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.     

Diagnostic value of two reagent strips (Multistix 8 SG and Combur 2 LN) in cirrhotic patients with spontaneous bacterial peritonitis and symptomatic bacterascites

OBJECTIVE: Spontaneous bacterial peritonitis is a life-threatening complication in patients with liver cirrhosis requiring a rapid diagnosis. We have tested two reagent strips, Multistix 8 SG and Combur 2 LN for bedside diagnosis of spontaneous bacterial peritonitis and symptomatic bacterascites, a variant of spontaneous bacterial peritonitis. METHODS: Responses of the two strips in colorimetric scale were compared with results given by cyto-bacteriological analysis of ascitic fluid. Results with positivity in grades 1 and 2 of colorimetric scale were analyzed. RESULTS: Four hundred and forty three paracentesis were performed in 116 patients including 46 samples of ascitic fluid with spontaneous bacterial peritonitis occurring in 25 patients and 20 samples of ascitic fluid with symptomatic bacterascites occurring in 17 patients. Forty two percent of spontaneous bacterial peritonitis were culture-negative neutrocytic ascites, gram-positive pathogens and enterobacteriaceae were responsible for 36% and 21% episodes of spontaneous bacterial peritonitis and 71% and 29% episodes of symptomatic bacterascites respectively. Fifty seven percent of spontaneous bacterial peritonitis had polymorphonuclear cell count<1000/mm3. For spontaneous bacterial peritonitis diagnosis, grade 1 positive Multistix and Combur tests had a sensitivity of 69.6% and 80.4% respectively, and a negative predictive value of 96% and 97.3%. Grade 2 positivity increased specificity to 98% and 99.2% and positive predictive value to 75% and 91% for the two strips respectively. Grade 1 positive tests had a sensitivity of 100% and 90% and a negative predictive value of 100% and 99.4% respectively for diagnosis of spontaneous bacterial peritonitis with polymorphonuclear count > 1000/mm3. For symptomatic bacterascites diagnosis, grade 1 positive tests had a sensitivity of 22.4% and 44.4% respectively and a negative predictive value of 96% and 97%. CONCLUSION: Although Combur had a higher sensitivity than Multistix for the diagnosis of spontaneous bacterial peritonitis, sensitivity of the two strips remains low with polymorphonuclear cell count<1000/mm3. Grade 2 positive Combur test had an acceptable positive predictive value. Sensitivity of both strips is insufficient for diagnosis of symptomatic bacterascites. Rapid cyto-bacteriological analysis of ascitic fluid remains necessary for diagnosis of these complications.     

Spontaneous bacterial peritonitis in asymptomatic outpatients with cirrhotic ascites

The prevalence and natural history of spontaneous bacterial peritonitis in asymptomatic patients with ascites secondary to cirrhosis is unknown. From a prospectively recorded database, we reviewed the clinical and laboratory features of all outpatients with cirrhotic ascites undergoing paracentesis between July 1994 and December 2000. The prevalence of spontaneous bacterial peritonitis in the population of 427 cirrhotic outpatients as defined by neutrocytic ascites (absolute neutrophil count >or=250 cells/mm(3)) was 3.5%. Of the 15 patients with neutrocytic ascites, 6 were culture positive (1.4%) and 9 culture negative (2.1%). Eight other patients (1.9%) had bacterascites. The organisms cultured from ascitic fluid in these asymptomatic patients with culture positive neutrocytic ascites and bacterascites were predominantly gram positive. No patient developed hepatorenal syndrome, and 1-year survival of 67% was better than historical data from hospitalized patients with spontaneous bacterial peritonitis. Moreover, patients who did not receive antibiotics for neutrocytic ascites fared no worse than patients who did receive antibiotics. In conclusion, spontaneous bacterial peritonitis in outpatients with cirrhotic ascites is less frequent, occurs in patients with less advanced liver disease, and may have a better outcome than its counterpart in hospitalized patients. In addition, the organisms cultured from ascitic fluid in outpatients are predominantly gram positive. A reassessment of diagnostic criteria for spontaneous bacterial peritonitis in outpatients may be required.     

