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Spontaneous bacterial peritonitis in liver cirrhosis: Treatment and prophylaxis

Spontane bakterielle Peritonitis bei Leberzirrhose: Behandlung und Prophylaxe

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Summary

Spontaneous bacterial peritonitis in liver cirrhosis is due to the passage of intestinal bacteria into intestinal lymph vessels, systemic circulation and ascitic fluid. It may occur in patients with severe portal hypertension and hepatic failure, impaired reticuloendothelial phagocytic activity and low ascitic fluid opsonic activity. Spontaneous bacterial peritonitis is a monomicrobial infection usually caused by gram-negative bacteria. The treatment of choice of spontaneous bacterial peritonitis is cefotaxime. Several subgroups of cirrhotic patients have been shown to be predisposed to develop spontaneous bacterial peritonitis, including cases with gastrointestinal hemorrhage, patients with high serum bilirubin and low ascitic fluid protein concentration (<1 g/dl), and patients who had recovered from an episode of spontaneous bacterial peritonitis. Since spontaneous bacterial peritonitis is associated with a relatively high in-hospital mortality rate (20–40%), prophylactic measures to prevent this infection are required. Short-term and long-term selective intestinal decontamination with oral norfloxacin has proved highly effective in preventing bacterial infection and spontaneous bacterial peritonitis in bleeding cirrhotic patients as well as recurrence of spontaneous bacterial peritonitis.

Zusammenfassung

Die spontane bakterielle Peritonitis bei Leberzirrhose beruht auf einer Passage der Bakterien über die Lymphgefäße des Dünndarms in den systemischen Kreislauf und in den Aszites. Betroffen sind Patienten mit schwerer portaler Hypertension und Leberversagen, gestörter Phagozytoseaktivität des retikuloendothelialen Systems und geringer Opsonisierungsfähigkeit des Aszites. Die spontane bakterielle Peritonitis ist eine monobakterielle Infektion, die meist durch gramnegative Bakterien ausgelöst wird. Cefotaxim ist das Mittel der Wahl bei spontaner bakterieller Peritonitis. Bei betimmten Untergruppen von Patienten mit Leberzirrhose besteht eine besondere Prädisposition für eine spontane bakterielle Peritonitis, einschließlich der Patienten mit gastrointestinaler Blutung, mit hohem Serumbilirubin und geringer Eiweißkonzentration im Aszites (<1 g/dl), sowie Patienten, die bereits eine Episode von spontaner bakterieller Peritonitis durchgestanden haben. Prophylaktische Maßnahmen sind wegen der hohen Letalität (20–40%) der Erkrankung während der Hospitalisierungsphase erforderlich. Die kurzfristige oder langfristige selektive Dekontamination des Darmes mit oralem Norfloxacin erwies sich als hochaktive Präventionsmaßnahme gegen bakterielle Infektionen und die spontane bakterielle Peritonitis bei blutenden Patienten mit Leberzirrhose und reduzierte Rezidive.

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References

  1. Rimola, A. Infections in liver disease. In:McIntyre, N., Benhamou, J. P., Bircher, J., Rizzetto, M., Rodés, J. (eds): Oxford Textbook of Clinical Hepatology. Oxford Medical Press. Oxford 1991, pp. 1272–1284.

    Google Scholar 

  2. Pinzello, G., Simonetti, R. G., Craxi, A., DiPiazza, S., Spano, C., Pagliaro, L. Spontaneous bacterial peritonitis: a prospective investigation in predominantly nonalcoholic cirrhotic patients. Hepatology 3 (1983) 545–549.

    PubMed  Google Scholar 

  3. Regina, W., Strauss, E. A prospective study of bacterial infections in patients with cirrhosis. J. Hepatol. 18 (1993) 353–358.

    PubMed  Google Scholar 

  4. Llach, J., Rimola, A., Navasa, M., Ginès, P., Salmerón, J. M., Ginès, A., Arroyo, V., Rodés, J. Incidence and predictive factors of first episode of spontaneous bacterial peritonitis in cirrhosis with ascites: relevance of ascitic fluid concentration. Hepatology 16 (1992) 724–727.

    PubMed  Google Scholar 

  5. Andreu, M., Solá, R., Sitges-Serra, A., Alia, C., Gallen, M., Vila, C., Coll, S., Oliver, M. I. Risk factors for spontaneous bacterial peritonitis in cirrhotic patients with ascites. Gastroenterology 104 (1993) 1133–1138.

