this article published by pubmed at 2011 which show Peer-Reviewed Studies by The PubMed , Medline(R) , EMBASE databases to answer the question SHOULD ALBUMIN be used in all patients with spontaneous bacterial peritonitis
Diagnosis of Inflammatory bowel disease have challenges including differentiating from Irritable bowel disease using noninvasive biomarkers. Fecal calprotectin is a novel fecal marker which meets the diagnostic & monitoring requirements for IBD.
this article published by pubmed at 2011 which show Peer-Reviewed Studies by The PubMed , Medline(R) , EMBASE databases to answer the question SHOULD ALBUMIN be used in all patients with spontaneous bacterial peritonitis
Diagnosis of Inflammatory bowel disease have challenges including differentiating from Irritable bowel disease using noninvasive biomarkers. Fecal calprotectin is a novel fecal marker which meets the diagnostic & monitoring requirements for IBD.
By Dr. Usama Ragab, Zagazig Faculty of Medicine
PSC incidence ranges from 0.5 to 1.25 cases/100 000.
The prevalence of the disease ranges between six and 20 cases/100 000.
Men are more likely to be affected (70%).
Prevalence of PSC may be increased in first degree relatives of PSC patients
ascites is a major complication of liver cirrhsos but also develops as a squally of other diseases ,ascites may be worsened with other events making it life threatening
First Urinary Tract Infection Episode in Children: Are Procalcitonin Values & US Examination of Importance in the Diagnosis of Upper Urinary Tract Infection ?
This lecture is for undergraduates and post graduates. It is a case based discussion, taking the audience from definition of ascites and spontaneous bacterial sepsis to its symptomatology, physical findings, diagnostic algorithm and management of ascites and bacterial peritonitis
By Dr. Usama Ragab, Zagazig Faculty of Medicine
PSC incidence ranges from 0.5 to 1.25 cases/100 000.
The prevalence of the disease ranges between six and 20 cases/100 000.
Men are more likely to be affected (70%).
Prevalence of PSC may be increased in first degree relatives of PSC patients
ascites is a major complication of liver cirrhsos but also develops as a squally of other diseases ,ascites may be worsened with other events making it life threatening
First Urinary Tract Infection Episode in Children: Are Procalcitonin Values & US Examination of Importance in the Diagnosis of Upper Urinary Tract Infection ?
This lecture is for undergraduates and post graduates. It is a case based discussion, taking the audience from definition of ascites and spontaneous bacterial sepsis to its symptomatology, physical findings, diagnostic algorithm and management of ascites and bacterial peritonitis
Introduction: Bloodstream infections (BSIs) are associated with a high mortality rate of 20%-50%. Blood culture is paramount to identify causative agents of BSIs to choose an appropriate antimicrobial therapy. Objectives: The present study was undertaken to analyze the various microorganisms causing BSIs and study their antimicrobial resistance patterns in a tertiary care hospital, Eastern India. Materials and Methods: A total of 239 blood specimens from clinically suspected cases of BSIs were studied for 6 months from July 2015 to December 2015. Blood specimens were incubated in BacT/ALERT ® 3D system (bioMerieux, Durham, NC, USA) a fully automated blood culture system for detection of aerobic growth. Identification and antimicrobial susceptibility testing were conducted on VITEK ® 2 (bioMerieux, Durham, NC, USA) as per Clinical Laboratory Standards Institute guidelines. Results: Out of 239 specimens, 41 (17.2%) yielded growth of different microorganisms. From these isolates, 20 (48.8%) were Gram-negative bacilli, 18 (43.9%) were Gram-positive cocci and rest 3 (7.3%) were yeasts. Among Gram-negative bacilli, Klebsiella pneumoniae sub spp. pneumoniae (70%) was most commonly isolated. Coagulase-negative staphylococci (88.9%) were the most common isolate among Gram-positive cocci. All three Candida spp. isolated were nonalbicans Candida (two Candida tropicalis and one Candida krusei). Gram-negative isolates were least resistant to tigecycline and colistin. All Gram-positive cocci were sensitive to linezolid. Conclusion: Monitoring of data regarding the prevalence of microorganisms and its resistance patterns would help in currently prescribing antimicrobial regimens and improving the infection control practices by formulating policies for empirical antimicrobial therapy.
Clinicobacteriological study of Urinary tract infection in pregnant womeniosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Introduction: Landscape of etiological profile and microbiological resistance of Spontaneous Bacterial Peritonitis (SBP) in Chronic Liver Disease (CLD) is continuously changing. Early antibiotic treatment of SBP is crucial but spread of Multidrug Resistant (MDR) organism makes its current management challenging. Our study provides fresh insight into its etiology and resistance profile to design better empiric regimen.
Objective: Study etiological profi le and resistance pattern of SBP in CLD Methods: This prospective observational study was conducted at Government Medical College, Srinagar from April 2018 to March 2019.
EVALUATION OF SERUM LEVELS OF FASTING LIPID PROFILE IN PRE-ECLAMPTIC WOMEN
Wuraola Serah Nnaemeka, Olisekodiaka, MJ, Onuegbu, AJ, Ezeugwunne, IP, Maduka, IG, Suru, SM , Johnkennedy Nnodim
IRO INTERNATIONAL JOURNAL OF MEDICAL AND APPLIED SCIENCES 2018, 1(1):20-23.
