Skip to main content

Advertisement

SpringerLink
Log in

Ascitic fluid infection in children with liver disease: time to change empirical antibiotic policy

  • Original Article
  • Published:
Hepatology International Aims and scope Submit manuscript

Abstract

Background and aims

Recent years have shown a rise in occurrence of multidrug resistant ascitic fluid infection (AFI) including resistant to third generation cephalosporins. Our aim was to find the prevalence, antibiotics resistance and outcome of AFI in children with liver disease.

Methods

Children (≤ 18 years) with liver disease-related ascites were prospectively enrolled from April 2015 to October 2017. Based on the results of ascitic fluid examination and culture, patients were classified as having AFI [spontaneous bacterial peritonitis (SBP), culture negative neutrocytic ascites (CNNA) and monomicrobial non-neutrocytic bacterascites (MNB)] and no-AFI. AFI diagnosed after 48 h of index hospitalization was considered as nosocomial.

Results

We enrolled 194 children with a median age of 85 [2–216] months. Chronic liver disease was the commonest etiology (153, 79%). AFI was present in 60 (31%) children [SBP (n = 13), CNNA (n = 39), MNB (n = 8)] of which 53% were nosocomial and resulted in high in-hospital mortality. Gram-negative bacilli dominated the ascitic fluid culture (12/21, 57%) and 10/12 (83%) of them were extended spectrum beta-lactamases (ESBL) producers. Six (60%) ESBL producers were sensitive to cefoperazone–sulbactam and 70% to carbapenems. Child–Pugh-Turcotte (CPT) score of ≥ 11 independently determined in-hospital mortality in children with AFI.

Conclusions

AFI was found in 31% children with liver disease and almost half of them were nosocomial resulting in high mortality. ESBL producing Gram-negative bacteria were the most frequently isolated organisms. Cefoperazone–sulbactam or carbapenems may be useful empirical antibiotics in nosocomial setting. Children with AFI and CPT score ≥ 11 should be evaluated for liver transplantation.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Gines P, Quintero E, Arroyo V, Terés J, Bruguera M, Rimola A, et al. Compensated cirrhosis: natural history and prognostic factors. Hepatology 1987;7(1):122–128

    Article  CAS  PubMed  Google Scholar 

  2. D’Amico G, Morabito A, Pagliaro L, Marubini E. Survival and prognostic indicators in compensated and decompensated cirrhosis. Dig Dis Sci 1986;31(5):468–475

    Article  PubMed  Google Scholar 

  3. 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;53(3):397–417

    Article  Google Scholar 

  4. El-Shabrawi MHF, El-Sisi O, Okasha S, Isa M, Elmakarem SA, Eyada I, et al. Diagnosis of spontaneous bacterial peritonitis in infants and children with chronic liver disease: a cohort study. Italian J Pediatr 2011;37(1):26–29

    Article  Google Scholar 

  5. Haghighat M, Dehghani SM, Alborzi A, Imanieh MH, Pourabbas B, Kalaniet M. Organisms causing spontaneous bacterial peritonitis in children with liver disease and ascites in Southern Iran. World J Gastroenterol 2006;12(36):5890–5892

    Article  PubMed  PubMed Central  Google Scholar 

  6. Preto-Zamperlini M, Farhat SCL, Perondi MBM, Pestana AP, Cunha PS, Pugliese RP, et al. Elevated C-reactive protein and spontaneous bacterial peritonitis in children with chronic liver disease and ascites. J Pediatr Gastroenterol Nutr 2014;58(1):96–98

    Article  CAS  PubMed  Google Scholar 

  7. Vieira SMG, Matte U, Kieling CO, Barth AL, Ferreira CT, Souza AF, et al. Infected and noninfected ascites in pediatric patients. J Pediatr Gastroenterol Nutr 2005;40(3):289–294

    Article  PubMed  Google Scholar 

  8. Srivastava A, Malik R, Bolia R, Yachha SK, Poddar U. Prevalence, clinical profile, and outcome of ascitic fluid infection in children with liver disease. J Pediatr Gastroenterol Nutr 2017;64(2):194–199

    Article  PubMed  Google Scholar 

  9. Rimola A, Garcı´a-Tsao G, Navasa M, Piddock LJ, Planas R, Bernard B, et al. Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis: a consensus document. J Hepatol 2000;32(1):32142–3253

    Article  Google Scholar 

  10. Alexopoulou A, Papadopoulos N, Eliopoulos DG,  Alexaki A, Tsiriga A, Toutouza M, et al. Increasing frequency of Gram-positive cocci and Gram-negative multidrug-resistant bacteria in spontaneous bacterial peritonitis. Liver Int 2013;33(7):975–981

    Article  CAS  PubMed  Google Scholar 

  11. Tandon P, Delisle A, Topal JE, Garcia-Tsao G. High prevalence of antibiotic-resistant bacterial infections among patients with cirrhosis at a US liver center. Clin Gastroenterol Hepatol 2012;10(11):1291–1298

    Article  PubMed  PubMed Central  Google Scholar 

  12. Fernández J, Acevedo J, Castro M, Garcia O, de Lope CR, Roca D, et al. Prevalence and risk factors of infections by multiresistant bacteria in cirrhosis: a prospective study. Hepatology 2012;55(5):1551–1561

    Article  PubMed  Google Scholar 

  13. Mowat C, Stanley AJ. Review article: spontaneous bacterial peritonitis: diagnosis, treatment and prevention. Aliment Pharmacol Ther 2001;15(12):1851–1895

    Article  CAS  PubMed  Google Scholar 

  14. Jindal A, Kumar M, Bhadoria AS, Maiwall R, Sarin SK. A randomized open label study of ‘imipenem vs. cefepime in spontaneous bacterial peritonitis. Liver Int 2016;36(5):677–687

