic patients compared to healthy subjects. SBP was associated with significantly elevated ascitic fluid levels of every one of the proinflammatory cytokines compared to those in cirrhotic controls. Also, serum levels of IL10 and both TNF receptors and ascitic fluid levels of sIL1Ra and sTNFR55 were higher in patients with SBP compared to cirrhotic controls. Ascitic fluid levels of proinflammatory cytokines decreased rapidly after resolution of the infection; however, nonsignificant changes were detected in ascitic fluid concentrations of antiinflammatory molecules. Thus, elevated levels of antiinflammatory compounds both in noninfected cirrhotic patients and in patients with SBP suggest a regulatory control of the inflammatory process by these molecules in liver cirrhosis patients.     

Rapid diagnosis of spontaneous bacterial peritonitis with leukocyte esterase reagent strips in a European and in an American center

BACKGROUND: Timely diagnosis and treatment of spontaneous bacterial peritonitis (SBP) are essential to survival. The purpose of the present paper was to evaluate leukocyte esterase reagent strips (Nephur-Test and MultistixSG10) in the bedside diagnosis of SBP. METHODS: Patients with cirrhotic ascites were prospectively included in France (center 1) and in the USA (center 2). Paracenteses were performed on admission and repeated as indicated. Bedside reagent strip testing was performed on the ascitic fluid and compared to manual cell count with differential and ascitic fluid culture. In center 1, the Nephur-Test was tested in all cases, with dual testing with MultistixSG10 in a subgroup. In center 2, all cases had dual testing. Spontaneous bacterial peritonitis was defined as a polymorphonuclear ascites count > or =250/microL. RESULTS: A total of 184 samples was obtained in 76 patients. Center 1 included 151 samples from 53 patients. Seven samples had SBP, obtained in six patients. Center 2 included 33 samples from 23 patients. Six samples had SBP, obtained in five patients. The sensitivity, specificity, positive and negative predictive value of the reagent strips were as follows. Center 1/Nephur-Test: 86%, 100%, 100%, 99%; center 1/MultistixSG10: 100%, 100%, 100%, 100%; center 2/Nephur-Test: 100%, 92.5%, 75%, 100%; center 2/MultistixSG10: 83%, 96%, 83%, 96%. CONCLUSION: Leukocyte esterase reagent strips may provide a rapid bedside diagnosis of SBP.     

Spontaneous bacterial peritonitis and culture negative neutrocytic ascites in patients with non-alcoholic liver cirrhosis

Abstract Medical records of 18 patients with spontaneous bacterial peritonitis (SBP) and 19 patients with culture negative neutrocytic ascites (CNNA) were reviewed. The diagnosis of SBP was based on a positive ascitic fluid culture, a polymorphonuclear cell count (PMN) greater than 250 cells/mm³ and the absence of an intra-abdominal source of infection. The diagnosis of CNNA was based on a PMN count greater than 250 cells/mm³, a negative ascitic fluid culture, the absence of an intra-abdominal source of infection and no antibiotic treatment in the preceding 30 days. All patients in both groups had liver cirrhosis, which was mainly (62.2%) due to HBV infection. A single strain, mostly 'a Gram-negative' bacillus, was recovered from the ascitic fluid culture in the vast majority of patients (83%) with SBP. There were no significant differences between the clinical data of both groups. However, the CNNA group had a significantly better Pugh score ( P value = 0.01) with a mean score of 9.42 ±2.24, compared to the SBP group (10.94 ±2.88). The only significant difference in the laboratory data was that the total bilirubin was higher in the SBP group ( P 0.01). Hospital mortality was significantly higher in the SBP patients compared to those with CNNA, 50 and 16%, respectively ( P 0.03). Recurrent ascitic fluid infection occurred in one of five patients who initially presented. In contrast no recurrence was documented in 12 patients with CNNA.
Spontaneous bacterial peritonitis is a serious complication of liver cirrhosis with significantly higher mortality than CNNA. A single organism, usually enteric, is the most common causative agent.     

