Use of metagenomic next-generation sequencing for diagnosis of peritonitis in end-stage liver disease.

Background: Conventional methods are low in positive rates and time-consuming for ascites pathogen detection in patients with end-stage liver disease (ESLD). With many advantages, metagenomic next-generation sequencing (mNGS) may be a good alternative method. However, the related studies are still lacking. Methods: Ascites from 50 ESLD patients were sampled for pathogen detection using mNGS and conventional methods (culture and polymorphonuclear neutrophils detection) in this prospective observational study. Results: Forty-two samples were detected positive using mNGS. 29 strains of bacteria, 11 strains of fungi, and 9 strains of viruses were detected. 46% of patients were detected to be co-infected with 2 or more pathogens by mNGS. Moreover, mNGS showed similar and high positive rates in ESLD patients with different clinical characteristics. Compared to conventional methods, mNGS had higher positivity rates (84% vs. 20%, P<0.001), sensitivity (45.2% vs. 23.8%, P=0.039), broader pathogen spectrum, shorter detection time (24 hours vs. 3-7 days), but lower specificity (25% vs 100%, P = 0.010). Furthermore, compared to conventional methods, mNGS showed similar consistence with final diagnosis (42% vs. 36%, P=0.539). Conclusions: mNGS may be a good supplement for conventional methods and helpful to early etiological diagnosis of peritonitis, and thus improve ESLD patients' survival.

Response-Guided Therapy With Cefotaxime, Ceftriaxone, or Ciprofloxacin for Spontaneous Bacterial Peritonitis: A Randomized Trial: A Validation Study of 2021 AASLD Practice Guidance for SBP.

INTRODUCTION: For the treatment of spontaneous bacterial peritonitis (SBP), cefotaxime, ceftriaxone, and ciprofloxacin were used as first-line agents. However, considering the increasing rate of antibiotic resistance, it is unclear which of these drugs can be initially recommended. This study aimed to compare the current efficacy of the 3 antibiotics, namely cefotaxime, ceftriaxone, and ciprofloxacin, for the treatment of SBP in patients with cirrhosis with ascites, when guided by therapeutic responses. METHODS: This study was a multicenter, prospective, randomized controlled trial. The inclusion criteria were 16- to 75-year-old patients with liver cirrhosis with ascites, having polymorphonuclear cell count of >250/mm 3 . We performed a follow-up paracentesis at 48 hours to decide continuing or changing the assigned antibiotics and then assessed the resolution rates at 120 and 168 hours of treatment. RESULTS: A total of 261 patients with cirrhosis who developed SBP were enrolled. Most of the patients were diagnosed as those with SBP within 48 hours of admission. The resolution rates at 120 hours, which is the primary endpoint, were 67.8%, 77.0%, and 73.6% in the cefotaxime, ceftriaxone, and ciprofloxacin groups, respectively ( P = 0.388), by intension-to-treat analysis. The 1-month mortality was similar among the groups ( P = 0.770). The model for end-stage liver disease score and the SBP resolution were significant factors for survival. CONCLUSION: The efficacy of empirical antibiotics, such as cefotaxime, ceftriaxone, and ciprofloxacin, against SBP was not significantly different. In addition, these antibiotics administered based on response-guided therapy were still efficacious as initial treatment for SBP, especially in those with community-acquired infections.

A Case of Roseomonas gilardii Peritonitis Associated with a Flooded Peritoneal Dialysis Treatment Space.

Bacterial peritonitis is a key complication of Peritoneal Dialysis (PD) and a preventable cause of withdrawal from PD treatment. Infection generally arises from contamination with skin commensals during handling of the dialysis delivery system or from translocation of gastrointestinal organisms and more rarely from an environmental organism. Herein, we report the case of a 73-year-old admitted for PD-related peritonitis due to Roseomonas gilardii with an associated environmental exposure from a domestic plumbing issue. We describe the presentation, case, and antibiotic regimen progression from empiric therapy of ceftazidime and vancomycin IP to ciprofloxacin. We acknowledge the importance of performing laboratory sensitivities given the high antibiotic resistance of the Roseomonas genus. We offer that nephrologists should consider Roseomonas as a potential causative organism of peritonitis, especially when initial or further history reveals exposure to potentially contaminated water.

Diagnostic utility of oxidative and non-oxidative markers for spontaneous bacterial peritonitis in non-malign ascites.

