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ORIGINAL ARTICLE

ABSTRACTAim: to determine relationship between MELD score

and the occurrence of SBP, prevalence of SBP, pattern of bacterial culture and antibiotic susceptibility of causative bacteria of liver cirrhotic patients at Sanglah Hospital.

Methods: study design was a cross-sectional analytic study. The population in this study consists of liver cirrhotic patients admitted at Sanglah Hospital Denpasar from June 2005 to February 2006.

Results: this result conrmed that the MELD score is a reliable index of disease severity & that higher MELD scores had a signicantly more frequent SBP prevalence in patients with a MELD score of 18 or more compared with that in patients with a MELD score of 17 or less (p=0.01; 95% CI = 1.379-15.537). Prevalence of SBP was 30.6%. Thirteen patients (68.4%) had monomicrobial positive culture of Aerob bacteria, consisting of Gram negative bacterias in 10 (77%), with Escherichia coli and Acinettobacter baumanii being the most frequent, and 3 (23%) had Gram positive bacteria. High sensitivity to Cefoperazone, Cefotaxim, Cef-tazidime, Cefpirome, Ciprooxacin, Fosfomicin, Meropenem, Streptomycin, Gentamycin, Trimethoprim/Sulphamethoxazole, were shown.

Conclusion: based on this study we concluded that severe liver cirrhosis with MELD score > 18 was associated with an increase risk of SBP, with a prevalence of 30.6%. Common causes of SBP mostly were Escherichia coli and Acinettobacter baumanii, which were sensitive to antibiotic treatment of Cefoperazone, Cefotaxime and Ciprooxacin.

Key words: SBP, MELD score, pattern of bacterial culture, antibiotic.

The Relationship Between a Model of End Stage Liver Disease Score (MELD Score) and The Occurrence of Spon-taneous Bacterial Peritonitis in Liver Cirrhotic Patients AA. Ayu Yuli Gayatri*, IGA. Suryadharma**, N. Purwadi**, IDN. Wibawa**

* Department of Internal Medicine Udayana University-Sanglah Hospital, Denpasar Bali, ** Division of Gastroenterohepatology, Department of Internal Medicine Udayana University-Sanglah Hospital, Denpasar Bali

INTRODUCTION Patients with end stage liver cirrhosis may frequently

develop a variety of complications, including spontaneous bacterial peritonitis (SBP). Importantly, these complica-tions may occur repeatedly and may eventually lead to mortality. From various epidemiological studies in Indonesia, the prevalence of SBP is approximately 10-30% with an associated mortality rate of 20-40%. The diagnosis is based on the presence of PMN count > 250 cells/mm3 or indicated by monomicrobial culture.1,2,3

In the current study, it is shown that the SBP patients who died had a signicantly higher baseline MELD score compared to those who survived. MELD is the latest attempt to rene the Child Turcotte Pugh score by removing more subjective clinical variables and using an index consists of bilirubin, INR and serum creatinin only.4,5,6 The key of successful treatment of SBP is the appropriate antibiotic regimens and an anticipation of high risk of infection. This study was conducted to determine the relationship between MELD score and the occurrence of SBP. We also investigated the prevalence of SBP, causative microorganism and its sensitivity to antibiotics. Hopefully, it would provide additional information to improve better management of liver cirrhotic patients.

METHODSThe design of this study was a cross-sectional

analytic study, which was conducted at Sanglah Hospital Denpasar. Samples were collected consecutively from June 2005 to February 2006. Adult patients with liver cirrhosis and ascites were eligible for enrollment, and they were asked to sign informed consent forms. Excluded from this study were patients with DIC, infection of abdominal wall, poor cooperative patients, intestinal obstruction and history of abdominal surgery.7 Study subjects consisted of 62 liver cirrhotic patients admitted to Sanglah Hospital Denpasar during that

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period of time. Diagnostic abdominal paracentesis was performed in all of subjects. Ascitic uid sample was collected in Brain Heart Infusion transport media and continued with Blood Agar and McConkey media. Antibiotic sensitivity test was performed by inoculation of the samples in Muller Hilton Agar.8 The MELD equation used to calculate the severity score for liver cirrhosis was as follows:

0.957x log (creatinine, mg/dl) + 0.378x log (bilirubin, mg/dl)

+ 1.120x log (INR) + 0.643

The maximal serum creatinin level considered within MELD score equation was 4.0 mg/dl.9 Data management and analysis were performed using the SPSS Software version 10 for windows. The association between MELD score and occurrence of SBP was analyzed by Chi Square test. The signicance level used in this study was 5%.

