Alimentary Pharmacology and Therapeutics Letters to the Editors
Letter: what else can improve survival in cirrhotic patients with spontaneous bacterial peritonitis and associated septic shock? P.-Z. Chen & C.-C. Wang Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and School of Medicine, Tzu Chi University, New Taipei City, Taiwan. E-mail: [email protected] doi:10.1111/apt.13220
SIRS, We read with great interest the article by Karvellas et al.1 In this study, the authors found cirrhotic patients with septic shock secondary to spontaneous bacterial peritonitis (SBP) had a high mortality rate (>80%). In addition, admission APACHEII, serum lactate and each hour of delay in instituting appropriate anti-microbial therapy predicted hospital mortality. Although their results imply the importance of timely and appropriate anti-microbial therapy on improvements in clinical outcome, several issues deserve further discussion. First, this study revealed that each hour of delay of appropriate anti-microbial therapy was associated with a 1.8 times increase in hospital mortality. However, the patients receiving appropriate anti-microbial therapy before the development of septic shock had a paradoxically lower survival rate (3/25, 12%) compared with those after the development of shock (19.8% in overall and 39.5% within 6 h). In cirrhotic patients complicated with SBP and septic shock, the common causes of mortality can be divided into two groups: one is liver-related death, such as complications of liver failure, and the other is nonliver related death, such as profound shock
Letter: what else can improve survival in cirrhotic patients with spontaneous bacterial peritonitis and associated septic shock? Authors’ reply C. J. Karvellas*,†, J. G. Abraldes†, Y. Arabi‡ , A. Kumar§ & For the Cooperative Anti-microbial Therapy of Septic Shock (CATSS) Database Research Group *Division of Critical Care Medicine and Gastroenterology/Hepatology, University of Alberta, Edmonton, AB, Canada. † Division of Gastroenterology and Hepatology, University of Alberta, Edmonton, AB, Canada.
Aliment Pharmacol Ther 2015; 42: 121–129 ª 2015 John Wiley & Sons Ltd
or multiple organ failure.2 The cause of death should be determined in these 25 patients with pre-shock administration of appropriate anti-microbial therapy. Furthermore, if the authors could perform sub-group analysis between survivors and nonsurvivors, especially for items including the cause of death and liver reserve such as Child–Pugh and MELD score, we could understand more about the reasons for mortality in those receiving timely and appropriate anti-microbial therapy. Second, the mortality rate of cirrhotic patients with fungal pathogen of SBP and associated septic shock is 100%. Realising the clinical characteristics of those patients can help guide clinicians to give anti-fungal agents earlier and possibly reverse the catastrophic outcome.3
ACKNOWLEDGEMENTS Declaration of personal interests: None. Declaration of funding interests: Chia-Chi Wang has received researching funding from the research department of Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation. REFERENCES 1. Karvellas CJ, Abraldes JG, Arabi YM, Kumar A; Cooperative Antimicrobial Therapy of Septic Shock (CATSS) Database Research Group. Appropriate and timely antimicrobial therapy in cirrhotic patients with spontaneous bacterial peritonitis-associated septic shock: a retrospective cohort study. Aliment Pharmacol Ther 2015; 41: 747–57. 2. Gines P, Fernandez J, Durand F, Saliba F. Management of critically-ill cirrhotic patients. J Hepatol 2012; 56(Suppl. 1): S13–24. 3. Hwang SY, Yu SJ, Lee JH, et al. Spontaneous fungal peritonitis: a severe complication in patients with advanced liver cirrhosis. Eur J Clin Microbiol Infect Dis 2014; 33: 259–64.