SOCIAL AND ECONOMIC BURDEN OF CANCER ON 2020- REVIEW Tamizhazhagan, Pugazh...Earthjournal Publisher
SOCIAL AND ECONOMIC BURDEN OF CANCER ON 2020- REVIEW
Tamizhazhagan, Pugazhendy, Sakthidasan, Jayanthi, Ki-Hyun Kim
IRO INTERNATIONAL JOURNAL OF MEDICAL AND APPLIED SCIENCES 2018, 1(1):24-30.
DEVELOPMENT AND VALIDATION OF STABILITY INDICATING RP-HPLC METHOD FOR ESTIMAT...Earthjournal Publisher
DEVELOPMENT AND VALIDATION OF STABILITY INDICATING RP-HPLC METHOD FOR ESTIMATION OF TERCONAZOLE
Gandhi Santosh V , Phalke Truprti R, Chaudhari Atul P
IRO INTERNATIONAL JOURNAL OF MEDICAL AND APPLIED SCIENCES 2018, 1(1):14-19.
PDF
SPORADIC OUTBREAK CASES OF DIPHTHERIA: A THREE YEARS’ STUDY IN A TERTIARY CAR...Earthjournal Publisher
SPORADIC OUTBREAK CASES OF DIPHTHERIA: A THREE YEARS’ STUDY IN A TERTIARY CARE CENTRE OF NORTHEAST INDIA.
Daiji Gogoi Mohan, Mayuri Gogoi,Naba Kumar Hazarika
IRO INTERNATIONAL JOURNAL OF MEDICAL AND APPLIED SCIENCES 2018, 1(1):1-5.
Call for case report,review and research article for journals
1.International journal of medical and applied sciences.
Volume 6 issue2,2018
2.IRO International journal of medical and applied sciences.
Print journal
Volume 1 issue2, 2018
email: earthjournals@gmail.com
www.earthjournals.in
. Recent Advances in Mucoadhesive Buccal Drug Delivery Systems and Its Marketed Scope and
Opportunities
K.P.Sampath Kumar ,DebjitBhowmik .AmitsankarDutta, Shravan Paswan, Lokesh Deb
Critical Review in Pharmaceutical Sciences 2012, 1(1):83-98.
NEUROLOGICAL MANIFESTATIONS OF HIV/AIDS: A CLINICAL PROSPECTIVE STUDYEarthjournal Publisher
&Objectives: To study the clinical profile of neurological manifestations of Human immunodeficiency
virus(HIV)/Acquired immunodeficiency syndrome(AIDS) and to correlate with the CD4+T lymphocyte
count.Material & Methods : 50 patients who were in the age goup18-55 years, had HIV infection and history
suggestive of Nervous system manifestations were included. The HIV patients with past/present history of
other immunocompromised conditions ( cytotoxic drugs for malignancies, Post organ transplant patients,
Patients using steroids for long term), previous history of epilepsy, focal neurological deficit and head injury
were excluded from the study. All the patients were examined in detail by history and clinical neurological
examination. For all the patients have done routine investigations, and specific investigations like CT/MRI
Brain, Nerve Conduction Studies, CSF Analysis,EEG and Specific antibodies for organisms or parasite done
only wherever it is required. All the patients were correlated with the CD4 T cell count.Results:: Among 50
patients, Commonest age group affected was 26-35 yrs with male predominance(62%). Most common symptom
was non specific headache(38%).Most common opportunistic infetction was Tuberculous meningitis(34%).
Toxoplasmsa encephalitis was the most common space occupying lesion(20%).More number of patients were
seen in the CD4 range in between 51-200 cells/mic.L(72%) with all the diseases had correlation with CD4 T cell
activityCONCLUSION: In the present study, Opportunistic infections were the leading cause in patients
infected with HIV having Neurological manifestastions, usually occurs when the patients had severe
immunosuppresion (CD4 count< 200 cells/μL).
Key words: HIV Positive patients, CD4 T cell count, Neurological manifestation
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Are There Any Natural Remedies To Treat Syphilis.pdf
STUDY OF ASCITIC FLUID FOR DIAGNOSIS OF SPONTANEOUS BACTERIAL PERITONITIS (SBP) IN ADULT PATIENTS WITH CIRRHOSIS
1. INTERNATIONAL JOURNAL OF MEDICAL AND APPLIED SCIENCES
E‐ISSN:2320‐3137
1 www.earthjournals.org Volume 3, Issue 1, 2014
Research Article
STUDY OF ASCITIC FLUID FOR DIAGNOSIS OF
SPONTANEOUS BACTERIAL PERITONITIS (SBP) IN ADULT
PATIENTS WITH CIRRHOSIS
S Bankar *, A De **, S Baveja***
Department of Microbiology, L.T.M. Medical College, Mumbai, India.
* Sheetal S. Bankar, Ex-Senior Resident in Microbiology (Presently working as Assistant Professor in T.N. Medical College, Mumbai),
M.B.B.S., M.D.; ** Anuradha S. De, Professor in Microbiology, M.B.B.S., M.D.; ***Sujata M. Baveja, Professor & Head in Microbiology,
M.B.B.S., M.D.
