Prevalence and predictors for spontaneous bacterial peritonitis in cirrhotic patients with ascites admitted at medical block in Korle-Bu Teaching Hospital, Ghana

Introduction Spontaneous bacterial peritonitis (SBP) is one of the most common and life-threatening complications of patients with cirrhotic ascites. Recognition and prompt treatment of this condition is essential to prevent serious morbidity and mortality. This study aimed to determine the prevalence of SBP among in-patients with cirrhotic ascites attending our facility and to determine the clinical and laboratory parameters associated with SBP. Methods A cross-sectional study was conducted involving one hundred and three (103) patients admitted at medical block in the Korle-Bu Teaching Hospital (KBTH) with cirrhotic ascites from 25th March, 2016 to 25th November, 2016. Demographic and clinical data were collected using a standardized questionnaire. Ascitic fluid culture and cell count were conducted. Positive ascitic fluid culture and/or ascitic polymorphonuclear leukocyte ≥ 250cells/mm3 were diagnostic for SBP. Results Of the 103 patients with cirrhotic ascites, the mean age was 43.5 ± 12.2 years. There were fifty eight (58) male patients. The prevalence of SBP was 25.24% (26/103). Majority, 5 (55.6%) of the bacteria isolated from ascitic fluid with SBP was Escherichia coli. Severe ascites and high INR were found to be independent predictors of SBP. Conclusion SBP is common among patients with cirrhotic ascites admitted at KBTH. Severe ascites and high INR were highly suggestive of SBP. Diagnostic paracentesis should be done immediately on admission to confirm the diagnosis irrespective of the clinical characteristics as part of baseline investigation.


Introduction
Spontaneous bacterial peritonitis (SBP) is a common and serious infection occurring in patients with cirrhosis and ascites [1].
Numerous studies suggest that 10-30% of hospitalized patients and 3.5% of outpatients with cirrhosis and ascites have SBP, with inhospital mortality ranging from 20-40% [2][3][4][5]. SBP may be the precipitating factor for the occurrence of kidney failure, hepatic encephalopathy, gastrointestinal bleeding, hypervolemic hyponatremia and development of acute on chronic liver failure, systemic sepsis and poor survival [6]. An increase in the permeability of the intestinal wall leads to translocation of bacteria and subsequent development of SBP [7,8]. Intestinal bacterial overgrowth and uncontrolled bacterial growth in ascitic fluid then occur, as a result of an impaired host immune response [9,10]. Factors associated with the risk of developing SBP in cirrhotic patients include upper gastrointestinal bleeding, poor liver function, low ascitic fluid protein levels, prior SBP and hospitalization [11,12]. Bacteria most commonly isolated from ascitic fluid in patients with SBP are usually those of the normal intestinal flora [13,14]. More than 92% of all cases are monomicrobial with aerobic gram negative bacilli being responsible for more than two thirds of cases [13]. Escherichia coli accounts for nearly half of these cases followed by Klebsiella species and other gram negative bacteria. Twenty-five percent of cases are caused by gram positive organisms with Streptococcus species being the most common [13]. The symptoms and signs of SBP are subtle compared with those of patients who have surgical peritonitis in the absence of ascites. SBP may be asymptomatic in about 10-32% of cases, particularly in outpatients [4,14,15]

Discussion
This study aimed to determine the prevalence, clinical and laboratory features predicting the presence of SBP among inpatients with cirrhotic ascites in a tertiary care center in Accra, Ghana. The prevalence of SBP in this study was 25.24%. This is similar compared to 10-30% found by most studies from the developed world [12,14,17,18] but lower than one reported by Oladimeji et al. [19].
This may be due to the severity of liver cirrhosis involved in the study.
Oladimeji et al. [19]  However, only severe ascites and high INR showed strong independent association with SBP from the multivariate analysis.
Severe ascites and high INR are among five markers used to stage the severity of liver disease according to Child-Pugh rankings [25].
The higher the CPS, the greater the risk of SBP [5]. This helps to explain why 70% of cases of SBP are seen in patients with Child-Pugh class C cirrhosis [26]. In the current study, though the Child-Pugh score was not an independent predictor of SBP, but 80% of the patients with SBP were in Child-Pugh grade C.
HBV (52.4%) was the major cause of liver cirrhosis in this study followed by alcohol (21.4%). This compared similarly with other studies done in Africa [27][28][29] but differed from reports from the western countries [30,31]. The most common causes of liver cirrhosis globally are thought to be HBV, HCV and alcohol but the causes vary from country to country and from region to region. In countries where alcohol consumption is more common, alcohol is the commonest cause of liver cirrhosis and in countries where chronic HBV infection is endemic, HBV is the commonest cause of liver cirrhosis [32]. HBV infection is endemic in sub-Saharan Africa including Ghana and this makes it the major cause of cirrhosis in this study. Alcohol abuse was the second commonest cause of liver cirrhosis in this study which implies that alcohol is a significant cause of liver cirrhosis in patients attending clinic at KBTH. This is of public health concern; therefore society should be educated on the harmful effects of alcohol abuse on the liver. In this study E. coli (55.6%) was the most common organism isolated followed by Klebsiella spp (22.2%). The isolation of these organisms is consistent with studies conducted by Bhuva et al.
[33] and Oladimeji et al. [19] which shows E. coli as the dominant bacteria cultured in patients with spontaneous bacterial peritonitis.

Conclusion
The common causes of decompensated liver cirrhosis with ascites

Acknowledgments
I would like to acknowledge Dr. Rafiq Okine, for his assistance during analysis of project data. Table 1: causes of liver cirrhosis