OBJECTIVE: In this study, we aimed to investigate the diagnostic availability of oxidant and antioxidant parameters in ascites for spontaneous bacterial peritonitis (SBP). MATERIAL AND METHODS: This study was carried out between July and October 2018 with 25 patients with SBP and 24 patients without SBP. Patients with acute infection, those taking vitamin supplements and antioxidant medication, smoking and drinking alcohol, and patients without ascites culture were excluded from the study. RESULTS: In patients with SBP compared those without SBP median paraoxonase (3.1 vs 15.6 ; p <0.001), median stimulated paraoxonase (12.6 vs 53.1 ; p <0.001), median arylesterase (769,9 vs 857,5 ; p = 0,003) and median catalase (10 vs 22,2 ; p = 0,003) were found to be lower and median myeloperoxidase (8.1 vs 1.1 ; p <0.001) were found to be higher. There was a positive correlation between paraoxonase levels and stimulated paraoxonase levels, arylesterase levels and catalase levels, there was a negative correlation between paraoxonase levels and myeloperoxidase levels. Paraoxonase levels 3.7 and lower, stimulated paraoxonase levels 25.8 and lower, arylesterase levels 853.4 and lower, catalase levels 11.8 and lower and myeloperoxidase levels 2.7 and more predicted the the presence of SBP with high specificity and high sensitivity. Paraoxonase and stimulated paraoxo-nase levels were found to have superior performance in predicting the presence of SBP compared to arylesterase levels (p <0.05). CONCLUSION: In this study it was shown that paraoxonase, stimulated paraoxonase, arylesterase, catalase and myeloperoxidase activities can be used for the diagnosis and severity of SBP.

Prevalence and Predictors of Third-Generation Cephalosporin Resistance in the Empirical Treatment of Spontaneous Bacterial Peritonitis.

OBJECTIVE: To better characterize the changing patterns of spontaneous bacterial peritonitis (SBP) in a tertiary academic center in the United States by identifying the prevalence of gram-positive organisms and cephalosporin resistance along with predictors of mortality and antibiotic drug resistance. PATIENTS AND METHODS: We reviewed 481 consecutive patients with SBP at Mayo Clinic in Rochester, Minnesota, from January 1, 2005, through December 31, 2016. Data on comorbid conditions, etiology of cirrhosis, factors predisposing to infection, and antimicrobial and antibiotic drug use were collected. RESULTS: We identified 96 patients (20%) with culture-positive SBP requiring treatment (median age, 60 years; age range, 22-87 years; 44% men). Gram-positive organisms account for more than half of the cases. Overall resistance to third-generation cephalosporins was 10% (n=10). Risk factors for third-generation cephalosporin resistance include nosocomial acquisition, recent antibiotic drug use, and hepatocellular carcinoma. The negative predictive value for antibiotic drug resistance in the present model was 96% (70 of 73). Overall mortality at 30 and 90 days was 23% and 37%, respectively. CONCLUSION: These findings support the recent observation of a rising prevalence of gram-positive organisms in SBP. Despite the changing pattern, third-generation cephalosporins seem to provide adequate empirical treatment in patients with community-acquired and health care-associated SBP without hepatocellular carcinoma.

A randomized controlled trial of alanyl-glutamine supplementation in peritoneal dialysis fluid to assess impact on biomarkers of peritoneal health.

In early clinical testing, acute addition of alanyl-glutamine (AlaGln) to glucose-based peritoneal dialysis (PD) fluids restored peritoneal cellular stress responses and leukocyte function. This study was designed to test the effect of extended treatment with AlaGln-supplemented PD fluid on biomarkers of peritoneal health. In a double-blinded, randomized crossover design, stable PD patients were treated with AlaGln (8 mM) or placebo added to PD fluid for eight weeks. As primary outcome measures, dialysate cancer-antigen 125 (CA-125) appearance rate and ex vivo stimulated interleukin-6 (IL-6) release were assessed in peritoneal equilibration tests. In 8 Austrian centers, 54 patients were screened, 50 randomized, and 41 included in the full analysis set. AlaGln supplementation significantly increased CA-125 appearance rate and ex vivo stimulated IL-6 release. AlaGln supplementation also reduced peritoneal protein loss, increased ex vivo stimulated tumor necrosis factor (TNF)-α release, and reduced systemic IL-8 levels. No adverse safety signals were observed. All 4 peritonitis episodes occurred during standard PD fluid treatment. A novel AlaGln-supplemented PD fluid improves biomarkers of peritoneal membrane integrity, immune competence, and systemic inflammation compared to unsupplemented PD fluid with neutral pH and low-glucose degradation. A phase 3 trial is needed to determine the impact of AlaGln supplementation on hard clinical outcomes.

