The empirical antibiotic treatment of nosocomial spontaneous bacterial peritonitis: Results of a randomized, controlled clinical trial

Abstract

Spontaneous bacterial peritonitis (SBP) is a common, life-threatening complication of liver cirrhosis. Third-generation cephalosporins have been considered the first-line treatment of SBP. In 2014, a panel of experts suggested a broader spectrum antibiotic regimen for nosocomial SBP, according to the high rate of bacteria resistant to third-generation cephalosporins found in these patients. However, a broader-spectrum antibiotic regimen has never been compared to third-generation cephalosporins in the treatment of nosocomial SBP. The aim of our study was to compare meropenem plus daptomycin versus ceftazidime in the treatment of nosocomial SBP. Patients with cirrhosis and nosocomial SBP were randomized to receive meropenem (1 g/8 hours) plus daptomycin (6 mg/kg/day) or ceftazidime (2 g/8 hours). A paracentesis was performed after 48 hours of treatment. A reduction in ascitic fluid neutrophil count <25% of pretreatment value was considered a treatment failure. The primary outcome was the efficacy of treatment defined by the resolution of SBP after 7 days of treatment. Thirty-two patients were randomized and 31 were analyzed. The combination of meropenem plus daptomycin was significantly more effective than ceftazidime in the treatment of nosocomial SBP (86.7 vs. 25%; P < 0.001). Ninety-day transplant-free survival (TFS) was not significantly different between the two groups. In the multivariate analysis, ineffective response to first-line treatment (hazard ratio [HR]: 20.6; P 5 0.01), development of acute kidney injury during hospitalization (HR: 23.2; P 5 0.01), and baseline mean arterial pressure (HR: 0.92; P 5 0.01) were found to be independent predictors of 90-day TFS. Conclusion: The combination of meropenem plus daptomycin is more effective than ceftazidime as empirical antibiotic treatment of nosocomial SBP. Efficacy of the empirical antibiotic treatment is a strong predictor of 90-day survival in patients with nosocomial SBP.

Preemptive therapy of spontaneous fungal peritonitis

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Altogether, our preclinical data on B-cell depletion (4) and published data in AIH patients (1) suggest that prospective studies using anti-CD20 as initial therapy to induce remission in patients with AIH are indicated. These studies will be able to provide safety profile and design tailored protocols for different subtypes of AIH patients, including those with other comorbidities.

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“…(1) Hassan et al screened for invasive fungal infection in 46 end-stage liver disease (ESLD) patients from the intensive care unit: both blood and ascitic fluid samples were collected for fungal culture and polymerase chain reaction.…”

“…In conclusion, echinocandins, instead of fluconazole, (1) should be considered as empirical or preemptive systemic antifungal therapy for ESLD patients with suspected SFP.…”

Spontán bakteriális peritonitis

“…Arányuk az elmúlt néhány évben fokozatosan nő, egyes tanulmányokban már meghaladta a GNB-két [24,25]. Nosocomialis infekciók esetén a GPB-k aránya 63% körül van [26]. A GPB-k irányába történő eltolódást legalább részben a nosocomialis és egészségügyi ellátáshoz kötötten megjelenő SBP-k gyakoribbá válása magyarázza.…”

Keeping high model for end‐stage liver disease score liver transplantation candidates alive

“…When nosocomial SBP is diagnosed, the European Association for the Study of the Liver guidelines recommend piperacillin/tazobactam or meropenem 6 a glycopeptide 11 ; however, the first randomized prospective 2-center clinical trial from Italy has shown superior outcomes with meropenem 1 daptomycin compared to ceftazidime. 20 Repeat paracentesis is not absolutely required. However, if clinical improvement is lacking, or relisting for transplant is desired, confirming a PMN count decrease of 25% in 48 hours or at a later time point an absolute PMN count of <250 cells/mm 3 indicates resolution.…”