‡
Intensive Care Department, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia. § Section of Critical Care Medicine and Section of Infectious Diseases, Health Sciences Center and St. Boniface Hospital, University of Manitoba, Winnipeg, MB Canada,. E-mail: [email protected] doi:10.1111/apt.13229
SIRS, We applaud the discussion points raised by Chen et al. in response to our recent article.1, 2 They raise the issue of why patients receiving appropriate anti-microbial 123
Letter: what else can improve survival in cirrhotic patients with spontaneous bacterial peritonitis and associated septic shock? P.-Z. Chen & C.-C. Wang Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and School of Medicine, Tzu Chi University, New Taipei City, Taiwan. E-mail: [email protected] doi:10.1111/apt.13220
SIRS, We read with great interest the article by Karvellas et al.1 In this study, the authors found cirrhotic patients with septic shock secondary to spontaneous bacterial peritonitis (SBP) had a high mortality rate (>80%). In addition, admission APACHEII, serum lactate and each hour of delay in instituting appropriate anti-microbial therapy predicted hospital mortality. Although their results imply the importance of timely and appropriate anti-microbial therapy on improvements in clinical outcome, several issues deserve further discussion. First, this study revealed that each hour of delay of appropriate anti-microbial therapy was associated with a 1.8 times increase in hospital mortality. However, the patients receiving appropriate anti-microbial therapy before the development of septic shock had a paradoxically lower survival rate (3/25, 12%) compared with those after the development of shock (19.8% in overall and 39.5% within 6 h). In cirrhotic patients complicated with SBP and septic shock, the common causes of mortality can be divided into two groups: one is liver-related death, such as complications of liver failure, and the other is nonliver related death, such as profound shock
Letter: what else can improve survival in cirrhotic patients with spontaneous bacterial peritonitis and associated septic shock? Authors’ reply C. J. Karvellas*,†, J. G. Abraldes†, Y. Arabi‡ , A. Kumar§ & For the Cooperative Anti-microbial Therapy of Septic Shock (CATSS) Database Research Group *Division of Critical Care Medicine and Gastroenterology/Hepatology, University of Alberta, Edmonton, AB, Canada. † Division of Gastroenterology and Hepatology, University of Alberta, Edmonton, AB, Canada.
Aliment Pharmacol Ther 2015; 42: 121–129 ª 2015 John Wiley & Sons Ltd
or multiple organ failure.2 The cause of death should be determined in these 25 patients with pre-shock administration of appropriate anti-microbial therapy. Furthermore, if the authors could perform sub-group analysis between survivors and nonsurvivors, especially for items including the cause of death and liver reserve such as Child–Pugh and MELD score, we could understand more about the reasons for mortality in those receiving timely and appropriate anti-microbial therapy. Second, the mortality rate of cirrhotic patients with fungal pathogen of SBP and associated septic shock is 100%. Realising the clinical characteristics of those patients can help guide clinicians to give anti-fungal agents earlier and possibly reverse the catastrophic outcome.3
ACKNOWLEDGEMENTS Declaration of personal interests: None. Declaration of funding interests: Chia-Chi Wang has received researching funding from the research department of Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation. REFERENCES 1. Karvellas CJ, Abraldes JG, Arabi YM, Kumar A; Cooperative Antimicrobial Therapy of Septic Shock (CATSS) Database Research Group. Appropriate and timely antimicrobial therapy in cirrhotic patients with spontaneous bacterial peritonitis-associated septic shock: a retrospective cohort study. Aliment Pharmacol Ther 2015; 41: 747–57. 2. Gines P, Fernandez J, Durand F, Saliba F. Management of critically-ill cirrhotic patients. J Hepatol 2012; 56(Suppl. 1): S13–24. 3. Hwang SY, Yu SJ, Lee JH, et al. Spontaneous fungal peritonitis: a severe complication in patients with advanced liver cirrhosis. Eur J Clin Microbiol Infect Dis 2014; 33: 259–64.
‡
Intensive Care Department, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia. § Section of Critical Care Medicine and Section of Infectious Diseases, Health Sciences Center and St. Boniface Hospital, University of Manitoba, Winnipeg, MB Canada,. E-mail: [email protected] doi:10.1111/apt.13229
SIRS, We applaud the discussion points raised by Chen et al. in response to our recent article.1, 2 They raise the issue of why patients receiving appropriate anti-microbial 123
