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Miquel Navasa - One of the best experts on this subject based on the ideXlab platform.
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primary prophylaxis of Spontaneous Bacterial Peritonitis delays hepatorenal syndrome and improves survival in cirrhosis
Gastroenterology, 2007Co-Authors: Javier Fernández, German Soriano, Ramon Planas, Miquel Navasa, Silvia Montoliu, David Monfort, Carmen Vila, Alberto Pardo, Enrique Quintero, Victor VargasAbstract:Background & Aims: Norfloxacin is highly effective in preventing Spontaneous Bacterial Peritonitis recurrence in cirrhosis, but its role in the primary prevention of this complication is uncertain. Methods: Patients with cirrhosis and low protein ascitic levels ( Results: Norfloxacin administration reduced the 1-year probability of developing Spontaneous Bacterial Peritonitis (7% vs 61%, P P = .02), and improved the 3-month (94% vs 62%, P = .003) and the 1-year (60% vs 48%, P = .05) probability of survival compared with placebo. Conclusions: Primary prophylaxis with norfloxacin has a great impact in the clinical course of patients with advanced cirrhosis. It reduces the incidence of Spontaneous Bacterial Peritonitis, delays the development of hepatorenal syndrome, and improves survival.
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restricted use of albumin for Spontaneous Bacterial Peritonitis
Gut, 2007Co-Authors: Vicente Arroyo, Javier Fernández, Samuel H Sigal, Carmen Stanca, Miquel NavasaAbstract:Spontaneous Bacterial Peritonitis (SBP) may precipitate deterioration of circulatory function with severe hepatic insufficiency, hepatic encephalopathy, and type-1 hepatorenal syndrome (HRS) and has 30% hospital mortality despite infection resolution.1 Predictors of this acute-on-chronic liver failure include ascitic fluid concentrations of granulocytes and cytokines and renal and hepatic insufficiency at diagnosis.1–3 Endotoxemia and the inflammatory response precipitate renal failure (RF) by accentuating splanchnic vasodilatation and impairing cardiac function.3–5 Compensatory activation of the renin-angiotensin and sympathetic nervous systems further decrease renal perfusion. Volume expansion with albumin (1.5 g/kg day one, 1 g/kg day three) significantly reduces the incidence of HRS and hospital mortality.2 In the sole reported trial, only patients with serum bilirubin (bili) >68.4 μmol/l, blood urea nitrogen (BUN) >30 mg/dl or serum creatinine (Cr) >88.4 μmol/l appeared …
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clinical liver pancreas and biliary tract primary prophylaxis of Spontaneous Bacterial Peritonitis delays hepatorenal syndrome and improves survival in cirrhosis
2007Co-Authors: Javier Fernández, German Soriano, Ramon Planas, Miquel Navasa, Silvia Montoliu, David Monfort, Carmen Vila, Alberto Pardo, Enrique Quintero, Victor VargasAbstract:Background & Aims: Norfloxacin is highly effective in preventing Spontaneous Bacterial Peritonitis recurrence in cirrhosis, but its role in the primary prevention of this complication is uncertain. Methods: Patients with cirrhosis and low protein ascitic levels ( 9 points with serum bilirubin level > 3 mg/dL) or impaired renal function (serum creatinine level > 1.2 mg/dL, blood urea nitrogen level > 25 mg/dL, or serum sodium level < 130 mEq/L) were included in a randomized controlled trial aimed at comparing norfloxacin (35 patients) vs placebo (33 patients) in the primary prophylaxis of Spontaneous Bacterial Peritonitis. The main end points of the trial were 3-month and 1-year probability of survival. Secondary end points were 1-year probability of development of Spontaneous Bacterial Peritonitis and hepatorenal syndrome. Results: Norfloxacin administration reduced the 1-year probability of developing Spontaneous Bacterial Peritonitis (7% vs 61%, P < .001) and hepatorenal syndrome (28% vs 41%, P .02), and improved the 3-month (94% vs 62%, P .003) and the 1-year (60% vs 48%, P .05) probability of survival compared with placebo. Conclusions: Primary prophylaxis with norfloxacin has a great impact in the clinical course of patients with advanced cirrhosis. It reduces the incidence of Spontaneous Bacterial Peritonitis, delays the development of hepatorenal syndrome, and improves survival.
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renal failure in patients with cirrhosis and sepsis unrelated to Spontaneous Bacterial Peritonitis value of meld score
Gastroenterology, 2005Co-Authors: Carlos Terra, Miquel Navasa, Javier Fernández, Monica Guevara, Aldo Torre, Rosa Gilabert, Marta Martinllahi, Maria E Baccaro, C Bru, Vicente ArroyoAbstract:Background & Aims: Although renal failure is a common complication of sepsis and patients with cirrhosis frequently develop sepsis, there have been no studies specifically assessing renal function in patients with cirrhosis and sepsis unrelated to Spontaneous Bacterial Peritonitis. The aim of this study was to investigate prospectively the frequency, characteristics, and outcome of renal failure in patients with cirrhosis and sepsis unrelated to Spontaneous Bacterial Peritonitis. Methods: One hundred six consecutive patients with cirrhosis and sepsis were studied prospectively. Patients with Spontaneous Bacterial Peritonitis were excluded. Results: Twenty-nine out of 106 patients (27%) with cirrhosis and sepsis developed acute renal failure as compared with only 8 of 100 patients (8%) from a control group of cirrhotic patients without infection (P < .0001). Renal failure in the sepsis group was reversible in 22 (76%; 21% of all patients) patients and nonreversible in 7 (24%; 6% of all patients) patients. Renal failure was associated with impairment of effective arterial blood volume, without evidence of tubular damage. The occurrence and type of renal failure correlated strongly with mortality (mortality at 3 months: nonreversible renal failure, 100%; reversible renal failure, 55%; no renal failure, 13%). Among variables obtained at diagnosis of sepsis, the Model for End-Stage Liver Disease (MELD) score was the only independent predictive factor of mortality. Conclusions: Renal failure is common in patients with cirrhosis and sepsis unrelated to Spontaneous Bacterial Peritonitis and is associated with arterial underfilling and renal vasoconstriction. Outcome is poor, even in the setting of reversible renal failure. The MELD score is the best prognostic marker of patients with cirrhosis and sepsis.