Usefulness of routine analysis of ascitic fluid at the time of therapeutic paracentesis in asymptomatic outpatients. Results of a multicenter prospective study

AIM: The guidelines of the American Association for the Study of Liver Diseases recommend performing exploratory paracentesis on each patient with cirrhosis and chronic ascites. The aim of the study was to evaluate the prevalence of spontaneous bacterial peritonitis and culture-negative neutrocytic ascites in a large population of consecutive asymptomatic cirrhotic ascitic ambulatory patients. METHODS: Patients with cirrhosis and tense ascites hospitalized from January to September 2000 in 5 hepatogastroenterology units prospectively underwent an exploratory paracentesis with cytobacteriological, biochemical and bedside inoculation into aerobic and anaerobic blood culture bottles. Patients studied were not receiving antibiotics except for norfloxacin and had no obvious sign of infection such as fever or hypothermia, chills, unusual abdominal tenderness, de novo or worsening hepatic encephalopathy, recent gastrointestinal bleeding, acute renal failure or marked arterial hypotension. Clinical and biological findings and ascitic fluid cytological and bacteriological results were evaluated at each exploratory paracentesis. The results are given in mean +/- standards deviations with range. RESULTS: Sixty-seven cirrhotic patients (48M/19F, mean age 59 +/- 9 years) had 270 therapeutic paracenteses, preceded by an exploratory aspiration. Fifty-nine patients (88%) had alcoholic cirrhosis. Twenty-five patients (37.3%) received norfloxacin. At first paracentesis 41 (61.2%) and 26 (38.8%) patients were class B and C respectively according to the Child-Pugh classification; the mean Child-Pugh score was 9 +/- 1.5. None had suspicion of infection. The mean number of paracenteses was 5 +/- 4.3 per patient; 59.6% of the paracenteses (161) were compensated with human albumin. Ascitic protein concentration was 17.5 +/- 8.6 g/l, ascitic fluid cell count and number of neutrophils were 127 +/- 155/mm3 and 5.9 +/- 14/mm3 (0-60), respectively. No patient had spontaneous bacterial peritonitis nor culture-negative neutrocytic ascites; 10 cases of monomicrobial bacterascites were observed, all with commensal germs. CONCLUSIONS: In the absence of obvious signs of infection, the prevalence of spontaneous bacterial peritonitis and culture-negative neutrocytic ascites in asymptomatic cirrhotic outpatients with ascites is near 0%. Moreover, for 100 large volume paracenteses, not performing exploratory paracentesis corresponds to a savings of 5,500 euros, without risk for these patients.     

The value of ascitic fluid polymorphonuclear cell count determination during therapy of spontaneous bacterial peritonitis in patients with liver cirrhosis

BACKGROUND/AIMS: Spontaneous bacterial peritonitis is one of the most common complications attending the onset of ascites in patients with liver cirrhosis. The aim of this study was to demonstrate whether it is possible, on the basis of ascitic fluid polymorphonuclear cell count in patients with liver cirrhosis and spontaneous bacterial peritonitis, to determine the optimal duration of cefotaxime therapy, as the most frequently applied empirical therapy, and possibly anticipate the disease recurrence. METHODOLOGY: In 16 patients with alcoholic liver cirrhosis and confirmed diagnosis of spontaneous bacterial peritonitis, cefotaxime therapy was administered 2g t.i.d. during 5 days. Before the therapy, at 48 hours, 5 days and 15-20 days after the cefotaxime therapy was started, in all patients with spontaneous bacterial peritonitis diagnostic abdominal paracentesis was performed, each time determining the ascitic fluid polymorphonuclear cell count together with microbiological analysis. RESULTS: In the course of the "primary" spontaneous bacterial peritonitis attack, 3 patients died (18.8%). In 4 patients the recurrence of spontaneous bacterial peritonitis was observed within 15-20 days after therapy was discontinued. Two patients died during the therapy of spontaneous bacterial peritonitis recurrence. After 48 hours of therapy, 11 patients with the "primary" spontaneous bacterial peritonitis attack were without any symptoms (68.8%). Out of these 11, 10 patients (62.5%) had the ascitic fluid polymorphonuclear cell count lower than 250/mm3. After 5 days of therapy, 12 patients (75%) were free of symptoms, and the number of ascitic fluid polymorphonuclear cell count < 250/mm3 was still found in 10 (62.5%) patients. No association between the presence of symptoms 48 hours after the therapy and the recurrence of spontaneous bacterial peritonitis was established. A significant association was found between the ascitic fluid polymorphonuclear cell count determined 48 hours after the therapy and the recurrence of spontaneous bacterial peritonitis. A recurrence occurred in only 1 patient with the number of ascitic fluid polymorphonuclear cell count < 250/mm3, 48 hours after the therapy was started. A recurrence of spontaneous bacterial peritonitis occurred in all the patients who had an ascitic fluid PMN cell count > or = 250/mm3, 48 hours after the therapy was started. CONCLUSIONS: By monitoring the ascitic fluid PMN cell count it seems to be possible to determine the efficacy and optimal duration of cefotaxime therapy in patients with spontaneous bacterial peritonitis when it is of most importance that the number of ascitic fluid PMN cell count should decrease below 250/mm3 during the therapy.     

