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Cirrhosis is a severe end‐stage liver disease marked by irreversible scarring of liver tissue. Ascites (the accumulation of fluid in the abdomen), is one of the many complications associated with cirrhosis. Ascites is associated with poor quality of life, increased risk of infection, and renal failure. The presence of ascites is a sign of poor prognosis. Spontaneous bacterial peritonitis (inflammation and infection of the membrane that is lining the abdominal cavity) is a complication of cirrhotic ascites that occurs in the absence of any intra‐abdominal, surgically treatable source of infection. Antibiotic therapy is indicated and should be initiated as soon as possible to avoid severe complications that may lead to death. This review aimed to evaluate the beneficial and harmful effects of different types and modes of antibiotic therapy in the treatment of spontaneous bacterial peritonitis in cirrhotic patients. Thirteen trials were included; each one of them compared different antibiotics in their experimental and control groups. No meta‐analyses could be performed, though data on the main outcomes were collected and analysed separately for each included trial. Based on the identified evidence, we cannot suggest the most appropriate management to treat spontaneous bacterial peritonitis in regard to the type, dosage, duration, or administration route of the antibiotic therapy. The clinical trials found dealt with different types of antibiotics, and, therefore, could not be combined. This review found no evidence that the effect or safety of one antibiotic is more beneficial than another. Further randomised clinical trials with an adequate design, including a large number of participants and sufficient duration should be carefully planned to provide a more precise estimate of the beneficial and harmful effects of antibiotic treatment for spontaneous bacterial peritonitis.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2009

Spontaneous bacterial peritonitis (infection and inflammation of the membrane lining the abdominal cavity) is a frequent complication among cirrhotic patients (patients with end‐stage liver disease marked by irreversible scarring of liver tissue) and is associated with significant morbidity and mortality. Selective intestinal decontamination, employing antibiotics, is a proposed prophylactic (preventive) measure. This systematic review of randomised clinical trials assesses whether antibiotic prophylaxis prevents spontaneous bacterial peritonitis and mortality among cirrhotic patients with ascites (excess fluid in the abdominal cavity) and no gastrointestinal bleeding. Nine trials are included in the review. The pooled rates of spontaneous bacterial peritonitis and mortality indicate that antibiotic prophylaxis reduces both. There are very few reports of adverse events. Reviewing these trials, we found poor methodology, evidence suggesting publication bias, and limited follow‐up periods. Thus, the recommendation to prescribe prophylactic antibiotics to cirrhotic patients without gastrointestinal bleeding is hampered by quality of the trials that generated the data. Due to potential hazards, both to society as a whole and the patients, as individuals, before antibiotic prophylaxis can be confidently recommended, trials of better design, well reported, and of longer follow‐up are required.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2009

The guideline covers the identification and assessment of suspected cirrhosis, monitoring to detect complications and management of complications such as ascites and hepatorenal syndrome and referral for tertiary care.

NICE Guideline - National Guideline Centre (UK).

Version: July 2016

BACKGROUND/AIMS: Spontaneous bacterial peritonitis (SBP) is a life-threatening disease that poses a great diagnostic challenge to clinicians. We aimed to systemically and quantitatively summarize the current evidence on the diagnostic value of the procalcitonin (PCT) test in identifying SBP.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2013

BACKGROUND & AIMS: Renal impairment increases mortality among patients with spontaneous bacterial peritonitis (SBP), despite administration of non-nephrotoxic antibiotics. Albumin infusion has been reported to reduce renal impairment and mortality in patients with SBP. We performed a meta-analysis of randomized controlled trials (RCTs) to quantify the effect of albumin infusion on renal impairment and mortality in patients with SBP.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2013

BACKGROUND AND AIM: Proton pump inhibitors (PPI) and H(2) -receptor antagonists (H2RA) are frequently prescribed in hospitalized patients with cirrhosis. There are conflicting reports regarding the role of acid-suppressive therapy in predisposing hospitalized patients with cirrhosis to spontaneous bacterial peritonitis (SBP). The aim of this meta-analysis was to evaluate the association between acid-suppressive therapy and the risk of SBP in hospitalized patients with cirrhosis.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2013

