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Appropriate and timely antimicrobial therapy in cirrhotic patients with spontaneous bacterial peritonitis‐associated septic shock: a retrospective cohort study
Author(s) -
Karvellas C. J.,
Abraldes J. G.,
Arabi Y. M.,
Kumar A.
Publication year - 2015
Publication title -
alimentary pharmacology and therapeutics
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 3.308
H-Index - 177
eISSN - 1365-2036
pISSN - 0269-2813
DOI - 10.1111/apt.13135
Subject(s) - medicine , spontaneous bacterial peritonitis , septic shock , retrospective cohort study , antimicrobial , intensive care unit , cirrhosis , peritonitis , odds ratio , cohort , gastroenterology , liver disease , sepsis , microbiology and biotechnology , biology
Summary Background Spontaneous bacterial peritonitis ( SBP )‐associated septic shock carries significant mortality in cirrhosis. Aim To determine whether practice‐related aspects of antimicrobial therapy contribute to high mortality. Methods Retrospective cohort study of all ( n = 126) cirrhotics with spontaneous bacterial peritonitis (neutrophil count >250 or positive ascitic culture)‐associated septic shock (1996–2011) from an international, multicenter database. Appropriate antimicrobial therapy implied either in vitro activity against a subsequently isolated pathogen (culture positive) or empiric management consistent with broadly accepted norms (culture negative). Results Overall hospital mortality was 81.8%. Comparing survivors ( n = 23) with non‐survivors ( n = 103), survivors had lower Acute Physiology and Chronic Health Evaluation ( APACHEII ) (mean ± s.d.; 22 ± 7 vs. 32 ± 8) and model for end‐stage liver disease ( MELD ) (24 ± 9 vs. 34 ± 11) scores and serum lactate on admission (4.9 ± 3.1 vs. 8.9 ± 5.3), P < 0.001 for all. Survivors were less likely to receive inappropriate initial antimicrobial therapy (0% vs. 25%, P = 0.013) and received appropriate antimicrobial therapy earlier [median 1.8 (1.1–5.2) vs. 9.5 (3.9–14.3) h, P < 0.001]. After adjusting for covariates, APACHEII [ OR , odds ratio 1.45 (1.04–2.02) per 1 unit increment, P = 0.03], lactate [ OR 2.34 (1.04–5.29) per unit increment, P = 0.04] and time delay to appropriate antimicrobials [ OR 1.86 (1.10–3.14) per hour increment, P = 0.02] were significantly associated with increased mortality. Conclusions Cirrhotic patients with septic shock secondary to spontaneous bacterial peritonitis have high mortality (>80%). Each hour of delay in appropriate antimicrobial therapy was associated with a 1.86 times increased hospital mortality. Admission APACHEII and serum lactate also significantly impacted hospital mortality. Earlier initiation of appropriate antimicrobial therapy could substantially improve outcome.