Identification of bacterial DNA in neutrocytic and non‐neutrocytic cirrhotic ascites by means of a multiplex polymerase chain reaction

Background: Even though bacterial cultures of ascitic fluid are negative in up to 65% of the cases of spontaneous bacterial peritonitis (SBP); bacterial DNA (bactDNA) has been frequently detected in episodes of SBP as well as in culture‐negative non‐neutrocytic ascites. Aims: To evaluate multiplex polymerase chain reaction (PCR) for pathogen identification in SBP and to determine the prevalence of ascitic bactDNA and its prognostic relevance in hospitalized patients with liver cirrhosis. Methods: Ascitic fluid from 68 consecutive patients who underwent diagnostic paracentesis was analysed for polymorphonuclear leucocyte (PMN) count, bacterial culture and bactDNA. BactDNA was identified by gel analysis after multiplex PCR of selectively enriched prokaryotic nucleic acids. Correlations of bactDNA status with PMN count, bacterial culture result and 3‐month mortality were determined for neutrocytic and for non‐neutrocytic ascites. Results: 11/68 patients presented with an elevated ascitic PMN count. BactDNA was detected in 5/5 culture‐positive neutrocytic samples, in 1/6 culture‐negative neutrocytic samples and in 8/56 culture‐negative non‐neutrocytic samples. Three‐month mortality did not differ with respect to ascitic bactDNA status (7/14 vs. 14/47, P=0.162). 3‐month mortality was increased in the presence of ascitic bactDNA for patients older than 65 years (4/5 vs. 4/14, P=0.046) and for patients with a model for end‐stage liver disease score >15 (7/10 vs. 9/30, P=0.025). Conclusions: Identification of ascitic bactDNA is an appropriate alternative to bacterial ascite culture for pathogen identification in patients at risk for SBP. Its prognostic relevance as a proposed marker of bacterial translocation for certain risk groups has to be further evaluated.     

Prevalence and prognosis of spontaneous bacterial peritonitis. Experience in patients from a general hospital in Porto Alegre,RS, Brazil (1991-2000)

BACKGROUND: Spontaneous bacterial peritonitis is a frequent complication that occurs in patients with cirrhosis and ascites and has a recurrence rate of 70% in 1 year. In addition, this infection determines a poor short and long-term prognosis and a shorter survival rate. AIMS: Evaluate the prevalence of spontaneous bacterial peritonitis in cirrhotic patients with ascites and the effect of its occurrence on the survival. PATIENTS/METHODS: One thousand and thirty admissions of patients with cirrhosis and ascites were reviewed and 114 episodes of spontaneous bacterial peritonitis were documented in 94 patients. The ascitic analysis was accomplished in all patients. The diagnosis of this infection was established when the ascitic fluid polymorphonuclear count was equal or above 250 cells mm3. RESULTS: The prevalence of this infection was 11.1% and the mortality rate 21.9%. Spontaneous bacterial peritonitis was community acquired in 61.4% and hospital acquired in 37.7%. The mortality rate was 18.6% and 27.9%, respectively. The infection resolved in 91.1% of the episodes by the analysis of ascitic fluid at 48 hours on antibiotics. The use of prophylactic antibiotics was documented in 22.3% of the episodes, but there are not significant differences on the mortality or type of bacteria isolated when comparing the patients with or without this treatment. CONCLUSIONS: Spontaneous bacterial peritonitis is a common complication in patients with cirrhosis and ascites and determines a worse prognosis, mainly when related with absence of initial response to antibiotics.     