The authors concluded that the consistently excellent negative predictive value of leucocyte esterase reagent strips in spontaneous bacterial peritonitis diagnosis in cirrhotic patients gained it a place in the ascitic tap diagnostic algorithm. The limited search for studies means that the authors' conclusions should be interpreted with caution.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2008

This review found a statistically significant association between acid suppressive therapy using proton pump inhibitors and the development of spontaneous bacterial peritonitis in patients with cirrhosis. Lack of information about the studies and their quality mean that the authors' conclusions should be interpreted with substantial caution and may not be reliable.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2011

The authors concluded that daily oral fluoroquinolone prophylaxis reduced the risk of first episode spontaneous bacterial peritonitis, severe infection and mortality in patients with cirrhosis and low protein ascites. The review was generally well conducted, but in view of the small amount of evidence available, a degree of caution may be advisable in interpreting these conclusions.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2009

This review concluded that compared with untreated controls oral antibiotic prophylaxis improved short-term survival and reduced the overall infections including spontaneous bacterial peritonitis in patients with advanced cirrhosis and ascites. This review was generally well conducted. The authors' conclusions reflect the evidence presented and they are likely to be reliable.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2009

The authors concluded that ascitic fluid should be inoculated into blood culture bottles at the bedside. Spontaneous bacterial peritonitis is more likely at pre-described parameters of ascitic polymorphonuclear count or blood-ascitic fluid pH, and portal hypertension is less likely below pre-described serum-ascites albumin gradients. Given several limitations, including study quality, the authors' conclusions should be interpreted with caution.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2008

This review concluded that fluoroquinolones appear to be a relatively safe and effective treatment for intra-abdominal infections. It is difficult to assess the reliability of these conclusions given that validity was not assessed, the reliance on a number of small diverse studies, and the considerable changes in bacterial resistance over recent years. Caution is advised.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2007

The term “cancer of unknown primary” refers to a condition in which a patient has metastatic malignancy without an identified primary source. This is a very heterogeneous disease in which the type of tumour, the extent of spread, and the outcome of treatment all vary widely. When categorising patients with cancer of unknown primary, one important factor initially considered is the cell type of origin of the metastatic disease. The majority of patients have malignancy which appears to derive from epithelial cells, and hence are regarded as having carcinoma of unknown primary. Patients with tumours of non-epithelial lineage (melanoma, sarcoma, lymphoma, germ-cell) form a distinct and important minority, since subsequent management can often be satisfactorily undertaken even in the absence of an identifiable primary source. Such patients are not considered in this guideline, since their care is adequately defined in existing guidelines for their specific tumour type. The term “carcinoma of unknown primary” (CUP) is used henceforth to refer to those patients with metastatic malignancy of epithelial, neuroendocrine or undifferentiated lineage whose investigation and management is considered within the scope of this guideline.

NICE Clinical Guidelines - National Collaborating Centre for Cancer (UK).

Version: July 2010

Since the publication of the NICE clinical guideline on the prevention of healthcare-associated infections (HCAI) in primary and community care in 2003, many changes have occurred within the NHS that place the patient firmly at the centre of all activities. First, the NHS Constitution for England defines the rights and pledges that every patient can expect regarding their care. To support this, the Care Quality Commission (CQC), the independent regulator of all health and adult social care in England, ensures that health and social care is safe, and monitors how providers comply with established standards. In addition, the legal framework that underpins the guidance has changed since 2003.

NICE Clinical Guidelines - National Clinical Guideline Centre (UK).

