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

  • Sumit Kumar Singh
  • Ujjal PoddarEmail author
  • Richa Mishra
  • Anshu Srivastava
  • Surender Kumar Yachha
Original Article


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.


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.


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.


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.


Ascites Children Nosocomial Infection 


Compliance with ethical standards

Conflict of interest

Sumit Kumar Singh, Ujjal Poddar, Richa Mishra, Anshu Srivastava and Surender Kumar Yachha declare that they have no conflict of interest.

Ethical standard

The primary study was approved by the institutional ethics committee, Sanjay Gandhi Postgraduate Institute of Medical Sciences and conducted in compliance with the Good Clinical Practice guidelines, the Declaration of Helsinki, and regulatory requirements.

Informed consent

All patients provided written informed consent and all protocols were approved by the institutional ethics committee.


  1. 1.
    Gines P, Quintero E, Arroyo V, Terés J, Bruguera M, Rimola A, et al. Compensated cirrhosis: natural history and prognostic factors. Hepatology 1987;7(1):122–128Google Scholar
  2. 2.
    D’Amico G, Morabito A, Pagliaro L, Marubini E. Survival and prognostic indicators in compensated and decompensated cirrhosis. Dig Dis Sci 1986;31(5):468–475Google Scholar
  3. 3.
    European Association for the Study of the Liver. EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol 2010;53(3):397–417Google Scholar
  4. 4.
    El-Shabrawi MHF, El-Sisi O, Okasha S, Isa M, Elmakarem SA, Eyada I, et al. Diagnosis of spontaneous bacterial peritonitis in infants and children with chronic liver disease: a cohort study. Italian J Pediatr 2011;37(1):26–29Google Scholar
  5. 5.
    Haghighat M, Dehghani SM, Alborzi A, Imanieh MH, Pourabbas B, Kalaniet M. Organisms causing spontaneous bacterial peritonitis in children with liver disease and ascites in Southern Iran. World J Gastroenterol 2006;12(36):5890–5892Google Scholar
  6. 6.
    Preto-Zamperlini M, Farhat SCL, Perondi MBM, Pestana AP, Cunha PS, Pugliese RP, et al. Elevated C-reactive protein and spontaneous bacterial peritonitis in children with chronic liver disease and ascites. J Pediatr Gastroenterol Nutr 2014;58(1):96–98Google Scholar
  7. 7.
    Vieira SMG, Matte U, Kieling CO, Barth AL, Ferreira CT, Souza AF, et al. Infected and noninfected ascites in pediatric patients. J Pediatr Gastroenterol Nutr 2005;40(3):289–294Google Scholar
  8. 8.
    Srivastava A, Malik R, Bolia R, Yachha SK, Poddar U. Prevalence, clinical profile, and outcome of ascitic fluid infection in children with liver disease. J Pediatr Gastroenterol Nutr 2017;64(2):194–199Google Scholar
  9. 9.
    Rimola A, Garcı´a-Tsao G, Navasa M, Piddock LJ, Planas R, Bernard B, et al. Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis: a consensus document. J Hepatol 2000;32(1):32142–3253Google Scholar
  10. 10.
    Alexopoulou A, Papadopoulos N, Eliopoulos DG,  Alexaki A, Tsiriga A, Toutouza M, et al. Increasing frequency of Gram-positive cocci and Gram-negative multidrug-resistant bacteria in spontaneous bacterial peritonitis. Liver Int 2013;33(7):975–981Google Scholar
  11. 11.
    Tandon P, Delisle A, Topal JE, Garcia-Tsao G. High prevalence of antibiotic-resistant bacterial infections among patients with cirrhosis at a US liver center. Clin Gastroenterol Hepatol 2012;10(11):1291–1298Google Scholar
  12. 12.
    Fernández J, Acevedo J, Castro M, Garcia O, de Lope CR, Roca D, et al. Prevalence and risk factors of infections by multiresistant bacteria in cirrhosis: a prospective study. Hepatology 2012;55(5):1551–1561Google Scholar
  13. 13.
    Mowat C, Stanley AJ. Review article: spontaneous bacterial peritonitis: diagnosis, treatment and prevention. Aliment Pharmacol Ther 2001;15(12):1851–1895Google Scholar
  14. 14.
