Prevention of Spontaneous BT by Epidermal Growth Factor

Of the many causes of BT, the most surprising is the so-called spontaneous BT, which can be prevented by breast milk in newborn rabbits (87). Go found it only in formula-fed neonatal rabbits (87). Among many substances postulated to play the primary role in breast milk that prevents BT is epidermal growth factor (EGF). Secretory IgA, lactoformin, glutamine, specific enteric bacteria, and oligosaccharides have also been implicated. Okuyama et al. studied three groups (a) breast-fed pups, (b)...

Spontaneous Bacterial Peritonitis

Just as ontogeny recapitulates phylogeny, the induction of cirrhosis in rats recapitulates SBP in humans. SBP is a common, lethal bacterial complication of cirrhosis with an incidence of 10-30 and a mortality rate of 15-20 (116). BT has been postulated to be the primary mechanism of passage of the infecting organisms from the gut to the peritoneal cavity, just as it has for gram-negative sepsis in intensive care units, for thermal injury induced sepsis, and for the sepsis associated with...

Gastrointestinal Bleeding

More than 10 of the patients present with gastrointestinal hemorrhage at the time of the diagnosis of SBP (5,10,26). This prevalence rate increases to nearly 25 when considering bleeding episodes that occur during the week prior to the diagnosis of SBP (5). Moreover, gastrointestinal hemorrhage is the cause of death in up to 28 of the patients with SBP who die before the infection is resolved and 14 of those who die after the resolution of infection during the same hospitalization. Overall,...

Induction And Enhancement Of Bacterial Translocation In Experimental Animals

To study the role of the integrity of the intestinal mucosal barrier against the BT of indigenous organisms, Morehouse et al. and others used ricinoleic acid (castor oil), which is known to damage the epithelial cells of the villi when administered directly into the GI canal of experimental animals (15,16) (Table 7.1). A single therapeutic, cathartic dose of ricinoleic acid was given into the stomachs of mice, after which the MLN, spleen, and liver were monitored bacteriologically. The...

Prognostic Factors

In recent years, several clinical and laboratory findings obtained prior to or during the course of SBP have been considered to be predictors of the failure of the resolution of infection or of the development of renal impairment and death. The identification of these risk factors allows treatment of SBP patients at especially high risk with specific measures to prevent renal impairment and, perhaps, to increase survival. On the other hand, SBP patients in relatively good clinical condition and...

References

Infecciones bacterianas en la cirrosis hep tica. In Actualidades en Gastroenterolog a y Hepatolog a. Rod s J, Chantar C, eds., Barcelona J.R. Prous, 1988, 149-189. 2. Su rez C, Pajares JM. Epidemiolog a de las infecciones en la cirrosis hep tica. Rev Clin Esp 1981 160 299-303. 3. Andreu M, Barrufet P, Force L, Sol R, Verdaguer A, Panad s A, Aran R. Fiebre en el enfermo con cirrosis hep tica estudio prospectivo durante seis meses. Med Clin (Barcelona) 1985 433-436. 4. Clemente-Ricote...

Thermal Injury

In an impressive, retrospective investigation, Sittig and Deitch studied the prognostic affects of bacteremia in humans after thermal trauma (106). They reviewed the records of all the patients who had been admitted to the Burn Clinic of the Louisiana State University in Shreveport between 1980 and 1986 with severe burns and who had developed bacteremia. Of the 1108 patients admitted with a mean burn size of at least 22 of the body surface area, 93 (8 ) developed bacteremia. The mean size of...

Measures For The Prevention Of Spontaneous Bacterial Peritonitis

Several measures (59) have been proposed to be helpful in preventing bacterial infections and SBP in cirrhotic patients, such as discontinuing alcohol intake (60), reducing the time of hospitalization (1,7), avoiding unnecessary instrumentation (3), improving nutritional status (61), and preventing other complications of cirrhosis, such as ascites formation, gastrointestinal hemorrhage, and hepatic encephalopathy (59), which could favor the development of SBP. In a recent study, Ho et al. (62)...

