Background and objectives
Spontaneous bacterial peritonitis (SBP) is a frequent complication in patients with chronic liver disease and ascites. This can develop slowly and insidiously or remain clinically unrecognized until the appearance of symptoms. The mortality rate after a single episode ranges from 20 to 40%, and early diagnosis is required for adequate treatment and prevention of new episodes. The aim was to study the clinicobacteriological profile of SBP and its variants in patients of cirrhosis.
Materials and methods
This prospective study was conducted on cirrhotic patients with ascites admitted in a tertiary care hospital. Basic demographics, symptoms, and clinical signs of patients were recorded. Diagnostic paracentesis was done for ascitic fluid cytology and culture. Identification and antimicrobial susceptibility of the isolates was done in VITEK system.
Of a total of 113 cirrhotic patients, 58 (51.3%) were diagnosed with SBP. Culture-negative neutrocytic ascites (CNNA) was the commonest presentation. The most common symptoms were abdominal distension followed by fatigue, anorexia, and jaundice. Majority of patients belonged to Child-Pugh\'s Grade C. Of 58 cases of SBP, 22 were culture positive. Gram-negative isolates were predominant (77.3%). Escherichiacoli was the commonest isolate. Gram-negative isolates were highly susceptible to colistin followed by tigecycline, amikacin, and carbapenems; 59% of the isolates were multidrug resistant (MDR) and 13.6% were extensively drug resistant (XDR).
Interpretation and conclusion
Prevalence of SBP in cirrhotic patients was 51.3% and Gram-negative isolates were predominant. Ascitic fluid culture and susceptibility testing can lead to accurate diagnosis of SBP and can guide for treatment as resistance to antibiotic is common.
How to cite this article
Harchand P, Gupta V, Ahluwalia G, Chhina RS. Clinical and Bacteriological Profile of Spontaneous Bacterial Peritonitis in Cirrhotic Patients. J Gastro Infect 2017;7(1):15-20.
Odze, RD.; Goldblum, JR. Cirrhosis in surgical pathology of GI tract, liver, biliary tract and pancreas. 2nd ed. Philadelphia (PA): Saunders Elsevier; 2009. pp. 1115-1145.
Guha, NI.; Iredale, JP. Clinical and diagnostic aspects of cirrhosis. In: Rodés J, Benhamou JP, Blei A, Reichen J, Rizzetto M, editors. Textbook of hepatology from basic science to clinical practice. 3rd ed. Oxford: Blackwell Publishing; 2007. pp. 604-622.
Lauer GM, Walker BD. Hepatitis C virus infection. N Engl J Med 2001 Jul;345(1):41-52.
Chowdry, SM.; Vaishnavi, C. Spontaneous bacterial peritonitis. In: Vaishnavi C, editor. Infections of the gastrointestinal system. New Delhi: Jaypee Brothers Medical Publishers; 2013. pp. 532-542.
Rimola A, García-Tsao G, Navasa M, Paddock LJ, Planas R, Bernard B, Inadomi JM. Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis: a consensus document. International Ascites Club. J Hepatol 2000 Jan;32(1):142-153.
Sapey T, Kabissa D, Fort E, Laurin C, Mendler MH. Instant diagnosis of spontaneous bacterial peritonitis using leukocyte esterase reagent strips: Nephur-Test vs. MultistixSG. Liver Int 2005 Apr;25(2):343-348.
Volk ML, Marrero JA. Advances in critical care hepatology. Minerva Anestesiol 2006 May;72(5):269-281.
Bandy, SM.; Tuttle, A. Spontaneous bacterial peritonitis. E-Medicine from Web Med; 2006.
Riggio O, Angeloni S. Ascitic fluid analysis for diagnosis and monitoring of spontaneous bacterial peritonitis. World Gastroenterol 2009 Aug;15(31):3845-3850.
Caruntu FA, Banea L. Spontaneous bacterial peritonitis: pathogenesis, diagnosis and treatment. J Gastrointest Liver Dis 2006 Mar;15(1):51-56.
Koulaouzidis A, Karagiannidis A, Tan WC, Linaker BD. Spontaneous bacterial peritonitis. Postgrad Med J 2007 Jun;83(980):379-383.
Yachha SK, Khanna V. Ascites in childhood liver disease. Indian J Pediatr 2006 Sep;73(9):819-824.
Bibi S, Ahmed W, Arif A, Khan F, Alam SE. Clinical, laboratory and bacterial profile of spontaneous bacterial peritonitis in chronic liver disease patients. J Coll Physicians Surg Pak 2015 Feb;25(2):95-99.
Terg R, Gadano A, Cartier M, Casciato P, Lucero R, Muñoz A, Romero G, Levi D, Terg G, Miguez C, et al. Serum creatinine and bilirubin predict renal failure and mortality in patients with spontaneous bacterial peritonitis: a retrospective study. Liver Int 2009 Mar;29(3):415-419.
Bellot P, Francés R, Such J. Bacterial translocation in cirrhosis. Gastroenterol Hepatol 2008 Oct;31(8):508-514.
Fitz, GJ. Approach to the patient with abnormal liver chemistries or jaundice. In: Podolsky DK, Camilleri M, Fitz JG, Kalloo AN, Shanahan F, Wang TC, editors. Yamada's textbook of gastroenterology. 6th ed. Hoboken (NJ): Wiley-Blackwell; 2016. pp. 819-833.