Estudio de pacientes ingresados por peritonitis en el Centro Nacional de Cirugía de Mínimo Acceso / Study of patients with peritonitis admitted to the National Center for Minimal Access Surgery

Introducción: La peritonitis postoperatoria es una de las complicaciones más frecuentes que se presenta tras procederes laparoscópicos. Objetivo: Caracterizar la evolución de los pacientes complicados con peritonitis después de un proceder laparoscópico. Material y método: Se realizó un estudio observacional descriptivo de los pacientes con peritonitis ingresados en la terapia intensiva, del Centro Nacional de Cirugía de Mínimo Acceso, desde septiembre de 2010 hasta diciembre de 2015. Se analizaron algunas variables demográficas, procederes laparoscópicos que se complicaron con este diagnóstico, complicaciones clínicas, antibioticoterapia utilizada, tipo de nutrición y la escala de evaluación fisiológica APACHE II como predictor de pronóstico. La información se obtuvo de las historias clínicas. Las variables cualitativas se resumieron utilizando frecuencias absolutas y porcentajes. Para las cuantitativas se utilizó la media y la desviación estándar. Resultados: Se complicaron con peritonitis 26 de 298 pacientes ingresados en el período (8,7 ), la edad media fue de 60 años, predominó el sexo femenino (57,7 por ciento). Se complicaron más con este diagnóstico los pacientes perforados postcolonoscopia (50 por ciento). El disbalance hidroelectrolítico (73,1 por ciento) fue la complicación asociada más frecuente. Se usó precozmente la nutrición enteral en 57,7 por ciento y los antibióticos más utilizados fueron ceftriaxone, amikacina y metronidazol. Predominó la evolución favorable a pesar que el score APACHE II se mantuvo en valores elevados. Conclusiones: Las perforaciones intestinales después de una colonoscopía tienen un alto riesgo de sufrir peritonitis secundaria, pero si se realiza un diagnóstico y tratamiento precoz su evolución es favorable(AU)

Introduction: Endoscopic dilatation is the first therapeutic option to eliminate benign esophageal stenosis and improve the symptoms and the quality of life of those patients who suffer from it. Objective:To describe the results of endoscopic dilatation in patients with benign esophageal stenosis treated in the National Center for Endoscopic Surgery from January 2015 to December 2016. Material and Methods:A case series longitudinal observational study was conducted in 59 patients with benign esophageal stenosis. Dilatations were done with Savary-Gilliard bougie and balloons. Results:The mean age was 52,5 years, and the condition predominated in 37 male patients (62,7 percent). Post-surgical, peptic, and caustic were the most frequent etiologies with 25, 14, and 6 cases, respectively. Short stenosis predominated in 51 cases. Bougies were used in 48 patients for a total of 149 dilatations, corresponding to a mean of 3,1 dilatations/ patients. Correction of the stenosis was made in 1-3 sessions in 47 percent of patients; 11 cases were dilated with balloon, corresponding to a mean of 1- 3 dilatations/ patients. Four patients from the group that were dilated with Savary-Gilliard bougies showed refractoriness. A perforation, and two bleedings occurred. After the dilatations, dysphagia improved or disappeared in 93,2 percent of patients. Conclusions:Endoscopic therapy through dilatation of benign esophageal stenosis indicated to be a good alternative method in achieving corrections in a few dilatation sessions, with a low number of complications, and an improvement of the dysphagia(AU)

Peritonitis espontánea por Streptococcus equi subsp. zooepidemicus / Spontaneous peritonitis by Streptococcus equi subsp. zooepidemicus

No disponible

[Integrated approach to correction enteral insufficiency in early postoperative period].

