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Nosocomial spontaneous bacterial peritonitis linked to antibiotic use, resistant organism, poor survival

Stephen Padilla
06 Aug 2019

A Singapore study has shown the association of nosocomial spontaneous bacterial peritonitis (N-SBP) with recent antibiotic use, longer hospitalization, more resistant organism and poorer survival among patients with SBP. Moreover, N-SBP and Model for End-stage Liver Disease (MELD) score are predictors of higher mortality in SBP.

“Early recognition and judicious use of antibiotics can improve survival in N-SBP,” the researchers said.

Thirty-three patients (mean age, 64.5 years; 69.7 percent male) with 39 episodes of SBP were included. Hepatitis B was the most common aetiology of cirrhosis (27.3 percent). The median MELD score was 17. Of the patients, 33.3 percent had acute-on-chronic liver failure and 60.6 percent had septic shock at presentation. One in four cases of SBP in Singapore (25.6 percent) were nosocomial in nature.

N-SBP was significantly associated with multidrug-resistant organisms (MDROs), previous antibiotic use in the past 3 months (p=0.014) and longer length of stay (p=0.011). [Singapore Med J 2019;doi:10.11622/smedj.2019085]

The 30- and 90-day mortality among SBP patients was 30.8 percent and 51.3 percent, respectively. MELD score >20 predicted 30-day mortality, while N-SBP and MEDL score >20 significantly predicted 90-day mortality.

Previous studies have shown the association of N-SBP with MDROs and poor outcomes. [Clin Infect Dis 2009;48:1230-1236; J Korean Med Sci 2006;21:666-671; Clin Gastroenterol Hepatol 2012;10:1291-1298]

“The rising trend of multidrug resistance worldwide continues to threaten the sustainability of effective treatments for common infections such as SBP,” the researchers said.

Knowledge of the local antibiotic resistance profile must guide empirical therapy knowing that early initiation of appropriate treatment improves survival and that N-SBP prevalence varies geographically ranging from 30.8 percent in Korea to 93.3 percent in France, they added. [World J Gastroenterol 2015;21:10409-10417; Turk J Gastroenterol 2016;27:294-295; Sci Rep 2017;7:46025; World J Hepatol 2015;7:304-314; J Hepatol 2012;56:825-832]

“In the present study, we reported a relatively lower prevalence of N-SBP in Singapore,” the researchers said. “With the low prevalence of resistant organisms among cirrhotic patients with SBP, the current empirical antibiotic recommendations of using ceftriaxone for C-SBP and piperacillin/tazobactam for N-SBP are reasonable options for Singapore.” [J Hepatol 2018;69:406-460]

Furthermore, all N-SBP patients in the current study were treated with adequate empirical coverage (piperacillin/tazobactam), suggesting that administration of appropriate antibiotics following local resistance patterns can improve short-term survival for N-SBP patients.

This study included all cirrhotic patients with SBP diagnosed between January 2014 and December 2017. N-SBP referred to SBP diagnosed >48 hours after hospitalization. Univariate and multivariate analyses were conducted to examine clinical outcomes as categorical outcomes.

The study was limited by its retrospective and nonrandomized design, small sample size, results derived from a single institution only, and the possible underdiagnosis of the incidence of SBP due to the exclusion of patients with clinical suspicion of SBP alone.

“A future prospective multicentre study would be ideal to verify our findings,” the researchers said.

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