Corresponding author:
Dr. Anuradha De, Professor,
Department of Microbiology, L.T.M. Medical College,
Sion, Mumbai - 400 022.
E-mail: dr_anuradhade@yahoo.com
Received on 30 December, 2013, Published on 30 Jan 2014
ABSTRACT
Ascitic fluid infections are a frequent complication among patients with cirrhosis and ascites, of which Spontaneous
Bacterial Peritonitis (SBP) is the most common, potentially fatal cause of deterioration in patients with advanced
cirrhosis with ascites. One hundred consecutive hospitalized patients of cirrhosis with ascites were included in this
prospective study. Ascitic fluid was analysed by culture by the conventional method and direct bedside inoculation
in tryptic soy broth (TSB), cell count and biochemical parameters. The cases were categorized into three groups –
Classic Spontaneous Bacterial Peritonitis (SBP), Culture Negative Neutrocytic ascites (CNNA) and Monomicrobial
non-neutrocytic bacterascites (MNB). Statistical analysis was done by Chi Square test, Paired and Unpaired ‘t’ tests.
Out of 100 patients of cirrhosis with ascites, 58% were SBP cases and 42 % were non-SBP cases. Amongst the 58
SBP cases, 53.45% cases were of Classic SBP, 36.21 % were CNNA and 10.34% cases were of MNB. Alcoholism
(84.48 %) was the commonest etiology in SBP cases. Escherichia coli was the commonest bacteria isolated,
followed by Pseudomonas aeruginosa and Acinetobacter species. Mean ascitic fluid polymorphonuclear count
(PMN) count was 755.19 ± 788.04 / mm3
. Overall susceptibility of bacteria to aminoglycosides, quinolones and
cephalosporins was 92.31%, 79.17% and 58.33% respectively. Hepatic encephalopathy was the major complication
(46.55%) in SBP cases. Highest mortality was seen in CNNA (66.67 %), followed by Classic SBP (45.16 %).SBP is
a serious complication in patients with advanced cirrhosis. It has high prevalence, high recurrence rate and poor long
term prognosis. A diagnostic paracentesis should always be performed routinely within 24 hours of admission and
ascitic fluid sample should be sent for culture, cytology and estimation of biochemical parameters, so as to initiate
prompt management in these patients and achieve a better survival rate.
2. INTERNATIONAL JOURNAL OF MEDICAL AND APPLIED SCIENCES
E‐ISSN:2320‐3137
2 www.earthjournals.org Volume 3, Issue 1, 2014
INTRODUCTION
Ascites is a common complication of cirrhosis of liver and indicates the presence of portal
hypertension and hepatic decompensation.[1]
Spontaneous Bacterial Peritonitis (SBP) is the most
common, potentially fatal, yet reversible cause of deterioration in patients with advanced
cirrhosis with ascites.[2]
SBP is defined as the infection of previously sterile ascitic fluid without
an apparent intra-abdominal source of infection.[3]
Ascitic fluid infection is classified into 5
categories based on ascitic fluid culture, polymorphonuclear (PMN) count and presence or
absence of surgical source of infection.[4]
The variants of Spontaneous Bacterial Peritonitis are Classic SBP, Culture Negative Neutrocytic
Ascites (CNNA) and Monomicrobial Non-neutrocytic Bacterascites (MNB). Classic
Spontaneous Bacterial Peritonitis (SBP) is diagnosed, when there is a positive ascitic fluid
culture, elevated ascitic fluid PMN count ≥ 250 cells/mm[3]
and no evidence of an intra-
abdominal surgically treatable source of infection. Culture Negative Neutrocytic Ascites
(CNNA) is diagnosed when ascitic fluid culture grows no bacteria, ascitic fluid PMN count is ≥
250 cells/mm3
, no antibiotic have been given (not even a single dose) and no other explanation
for an elevated ascitic PMN count (e.g. haemorrhage into ascites, peritoneal carcinomatosis,
tuberculosis or pancreatitis) can be identified. Monomicrobial non-neutrocytic bacterascites
(MNB) is diagnosed when there is a positive ascitic fluid culture for a single organism, an ascitic
fluid PMN count < 250 cells/mm3
and no evidence of an intra-abdominal surgically treatable
source of infection. Secondary bacterial peritonitis is diagnosed when ascitic fluid culture is
positive (usually for multiple organisms), PMN count is ≥ 250 cells/mm3
and an intra-abdominal
surgically treatable primary source of infection (peritoneal intestine, perinephric abscess) has
been identified. Polymicrobial bacterascites is diagnosed when multiple organisms are seen on
Gram stain which is cultured from the ascitic fluid and PMN count is < 250 cells/mm.[3]
Prevalence of SBP in cirrhotic patients varies in different parts of the world. In India, it ranges
from 9.3% - 34.92%,[5,6]
in other Asian countries from 22% - 58%[7,8]
and in the Western
countries from 7.7% - 35.4%.[9,10]
In India, the mortality ranges from 27.2 % - 43%,[6,11]
in other
Asian countries from 15% - 35%[7,12]
and in the Western countries from 15.45% - 50 %.[13,14]
There are reports mentioning the clinical aspects and treatment of SBP, but the microbiological
investigations for etiology of SBP are lacking in these reports. There is also scarcity of
documented reports on prevalence of SBP in this part of India and in view of high rate of
morbidity and mortality associated with SBP, this study was carried out.
