Ascitic fluid infection in children with liver disease: time to change empirical antibiotic policy

Hepatol Int. 2020 Jan;14(1):138-144. doi: 10.1007/s12072-019-09968-x. Epub 2019 Jul 9.

Abstract

Background and aims: Recent years have shown a rise in occurrence of multidrug resistant ascitic fluid infection (AFI) including resistant to third generation cephalosporins. Our aim was to find the prevalence, antibiotics resistance and outcome of AFI in children with liver disease.

Methods: Children (≤ 18 years) with liver disease-related ascites were prospectively enrolled from April 2015 to October 2017. Based on the results of ascitic fluid examination and culture, patients were classified as having AFI [spontaneous bacterial peritonitis (SBP), culture negative neutrocytic ascites (CNNA) and monomicrobial non-neutrocytic bacterascites (MNB)] and no-AFI. AFI diagnosed after 48 h of index hospitalization was considered as nosocomial.

Results: We enrolled 194 children with a median age of 85 [2-216] months. Chronic liver disease was the commonest etiology (153, 79%). AFI was present in 60 (31%) children [SBP (n = 13), CNNA (n = 39), MNB (n = 8)] of which 53% were nosocomial and resulted in high in-hospital mortality. Gram-negative bacilli dominated the ascitic fluid culture (12/21, 57%) and 10/12 (83%) of them were extended spectrum beta-lactamases (ESBL) producers. Six (60%) ESBL producers were sensitive to cefoperazone-sulbactam and 70% to carbapenems. Child-Pugh-Turcotte (CPT) score of ≥ 11 independently determined in-hospital mortality in children with AFI.

Conclusions: AFI was found in 31% children with liver disease and almost half of them were nosocomial resulting in high mortality. ESBL producing Gram-negative bacteria were the most frequently isolated organisms. Cefoperazone-sulbactam or carbapenems may be useful empirical antibiotics in nosocomial setting. Children with AFI and CPT score ≥ 11 should be evaluated for liver transplantation.

Keywords: Ascites; Children; Infection; Nosocomial.

MeSH terms

  • Adolescent
  • Anti-Bacterial Agents / therapeutic use
  • Antimicrobial Stewardship
  • Child
  • Child, Preschool
  • Drug Resistance, Bacterial
  • Female
  • Gram-Positive Bacterial Infections / complications
  • Gram-Positive Bacterial Infections / drug therapy
  • Gram-Positive Bacterial Infections / epidemiology*
  • Humans
  • India / epidemiology
  • Infant
  • Liver Cirrhosis / complications*
  • Male
  • Peritonitis / complications
  • Peritonitis / drug therapy
  • Peritonitis / epidemiology*
  • Peritonitis / mortality
  • Prevalence
  • Prospective Studies

Substances

  • Anti-Bacterial Agents