Therapeutic Efficacy

The efficacy of cefotaxime in patients with SBP has been evaluated in different studies (17-19). The first investigation consisted in a randomized controlled trial comparing cefotaxime (2 g every 4 h in patients without renal failure) versus the combination of ampicillin plus tobramycin in a large series of cirrhotic patients with SBP or other severe bacterial infections (17) (Table 11.2). Cefotaxime was more effective in achieving the resolution of SBP than ampicillin plus tobramycin, and,...

Iintroduction

Spontaneous bacterial peritonitis (SBP), defined as an infection of ascitic fluid that occurs in the absence of any obvious intraabdominal source, is a frequent complication of cirrhosis. Although SBP was first reported in France around the turn of this century, over the next 70 years only sporadic reports appeared in the medical literature. After the landmark series of Conn and Fessel (1) in 1971, a large number of studies have helped to characterize further the spectrum of this complication....

Distribution Of The Species Of Bacteria Recovered From The Patients With Spontaneous Peritonitis

Virulence of intestinal bacteria has been defined as the ability to invade the epithelial cell. Whether or not virulence is inherent in the bacteria themselves, or is affected by resistance of the epithelial cells or both is not clear. E. coli have been the organisms most commonly responsible. These organisms have exhibited normal cultural characteristics and the expected antibiotic sensitivity spectra. . . . Certainly some subtypes of E. coli and other normal components of the indigent...

Months

Figure 12.3 Cumulative probability of survival in patients who recovered from the first episode of spontaneous bacterial peritonitis. (From Ref. 7.) patients are frequently submitted to aggressive diagnostic and therapeutic interventions, it is possible that some bacterial infections are related to the increased risk of infection associated with these invasive procedures. This fact may explain some episodes of urinary tract infection in patients with urinary catheters, of pneumonia in patients...

Info

50 of the spleens, 38 of the liver and kidneys, 25 of the peritoneal fluid specimens, and 12 of the portal blood samples. No such spread was seen in either group without MLN excision (Groups II and IV), although these groups had a high rate of BT to AF (approximately 85 ). Peritoneal translocation was significantly less frequent when the MLN had been excised. These observations suggest that SBP is not primarily a lymph-transmitted infection, although it is one route of infection and that can be...

Immunotherapy Of Tuberculosis

There have been reports of the addition of Mycobacterium vaccae immunotherapy in pulmonary tuberculosis with both drug-sensitive and drug-resistant organisms. Prior et al. administered immunotherapy with Mycobacterium vaccae to second-line antituberculous drugs and observed a dramatic cure in a patient with drug-resistant abdominal tuberculosis (64). At present the treatment of tuberculosis in this new type of tuberculin immunotherapy, particularly of multiple drug-resistant tuberculosis,...

Introduction

Bacterial translocation (BT)* is defined as the passage of viable bacteria, viruses, or other organisms from the gastrointestinal (GI) lumen to extragastroin-testinal sites. The term translocation was first employed by Keller and Engley in 1958 to describe the passage of orally administered bacteriophage from the lumen of the intestines of mice to blood or to lymph nodes (1). Wolochow et al. in 1966 were the first to use the term translocation to describe the passage of bacteria (Serrada...

Suppression Of Intestinal Bacterial Flora

Ozfelik and associates in Istanbul compared the effects in Sprague-Dawley rats with surgical manipulation (or sham surgery) which received either lactulose (2 ml of a 33 solution) or saline intragastrically starting three days before surgery (36) (see Table 8.3). The surgical trauma consisted of laparotomy followed by palpation and compression of the gastrointestinal tract from duodenum to rectum for several minutes. (I predict that it will be difficult to standardize and calibrate manual...

Reduced Protein Concentration and Opsonic Activity in Ascitic Fluid

It is now clearly established that impairment in local defense mechanisms against infection plays an important role in the pathogenesis of SBP in cirrho sis (3-5). First, it was demonstrated that the antimicrobial activity of ascitic fluid, as assessed by measuring opsonic activity, is more greatly reduced in ascites of cirrhosis compared to the ascites of other etiologies (such as malignant ascites and cardiac ascites) or with normal peritoneal fluid (31 -33). Opsonization is a prerequisite...