MATERIALS AND METHODS
This was a prospective study of one year duration from January to December 2010. One hundred
consecutive adult patients admitted in this tertiary care hospital with cirrhosis were studied after
clearance from Institutional Ethics Committee. Ascites due to renal, cardiac, tubercular and
malignant pathology, secondary peritonitis and HIV positive patients were excluded from the
study.
Ten ml of ascitic fluid was tapped from the patient under proper aseptic precautions. Five ml of it
was inoculated directly into 25 ml of tryptic soy broth at the bedside.[5]
Tryptic soy broth was
incubated at 370
C and 3 subcultures were done on Blood Agar (BA) and MacConkey Agar (MA)
after 24 hours (2nd
day), 72 hrs (4th
day) and on the 7th
day. Two ml of the fluid was centrifuged
at 1500 rpm for 10 minutes. Supernatant was discarded. Deposit obtained was utilized for Gram
staining and then processed by conventional method on BA and MA.[11]
BA was incubated at
370
C at 5% CO2 atmosphere for 48 hours. MA was incubated at 370
C for 48 hours. BA was
3. INTERNATIONAL JOURNAL OF MEDICAL AND APPLIED SCIENCES
E‐ISSN:2320‐3137
3 www.earthjournals.org Volume 3, Issue 1, 2014
incubated at 370
C at 5% CO2 atmosphere for 48 hours. MA was incubated at 370
C for 48 hours.
Any growth in BA and/or MA plates was identified by standard biochemical tests. For all the
isolates, antibiotic susceptibility pattern was done by Kirby Bauer disc diffusion method
(KBDDM) on Mueller Hinton Agar (MHA), according to CLSI guidelines.[15]
Remaining 3 ml
was put in EDTA bulb for cell count and protein estimation.
Statistical analysis was carried out for significance by calculating the ‘p’ value. The categorical
data was analysed by Chi square test and Fischer exact correction test Open Epidemiological
Statistics for public health (Open Epi) software version 2.3). The quantitative data was expressed
as mean ± SD and analysed by Unpaired ‘t’ test (Student’s ‘t’ test).
RESULTS
One hundred patients of hepatic cirrhosis with ascites were studied, of which 93 were male and 7
were female. 59% of cases were in the age group of 41-60 years. Only alcoholism was the
etiology in 85% cases, followed by 9% HBsAg reactive, 5% anti-HCV reactive and 1% anti-
HEV reactive patients.
Out of total 100 cases, number of SBP cases was 58 (58 %). Amongst 58 SBP cases, Classic
SBP was the most common variant - 53.45 % (31/58), followed by MNB - 36.21 % (21/58) and
CNNA - 10.34% (6/58). Growth by only TSB was seen in 63.46% cases (33/58) and growth by
both the methods (Conventional + TSB) was seen in 36.54% cases (19/58). Thus, all culture
positive cases of SBP (52) showed growth in tryptic soy broth (TSB) by direct bedside
inoculation (100%). Males predominated (89.66%) in SBP cases. Alcoholism was the
commonest etiology of SBP (84.48%), followed by 8.62% HBsAg reactive and 6.90% anti-HCV
reactive patients.
By Chi square test, growth by direct bedside inoculation in TSB was statistically significant in
comparison to conventional method in 100 cases (p < 0.00001) as well as in 58 SBP cases (p <
0.000001).
By conventional method, 19 bacteria were recovered – 18 (94.74%) Gram negative bacilli and
one (05.26%) Gram positive cocci. By direct bedside inoculation in TSB, 52 bacteria were
recoverd – 41 (78.85%) Gram negative bacilli and 11 (21.15%) Gram positive cocci. Amongst
the Gram negative bacilli, Escherichia coli was the commonest bacteria, 11 (57.89%) by
conventional method and 21 (40.38%) by inoculation in TSB (Table 1). Whereas Escherichia
coli was commonest in Classic SBP, Pseudomonas aeruginosa was more in MNB. (Table 2).
82 % (82/100) of the patients belonged to Child Turcotte Pugh class C, 17% to class B and only
1% to class A. Fever, pain in abdomen, yellowish discoloration of body and sclera, altered
mental status and oliguria were the common clinical features in 68.97%, 82.76%, 82.76%,
53.45% and 25.86% respectively in SBP cases. They were statistically significant in SBP as
compared to non-SBP cases by Chi square test.
Total leucocyte count (TLC) was (mean ± SD) 11331.1 ± 7542.15 / mm3
in SBP cases and
7736.36 ± 4034.05 in non SBP cases. Serum bilirubin was comparatively higher in the SBP cases
with a (mean ± SD) 6.12 ± 7.41 mg/dl than the non-SBP cases (4.25 ± 4.3 mg/dl). Serum
creatinine was (mean ± SD) 1.73 ± 1.67 mg/dl in SBP cases and 1.18 ± 0.68 in SBP cases. SGOT
levels (mean ± SD) 102.14 ± 95.13 U/L in SBP cases and 69.55 ± 40.11 in SBP cases. Serum
protein and albumin levels in SBP cases were (mean ± SD) 6.12 ± 1.20 g/dl and 2.33 ± 0.71 g/dl
respectively. Total white blood cell (WBC) count, serum creatinine and SGOT levels were
statistically significant in SBP cases as compared to non-SBP cases by Unpaired ‘t’ test.
