title: Unsuspected infection is infrequent in asymptomatic outpatients with refractory ascites undergoing therapeutic paracentesis.
abstract: OBJECTIVE
  Large-volume paracentesis is a safe and effective means of treating patients with refractory ascites. However, there is limited information regarding the need for ascitic fluid studies in asymptomatic outpatients presenting for therapeutic paracentesis. The aim of this prospective study was to define the incidence and natural history of peritoneal fluid infection in asymptomatic outpatients undergoing therapeutic paracentesis.
  
  
  METHODS
  Over a 13-month period, 118 therapeutic paracenteses were performed in 29 outpatients with decompensated cirrhosis (Child-Pugh class B = 38%, C = 62%). After a brief medical history and physical examination, ascitic fluid cell count with differential and culture were obtained from all participating subjects. Seven (24%) of the subjects were receiving norfloxacin prophylaxis, accounting for antibiotic coverage during 40% of the procedures performed. The clinical course and outcome of study subjects during a mean follow-up of 137 days was reviewed.
  
  
  RESULTS
  All 118 (100%) of the ascitic fluid samples demonstrated absolute neutrophil counts of <250/mm3 (mean = 6.5 +/- 22.5 pmn/mm3). Asymptomatic bacterascites was identified from three of the 118 (2.5%) fluid samples, but all of these subjects spontaneously recovered without treatment or sequelae. During follow-up, six episodes of symptomatic or hospital-associated peritoneal fluid infection were identified in study participants, emphasizing the importance of fluid studies in other clinical settings.
  
  
  CONCLUSIONS
  Although further studies are needed, the routine culture of ascitic fluid in asymptomatic outpatients with refractory ascites requiring therapeutic paracentesis may not be necessary when there is a low index of suspicion for occult infection. In circumstances of clinical uncertainty, however, obtaining ascitic fluid cell counts with differential is recommended to insure patient safety.
authors.affiliation: Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, USA.
authors.forename: M A
authors.initials: MA
authors.lastname: Jeffries
authors.forename: M A
authors.initials: MA
authors.lastname: Stern
authors.forename: N T
authors.initials: NT
authors.lastname: Gunaratnam
authors.forename: R J
authors.initials: RJ
authors.lastname: Fontana
mesh_terms: D000328:Adult; D000368:Aged; D000553:Ambulatory Care; D000890:Anti-Infective Agents / Q000627:therapeutic use; D019072:Antibiotic Prophylaxis; D001201:Ascites / Q000209:etiology / Q000628:therapy*; D001202:Ascitic Fluid / Q000166:cytology / Q000382:microbiology; D001424:Bacterial Infections / Q000175:diagnosis* / Q000209:etiology / Q000517:prevention & control; D005260:Female; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications; D008297:Male; D008875:Middle Aged; D009643:Norfloxacin / Q000627:therapeutic use; D019152:Paracentesis; D010538:Peritonitis / Q000175:diagnosis* / Q000209:etiology / Q000517:prevention & control; D011446:Prospective Studies
chemical_list: D000890:Anti-Infective Agents; D009643:Norfloxacin