Ns

Note Group 1, patients with encapsulated E coli group 2, patients with nonencapsulated E coli. The numbers in parentheses refer to percentages. * Number of patients who developed one or more complications. b Number of complications per patient (mean SD). The other numbers in the table refer to number of patients. Source Ref. 41. Note Group 1, patients with encapsulated E coli group 2, patients with nonencapsulated E coli. The numbers in parentheses refer to percentages. * Number of patients who...

Pharmacokinetic Properties

The intravenous bolus administration of 1 g of cefotaxime causes a mean peak plasma concentration (C that ranges between 81 and 102 mg L, whereas a single bolus dose of 2 g produces Cm values between 175 and 215 mg L (12). Mean plasma concentrations of cefotaxime and desacetyl-cefotaxime, the active metabolite of cefotaxime, 8 h after the administration of cefotaxime range from 0.5 to 1.0 mg L, although higher trough values have been reported in elderly patients (12-14). The apparent volume of...

What Are The Factors That Render Cirrhotic Patients Particularly Prone To Develop Spontaneous Peritonitis

First, is the failure of hepatic removal of bacteria from the blood stream. Many investigators have demonstrated that major vascular abnormalities develop in the hepatic circulation of cirrhotic patients with portal hypertension. Mclndoe described the extrahepatic portal-systemic collateral networks that shunt portal venous blood around the liver (9). He estimated that more than 80 percent of portal blood may bypass the liver in advanced cirrhosis, and more recent investigations have confirmed...

Definitions

A number of definitions are needed to simplify the understanding and presentation of these complex relationships. Prevalence is loosely defined in the Random House Dictionary of the English Language as the extent of occurrence of an event, disease, symptom, sign, cost or other characteristic. It is not limited to a specific unit of time, but it may be restricted to a specific country or type of disease, e.g., alcoholic cirrhosis. Incidence is more rigorously defined as the rate of occurrence of...

Bpip

Reduces rate of BT Reduces mortality Reduces colony count Enhances bacterial killing Improves mucosal barrier function Improves survival Increases bacterial killing Enhances bacterial killing Decreases BT Decreases BT Inhibits endotoxin and his associates studied the effects of an arginine-supplemented diet (11) because arginine has been shown to have beneficial immunomodulating activity in infected animals (12). In their endotoxin-induced BT model in mice, they demonstrated that arginine (2...

Different Types Of Cirrhosis With

This pattern of4 'variations on a theme'' has continued, virtually every possible variable has been documented, and thus the syndrome has been broadened considerably. All of the first 29 patients, for example, had micronodular alcoholic cirrhosis. It was not difficult to predict that other types of cirrhosis would also be associated with SBP. These variations, some of which were observed in our series, but most of which have been reported by other investigators elsewhere, will be documented...

Noncirrhotic SBP

SBP has also occurred in patients with ascites of noncirrhotic origin such as neoplastic ascites (49), i.e., the ascites that develops in patients with portal hypertension following metastases to the liver and or the peritoneum. Actually one can sense that these are pathogenetically two very different phenomena. Metastases to the peritoneum tend to cause a syndrome characterized by blood and neoplastic cells in the ascitic fluid. On the other hand, intrahepatic metastases tend to cause ascites...

Rationale For Primary Prophylaxis Of Spontaneous Bacterial Peritonitis

Spontaneous bacterial peritonitis (SBP) is a frequent complication in cirrhotic patients with an incidence ranging between 8 and 27 during a single hospitalization (1-3). Considering patients with ascites and without previous SBP, the one-year probability of developing the first episode of SBP is 11 -29 (4,5). These figures increase to 20-50 when considering high-risk groups defined by low ascitic fluid total protein (< 10 g L) or high serum bilirubin levels (> 2.5 mg dL) (4,5). Moreover,...

Historical Vignette

It is of historical interest that Ludwig von Beethoven is probably the first patient known by name to have had SBP, especially since the clinical description of his case had been written 135 years before this syndrome was first described. Ever since I became aware of Beethoven's illness, it has seemed to me that SBP is the most likely explanation for his symptoms. It is even more astounding that this disease occurred in such an illustrious person. If he had not been so famous, his case history...

