ABSTRACT
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Subject(s)
Humans , Male , Female , Adult , Middle Aged , Peritonitis/drug therapy , Anti-Bacterial Agents/therapeutic use , Carbapenems/therapeutic use , Treatment Failure , Cross Infection/drug therapySubject(s)
Anti-Bacterial Agents/therapeutic use , Cross Infection/drug therapy , Escherichia coli Infections/drug therapy , Escherichia coli/drug effects , Klebsiella Infections/drug therapy , Klebsiella pneumoniae/drug effects , Peritonitis/drug therapy , beta-Lactams/therapeutic use , Adult , Aged , Anti-Bacterial Agents/administration & dosage , Anti-Bacterial Agents/pharmacology , Cross Infection/microbiology , Drug Resistance, Multiple, Bacterial , Drug Substitution , Ertapenem , Escherichia coli/enzymology , Escherichia coli Infections/enzymology , Esophageal and Gastric Varices/complications , Female , Gastrointestinal Hemorrhage/etiology , Hepatorenal Syndrome/complications , Humans , Klebsiella Infections/enzymology , Klebsiella pneumoniae/enzymology , Liver Transplantation , Male , Middle Aged , Peritonitis/microbiology , Postoperative Complications/drug therapy , Postoperative Complications/microbiology , Treatment Failure , beta-Lactam Resistance , beta-Lactamases/metabolism , beta-Lactams/administration & dosage , beta-Lactams/pharmacologyABSTRACT
BACKGROUND & AIMS: The recent emergence of third-generation cephalosporin resistance in spontaneous bacterial peritonitis is of great concern, although neither the risk factors for resistance nor its real impact on mortality have been well defined. METHODS: We conducted a retrospective study of all spontaneous bacterial peritonitis episodes with positive blood and/or ascitic culture at our center (2001-2009). Episodes were classified according to the place of acquisition: community, healthcare system, or nosocomial. RESULTS: Two hundred and forty-six episodes were analyzed in 200 patients (150 males, 57.3 years): 34.6% community-acquired, 38.6% healthcare system-acquired, and 26.8% nosocomially-acquired. Third-generation cephalosporin resistance occurred in 21.5% (7.1% community-acquired, 21.1% healthcare system-acquired, 40.9% nosocomially-acquired). These resistant cases were categorized as extended-spectrum ß-lactamase-producing Gram-negative bacilli, other resistant Gram-negative bacilli, and Enterococci. Risk factors for resistance were previous use of cephalosporins, diabetes mellitus, upper gastrointestinal bleeding, nosocomial acquisition, and a low polymorphonuclear count in ascites. Regarding third-generation cephalosporin resistance, adequate empirical treatment was 80.7%. Independent predictors of mortality were nosocomial acquisition, poor hepato-renal function, immunosuppressive therapy, a marked inflammatory response during the episode and either third-generation cephalosporin-resistance or low rates of adequate empirical treatment. CONCLUSIONS: The risk of third-generation cephalosporin resistance was particularly high in nosocomially-acquired episodes of spontaneous bacterial peritonitis, but also occurred in healthcare system-acquired cases. The extent of resistance and the adequacy of empirical antibiotics had a significant effect on mortality along with the patient's hepato-renal function. These data can help determine the most suitable empirical antimicrobial treatments in these patients.