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A randomized unblinded pilot study comparing albumin versus hydroxyethyl starch in Spontaneous Bacterial Peritonitis
Hepatology (Baltimore Md.), 2005Co-Authors: Javier Fernández, Joan Monteagudo, Xavier Bargalló, Wladimiro Jiménez, Jaume Bosch, Vicente Arroyo, Miquel NavasaAbstract:The administration of albumin improves circulatory function, prevents hepatorenal syndrome, and reduces hospital mortality in patients with cirrhosis and Spontaneous Bacterial Peritonitis. This randomized unblinded pilot study compared the effect of albumin (10 patients) and the synthetic plasma expander hydroxyethyl starch 200/0.5 (10 patients) on the systemic hemodynamics of patients with Spontaneous Bacterial Peritonitis. Baseline measurements were performed within 12 hours after diagnosis of infection. Patients then received 2 doses of the volume expander (1.5 g/kg body weight after baseline measurements and 1 g/kg body weight on day 3). Measurements were repeated after infection resolution. Treatment with albumin was associated with a significant increase in arterial pressure and a suppression of plasma renin activity, indicating an improvement in circulatory function. This occurred in the setting of a significant expansion of central blood volume (increase in cardiopulmonary pressures and atrial natriuretic factor) and an increase in systolic volume and systemic vascular resistance. In contrast, no significant changes were observed in these parameters in patients treated with hydroxyethyl starch. Von Willebrand-related antigen plasma levels significantly decreased in patients treated with albumin but not in those treated with hydroxyethyl starch. Serum nitrates and nitrites increased in patients treated with hydroxyethyl starch but not in those treated with albumin. These data suggest an effect of albumin on endothelial function. In conclusion, albumin but not hydroxyethyl starch improves systemic hemodynamics in patients with Spontaneous Bacterial Peritonitis. This effect is due not only to volume expansion but also to an action on the peripheral arterial circulation.
German Soriano - One of the best experts on this subject based on the ideXlab platform.
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Bacterial dna in the diagnosis of Spontaneous Bacterial Peritonitis
Alimentary Pharmacology & Therapeutics, 2011Co-Authors: German Soriano, Oscar Esparcia, Michel Montemayor, Carlos Guarnerargente, Roser Pericas, Xavier Torras, N Calvo, Eva RomanAbstract:Aliment Pharmacol Ther 2011; 33: 275–284 Summary Background Despite inoculation into blood culture bottles, ascitic fluid culture is negative in 50% of cases of Spontaneous Bacterial Peritonitis (SBP). Aim To determine whether 16S rDNA gene detection by real-time polymerase chain reaction (PCR) and sequencing increases the efficacy of culture in microbiological diagnosis of Spontaneous Bacterial Peritonitis. Methods We prospectively included 55 consecutive Spontaneous Bacterial Peritonitis episodes in cirrhotic patients, 20 cirrhotic patients with sterile ascites and 27 patients with neoplasic ascites. Ascitic fluid was inoculated into blood culture bottles at the bedside and tested for Bacterial DNA by real-time PCR and sequencing of 16S rDNA gene. Results Bacterial DNA was detected in 23/25 (92%) culture-positive SBP, 16/30 (53%) culture-negative SBP (P = 0.002 with respect to culture-positive SBP), 12/20 (60%) sterile ascites (P = 0.01 with respect to culture-positive SBP) and 0/27 neoplasic ascites (P < 0.001 with respect to other groups). Sequencing identified to genus or species level 12 culture-positive SBP, six culture-negative SBP and six sterile ascites. In the remaining cases with positive PCR, sequencing did not yield a definitive Bacterial identification. Conclusions Bacterial DNA was not detected in almost half the culture-negative Spontaneous Bacterial Peritonitis episodes. Methodology used in the present study did not always allow identification of amplified Bacterial DNA.
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primary prophylaxis of Spontaneous Bacterial Peritonitis delays hepatorenal syndrome and improves survival in cirrhosis
Gastroenterology, 2007Co-Authors: Javier Fernández, German Soriano, Ramon Planas, Miquel Navasa, Silvia Montoliu, David Monfort, Carmen Vila, Alberto Pardo, Enrique Quintero, Victor VargasAbstract:Background & Aims: Norfloxacin is highly effective in preventing Spontaneous Bacterial Peritonitis recurrence in cirrhosis, but its role in the primary prevention of this complication is uncertain. Methods: Patients with cirrhosis and low protein ascitic levels ( Results: Norfloxacin administration reduced the 1-year probability of developing Spontaneous Bacterial Peritonitis (7% vs 61%, P P = .02), and improved the 3-month (94% vs 62%, P = .003) and the 1-year (60% vs 48%, P = .05) probability of survival compared with placebo. Conclusions: Primary prophylaxis with norfloxacin has a great impact in the clinical course of patients with advanced cirrhosis. It reduces the incidence of Spontaneous Bacterial Peritonitis, delays the development of hepatorenal syndrome, and improves survival.