Collee, JG.; Duguid, JP.; Fraser, AG., et al. Laboratory strategy in the diagnosis of infective syndromes. In: Collee JG, Fraswer AG, Marmion BP, Simmons A, editors. Mackie and McCartney practical medical microbiology. 14th ed. Edinburg: Churchill Livingstone; 2006. pp. 106-108.
Koulaouzidis A, Bhat S, Saeed AA. Spontaneous bacterial peritonitis. World J Gastroenterol 2009 Mar;15(9):1042-1049.
Magiorakos AP, Srinivasan A, Carey RB, Carmeli Y, Falagas ME, Giske CG, Harbarth S, Hindler JF, Kahlmeter G, Olsson- Liljequist B, et al. Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for a acquired resistance. Clin Microbiol Infect 2012 Mar;18(3):268-281.
Nadagouda SB, Mahesh B, Kashinakunti SV, Birader MS. Spontaneous bacterial peritonitis in cirrhosis of liver with ascites—a cross sectional study. Int J Biol Med Res 2013;4(2): 3143-3147.
Paul K, Kaur J, Kazal HL. To study the incidence, predictive factors and clinical outcome of spontaneous bacterial peritonitis in patients of cirrhosis with ascites. J Clin Diagn Res 2015 Jul;9(7):OC9-OC12.
Chawla P, Kaur D, Chhina RS, Gupta V, Chaudhary J, Aggarwal M. Etiology and antimicrobial susceptibility profile of isolates from ascitic fluid of patients with spontaneous bacterial peritonitis. J Gastrointest Infect 2014;4:47-50.
Syed VA, Ansari JV, Karki P, Regmi M, Khanal B. Spontaneous bacterial peritonitis (SBP) in cirrhotic ascites: a prospective study in a tertiary care hospital, Nepal. Kathmandu Univ Med J (KUMJ) 2007 Jan-Mar;5(1):48-59.
Zaman A, Kareem R, Mahmood R, Hameed K, Khan EM. Frequency of microbial spectrum of spontaneous bacterial peritonitis in established cirrhosis liver. J Ayub Med Coll Abbottabad 2011 Oct-Dec;23(4):15-17.
Khan Z, Khan I, Din J, Subhan F, Khan B, Khan H. Frequency of spontaneous bacterial peritonitis in cirrhotic patients with ascites due to Hepatitis C virus and efficacy of Ciprofloxacin in its treatment. Gomal J Med Sci 2009 Jul-Dec;7(2): 149-154.
Ahmad M, Ali AA, Mumtaz M. Spontaneous bacterial peritonitis; microbiological analysis of ascitic fluid in patients with complicated liver cirrhosis. Prof Med J 2011;18:557-561.
Khan AG, Khan H, Khattak AK, Amin M. Microbial spectrum of spontaneous bacterial peritonitis in patients with cirrhosis and ascites. Pak J Gastroenterol 2012;26:26-29.
Agarwal MP, Choudhury BR, Banerjee BD, Kumar A. Ascitic fluid examination for diagnosis of spontaneous bacterial peritonitis in cirrhotic ascites. JIACM 2008 Jan-Mar;9(1): 29-32.
Nouman S, Hussain A, Hussain M, Ahmed M. Frequency of spontaneous bacterial peritonitis in chronic liver disease. Ann KEM Univ 2010 Oct;16(2):112-115.
Zaman H, Mufti SE, Abbasi M. Comparative studies of clinical and biochemical pattern of spontaneous bacterial peritonitis (SBP) versus non-SBP ascites in cirrhotic patients. KMJ 2010;2:3-9.
Kamani L, Mumtaz K, Ahmed US, Ali AW, Jafri W. Outcomes in culture positive and culture negative ascitic fluid infection in patients with viral cirrhosis: cohort study. BMC Gastroenterol 2008 Dec;8:59-64.
Vaishnavi C. Translocation of gut flora and its role in sepsis. IJMM 2013 Oct-Dec;31(4):334-342.
Beg M, Hussain S, Ahmad N, Akhtar N. Serum/ascites albumin gradient in differential diagnosis of ascites. J Indian Acad Clinic Med 2001 Jan-Jun;2(1-2):51-54.
Biecker E. Diagnosis and therapy of ascites in liver cirrhosis. World J Gastroenterol 2011 Mar;17(10):1237-1248.
European Association for the Study of the Liver. EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis. J Hepatol 2010 Sep;53(3):397-417.
Kim SU, Chon YE, Lee CK, Park JY, Kim DY, Han KH, Chon CY, Kim S, Jung KS, Ahn SH. Spontaneous bacterial peritonitis in patients with hepatitis B related liver cirrhosis: community acquired versus nosocomial. Yonsei Med J 2012 Mar;53(2):328-336.
Banker S, De A, Baveja S. Study of ascitic fluid for diagnosis of spontaneous bacterial peritonitis (SBP) in adult patients with cirrhosis. Int J Med Appl Sci 2014 Jan;3(1):1-9.
Li YT, Yu CB, Huang JR, Qin ZJ, Li LJ. Pathogen profile and drug resistance analysis of spontaneous peritonitis in cirrhotic patients. World J Gastroenterol 2015 Sep;21(36):10409-10417.