Digestive Diseases and Sciences

, Volume 64, Issue 8, pp 2359–2367 | Cite as

Evidence of Significant Ceftriaxone and Quinolone Resistance in Cirrhotics with Spontaneous Bacterial Peritonitis

  • Eric Ardolino
  • Susan S. Wang
  • Vilas R. PatwardhanEmail author
Original Article



There are few studies addressing the impact of cephalosporin and quinolone resistance on hospital length of stay and mortality in spontaneous bacterial peritonitis (SBP). We aim to describe the shifting epidemiology of SBP at our institution and its impact on clinical outcomes.


We performed a single-center retrospective cohort study of all cases of SBP from 2005 to 2015 at a transplant center. Cases were identified using hospital billing data. Patient data were confirmed using the electronic medical record. Univariate and multivariate logistic regression and Cox proportional hazards models were used to identify factors that were associated with prolonged hospital length of stay and reduced survival. Culture-positive cases (N = 56) were compared to culture-negative cases (N = 104). Subpopulation analysis of the culture-positive cases compared ceftriaxone-resistant (N = 25) to ceftriaxone-susceptible (N = 31) cases.


We identified 160 cases of SBP (56 culture positive and 104 culture negative; 21 nosocomial, 79 hospital associated, and 60 community acquired). Forty-five percent (N = 25 total, 13 hospital associated and 6 nosocomial) of bacterial isolates were resistant to ceftriaxone, with 37.5% (N = 21) being gram positive, including 8 methicillin-resistant staphylococcus and 6 vancomycin-resistant enterococcus. Multivariate analysis identified hospital-associated SBP, age, alcoholic cirrhosis, and MELD-Na score as variables associated with worse survival (P < 0.05), with a trend toward worse survival in culture-positive cases (P = 0.123). Only MELD-Na was associated with prolonged length of stay.


The burden of resistant pathogens causing SBP is significant, notably in hospital-associated SBP. Culture-positive SBP may represent a higher risk group compared to culture-negative SBP.


Spontaneous bacterial peritonitis Cirrhosis SBP Cephalosporin resistance Quinolone resistance 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Research involving human participants and/or animals

For this type of study, formal consent is not required. This article does not contain any studies with animals performed by any of the authors.

Informed consent

Waiver for informed consent was approved by the BIDMC IRB committee.


