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Research Article Volume 6 Issue 2
Prevalence and microbiological features of spontaneous bacterial peritonitis in hospitalized ascitic patients: Single center study
Sahar El Gharabawy,1 Noha EL Mashad,2 Tarek Fouad Sheta,2
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Ibrahim Elsayed Ibrahim Abdel Aziz3
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1Department of internal medicine, Faculty of medicine ?Mansoura University, Egypt
2Department of clinical pathology, Faculty of medicine ?Mansoura University, Egypt
3Aga Hospital, Pakistan
Correspondence: Tarek Fouad Sheta, Department of internal medicine, Faculty of medicine, Mansoura University, Egypt
Received: March 20, 2018 | Published: April 26, 2018
Citation: Gharabawy SE, Mashad NE, Sheta TF, et al. Prevalence and microbiological features of spontaneous bacterial peritonitis in hospitalized ascitic patients: Single center study. J Bacteriol Mycol Open ccess. 2018;6(2):160-163. DOI: 10.15406/jbmoa.2018.06.00196
Abstract
Spontaneous bacterial peritonitis (SBP) is a common serious complication in cirrhotic patients. The aim of this work is to determine the microbiological causes and their susceptibility pattern in patients with SBP admitted to Hepatology Unit at Mansoura Specialized Medical Hospital. This study included 400 patients with liver cirrhosis, ascites and clinical picture suggestive of SBP. All patients suspected to paracentesis. The aspirated fluid was examined for total leucocyte count and bacterial culture. 179 patients (58.3 %) out of 400 SBP patients were found to have Culture Negative Neutrocytic Ascitis (CNNA) while were 128(41.7%) patients had positive cultures. The causative microorganism was found to be E coli which was found in 57 patients (44%), staph. aureus in 32 patients (25%) and then K pneuminiae found in 20 patients (16%) finally strept pneumoniae in 19 patients (15%) of culture positive patients. Amoxicillin and Clavulanic acid (AMC) were the most sensitive antibiotic to be used as an oral antibiotics giving 92% sensitivity on all the detected bacteria.
Keywords: SBP, CNNA, strept pneumonia, HCV, HBV, asterixis
Introduction
Spontaneous bacterial peritonitis (SBP) is infection of the ascitic fluid that occurs in the absence of a visceral perforation or abdominal inflammatory focus such as abscess, acute pancreatitis. SBP is a serious complication in cirrhotic patients.1,2
The prevalence of SBP on a study was conducted on 100 cirrhotic,ascitic patients presented to the Internal Medicine Department, Kasr Elaini hospital was about 57%.3 It has been suggested that the microbiological causes of SBP and the susceptibility of the causative organisms to antibiotics are changing for several reasons.4,5 We are in need of these results to treat patients successfully to prevent complications.
Patients & methods
This study included 400 patients (222 were males and 178 were females) admitted to Hepatology Unit at Mansoura Specialized Medical Hospital with liver cirrhosis, ascites and clinical picture suggestive of spontaneous bacterial peritonitis (abdominal pain, fever and or impaired level of consciousness). This study was performed during the period between 11-2014 and 2-2015.
Depending upon polymorph leucocytic count in the aspirated ascitic fluid, patients were divided into two groups:
A-SBP patients with ascetic fluid polymorph nuclear count (PMNL) ≥250 cells/mm3
B-NON SBP with ascetic fluid polymorph nuclear count (PMNL) <250 cells/mm3
Patients who were on antibiotic therapy were excluded.
Methods
All patients were submitted for
- History taking (HCV, HBV, alcohol consumption, previous attacks of spontaneous bacterial peritonitis).
- Clinical examination including symptoms: abdominal distension, elevation of body temperature, abdominal pain, impairment of consciousness level, vomiting of blood and bleeding per rectum and signs: ascites, fever, abdominal tenderness, encephalopathy {flabbing tremors (asterixis) impaired consciousness level and confusion}, jaundice and lower limb oedema.
- Laboratory investigation
- Statistical analysis
On the day of admission, all patients suspected to paracentesis under local anaethestic and strict aseptic condition was done.
The aspirated fluid was examined for
Total leucocyte count
Culture on automated blood culture system (Bact/ALERT 3D) from biomerieux.
Data were tabulated, coded then analyzed using the computer program SPSS (Statistical package for social science) version 17.0.