Version: March 2012

Numerous studies have demonstrated racial and ethnic disparities in health care in the United States.These disparities have been demonstrated in the Veterans Affairs (VA) healthcare system, where financial barriers to receiving care are minimized. The VA is committed to delivering high-quality care in an equitable manner, and as such, to eliminating racial and ethnic disparities in health care. To inform this effort, we systematically reviewed the existing evidence on disparities within the VA, to address the following objectives: 1) Determine in which clinical areas racial and ethnic disparities are prevalent within the VA; 2) Describe what is known about the sources of those disparities; and 3) Qualitatively synthesize that knowledge to determine the most promising avenues for future research aimed at improving equity in VA health care.

Evidence-based Synthesis Program - Department of Veterans Affairs (US).

Version: June 2007

This guideline contains recommendations specific to twin and triplet pregnancies and covers the following clinical areas: optimal methods to determine gestational age and chorionicity; maternal and fetal screening programmes to identify structural abnormalities, chromosomal abnormalities and feto-fetal transfusion syndrome (FFTS), and to detect intrauterine growth restriction (IUGR); the effectiveness of interventions to prevent spontaneous preterm birth; and routine (elective) antenatal corticosteroid prophylaxis for reducing perinatal morbidity. The guideline also advises how to give accurate, relevant and useful information to women with twin and triplet pregnancies and their families, and how best to support them.

NICE Clinical Guidelines - National Collaborating Centre for Women's and Children's Health (UK).

Version: September 2011

Patients with liver cirrhosis have an impaired immune response. Often, liver cirrhosis patients experience complications from portal hypertension, such as gastroesophageal varices. These varices can bleed, increasing the risk of infection and death in a short period of time, despite proper endoscopic management. Patients who develop bacterial infections during hospitalisation for gastroesophageal haemorrhage are at increased risk of dying. Twelve trials (1241 patients) assessing several antibiotic prophylaxis regimens versus no intervention or placebo were analysed, showing that antibiotic prophylaxis successfully reduced the incidence of bacterial infections. Antibiotic prophylaxis was also associated with a reduction in mortality, mortality from bacterial infections, rebleeding rate, and days of hospitalisation. The prophylactic treatment was not associated with important adverse effects. Five trials (650 patients) assessed one antibiotic regimen compared with another. All antibiotic regimens provided similar benefits and none seemed superior. Thus, to this point there is no evidence to recommend one specific antibiotic regimen over the other. All trials analysed were subject to bias; thus, results should be interpreted carefully.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2010

The objective of this report was to perform a systematic review of the beneficial and harmful effects of rifaximin for reducing the risk of overt hepatic encephalopathy (HE) recurrence in patients ≥ 18 years of age who are at risk of HE recurrence despite the use of lactulose, or who are intolerant to lactulose.

Common Drug Review - Canadian Agency for Drugs and Technologies in Health.

Version: July 2015

The guideline is intended to cover the care of healthy women with uncomplicated pregnancies entering labour at low risk of developing intrapartum complications. In addition, recommendations are included that address the care of women who start labour as ‘low risk’ but who go on to develop complications. These include the care of women with prelabour rupture of membranes at term, care of the woman and baby when meconium is present, indications for continuous cardiotocography, interpretation of cardiotocography traces, and management of retained placenta and postpartum haemorrhage. Aspects of intrapartum care for women at risk of developing intrapartum complications are covered by a range of guidelines on specific conditions (see section 1.8) and a further guideline is planned on intrapartum care of women ‘at high risk’ of complications during pregnancy and the intrapartum period.

NICE Clinical Guidelines - National Collaborating Centre for Women's and Children's Health (UK).

Version: December 2014

Infections that occur in the wound created by an invasive surgical procedure are generally referred to as surgical site infections (SSIs). SSIs are one of the most important causes of healthcare-associated infections (HCAIs). A prevalence survey undertaken in 2006 suggested that approximately 8% of patients in hospital in the UK have an HCAI. SSIs accounted for 14% of these infections and nearly 5% of patients who had undergone a surgical procedure were found to have developed an SSI. However, prevalence studies tend to underestimate SSI because many of these infections occur after the patient has been discharged from hospital.

NICE Clinical Guidelines - National Collaborating Centre for Women's and Children's Health (UK).

Version: October 2008

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