    PubMed  Google Scholar 

  6. Runyon, B. A. Pathogenesis and diagnosis of spontaneous bacterial peritonitis. In:Rodés, J., Arroyo, V. (eds): Therapy in liver diseases. Ediciones DOYMA S.A., Barcelona 1992, pp. 388–396.

    Google Scholar 

  7. Runyon, B. A., Sugano, S., Kanel, G., Mellencamp, M. A. A rodent model of cirrhosis, ascites and bacterial peritonitis. Gastroenterology 100 (1991) 489–493.

    PubMed  Google Scholar 

  8. Rimola, A., Soto, R., Bory, F., Arroyo, V., Piera, C., Rodés, J. Reticuloendothelial systemic phagocytic activity in cirrhosis and its relation to bacterial infections and prognosis. Hepatology 4 (1984) 53–58.

    PubMed  Google Scholar 

  9. Runyon, B. A., Morrisey, R. L., Hoefs, J. C. Opsonic activity of human ascitic fluid. A potentially important protective mechanism against spontaneous bacterial peritonitis. Hepatology 5 (1985) 634–637.

    Google Scholar 

  10. Runyon, B. A. Patients with deficient ascitic fluid opsonic activity are predisposed to spontaneous bacterial peritonitis. Hepatology 8 (1988) 632–635.

    Google Scholar 

  11. Runyon, B. A. Low-protein-concentration ascitic fluid is predisposed to spontaneous bacterial peritonitis. Gastroenterology 91 (1986) 1343–1346.

    PubMed  Google Scholar 

  12. Runyon, B. A., Canawati, H. N., Akriviadis, E. A. Optimization of ascitic fluid culture technique. Gastroenterology 95 (1988) 1351–1355.

    Google Scholar 

  13. Runyon, B. A., Antillon, M. R., Akriviadis, E. A., McHutchison, J. G. Bedside inoculation of blood culture bottles with ascitic fluid is superior to delayed inoculation in the detection of spontaneous bacterial peritonitis. J. Clin. Microbiol. 28 (1990) 2811–2812.

    PubMed  Google Scholar 

  14. Castellote, J., Xiol, X., Verdaguer, R., Ribes, J., Guardiola, J., Giménez, A., Casais, L. Comparison of two ascitic fluid culture methods in cirrhotic patients with spontaneous bacterial peritonitis. Am. J. Gastroenterol. 85 (1990) 1605–1608.

    PubMed  Google Scholar 

  15. Bobadilla, M., Sifuentes, J., García-Tsao, G. Improved method for bacteriological diagnosis of spontaneous bacterial peritonitis. J. Clin. Microbiol. 27 (1989) 2145–2147.

    PubMed  Google Scholar 

  16. García-Tsao, G., Conn, H. O., Lerner, E. The diagnosis of bacterial peritonitis: comparison of pH, lactate concentration and leucocyte count. Hepatology 5 (1985) 91–96.

    PubMed  Google Scholar 

  17. Byl, B., Roucloux, I., Crusiaux, A., Dupont, E., Devière, J. Tumor necrosis factor α and interleukin-6 plasma levels in infected cirrhotic patients. Gastroenterology 104 (1993) 1492–1497.

    PubMed  Google Scholar 

  18. Zeni, F., Tardy, B., Vindimian, M., Comtet, C., Page, Y., Cusey, I., Bertrand, J. C. High levels of tumor necrosis factor-α and interleukin-6 in the ascitic fluid of cirrhotic patients with spontaneous bacterial peritonitis. Clin. Infect. Dis. 17 (1993) 218–223.

    PubMed  Google Scholar 

  19. Conn, H. O. Spontaneous bacterial peritonitis and bacteremia in Laennec's cirrhosis caused by enteric organisms. A relatively common but rarely recognized syndrome. Ann. Intern. Med. 60 (1964) 568–580.

    PubMed  Google Scholar 

  20. Conn, H. O., Fessel, J. M. Spontaneous bacterial peritonitis in cirrhosis: variations on a theme. Medicine (Baltimore) 50 (1971) 161–197.

