Routine analysis of ascitic fluid for evidence of infection in children with chronic liver disease: Is it mandatory?

Abstract

Ascitic fluid infection is a major cause of morbidity and mortality in cirrhotic patients, requiring early diagnosis and therapy. We aimed to determine predictors of ascitic fluid infection in children with chronic liver disease. The study included 45 children with chronic liver disease and ascites who underwent 66 paracentesis procedures. Full history taking and clinical examination of all patients were obtained including fever, abdominal pain and tenderness and respiratory distress. Investigations included: complete blood count, C-reactive protein, full liver function tests, ascitic fluid biochemical analysis, cell count and culture. Our results showed that patients’ ages ranged between 3 months to 12 years. Prevalence of ascitic fluid infection was 33.3%. Gram-positive bacteria were identified in six cases, and Gram-negative bacteria in five. Fever and abdominal pain were significantly more associated with infected ascites (p value = 0.004, 0.006). Patients with ascitic fluid infection had statistically significant elevated absolute neutrophilic count and C-reactive protein. Logistic regression analysis showed that fever, abdominal pain, elevated absolute neutrophilic count and positive C-reactive protein are independent predictors of ascitic fluid infection. Fever, elevated absolute neutrophilic count and positive C-reactive protein raise the probability of ascitic fluid infection by 3.88, 9.15 and 4.48 times respectively. The cut-off value for C-reactive protein for ascitic fluid infection was 7.2 with sensitivity 73% and specificity of 71%. In conclusion, prevalence of ascitic fluid infection in pediatric patients with chronic liver disease and ascites was 33.3%. Fever, abdominal pain, positive C-reactive protein and elevated absolute neutrophilic count are strong predictors of ascitic fluid infection. Therefore an empirical course of first-line antibiotics should be immediately started with presence of any of these predictors after performing ascitic fluid tapping for culture and sensitivity. In absence of these infection parameters, routine ascitic fluid analysis could be spared.

Prevalence of culture negative ascitic fluid infection among patients with chronic liver disease.

“…Children having ascites are more prone to get ascitic fluid infection therefore special care should be given to children and if there is no signs and symptoms of ascitic fluid infection then ascitic tap should be avoided to prevent development of nosocomial peritonitis. 13,14 Diagnosis of spontaneous bacterial peritonitis is made by culture of ascitic fluid but sometimes culture is negative inspite of ascitic fluid infection and increased neutrophil count in ascitic fluid so culture alone is not sufficient to diagnose SBP hence a study conducted in Egypt studied Amyloid-A in serum and ascitic fluid as a diagnostic marker for SBP. They reported sensitivity and specificity 90% and 60% respectively of ascitic fluid Amyloid-A level for diagnosing SBP.…”

Bacterial profile, drug resistance pattern, clinical and laboratory predictors of ascites infection in cirrhosis patients

“…We found that clinical data like maximum liver span, spleen size, fever, and jaundice were important predictors of SBP. For instance, other studies showed that fever was one of the predictors of SBP in children with cirrhosis [ 38 ]. Likewise, laboratory parameters including platelet count, WBC count, and ascitic fluid levels of albumin, were important predictors of SBP in cirrhosis patients.…”

Beyond Varices: Complications of Cirrhotic Portal Hypertension in Pediatrics

“…5,7,57 There are limited data on the incidence and characteristics of SBP in children with cirrhosis. The incidence of SBP ranges from 17 to 38% in children with chronic liver disease from single-center experiences, [58][59][60][61][62][63] with only 50% of patients showing symptoms to suggest SBP in one study. 63 In adults, gram-negative organisms such as Escherichia coli and Klebsiella pneumoniae account for up to approximately 60% of positive ascitic fluid cultures; in contrast, grampositive organisms, such as Streptococcus pneumoniae, have been more commonly isolated in children.…”

“…32 Very few of the published studies in children with infected ascites present data on antimicrobial agents used or antibiotic sensitivity of the bacteria on positive cultures. [58][59][60][61]64,67 Published studies suggest isolated bacteria in ascitic fluid cultures were sensitive to commonly used antibiotics (cefotaxime, ceftriaxone, ciprofloxacin). 65,67 The use of primary or secondary prophylaxis or the use of IV albumin for SBP has not been reported in children.…”