Arab Journal of Gastroenterology 12 (2011) 2024

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Arab Journal of Gastroenterology

journal homepage: www.elsevier.com/locate/ajg

Original Article

Detection of ascitic uid infections in patients with liver cirrhosis and ascites
Marwa S. Mostafa a, Eman A. El-Seidi a, Abdel Meguid Kassem b,, Mohamed A. Shemis c, Mohamed Saber c,
Michael N. Michael a
a

Medical Microbiology and Immunology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
Tropical Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt
c
Biochemistry Department, Theodor Bilharz Research Institute, Giza, Egypt
b

a r t i c l e

i n f o

Article history:
Received 29 June 2010
Accepted 24 December 2010

Keywords:
Ascites
Spontaneous bacterial peritonitis
PCR
Bacterial translocation

a b s t r a c t
Background and study aims: Ascitic uid infections (AFIs) are the frequent complications of advanced liver
disease. Bacterial translocation is considered a key step in the pathogenesis of gut-derived bacterial infections; mainly spontaneous bacterial peritonitis (SBP) in cirrhotic patients. Bacterial DNA (bactDNA) in
ascitic uid and serum has been suggested as a surrogate marker for bacterial translocation. We
attempted at the isolation and identication of bacteria in ascitic uid in cirrhotic patients and the
assessment of polymerase chain reaction (PCR) in ascitic uid and serum.
Patients and methods: Fifty cirrhotic patients having ascites with no signs of infection were included.
Ascitic uid cultures were obtained from patients. Ascitic uid and serum were subjected to DNA extraction and PCR for the universal amplication of a region of the 16S ribosomal RNA (16S rRNA) gene to
detect bactDNA.
Results: Bacteria were isolated from 9 (18%) of the ascitic uid samples, and were mainly Gram-positive
bacteria. BactDNA was detected simultaneously in the ascitic uid and serum of 17 (34%) patients and in
the ascitic uid of only 2 patients. In a single patient with positive ascitic uid culture no bactDNA was
detected in ascitic uid or serum. By considering AFIs as a positive ascitic uid culture and/or the presence of bactDNA in the ascitic uid and/or serum, ascitic uid culture could detect 9 out of 20 patients
with AFIs (45%), PCR of ascitic uid could detect 19 out of 20 (95%) while PCR of serum could detect
17 out of 20 (85%). In 10 patients with culture negative non-neutrocytic ascites (CNNNA) bactDNA could
be detected in serum and ascitic uid.
Conclusion: AFI can be caused by Gram positive as well as Gram negative organisms. A substantial percentage of cases with CNNNA show bactDNA in serum and ascitic uid. PCR of ascitic uid should, therefore, be used in the diagnostic workup of suspected cases of ascitic uid infections.
2011 Arab Journal of Gastroenterology. Published by Elsevier B.V. All rights reserved.

Introduction
Ascitic uid infections (AFIs) are considered serious complications in cirrhotic patients and are associated with high morbidity
and mortality. AFIs include spontaneous bacterial peritonitis (SBP)
with polymorphnuclear (PMN) count P250 mm3 and positive
ascitic uid culture without any evidence of external or intraabdominal source of infection [1] as well as culture negative neutrocytic ascites (CNNA) with PMN >250 mm3 and a negative
ascitic uid culture [2]. The reported incidence of AFIs was found
to be 830% [1]. SBP has a very high recurrence rate of up to 70%
at 1 year [3] and in-hospital mortality ranges from 20% to 40%
[4,5] and may reach up to 78% [1]. SBP is considered to be the

Corresponding author.
E-mail address: kassem@git.eg.net (A.M. Kassem).

nal consequence of repeated episodes of bacterial translocation

(BT) from the intestinal lumen with bacteria eventually reaching
the ascitic uid [6,7]. Therefore, the detection of bacterial DNA
(bactDNA) may be considered a marker of bacterial translocation,
particularly in the cases of cirrhosis and culture negative nonneutrocytic ascites (CNNNA); with PMN <250 mm3 and a negative ascitic uid culture [8]. The diagnosis of bacteriascites is
based on a positive ascitic uid culture, an ascitic PMN count
<250 cells/mm3 and lack of symptoms and signs suggestive for
SBP, for example fever, abdominal pain, icterus or hepatic encephalopathy [9]. Early diagnosis of SBP along with prompt initiation
of appropriate antibiotic therapy can be helpful in overall patients
survival [10,11]. The aim of this study was to isolate and identify
bacteria in the ascitic uid of patients having liver cirrhosis and
ascites and to assess the value of polymerase chain reaction
(PCR) in the detection of bacterial DNA (bactDNA) in their ascitic
uid and/or sera.