  1. 1.
    Navasa M, Follo A, Llovet JM, et al. Randomized, comparative study of oral ofloxacin versus intravenous cefotaxime in spontaneous bacterial peritonitis. Gastroenterology. 1996;111:1011–1017.CrossRefGoogle Scholar
  2. 2.
    Karvellas CJ, Abraldes JG, Arabi YM, et al. Appropriate and timely antimicrobial therapy in cirrhotic patients with spontaneous bacterial peritonitis-associated septic shock: a retrospective cohort study. Aliment Pharmacol Ther. 2015;41:747.CrossRefPubMedGoogle Scholar
  3. 3.
    Runyon BA. Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis 2012. Hepatology. 2013;57:1651–1653. Scholar
  4. 4.
    Felisart J, Rimola A, Arroyo V, et al. Cefotaxime is more effective than is ampicillin-tobramycin in cirrhotics with severe infection. Hepatology. 1985;5:457–462.CrossRefPubMedGoogle Scholar
  5. 5.
    Franca AV, Giordano HM, Seva-Pereira T, Soares EC. Five days of ceftriaxone to treat spontaneous bacterial peritonitis in cirrhotic patients. J Gastroenterol. 2002;37:119–122.CrossRefPubMedGoogle Scholar
  6. 6.
    Rimola A, Almeron JM, Clemente G, et al. Two different dosages of cefotaxime in the treatment of spontaneous bacterial peritonitis in cirrhosis: results of a prospective, randomized, multicenter study. Hepatology. 1995;21:674–679.CrossRefPubMedGoogle Scholar
  7. 7.
    McHutchison JG, Runyon BA. Spontaneous bacterial peritonitis. In: Surawicz CM, Owen RL, eds. Gastrointestinal and hepatic infections. Philadelphia: WB Saunders; 1995:455.Google Scholar
  8. 8.
    Blaise M, Paterson D, Trinchet JC, Levacher S, Beaugrand M, Pourriat JL. Systemic antibiotic therapy prevents bacterial infection in cirrhotic patients with gastrointestinal hemorrhage. Hepatology. 1994;20:34–38.CrossRefPubMedGoogle Scholar
  9. 9.
    Fernandez J, Acevedo J, Castro M, et al. Prevalence and risk factors of infections by resistant bacteria in cirrhosis: a prospective study. Hepatology. 2012;55:1551–1561.CrossRefPubMedGoogle Scholar
  10. 10.
    Yakar T, Guclu M, Serin E, et al. A recent evaluation of empirical cephalosporin treatment and antibiotic resistance of changing bacterial profiles in spontaneous bacterial peritonitis. Dig Dis Sci. 2010;55:1149–1154. Scholar
  11. 11.
    Sofjan AK, Musgrove RJ, Beyda ND, Russo HP, Lasco TM, et al. Prevalence and predictors of spontaneous bacterial peritonitis due to ceftriaxone-resistant organisms at a large tertiary center in the United States. J Glob Antimicrob Resist. 2018 May 26; PubMed PMID: 29842975.Google Scholar
  12. 12.
    Fiore M, Gentile I, Maraolo AE, et al. Are third-generation cephalosporins still the empirical antibiotic treatment of community-acquired spontaneous bacterial peritonitis? A systematic review and meta-analysis. Eur J Gastroenterol Hepatol. 2018;30:329–336. Scholar
  13. 13.
    Fiore M, Maraolo AE, Gentile I, et al. Nosocomial spontaneous bacterial peritonitis antibiotic treatment in the era of multi-drug resistance pathogens: a systematic review. World J Gastroenterol. 2017;23:4654–4660. Scholar
  14. 14.
    Jalan R, Fernandez J, Wiest R, et al. Bacterial infections in cirrhosis: a position statement based on the EASL Special Conference 2013. J Hepatol. 2014;60:1310–1324.CrossRefPubMedGoogle Scholar
  15. 15.
    Chaulk J, Carbonneau M, Qamar H. Third-generation cephalosporin-resistant spontaneous bacterial peritonitis. Can J Gastroenterol Hepatol. 2014;28:83–88.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Piroth L, Pechinot A, Di Martino V, Hansmann Y, Putot A, et al. Evolving epidemiology and antimicrobial resistance in spontaneous bacterial peritonitis: a two-year observational study. BMC Infect Dis. 2014 May 23;14:287. PubMed PMID: 24884471; PubMed Central PMCID: PMC4055793.Google Scholar
  17. 17.
    Alexopoulou A, Vasilieva L, Agiasotelli D, et al. Extensively drug-resistant bacteria are an independent predictive factor of mortality in 130 patients with spontaneous bacterial peritonitis or spontaneous bacteremia. World J Gastroenterol. 2016;22:4049–4056. Scholar
  18. 18.
    Falcone M, Russo A, Pacini G, et al. Spontaneous bacterial peritonitis due to Methicillin-Resistant Staphylococcus Aureus in a patient with cirrhosis: the potential role for daptomycin and review of the literature. Infect Dis Rep. 2015;7:6127.PubMedPubMedCentralGoogle Scholar
  19. 19.
    Hillebrand DJ, Runyon BA, Yasmineh WG, Rynders GP. Ascitic fluid adenosine deaminase insensitivity in detecting tuberculous peritonitis in the United States. Hepatology. 1996;24:1408.CrossRefPubMedGoogle Scholar
  20. 20.
    Runyon BA, Hoefs JC, Morgan TR. Ascitic fluid analysis in malignancy-related ascites. Hepatology. 1988;8:1104.CrossRefPubMedGoogle Scholar
  21. 21.
    Pelletier G, Salmon D, Ink O, Hannoun S, Attali P, et al. Culture-negative neutrocytic ascites: a less severe variant of spontaneous bacterial peritonitis. J Hepatol. 1990;10:327–331. PubMed PMID: 2365982.CrossRefPubMedGoogle Scholar
  22. 22.
    Bal CK, Bhatia V, Daman R. Predictors of fifty days in-hospital mortality in patients with culture negative neutrocytic ascites. BMC Gastroenterol. 2017 May 16;17:64. PubMed PMID: 28511674; PubMed Central PMCID: PMC5434542.Google Scholar
  23. 23.
    Baskol M, Gursoy S, Baskol G, et al. Five days of ceftriaxone to treat culture negative neutrocytic ascites in cirrhotic patients. J clin Gastroenterol. 2003;37:403–405.CrossRefPubMedGoogle Scholar
  24. 24.
    Evans LT, Kim WR, Poterucha JJ, et al. Spontaneous bacterial peritonitis in asymptomatic outpatients with cirrhotic ascites. Hepatology. 2003;37:897–901.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Eric Ardolino
    • 1
  • Susan S. Wang
    • 2
  • Vilas R. Patwardhan
    • 1
    Email author
  1. 1.Liver CenterBeth Israel Deaconess Medical CenterBostonUSA
  2. 2.Department of MedicineDartmouth-Hitchcock Medical CenterLebanonUSA

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