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Ascitic fluid total leucocyte count (1044.40 ± 1013.26/ mm3
), polymorphonuclear count (755.19
± 788.04/ mm3
) and lymphocyte counts (254.02 ± 215.60 / mm3
) were statistically significant in
SBP cases as compared to non-SBP cases.
Table 3 shows the biochemical parameters in the three variants of SBP. By Unpaired ‘t’ test,
ascitic fluid PMN count was found to be statistically significant between Classic SBP and MNB
(p = 0.0000001) and between CNNA and MNB (p = 0.02585). However, it showed no statistical
significance between Classic SBP and CNNA (p = 0.4494). By Unpaired ‘t’ test, ascitic fluid
protein was not found to be statistically significant between any of the variants - Classic SBP and
MNB (p=0.1215), CNNA and MNB (p= 0.1037) and Classic SBP and CNNA (p=0.6010). By
Unpaired ‘t’ test, serum bilirubin was found to be statistically significant between CNNA and
MNB (p= 0.0354). However, it showed no statistical significance between Classic SBP and
MNB (p=0.2113) and between Classic SBP and CNNA (p=0.1183). By Unpaired ‘t’ test, serum
creatinine was found to be statistically significant between Classic SBP and MNB (p= 0.02158).
It was not found to be statistically significant between CNNA and MNB (p=0.3504) and between
Classic SBP and CNNA (p=0.5437).
Overall susceptibility of bacteria to aminoglycosides, quinolones and cephalosporins was
92.31%, 79.17% and 58.33% respectively (Table 4). All Gram negative bacilli were 100%
susceptible to amikacin and imipenem, followed by 91.43% to piperacillin-tazobactam, 80% to
ciprofloxacin, 54.29% to cefotaxime and only 20.25% to amoxycillin-clavulanic acid.
Escherichia coli susceptibility to cefotaxime was 57.14%. Pseudomonas aeruginosa showed
100% susceptibility to imipenem. None of the isolates were Extended spectrum beta–lactamase
(ESBL) producer. Streptococci was not susceptible to penicillin but was susceptible to
vancomycin and linezolid. No Methicillin Resistant Staphylococcus aureus (MRSA),
Vancomycin Intermediate Staphylococcus aureus (VISA), Vancomycin Resistant
Staphylococcus aureus (VRSA) and Vancomycin Resistant Enterococci (VRE) were detected.
Duration of hospital stay of < 4 days was found to be statistically significant (p = 0.0000001) in
SBP patients as compared to non- SBP patients. All SBP patients with < 4 days hospital stay
expired. Duration of hospital stay of < 4 days was statistically significant in Classic SBP as
compared to CNNA and MNB cases. All MNB cases had duration of hospital stay of ≥ 4 days.
Complications were seen in 41% patients, of which hepatic encephalopathy was the commonest
(38%). In SBP and non - SBP cases, complications were 51.72 % (30/58) and 26.19% (11/42)
respectively. Major complication seen in SBP cases was also hepatic encephalopathy, seen in
46.55% (27/58) cases. Maximum complications were seen in CNNA (83.33%), followed by
Classic SBP (67.74%).
Overall mortality was 24 %. In SBP cases, mortality was 34.49% (20/58). Mortality in SBP cases
was statistically significant in comparison to non-SBP cases (p = 0.003922). Highest mortality
was seen in CNNA (66.67%), followed by Classic SBP (45.16%).
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Table 1: Different bacteria grown by the three methods
Bacteria
Conventional
Method
Direct bedside inoculation in TSB
No. % No. %
Escherichia coli 11 57.89 21 40.38
Pseudomonas aeruginosa 4 21.07 6 11.54
Acinetobacter species 1 05.26 6 11.54
Enterobacter species 1 05.26 5 09.62
Proteus mirabilis 1 05.26 2 03.85
Klebsiella pneumoniae 0 00.00 1 01.92
Enterococcus species 0 00.00 4 07.69
Streptococcus species 1 05.26 4 07.69
Methicillin Sensitive
Staphylococcus aureus
0 00.00 3 05.77
Total 19 100 52 100
Table 2: Different bacteria grown by both the methods in Classic SBP and MNB cases
Bacteria
Conventional
Method
Direct bedside inoculation in TSB
Classic
SBP
MNB
Classic
SBP
MNB
No. (%) No. (%) No. (%) No. (%)
Escherichia coli 10 (76.93) 1 (16.67) 18 (58.06) 3 (14.29)
Pseudomonas aeruginosa 1 (07.69) 3 (50.00) 3 (09.67) 3 (14.29)
Acinetobacter species 1 (07.69) 0 2 (06.45) 4 (19.05)
Enterobacter species 0 1 (16.67) 2 (06.45) 3 (14.29)
Proteus mirabilis 1 (07.69) 0 1 (03.23) 1 (04.75)
Klebsiella pneumoniae 0 0 1 (03.23) 0
Enterococcus species 0 0 2 (06.45) 2 (09.52)
Streptococcus species 0 1 (16.67) 1 (03.23) 3 (14.29)
Methicillin Sensitive
Staphylococcus aureus
0 0 1 (03.23) 2 (09.52)
Total
13 6 31 21
19 52
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Table 3: Biochemical parameters in variants of SBP
Variants of SBP Classic SBP MNB CNNA
Ascitic fluid
Polymorphonuclear
(PMN ) count /mm3
1096.33 ± 812.73 82.73 ± 70.56 828.86 ± 582.00
Ascitic fluid protein level
(g/dl)
1.99 ± 1.00 1.59 ± 0.72 2.23 ± 1.13
Serum bilirubin (mg/dl) 5.51 ± 4.76 3.85 ± 4.45 16.7 ± 14.4
Serum creatinine (mg/dl) 1.80 ± 1.02 1.18 ± 0.76 2.87 ± 4.00
Table 4: Susceptibility of bacteria to three groups of antimicrobial agents
Bacteria
Antimicrobial agents
Aminoglycosides Quinolones Cephalosporins
No.