RESULTSIn this study, the prevalence of SBP was 30.6%.

Of the 62 patients (mean age 55.23, 80.6% male), the etiology of liver cirrhotic was chronic hepatitis B in 45.2% and hepatitis C in 23% of patients. The details of patient characteristics are shown in table 1.

In this study, based on MELD score, most patients had MELD score < 17 (74.2%). Among the 46 patients who had MELD score > 18, there were 9 (14.5%) patients with SBP. The correlation between MELD score and occurrence of SBP are given in table 5.

The study found a signicant relationship between occurrence of SBP and MELD score of 18 or more compared with a MELD score of 17 or less (p= 0.01; 95% CI= 1.379-15.537).

DISCUSIONEstablishment of prognostic factors is the key towards

evaluating clinical interventions in any disease. The most commonly used prognostic model in patients with cirrhosis is Child-Turcotte-Pugh (CPS). In order to overcome the limits of the CPS score, previous studies have evaluated a “combined score” with quantitative liver function test, have created new scores, or have applied scores that were originally formulated to evaluate multi-organ insufficiency in critically ill patients to cirrhotic patients. A new approach is the MELD formula which is used in patients with end stage cirrhosis awaiting liver transplantation. Previously, a MELD score 18 was identied as a threshold for high risk patients with a median survival time of three months or less.4,5

In this study we conrmed that the MELD score is a reliable index of disease severity and that higher MELD scores had a signicantly more frequent SBP prevalence in patients with a MELD score of 18 or more compared with that in patients with a MELD score of 17 or less (p=0.01; 95%CI= 1.379-15.537).

Prevalence of SBP was 30.6%, which was not much different from the other local or foreign studies. The number and species distribution of the isolated microorganisms from SBP patients did not change over

Of the 19 SBP patients, there were 13 (68.4%) positive monomicrobial culture, consisting of Gram negative 10 (77%) and Gram positive 3 (23%). The most common infecting microorganisms were Escherichia coli (15.4%), Acinettobacter baumanii (15.4%) and Streptococcus β haemolitycus (15.4%). (Table 2)

Those microorganisms showed sensitivity to Cephalosporins (Cefoperazone, Cefotaxime, Cef-tazidime, Cefpirome), Quinolone (Ciprofloxacine), Fosfomicin, Meropenem, Streptomicin, Gentamicin, Trimethoprim/Sulphamethoxazole, Tetracycline, and Chloramphenicole. The Gram positive microorganisms also showed sensitivity to antibiotics such as Amoxicillin, Ampicillin, Linezolid and Meticillin. (Table 3 and 4)

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the last 20 years period. Most infections were caused by Enterobacteriaceae and their percentage did not change signicantly. Aerob Gram negative bacteria, primarily Escherichia coli are the most common isolates, although the frequency of episodes caused by Gram positive bacteria has recently increased.10

Among 19 SBP patients on this study, thirteen patients (68.4%) had positive monomicrobial culture of Aerob bacteria, consisting of Gram negative bacteria

10 (77%), with Escherichia coli and Acinettobacter baumanii being the most frequent gram negative bacteria. The rest were gram positive bacteria found in 3 patients (23%). Many studies on microorganisms’ pattern have been conducted and reported, but this would be the rst from Sanglah Hospital Denpasar, and hopefully would provide additional information for clinicians. Good susceptibility to cefoperazone, cefo-taxim, ceftazidime, cefpirome, ciprooxacin, fosfomicin, meropenem, streptomycin, gentamycin, trimethoprim/sulphamethoxazole, were shown. The gram positive bacteria also showed sensitivity to amoxicillin, ampicil-lin, linezolid, and meticillin. Among all of antibiotics evaluated, the third generation cephalosporine and quinolone as the recommended therapy for SBP by PPHI, and also the most commonly used antibiotics

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regimen at Sanglah Hospital Denpasar, still showed good clinical response.3

CONCLUSIONFrom this study, it can be concluded that increase

risk of SBP occurs along with increase of MELD score, while according to severity of liver cirrhosis, the MELD score >18 is associated with the increase risk of SBP with prevalence of 30.6%. It is also shown that the most common microorganisms among SBP patients were Escherichia coli and Acinettobacter baumanii. Cefo-perazone, Cefotaxime and Ciprooxacin were among the most frequently used antibiotics at Sanglah Hospital Denpasar and treatment result was favorable.

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