cefotaxime and Ascites

Several pathogenic processes have been implicated in the development of abdominal ascites. Portal hypertension, most usually in the context of liver cirrhosis, can explain about 75% of the cases, whereas infective, inflammatory and infiltrative aetiologies can account for the rest. In this article, we discuss the consensus best practice as published by three professional bodies for the management of ascites, spontaneous bacterial peritonitis (SBP) and hepatorenal syndrome (HRS). The aim of this study was to compare available clinical guidelines and identify areas of agreement and conflict. We carried out a review of the guidance documentation published by three expert bodies including the British Society of Gastroenterology, the European Association for the Study of the Liver (EASL) and the American Association for the Study of Liver Diseases (AASLD), as well as a wider literature search for ascites, SBP and HRS. Abdominal ultrasonography, diagnostic paracentesis and ascitic fluid cultures are recommended by all three guidelines, especially when there is strong clinical suspicion for infection. EASL and AASLD advocate the use of ascitic amylase and mycobacterial cultures/PCR when there is strong suspicion for tuberculosis and pancreatitis, respectively. Ascitic cytology can be useful when cancer is suspected and has a good diagnostic yield if performed correctly. EASL supports the use of urinary electrolytes for all patients; however, the British Society of Gastroenterology and AASLD only recommend their use for therapy monitoring. All three societies recommend cefotaxime as the antibiotic of choice for SBP and large-volume paracentesis for the management of ascites greater than 5 l in volume. For HRS, cautious diuresis, volume expansion with albumin and the use of vasoactive drugs are recommended. There appears to be good concordance between recommendations by the European, American and British guidelines for the management of ascites and the possible complications arising from it.

Topics: Albumins; Anti-Bacterial Agents; Ascites; Bacterial Infections; Cefotaxime; Consensus; Diuretics; Evidence-Based Medicine; Hepatorenal Syndrome; Humans; Paracentesis; Peritonitis; Plasma Substitutes; Practice Guidelines as Topic; Risk Factors; Treatment Outcome

Bacterial infections are well described complications of cirrhosis that greatly increase mortality rates. Two factors play important roles in the development of bacterial infections in these patients: the severity of liver disease and gastrointestinal haemorrhage. The most common infections are spontaneous bacterial peritonitis, urinary tract infections, pneumonia and sepsis. Gram-negative and gram-positive bacteria are equal causative organisms. For primary prophylaxis, short-term antibiotic treatment (oral norfloxacin or ciprofloxacin) is indicated in cirrhotic patients (with or without ascites) admitted with gastrointestinal haemorrhage (variceal or non-variceal). Administration of norfloxacin is advisable for hospitalized patients with low ascitic protein even without gastrointestinal haemorrhage. The first choice in empirical treatment of spontaneous bacterial peritonitis is the iv. III. generation cephalosporin; which can be switched for a targeted antibiotic regime based on the result of the culture. The duration of therapy is 5-8 days. Amoxicillin/clavulanic acid and fluoroquinolones--patients not on prior quinolone prophylaxis--were shown to be as effective and safe as cefotaxime. In patients with evidence of improvement, iv. antibiotics can be switched safely to oral antibiotics after 2 days. In case of renal dysfunction, iv albumin should also be administered. Long-term antibiotic prophylaxis is recommended in patients who have recovered from an episode of spontaneous bacterial peritonitis (secondary prevention). For "selective intestinal decontamination", poorly absorbed oral norfloxacin is the preferred schedule. Oral ciprofloxacin or levofloxacin (added gram positive spectrum) all the more are reasonable alternatives. Trimethoprim/sulfamethoxazole is only for patients who are intolerant to quinolones. Prophylaxis is indefinite until disappearance of ascites, transplant or death. Long-term prophylaxis is currently not recommended for patients without previous spontaneous bacterial peritonitis episode, not even when refractory ascites or low ascites protein content is present.

Topics: Administration, Oral; Amoxicillin-Potassium Clavulanate Combination; Anti-Bacterial Agents; Ascites; Bacteremia; Bacterial Infections; Cefotaxime; Cephalosporins; Ciprofloxacin; Fluoroquinolones; Gastrointestinal Hemorrhage; Humans; Infusions, Intravenous; Liver Cirrhosis; Norfloxacin; Peritonitis; Pneumonia, Bacterial; Primary Prevention; Severity of Illness Index; Trimethoprim, Sulfamethoxazole Drug Combination; Urinary Tract Infections

Recent studies have shown that spontaneous bacterial peritonitis (SBP) is more common than previously thought among patients admitted to the hospital with cirrhotic ascites. Other recent studies have clarified which antibiotic regimens are most successful for treatment and prevention, often shortening the duration of treatment. Still, the prognosis is poor and recurrence of SBP is common.