1687-1979/$ - see front matter 2011 Arab Journal of Gastroenterology. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.ajg.2011.01.004

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M.S. Mostafa et al. / Arab Journal of Gastroenterology 12 (2011) 2024

Patients and methods

The study was approved by the local ethical committee at the
Faculty of Medicine, Cairo University. Fifty patients having liver
cirrhosis and ascites and who were admitted to the Tropical Medicine Department, Cairo University Hospitals, were included in the
study from October 2005 to January 2007. Included patients had
cirrhosis as diagnosed clinically as well as by laboratory and/or
ultrasonographic examination. Exclusion criteria included the
presence of any clinical sign of infection, previous episodes of
SBP, paracentesis within the last 4 months and antibiotic intake
within the preceding 2 weeks, including selective intestinal
decontamination with noroxacin. Written informed consent was
obtained from all patients. Basic clinical, haemodynamic, serum,
and ascitic uid characteristics (including age, sex, blood total
leukocytic count (TLC), serum albumin, urea, creatinine, total
bilirubin, direct bilirubin, aspartate transaminase (AST), alanine
transaminase (ALT), alkaline phosphatase, ascitic uid total
protein, albumin, and polymorphnuclear leukocytes (PMN)) were
obtained and analyzed. The microbiological investigations were performed at the Medical Microbiology and Immunology Department,
Faculty of Medicine, Cairo University as well as the Biochemistry
and Molecular Biology Department, Theodor Bilharz Research
Institute.
Ascitic uid specimens (15 ml obtained by paracentesis) as well
as blood samples were obtained at admission under strict aseptic
conditions. Ten milliliters of ascitic uid obtained from each patient were inoculated bed-side into a blood culture bottle (Oxoid,
Signal blood culture system), then incubated at 37 C for at least
7 days or until the positive signal was detected (according to manufacturers instructions). Subcultures, both aerobically and anaerobically, were done on blood agar and MacConkeys agar plates [12].
Positive cultures were identied by Grams stain. Gram positive
bacteria were identied by standard biochemical reactions [13],
whereas Gram negative bacilli were identied by Microbact GNB
12A identication kit (Oxoid, UK). The rest of the ascitic uid specimens as well as sera were stored at 70 C until DNA extraction
was done.

1000
900
800
700
600
500
400
300
200
100

Fig. 1. Agarose gel electrophoresis of PCR products. Lane 1: molecular weight

marker. Lanes 2, 3, 5 and 6: negative samples. Lanes 4 and 7: positive sample and
positive control, respectively. Lane 8: negative control.

using BIO RAD MJ Mini Personal Thermal Cycler. The amplication

protocol was 95 C for 5 min followed by 40 cycles composed of
94 C for 45 s, 55 C for 45 s and 72 C for 60 s and a nal extension
step at 72 C for 10 min.
Post-PCR gel electrophoresis
Ten microliters of amplied products was electrophoresed on a
2% agarose gel, stained with ethidium bromide, and visualized
using UV transilluminator (Spectroline Biovision). The sizes of
PCR products were estimated according to the migration pattern
of a 100-bp DNA ladder (Fermentas, Germany). A band of 540 base
pair was obtained from positive controls and positive samples corresponding to the specic amplication of the prokaryotic 16S
ribosomal RNA gene. Fig. 1 represents a sample of agarose gel electrophoresis of PCR products.
Statistical analysis

Total DNA was extracted from the ascitic uid samples and sera
using Genomic DNA purication kit (Promega, Madison, USA),
according to manufacturers instructions. Positive and negative
controls were included in each PCR run. Positive control DNA
was obtained by extraction of bacterial DNA from overnight broth
culture of Staphylococcus aureus (ATCC 25213) and Escherichia coli
(ATCC 35320) according to Fang and Hedin [14], whereas sterile
distilled water was used as a negative control.