Subject(s)
Ceftriaxone/therapeutic use , Community-Acquired Infections , Cross Infection , Drug Resistance, Bacterial , Infectious Disease Transmission, Professional-to-Patient , Peritonitis/microbiology , Peritonitis/mortality , Adult , Aged , Anti-Bacterial Agents/pharmacology , Anti-Bacterial Agents/therapeutic use , Ceftriaxone/pharmacology , Enterococcus/drug effects , Enterococcus/isolation & purification , Female , Gram-Negative Bacteria/drug effects , Gram-Negative Bacteria/isolation & purification , Gram-Positive Bacteria/drug effects , Gram-Positive Bacteria/isolation & purification , Humans , Incidence , Male , Middle Aged , Peritonitis/epidemiology , Retrospective Studies , Risk Factors , Treatment OutcomeSubject(s)
Carcinoma, Hepatocellular/complications , Hepatitis C/drug therapy , Liver Cirrhosis/drug therapy , Liver Neoplasms/complications , Receptors, Fc/therapeutic use , Recombinant Fusion Proteins/therapeutic use , Surgical Procedures, Operative , Thrombocytopenia/complications , Thrombopoietin/therapeutic use , Embolization, Therapeutic , Hepatitis C/complications , Humans , Jehovah's Witnesses , Liver Cirrhosis/complications , Male , Middle Aged , Platelet Count , Portal Vein/diagnostic imaging , Portal Vein/pathology , RadiographySubject(s)
Humans , Male , Middle Aged , Thrombocytopenia/complications , Thrombocytopenia/diagnosis , Liver Cirrhosis/complications , Liver Cirrhosis/diagnosis , Carcinoma, Hepatocellular/complications , Carcinoma, Hepatocellular/diagnosis , Thrombocytopenia/drug therapy , Thrombocytopenia/physiopathology , Thrombocytopenia , Carcinoma, Hepatocellular/physiopathology , Carcinoma, Hepatocellular/surgery , Carcinoma, Hepatocellular , Informed Consent/standardsABSTRACT
BACKGROUND & AIMS: Secondary bacterial peritonitis in cirrhotic patients is an uncommon entity that has been little reported. Our aim is to analyse the frequency, clinical characteristics, treatment and prognosis of patients with secondary peritonitis in comparison to those of patients with spontaneous bacterial peritonitis (SBP). METHODS: Retrospective analysis of 24 cirrhotic patients with secondary peritonitis compared with 106 SBP episodes. RESULTS: Secondary peritonitis represented 4.5% of all peritonitis in cirrhotic patients. Patients with secondary peritonitis showed a significantly more severe local inflammatory response than patients with SBP. Considering diagnosis of secondary peritonitis, the sensitivity of Runyon's criteria was 66.6% and specificity 89.7%, Runyon's criteria and/or polymicrobial ascitic fluid culture were present in 95.6%, and abdominal computed tomography was diagnostic in 85% of patients in whom diagnosis was confirmed by surgery or autopsy. Mortality during hospitalization was higher in patients with secondary peritonitis than in those with SBP (16/24, 66.6% vs. 28/106, 26.4%) (p<0.001). There was a trend to lower mortality in secondary peritonitis patients who underwent surgery (7/13, 53.8%) than in those who received medical treatment only (9/11, 81.8%) (p=0.21). Considering surgically treated patients, the time between diagnostic paracentesis and surgery was shorter in survivors than in non-survivors (3.2+/-2.4 vs. 7.2+/-6.1 days, p=0.31). CONCLUSIONS: Secondary peritonitis is an infrequent complication in cirrhotic patients but mortality is high. A low threshold of suspicion on the basis of Runyon's criteria and microbiological data, together with an aggressive approach that includes prompt abdominal computed tomography and early surgical evaluation, could improve prognosis in these patients.
Subject(s)
Liver Cirrhosis/complications , Peritoneal Cavity/microbiology , Peritonitis/diagnosis , Peritonitis/therapy , Aged , Ascitic Fluid/microbiology , Diagnosis, Differential , Female , Humans , Incidence , Male , Middle Aged , Peritoneal Cavity/diagnostic imaging , Peritonitis/mortality , Prognosis , Retrospective Studies , Sensitivity and Specificity , Severity of Illness Index , Survival Rate , Tomography, X-Ray ComputedABSTRACT
Ezetimibe is the first member of a new family of lipid-lowering drugs that inhibits uptake of dietary and biliary cholesterol. It was approved by the FDA in 2002 for hypercholesterolemia alone or in combination with statins. Its use has been spreading over the last years. Ezetimibe was considered a safe drug. We report a case of a woman who developed a serious hepatocellular drug-induced liver disease after 4 mo therapy with 10 mg daily of ezetimibe. After withdrawal of the drug, the patient recovered slowly. Ezetimibe may produce serious toxic hepatitis and prompt withdrawal is mandatory in case of a significant abnormality in liver testing after beginning or during treatment with ezetimibe.