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clinical liver pancreas and biliary tract primary prophylaxis of Spontaneous Bacterial Peritonitis delays hepatorenal syndrome and improves survival in cirrhosis
2007Co-Authors: Javier Fernández, German Soriano, Ramon Planas, Miquel Navasa, Silvia Montoliu, David Monfort, Carmen Vila, Alberto Pardo, Enrique Quintero, Victor VargasAbstract:Background & Aims: Norfloxacin is highly effective in preventing Spontaneous Bacterial Peritonitis recurrence in cirrhosis, but its role in the primary prevention of this complication is uncertain. Methods: Patients with cirrhosis and low protein ascitic levels ( 9 points with serum bilirubin level > 3 mg/dL) or impaired renal function (serum creatinine level > 1.2 mg/dL, blood urea nitrogen level > 25 mg/dL, or serum sodium level < 130 mEq/L) were included in a randomized controlled trial aimed at comparing norfloxacin (35 patients) vs placebo (33 patients) in the primary prophylaxis of Spontaneous Bacterial Peritonitis. The main end points of the trial were 3-month and 1-year probability of survival. Secondary end points were 1-year probability of development of Spontaneous Bacterial Peritonitis and hepatorenal syndrome. Results: Norfloxacin administration reduced the 1-year probability of developing Spontaneous Bacterial Peritonitis (7% vs 61%, P < .001) and hepatorenal syndrome (28% vs 41%, P .02), and improved the 3-month (94% vs 62%, P .003) and the 1-year (60% vs 48%, P .05) probability of survival compared with placebo. Conclusions: Primary prophylaxis with norfloxacin has a great impact in the clinical course of patients with advanced cirrhosis. It reduces the incidence of Spontaneous Bacterial Peritonitis, delays the development of hepatorenal syndrome, and improves survival.
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effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and Spontaneous Bacterial Peritonitis
The New England Journal of Medicine, 1999Co-Authors: Pau Sort, German Soriano, Victor Vargas, Miquel Navasa, Vicente Arroyo, Xavier Aldeguer, Luis Ruizdelarbol, Lluis Castells, Monica GuevaraAbstract:Background In patients with cirrhosis and Spontaneous Bacterial Peritonitis, renal function frequently becomes impaired. This impairment is probably related to a reduction in effective arterial blood volume and is associated with a high mortality rate. We conducted a study to determine whether plasma volume expansion with intravenous albumin prevents renal impairment and reduces mortality in these patients. Methods We randomly assigned 126 patients with cirrhosis and Spontaneous Bacterial Peritonitis to treatment with intravenous cefotaxime (63 patients) or cefotaxime and intravenous albumin (63 patients). Cefotaxime was given daily in doses that varied according to the serum creatinine level, and albumin was given at a dose of 1.5 g per kilogram of body weight at the time of diagnosis, followed by 1 g per kilogram on day 3. Renal impairment was defined as nonreversible deterioration of renal function during hospitalization. Results The infection resolved in 59 patients in the cefotaxime group (94 percent) and 62 in the cefotaxime-plus-albumin group (98 percent) (P=0.36). Renal impairment developed in 21 patients in the cefotaxime group (33 percent) and 6 in the cefotaxime-plus-albumin group (10 percent) (P=0.002). Eighteen patients (29 percent) in the cefotaxime group died in the hospital, as compared with 6 (10 percent) in the cefotaxime-plus-albumin group (P=0.01); at three months, the mortality rates were 41 percent (a total of 26 deaths) and 22 percent (a total of 14 deaths), respectively (P=0.03). Patients treated with cefotaxime had higher levels of plasma renin activity than those treated with cefotaxime and albumin; patients with renal impairment had the highest values. Conclusions In patients with cirrhosis and Spontaneous Bacterial Peritonitis, treatment with intravenous albumin in addition to an antibiotic reduces the incidence of renal impairment and death in comparison with treatment with an antibiotic alone. (N Engl J Med 1999;341:403-9.)
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effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and Spontaneous Bacterial Peritonitis
The New England Journal of Medicine, 1999Co-Authors: Pau Sort, German Soriano, Victor Vargas, Miquel Navasa, Vicente Arroyo, Xavier Aldeguer, Luis Ruizdelarbol, Lluis Castells, Monica GuevaraAbstract:Background In patients with cirrhosis and Spontaneous Bacterial Peritonitis, renal function frequently becomes impaired. This impairment is probably related to a reduction in effective arterial blood volume and is associated with a high mortality rate. We conducted a study to determine whether plasma volume expansion with intravenous albumin prevents renal impairment and reduces mortality in these patients. Methods We randomly assigned 126 patients with cirrhosis and Spontaneous Bacterial Peritonitis to treatment with intravenous cefotaxime (63 patients) or cefotaxime and intravenous albumin (63 patients). Cefotaxime was given daily in doses that varied according to the serum creatinine level, and albumin was given at a dose of 1.5 g per kilogram of body weight at the time of diagnosis, followed by 1 g per kilogram on day 3. Renal impairment was defined as nonreversible deterioration of renal function during hospitalization. Results The infection resolved in 59 patients in the cefotaxime group (94 percent) and 62 in the cefotaxime-plus-albumin group (98 percent) (P=0.36). Renal impairment developed in 21 patients in the cefotaxime group (33 percent) and 6 in the cefotaxime-plus-albumin group (10 percent) (P=0.002). Eighteen patients (29 percent) in the cefotaxime group died in the hospital, as compared with 6 (10 percent) in the cefotaxime-plus-albumin group (P=0.01); at three months, the mortality rates were 41 percent (a total of 26 deaths) and 22 percent (a total of 14 deaths), respectively (P=0.03). Patients treated with cefotaxime had higher levels of plasma renin activity than those treated with cefotaxime and albumin; patients with renal impairment had the highest values. Conclusions In patients with cirrhosis and Spontaneous Bacterial Peritonitis, treatment with intravenous albumin in addition to an antibiotic reduces the incidence of renal impairment and death in comparison with treatment with an antibiotic alone. (N Engl J Med 1999;341:403-9.)
Carlos Guarner - One of the best experts on this subject based on the ideXlab platform.