    PubMed  Google Scholar 

  21. Rimola, A. Treatment and prophylaxis of spontaneous bacterial peritonitis. In:Rodés, J., Arroyo, V. (eds): Therapy in liver diseases. Ediciones DOYMA S.A., Barcelona 1992, pp. 397–406.

    Google Scholar 

  22. Cabrera, J., Arroyo, V., Ballesta, A. M., Rimola, A., Gual, J., Elena, M., Rodés, J. Aminoglycoside nephrotoxicity in cirrhosis: value of β2-microglobulin to discriminate functional renal failure from acute tubular damage. Gastroenterology 82 (1982) 97–105.

    PubMed  Google Scholar 

  23. Moore, R. D., Smith, C. R., Lipsky, J. J., Mellits, E. D., Lietman, P. S. Risk factors for nephrotoxicity in patients treated with aminoglycoside. Ann. Int. Med. 100 (1984) 352–357.

    PubMed  Google Scholar 

  24. Felisart, J., Rimola, A., Arroyo, V., Pérez-Ayuso, R. M., Quintero, E., Ginès, P., Rodés, J. Cefotaxime is more effective than is ampicillin-tobramycin in cirrhotics with severe infections. Hepatology 5 (1985) 457–462.

    PubMed  Google Scholar 

  25. Runyon, B. A., McHutchison, J. G., Antillon, M. R., Akriviadis, E. A., Montano, A. A. Short-course versus long-course antibiotic treatment of spontaneous bacterial peritonitis. A randomized controlled study of 100 patients. Gastroenterology 100 (1991) 1737–1742.

    PubMed  Google Scholar 

  26. Spanish Collaborative Group for Study of Spontaneous Bacterial Peritonitis Two different dosages of cefotaxime in the treatment of spontaneous bacterial peritonitis in cirrhosis. Preliminary results of a multicenter randomized, comparative study. Hepatology 16 (1992) 594.

    Google Scholar 

  27. Toldeo, C., Salmerón, J. M., Rimola, A., Navasa, M., Arroyo, V., Llach, J., Ginès, A., Ginès, P., Rodés, J. Spontaneous bacterial peritonitis in cirrhosis: predictive factors of infection resolution and survival in patients treated with cefotaxime. Hepatology 17 (1993) 251–257.

    PubMed  Google Scholar 

  28. Follo, A., Llovet, J. M., Navasa, M., Planes, R., Forns, X., Francitorra, A., Rimola, A., Gassull, M. A., Arroyo, V., Rodés, J.: Renal impairment following spontaneous bacterial peritonitis in cirrhosis. Incidence, clinical course, predictive factors and prognosis. Hepatology (1994) (in press).

  29. Ariza, J., Xiol, X., Esteve, M., Fernández, F., Liñares, J., Alonso, T., Gudiol, F. Aztreonam vs. cefotaxime in the treatment of gram-negative spontaneous peritonitis in cirrhotic patients. Hepatology 14 (1991) 91–98.

    PubMed  Google Scholar 

  30. Mercader, J., Gómez, J., Ruiz, J., Garre, M. C., Valdés, M. Use of ceftriaxone in the treatment of bacterial infections in cirrhotic patients. Chemotherapy 35 (Suppl. 2) (1989) 23–26.

    Google Scholar 

  31. Gómez-Jimenez, J., Ribera, E., Gasser, I., Artaza, M. A., Del Valle, O., Pamissa, A., Martínez-Vázquez, J. M. Randomized trial comparing ceftriaxone with cefonicid for treatment of spontaneous bacterial peritonitis in cirrhotic patients. Antimicrob. Agents Chemother. 37 (1993) 1587–1592.

    PubMed  Google Scholar 

  32. Grange, J. D., Amiot, X., Grange, V., Gutmann, L., Biour, M., Bodin, F., Poupon, R. Amoxicillin-clavulanic acid therapy of spontaneous bacterial peritonitis: a prospective study of twenty-seven cases in cirrhotic patients. Hepatology 11 (1990) 360–364.

    PubMed  Google Scholar 

  33. Silvain, C., Breux, J. P., Grollier, G., Rouffineau, J., Breq-Giraudon, B., Breauchant, M. Les septicémies et les infections du liquide d'ascite du cirrhotique peuvent-elles être traitées exclusivement par voie orale? Gastroenterol. Clin. Biol. 13 (1989) 335–339.

