In 2023, Chinese Society of Hepatology of Chinese Medical Association convened a panel of experts to update the Chinese guidelines on the management of ascites and associated complications in cirrhosis which was launched in 2017 and renamed this guidelines as \"Guidelines on the Management of Ascites in Cirrhosis.\" This comprehensive resource offers essential recommendations for the diagnosis and treatment of cirrhotic ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome.

UNASSIGNED: Gordonia terrae is an opportunistic pathogen that rarely causes clinical infections. Here, we first report a case of spontaneous bacterial peritonitis in patients with hepatitis C cirrhosis caused by Gordonia terrea.
UNASSIGNED: A 71-year-old male patient was diagnosed with spontaneous bacteria peritonitis secondary to hepatitis C cirrhosis. The result of bacterial culture in ascites was positive, and the pathogenic bacteria was preliminarily identified as the Gordonia genus by matrix-assisted laser desorption ionization-time of flight mass spectrometry. After 16S rRNA sequencing analysis, it was determined to be the Gordonia terrea. Symptoms relieved after treatment with ceftazidime.
UNASSIGNED: This case indicates that the clinical infections caused by Gordonia terrea should be brought to the forefront. Accurate and rapid bacterial identification results are highly beneficial to the diagnosis and therapeutic regime.

BACKGROUND: Droplet digital PCR (ddPCR) is increasingly used in diagnosing clinical pathogens, but its effectiveness in cirrhosis patients with suspected ascites infection remains uncertain.
METHODS: The diagnostic performance of ddPCR was assessed in 305 ascites samples, utilizing culture and clinical composite standards. The quantitative value and potential clinical impact of ddPCR were further analyzed in patients with spontaneous bacterial peritonitis.
RESULTS: With culture standards, ddPCR demonstrated a sensitivity of 86.5% and specificity of 83.2% for bacterial or fungal detection. After adjustment of clinical composite criteria, specificity increased to 96.4%. Better diagnostic performance for all types of targeted pathogens, particularly fungi, was observed with ddPCR compared to culture, and more polymicrobial infections were detected (30.4% versus 5.7%, p < 0.001). Pathogen loads detected by ddPCR correlated with white blood cell count in ascites and blood, as well as polymorphonuclear cell (PMN) count in ascites, reflecting infection status rapidly. A positive clinical impact of 55.8% (43/77) was observed for ddPCR, which was more significant among patients with PMN count ≤ 250/mm3 in terms of medication adjustment and new diagnosis. ddPCR results for fungal detection were confirmed by clinical symptoms and other microbiological tests, which could guide antifungal therapy and reduce the risk of short-term mortality.
CONCLUSIONS: ddPCR, with appropriate panel design, has advantages in pathogen detection and clinical management of ascites infection, especially for patients with fungal and polymicrobial infections. Patients with atypical spontaneous bacterial peritonitis benefited more from ddPCR.

Escherichia coli is a prevalent causative pathogen of spontaneous bacterial peritonitis (SBP). In this retrospective study, we investigated the microbiological characteristics and antibiotic susceptibility of E. coli clinical isolates obtained from liver cirrhosis patients suffering from nosocomial SBP. Our results showed that extended-spectrum β-lactamase (ESBL)-producing E. coli accounted for 47% of the cases, while 62% of the isolates were multi-drug resistant (MDR) pathogens. ESBL-producing and MDR isolates showed high incidences of resistance to third-generation cephalosporins, but they displayed susceptibility to carbapenems, β-lactamase inhibitors, and aminoglycosides. Importantly, liver cirrhosis patients with MDR E. coli SBP showed a significantly higher death rate than patients with non-MDR infections (P = 0.021). The 30-day mortality of nosocomial SBP was independently correlated with female gender [odds ratio (OR) = 5.200, 95% confidence interval (CI) = 1.194-22.642], liver failure (OR = 9.609, 95% CI = 1.914-48.225), hepatocellular carcinoma (OR = 8.176, 95% CI = 2.065-32.364), hepatic encephalopathy (OR = 8.176, 95% CI = 2.065-32.364), model of end-stage liver disease score (OR = 1.191, 95% CI = 1.053-1.346), white blood cell count (OR = 0.847, 95% CI = 0.737-0.973), and ascites polymorphonuclear (OR = 95.903, 95% CI = 3.410-2697.356). In conclusion, third-generation cephalosporins may be inappropriate for empiric treatment of nosocomial SBP caused by E. coli, due to the widespread presence of ESBLs and high incidence of MDR pathogens.