Topics: Anti-Bacterial Agents; Antibiotic Prophylaxis; Ascites; Ascitic Fluid; Cefotaxime; Gram-Negative Bacterial Infections; Humans; Incidence; Lactams; Liver Cirrhosis; Peritonitis; Time Factors

Topics: Animals; Ascites; Bacterial Infections; Bacterial Translocation; Cefotaxime; Diagnosis, Differential; Drug Therapy, Combination; Humans; Intestine, Small; Liver Cirrhosis; Metronidazole; Norfloxacin; Peritonitis; Prognosis; Risk Factors

For the treatment of spontaneous bacterial peritonitis (SBP), cefotaxime, ceftriaxone, and ciprofloxacin were used as first-line agents. However, considering the increasing rate of antibiotic resistance, it is unclear which of these drugs can be initially recommended. This study aimed to compare the current efficacy of the 3 antibiotics, namely cefotaxime, ceftriaxone, and ciprofloxacin, for the treatment of SBP in patients with cirrhosis with ascites, when guided by therapeutic responses.. This study was a multicenter, prospective, randomized controlled trial. The inclusion criteria were 16- to 75-year-old patients with liver cirrhosis with ascites, having polymorphonuclear cell count of >250/mm 3 . We performed a follow-up paracentesis at 48 hours to decide continuing or changing the assigned antibiotics and then assessed the resolution rates at 120 and 168 hours of treatment.. A total of 261 patients with cirrhosis who developed SBP were enrolled. Most of the patients were diagnosed as those with SBP within 48 hours of admission. The resolution rates at 120 hours, which is the primary endpoint, were 67.8%, 77.0%, and 73.6% in the cefotaxime, ceftriaxone, and ciprofloxacin groups, respectively ( P = 0.388), by intension-to-treat analysis. The 1-month mortality was similar among the groups ( P = 0.770). The model for end-stage liver disease score and the SBP resolution were significant factors for survival.. The efficacy of empirical antibiotics, such as cefotaxime, ceftriaxone, and ciprofloxacin, against SBP was not significantly different. In addition, these antibiotics administered based on response-guided therapy were still efficacious as initial treatment for SBP, especially in those with community-acquired infections.

Topics: Adolescent; Adult; Aged; Anti-Bacterial Agents; Ascites; Bacterial Infections; Cefotaxime; Ceftriaxone; Ciprofloxacin; End Stage Liver Disease; Humans; Liver Cirrhosis; Middle Aged; Peritonitis; Prospective Studies; Severity of Illness Index; Young Adult

Topics: Abdominal Cavity; Aged, 80 and over; Anti-Infective Agents; Ascites; Cefotaxime; Diagnosis, Differential; Diet, Sodium-Restricted; Diuretics; Edema; Humans; Inflammation; Liver Cirrhosis; Lower Extremity; Male; Norfloxacin; Paracentesis; Peritonitis; Spironolactone; Tomography, X-Ray Computed; Trimethoprim, Sulfamethoxazole Drug Combination; Ultrasonography

Spontaneous bacterial peritonitis (SBP) is a significant cause of mortality in cirrhosis. Reducing toxic burden of infected ascitic fluid through paracentesis needs further studies as adjunctive therapy of SBP. We aimed to evaluate different therapies for SBP.. Thirty-six cirrhotic ascitic patients with SBP were examined and classified according to treatment modality (5-7 days) into: Group A received cefotaxime, group B received cefotaxime and albumin 1.5 g/kg body weight within 6h of SBP being diagnosed and 1g/kg body weight on day 3, group C received cefotaxime and paracentesis with volume dependent albumin infusion. Control group of 12 cirrhotic ascitic patients free from SBP were included. Routine laboratory tests, ascitic fluid analysis for leucocytes and culture were done, inflammatory mediators such as nitric oxide and tumour necrosis factor alpha were measured in serum and ascitic fluid. Duplex-Doppler assessment of portal flow volume and renal resistive index, Echocardiography to measure end diastolic and end systolic volumes, stroke volume and cardiac output were done. Tests were carried out before and after therapy.. Treatment response was assessed by, cardiac haemodynamics, portal and renal flow and NO and TNF. All studied parameters; laboratory, cardiac, Doppler exhibited a significant improvement in group B in contrast to the other groups as demonstrated by post therapy reduction of (blood and ascitic fluid WBCs & PNLS, serum and ascitic NO & TNF and renal resistive index), elevation of (serum albumin and portal flow volume) and improvement of cardiac haemodynamic.. Treatment of spontaneous bacterial peritonitis by cefotaxime and body weight based albumin infusion gave most favourable results compared to other regimens. Postulation of removing toxic burden through paracentesis has not been confirmed.

Topics: Adult; Albumins; Analysis of Variance; Anti-Bacterial Agents; Ascites; Ascitic Fluid; Bacterial Infections; Cefotaxime; Humans; Kidney; Liver Circulation; Liver Cirrhosis; Male; Middle Aged; Nitric Oxide; Paracentesis; Peritonitis; Portal System; Renal Artery; Stroke Volume; Tumor Necrosis Factor-alpha; Ultrasonography

We herein report a case of spontaneous bacterial peritonitis (SBP) caused by Staphylococcus epidermidis in an adult patient on regular hemodialysis (due to terminal renal failure caused by hypertension) and not on immunosuppressive therapy.