susceptible
Total
no.
tested
No.
susceptible
Total
no.
tested
No.
susceptible
Total
no.
tested
Gram positive cocci 09 11 06 07 05 07
Enterobacteriaceae +
Acinetobacter species
35 35 28 35 19 35
Pseudomonas
aeruginosa
04 06 04 06 04 06
Total (%)
48
(92.31)
52
38
(79.17)
48
28
(58.33)
48
DISCUSSION
Youngest patient in the study was 21 years old and the oldest was 63 years old. Maximum
number of cases of cirrhosis with ascites was seen in the age group of 41-60 years (59%). This
was almost similar to a study from Nepal where 56% were in the age group between 40-59
years.[16]
In 58 cases of SBP, males predominated (89.66%). In the Nepal study, amongst the
SBP cases, 94% were males.[16]
The commonest etiology in these patients with cirrhosis was alcoholism (90%) – 85% had
history of only alcoholism and 5% were alcoholics and HBs antigen reactive. A similar study
from this part of India had also shown alcoholism as the main etiology (57.14%).[11]
A recent
Asian study also have reported alcohol related cirrhosis in 97.53% cases, while only 2.4% were
non-alcoholic.[7]
In the present study, spontaneous bacterial peritonitis (SBP) was present in 58% of cases and the
remaining 42% were non-SBP cases. This is similar to the studies reported from Peshawar and
Larkana in 2010 (58% and 54% respectively).[8,17]
The probable reasons for higher prevalence in
the present study and latter studies may be late referral to the tertiary care hospital, low socio
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economic conditions and malnutrition.[17]
In this study, Classic SBP was commonest (53.45%),
followed by 36.21% of MNB. CNNA encountered was only 10.34%. However the study from
Larkana did not have any case of MNB, but prevalence of CNNA was 46% .[8]
A recent study
from India in 2010 have reported Classic SBP in 66.67% cases, CNNA in 25% and MNB in
8.33%,[5]
which is almost similar to this study.
Gram negative bacilli (GNB) predominated – 94.74% by conventional method and 78.85% by
direct inoculation in TSB. Almost all the studies of ascitic fluid cultures have shown
predominance of Gram negative bacilli ranging from 28.17% to 100%.[5,6,7,8,9,16-18]
Amongst the
Gram negative bacilli, Escherichia coli was the commonest bacteria – 57.89% and 40.38%,
followed by Pseudomonas aeruginosa – 21.07% and 11.54% by conventional method and by
direct inoculation in TSB respectively (Table 1). Various studies have isolated Escherichia coli
from 22.22 to 75% from ascitic fluid.[5,6,7,16,18]
Pseudomonas aeruginosa and Acinetobacter
species have also been isolated from ascitic fluid cultures from other studies.[5,6,7,8,9,12,16,17]
Overall 82% of cases were in Child Turcotte Pugh (CTP) class C in this study). In studies from
Asian countries, 85% to 88% of their cases belonged to CTP class C.[7,16]
In a study from
Wardha, all belonged to CTP class C (100%).[6]
In this study, fever and pain in abdomen was
present in 68.97% and 82.76% patients of SBP respectively and jaundice was present in 82.76%
patients. A recent Indian study have reported abdominal pain, fever, jaundice and GI bleed in
75%, 62.5%, 62.5% and 25% cases of SBP respectively.[5]
Total leucocyte count (TLC) in this study was (mean ± SD) 11331.1 ± 7542.15 / mm3
in SBP
cases, which correlated well with a study from Nepal (12580 ± 6564 / mm3
).[7]
Serum protein
and albumin levels in SBP cases in this study, is almost similar to a study by Syed et al, where
the respective values were (mean ± SD) 6.18 ± 1.32 g/dl and 2.22 ± 0.41 g/dl. Even studies from
Karnataka and Mumbai have reported serum albumin (mean ± SD) of 2.46 ± 0.54 g/dl and 1.98 ±
0.2 g/dl respectively.[5,11]
In this study, serum bilirubin was comparatively higher in the SBP cases than the non-SBP cases,
but this was not statistically significant. Even Doddamani et al and Amrapurkar et al from India
have reported serum bilirubin of 6.87 mg/dl and 6.80 ± 5.5 mg/dl respectively in SBP cases.[5,11]
In this study, serum creatinine in SBP cases was 1.73 ± 1.67 mg/dl, which was statistically
significant when compared to non-SBP cases. Two studies from Nepal have reported serum
creatinine values of 1.57 ± 1.36 mg/dl and 1.60 ± 0.7 mg/dl in the SBP group and they also
showed statistical significance in cases of SBP.[7,16]
Ascitic fluid PMN count in this study was statistically significant in SBP cases as compared to
non-SBP cases. Other studies also have shown a high ascitic fluid PMN count in SBP cases to