Five days of ceftriaxone to treat spontaneous bacterial peritonitis in cirrhotic patients

Background. The aim of this study was to determine whether a short course of ceftriaxone was sufficient to cure spontaneous bacterial peritonitis (SBP) in cirrhotic patients. Methods. We studied 33 cirrhotic patients with SBP. All of them were treated with ceftriaxone, 1.0 g IV, every 12 h for 5 days. Twenty-one variables were recorded to evaluate their relationship to the resolution of SBP. Results. The mean age of the patients was 45 years. Twenty-three were males and 10 females. The etiology of cirrhosis was alcoholic in 42% of the patients, and 82% of the patients belonged to Child-Pugh Class C. Hepatic encephalopathy was present in 39% of the patients. The most frequent organism causing SBP was Escherichia coli (60%). Resolution of SBP on day 5 of treatment was achieved in 73% of the patients. Total resolution of SBP after prolonged therapy with ceftriaxone or another agent, selected according to antibiotic susceptibility, was achieved in 94% of the patients. Hospital mortality was 12%. Multivariate analysis showed no factor that was significantly related to the resolution of SBP, but univariate analysis showed that renal impairment and positive culture tended to be related. Conclusions. A short course (5 days) of ceftriaxone is useful therapy for SBP. If the polymorphonuclear differential count in ascitic fluid is less than 250 cells/mm³ on day 5 of treatment, the antibiotic can be discontinued. Received: April 2, 2001 / Accepted: August 10, 2001     

Diagnostic accuracy of a rapid urine-screening test (Multistix8SG) in cirrhotic patients with spontaneous bacterial peritonitis

OBJECTIVE: To assess the diagnostic accuracy of a rapid urine-screening test (Multistix8SG) for spontaneous bacterial peritonitis (SBP) in cirrhotic patients. METHODS: Seventy-two consecutive patients (44 males, 28 females; mean age 61.6 years) with cirrhosis and ascites were included in the study. A diagnostic paracentesis was performed on hospital admission in all patients and 2 days after antibiotic treatment in the case of SBP (polymorphonuclear [PMN] count over 250/mm in ascitic fluid). Each fresh sample of ascitic fluid was also tested using the Multistix8SG urine test, and the results were scored as negative, trace or positive. RESULTS: Nine of the 72 patients had SBP and the Multistix8SG urine test was positive. After 48 h of antibiotic therapy, the PMN count of three of these nine patients was still above 250/mm and the Multistix8SG test remained positive. In three other patients with SBP, the PMN count dropped below 250/mm and the Multistix8SG test result had become negative. Two of the nine SBP patients died before 48 h, and paracentesis was not performed in the ninth case. In the other 63 patients, the PMN count in ascitic fluid was below 250/mm; the Multistix8SG test revealed 17 trace results and 46 negative results. At the threshold of 250 PMN/mm in ascitic fluid, this test had a sensitivity and a specificity of 100%. CONCLUSION: A positive Multistix8SG urine test result in ascitic fluid appears to be an indication for antibiotic treatment.     

Detection of ascitic fluid infections in patients with liver cirrhosis and ascites

Background and study aimsAscitic fluid infections (AFIs) are the frequent complications of advanced liver disease. Bacterial translocation is considered a key step in the pathogenesis of gut-derived bacterial infections; mainly spontaneous bacterial peritonitis (SBP) in cirrhotic patients. Bacterial DNA (bactDNA) in ascitic fluid and serum has been suggested as a surrogate marker for bacterial translocation. We attempted at the isolation and identification of bacteria in ascitic fluid in cirrhotic patients and the assessment of polymerase chain reaction (PCR) in ascitic fluid and serum.Patients and methodsFifty cirrhotic patients having ascites with no signs of infection were included. Ascitic fluid cultures were obtained from patients. Ascitic fluid and serum were subjected to DNA extraction and PCR for the universal amplification of a region of the 16S ribosomal RNA (16S rRNA) gene to detect bactDNA.ResultsBacteria were isolated from 9 (18%) of the ascitic fluid samples, and were mainly Gram-positive bacteria. BactDNA was detected simultaneously in the ascitic fluid and serum of 17 (34%) patients and in the ascitic fluid of only 2 patients. In a single patient with positive ascitic fluid culture no bactDNA was detected in ascitic fluid or serum. By considering AFIs as a positive ascitic fluid culture and/or the presence of bactDNA in the ascitic fluid and/or serum, ascitic fluid culture could detect 9 out of 20 patients with AFIs (45%), PCR of ascitic fluid could detect 19 out of 20 (95%) while PCR of serum could detect 17 out of 20 (85%). In 10 patients with culture negative non-neutrocytic ascites (CNNNA) bactDNA could be detected in serum and ascitic fluid.ConclusionAFI can be caused by Gram positive as well as Gram negative organisms. A substantial percentage of cases with CNNNA show bactDNA in serum and ascitic fluid. PCR of ascitic fluid should, therefore, be used in the diagnostic workup of suspected cases of ascitic fluid infections.     