Results
The study showed a significant increase in gram negative bacteria as a causative micro-organism in culture positive SBP patients. The causative organisms detected were E. coli (44%), Staph. aureus (25%), K. pneumoniae (16%) and Strept. pneumoniae (15%).
The culture results showed that E coli was highly sensitive to Amoxicillin and clavulanic (91.2%) followed by erythromycin (89.4%) and amoxicillin (87.7%). Staph aureus was most sensitive to cefoprazone (100%) while k. pneumoniae is most sensitive to meropenem (95%) It also shows that Strept pneumoniae is most sensitive to AMC, Ofloxacin and meropenem (100%).
Discussion
Spontaneous bacterial peritonitis is a grave and fatal complication for individuals with liver cirrhosis and ascites with high mortality and recurrence rates and poor long term prognosis.6 In this study, we found that 78.5% of SBP patients were in class C while 21.5% in class B according to child Pugh classification (Table 1) (Table 2) (p value <0.001).
In this study that was conducted on patients having decompensated cirrhosis, we found a high prevalence of SBP in 307 patients (76.7%) (Table 3).
This agrees with a study by Abeer et al.3 who found the prevalence of SBP in a study was conducted on 100 cirrhotic, ascetic patients presented to the Internal Medicine Department, Kasr Elaini hospital was about 57%.
In another study by Gills et al.7 it was found that the prevalence of SBP in ascitic patients who were admitted into the medical ward of the Ekiti State University Teaching Hospital (EKSUTH), AdoEkiti, Nigeria is about 50 %-60%.
According to results of ascetic fluid culture of SBP patients, it was also found that 179 patients (58.3 %) among 400 SBP patients were found to have Culture Negative Neutrocytic Ascitis (CNNA) while were 128 (41.7%) patients had positive cultures (Table 4).
Payal et al.8 studied 217 clinically suspected cases of SBP and concluded that 71 (43.80%) had ascitic fluid polymorphonuclear cells (PMN) count ≥250/mm3. 31 (43.6%) cases were culture positive and 40 (56.4%) cases were culture-negative neutrocytic ascites.
It was also found that positive cultures were gram negative in 77 patients culture (60.2%) and gram positive in 51 patients culture (39.8%) (p<0.001) as shown in (Table 5). In the presnt study, the causative micro organism was found to be E coli which was found in 57 patients (44%), Staph aureus in 32 patients (25%) and then K pneumoniae found in 20 patients (16%) finally Strept pneumoniae in 19 patients (15%) of culture positive patients (Table 6).
It was also found that Gram negative bacteria were highly sensitive for Amoxicillin and Clavulanic acid (AMC), Meropenem and Erythromycin (Table 7) (Table 8) meanwhile Gram positive bacteria were highly sensitive for Amoxicillin and Clavulanic acid (AMC), Ofloxacin and cefoprazone (Table 7). So from results obtained In this study, it could be concluded that. Amoxicillin and Clavulanic acid (AMC) the most sensitive antibiotic to be used as an oral antibiotics giving 92% sensitivity on all the bacteria detected (88.3% for Gram negative cultures and 98% for Gram positive cultures) (Table 9).