Data were analyzed using SPSS, version 15. Mean and standard
deviation were used for quantitative variables, whereas number
and percent were used for qualitative variables. Comparisons between groups were done using Chi-square test for qualitative variables and independent sample t-test for normally distributed
quantitative variables, while non-parametrical MannWhitney test
was used for quantitative variables with no normal distribution. p
Values of 5% or less were considered as statistically signicant.
Sensitivity, specicity, positive predictive value (PPV), negative
predictive value (NPV), and total accuracy were calculated to assess
the validity of different tests, while phi symmetric measures were
used to assess the agreement between the tests.

DNA amplication

Results

A PCR reaction for the universal amplication of a region of 16S

ribosomal RNA (16S rRNA) gene was performed according to Such
et al. [8]. Universal eubacterial primers located at positions 727
and 531514 (E. coli numbering) were used to amplify any known
bacterial 16S rRNA gene (forward primer 50 -AGA GTT TGA TCA TGG
CTC AG-30 and reverse primer 50 -ACC GCG ACT GCT GCT GGC
AC-30 ). Fifteen microliters of the template DNA was added to a
reaction mix containing 10 mM Tris buffer (pH 8.8), 50 mM KCl,
2 mM MgCl2 (Stratagene, USA), 200 lM of each deoxynucleotide
triphosphate (dNTP) (Promega Corporation, Madison, WI, USA),
50 pmol of each primer (Operon, USA), and 2.5 units Thermostable
Paq5000 DNA polymerase (Stratagene, USA). The nal volume was
completed with sterile distilled water to 50 ll. PCR was performed

Fifty patients with liver cirrhosis and ascites were included in

the present study. Their age ranged from 34 to 70 years (the mean
age was 52.8 7.6 years). Thirty-eight patients (76%) were males
and 12 patients (24%) were females. Bacteria were isolated from
9 out of 50 (18%) ascitic uid specimens. All positive cultures revealed growth of a single organism. Isolated bacteria included: four
isolates of coagulase negative staphylococci (CoNS) (8%), two isolates of E. coli (4%), one isolate of diphtheroids (2%), one isolate
of anthracoids (2%) and one isolate of Acinetobacter lwofi (2%).
Out of 50 ascitic uid samples, bactDNA was detected in 19
samples (38%). Eight out of nine culture positive ascitic uid samples were found to contain bactDNA. However, one culture positive
ascitic uid sample (that grew A. lwofi) was repeatedly negative

DNA extraction

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M.S. Mostafa et al. / Arab Journal of Gastroenterology 12 (2011) 2024

Table 1
Ascitic uid culture and PCR of bactDNA in the ascitic uid and in serum.
(No. = 20)

Ascitic uid PMN

Ascitic uid culture

SBP (No. = 2)
CNNA (No. = 1)

>250 mm3
>250 mm3

E. coli
Negative

2
1

4
2

BA (No. = 7)

<250 mm3

CoNS
A. lwofi
Diphtheroids
Anthracoids

4
1
1
1

CNNNA (No. = 10)

<250 mm3

Negative

10

Isolated bacteria

No.

BactDNA in ascitic uid

BactDNA in serum

Positive
Positive

Positive
Positive

14

Positive
Negative
Positive
Positive

Positive
Negative
Negative
Negative

20

Positive

Positive

PMN: Polymorphnuclear leucocytes; SBP: Spontaneous bacterial peritonitis; CNNA: Culture negative neutrocytic ascites; BA: Bacteriascites; CNNNA: Culture negative non-neutrocytic ascites; CoNS: Coagulase negative staphylococci.

