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Abstract
Summary
Spontaneous bacterial peritonitis (SBP) is a common and severe complication in cirrhotic patients with ascites which occurs in 10- 30% of patients with cirrhotic ascites admitted to hospitals with a mortality rate ranging between 30-50 % mainly due to renal failure. The diagnosis of SBP is made when the polymorphonuclear leukocyte (PMN) count in ascitic fluid is greater than 250 cells per cubic millimeter.
Most organisms causing SBP are derived from the intestinal microbial flora (mainly Enterobacteriaceae) and Escherichia coli is the most frequently isolated organism. However, there is increasing incidence of SBP caused by gram- positive bacteria in cirrhotic patients with ascites during the recent years, which may have implications in their management. The seriousness of this complication; (SBP) and the evidence of increasing frequency of gram -positive bacteria in SBP motivated us to study the prevalence of SBP, causative organisms and their antibiotic sensitivity in patients admitted to our hospital.
This cross–sectional study was carried out on 198 patients with cirrhotic ascites admitted to Suez Canal University Hospital from May to December 2006. Patients were 145 (73.2%) males and 53 (26.8%) females, their age ranged between 32 and 80 years (mean= 54.3±9.3). All were presenting with cirrhotic ascites according to clinical, laboratory and ultrasonic criteria regardless to the presence or absence of clinical evidence of SBP. All patients included in the study were subjected to history taking, physical examination, laboratory tests including; complete blood count, liver functions, Prothrombin time, and serum creatinine, abdominal ultrasound, chest x-ray and ascitic fluid examination which included cell count, total proteins, ascitic fluid culture in blood culture bottles, antibiotic sensitivity and cytological examination for malignant cells when indicated.
The prevalence of SBP among our study population was 20.2% (40 patients) of which, 55% (22 patients) were culture positive and 45% (18 patients) were culture negative. One patient (0.5%) fulfilled the diagnosis of monomicrobial bacterascites and the remaining 157 patients (79.3%) had negative ascitic fluid infection.
Ascitic fluid cultures were positive in 23 (11.6%) patients. Gram –ve bacilli were found in 16 patients (69.9%) and gram +ve cocci were found in 7 patients (30.1%). E. coli was the most commonly found organism (52.2%), followed by Streptococci (17.4%), Staphylococci and Klebsiella (13%) and finally Citrobacter (4.3%). Antibiotic sensitivity results revealed that cefotaxime, levofloxacin and amoxicillin-clavulinic acid were the most sensitive antibiotics found in 22 (95.7%) patients, followed by ceftriaxone, ofloxacin and ampicillin-sulbactam in 21 (91.3%) patients and ciprofloxacin in 20 (87%) patients. All gram negative bacilli were sensitive to cefotaxime while all the gram positive cocci were sensitive to levofloxacin, amoxicillin-clavulinic and ampicillin–sulbactam.
The presenting complaints of patients with SBP were abdominal pain (60%), followed by disturbed level of consciousness (27.5%), gastrointestinal bleeding (10%), while (10%) were presented with marked abdominal swelling (ascites) without symptoms or signs of peritonitis. Although univariate analysis of the study variables revealed many significant clinical (abdominal pain/discomfort, diarrhea, fever, bleeding tendency, Jaundice Spider nevi, fever and diffuse abdominal tenderness) and laboratory (leukocytosis, hypoproteinaemia, prolonged Prothrombin and low ascitic fluid proteins) and Child-Pugh class C, Multivariate analysis revealed that only ascitic fluid proteins (<1gm %) was found to be the independent predictor for SBP in patients with cirrhotic ascites in Suez Canal University Hospital throughout this study.
Conclusions and Recommendations
Summary
Spontaneous bacterial peritonitis (SBP) is a common and severe complication in cirrhotic patients with ascites which occurs in 10- 30% of patients with cirrhotic ascites admitted to hospitals with a mortality rate ranging between 30-50 % mainly due to renal failure. The diagnosis of SBP is made when the polymorphonuclear leukocyte (PMN) count in ascitic fluid is greater than 250 cells per cubic millimeter.
Most organisms causing SBP are derived from the intestinal microbial flora (mainly Enterobacteriaceae) and Escherichia coli is the most frequently isolated organism. However, there is increasing incidence of SBP caused by gram- positive bacteria in cirrhotic patients with ascites during the recent years, which may have implications in their management. The seriousness of this complication; (SBP) and the evidence of increasing frequency of gram -positive bacteria in SBP motivated us to study the prevalence of SBP, causative organisms and their antibiotic sensitivity in patients admitted to our hospital.
This cross–sectional study was carried out on 198 patients with cirrhotic ascites admitted to Suez Canal University Hospital from May to December 2006. Patients were 145 (73.2%) males and 53 (26.8%) females, their age ranged between 32 and 80 years (mean= 54.3±9.3). All were presenting with cirrhotic ascites according to clinical, laboratory and ultrasonic criteria regardless to the presence or absence of clinical evidence of SBP. All patients included in the study were subjected to history taking, physical examination, laboratory tests including; complete blood count, liver functions, Prothrombin time, and serum creatinine, abdominal ultrasound, chest x-ray and ascitic fluid examination which included cell count, total proteins, ascitic fluid culture in blood culture bottles, antibiotic sensitivity and cytological examination for malignant cells when indicated.
The prevalence of SBP among our study population was 20.2% (40 patients) of which, 55% (22 patients) were culture positive and 45% (18 patients) were culture negative. One patient (0.5%) fulfilled the diagnosis of monomicrobial bacterascites and the remaining 157 patients (79.3%) had negative ascitic fluid infection.
Ascitic fluid cultures were positive in 23 (11.6%) patients. Gram –ve bacilli were found in 16 patients (69.9%) and gram +ve cocci were found in 7 patients (30.1%). E. coli was the most commonly found organism (52.2%), followed by Streptococci (17.4%), Staphylococci and Klebsiella (13%) and finally Citrobacter (4.3%). Antibiotic sensitivity results revealed that cefotaxime, levofloxacin and amoxicillin-clavulinic acid were the most sensitive antibiotics found in 22 (95.7%) patients, followed by ceftriaxone, ofloxacin and ampicillin-sulbactam in 21 (91.3%) patients and ciprofloxacin in 20 (87%) patients. All gram negative bacilli were sensitive to cefotaxime while all the gram positive cocci were sensitive to levofloxacin, amoxicillin-clavulinic and ampicillin–sulbactam.
The presenting complaints of patients with SBP were abdominal pain (60%), followed by disturbed level of consciousness (27.5%), gastrointestinal bleeding (10%), while (10%) were presented with marked abdominal swelling (ascites) without symptoms or signs of peritonitis. Although univariate analysis of the study variables revealed many significant clinical (abdominal pain/discomfort, diarrhea, fever, bleeding tendency, Jaundice Spider nevi, fever and diffuse abdominal tenderness) and laboratory (leukocytosis, hypoproteinaemia, prolonged Prothrombin and low ascitic fluid proteins) and Child-Pugh class C, Multivariate analysis revealed that only ascitic fluid proteins (<1gm %) was found to be the independent predictor for SBP in patients with cirrhotic ascites in Suez Canal University Hospital throughout this study.
Conclusions and Recommendations