    Jindal A, Kumar M, Bhadoria AS, Maiwall R, Sarin SK. A randomized open label study of ‘imipenem vs. cefepime in spontaneous bacterial peritonitis. Liver Int 2016;36(5):677–687Google Scholar
  15. 15.
    Vergani GM, Heller S, Jara P, Chang MH, Fujisawa T, González-Peralta RP, et al. Autoimmune hepatitis. J Pediatr Gastroenterol Nutr 2009;49(2):158–164Google Scholar
  16. 16.
    Roberts EA, Schilsky ML. Diagnosis and treatment of Wilson disease: an update. Hepatology 2008;47(6):2089–2111Google Scholar
  17. 17.
    Squires RH, Shneider BL, Bucuvalas J, Alonso E, Sokol RJ, Narkewicz MR, et al. Acute liver failure in children: the first 348 patients in the pediatric acute liver failure study group. J Pediatr 2006;148(5):652–658Google Scholar
  18. 18.
    Lee WS, McKiernan P, Kelly DA. Etiology, outcome and prognostic indicators of childhood fulminant hepatic failure in the United Kingdom. J Pediatr Gastroenterol Nutr 2005;40(5):575–581Google Scholar
  19. 19.
    Alam S, Lal BB, Sood V, Rawat D. Pediatric acute-on-chronic liver failure in a specialized liver unit: prevalence, profile, outcome, and predictive factors. J Pediatr Gastroenterol Nutr 2016;63(4):400–405Google Scholar
  20. 20.
    Jagadisan B, Srivastava A, Yachha SK, Poddar U. Acute on chronic liver disease in children from the developing world: recognition and prognosis. J Pediatr Gastroenterol Nutr 2012;54(1):77–82Google Scholar
  21. 21.
    Yachha SK, Goel A, Khanna V, Poddar U, Srivastava A, Singh U. Ascitic form of sporadic acute viral hepatitis in children: a distinct entity for recognition. J Pediatr Gastroenterol Nutr 2010;50(2):184–187Google Scholar
  22. 22.
    Thomas FB, Fromkes JJ. Spontaneous bacterial peritonitis associated with acute viral hepatitis. J Clin Gastroenterol 1982;4(3):259–262Google Scholar
  23. 23.
    Poddar U, Thapa BR, Prasad A, Sharma AK, Singh K. Natural history and risk factors in fulminant hepatic failure. Arch Dis Child 2002;87:54–56Google Scholar
  24. 24.
    Wiest R, Krag A, Gerbes A. Spontaneous bacterial peritonitis: recent guidelines and beyond. Gut 2012;61(4):297–310Google Scholar
  25. 25.
    Felisart J, Rimola A, Arroyo V, Perez-Ayuso RM, Quintero E, Gines P, et al. Cefotaxime is more effective than is ampicillin-tobramycin in cirrhotics with severe infections. Hepatology 1985;5(3):457–462Google Scholar
  26. 26.
    Shi L, Wu D, Wei L, Liu S, Zhao P, Tu B, et al. Nosocomial and Community-Acquired Spontaneous Bacterial Peritonitis in patients with liver cirrhosis in China: Comparative Microbiology and Therapeutic Implications. Sci Rep 2017;7(4):1–7Google Scholar
  27. 27.
    Fiore M, Maraolo AE, Gentile I, Borgia G, Leone S, Sansoneet P, et al. Nosocomial spontaneous bacterial peritonitis antibiotic treatment in the era of multi-drug resistance pathogens: A systematic review. World J Gastroenterol 2017;23(25):4654–4660Google Scholar
  28. 28.
    Cheong HS, Kang CI, Lee JA, Moon SY, Joung MK, Chung DR, et al. Clinical significance and outcome of nosocomial acquisition of spontaneous bacterial peritonitis in patients with liver cirrhosis. Clin Infect Dis 2009;48(9):1230–1236Google Scholar
  29. 29.
    Nobre SR, Cabral JEP, Gomes JJF, Leitão MC. In-hospital mortality in spontaneous bacterial peritonitis: a new predictive model. Eur J Gastroenterol Hepatol 2008;20(12):1176–1181Google Scholar
  30. 30.
    Singh N, Wagener MM, Gayowski T. Changing epidemiology and predictors of mortality in patients with spontaneous bacterial peritonitis at a liver transplant unit. Clin Microbiol Infect 2003;9(6):531–537Google Scholar

Copyright information

© Asian Pacific Association for the Study of the Liver 2019

Authors and Affiliations

  1. 1.Department of Pediatric GastroenterologySanjay Gandhi Postgraduate Institute of Medical SciencesLucknowIndia
  2. 2.Department of MicrobiologySanjay Gandhi Postgraduate Institute of Medical SciencesLucknowIndia

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