OBJECTIVE: To investigate the survival outcomes and risk factors for mortality in cirrhotic patients with probable spontaneous bacterial peritonitis (SBP).
METHODS: We retrospectively analyzed the clinical data of 323 cirrhotic patients with ascites admitted from June 2021 to May 2022, including 115 patients with SBP [ascites polymorphonuclear leucocyte (PMN) count ≥250/mm3], 52 patients with bacterascites (PMN count < 250/mm3 with positive microbiological finding in ascites), 67 patients with probable SBP (PMN count < 250/mm3 with negative microbiological finding in ascites but clinical symptoms of SBP) and 89 patients without infection (PMN count < 250/mm3 with negative microbiological finding without clinical symptoms of SBP). The clinical characteristics, laboratory data and 90-day mortality of the patients were compared among the 4 groups. Cox proportional hazard model and propensity score matching (PSM) in a 1∶1 ratio were used to analyze the risk factors for mortality in patients with probable SBP.
RESULTS: The patients with probable SBP had a 90-day mortality rate of 43.28%, similar to those of patients with SBP (46.95%, P=0.121) and bacterascites (48.07%, P=0.805) but significantly higher than that of non-infected patients (11.23%, P < 0.001). In the 46 pairs of patients matched using PSM, the 90-day mortality rates were higher in probable SBP group than in non-infected group both before (43.28% vs 11.23%, P < 0.001) and after PSM (34.78% vs 15.21%, P=0.038). Cox regression analysis indicated that probable SBP was an independent predictor of 90-day mortality in cirrhotic patients with ascites (HR=1.539, 95% CI: 1.048-2.261, P=0.028). A Model for End-Stage Liver Disease (MELD) score > 15 (HR=1.943, 95% CI: 1.118-3.377, P=0.018) and procalcitonin level > 0.48 ng/mL (HR=1.989, 95% CI: 1.111-3.560, P=0.021) at diagnostic paracentesis were both independent risk factors for 90-day mortality in patients with probable SBP.
CONCLUSIONS: Cirrhotic patients with probable SBP have poor survival outcomes, and their management should be further optimized based on their MELD score and procalcitonin level.

BACKGROUND: Spontaneous bacterial peritonitis (SBP) is a common complication in patients with cirrhosis. The diagnosis of SBP is still mostly based on ascites cultures and absolute ascites polymorphonuclear (PMN) cell count, which restricts the widely application in clinical settings. This study aimed to identify reliable and easy-to-use biomarkers for both diagnosis and prognosis of cirrhotic patients with SBP.
METHODS: We conducted a retrospective study including 413 cirrhotic patients from March 2013 to July 2022 in the First Affiliated Hospital of Guangxi Medical University. Patients\' clinical characteristics and laboratory indices were collected and analyzed. Two machine learning methods (Xgboost and LASSO algorithms) and a logistic regression analysis were adopted to screen and validate the indices associated with the risk of SBP. A predictive model was constructed and validated using the estimated area under curve (AUC). The indices related to the survival of cirrhotic patients were also analyzed.
RESULTS: A total of 413 cirrhotic patients were enrolled in the study, of whom 329 were decompensated and 84 were compensated. 52 patients complicated and patients with SBP had a poorer Child-Pugh score (P < 0.05). Patients with SBP had a greater proportion of malignancies than those without SBP(P < 0.05). The majority of laboratory test indicators differed significantly between patients with and without SBP (P < 0.05). Albumin, neutrophil-to-lymphocyte ratio (NLR), and ferritin-to-neutrophil ratio (FNR) were found to be independently associated with SBP in decompensated cirrhotic patients using LASSO algorithms, and logistic regression analysis. The model established by the three indices showed a high predictive value with an AUC of 0.808. Furthermore, increased neutrophils, ALP, and C-reactive protein-to-albumin ratio (CAR) were associated with the shorter survival time of patients with decompensated cirrhosis, and the combination of these indices showed a greater predictive value for cirrhotic patients.
CONCLUSIONS: The present study identified FNR as a novel index in the diagnosis of SBP in decompensated patients with cirrhosis. A model based on neutrophils, ALP and CAR showed high performance in predicting the prognosis of patients with decompensated cirrhosis.

The microbial spectrum and antimicrobial resistance patterns change over time and vary across regions in patients with spontaneous bacterial peritonitis (SBP). There is an urgent need to clarify the factors associated with in-hospital mortality in these patients.
In this study, 377 patients with SBP and 794 patients with bacterascites were analyzed for the microbial spectrum, antimicrobial resistance profiles, and laboratory findings.
The most common pathogens were Escherichia coli (96, 25.5%), Staphylococcus epidermidis (55, 14.6%), and Enterococcus faecium (42, 11.1%). Multidrug-resistant (MDR) bacteria comprised 49.7% of gram-positive bacteria (GPB) and 48.8% of gram-negative bacteria (GNB). The most sensitive antibiotics were amikacin (91.5%), meropenem (89.8%) and piperacillin/tazobactam (87.6%). Extensively drug-resistant (XDR) (OR=51.457, p < 0.001), neutrophil count (OR=1.088, p < 0.001), and the model for end-stage liver disease (MELD) score (OR=1.124, p < 0.001) were independent predictive factors of in-hospital mortality in patients with SBP.
MDR represented nearly half of the bacteria isolated from patients with SBP, of which the high prevalence of extended-spectrum β-lactamase-producing and Carbapenem-resistant bacteria is concerning. The presence of XDR, higher MELD score, and neutrophil count were independent predictive factors associated with higher in-hospital mortality in patients with SBP, indicating that intensive care should be provided to these patients.

