Introduction Ascites is an important development in the course of liver cirrhosis, associated with a 50% mortality over 2 years ^[1]. The aetiology of spontaneous bacterial peritonitis (SBP) is thought to be the translocation of intra-luminal gut bacterial to ascitic fluid, in the absence of luminal perforation or abscess formation ^[2]. Initially the mortality exceeded 90%; however, with early recognition and appropriate antibiotics, the mortality has reduced to 20% ^[1-2]. The British Society of Gastroenterology (BSG) have produced guidelines for decompensated liver cirrhosis including the investigations of ascites.

Method We collated every blood culture bottles and sterile containers received with ascitic fluid from January 2015 to March 2016. We identified every patient with a positive blood culture bottles and every sterile container with a neutrophil count greater than 250 cells/mm³. Each result had their case notes reviewed and compared to the BSG standards

Results There were a total of 954 sterile containers and 352 blood culture bottles. 3.5% of sterile containers (n=33) had a neutrophil count >250 cells/mm³. The average neutrophil count was 1488 (range 260–6300). A neutrophil count greater than 1500 was predictive of a positive growth (54% vs 4.7%), only E.Coli was grown from containers. In comparison, 7.9% (n=28) of blood culture bottles grew an organism and returned a much more varied growth. Only 21% of patients had samples sent in both sterile containers and blood culture bottles. 82% of cases were treated with the locally recommended Piperacillin/Tazobactam; unless allergic to penicillins, when they were treated with Carbapenems. 24% (n=10) of cases treated with Piperacillin responded poorly and were escalated to either a Carbapenem or Linezolid, those with a positive culture grew multidrug resistant bacteria, including Piperacillin/Tazobactam. There was an overall in-hospital mortality of 30.1% (n=16).

Conclusion Spontaneous bacterial peritonitis remains a high mortality diagnosis (30.1%), where the prompt investigation, diagnosis and management is associated with improved patient outcomes and survival. The implementation of the BSG guidelines from all acute hospitals is imperative and should be complemented with education of staff to use both sterile containers for neutrophil counts and blood culture bottles. The emergence of penicillin-resistant organisms from the ascitic fluid is a concern, further highlighting the importance of integrating the guidance into hospital practice.

References

1. . Moore KP, Aithal GP. Guidelines on the management of ascites in cirrhosis. Gut 2006;55:(suppl 6).

2. . Garcia-Tsao G. Current management of the complication of cirrhosis and portal hypertension: variceal haemorrhage, ascites and spontaneous bacterial peritonitis. Gastroenterology. 2001;120(3):726–748.

Disclosure of Interest None Declared