| Background and aim:Spontaneous Bacterial Peritonitis is a common and serious complication of cirrhotic ascites with high morbidity(10-30%)and mortality(50-70%).Therefore,it is the key to improve the prognosis of SBP and reduce the mortality of patients with cirrhosis to clarify the risk factors and pathogenic characteristics of SBP,and to provide effective prevention and timely and effective treatment.The purpose of this study was to study the risk factors,etiology and clinical application of antibacterial and the prognosis of cirrhosis with SBP,so as to provide an objective basis for early warning,rapid diagnosis and timely and effective treatment of SBP.Method:This is a retrospectively study.We studied a total of 1299 cirrhotic ascites patients who were treated in the department of hepatobiliary medicine,Bethune First Hospital of Jilin University from July 2014 to June 2018.487 patients complicated with SBP were registered in the SBP group,and 812 patients not complicated with SBP were enrolled in the control group.We analyzed the general and clinical data(age,gender,etiology,past history,Complications(upper gastrointestinal bleeding,hepatic encephalopathy,hepatorenal syndrome and liver cancer),Child-Pugh classification,ascites index(PMN,albumin,WBC),albumin level,liver function indicators(AST,ALT,GGT,CHE,ALP,ALB,TBIL),blood routine index(WBC,NE%),coagulation parameters(PT,INR,PAA),renal function indicators(BUN,creatinine,serum sodium)).At the same time,the species,drugs sensitivity,drug resistance of bacteria cultured from ascites,clinical application antibiotics and the prognosis of disease were also analyzed.Univariate analysis was conducted on the factors that might affect the occurrence of SBP.Multivariate Logistic regression model analysis was conducted on the significant factors,and the related factors were determined as independent related factors of SBP.Patients whose ascites were not cultivated bacteria,cultivated bacteria and the clinical application time of antibacterial consistent with the results of drug susceptibility and cultivated bacteria but the clinical application time of antibacterial inconsistent with the results of drug susceptibility was divided into improved group and minor improvement or deterioration group,and the application of single factor analysis was applied to compare antibiotics application time.Result:Results of univariate analysis of related factors of cirrhosis ascites with SBP:some parameters(previous history of SBP,hepatorenal syndrome,ascites albumin,serum albumin,ALP,CHE,PT,INR,PAA,BUN,serum creatinine,serum sodium)were statistically significant differences between SBP group and control group(P<0.001).Results of multivariate Logistic regression analysis of related factors of cirrhosis ascites complicated with SBP:the multivariate Logistic regression analysis indicated that previous SBP history(OR:12.731,95%CI:3.789,42.770;P<0.001),prothrombin activity(OR:0.992,95%CI:0.987,0.998;P=0.005)and serum creatinine(OR:1.002,95%CI:1.001,1.004;P=0.001)were predicative of the occurrence of cirrhotic ascites with SBP.Etiological characteristics of cirrhosis with spontaneous peritonitis:in this study,there were 487 patients with cirrhotic ascites with SBP,and 268 patients with pathogenic bacteria cultured in ascites.56 episodes were infected with two or more bacteria.Among these,there were 28 cases of G~+bacteria combined infection,21cases of G~-bacteria combined infection,and 7 cases of G~+and G~-bacteria combined infection.A total of 339 strains of bacteria were cultured.Of the 339 strains of bacteria,G~+bacteria were the main pathogenic bacteria,which accounted for 71.1%,and G~-bacteria accounted for 28.3%and fungi accounted for 0.6%.Among the cultured pathogens,Staphylococcus and Streptococcus accounted for the highest proportion,which was 32.2%(109/339)and 18.6%(63/339),respectively.Enterobacteria,Enterococcus and Acinetobacter accounted for a slightly lower proportion,which was 13.0%(44/339),8.2%(28/339)and 7.1%(24/339),respectively.Pseudomonas aeruginosa accounted for 1.7%(6/339).Among the G~+bacteria,the proportion of Staphylococcus,Streptococcus and Enterococcus was45.2%(109/241),26.1%(63/241)and 11.6%(28/241),respectively.Among Staphylococcus,Staphylococcus epidermidis accounted for the highest proportion,which was 31.2%(34/109),and Methicillin-resistant Coagulase-negative Staphylococcus accounted for 8.3%(9/109).Among the G~-bacteria,Enterobacter was the most common,which accounting for 45.8%(44/96).Of the 44 strains of Enterobacter,the propotion of Escherichia was 45.5%(20/44)and the propotion of other Enterobacter was 54.5%(24/44).The proportion of multi-drug resistant bacteria was 26.3%(89/339).Enterobacteriaceae,Enterococcus,Acinetobacter baumannii and MRCNS was 52.4%(11/21)、23.8%(5/21)、14.3%(3/21)、9.5%(2/21).The proportion of Coagulase negative staphylococcus(CNS),Enterobacter,Enterococcus,Acinetobacter,Methicillin-resistant staphylococcus aureus and Methicillin-resistant Coagulase negative staphylococcus aureus was 43.8%(39/89),13.5%(12/89),6.7%(6/89),4.5%(4/89),4.5%(4/89)and 3.4%(3/89).Among the G~+bacteria,Staphylococcus epidermidis has the highest proportion in Staphylococcus.Its drug resistance rate to levofloxacin and moxifloxacin were40.6%(13/32)and 28.6%(6/21).Its drug resistance rate to vancomycin was 3.4%(1/29).Its drug resistance rate to teicoplanin,Linezolid and tegacycline was zero.The drug resistance rate of streptococcus to cefotaxime,ceftriaxone,cefepime and levofloxacin was 7.1%(4/56),7.0%(4/57),3.6%(2/56)and 25.5%(13/51).The drug resistance rate to linezolid was 1.7%(1/58)and vancomycin