BACKGROUND: Spontaneous bacterial peritonitis (SBP) is a life-threatening complication in patients with advanced cirrhosis. Prophylactic Norfloxacin used to be considered effective in SBP prevention, but in recent years its efficacy has been partially compromised by increasing quinolone-resistant bacteria. However, whether the effects of alternative prophylactic regimens are superior to norfloxacin remains controversial. The goal of this study is to compare the effects of norfloxacin with other antibiotics in SBP prophylaxis for cirrhotic patients.
METHODS: We systematically searched Pubmed, Embase, and Cochrane Library Databases. Two reviewers independently identified relevant random control trials (RCTs) comparing the role of norfloxacin and other antibiotics in SBP prevention.
RESULTS: Eight studies comprising 1043 cirrhotic patients were included in this study. Norfloxacin and alternative antibiotics displayed comparable effects in SBP prophylaxis, survival benefit, overall infection prevention, and safety. Subgroup analyses revealed that rifaximin prophylaxis could reduce the recurrence of SBP with fewer adverse events but failed to improve overall survival compared with norfloxacin.
CONCLUSIONS: Other antibiotics are a reasonable alternative to norfloxacin in the prophylaxis of SBP. Rifaximin prophylaxis could be an alternative choose of antibiotic for SBP prevention because of its better protective effect and safety.

OBJECTIVE: Identifying a predictive biomarker for spontaneous bacterial peritonitis (SBP) is of crucial importance in cirrhotic patients with ascites. This study was designed to identify the predictive value of serum or ascitic heme oxygenase-1 (HO-1) for SBP in this population.
METHODS: In this cohort study, 60 patients with liver cirrhosis and ascites accompanied by SBP (studied cohort, n=26) or not (control cohort, n=34) were retrospectively included. HO-1 levels in the serum and ascites were detected by ELISA. The predictive performance of HO-1 was evaluated by calculating the area under the curve (AUC) in receiver operating characteristic (ROC) curve analysis.
RESULTS: The HO-1 level of SBP patients was significantly higher than that of non-SBP patients both in the serum and ascites (p<0.001). Serum, ascites HO-1, and their combination displayed an AUC of 0.897 (95% CI, 0.808-0.986), 0.825 (95% CI, 0.708-0.941), and 0.902 (95% CI, 0.817-0.986) for discriminating SBP from non-SBP patients. HO-1 level between serum and ascites had a higher correlation in patients in a Child-Pugh B stage (R=0.691, p<0.001) than in the Child-Pugh C stage (R=0.475, p=0.014). The correlation between HO-1 level and inflammatory factors or biochemical parameters was observed in SBP patients and presented in a Child-Pugh stage-dependent manner.
CONCLUSIONS: HO-1 level has the ability to predict the occurrence of SBP in cirrhotic patients with ascites which has the potential to be a biomarker for the early prediction of SBP and move into the clinical setting. However, the Child-Pugh stage should be considered when using the HO-1 as a predictive biomarker.

BACKGROUND: Spontaneous fungal peritonitis (SFP) and fungiascites is less well-recognized and described in patients with liver cirrhosis. The aims of this study were to determine the clinical characteristics, prognosis, and risk factors of cirrhotic patients with SFP/fungiascites and to improve early differential diagnosis with spontaneous bacterial peritonitis (SBP).
METHODS: This was a retrospective case-control study of 54 cases of spontaneous peritonitis in cirrhotic patients (52 SFP and 2 fungiascites) with fungus-positive ascitic culture. Fifty-four SBP cirrhotic patients with bacteria-positive ascitic culture were randomly enrolled as a control group. A nomogram was developed for the early differential diagnosis of SFP and fungiascites.
RESULTS: Hospital-acquired infection was the main cause of SFP/fungiascites. Of the 54 SFP/fungiascites patients, 31 (57.41%) patients carried on with the antifungal treatment, which seemed to improve short-term (30-days) mortality but not long-term mortality. Septic shock and HCC were independent predictors of high 30-day mortality in SFP/fungiascites patients. We constructed a predictive nomogram model that included AKI/HRS, fever, (1,3)-β-D-glucan, and hospital-acquired infection markers for early differential diagnosis of SFP/fungiascites in cirrhotic patients with ascites from SBP, and the diagnostic performance was favorable, with an AUC of 0.930 (95% CI: 0.874-0.985).
CONCLUSIONS: SFP/fungiascites was associated with high mortality. The nomogram established in this article is a useful tool for identifying SFP/fungiascites in SBP patients early. For patients with strongly suspected or confirmed SFP/fungiascites, timely antifungal therapy should be administered.