A Recent Evaluation of Empirical Cephalosporin Treatment and Antibiotic Resistance of Changing Bacterial Profiles in Spontaneous Bacterial Peritonitis

The aim of this research is to evaluate the recent changes in microorganisms causing spontaneous bacterial peritonitis in cirrhotic patients, antibiotic resistance, and response to empirical cephalosporin therapy. A total of 218 patients with ascites secondary to cirrhosis were enrolled. Parenteral cefotaxime or cefepime was given to patients who had a neutrophil count of 250/mm³ or more or a positive bacterial culture of ascitic fluid. Antibiotic failure was defined by an absence of clinical improvement and an insufficient decrease in neutrophil count of ascites (<25% of initial value) by the third day of therapy. Of all the patients, 44.6% had culture-negative neutrocytic ascites, 24.8% had spontaneous bacterial peritonitis, and 10.1% had monomicrobial nonneutrocytic bacterascites. Growth in culture was observed in 76 patients (34.9%). The two most common isolated bacteria were Escherichia coli (33.8%) and coagulase-negative Staphylococcus (CoNS; 19.7%). The two cephalosporins were effective against E. coli (82%) and but not against CoNS (44%), while levofloxacin showed reasonable activity against both E. coli (71%) and CoNS (90%) in vitro. We confirmed a recent increased incidence of spontaneous bacterial peritonitis caused by Gram-positive bacteria. Levofloxacin seems to be a good alternative treatment for patients with uncomplicated spontaneous ascites infections.     

Ascitic fluid pH in alcoholic cirrhosis: a reevaluation of its use in the diagnosis of spontaneous bacterial peritonitis.

An ascitic fluid pH less than or equal to 7.31 has been advanced as being the best index in the early diagnosis of spontaneous bacterial peritonitis in cirrhotic patients. In order to test the validity of this criteria, 55 patients with alcoholic cirrhosis and ascites were studied. In each patient, arterial blood and ascitic fluid samples were analysed for pH, PCO2, total CO2 and PO2, and the pH gradient between blood and ascites was calculated. White blood cell and polymorphonuclear cell counts were determined in ascitic fluid, and cultures of ascites were done under aerobic and anaerobic conditions. Twelve patients had a culture proven spontaneous bacterial peritonitis. Their mean ascitic fluid pH (+/- SD) was 7.38 +/- 0.09 (range 7.21-7.49) and differed significantly (p less than 0.05) from that found in patients without spontaneous bacterial peritonitis: 7.44 +/- 0.06 (range 7.34-7.6.3). A marked overlap was observed, however, between the two groups, and only three out of the 12 patients with spontaneous bacterial peritonitis had an ascitic fluid pH less than or equal to 7.31. The pH gradient was 0.10 +/- 0.08 (range -0.01 to +0.28) in the spontaneous bacterial peritonitis group, as compared with 0.02 +/- 0.04 (range -0.09 to +0.12) in the sterile group (p less than 0.01), but a marked overlap was also noted between the two groups. In the spontaneous bacterial peritonitis group, the polymorphonuclear count was 3588 +/- 3849/microliter (range 60-11 776) versus 41 +/- 138/microliter (range 0-813) in the sterile group (p less than 0.0001). All but one patient in the spontaneous bacterial peritonitis group and only two patients in the sterile group had over 250 polymorphonuclear/ microliter. Thus, in our experience, neither the ascitic fluid pH nor the pH gradient values accurately discriminated the individual patients with and without spontaneous bacterial peritonitis. A polymorphonuclear count less than 250/ microliter remained the best criteria for the diagnosis of spontaneous bacterial peritonitis in cirrhotic patients, before having the results of ascitic fluid cultures.     