    PubMed  Google Scholar 

  34. Grupo Colaborativo para el estudio de la peritonitis bacteriana espontánea Eficacia de ofloxacino por vía oral frente a cefotaxima endovenosa en la peritonitis bacteriana espontánea (PBE) no complicada. Resultados preliminares de un estudio multicéntrico, prospectivo y aleatorizado. Gastroenterol. Hepatol. 17 (1994) 215.

    Google Scholar 

  35. Nord, C. E. Effect of new quinolones on the human gastrointestinal microflora. Rev. Infect. Dis. 10 (Suppl. 1) (1988) 193–196.

    Google Scholar 

  36. Winston, D. J., Karp, J., Talbot, G., Levvit, L., Corrado, M., Ho, W. G., Camplin, R. E., Barlett, J., Finley, R. S., Joshi, J. H., Deresinski, S. Norfloxacin for the prevention of bacterial infections in granulocytopenic patients. Am. J. Med. 82 (Suppl. 6B) (1987) 40–46.

    PubMed  Google Scholar 

  37. Bleichner, G., Boulanger, R., Squara, P., Sollet, J. P., Parent, A. Frequency of infections in cirrhotic patients presenting with acute gastrointestinal hemorrhage. Br. J. Surg. 73 (1986) 724–726.

    PubMed  Google Scholar 

  38. Sorell, W. T., Quigley, E. M. M., Jin, G., Johnson, T. J., Rikkers, L. F. Bacterial translocation in the portal-hypertensive rats: studies in basal conditions and on exposure to hemorrhagic shock. Gastroenterology 104 (1993) 1722–1726.

    PubMed  Google Scholar 

  39. Rimola, A., Bory, F., Terés, J., Pérez-Ayuso, R. M., Arroyo, V., Rodés, J. Oral non-absorbable antibiotics prevent infection in cirrhosis with gastrointestinal hemorrhage. Hepatology 5 (1985) 463–467.

    PubMed  Google Scholar 

  40. Soriano, G., Guarner, C., Tomás, A., Villanueva, C., Torras, X., González, D., Sainz, S., Angera, A., Cussó, X., Balanzó, J., Vilardell, F. Norfloxacin prevents bacterial infection in cirrhotics with gastrointestinal hemorrhage. Gastroenterol. 103 (1992) 1267–1272.

    Google Scholar 

  41. Soriano, G., Guarner, C., Teixidó, M., Such, J., Barrios, J., Enríquez, J., Vilardell, J. Selective intestinal decontamination prevents spontaneous bacterial peritonitis. Gastroenterology 100 (1991) 477–481.

    PubMed  Google Scholar 

  42. Titó, L., Rimola, A., Ginès, P., Llach, J., Arroyo, V., Rodés, J. Recurrence of spontaneous bacterial peritonitis in cirrhosis: frequency and predictive factors. Hepatology 8 (1988) 27–31.

    PubMed  Google Scholar 

  43. Ginès, P., Rimola, A., Planas, R., Vargas, V., Marco, F., Almela, M., Forné, M., Miranda, M. L., Llach, J., Salmerón, J. M., Esteve, M., Marqués, M., Jiménez de Anta, M. T., Arroyo, V., Rodés, J. Norfloxacin prevents spontaneous bacterial peritonitis recurrence in cirrhosis: results of a double-blind, placebo-controlled trial. Hepatology 12 (1990) 716–724.

    PubMed  Google Scholar 

  44. Dupeyron, C., Mangeney, N., Sedrati, L., Campillo, B., Fouet, P., Leluan, G. Rapid emergence of quinolone resistance in cirrhotic patients treated with norfloxacin to prevent spontaneous bacterial peritonitis. Antimicrob. Agents Chemother. 38 (1994) 340–344.

    PubMed  Google Scholar 

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Authors and Affiliations

  1. Liver Unit, Hospital Clinic i Provincial, University of Barcelona, Villarroel 170, E-08036, Barcelona, Spain

    V. Arroyo M.D., M. Navasa M.D. & A. Rimola M.D.

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  2. M. Navasa M.D.
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Arroyo, V., Navasa, M. & Rimola, A. Spontaneous bacterial peritonitis in liver cirrhosis: Treatment and prophylaxis. Infection 22 (Suppl 3), S167–S175 (1994). https://doi.org/10.1007/BF01782702

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