1. hospitalized with spontaneous bacterial peritonitis
The association between MELD-Na and clinical outcomes in patients with cirrhosis
hospitalized with spontaneous bacterial peritonitis
Poster
Caitlin McHugh, Brandon Taylor, Gregory Caspero, Michael Steffes, Mehdi Hedjazi, Mary Kimmel; PharmD candidates
Jordan R Covvey, PharmD, PhD, BCPS1; David E Zimmerman, PharmD, BCPS1,2; Anthony J Guarascio, PharmD, BCPS1,3; Branden D Nemecek, PharmD, BCPS1,2
1Duquesne University School of Pharmacy, Pittsburgh PA; 2UPMC Mercy Hospital, Pittsburgh, PA; 3Allegheny General Hospital, Pittsburgh PA
BACKGROUND
RESULTS/TABLES
DISCUSSION/CONCLUSION
Out of 251 total patients, 182 (72.5%) had a confirmed diagnosis of SBP and 69 (27.5%) were empirically treated (Table 1)
The most common bacteria found in ascitic fluid cultures of confirmed SBP patients were S. aureus (39%), E. coli (31%), and viridans group streptococci (18%)
Among all patients, 36% were treated with cefotaxime, 17% with ceftriaxone, and 16% with piperacillin/tazobactam (Table 2)
Overall in-hospital mortality rate among included patients was 11.2% with an average length of stay being 11.4 days (Table 3)
The mean length of ICU stay was 8.2 days (Table 3)
The mean MELD score amongst all patients was 24, and the mean MELD-Na score amongst all patients was 26
Higher MELD-Na scores (>30) in patients with SBP correlated with a higher risk of ICU admission and an increased rate of mortality (Table 4)
Similar trends were observed in regard to associations between MELD and MELD-Na for in-hospital mortality and ICU admission
Continued research should be conducted to evaluate the relationship between MELD-Na scores and clinical outcomes in patients with cirrhosis and SBP
Further research may show that MELD-Na scores can serve as a predictive outcome indicator in patients with cirrhosis who develop SBP
Spontaneous bacterial peritonitis (SBP) is the most common bacterial infection in patients with cirrhosis, and is associated with an estimated 30 percent mortality rate1
SBP is an infection of ascites fluid without an intra-abdominal surgically treatable source1
The MELD (Model for End-stage Liver Disease) provides a severity/prognostic index for predicting short-term mortality in patients with cirrhosis2
MELD-Na is an updated version of the MELD score that includes serum sodium as a prognostic factor2
Prior analyses of MELD-Na do not focus on clinical outcomes for SBP leading to this investigation
Table 1: Demographics
Total
(n=251)
Confirmed SBP (n=182)
Suspected SBP (n=69)
Male sex, n (%)
173 (68.9)
133 (73.1)
40 (58.)
Caucasian, n (%)
230 (91.6)
166 (91.2)
64 (92.8)
Age in years, mean (± SD)
57 (11.0)
57.1 (10.8)
56.8 (11.5)
BMI, mean (± SD)
28.4 (8.1)
28.1 (8.4)
28.8 (8.0)
Etiology of cirrhosis:
Alcohol, n (%)
135 (53.8)
102 (56.0)
32 (46.4)
NASH, n (%)
35 (13.9)
22 (12.1)
13 (18.8)
HCV, n (%)
78 (31.1)
53 (29.1)
25 (36.2)
Other, n (%)
46 (18.3)
44 (24.2)
20 (29.0)
Prior SBP, n (%)
70 (28.3)
51 (28.0)
29 (27.5)
Development of AKI, n (%)
102 (40.6)
81 (44.5)
22 (31.9)
Table 2: Treatment
Total
(n=251)
Confirmed SBP (n= 182)
Suspected SBP (n=69)
Cefotaxime n, (%)
90 (36)
62 (34)
21 (30)
Ceftriaxone n, (%)
43 (17)
24 (13)
16 (23)
Piperacillin/tazobactam n, (%)
40 (16)
22 (12)
10 (14)
Ampicillin/sulbactam n, (%)
35 (14)
0 (0)
15 (22)
Vancomycin n, (%)
30 (12)
13 (7)
3 (4)
Table 3: Clinical outcomes
Total
(n=251)
Confirmed SBP (n=182)
Suspected SBP
(n=69)
Mortality during hospital stay, n (%)
28 (11.2)
20 (11.0)
8 (11.6)
Average hospital length of stay, days (± SD)
11.4 (11.0)
12.0 (10.7)
9.9 (11.50)
ICU admission, n (%)
91 (36.3)
61 (33.5)
30 (43.5)
Average ICU length of stay, days (± SD)
8.2 (89.0)
9.1 (9.1)
6.3 (8.6)
OBJECTIVES
Table 4: Clinical outcomes by MELD and MELD-Na
MELD
<11
11-20
MELD-Na
20-30
MELD-Na 20-30
MELD >30
>30
Total patients, n (%)
13 (5.2)
84 (33.5)
48 (19.1)
85 (33.9)
106 (42.2)
44 (17.5)
63 (25.1)
Mortality, n (%)
1 (7.7)
3 (3.6)
3 (6.3)
8 (9.4)
8 (7.5)
10 (22.7)
14 (22.2)
Average LOS, days
10.1
8.21
7.9
11.3
10.6
16.0
14.5
ICU admission, n (%)
3 (23.1)
17 (20.2)
12 (25.0)
29 (34.1)
33 (31.1)
30 (68.2)
37 (58.7)
Average ICU LOS, days
5.7
2.8
4.3
9.0
6.15
9.5
10.0
To evaluate clinical outcomes during hospitalization for SBP using the updated MELD score, which now includes serum sodium as a prognostic factor (MELD-Na)
METHODS
Retrospective chart review that included hospitalized patients treated with antibiotics for diagnosed or suspected SBP from
Data was extracted from the University of Pittsburgh Medical Center (UPMC) health system electronic medical record using ICD-9 CM coding for cirrhosis (571.2, 5, 6) and SBP (567.23)
SBP diagnoses were considered confirmed if the patient had either polymorphonuclear (PMN) count ≥ 250 cells/mm3, or presence of bacteria in the ascitic fluid
Data collected included relevant patient demographics, laboratory markers, treatment characteristics, and selected clinical outcomes
Clinical outcomes included length of hospital stay, length of ICU stay, and in-hospital mortality
MELD and MELD-Na scores were calculated to assess disease severity and were stratified into established categories
Descriptive statistics were utilized
IRB approval was obtained from UPMC and Duquesne University
REFERENCES
Such J, Runyon BA. Spontaneous bacterial peritonitis. Clin Infect Dis. 1998;27(4):
Kamath PS, Wiesner RH, Malinchoc M, et al. A model to predict survival in patients with end-stage liver disease. Hepatology ;33(2):
AUTHOR DISCLOSURES
Authors of this presentation have no disclosures to report concerning possible financial or personal relationships that may have a direct or indirect interest in the subject matter of this presentation
Figure 1: Mortality based on MELD and MELD-Na
Figure 2: ICU admission based on MELD and MELD-Na