AIM: The purpose of the research was to study the effectiveness of enteral insufficiency correction at an acute peritonitis by applying minimally invasive techniques, electrical stimulation and rehabilitation of the bowel and abdominal intestine using Remaxol drug. MATERIAL AND METHODS: The analysis of the results of clinical and laboratory examination and treatment of 110 patients with acute diffuse peritonitis. In the comparison group (62 patients) in the early postoperative period applied standardized treatment, including software reorganization of the abdominal cavity, in the study group (48 patients) -- a comprehensive treatment that includes software laparoscopic sanation abdominal electrical stimulation of the duodenum, and intra-abdominal (single dose, 200 ml), and intracolonic (200 ml, 2 times daily) administration Remaxol. It was noted a significant improvement in treatment outcomes, including reduced mortality by 2.3 times, the shortening of hospital stay by 1.3 times. RESULTS: The major component of the positive effect of the developed scheme of therapy is its ability to promptly arrest the effects of enteral insufficiency, maintain the functional status of the liver. The relatively rapid recovery of motor and intestinal barrier function leads to a lowering of enteral insufficiency syndrome, which along with increased liver detoxification ability underlies the significant reduction of endogenous intoxication in three days. An important contribution to the effectiveness of the treatment makes intra and intracolonic administration Remaxol. The drug, possessing antioxidant, antihypoxic, hepatoprotective effects, contributes to the relatively rapid improvement of the barrier function of the peritoneum and intestines, detoxification ability of the liver recovery that significantly contributes to the relief of endogenous intoxication.

Microbiology and resistance in first episodes of spontaneous bacterial peritonitis: implications for management and prognosis.

PURPOSE: International guidelines for antibiotic treatment of spontaneous bacterial peritonitis (SBP) are based on studies conducted decades ago and do not reflect regional differences of bacterial epidemiology. METHODS: We retrospectively analyzed epidemiology of agents, antibiotic resistance patterns, and survival in liver cirrhosis patients with their first episode of SBP during the years 2007-2013. RESULTS: Of the 311 patients included, 114 patients had a positive ascites culture, and 197 had an ascitic neutrophil count >250 µL. Gram-positive bacteria (47.8%) were more frequently found than Gram-negatives (44.9%), fungi in 7.2%. Enterobacter spp. (40.6%), Enterococcus spp. (26.1%), and Staphylcoccus spp. (13.8%) were the most frequently isolated agents. Third-generation cephalosporins covered 70.2% of non-nosocomial and 56.3% of nosocomial-acquired SBP cases.When SBP was diagnosed by a positive ascitic culture, survival was highly significantly reduced (mean: 13.9 ± 2.9 months; 95% confidence interval [CI]: 8.1-19.8) compared with culture-negative SBP patients (mean: 44.1 ± 5.4 months; 95% CI: 33.4-54.9; P = 0.000). Along with model of end-stage liver disease score and intensive care unit contact, a positive ascites culture remained an independent risk factor associated with poor survival (odds ratio: 1.49; 95% CI: 1.09-2.03) in multivariate analysis; piperacillin/tazobactam proved to be an adequate antibiotic for nosocomial and non-nosocomial SBP in 85.1% and 92.5%, respectively. SBP infection with Enterococcus spp. was associated with poor patient survival (P = 0.048). CONCLUSIONS: Third-generation cephalosporins have poor microbial coverage for treatment of SBP. Current guidelines need to adapt for the emerging number of Gram-positive infectious agents in SBP patients.

Pathogen profile and drug resistance analysis of spontaneous peritonitis in cirrhotic patients.

AIM: To investigate the microbiological characteristics and drug resistance in liver cirrhosis patients with spontaneous peritonitis. METHODS: We analyzed the data of patients with liver cirrhosis and abdominal infection at the First Affiliated Hospital of Zhejiang University between January 2011 and December 2013. Pathogens present in the ascites were identified, and their sensitivity to various antibiotics was determined. RESULTS: We isolated 306 pathogenic bacteria from 288 cases: In 178 cases, the infection was caused by gram-negative strains (58.2%); in 85 cases, gram-positive strains (27.8%); in 9 cases, fungi (2.9%); and in 16 cases, more than one pathogen. The main pathogens were Escherichia coli (E. coli) (24.2%), Klebsiella pneumoniae (18.9%), Enterococcus spp. (11.1%), and Staphylococcus aureus (7.5%). Of the 306 isolated pathogens, 99 caused nosocomial infections and 207 caused community-acquired and other infections. The E. coli and K. pneumoniae strains produced more extended-spectrum ß-lactamases in cases of nosocomial infections than non-nosocomial infections (62.5% vs 38%, P < 0.013; 36.8% vs 12.8%, P < 0.034, respectively). The sensitivity to individual antibiotics differed between nosocomial and non-nosocomial infections: Piperacillin/tazobactam was significantly more effective against non-nosocomial E. coli infections (4% vs 20.8%, P < 0.021). Nitrofurantoin had stronger antibacterial activity against Enterococcus species causing non-nosocomial infections (36.4% vs 86.3%, P < 0.009). CONCLUSION: The majority of pathogens that cause abdominal infection in patients with liver cirrhosis are gram-negative, and drug resistance is significantly higher in nosocomial infections than in non-nosocomial infections.