the range of (mean ± SD) 785.5 ± 726.4 /mm3
to 2052.41 ± 206.83 /mm3
. All the studies
between the 2 groups were of statistical significance.[7,16-18]
Ascitic fluid PMN count of > 250/
mm3
should be considered as diagnostic of SBP.[19]
This count was found to be of statistical
significance between Classic SBP and MNB (p= 0.0000001) and also between CNNA and MNB
(P= 0.02585), but it was not statistically significant between Classic SBP and CNNA (p =
0.4494). Runyon and Hoefs showed that patients with CNNA behave similar to those with
Classic SBP[20]
and in this study also PMN counts of Classic SBP and CNNA (mean ± SD) were
1096.33 ± 812.73 /mm3
and 828.86 ± 582.0 /mm3
respectively. Ascitic fluid total leucocyte
count (mean ± SD) was 1044.40 ± 1013.26 / mm3
in SBP cases and was statistically significant
in comparison to non-SBP cases, which is similar to other Asian studies.[7,21,22]
Overall aminoglycoside susceptibility in this study was 92.31%, followed by 79.17%
susceptibility to quinolones and 58.33% to cephalosporins. In a recent report from Egypt,
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cefotaxime susceptibility was 29.11% and ciprofloxacin susceptibility was 17.72%.[18]
Ciprofloxacin resistance from 2002 to 2005 in a Korean study was 18%,[23]
which is in
accordance to this study (20%), whereas cefotaxime resistance during the same period in their
study was 14.8% and in the present study it is 41.67%.
Amoxycillin-clavulanic acid susceptibility was reported less in the study from Egypt (20.25%),
as compared to this study (42.86%) in Gram negative bacilli. The present study shows only
54.29% susceptibility of Gram negative bacilli to cefotaxime. Even the predominant isolate
Escherichia coli showed susceptibility of only 57.14% to the same antibiotic. Therefore, it is
important for the clinicians to be aware of the recent increase in cefotaxime resistance in Gram
negative isolates from SBP cases.[23]
Though cefotaxime remains the drug of choice for treatment
of SBP, the resistance of Gram negative isolates to cefotaxime as reported by the present study is
45.71%. In view of this, the clinicians should be made aware that even if they start with
cefotaxime, they should change over to other antimicrobials like quinolones and
aminoglycosides, according to the antimicrobial susceptibility report from the laboratory.
Hepatic encephalopathy as a major complication was also seen in studies from Lahore (40%)[24]
and Larkana (32%),[8]
which are almost similar to the present study (38%). Overall mortality in
this study was 24%, which is exactly similar to a study from Portugal (24%).[25]
Mortality in the
range of 21-28% have been reported by an Indian study[6]
and another Asian study.[12]
CONCLUSION
Spontaneous Bacterial Peritonitis (SBP) is a serious complication in patients of advanced
cirrhosis with ascites. It is still a highly relevant condition in clinical practice due to its high
prevalence, high recurrence rate and poor long term prognosis. Hence, a diagnostic paracentesis
should always be performed routinely within 24 hours of admission and ascitic fluid sample
should be sent for culture, estimation of cell count and biochemical parameters. This is required
to initiate prompt management in these patients so as to reduce mortality and achieve a better
survival rate. Direct bedside inoculation in TSB is a superior method of ascitic fluid culture than
the conventional method for the diagnosis of SBP. Clinicians should be aware of increased
resistance of bacteria to cefotaxime. Ciprofloxacin could be a promising alternative antimicrobial
in management of SBP.
REFERENCES
1. Moore K. Cirrhosis and Ascites. In Oxford Textbook of Medicine, Vol. 2, 5th
Ed. Eds: Warrell DA, Cox TM,
Firth JD. Oxford University Press, New York, 2010; pp 2482 – 3.
2. Sheer TA, Runyon BA. Spontaneous Bacterial Peritonitis 2005; 23: 39-46.
3. Arroyo V, Navasa M. Ascites and Spontaneous Bacterial Peritonitis. In Schiff’s Diseases of the Liver. Vol 1. 10th
Ed. Eds: Schiff ER, Sorrel MF, Maddrey WC. Lippincott Williams and Wilkins, Philadelphia, 2007; pp 530-63.
4. Runyon BA. Ascites and spontaneous bacterial peritonitis. In: Sleisenger and Fordtran’s Gastrointestinal and
Liver diseases. Pathophysiology/ Diagnosis/ Management. Vol 2, 9th
Ed. Eds: Feldman M, Friedman LS, Brandt LJ.
Saunders, Elsevier, Philadelphia. 2010: 1516-41.