for bactDNA (DNA extraction and PCR were repeated three times).
The remaining 11 bactDNA positive ascitic uid samples were
culture negative. The phi coefcient of correlation between ascitic
uid culture and PCR was 0.491, i.e. moderate correlation
(p-value = 0.001).
Out of 50 serum samples, bactDNA was detected in 17 samples
(34%). Six out of nine patients who had culture positive ascitic uid
samples were found to have bactDNA in their sera; these also had
bactDNA in their ascitic uid samples. The single patient who had
culture positive ascitic uid (A. lwofi) and bactDNA negative ascitic uid sample had also repeatedly negative bactDNA in the serum
sample. The other two patients, who had culture positive ascitic
uid (having diphtheroids and anthracoids) and bactDNA positive
ascitic uid, had also repeatedly negative bactDNA in their sera.
The remaining 11 patients were the same patients who had culture
negative ascitic uid and bactDNA positive ascitic uid samples.
Table 1 summarizes the microbiological results in the study
patients.
Results of serum and ascitic uid bactDNA show a signicant
correlation. The phi coefcient of correlation between PCR of
bactDNA in ascitic uid and PCR of bactDNA in serum was 0.917
(p-value <0.001) (Table 2). Taking ascitic uid bactDNA as a gold
standard, the accuracy of diagnosing AFI was 76% for ascitic uid
culture and 96% for serum bactDNA (Table 3).
According to the aforementioned results, all patients were classied into two groups: group I patients who had AFIs (including
20 patients, 40%; who had positive ascitic uid culture and/or
Table 2
PCR of bactDNA in serum vs. PCR of bactDNA in ascitic uid.
Ascitic uid PCR

Total

Negative

Positive

Serum PCR
Negative No. (%)
Positive No. (%)

31 (100%)
0 (0%)

2 (10.5%)
17 (89.5%)

33 (66%)
17 (34%)

Total No. (%)

31 (100%)

19 (100%)

50 (100%)

The phi coefcient of correlation between PCR of bactDNA in ascitic uid and PCR of
bactDNA in serum was 0.917 (p value <0.001).

Table 3
Sensitivity, specicity, PPV, NPV and total accuracy of ascitic uid culture and PCR of
bactDNA in serum, considering PCR of bactDNA in the ascitic uid as the gold
standard.
Test

Sensitivity
(%)

Ascitic uid
culture
PCR of bactDNA in
serum

42.1
89.5

Specicity
(%)
96.8
100

PPV
(%)
88.9
100

NPV
(%)

Total
accuracy (%)

73.2

76

93.9

96

Table 4
Demographic and laboratory data of group I and group II patients.
Variable (mean SD)

Group I
(No. = 20)

Group II
(No. = 30)

Age (in years)

51 5

54 9

0.149

Sex
Male
Female

15 (75%)
5 (25%)

23 (76.7%)
7 (23.3)

1.000

7077.5 5565.6

6157.9 3450.9

0.760

2.5 0.3
78.4 121.2
1.2 0.4
3.4 4
1.8 3
96.2 9.1

2.5 0.6
50 31.6
1.2 0.6
2.4 1.6
1.2 1.2
59.6 37.8

0.925
0.807
0.760
0.992
0.984
0.04*

41.2 28.5

36 28.5

0.272

131 38.4

135 57

0.777

1.3 0.5
0.5 0.2
211 427.6

1.4 0.6
0.5 0.3
49 151

0.611
0.625
0.300

Total leukocytic count (TLC)

(cells/mm3)
Albumin (g/dl)
Urea (mg/dl)
Creatinine (mg/dl)
Total bilirubin (mg/dl)
Direct bilirubin (mg/dl)
Aspartate transaminase (AST)
(u/ml)
Alanine transaminase (ALT) (u/
ml)
Alkaline phosphatase (u/ml)
Ascitic uid
Protein (g/dl)
Albumin (g/dl)
PMN (cells/mm3)
*

There was no statistically signicant difference of any of the values except for
AST; which was signicantly higher in group I than in group II.

positive bactDNA in the ascitic uid and/or serum. Group II

patients without AFIs (including 30 patients, 60%; who had neither
positive ascitic uid culture nor positive bactDNA in the ascitic
uid and/or serum).
In the study, 10 patients out of 50 (20%) were diagnosed as SBP,
CNNA, or BA by means of positive ascitic uid culture and/or PMN
cell count >250 cells/mm3. The remaining 40 patients were
diagnosed as CNNNA, out of those, bactDNA was detected in 10
patients, i.e. 25% of the cases of CNNNA had bactDNA in their ascitic uid as well as in their sera. Basic clinical, serum, and ascitic
uid analytical characteristics in patients with CNNNA with
bactDNA and without bactDNA were compared and there was no
statistically signicant difference among the two categories
(Table 4).

