title: First-line treatment with cephalosporins in spontaneous bacterial peritonitis provides poor antibiotic coverage.
abstract: OBJECTIVE
  Spontaneous bacterial peritonitis is a common infection in cirrhosis, associated with a high mortality. Third-generation cephalosporins are recommended as first-line treatment. The aim was to evaluate the epidemiology of microbiological ascitic fluid findings and antimicrobial resistance in Denmark.
  
  
  METHODS
  All patients with cirrhosis and a positive ascitic fluid culture, at three university hospitals in the Copenhagen area during a 7-year period, were retrospectively evaluated. Patients with apparent secondary peritonitis were excluded from the study.
  
  
  RESULTS
  One hundred and forty cases with 187 microbiological isolates were identified. The findings were: Gram-positive cocci, n = 86 (45.9%); Enterobacteriaceae, n = 59 (31.7%), with Escherichia coli identified in 31 cases; anaerobes, n = 14 (7.5%); yeast, n = 12 (6.4%); and cutaneous flora, n = 15 (8.0%). One case of Listeria monocytogenes was identified (0.5%). Overall antibiotic coverage was 57% for cephalosporins, 73% for piperacillin-tazobactam, and 72% for meropenem. Mortality rates in patients with isolates susceptible or resistant to the initial antibiotic treatment at 30 days follow-up were 35% and 55%, respectively (p = 0.017, Log-rank test).
  
  
  CONCLUSIONS
  Almost half of the isolates were Gram-positive cocci, and as the overall antibiotic coverage with a cephalosporin was only 57%, and survival significantly dependent on whether the microbial etiology was susceptible to initial antibiotic treatment or not, a change of standard empiric antibiotic regime should be considered. Piperacillin-tazobactam could be a favorable choice.
authors.affiliation: Department of Internal Medicine I, Division of Gastroenterology, Copenhagen University Hospital, Bispebjerg Hospital, Copenhagen, Denmark. srdannovovic@gmail.com
authors.forename: Srdan
authors.initials: S
authors.lastname: Novovic
authors.forename: Synne
authors.initials: S
authors.lastname: Semb
authors.forename: Henrik
authors.initials: H
authors.lastname: Olsen
authors.forename: Claus
authors.initials: C
authors.lastname: Moser
authors.forename: Jenny Dahl
authors.initials: JD
authors.lastname: Knudsen
authors.forename: Christian
authors.initials: C
authors.lastname: Homann
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D001202:Ascitic Fluid / Q000382:microbiology*; D002511:Cephalosporins / Q000627:therapeutic use*; D003718:Denmark; D024881:Drug Resistance, Bacterial; D004926:Escherichia coli; D004927:Escherichia coli Infections / Q000150:complications; D005260:Female; D016908:Gram-Positive Bacterial Infections / Q000150:complications; D006095:Gram-Positive Cocci; D006801:Humans; D053208:Kaplan-Meier Estimate; D008103:Liver Cirrhosis / Q000150:complications*; D008297:Male; D000077731:Meropenem; D008875:Middle Aged; D009181:Mycoses / Q000150:complications; D010397:Penicillanic Acid / Q000031:analogs & derivatives / Q000627:therapeutic use; D010538:Peritonitis / Q000188:drug therapy* / Q000382:microbiology*; D010878:Piperacillin / Q000627:therapeutic use; D000077725:Piperacillin, Tazobactam Drug Combination; D012189:Retrospective Studies; D013845:Thienamycins / Q000627:therapeutic use
chemical_list: D000900:Anti-Bacterial Agents; D002511:Cephalosporins; D013845:Thienamycins; D000077725:Piperacillin, Tazobactam Drug Combination; D010397:Penicillanic Acid; D000077731:Meropenem; D010878:Piperacillin