SBP(307) |
Non SBP(93) |
P |
||||
No |
% |
No |
% |
|||
Childpuogh |
B |
66 |
21.50% |
42 |
45.20% |
<0.001** |
C |
241 |
78.50% |
51 |
54.80% |
||
Table 1 Classification of all patients according to child pugh score
SBP (307) |
Non SBP (93) |
P |
|||
WBC |
8.7 |
1.30-32.00 |
9 |
4.10-25.30 |
0.9 |
HB |
9.2 |
±1.98 |
9.28 |
±2.04 |
0.7 |
Platlets |
72 |
8.80-400.00 |
81 |
12.00-200.00 |
0.6 |
Creatinine |
1.8 |
0.70-7.00 |
1.7 |
0.70-7.00 |
0.4 |
Albumin |
2.68 |
±.77 |
2.79 |
±.71 |
0.2 |
HCVab |
142 |
46.30% |
38 |
40.90% |
0.36 |
HBVsAg |
28 |
9.10% |
13 |
14.00% |
0.17 |
AST |
84 |
16.00-887.00 |
59 |
2.00-441.00 |
0.08 |
ALT |
54 |
14.00-420.00 |
48 |
15.00-232.00 |
0.01* |
Bilirubin |
3.2 |
0.80-61.00 |
3 |
1.20-18.00 |
0.3 |
PT |
15.3 |
12.50-62.00 |
15.2 |
12.40-58.00 |
0.9 |
INR |
1.62 |
±.84 |
1.59 |
±.74 |
0.7 |
Na |
126 |
90.00-1112.00 |
126 |
90.00-140.00 |
0.2 |
K |
4 |
2.30-32.00 |
3.8 |
2.30-5.00 |
0.6 |
PMNL in ascitic fluid |
600 |
250.00-70000.00 |
100 |
50.00-300.00 |
<0.001** |
Table 2 Laboratory data
No |
% |
P value |
||
Group 1 |
SBP |
307 |
76.70% |
<0.001** |
Group 2 |
Non SBP |
93 |
23.30% |
|
Total |
400 |
100% |
Table 3 Classification of studied patients according to PMNL count of ascetic fluid
No |
% |
P value |
||
Culture |
Negative (CNNA) |
17900% |
58.30% |
0.017* |
Positive |
128 |
41.70% |
||
Total |
307 |
100% |
Table 4 Classification of SBP patients according to culture results
Organism |
No |
% |
P |
Gram negative |
77 |
60.20% |
<0.001** |
Gram positive |
51 |
39.80% |
|
Total |
128 |
100% |
Table 5 Classification of SBP according to gram stain
Bacteria in positive culture |
No |
% |
P |
E coli (Gram -ve) |
5700.00% |
44% |
<0.001** |
Staph aureus (Gram +ve) |
3200.00% |
25% |
|
K Pnumonia (Gram -ve) |
2000.00% |
16% |
|
Strepto pnumonia (Gram +ve) |
19 |
15% |
|
Total |
128 |
100% |
Table 6 Types of micro-organisms in culture positive SBP
Bacteria |
|||||||
Gram-ve (n=77) |
Gram+ve (n=51) |
Total (128) |
P value |
||||
No |
% |
No |
% |
Total sensitive |
% |
||
Cefatriaxone |
62 |
80.50% |
45 |
88.20% |
107 |
83.50% |
- |
AMC (Amoxicillin and |
68 |
88.30% |
50 |
98.00% |
118 |
92.19% |
0.6 |
Clavulanic acid) |
|||||||
SAM(Ampicillin- |
64 |
83.10% |
48 |
94.10% |
112 |
87.50% |
0.8 |
Salbactam) |
|||||||
Ofloxacin |
62 |
80.50% |
50 |
98.00% |
112 |
87.50% |
0.8 |
Cefoprazone |
61 |
79.20% |
50 |
98.00% |
111 |
86.72% |
0.8 |
Meropenem |
66 |
85.70% |
45 |
88.20% |
111 |
86.71% |
0.8 |
CEPHALEX |
62 |
80.50% |
46 |
90.20% |
108 |
84.40% |
0.96 |
Clarithromycin |
63 |
81.80% |
45 |
88.20% |
108 |
84.38% |
0.96 |
Erythromycin |
67 |
87.00% |
40 |
78.40% |
107 |
83.60% |
1 |
Teicloplanin |
60 |
77.90% |
46 |
90.20% |
106 |
82.80% |
0.96 |
Nitrofurantion |
60 |
77.90% |
45 |
88.20% |
105 |
82.03% |
0.92 |
SXT(Sulphamethoxazole |
57 |
74.00% |
45 |
88.20% |
102 |
79.70% |
0.8 |
And Trimethoprim) |
|||||||
norfloxacin |
51 |
66.20% |
46 |
90.20% |
97 |
75.78% |
0.6 |
TZP(Piperacillin and |
57 |
74.00% |
36 |
72.00% |
93 |
72.66% |
0.45 |
Tozabactam ) |
|||||||
CIPRO |
53 |
68.80% |
34 |
66.70% |
87 |
67.90% |
0.28 |
Amoxicillin |
57 |
74.02% |
29 |
56.80% |
86 |
67.20% |
0.25 |
Vancomycin |
33 |
42.80% |
43 |
25.50% |
76 |
59.37% |
0.08 |
Amikacin |
53 |
68.80% |
6 |
11.80% |
59 |
46.10% |
0.003* |
Table 7 Antibiotic sensitivity in positive cultures
Acknowledgements
None.
Conflict of interest
The authors declare there is no conflict of interest.
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