Diagnosis of spontaneous bacterial peritonitis in infants and children with chronic liver disease: A cohort study

Abstract

BackgroundSpontaneous bacterial peritonitis (SBP) is a serious complication in infants and children with chronic liver disease (CLD); however its diagnosis might be difficult. We aimed to study the feasibility of diagnosing SBP by routine ascitic fluid tapping in infants and children with CLD.MethodsWe enrolled thirty infants and children with biopsy-proven CLD and ascites. Ascitic fluid was examined for biochemical indices, cytology and cell count. Aerobic and anaerobic bacteriological cultures of ascitic fluid were preformed. Direct smears were prepared from ascitic fluid deposit for Gram and Zheil-Nelson staining.ResultsPatients were divided into three groups: Group I included five patients with SBP in which the cell count was ≥ 250/mm3 and culture was positive (16.7%), Group II, eight patients with culture negative neutrocytic ascites (CNNA) with cells ≥ 250/mm3 and negative culture (26.7%) and Group III, seventeen negative patients (56.6%) in which cells were <250/mm3 and culture was negative. None of our patients had bacteriascites (i.e. culture positive with cells <250/mm3). Presence of fever was significantly higher in SBP and CNNA. The mean lactate dehydrogenase (LDH) level was significantly higher in ascitic fluid in the infected versus sterile cases (p < 0.002). A ratio of ascitic/serum LDH ≥ 0.5 gave a sensitivity of 80%, specificity of 88%, positive predictive value (PPV) of 66.7%, negative predictive value (NPV) of 93.7% and accuracy of 63.3%. The mean pH gradient (arterial - ascitic) was significantly higher in SBP and CNNA cases when compared to the negative cases (p < 0.001). Ascitic fluid protein level of ≤ 1 gm/dl was found in 13/30 (43.3%) of studied cases with a sensitivity of 100%, specificity of 64.7%, PPV of 45.5%, NPV of 100% and diagnostic accuracy of 53.3% (p = 0.0001).ConclusionsSBP is a rather common complication in children with CLD. Culture of the ascitic fluid is not always diagnostic of infection. Biochemical parameters of the ascitic fluid definitely add to the diagnostic accuracy. LDH ascitic/serum ratio ≥ 0.5, an arterial-ascitic pH gradient ≥ 0.1 and total ascitic fluid protein ≤ 1 gm/dl are the most significant parameters suggesting infection.

A Comparative Study on Ascetic Fluid Biochemical Markers in Cirrhotic Children with and Without Spontaneous Bacterial Peritonitis: A Cross-Sectional Observation

“…Similar to this finding, LDH was also reported in higher levels in SBP patients compared to sterile cases. LDH also showed 80%, 88%, 66.7%, and 93.7% sensitivity, specificity, PPV, and NPV, respectively, which are close to our values (8). More studies are needed to further show diagnostic validity of biochemical indices such as albumin and LDH in the diagnosis of SBP.…”

“…In the non-SBP group, one patient grew klebsiella and the other Enterococcus. In SBP patients, the most identified microorganism was E. coli (8,53.3%) following by Acinetobacter, Enterococcus, and streptococcus pneumonia (each with 2 cases, 13.3%). In addition, one culture was grown with klebsiella among SBP patients.…”

“…In previous studies, the frequency of SBP among patients with ascetic fluid infection (AFI) has been reported as 25% -51% (1,(5)(6)(7). The different reported ratios of SBP in AFI may be due to different diagnostic criteria recruited by these studies as some authors may consider culture-positive patients as SBP, while others define SBP merely based on PMN count of ascetic fluid, as we recruited in our study (6,8).…”

Serum C-Reactive Protein in Children with Liver Disease and Ascites

“…Spontaneous bacterial peritonitis (SBP) is defined as an infection of ascetic fluid without a proven intra-abdominal source ( 1 , 2 ). SBP is a common and severe complication in cirrhotic patients ( 3 ), and is the major cause of mortality and morbidity among them ( 4 ). Bacterial infection due to complications such as hepatic encephalopathy or hepatic failure, disruption of homeostasis, and renal insufficiency are common causes of the increased morbidity and mortality rates in cirrhotic patients ( 5 , 6 ).…”

Medical Management of Chronic Liver Diseases (CLD) in Children (Part II)

“…Additional proposed criteria are serum sodium concentration £130 mmol L and 24-hour urine output <1mL kg h. [70] Once HRS type 1 is diagnosed, treatment should be started early in order to prevent progression of renal failure. Diagnosis and management strategy in patients with spontaneous bacterial peritonitis (SBP) [10,[49][50][51][52][53][54][55][56] [49] or Ceftriaxone 50-75 mg kg day divided q12-24h IV IM; max. Excessive administration of Table III.…”