was zero.The resistance rate of enterococcus to levofloxacin,teicoplanin and vancomycin was 28.6%(8/28),16.7%(2/12)and 12%(3/25),respectively.Its drug resistance rate to tigecycline and linezolid zero.Teicoplanin,vancomycin,linezolid and tigacycline have low resistance to common gram-positive bacteria such as staphylococcus epidermidis,streptococcus and enterococcus.Escherichia coli were the dominant bacteria in G~-bacteria.Its drug resistance rate to ceftriaxone,cefepime and piperacillin/tazobactam was 58.8%(10/17),9.5%(2/21)and 6.3%(1/16).Its resistance rate to both of levofloxacin and ciprofloxacin was 41.2%(7/17).Its drug resistance rate to all of amikacin,meropenem and imipenem was zero.The drug resistance rate of acinetobacter to ceftriaxone and cefepime was 38.5%(5/13)and 15.8%(3/19).Its drug resistance rate to levofloxacin was 22.7%(5/22).Its drug resistance rate to meropenem and imipenem was 20.0%(1/5)and 14.3%(3/21).Its drug resistance rate to piperacillin/tazobactam and amikacin was 16.7%(1/6)and 10.0%(1/10).The drug resistance rate of other enterobacter to ceftriaxone,cefepime and amikacin was 4.3%(1/23),4.8%(1/21)and 4.5%(1/22),respectively.Its drug resistance rate to all of piperacillin/tazobatam,meropenem and imipenem was zero.The drug resistance rate of pseudomonas aeruginosa to piperacillin/tazobactam,cefepime,meropenem,imipenem and amikacin.Piperacillin/tazobactam,cefepime,meropenem,imipenem and amikacin have low resistance to common gram-negative bacteria such as escherichia coli,acinetobacter,other enterobacteriaceae,and pseudomonas aeruginosa.There were 487 patients with cirrhotic ascites combined with SBP,and the improvement rate was 51.7%(252/487).There were 219 cases of patients with no pathogenic bacteria cultured in ascites and cirrhosis complicated with SBP.Its clinical application of antibacterial was more commonly treated with cefepime,enzyme inhibitor,meropenem,cefmenoxime and moxifloxacin and except cefoperazone/tazobactam,the total improvement rate of disease was 53.4%(117/219).According to the prognosis of these patients,they were divided into the improvement group and the non-recovery or deterioration group.The results of single factor analysis showed that the application time of antibacterial in the improvement group was higher than that in the non-recovery or deterioration group.The improvement rate of the patients with pathogenic bacteria cultured in ascites and antibacterial application consistent with drug sensitivity was 53.7%(72/134).According to the prognosis of these patients,they were divided into the improvement group and the non-recovery or deterioration group.The application time of antibacterial in the improvement group was higher than that in the non-recovery or deterioration group.The improvement rate of the patients with pathogenic bacteria cultured in ascites but antibacterial application inconsistent with drug sensitivity was 36.6%(49/134).Its clinical application of antibacterial was more commonly treated with cefepime,cefmenoxime,moxifloxacin and enzyme inhibitor.According to the prognosis of these patients,they were divided into the improvement group and the non-recovery or deterioration group.The results of single factor analysis showed that there was no significant difference in the application time of antibacterial between the improvement group and the non-recovery or deterioration group(P>0.05).Conclusion:1.Previous history of SBP,prothrombin activity and serum creatinine are independent related factors for cirrhotic ascites with SBP.2.The proportion of G~+bacteria in SBP pathogens has a significant increasing trend G~+bacteria are the main pathogenic bacteria of SBP in patients with cirrhotic ascites in this study.Staphylococcus and Streptococcus are the most common in G~+bacteria,among which Staphylococcus epidermidis accounted for the highest proportion in Staphylococcus.Enterobacteria and Acinetobacter are the most common in G~-bacteria,among which Escherichia coli accounted for the highest proportion in Enterobacteria.3.Staphylococcus epidermidis in the Staphylococcus that caused the occurrence of SBP in patients with cirrhosis is highly resistant to levofloxacin and moxifloxacin,and less resistant to teicolanine,tigacycline and linezolid.Teicoplanin,vancomycin,linezolid and tigacycline have low resistance to common gram-positive bacteria such as staphylococcus epidermidis,streptococcus and enterococcus.Escherichia coli among G~-bacteria have high resistance to levofloxacin,ciprofloxacin and ceftriaxone,low resistance to cefepime,piperacillin/tazobactam,and the lowest resistance rate to imipenem and meropenem.Piperacillin/tazobactam,cefepime,meropenem,imipenem and amikacin have low resistance to common gram-negative bacteria such as escherichia coli,acinetobacter,other enterobacteriaceae,and pseudomonas aeruginosa.4.For patients without cultured pathogenic bacteria in ascites who are treated with empirical antibacterial treatment and patients with cultured pathogenic bacteria in ascites and the application of antibacterial consistent with drug sensitivity results,the application time of antibacterial in the improvement group is longer than that in the non-recovery or deterioration group and its improvement rate is higher.For patients with cultured pathogenic bacteria in ascites but the antibacterial application inconsistent drug sensitivity results,there is no significant difference between the improvement group and the non-recovery or deterioration group in the application time of antibacterial and its improvement rate is lower. |
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