Utility of an algorithm in differentiating spontaneous from secondary bacterial peritonitis

To prospectively assess the value of an algorithm in differentiating spontaneous from secondary bacterial peritonitis, we performed serial paracenteses in 43 episodes of ascitic fluid infection (28 spontaneous and 15 secondary) in 40 patients. The algorithm involved identification of (a) secondary peritonitis associated with gut perforation, based on previously proposed criteria in patients with neutrocytic ascites (ascitic fluid total protein greater than 1 g/dl, glucose less than 50 mg/dl, and lactate dehydrogenase greater than the upper limit of normal for serum) and (b) separation of spontaneous from secondary peritonitis (unassociated with perforation) based on the response of the ascitic fluid cell count to antibiotic therapy. The perforation criteria had 100% sensitivity in detecting episodes of actual gut perforation; their specificity, however, was low (45%). After 48 h of treatment the concentration of ascitic fluid neutrophils was below the baseline pretreatment value in all episodes of spontaneous peritonitis but in only two thirds of the patients with secondary peritonitis. This algorithm is useful in (a) identifying patients who have infected ascites associated with perforation of an intraabdominal viscus, and (b) differentiating spontaneous from nonperforation secondary peritonitis on the basis of the response of the ascitic fluid cell count to appropriate antibiotic therapy. The optimal time for repeat paracentesis in patients with infected ascites appears to be 48 h after initiation of treatment.     

Prevalence of Peritonitis and the Ascitic Fluid Protein Concentration among Chronic Liver Disease Patients

The prevalence of spontaneous bacterial peritonitis (SBP) or its variants, bacterascites (BA), and culture-negative neutrocytic ascites (CNNA), may vary depending on the underlying liver disease and protein content of ascites. In this study, we compared the frequency of peritonitis (SBP, BA, CNNA) upon admission in alcoholic (ALD), cholestatic (CLD), and hepatocellular liver disease (HLD); determined the relationship between Child's class and prevalence of peritonitis; and assessed ascitic total protein as a risk factor for peritonitis. Between January 1989 and April 1991, 113 consecutive patients were admitted with chronic liver disease and ascites (49, ALD; 22, CLD; and 42, HLD). All had admission paracentesis. SBP was defined as polymorphonuclear cell count (PMN) ≥250 mm³ with a positive culture, BA as PMN <250/mm³ and positive culture, and CNNA as PMN 250/mm³ with negative culture. No patients with obvious intraabdominal source for infection ( i.e. , secondary peritonitis) were included in the analysis. The prevalence of peritonitis was 8/113 (7%); four patients had SBP, one BA, and three CNNA. The occurrence of peritonitis was independent of the type of liver disease (ALD, 8%; CLD, 9%; HDL, 5%). Neither ascitic fluid total protein nor the severity of liver disease (Child's class) predicted the occurrence of peritonitis. We conclude that the occurrence of peritonitis is unrelated to the type of liver disease, and severity of liver disease did not predict the presence of peritonitis. Also, ascitic fluid total protein <1.0 g/dl may not be a sensitive predictor of risk of peritonitis.     

Bacterial DNA in patients with cirrhosis and noninfected ascites mimics the soluble immune response established in patients with spontaneous bacterial peritonitis

Bacterial infections and severity of associated inflammatory reaction influence prognosis in patients with advanced cirrhosis. We compared the innate immune response to bacterial DNA (bactDNA) translocation with that caused by viable bacteria translocation in patients with spontaneous bacterial peritonitis and the relationship between the cytokine response and serum levels of bactDNA. The bactDNA translocation was investigated in 226 patients with cirrhosis and noninfected ascites, 22 patients with spontaneous bacterial peritonitis, and 10 patients with ascites receiving continuous norfloxacin. Serum and ascitic fluid tumor necrosis factor alpha, interferon-gamma, interleukin-12, and nitric oxide metabolites were measured via enzyme-linked immunosorbent assay. Bacterial genomic identifications were made via amplification and sequencing of the 16S ribosomal RNA gene and digital quantization with DNA Lab-on-chips. The bactDNA was present in 77 noninfected patients (34%) and in all cases of spontaneous bacterial peritonitis, even in those with culture-negative ascitic fluid. No patient receiving norfloxacin showed bactDNA translocation. Levels of all cytokines were similar in patients with bactDNA translocation or spontaneous bacterial peritonitis and significantly higher than in patients without bactDNA or in those receiving norfloxacin. Serum bactDNA concentration paralleled levels of all cytokines and nitric oxide in a series of patients with bactDNA translocation or spontaneous bacterial peritonitis followed during 72 hours. Antibiotic treatment in the series of patients with spontaneous bacterial peritonitis did not abrogate bactDNA translocation in the short term. CONCLUSION: bactDNA translocation-associated cytokine response is indistinguishable from that in patients with spontaneous bacterial peritonitis and is dependent on bactDNA concentration. Norfloxacin abrogates bactDNA translocation and cytokine response.     

