Neutrophil-lymphocyte ratio predicts hospital-acquired bacterial infections in decompensated cirrhosis

Neutrophil-to-Lymphocyte Ratio as a Potential Early Marker of Antibiotic Resistance in Patients with Infected Cirrhotic Ascites

“…Accordingly, coagulase-negative staphylococci and Enterococcus species were the two most commonly isolated pathogens following E. coli, while antibiotic resistance was evident in half of the patients with infected ascites in our cohort. This indicates the role of in-depth assessment of pathogen profiles in SBP to control the emer-gence and development of pathogenic bacteria-resistant strains, while also emphasizing the critical importance of earlier recognition of antibiotic resistance in patients with infected ascites to prevent fatal complications [3]. Our findings indicate changes from baseline in NLR differ significantly with respect to treatment response in patients with infected cirrhotic ascites with a progressive increase in NLR levels during treatment in case of antibiotic resistance.…”

“…As a result, % change from baseline NLR on Day 1 was shown to be an early marker for differentiating between antibiotic resistance and antibiotic sensitivity with a sensitivity of 87. Moreover, a change in bacterial profile of SBP has been documented in recent studies with an increase in the incidence of gram-positive pathogens as well as a trend towards an increased frequency of bacteria resistant to multiple antibiotics [3,21]. This has been attributed to the use of antibiotics that alter the intestinal flora enabling translocation of gram-positive bacteria, as well as increased resistance to antibiotics commonly used for the treatment of SBP such as quinolones [21].…”

“…The presence of ascitic fluid infection was determined on the basis of WBC/PMNL counts and culture positivity in ascitic fluid. Patients with WBC count ≥ 500/mm 3 and PMNL > 250/mm 3 in ascitic fluid were considered to have infected ascites, while those with WBC count < 500/mm 3 and PMNL count < 250/mm 3 in ascitic fluid and with a negative culture were considered to have sterile ascites. Antibiotic resistance was defined via paracentesis as the presence of < 25% decrease in pretreatment ascitic fluid WBC count after 2-day treatment [1,9,10].…”

“…Ascites is an important landmark and a poor prognostic factor in the clinical course of cirrhosis, while is also associated with an increased risk of spontaneous bacterial peritonitis (SBP) [1] and consequent development of acute decompensation that accounts for further risk of mortality in cirrhosis patients [2]. Early diagnosis and prompt management of SBP is therefore of critical im-portance in the management of cirrhotic ascites to prevent life-threatening complications such as hepatic encephalopathy and hepatorenal syndrome [3,4]. In recent years, a change in epidemiology of bacterial infections has been documented in cirrhosis patients with an increase in the prevalence of SBP caused by multi-resistant bacteria associated with higher mortality rates than infections caused by pathogens that are sensitive to antimicrobials [5,6].…”

“…Given the consideration of antibiotic resistance to be an independent life-threatening poor prognostic factor in cirrhotic patients with SBP, prompt identification of antibiotic resistance seems crucial to be able to adjust bacterial coverage of treatment to increase the chance of survival [6,7]. Abdominal paracentesis is considered a mandatory approach in all patients with cirrhosis requiring hospital admission to diagnose infected ascites and also to assess treatment response based on ascitic neutrophil counts at baseline and after 2 days of antibiotic treatment [2,3,8]. However, in accordance with invasiveness of the technique, complications such as abdominal hematoma, hemoperitoneum or bowel perforation are rare but not impossible, while the procedure may also be challenging with difficulty of obtaining samples in some patients necessitating repetition of the procedure and thus increasing the risk of iatrogenic peritonitis [8][9][10].…”