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risk of a first community acquired Spontaneous Bacterial Peritonitis in cirrhotics with low ascitic fluid protein levels
Gastroenterology, 1999Co-Authors: Carlos Guarner, Miriam Sabat, Maria Teresa Novella, German Soriano, Jordi Ortiz, R. Sola, Montserrat Andreu, Maria Carmen Vila, Susana Coll, C GomezAbstract:Abstract Background & Aims: Long-term primary antibiotic prophylaxis of Spontaneous Bacterial Peritonitis has been suggested to be useful in cirrhotic patients with low ascitic fluid protein levels. However, it is unlikely that all such patients need prophylactic treatment. The aim of this study was to identify the group of cirrhotic patients with low ascitic fluid protein levels at high risk of developing a first episode of Spontaneous Bacterial Peritonitis during outpatient follow-up. Methods: One hundred nine cirrhotic patients with low ascitic fluid protein levels and without previous episodes of Spontaneous Bacterial Peritonitis were followed up in an outpatient clinic. Results: Twenty-eight patients developed a first Spontaneous Bacterial Peritonitis episode. In the multivariate analysis, serum bilirubin level (>3.2 mg /dL) and platelet count ( 3 ) independently correlated with the risk of developing the first Spontaneous Bacterial Peritonitis ( P P 1.09) were established. The probability of developing a first Spontaneous Bacterial Peritonitis episode at 1-year follow-up was significantly higher in the high risk-group (low-risk group, 23.6%; high-risk group, 55%; P P P Conclusions: Cirrhotic patients with low ascitic fluid protein levels (≤1 g /dL) and high bilirubin level and/or low platelet count are at high risk of developing a first episode of Spontaneous Bacterial Peritonitis during long-term follow-up.
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continuous versus inpatient prophylaxis of the first episode of Spontaneous Bacterial Peritonitis with norfloxacin
Hepatology, 1997Co-Authors: Maria Teresa Novella, Jordi Gana, Miriam Sabat, Susanna Coll, Maria Vila, German Soriano, Jordi Ortiz, R. Sola, Montserrat Andreu, Carlos GuarnerAbstract:Cirrhotic patients with ascites and low ascitic fluid total protein and/or high serum bilirubin levels are at high risk to develop the first episode of Spontaneous Bacterial Peritonitis during long-term follow-up. The aim of the present study was to determine the efficacy of continuous long-term selective intestinal decontamination with norfloxacin in the prevention of this complication. One hundred nine cirrhotic patients with ascites and ascitic fluid total protein levels of ⩽ 1 g/dL or serum bilirubin levels of > 2.5 mg/dL without previous Spontaneous Bacterial Peritonitis were prospectively randomized into two groups: group 1 (n = 56) received norfloxacin, 400 mg daily administered orally, and group 2 (n = 53) was the long-term control group, receiving norfloxacin only during hospitalization. During a mean follow-up of 43 +/- 3 weeks, there was one Spontaneous Bacterial Peritonitis (1.8%) in group 1 and 9 (16.9%) in group 2 (P < .01). The incidence of community-acquired Spontaneous Bacterial Peritonitis was lower in group 1 (1.8% vs. 13.2%, P < .05), whereas the incidence of nosocomial Spontaneous Bacterial Peritonitis (0% vs. 3.7%) and the incidence of extraperitoneal infections (25% vs. 24.5%) were similar in both groups (P = NS). The actuarial probability of survival at 18 months was 75% in group 1 and 62% in group 2 (P = NS). Resistance to norfloxacin was observed in 9 of 10 (90%) Escherichia coli isolated in infections from group 1 and in 4 of 11 (36.3%) from group 2 (P < .05). The overall incidence of infections caused by norfloxacin-resistant bacteria was higher in group 1 (19.6% vs. 15%), but it did not reach statistical significance. Continuous long-term selective intestinal decontamination with norfloxacin is effective in preventing the first Spontaneous Bacterial Peritonitis in cirrhotic patients at high risk. However, the emergence of infections caused by norfloxacin-resistant bacteria must be weighed carefully against the benefits of continuous long-term prophylaxis.
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continuous versus inpatient prophylaxis of the first episode of Spontaneous Bacterial Peritonitis with norfloxacin
Hepatology, 1997Co-Authors: Maria Teresa Novella, Jordi Gana, Miriam Sabat, Susanna Coll, Maria Vila, German Soriano, Jordi Ortiz, R. Sola, Montserrat Andreu, Carlos GuarnerAbstract:Cirrhotic patients with ascites and low ascitic fluid total protein and/or high serum bilirubin levels are at high risk to develop the first episode of Spontaneous Bacterial Peritonitis during long-term follow-up. The aim of the present study was to determine the efficacy of continuous long-term selective intestinal decontamination with norfloxacin in the prevention of this complication. One hundred nine cirrhotic patients with ascites and ascitic fluid total protein levels of 2.5 mg/dL without previous Spontaneous Bacterial Peritonitis were prospectively randomized into two groups: group 1 (n = 56) received norfloxacin, 400 mg daily administered orally, and group 2 (n = 53) was the long-term control group, receiving norfloxacin only during hospitalization. During a mean follow-up of 43 +/- 3 weeks, there was one Spontaneous Bacterial Peritonitis (1.8%) in group 1 and 9 (16.9%) in group 2 (P < .01). The incidence of community-acquired Spontaneous Bacterial Peritonitis was lower in group 1 (1.8% vs. 13.2%, P < .05), whereas the incidence of nosocomial Spontaneous Bacterial Peritonitis (0% vs. 3.7%) and the incidence of extraperitoneal infections (25% vs. 24.5%) were similar in both groups (P = NS). The actuarial probability of survival at 18 months was 75% in group 1 and 62% in group 2 (P = NS). Resistance to norfloxacin was observed in 9 of 10 (90%) Escherichia coli isolated in infections from group 1 and in 4 of 11 (36.3%) from group 2 (P < .05). The overall incidence of infections caused by norfloxacin-resistant bacteria was higher in group 1 (19.6% vs. 15%), but it did not reach statistical significance. Continuous long-term selective intestinal decontamination with norfloxacin is effective in preventing the first Spontaneous Bacterial Peritonitis in cirrhotic patients at high risk. However, the emergence of infections caused by norfloxacin-resistant bacteria must be weighed carefully against the benefits of continuous long-term prophylaxis.