Ascitic fluid polymorphonuclear cell count and serum to ascites albumin gradient in the diagnosis of bacterial peritonitis

The analysis of ascitic fluid has been complicated by several recently reported new tests. To simplify this assessment, we evaluated nine parameters prospectively and simultaneously in blood and ascitic fluid from 285 patients with ascites to determine which were the most reliable for immediate diagnosis of the etiology of the ascites and of its complications. Subjects were first divided into four groups: sterile cirrhotic ascites (n = 201), spontaneous bacterial peritonitis (n = 41), malignant ascites (n = 34), and miscellaneous ascites (n = 9). An ascitic fluid polymorphonuclear count greater than 500/microliters was the test with the greatest accuracy (96%) for the diagnosis of spontaneous bacterial peritonitis. Neither the most precise cutoff values for ascitic fluid pH (less than 7.32) and ascitic fluid lactate (greater than 32 mg/dl), nor their respective blood-ascitic fluid gradients (greater than 0.11 and less than -20 mg/dl) were more reliable indexes of spontaneous bacterial peritonitis, mainly due to the decreased ascitic fluid pH and increased ascitic fluid lactate observed in malignant ascites, tuberculous peritonitis, and pancreatic ascites. A blood-ascitic fluid albumin gradient less than 1.1 g/dl was the most accurate parameter for the diagnosis of malignant ascites (diagnostic efficacy, 93%). Therefore, the etiologic analysis of ascitic fluid might be simplified and the single practice of two tests, ascitic fluid polymorphonuclear cell count and blood-ascitic fluid albumin gradient, provides immediately useful information.     

Polymorphonuclear cell count response and duration of antibiotic therapy in spontaneous bacterial peritonitis

The purposes of this study were (a) to measure serially ascitic fluid polymorphonuclear cell response in treated spontaneous bacterial peritonitis and (b) to determine whether an ascitic fluid polymorphonuclear cell count of less than 250 per mm3 on serial paracenteses was a satisfactory endpoint for antibiotic therapy. Thirty of 33 patients showed an exponential fall in ascitic fluid polymorphonuclear cell count after 48 hr of antibiotic therapy; the magnitude of decrease correlated with survival (p less than 0.01). Among the patients whose antibiotic therapy was discontinued when the ascitic fluid polymorphonuclear cell count reached 250 per mm3 or less, the duration of therapy was considerably shorter than for the patients who received "conventional" therapy (p less than 0.01). Recurrence of spontaneous bacterial peritonitis was similar in the two groups. Mortality correlated with the severity of underlying liver disease but not with duration of antibiotic therapy.     

Is the acidity of ascitic fluid a reliable index in making the presumptive diagnosis of spontaneous bacterial peritonitis?

Ascitic fluid pH and arterial-ascitic fluid pH gradient were compared to ascitic fluid polymorphonuclear cell count in 84 patients with cirrhotic ascites and in 12 with malignant ascites to assess their role as diagnostic tests for spontaneous bacterial peritonitis and to clarify the relationship between ascitic fluid pH and lactate. Ascitic fluid pH was significantly lower (pH 7.30) in spontaneous bacterial peritonitis (n = 18) and probable spontaneous bacterial peritonitis (n = 12) than in sterile ascites (pH 7.41; n = 54). Since blood pH levels were not different in the presence of infection, arterial-ascitic fluid pH gradient was significantly higher in spontaneous bacterial peritonitis and probable spontaneous bacterial peritonitis than in sterile ascites (0.12 vs. 0.02). The close correlations between arterial-ascitic pH gradient and lactate (r = 0.77, p less than 0.0001), lactate and bicarbonate gradient (r = 0.64, p = 0.003) and arterial-ascitic pH gradient and pCO2 gradient (r = -0.90, p less than 0.0001) suggest that the low ascitic fluid pH may be due to an increase in lactate and CO2. Patients with Escherichia coli-induced spontaneous bacterial peritonitis had significantly lower ascitic fluid pH and higher lactate than those with spontaneous bacterial peritonitis by other organisms. Values of ascitic fluid pH, lactate and arterial-ascitic fluid pH gradient in malignant ascites were similar to those of spontaneous bacterial peritonitis and probable spontaneous bacterial peritonitis. Cutoff points, selected by receiver operating characteristic curves analysis, of 450 per mm3 for polymorphonuclear cells and of 0.07 for arterial-ascitic fluid pH gradient, allow high positive and negative predictive values for spontaneous bacterial peritonitis.(ABSTRACT TRUNCATED AT 250 WORDS)     