5. Doddamani G B, P.Sunita, Kora SA. Spontaneous Bacterial Peritonitis in ascites: A prospective study in a tertiary
care hospital. Journal of clinical and diagnostic research 2010; 4: 2737- 41
6. Jain PA, Chandra SL, Gupta S, Gupta OP, Jajoo NU, Kalantri PS. Spontaneous Bacterial Peritonitis in Liver
Cirrhosis with ascites. J Assoc Phys India 1999; 47. 619-21
7. Syed VA, Ansari JA, Karki P. Regmi M, Khana B. Spontaneous Bacterial Peritonitis: A prospective study in
tertiary care Hospital, Nepal. Kathmandu University Medical Journal 2007; 5: 48-59.
8. Jalbani A, Shah AH, Ansari IA, Chutto MA, Gurbakhshani KM. Spontaneous bacterial peritonitis, an experience
at CMCH Larkana. Medical Channel 2010, 16: 39-41.
9. INTERNATIONAL JOURNAL OF MEDICAL AND APPLIED SCIENCES
E‐ISSN:2320‐3137
9 www.earthjournals.org Volume 3, Issue 1, 2014
9. Gunjaca I, Francetic I. Prevalence and clinical outcome of spontaneous bacterial peritonitis in hospitalized
patients with liver cirrhosis: a prospective observational study in central part of Croatia. Acta Clin Croat 2010; 49:
11- 8.
10. Lata J, Fejfar T, Krechler T, Musil T, Husova L, Senkyrik M, et al. Spontaneous bacterial peritonitis in the
Czech Republic: Prevalence and aetiology. Eur J Gastroenterol Hepatol 2003; 15: 739-43.
11. Amprapurkar DN, Vishwanathan N, Parikh SS, Kalro RH, Desai HG. Prevalence of spontaneous bacterial
peritonitis. J Assoc Phys India 1992; 40: 236-8.
12. Heo J, Seo YS, Yim HJ, Hahn T, Park SH, Ahn SH, et al. Clinical Features and Prognosis of Spontaneous
Bacterial Peritonitis in Korean Patients with Liver Cirrhosis: A Multicenter Retrospective Study. Gut and Liver
2009; 3: 197-204.
13. Leandro G, Colloredo Mels G, Minola M, Manghisi OG, Di Nolfo MA, Moretti GB. The spontaneous bacterial
peritonitis in cirrhotic patients. The new gold standard. Ital J Gastroenterol; 23: 416-20.
14. Rotkvic I, Sikiric P, Jukic J, Krizanac S, Zjacic-Rotkvic V, Anic T, et al. Spontaneous bacterial peritonitis in
patients with decompensated cirrhosis and” tense” ascites. Acta Med lugosl 1990; 44: 285-95.
15. Performance Standards for Antimicrobial Susceptibility Testing; Twenty Third Informational Supplement.
Clinical Laboratory Standards Institute. 2013;M100-S23.
16. Nepal N, Pande PR, Pande R, Khatri R. Study of frequency of Spontaneous Bacterial Peritonitis in patients with
alcoholic liver cirrhosis with ascites. Postgrad Med J of NAMS 2009; 9: 45-9.
17. Khan TM, Ali A, Noor-ul-Iman. Yield of ascitic fluid cultures in Spontaneous Bacterial Peritonitis in cirrhosis. J
Med Sci 2010; 18: 59-62.
18. El-Bendary MM, Abdel-Aziz M, El-Sherbiny Walid A, Farag R E, El-Gilany AH, Zaghloul Mohd HE.
Spontaneous Bacterial Peritonitis: Clinico-epidemiological and microbiological study. Benha Med J 2009; 26: 287-
9.
19. Boixeda D, De Luis DA, De, Argila CM. Spontaneous bacterial peritonitis. Clinical and microbiologic study of
233 episodes. J Clin Gastroenterol 1996; 23: 275-9.
20. Runyon BA, Hoefs JC. Culture-negative neutrocytic ascites: A variant of spontaneous bacterial peritonitis.
Hepatol 1984; 4: 1209-11.
21. Runyon BA, Canawati HN, Akriviadis EA. Optimization of ascitic fluid culture technique. Gastroenterol 1988;
95: 1351-5.
22. Pawar GP, Gupta M, Satija VK. Evaluation of culture techniques for detection of spontaneous bacterial
peritonitis in cirrhotic ascites. Indian J Gastroenterol.1994; 13:139-140.
23. Park MK, Lee JH, Byun YH, Lee HIe, Gwak GY, Choi MS, et al. Changes in the profiles of causative agents
and antibiotic resistance rate for spontaneous bacterial peritonitis: an analysis of cultured microorganisms in recent
12 years. Korean J Hepatol. 2007; 13: 370 - 7.
24. Nouman S, Hussain A, Hussain M, Ahmed M. Frequency of Spontaneous Bacterial Peritonitis in chronic liver
disease. Annals 2010; 16: 112-5.
25. Dinis-Ribeiro M, Cortez-Pinto H, Marinho R, Valente A, Raimundo M, Salgado MJ, et al Spontaneous bacterial
peritonitis in patients with hepatic cirrhosis: Evaluation of a treatment protocol at specialized units. Rev Esp Enferm
Dig 2002; 94: 473-81.