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Spontaneous Bacterial Peritonitis
Seminars in Liver Disease, 1997Co-Authors: Carlos Guarner, German SorianoAbstract:Spontaneous Bacterial Peritonitis (SBP) is considered a Bacterial infection of ascitic fluid without any intraabdominal, surgically treatable source of infection. Multiple variants of this infection with a different clinical setting and outcome have been described during the past decade. Bacterial translocation from the gut to mesenteric lymph nodes, depressed activity of the reticuloendothelial phagocytic system and decreased antimicrobial capacity of ascitic fluid seem to be the main steps in the pathogenesis of ascitic fluid infection. Diagnosis of ascitic fluid infection is based on clinical suspicion and analysis of ascitic fluid, especially white cell count and culture in blood culture bottles. A low threshold for performing an abdominal paracentesis is the key for an early diagnosis and treatment. A third-generation cephalosporin is the treatment of choice, achieving a cure rate higher than 80%. Nonazotemic patients with nonadvanced, uncomplicated SBP may be treated with oral ofloxacin. Prophylactic selective intestinal decontamination with oral norfloxacin is extremely useful in preventing SBP in patients that are at high risk for developing SBP, such as hospitalized cirrhotic patients with gastrointestinal hemorrhage or low ascitic fluid total protein. Primary or secondary long-term prophylaxis of SBP also decreases the incidence of SBP, but these patients should be carefully observed for detecting possible infections caused by quinolone-resistant organisms. Since long-term prognosis of SBP patients is poor, survivors should be considered for liver transplantation.
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randomized comparative study of oral ofloxacin versus intravenous cefotaxime in Spontaneous Bacterial Peritonitis
Gastroenterology, 1996Co-Authors: Miquel Navasa, Antoni Rimola, Carlos Guarner, Francesc Marco, Josep M. Llovet, A Follo, G Clemente, V Vargas, Montserrat ForneAbstract:Abstract BACKGROUND & AIMS: Treatment of Spontaneous Bacterial Peritonitis currently involves intravenous antibiotic administration. To test the possibility of treating Spontaneous Bacterial Peritonitis with oral antibiotics, oral ofloxacin was compared with intravenous cefotaxime in this infection. METHODS: One hundred twenty-three cirrhotics with uncomplicated Spontaneous Bacterial Peritonitis (no septic shock, grade II-IV hepatic encephalopathy, serum creatinine level of > 3 mg/dL, and gastrointestinal hemorrhage or ileus) were randomly given oral ofloxacin (64 patients) or intravenous cefotaxime (59 patients). RESULTS: Infection resolution rate was 84% in the ofloxacin group and 85% in the cefotaxime group. Peak serum levels and trough serum and ascitic fluid levels of ofloxacin and cefotaxime measured on days 3 (23 patients) and 6 (11 patients) of therapy were greater than the minimal inhibitory concentration of isolated organisms. Hospital survival rate was 81% in each group of patients. Blood urea nitrogen and hepatic encephalopathy at diagnosis were associated with prognosis. None of the 36 nonazotemic patients with community-acquired Spontaneous Bacterial Peritonitis and without hepatic encephalopathy developed complications during hospitalization, and all were alive at time of discharge. CONCLUSIONS: Oral ofloxacin is as effective as intravenous cefotaxime in uncomplicated Spontaneous Bacterial Peritonitis. Nonazotemic cirrhotic patients with uncomplicated community-acquired Spontaneous Bacterial Peritonitis and without hepatic encephalopathy have an excellent prognosis and may be treated with oral ofloxacin without requiring hospitalization. (Gastroenterology 1996 Oct;111(4):1011-7)
Vicente Arroyo - One of the best experts on this subject based on the ideXlab platform.
