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Colon Ascendens Stent Peritonitis CASP - a Standardized Model for Polymicrobial Abdominal Sepsis
Published on: December 18, 2010
Impact of Bacteria Types on the Clinical Outcomes of Spontaneous Bacterial Peritonitis
Cameron Furey1, Selena Zhou1, Joo Hye Park1
1Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine of USC, University of Southern, California2011 Zonal Avenue, HMR 801A, Los Angeles, CA, 90033-9141, USA.
Background And Aims:
Cirrhotic patients presenting with spontaneous bacterial peritonitis (SBP) have elevated risk of short-term mortality. While high Model for End-Stage Liver Disease-Sodium score (MELD-Na) and ascites culture yielding multi-drug resistance (MDR) bacteria are well established risk factors for further aggravating mortality, the impact of individual, causative microorganisms and their respective pathogenesis have not been previously investigated.
Methods:
This is a retrospective study of 267 cirrhotic patients at two tertiary care hospitals undergoing paracentesis from January 2015 to January 2021 who presented with ascitic PMN count > 250 cells/mm3. The primary outcome was SBP progression defined as death or liver transplantation within 1-month of paracentesis stratified by microorganism type.
Results:
Of 267 patients with SBP, the ascitic culture yielded causative microorganism in 88 cases [median age 57 years (IQR 52-64)]; 68% male; median MELD-Na 29 (IQR 23-35). The microbes isolated were E. coli (33%), Streptococcus (15%), Klebsiella (13%), Enterococcus (13%), Staphylococcus (9%) and others (18%); 41% were MDR. Cumulative incidence of SBP progression within 1-month was 91% (95% CI 67-100) for Klebsiella, 59% (95% CI 42-76) for E. coli, and 16% (95% CI 4-51) for Streptococcus. After adjusting for MELD-Na and MDR, risk of SBP progression remained elevated for Klebsiella (HR 2.07; 95% CI 0.98-4.24; p-value = 0.06) and decreased for Streptococcus (HR 0.28; 95% CI 0.06-1.21; p-value = 0.09) compared to all other bacteria.
Conclusion:
Our study found Klebsiella-associated SBP had worse clinical outcomes while Streptococcus-associated SBP had the most favorable outcomes after accounting for MDR and MELD-Na. Thus, identification of the causative microorganism is crucial not only for optimizing the treatment but for prognostication.
Insights
Spontaneous bacterial peritonitis (SBP) in cirrhotic patients has varying mortality risks based on the causative bacteria. Klebsiella infection is linked to worse outcomes, while Streptococcus shows a more favorable prognosis, impacting patient prognostication.
Area of Science:
- Hepatology
- Infectious Diseases
- Microbiology
Background:
- Spontaneous bacterial peritonitis (SBP) significantly increases short-term mortality risk in cirrhotic patients.
- High Model for End-Stage Liver Disease-Sodium (MELD-Na) scores and multi-drug resistant (MDR) bacteria in ascites are known adverse prognostic factors.
- The specific impact of individual causative microorganisms on SBP progression and mortality has not been well-defined.
Purpose of the Study:
- To investigate the impact of specific causative microorganisms on SBP progression and mortality in cirrhotic patients.
- To determine if the type of bacteria isolated from ascites influences clinical outcomes beyond established risk factors like MELD-Na and MDR.
- To assess the prognostic value of identifying individual pathogens in SBP management.
Main Methods:
- Retrospective analysis of 267 cirrhotic patients with SBP diagnosed via paracentesis between January 2015 and January 2021.
- Patients were stratified by the causative microorganism identified in ascitic fluid cultures.
- Primary outcome: SBP progression, defined as death or liver transplantation within one month of paracentesis, analyzed by microorganism type, adjusting for MELD-Na and MDR status.
Main Results:
- Eighty-eight SBP cases yielded causative microorganisms, with E. coli (33%), Streptococcus (15%), and Klebsiella (13%) being most common; 41% of isolates were MDR.
- One-month SBP progression rates varied significantly: 91% for Klebsiella, 59% for E. coli, and 16% for Streptococcus.
- After adjusting for MELD-Na and MDR, Klebsiella remained associated with an elevated risk (HR 2.07) and Streptococcus with a decreased risk (HR 0.28) of SBP progression compared to other bacteria.
Conclusions:
- The causative microorganism in SBP plays a critical role in determining patient outcomes.
- Klebsiella-associated SBP confers a worse prognosis, whereas Streptococcus-associated SBP is linked to more favorable outcomes, even after accounting for MELD-Na and MDR.
- Identifying specific pathogens is essential for accurate prognostication and optimizing treatment strategies in cirrhotic patients with SBP.
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