Recurrent and Treatment-Unresponsive Spontaneous Bacterial Peritonitis Worsens survival in Decompensated Liver Cirrhosis

Abstract

Background: Spontaneous bacterial peritonitis (SBP) remains a major complication of cirrhosis. However, the incidence and the real impact of SBP in determining patient survival rates remain unclear. This study aims to evaluate the incidence and risk factors for SBP development and the role of SBP in predicting transplant-free survival.

Methods: Two hundred two consecutive patients underwent 492 paracenteses with biochemical and microbiological analysis of the ascitic fluid. When multiple paracenteses had been performed on a given patient, the first SBP-positive paracentesis or the first paracentesis conducted when none was diagnostic for SBP was included in the study.

Results: SBP was detected in 28 of 202 (13.9%) patients; in 26 of 28 patients, the neutrophil count in the ascitic fluid was ≥250 cells/μl, and in 15 of 28 patients, the cultures were positive. Variables independently associated with SBP were as follows: a higher model of end-stage liver disease (MELD) score, the serum glucose value, elevated CRP serum levels, and higher potassium serum levels. Overall, the median (range) transplant-free survival was 289 (54-1253) days. One hundred (49.5%) patients died, whereas 35 patients (17.3%) underwent liver transplantation. Independent predictors of death or liver transplantation were a higher MELD score and the development of SBP, especially if it was antibiotic-resistant or recurrent SBP.

Conclusion: The occurrence of SBP is associated with more severe liver dysfunction in conjunction with the presence of inflammation. Unlike the occurrence of SBP per se, failure of first-line antibiotic treatment and SBP recurrence appear to strongly influence the mortality rate.

Keywords: ALP, alkaline phosphatase; ALT, alanine aminotransferase; AST, aspartate aminotransferase; BMI, body mass index; CLIF-SOFA, chronic liver failure-sequential organ failure assessment; CP, Child-Pugh; CRP, C-reactive protein; EPS, hepatic encephalopathy; HBV, hepatitis B virus; HCV, hepatitis C virus; INR, international normalized ratio; LT, liver transplantation; MELD, model of end-stage liver disease; OR, odds ratio; PLT, platelet; SBP, Spontaneous bacterial peritonitis; SIRS, systemic inflammatory response syndrome; WBC, white blood cell; antibiotic-resistant infections; ascites; gGT, gamma-glutamyl transpeptidase; liver transplantation; survival.

Figure 1

Diagram illustrating the selection of patients who underwent at least one paracentesis owing to the presence of ascites. In each box, patients are numbered, whereas the brackets report the total number of paracenteses performed. Patients presenting ascites unrelated to liver diseases (n = 329), patients with ascites related to liver diseases but not attending the liver unit (n = 506), and patients with hepatocellular carcinoma (n = 77) were excluded. In total, 202 patients with cirrhosis complicated with ascites were enrolled in the study, and all of them were treated in the liver unit.

Figure 2

Comparison of transplant-free survival in patients with or without SBP. Subjects with SBP were stratified into three groups: those with only one episode of cephalosporin-susceptible SBP, those with cephalosporin-resistant SBP, and those who developed recurrent episodes of SBP. The statistical analysis was performed by means of the Mantel-Cox test for linear trends. SBP, spontaneous bacterial peritonitis.