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restricted use of albumin for Spontaneous Bacterial Peritonitis
Gut, 2007Co-Authors: Vicente Arroyo, Javier Fernández, Samuel H Sigal, Carmen Stanca, Miquel NavasaAbstract:Spontaneous Bacterial Peritonitis (SBP) may precipitate deterioration of circulatory function with severe hepatic insufficiency, hepatic encephalopathy, and type-1 hepatorenal syndrome (HRS) and has 30% hospital mortality despite infection resolution.1 Predictors of this acute-on-chronic liver failure include ascitic fluid concentrations of granulocytes and cytokines and renal and hepatic insufficiency at diagnosis.1–3 Endotoxemia and the inflammatory response precipitate renal failure (RF) by accentuating splanchnic vasodilatation and impairing cardiac function.3–5 Compensatory activation of the renin-angiotensin and sympathetic nervous systems further decrease renal perfusion. Volume expansion with albumin (1.5 g/kg day one, 1 g/kg day three) significantly reduces the incidence of HRS and hospital mortality.2 In the sole reported trial, only patients with serum bilirubin (bili) >68.4 μmol/l, blood urea nitrogen (BUN) >30 mg/dl or serum creatinine (Cr) >88.4 μmol/l appeared …
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renal failure in patients with cirrhosis and sepsis unrelated to Spontaneous Bacterial Peritonitis value of meld score
Gastroenterology, 2005Co-Authors: Carlos Terra, Miquel Navasa, Javier Fernández, Monica Guevara, Aldo Torre, Rosa Gilabert, Marta Martinllahi, Maria E Baccaro, C Bru, Vicente ArroyoAbstract:Background & Aims: Although renal failure is a common complication of sepsis and patients with cirrhosis frequently develop sepsis, there have been no studies specifically assessing renal function in patients with cirrhosis and sepsis unrelated to Spontaneous Bacterial Peritonitis. The aim of this study was to investigate prospectively the frequency, characteristics, and outcome of renal failure in patients with cirrhosis and sepsis unrelated to Spontaneous Bacterial Peritonitis. Methods: One hundred six consecutive patients with cirrhosis and sepsis were studied prospectively. Patients with Spontaneous Bacterial Peritonitis were excluded. Results: Twenty-nine out of 106 patients (27%) with cirrhosis and sepsis developed acute renal failure as compared with only 8 of 100 patients (8%) from a control group of cirrhotic patients without infection (P < .0001). Renal failure in the sepsis group was reversible in 22 (76%; 21% of all patients) patients and nonreversible in 7 (24%; 6% of all patients) patients. Renal failure was associated with impairment of effective arterial blood volume, without evidence of tubular damage. The occurrence and type of renal failure correlated strongly with mortality (mortality at 3 months: nonreversible renal failure, 100%; reversible renal failure, 55%; no renal failure, 13%). Among variables obtained at diagnosis of sepsis, the Model for End-Stage Liver Disease (MELD) score was the only independent predictive factor of mortality. Conclusions: Renal failure is common in patients with cirrhosis and sepsis unrelated to Spontaneous Bacterial Peritonitis and is associated with arterial underfilling and renal vasoconstriction. Outcome is poor, even in the setting of reversible renal failure. The MELD score is the best prognostic marker of patients with cirrhosis and sepsis.
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A randomized unblinded pilot study comparing albumin versus hydroxyethyl starch in Spontaneous Bacterial Peritonitis
Hepatology (Baltimore Md.), 2005Co-Authors: Javier Fernández, Joan Monteagudo, Xavier Bargalló, Wladimiro Jiménez, Jaume Bosch, Vicente Arroyo, Miquel NavasaAbstract:The administration of albumin improves circulatory function, prevents hepatorenal syndrome, and reduces hospital mortality in patients with cirrhosis and Spontaneous Bacterial Peritonitis. This randomized unblinded pilot study compared the effect of albumin (10 patients) and the synthetic plasma expander hydroxyethyl starch 200/0.5 (10 patients) on the systemic hemodynamics of patients with Spontaneous Bacterial Peritonitis. Baseline measurements were performed within 12 hours after diagnosis of infection. Patients then received 2 doses of the volume expander (1.5 g/kg body weight after baseline measurements and 1 g/kg body weight on day 3). Measurements were repeated after infection resolution. Treatment with albumin was associated with a significant increase in arterial pressure and a suppression of plasma renin activity, indicating an improvement in circulatory function. This occurred in the setting of a significant expansion of central blood volume (increase in cardiopulmonary pressures and atrial natriuretic factor) and an increase in systolic volume and systemic vascular resistance. In contrast, no significant changes were observed in these parameters in patients treated with hydroxyethyl starch. Von Willebrand-related antigen plasma levels significantly decreased in patients treated with albumin but not in those treated with hydroxyethyl starch. Serum nitrates and nitrites increased in patients treated with hydroxyethyl starch but not in those treated with albumin. These data suggest an effect of albumin on endothelial function. In conclusion, albumin but not hydroxyethyl starch improves systemic hemodynamics in patients with Spontaneous Bacterial Peritonitis. This effect is due not only to volume expansion but also to an action on the peripheral arterial circulation.
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effect of intravenous albumin on systemic and hepatic hemodynamics and vasoactive neurohormonal systems in patients with cirrhosis and Spontaneous Bacterial Peritonitis
Journal of Hepatology, 2004Co-Authors: Javier Fernández, Miquel Navasa, Wladimiro Jiménez, Jaume Bosch, Juan Carlos Garciapagan, Juan Gabraldes, Vicente ArroyoAbstract:Abstract Background/Aims Albumin administration prevents renal failure and improves survival in Spontaneous Bacterial Peritonitis. This study characterizes the mechanisms of action of albumin in this condition. Methods Systemic and splanchnic hemodynamics, plasma renin activity and plasma concentration of interleukin-6, serum concentration of nitric oxide and ascitic fluid levels of nitric oxide and interleukin-6 were assessed at diagnosis and resolution of infection in 12 patients with Spontaneous Bacterial Peritonitis treated with ceftriaxone plus albumin. At infection resolution there was a significant improvement in circulatory function, as indicated by a significant increase in mean arterial pressure (+8%, P =0.02), a fall in heart rate (−10%, P =0.01), a suppression of plasma renin activity (−67%, P =0.002) and a decrease in creatinine levels. These changes were related to both an increase in cardiac work (stroke work index: +18%, P =0.005) and in peripheral vascular resistance (+14%, P =0.05). The improvement in cardiac function was due to an increase in filling. No significant changes were observed in portal pressure or hepatic blood flow. Conclusions These results indicate that the beneficial effects of albumin administration on systemic hemodynamics and renal function in Spontaneous Bacterial Peritonitis are related to both an improvement in cardiac function and a decrease in the degree of arterial vasodilation.