Ileum and colon perforation following peritoneal dialysis-related peritonitis and high-dose calcium polystyrene sulfonate.

A rare but severe complication, intestinal necrosis, has been reported after sodium polystyrene sulfonate (SPS; Kayexalate) and sorbitol intake. Some case reports described bowel perforation following calcium polystyrene sulfonate (CPS; Kalimate) administration. We report a case of ileum and colon perforation following peritoneal dialysis-related peritonitis and high-dose Kalimate in a 59-year-old female patient. The patient had a history of hypertension, diabetes mellitus, and end-stage renal disease (ESRD). During hospitalization for peritoneal dialysis-related peritonitis, she developed hyperkalemia, and Kalimate was administered orally. However, severe abdominal distension and pain occurred just one day after Kalimate intake. An urgent surgery disclosed several perforations in the ileum and sigmoid colon. Pathology of the resected gut showed transmural necrosis and perforation with basophilic angulated crystals. The patient finally expired during hospitalization due to refractory septic shock.

[Application of ozonated perftoran in the treatment of spreaded peritonitis].

Results of surgical treatment of 114 patients, suffering spreaded peritonitis of various etkoogy, were analyzed. To patients of the comparison group basic conservative therapy was conducted. In patients of the main group was applied intravenous infusion of ozonated perftoran (OP) in 1 mg/kg dose, concentration of ozone 5 mg/l, solely or together with metabolic immunomodulator and detoxicator glutoxim. To all the patients the routine clinical investigations were conducted: in the blood erythrocytes there were measured concentration of diane conjugates, of malonic dialdehyde, activity of catalase, content of the middle molecular mass peptides in blood and urine, as well as of rest nitrogen, urea, creatinine, common bilirubin, state of the protein and electrolyte balance. Basing on analysis of results of the conducted investigations there was revealed, that combined, local and systematic, application of OP and glutoxim together with basic therapy in spreaded peritonitis is pathogenetically substantiated.

Spontaneous bacterial peritonitis by Pasteurella multocida under treatment with rifaximin.

Spontaneous bacterial peritonitis (SBP) is a life-threatening complication of liver cirrhosis. Recently, rifaximin, a non-absorbable antibiotic which is used to prevent recurrent hepatic encephalopathy, has been proposed as effective prophylaxis for SBP. Here, we present an unusual case of SBP under treatment with rifaximin. A 50-year-old woman with liver cirrhosis was admitted because of tense ascites and abdominal pain. She was under long-term oral prophylaxis with rifaximin due to hepatic encephalopathy. Paracentesis revealed SBP caused by Pasteurella multocida, which was sensitive to multiple antibiotics, including rifaximin. Treatment with ceftriaxone resulted in rapid resolution of the peritonitis and restoration of the patient. Since P. multocida is usually transmitted from pets, the patient's cat was tested and could be identified as the most likely source of infection. This case should elicit our awareness that uncommon pathogens and unusual routes of transmission may lead to SBP, despite antibacterial prophylaxis with non-absorbable antibiotics. Nevertheless, such infections may still remain sensitive to systemic therapy with conventional antibiotics.

First Case of Continuous Ambulatory Peritoneal Dialysis-Related Peritonitis Caused by Cryptococcus arboriformis

No abstract available.

[Optimization of diagnosis and control of treatment of gastrointestinal paresis in the early postoperative period in extended peritonitis].

The results of treatment of patients, operated on for extended peritonitis in reactive and toxic phases, presenting with prominent gastrointestinal paresis, using the impulse stimulation of their peristalsis and early enteral nutrition under guidance of electrogastroenterography, are analyzed. The method is simple in application, it may be used in surgical and reanimation stationaries of any level, it has not the current restrictions and special contraindications.