A Real-World Evaluation of Repeat Paracentesis-guided Management of Spontaneous Bacterial Peritonitis.
BACKGROUND
Spontaneous bacterial peritonitis (SBP) is a common infection in cirrhosis associated with high mortality. More than 20% of patients with SBP do not respond to initial antibiotics. Guidelines differ in recommendations to repeat paracentesis (retap) to confirm antibiotic efficacy. We aim to evaluate the effect of retap-guided management of SBP on antibiotic escalation and 30-day transplant-free survival.


METHODS
Retrospective cohort study of cirrhotic patients with SBP admitted to a single transplant center from 2010 to 2014. Patients were divided into 2 groups: retap-guided management versus no retap. Prevalence of initial antibiotic treatment failure, defined as <25% decrease in ascitic polymorphonuclear cells, and factors associated with treatment failure, antibiotic escalation and 30-day transplant-free survival were evaluated.


RESULTS
Out of 210 patients, 146 (age 58, 74% male, mean model for end-stage liver disease score, 25) had retap and treatment failure was noted in 28 (22%). Gram-positive bacteria accounted for 44% of all positive cultures and third-generation cepahalosporin resistance was noted in 23%. Thirty-day transplant-free survival was 72% and 62% in retap and control groups, respectively (P=0.07). Treatment failure independently doubled the 30-day mortality rate (hazard ratio: 2.15, 1.03 to 4.50, P=0.04). After adjusting for age, model for end-stage liver disease and nosocomial infection, retap-guided management was not associated with improved survival (P=0.34).


CONCLUSIONS
The prevalence of initial treatment failure is high (22%) in patients with SBP and doubles the 30-day mortality risk, supporting recommendations to retap all patients with SBP.
*Department of Medicine, The Icahn School of Medicine at Mount Sinai, Division of Liver Diseases, Recanati/Miller Transplantation Institute †Department of Medicine, The Icahn School of Medicine at Mount Sinai, Division of Infectious Diseases, New York, NY.
Aparna
A
Goel
Mollie
M
Biewald
Shirish
S
Huprikar
Thomas
T
Schiano
Gene Y
GY
Im
D001424:Bacterial Infections / Q000150:complications / Q000401:mortality / Q000601:surgery*; D015331:Cohort Studies; D005260:Female; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications*; D008297:Male; D008875:Middle Aged; D009518:New York; D019152:Paracentesis; D010538:Peritonitis / Q000150:complications / Q000401:mortality / Q000601:surgery*; D012086:Reoperation; D012189:Retrospective Studies; D016019:Survival Analysis; D017211:Treatment Failure