Two different dosages of cefotaxime in the treatment of spontaneous bacterial peritonitis in cirrhosis: Results of a prospective,randomized, multicenter study

Cefotaxime (CTX) is considered one of the first-choice antibiotics in the therapy of spontaneous bacterial peritonitis (SBP) in cirrhosis. Because CTX is largely metabolized in the liver, this drug may also be effective in SBP by administering lower doses than those habitually used. To investigate this possibility, a prospective, randomized, multicenter study was performed to compare the therapeutic efficacy of two different dosages of CTX in 143 patients with SBP: 71 (group I) were allocated to receive a high dose (2 g every 6 hours, which is one of the most frequently recommended doses in this infection), and 72 (group II) were allocated to receive a low dose (2 g every 12 hours). At inclusion, both groups were similar in relation to clinical and laboratory data, with the exception of a higher incidence of positive ascitic fluid culture in group I than in group II (59% vs. 40%; P = .029). The rate of infection resolution was similar for both groups (77% vs. 79%). Hospital survival was also similarin both groups (69% vs. 79%). No difference was observed between patients with positive or negative ascitic fluid cultures with regard to infection resolution and patient survival. The duration of antibiotic therapy was similar in both groups (9.0 ± 3.3 days in group I vs. 8.8 ± 3.1 days in group II). In a subset of 13 patients from group I and 11 patients from group II CTX levels were determined in serum (peak and trough) and ascitic fluid (concomitantly with trough serum). Peak serum levels were similar in patients from both groups. In contrast, trough serum and/or ascitic fluid levels were significantly lower or more frequently undetectable in group II patients than in group I patients. Nevertheless, this feature did not correlate with infection resolution or patient survival. These results indicate that the high efficacy of CTX in SBP can be maintained by using doses lower than those habitually recommended.     

Impaired functions of normal peripheral polymorphonuclear leukocytes in cirrhotic ascitic fluid.

The function of normal polymorphonuclear cells in the ascitic fluid of 32 patients with cirrhotic ascites and 17 patients with malignant ascites was studied independently of ascitic fluid heat-labile factors. Polymorphonuclear (PMN) function was assessed by a chemiluminescence method using preopsonized zymosan as stimuli. The chemiluminescence response was higher in malignant ascitic fluid than in cirrhotic ascitic fluid (0.84 and 0.15, respectively, p < 0.001). These results were confirmed by a microbiological assessment of phagocytosis. Suppressive factors were evidenced by making ascitic fluid dilutions and using cell-free chemiluminescence measurements. Addition of malignant ascitic fluid to cirrhotic ascitic fluid showed that there is also a deficiency in supportive factors other than C3. The impaired PMN production of oxidative metabolites we observed in cirrhotic ascitic fluid can partly explain the high susceptibility of cirrhotic patients to spontaneous bacterial peritonitis independently of C3 levels.     

Spontaneous Bacterial Peritonitis: Clinical and Laboratory Features with Reference to Hospital-Acquired Cases

A review of a large secondary and tertiary care hospital's experience with spontaneous bacterial peritonitis (SBP) over 7 yr revealed that in most cases this complication emerges after the patient is admitted to the hospital. Compared with a hospitalized control group, SBP patients were more likely to have gastrointestinal bleeding and renal failure and to require invasive procedures or therapies. Thus, hospitalized cirrhotics with ascites who develop SBP are more debilitated before development of SBP. The clinical signs and symptoms of this disorder are diverse; simple tests of ascitic fluid properties (white blood cell count, polymorphonuclear cell count, and lactate dehydrogenase) correlate closely with positive cultures, affording the clinician a chance to make an early presumptive diagnosis. Recognition of nosocomial SBP has important implications for the management of hospitalized cirrhotic patients. Further study is needed to determine if invasive procedures actually cause some cases of SBP or if the apparent association is simply due to identification of a sicker, more debilitated group of patients.