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effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and Spontaneous Bacterial Peritonitis
The New England Journal of Medicine, 1999Co-Authors: Pau Sort, German Soriano, Victor Vargas, Miquel Navasa, Vicente Arroyo, Xavier Aldeguer, Luis Ruizdelarbol, Lluis Castells, Monica GuevaraAbstract:Background In patients with cirrhosis and Spontaneous Bacterial Peritonitis, renal function frequently becomes impaired. This impairment is probably related to a reduction in effective arterial blood volume and is associated with a high mortality rate. We conducted a study to determine whether plasma volume expansion with intravenous albumin prevents renal impairment and reduces mortality in these patients. Methods We randomly assigned 126 patients with cirrhosis and Spontaneous Bacterial Peritonitis to treatment with intravenous cefotaxime (63 patients) or cefotaxime and intravenous albumin (63 patients). Cefotaxime was given daily in doses that varied according to the serum creatinine level, and albumin was given at a dose of 1.5 g per kilogram of body weight at the time of diagnosis, followed by 1 g per kilogram on day 3. Renal impairment was defined as nonreversible deterioration of renal function during hospitalization. Results The infection resolved in 59 patients in the cefotaxime group (94 percent) and 62 in the cefotaxime-plus-albumin group (98 percent) (P=0.36). Renal impairment developed in 21 patients in the cefotaxime group (33 percent) and 6 in the cefotaxime-plus-albumin group (10 percent) (P=0.002). Eighteen patients (29 percent) in the cefotaxime group died in the hospital, as compared with 6 (10 percent) in the cefotaxime-plus-albumin group (P=0.01); at three months, the mortality rates were 41 percent (a total of 26 deaths) and 22 percent (a total of 14 deaths), respectively (P=0.03). Patients treated with cefotaxime had higher levels of plasma renin activity than those treated with cefotaxime and albumin; patients with renal impairment had the highest values. Conclusions In patients with cirrhosis and Spontaneous Bacterial Peritonitis, treatment with intravenous albumin in addition to an antibiotic reduces the incidence of renal impairment and death in comparison with treatment with an antibiotic alone. (N Engl J Med 1999;341:403-9.)
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tumor necrosis factor and interleukin 6 in Spontaneous Bacterial Peritonitis in cirrhosis relationship with the development of renal impairment and mortality
Hepatology, 1998Co-Authors: Miquel Navasa, Antoni Rimola, Ramon Planas, A Follo, Wladimiro Jiménez, Vicente Arroyo, Anna Francitorra, Xavier Filella, Joan RodesAbstract:Spontaneous Bacterial Peritonitis (SBP) is associated with an important production of inflammatory mediators. However, it is unknown whether there is a relationship between the abdominal production of these mediators and the development of renal impairment, one of the most important prognostic parameters in Spontaneous Bacterial Peritonitis. We studied 52 cirrhotic patients at diagnosis and resolution of the infection, by measuring endotoxin, tumor necrosis factor (TNF), and interleukin-6 (IL-6) levels in plasma and ascitic fluid. Thirteen patients (25%) developed renal impairment. Patients developing renal impairment showed significantly higher plasma and ascitic fluid cytokine levels at diagnosis of infection than patients who did not (plasma TNF-α: 96.0 ± 38.7 vs. 39.1 ± 3.6 pg/mL, P = .0209; ascitic fluid TNF-α: 474.5 ± 118.1 vs. 160.8 ± 42.7 pg/mL, P = .0173; plasma IL-6: 6,635 ± 2,897 vs. 458 ± 109 pg/mL, P = .0004; ascitic fluid IL-6: 182,559 ± 47,328 vs. 39,250 ± 10,803 pg/mL, P = .0001). Independent predictors of development of renal impairment at diagnosis were: renal failure (blood urea nitrogen > 30 mg/dL or serum creatinine > 1.5 mg/dL) (P < .001), IL-6 levels in ascitic fluid (P < .001), and mean arterial pressure (P < .05). Ten of the 13 (77%) patients who developed renal impairment died during hospitalization, but only 2 of the 39 (5%) patients who did not (P= .0001). In addition, renal failure at diagnosis of the infection was the only independent predictor of hospital mortality (P < .001). In conclusion, the inflammatory response to the infection may be an important mechanism of renal impairment and the associated mortality in SBP.
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renal impairment after Spontaneous Bacterial Peritonitis in cirrhosis incidence clinical course predictive factors and prognosis
Hepatology, 1994Co-Authors: A Follo, Antoni Rimola, Ramon Planas, Josep M. Llovet, Miquel Navasa, M A Gassull, Vicente Arroyo, Xavier Forns, Anna Francitorra, Joan RodesAbstract:Although Spontaneous Bacterial Peritonitis is considered a precipitating factor of renal impairment in cirrhosis, no study specifically addressing this problem has been reported. This study was aimed at assessing the incidence, clinical course, predictive factors and prognosis of renal impairment in cirrhotic patients with Peritonitis. Therefore, 252 consecutive episodes of Spontaneous Bacterial Peritonitis in 197 patients were analyzed. Clinical and laboratory data obtained before and after diagnosis of Peritonitis were considered as possible predictors of renal impairment and hospital mortality. Renal impairment occurred in 83 (33%) episodes, and in every instance it fulfilled the criteria of functional kidney failure. Renal impairment was progressive in 35 episodes, steady in 27 and transient in 21. Blood urea nitrogen and serum sodium concentration before Peritonitis and band neutrophils count in blood at diagnosis were independent predictors for the development of renal impairment. Renal impairment was the strongest independent predictor of mortality during hospitalization. Other independent prognostic factors were blood urea nitrogen level before Peritonitis, age, positive ascitic fluid culture and serum bilirubin level during infection. These results indicate that renal impairment is a frequent event in cirrhotic patients with Spontaneous Bacterial Peritonitis that occurs mainly in patients with kidney failure before infection. Renal impairment is the most important predictor of hospital mortality in cirrhotic patients with Spontaneous Bacterial Peritonitis.
