Hepatology Unit, Gastroenterology Department, Hospital Universitari de Bellvitge, IDIBELL, Universitat de Barcelona, Barcelona, Spain.
J Hepatol. 2012 Apr;56(4):825-32. doi: 10.1016/j.jhep.2011.11.010. Epub 2011 Dec 13.
BACKGROUND & AIMS: The recent emergence of third-generation cephalosporin resistance in spontaneous bacterial peritonitis is of great concern, although neither the risk factors for resistance nor its real impact on mortality have been well defined.
We conducted a retrospective study of all spontaneous bacterial peritonitis episodes with positive blood and/or ascitic culture at our center (2001-2009). Episodes were classified according to the place of acquisition: community, healthcare system, or nosocomial.
Two hundred and forty-six episodes were analyzed in 200 patients (150 males, 57.3 years): 34.6% community-acquired, 38.6% healthcare system-acquired, and 26.8% nosocomially-acquired. Third-generation cephalosporin resistance occurred in 21.5% (7.1% community-acquired, 21.1% healthcare system-acquired, 40.9% nosocomially-acquired). These resistant cases were categorized as extended-spectrum β-lactamase-producing Gram-negative bacilli, other resistant Gram-negative bacilli, and Enterococci. Risk factors for resistance were previous use of cephalosporins, diabetes mellitus, upper gastrointestinal bleeding, nosocomial acquisition, and a low polymorphonuclear count in ascites. Regarding third-generation cephalosporin resistance, adequate empirical treatment was 80.7%. Independent predictors of mortality were nosocomial acquisition, poor hepato-renal function, immunosuppressive therapy, a marked inflammatory response during the episode and either third-generation cephalosporin-resistance or low rates of adequate empirical treatment.
The risk of third-generation cephalosporin resistance was particularly high in nosocomially-acquired episodes of spontaneous bacterial peritonitis, but also occurred in healthcare system-acquired cases. The extent of resistance and the adequacy of empirical antibiotics had a significant effect on mortality along with the patient's hepato-renal function. These data can help determine the most suitable empirical antimicrobial treatments in these patients.
第三代头孢菌素耐药性在自发性细菌性腹膜炎中的新近出现令人非常担忧，尽管耐药性的危险因素及其对死亡率的实际影响尚未明确。
我们对我院（2001-2009 年）所有血和/或腹水培养阳性的自发性细菌性腹膜炎发作进行了回顾性研究。根据感染部位将发作分类：社区获得性、医疗保健系统获得性或医院获得性。
在 200 例患者中分析了 246 例发作（男性 150 例，57.3 岁）：34.6%社区获得性，38.6%医疗保健系统获得性，26.8%医院获得性。第三代头孢菌素耐药性发生率为 21.5%（社区获得性 7.1%，医疗保健系统获得性 21.1%，医院获得性 40.9%）。这些耐药病例被分为产超广谱β-内酰胺酶的革兰阴性杆菌、其他耐药革兰阴性杆菌和肠球菌。耐药的危险因素包括先前使用头孢菌素、糖尿病、上消化道出血、医院获得性感染和腹水中性粒细胞计数低。关于第三代头孢菌素耐药性，适当的经验性治疗率为 80.7%。死亡率的独立预测因素包括医院获得性感染、肝肾功能不良、免疫抑制治疗、发作期间炎症反应明显以及第三代头孢菌素耐药或经验性治疗率低。
医院获得性自发性细菌性腹膜炎发作中第三代头孢菌素耐药的风险特别高，但在医疗保健系统获得性病例中也有发生。耐药程度和经验性抗生素的充分性对死亡率以及患者的肝肾功能有重要影响。这些数据可以帮助确定这些患者最适合的经验性抗菌治疗。
