Abstract
BackgroundSpontaneous bacterial peritonitis (SBP)-associated septic shock carries significant mortality in cirrhosis.
AimTo determine whether practice-related aspects of antimicrobial therapy contribute to high mortality.
MethodsRetrospective 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).
ResultsOverall hospital mortality was 81.8%. Comparing survivors (n=23) with non-survivors (n=103), survivors had lower Acute Physiology and Chronic Health Evaluation (APACHEII) (means.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.
ConclusionsCirrhotic 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.