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Spontaneous Bacterial Peritonitis in cirrhosis predictive factors of infection resolution and survival in patients treated with cefotaxime
Hepatology, 1993Co-Authors: C Toledo, Antoni Rimola, Pere Ginès, Josep Llach, Miquel Navasa, Vicente Arroyo, Joanmanuel Salmeron, Angels Gines, Joan RodesAbstract:Cefotaxime is the most commonly used antibiotic for initial therapy of Spontaneous Bacterial Peritonitis in cirrhosis. However, since the introduction of cefotaxime no study has been performed to investigate factors influencing prognosis in cirrhotic patients with this type of infection. In this study, predictive factors for infection resolution and patient survival were investigated in 213 consecutive episodes of Spontaneous Bacterial Peritonitis in 185 cirrhotic patients. All patients were initially treated with cefotaxime. One hundred sixty-five episodes (77%) resolved with cefotaxime alone, and two more episodes (1%), initially unresponsive to cefotaxime, were cured after modification of antibiotic therapy. In a multivariate analysis (stepwise logistic regression), only 4 of 51 clinical and laboratory variables obtained at the time of diagnosis of infection were identified as independent predictors of infection resolution: band neutrophils in white blood cell count, community-acquired vs. hospitalacquired Peritonitis, blood urea nitrogen level and serum aspartate aminotransferase level. No patient experienced serious adverse effects related to cefotaxime. Eighty-two patients died during hospitalization (38% mortality rate in relation to the 213 episodes of Peritonitis). In the multivariate analysis, six variables were independently correlated with survival: blood urea nitrogen level, serum aspartate aminotransferase level, community-acquired vs. hospitalacquired Peritonitis, age, Child-Pugh score and ileus. No microbiological data had predictive value for infection resolution or survival. These results indicate that in cirrhotic patients with Spontaneous Bacterial Peritonitis treated with cefotaxime, infection resolution and patient survival may be predicted by several clinical and laboratory variables obtained at the time of infection diagnosis; the most important are blood urea nitrogen level, serum aspartate aminotransferase level and site (community or hospital) of Peritonitis acquisition. (HEPATOLOGY 1993;17:251–257.)
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Spontaneous Bacterial Peritonitis in cirrhosis predictive factors of infection resolution and survival in patients treated with cefotaxime
Hepatology, 1993Co-Authors: C Toledo, Antoni Rimola, Pere Ginès, Josep Llach, Miquel Navasa, Vicente Arroyo, Joanmanuel Salmeron, Angels Gines, Joan RodesAbstract:Cefotaxime is the most commonly used antibiotic for initial therapy of Spontaneous Bacterial Peritonitis in cirrhosis. However, since the introduction of cefotaxime no study has been performed to investigate factors influencing prognosis in cirrhotic patients with this type of infection. In this study, predictive factors for infection resolution and patient survival were investigated in 213 consecutive episodes of Spontaneous Bacterial Peritonitis in 185 cirrhotic patients. All patients were initially treated with cefotaxime. One hundred sixty-five episodes (77%) resolved with cefotaxime alone, and two more episodes (1%), initially unresponsive to cefotaxime, were cured after modification of antibiotic therapy. In a multivariate analysis (stepwise logistic regression), only 4 of 51 clinical and laboratory variables obtained at the time of diagnosis of infection were identified as independent predictors of infection resolution: band neutrophils in white blood cell count, community-acquired vs. hospital-acquired Peritonitis, blood urea nitrogen level and serum aspartate aminotransferase level. No patient experienced serious adverse effects related to cefotaxime. Eighty-two patients died during hospitalization (38% mortality rate in relation to the 213 episodes of Peritonitis). In the multivariate analysis, six variables were independently correlated with survival: blood urea nitrogen level, serum aspartate aminotransferase level, community-acquired vs. hospital-acquired Peritonitis, age, Child-Pugh score and ileus. No microbiological data had predictive value for infection resolution or survival.(ABSTRACT TRUNCATED AT 250 WORDS)
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incidence and predictive factors of first episode of Spontaneous Bacterial Peritonitis in cirrhosis with ascites relevance of ascitic fluid protein concentration
Hepatology, 1992Co-Authors: Josep Llach, Joan M Salmeron, Pere Ginès, Miquel Navasa, Vicente Arroyo, Angels Gines, M Antoni D Rimola, Joan RodesAbstract:To investigate the long-term probability of the appearance of the first episode of Spontaneous Bacterial Peritonitis in cirrhosis with ascites and to identify predictors of this complication, we closely followed throughout their illness 127 patients consecutively admitted to our unit for the treatment of an episode of ascites without prior Spontaneous Bacterial Peritonitis (follow-up period: 21 ± 22 mo). Thirteen patients (10%) had the first Spontaneous Bacterial Peritonitis episode during follow-up. The appearance probability of this complication is 11% at 1 yr and 15% at 3 yr. Thirty-three variables obtained at admission (including clinical data, standard liver and kidney function test results, ascitic fluid protein concentrations and hemodynamic parameters) were analyzed in relation to their value in predicting Spontaneous Bacterial Peritonitis development. In univariate analysis (Kaplan-Meier curves) five variables reached statistical significance (p < 0.05) as predictive factors for the development of the first Spontaneous Bacterial Peritonitis episode. These five variables were poor nutritional status, increased serum bilirubin levels, increased serum AST levels, decreased prothrombin activity and reduced total protein concentration in ascitic fluid. When these five variables were introduced in a multivariate analysis, only the ascitic fluid protein concentration was found to correlate independently with Spontaneous Bacterial Peritonitis development (p = 0.002). The probability of first Spontaneous Bacterial Peritonitis after 3 yr of follow-up was 24% and 4% in patients with ascitic fluid protein content lower than 1 gm/dl and greater than or equal to 1 gm/dl, respectively. We concluded that the most important predictor of the development of the first Spontaneous Bacterial Peritonitis episode in cirrhosis with ascites is the total protein concentration in ascitic fluid. (HEPATOLOGY 1992;16:724–727.)