    Article  CAS  PubMed  Google Scholar 

  15. Vergani GM, Heller S, Jara P, Chang MH, Fujisawa T, González-Peralta RP, et al. Autoimmune hepatitis. J Pediatr Gastroenterol Nutr 2009;49(2):158–164

    Article  PubMed  Google Scholar 

  16. Roberts EA, Schilsky ML. Diagnosis and treatment of Wilson disease: an update. Hepatology 2008;47(6):2089–2111

    Article  CAS  PubMed  Google Scholar 

  17. Squires RH, Shneider BL, Bucuvalas J, Alonso E, Sokol RJ, Narkewicz MR, et al. Acute liver failure in children: the first 348 patients in the pediatric acute liver failure study group. J Pediatr 2006;148(5):652–658

    Article  PubMed  PubMed Central  Google Scholar 

  18. Lee WS, McKiernan P, Kelly DA. Etiology, outcome and prognostic indicators of childhood fulminant hepatic failure in the United Kingdom. J Pediatr Gastroenterol Nutr 2005;40(5):575–581

    Article  PubMed  Google Scholar 

  19. Alam S, Lal BB, Sood V, Rawat D. Pediatric acute-on-chronic liver failure in a specialized liver unit: prevalence, profile, outcome, and predictive factors. J Pediatr Gastroenterol Nutr 2016;63(4):400–405

    Article  CAS  PubMed  Google Scholar 

  20. Jagadisan B, Srivastava A, Yachha SK, Poddar U. Acute on chronic liver disease in children from the developing world: recognition and prognosis. J Pediatr Gastroenterol Nutr 2012;54(1):77–82

    Article  PubMed  Google Scholar 

  21. Yachha SK, Goel A, Khanna V, Poddar U, Srivastava A, Singh U. Ascitic form of sporadic acute viral hepatitis in children: a distinct entity for recognition. J Pediatr Gastroenterol Nutr 2010;50(2):184–187

    Article  PubMed  Google Scholar 

  22. Thomas FB, Fromkes JJ. Spontaneous bacterial peritonitis associated with acute viral hepatitis. J Clin Gastroenterol 1982;4(3):259–262

    Article  CAS  PubMed  Google Scholar 

  23. Poddar U, Thapa BR, Prasad A, Sharma AK, Singh K. Natural history and risk factors in fulminant hepatic failure. Arch Dis Child 2002;87:54–56

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Wiest R, Krag A, Gerbes A. Spontaneous bacterial peritonitis: recent guidelines and beyond. Gut 2012;61(4):297–310

    Article  CAS  PubMed  Google Scholar 

  25. Felisart J, Rimola A, Arroyo V, Perez-Ayuso RM, Quintero E, Gines P, et al. Cefotaxime is more effective than is ampicillin-tobramycin in cirrhotics with severe infections. Hepatology 1985;5(3):457–462

    Article  CAS  PubMed  Google Scholar 

  26. Shi L, Wu D, Wei L, Liu S, Zhao P, Tu B, et al. Nosocomial and Community-Acquired Spontaneous Bacterial Peritonitis in patients with liver cirrhosis in China: Comparative Microbiology and Therapeutic Implications. Sci Rep 2017;7(4):1–7

    Google Scholar 

  27. Fiore M, Maraolo AE, Gentile I, Borgia G, Leone S, Sansoneet P, et al. Nosocomial spontaneous bacterial peritonitis antibiotic treatment in the era of multi-drug resistance pathogens: A systematic review. World J Gastroenterol 2017;23(25):4654–4660

    Article  PubMed  PubMed Central  Google Scholar 

  28. Cheong HS, Kang CI, Lee JA, Moon SY, Joung MK, Chung DR, et al. Clinical significance and outcome of nosocomial acquisition of spontaneous bacterial peritonitis in patients with liver cirrhosis. Clin Infect Dis 2009;48(9):1230–1236

    Article  PubMed  Google Scholar 

  29. Nobre SR, Cabral JEP, Gomes JJF, Leitão MC. In-hospital mortality in spontaneous bacterial peritonitis: a new predictive model. Eur J Gastroenterol Hepatol 2008;20(12):1176–1181

    Article  PubMed  Google Scholar 

  30. Singh N, Wagener MM, Gayowski T. Changing epidemiology and predictors of mortality in patients with spontaneous bacterial peritonitis at a liver transplant unit. Clin Microbiol Infect 2003;9(6):531–537

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, 226014, India

    Sumit Kumar Singh, Ujjal Poddar, Anshu Srivastava & Surender Kumar Yachha

  2. Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India

    Richa Mishra

Authors
  1. Sumit Kumar Singh
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ujjal Poddar
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Richa Mishra
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Anshu Srivastava
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Surender Kumar Yachha
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ujjal Poddar.

Ethics declarations

Conflict of interest

Sumit Kumar Singh, Ujjal Poddar, Richa Mishra, Anshu Srivastava and Surender Kumar Yachha declare that they have no conflict of interest.

Ethical standard

The primary study was approved by the institutional ethics committee, Sanjay Gandhi Postgraduate Institute of Medical Sciences and conducted in compliance with the Good Clinical Practice guidelines, the Declaration of Helsinki, and regulatory requirements.

Informed consent

All patients provided written informed consent and all protocols were approved by the institutional ethics committee.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Singh, S.K., Poddar, U., Mishra, R. et al. Ascitic fluid infection in children with liver disease: time to change empirical antibiotic policy. Hepatol Int 14, 138–144 (2020). https://doi.org/10.1007/s12072-019-09968-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12072-019-09968-x

Keywords

Search

Navigation