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.     

Optimization of ascitic fluid culture technique

The conventional method of ascitic fluid culture detects bacteria in only 42%-65% of patients who have neutrocytic ascites and suspected spontaneous bacterial peritonitis. In this study ascitic fluid was cultured by the conventional method as well as by a new method consisting of bedside inoculation of blood culture bottles with ascites. The conventional cultures grew bacteria in only 13 (43%) of 30 episodes of neutrocytic ascites, whereas the blood culture bottles grew bacteria in 28 (93%); this difference was significant (p less than 0.0001). The blood culture bottle method also resulted in more rapid detection of bacterial growth. The median concentration of bacteria in infected ascites was one organism per milliliter. Bedside inoculation of blood culture bottles with ascitic fluid is more sensitive than the conventional method in detecting bacterial peritonitis. The insensitivity of the conventional method is probably due to the low concentration of bacteria in infected ascites and the small volume of ascites cultured by this method.     

Incidence and predictive factors of first episode of spontaneous bacterial peritonitis in cirrhosis with ascites: relevance of ascitic fluid protein concentration.

To investigate the long-term probability of the appearance of the first episode of spontaneous bacterial peritonitis in cirrhosis with ascites and to identify predictors of this complication, we closely followed throughout their illness 127 patients consecutively admitted to our unit for the treatment of an episode of ascites without prior spontaneous bacterial peritonitis (follow-up period: 21 +/- 22 mo). Thirteen patients (10%) had the first spontaneous bacterial peritonitis episode during follow-up. The appearance probability of this complication is 11% at 1 yr and 15% at 3 yr. Thirty-three variables obtained at admission (including clinical data, standard liver and kidney function test results, ascitic fluid protein concentrations and hemodynamic parameters) were analyzed in relation to their value in predicting spontaneous bacterial peritonitis development. In univariate analysis (Kaplan-Meier curves) five variables reached statistical significance (p less than 0.05) as predictive factors for the development of the first spontaneous bacterial peritonitis episode. These five variables were poor nutritional status, increased serum bilirubin levels, increased serum AST levels, decreased prothrombin activity and reduced total protein concentration in ascitic fluid. When these five variables were introduced in a multivariate analysis, only the ascitic fluid protein concentration was found to correlate independently with spontaneous bacterial peritonitis development (p = 0.002). The probability of first spontaneous bacterial peritonitis after 3 yr of follow-up was 24% and 4% in patients with ascitic fluid protein content lower than 1 gm/dl and greater than or equal to 1 gm/dl, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)     

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.     

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

A review of the medical records of patients diagnosed as having "spontaneous bacterial peritonitis" (SBP) revealed 18 episodes of culture-negative neutrocytic ascites (CNNA) in 17 patients. The following criteria were all required in order to qualify for this diagnosis: (i) an ascitic fluid neutrophil count greater than 500 cells per mm3; (ii) negative ascitic fluid culture (5); (iii) absence of an intraabdominal source of infection; (iv) no antibiotic treatment within 30 days, and (v) no evidence of pancreatitis. Five patients had positive blood cultures. Two patients with CNNA had SBP in the past, and two other patients, who survived the episode of CNNA, subsequently developed SBP. Clinical signs and symptoms of patients with CNNA were not different from those of 32 patients with 33 episodes of culture-positive SBP. The mortality of CNNA (50%) was not different from that of SBP (70%). Because of the high mortality and because of the similarity of CNNA to SBP, it is presumed that many patients with CNNA have bacterial infection of their ascitic fluid, and it is recommended that they be treated with antibiotics.