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. 2025 Aug 28;15(9):1363.
doi: 10.3390/life15091363.

Higher NLR Values Can Predict Gram-Negative Spontaneous Bacterial Peritonitis and a High In-Hospital Mortality Rate in Patients with Spontaneous Bacterial Peritonitis

Sergiu Marian Cazacu  1 , Ovidiu Mircea Zlatian  2 , Dragos Ovidiu Alexandru  3 , Elena Leocadia Plesea  2 , Ioan Alexandru Vacariu  4 , Mihai Cimpoeru  5 , Ion Rogoveanu  1 , Camelia Cristiana Bigea  4 , Cristina Maria Marginean  6 , Sevastita Iordache  1
Affiliations

Higher NLR Values Can Predict Gram-Negative Spontaneous Bacterial Peritonitis and a High In-Hospital Mortality Rate in Patients with Spontaneous Bacterial Peritonitis

Sergiu Marian Cazacu et al. Life (Basel). .

Abstract

Background: Spontaneous bacterial peritonitis (SBP) represents a significant complication of liver cirrhosis; Gram-positive bacteria (GPB) predominance was recently noted in some areas, with increased antibiotic resistance. Etiology and mortality prediction are important in culture-negative SBP and for empirical antibiotherapy before the arrival of culture results.

Methods: A retrospective study was performed on patients with cirrhosis and ascites admitted between 2018 and 2024, divided into culture-positive SBP (Gram-positive and Gram-negative), culture-negative SBP, and non-infected ascites. The NLR (neutrophil-to-lymphocyte ratio) accuracy for the prediction of SBP and in-hospital mortality was estimated using ROC analysis.

Results: Overall, 45 culture-positive SBP, 28 culture-negative SBP, and 600 control ascites were diagnosed; Gram-positive SBP represented 60%; median NLR values were significantly higher in patients with Gram-negative compared with Gram-positive SBP (8.79 in Gram-negative versus 3.92 in Gram-positive SBP, AUC 0.752, p = 0.003); and a limited role in SBP prediction was recorded (AUC 0.642, p = 0.003), with no difference between culture-positive and culture-negative SBP. The NLR median values were higher for patients who died in hospital in all patients with cirrhosis, in SBP, and culture-positive SBP, but not in culture-negative SBP.

Conclusions: Higher NLR values were associated with Gram-negative SBP etiology and with in-hospital mortality in all cirrhosis, in SBP, and especially in culture-positive and Gram-negative SBP cases. High NLR values can predict the Gram-negative etiology in patients with an ascitic neutrophil count above 250/mm3, which can be used to guide empirical antibiotherapy until cultures are available or in culture-negative SBP.

Keywords: Gram-negative bacteria; Gram-positive bacteria; antibiotic susceptibility; spontaneous bacterial peritonitis.

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Conflict of interest statement

The authors declare no conflicts of interest.

Figures

Figure 1
Figure 1
Flowchart for patients enrolled in our study.
Figure 2
Figure 2
(A,B) Box plot and AUC for predicting the presence of SBP; (C,D) box plot and AUC for predicting the presence of culture-positive SBP; (E,F) box plot and AUC for predicting the presence of Gram-positive or Gram-negative SBP.
Figure 3
Figure 3
(A,B) Box plot and AUC for predicting in-hospital mortality in patients with SBP; (C,D) box plot and AUC for predicting in-hospital mortality in patients with cirrhosis and no ascitic infection.
Figure 4
Figure 4
(A,B) Box plot and AUC for predicting in-hospital mortality in patients with culture-positive SBP; (C,D) box plot and AUC for predicting in-hospital mortality in patients with Gram-positive SBP; (E,F) box plot and AUC for predicting in-hospital mortality in patients with Gram-negative SBP; (G,H) box plot and AUC for predicting in-hospital mortality in patients with culture-negative SBP.
Figure 4
Figure 4
(A,B) Box plot and AUC for predicting in-hospital mortality in patients with culture-positive SBP; (C,D) box plot and AUC for predicting in-hospital mortality in patients with Gram-positive SBP; (E,F) box plot and AUC for predicting in-hospital mortality in patients with Gram-negative SBP; (G,H) box plot and AUC for predicting in-hospital mortality in patients with culture-negative SBP.
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