Topics: Adult; Anti-Bacterial Agents; Ascites; Cefotaxime; Drug Therapy, Combination; Humans; Imipenem; Kidney Failure, Chronic; Male; Peritonitis; Renal Dialysis; Staphylococcal Infections; Staphylococcus epidermidis; Vancomycin

To evaluate the sensitivity, specificity, and predictive values of dipstick testing (DT) for detecting spontaneous bacterial peritonitis (SBP), defined by an ascites neutrophil polymorphonuclear cell count > or = 250/mm3, in patients with cirrhosis.. The study includes all patients with cirrhosis and ascites admitted to our general hospital on the southern outskirts of the Paris metropolitan area (France) from June 2003 to May 2004 (n = 47:27 men and 20 women). Diagnostic abdominal paracentesis was performed on admission, and a Multistix SG (Bayer Pharma) reagent strip was immersed in one ascitic sample from each patient. Readings after 120 s were either negative (DT-) or positive (DT+, with 4 levels of positivity: trace, +, ++, or +++). In case of cytologically-proven SBP, patients were treated with cefotaxime, and subsequent paracentesis with DT and cytologic testing took place every 48 hours, until recovery.. Six of the 47 patients had proven SBP, all with clinical signs of SBP (fever and/or abdominal pain); five of these patients were DT+ and one was DT-. In the five patients initially DT+, the DT became negative at the same time as the cytologic criteria for SBP disappeared. Forty-one patients did not meet the cytologic criteria for SBP: 34 were DT- and 7 were DT+ (traces: 4, ++: 2, +++:1); two of these had clinical signs suggestive of SBP.. Although the sensitivity (83%), specificity (83%) and negative predictive value (97%) of DTwere satisfactory, its positive predictive value (42%) was low. Dipstick testing of ascitic fluid is easy to perform and inexpensive and may be recommended for diagnosis and follow-up of SBP, especially in emergency settings.

Topics: Aged; Anti-Bacterial Agents; Ascites; Cefotaxime; Data Interpretation, Statistical; Female; Humans; Liver Cirrhosis; Male; Middle Aged; Neutrophils; Paracentesis; Peritonitis; Predictive Value of Tests; Reagent Strips; Sensitivity and Specificity

Topics: Ampicillin; Ascites; Cefotaxime; Cholecystectomy; Diabetes Mellitus, Type 1; Disease Susceptibility; Drug Therapy, Combination; Echinococcosis, Hepatic; Female; Hepatitis C, Chronic; Humans; Hypertension, Portal; Listeriosis; Liver Cirrhosis; Middle Aged; Peritonitis; Postoperative Complications

Topics: Aged; Alcohol Drinking; Ascites; Cefotaxime; Cephalosporins; Citrobacter; Diagnosis, Differential; Diuretics; Enterobacteriaceae Infections; Fever; Humans; Jaundice; Male; Peritonitis; Spironolactone

We have compared in two separate studies the kinetics of ceftriaxone and cefotaxime in 8 cirrhotic patients with ascites and 8 control subjects after a single 20 min intravenous infusion of 1 g of each drug. The apparent volumes of distribution (Vz) were found to be significantly higher in cirrhotics than in control subjects (0.87, versus 0.49, l.kg-1, for cefotaxime and 0.23 versus 0.13 for ceftriaxone). The elimination kinetics of ceftriaxone were similar in the two groups. In contrast, the total and non-renal clearances of cefotaxime were reduced in cirrhotic patients. The two drugs rapidly entered the ascitic fluid. Peritoneal concentrations of ceftriaxone were higher than 7 micrograms.ml-1 from the second hour after the infusion and were 8.9 micrograms.ml-1 at 24 h. Peritoneal concentrations of cefotaxime were higher than 4 micrograms.ml-1 from 0.5 to 8 h after the infusion.

Topics: Ascites; Cefotaxime; Ceftriaxone; Female; Humans; Liver Cirrhosis, Alcoholic; Male; Middle Aged; Peritoneal Cavity

Pharmacokinetic values of cefotaxime were measured in 12 cirrhotic male patients (6 without ascites and 6 with ascites) after intravenous injection of a single 2 gram dose of the antibiotic. In patients without ascites elimination of the drug was about the same as in normal subjects or control patients, although clearance was increased. In patients with ascites, the drug elimination half-life was significantly more prolonged (7.5 +/- 3.9 h versus 1.3 +/- 0.4 h, P less than 0.01) and the drug clearance was significantly lower (193.6 +/- 92.4 ml/min versus 475.8 +/- 152.2 ml/min, P less than 0.01) than in the other group. The accumulation of cefotaxime in these patients produced concentration in the ascites fluid that were above the critical therapeutic values for about 20 hours.

Topics: Ascites; Cefotaxime; Half-Life; Humans; Liver Cirrhosis; Male; Metabolic Clearance Rate