What Are The Possible Routes By Which Bacteria May Enter The Peritoneum

Organisms can come directly from the gastrointestinal tract, from the blood stream, from the lymphatics or, in females, from the genital tract. The rarest route is through the Fallopian tubes. . . . This route of entry has been implicated by McCartney to explain the predominance of girls with primary peritonitis (5). Obviously, this mechanism played no role in any of our patients, all of whom were male. It is conceivable that this route could have been responsible for some of the women...

Phospholipids in Prevention of BT

Wang and associates have shown that BT after hepatectomy in Sprague-Dawley rats can be decreased by the administration of phospholipids (phosphoti- dylcholine and phosphotidylinositol) (52). Presumably, these effects are mediated by maintaining the integrity of the intestinal barrier. Wang et al. have also shown that ethylhydroxyethyl cellulose prevents the BT induced by large hepatic resections (90 ) in rats (53). Although the mechanism of this effect is not known, it might be caused by the...

Shortterm Prophylaxis Of Bacterial Infections In Hospitalized Cirrhotic Patients

Several studies have demonstrated that short-term prophylactic antibiotic therapy during hospitalization dramatically reduces the incidence of nosocomial bacterial infections in cirrhotic patients admitted with gastrointestinal bleeding or with ascites with a low ascitic fluid total protein concentration. A. Cirrhotic Patients with Gastrointestinal Bleeding In 1985, Rimola et al. (28) published the first study on antibiotic prophylaxis of bacterial infections in cirrhotic patients. This...

Fibrous Encapsulating Peritonitis The Cocoon Syndrome

In their description of a most unusual case of SBP in a noncirrhotic patient, Leport et al. described a patient who, in the absence of any history of preceding liver disease, developed pneumococcal bacteremia, but whose ascitic fluid was sterile (42). The patient, a 36-year-old Moroccan woman, who had had no history of alcohol ingestion, abdominal disease, or surgery, developed fever, abdominal pain, and diarrhea. She had given birth to nine children uneventfully. On physical examination she...

Other Iatrogenic Types of SBP

Iatrogenic is defined as induced by a physician or by the physician's actions. Iatrogenic SBP can therefore be defined as an episode of SBP induced by a healthcare worker during or as a consequence of a diagnostic or therapeutic procedure. Physicians, surgeons, dentists, nurses, or their colleagues are all capable (and culpable) of inducing SBP in cirrhotic patients. A physician's failure to incise an abscess may induce SBP as an act of omission whereas the bacteremia following such an incision...

Laboratory Variations In

Culture-Negative SBP (CNSBP) and Culture-Negative Neutrocytic Ascites (CNNA) CNSBP is defined as the presence of the clinical picture of SBP, ascites that contains more than 250 polymorphonuclear leukocytes (PMNs) per cubic millimeter, a sterile ascitic fluid culture, and no explanation for the abdominal finding (50). In the most simple sense it represents culture-negative SBP. How can such a syndrome develop What does it signify First, it may represent SBP at an early phase in its course,...

Chronic Ambulatory Peritoneal Dialysis CAPD

CAPD may be considered either a common variant of SBP or a completely separate syndrome with many features in common (57). Although I consider it to be the latter, it is appropriate to discuss it in detail here. Infection of the peritoneal cavity by bacteria is the major complication of CAPD (55,56). SBP is a bacterial infection of a pre-existing pathophysiological accumulation of peritoneal fluid, a pathophysiological consequence of portal hypertension that develops almost exclusively in...

Multiplicity of Infecting Species

More than 70 species of bacteria have been isolated from the AF of patients with bacteriologically proved SBP Table 3.4 . The infecting bacteria are predominantly species indigent to the human gastrointestinal tract. They are usually aerobic, gram-negative rods, but coccal forms of all types may be present. They have been arbitrarily divided into a aerobic, gram-negative bacilli, b cocci, both gram-negative and gram-positive, c anaerobic bacteria, d inherently pathogenic bacteria, and e...