Discussion
Infections of the ascitic uid in patients with ascites are associated with great risks and, therefore, require special attention from
the clinician. It is important to investigate the pattern of infections
to draw conclusion that may inuence treatment regimens. In the
present study, all positive ascitic uid cultures revealed growth of
a single organism, i.e. monomicrobial infection, with the predominance of Gram positive over Gram negative bacteria (66.7% vs.

M.S. Mostafa et al. / Arab Journal of Gastroenterology 12 (2011) 2024

33.3%, respectively). This is in concordance to other studies that revealed monomicrobial infection [8,1518]. Although only a few
species and genera of intestinal bacteria have been proposed to
translocate into the mesenteric lymph nodes, more than 70 different microbial species have been isolated in ascitic uid from
patients with bacteriologically conrmed SBP [19]. In one study,
S. aureus was the second most commonly isolated organism in patients with decompensated cirrhosis after E. coli [20].
Sixty percent of nosocomial-acquired infections are currently
caused by Gram positive bacteria [21]. Moreover, increasing number of episodes of SBP caused by Gram positive bacteria was observed, particularly in association with the increasing numbers of
invasive procedures, hospitalization particularly in intensive care
units (ICU), and treatment with quinolones [16]. There is growing
evidence by many studies that the detection of Staphylococcus spp.
in the ascitic uid is not because of sample contamination but because of bacterial translocation [8,17,22,23].
Such et al. [8] considered the simultaneous presence of bacterial
DNA in the ascitic uid and the blood a molecular evidence of bacterial translocation. Accordingly, this is applicable in our study, too.
In the present study, bactDNA was detected in ascitic uid and/
or serum in 19 out of 50 (38%) patients with liver cirrhosis and
ascites, eight of them only had culture positive ascitic uid.
BactDNA was detected simultaneously in the ascitic uid and serum in 17 (34%) patients and in the ascitic uid only in two patients.
BactDNA was not detected in one culture positive ascitic uid
sample that grew A. lwofi. Two possible explanations were considered: (1) the used primers are not specic to the 16S rRNA of this
organism and (2) contamination of the culture after collecting the
sample. Similarly, three possible explanations were suggested for
the two cases that had positive bactDNA in the ascitic uid only
and not in the serum: (1) too low concentration of the bactDNA
in the serum to be detected by PCR; (2) contamination of the ascitic
uid during collection of the sample; (3) they were not cases of
bacterial translocation, i.e. they were cases of secondary infection
of ascitic uid (secondary peritonitis), however, this latter possibility is very remote because patients with positive signs of infection
were excluded from the study. Similarly, Vieira et al. [15] detected
bactDNA in 18 out of 40 (45%) patients with liver cirrhosis and
ascites. Cultivation of ascitic uid using blood culture technique
and PCR of bactDNA in the ascitic uid was in agreement in
87.5% of cases. BactDNA was not detected in one culture positive
ascitic uid sample, a nding similar to that in our study. Bruns
et al. [17] detected bactDNA by multiplex PCR in ascitic uid in
14 out of 68 (20.6%) of patients with liver cirrhosis and ascites.
Because the presence of bactDNA in the culture negative mesenteric lymph nodes (MLN) is associated with an inammatory
reaction similar to that observed in culture positive samples, studies suggested that the concept of bacterial translocation might be
expanded to consider it as the presence of bacterial genome fragments in MLN, irrespective of the results of microbial culture [22].
The application of nucleic acid amplication techniques for
pathogen detection in the ascitic uid may provide advantages
over bacterial culture techniques, especially for microorganisms
that are hard to cultivate or in patients after antibiotic treatment
[17]. Considering that PCR of bactDNA in ascitic uid as the gold
standard, detection of bactDNA in the serum showed higher sensitivity and specicity in the detection of bacterial translocation
(89% and 100%, respectively) than the cultivation of ascitic uid
using the blood culture technique (42.1% and 96.8%, respectively).
The introduction of 16S ribosomal RNA gene-based methods for
the detection of bactDNA revolutionized the position of the microbiological studies beyond culture-based protocols [24] and provided a tool to detect bacterial DNA fragments that provided
molecular evidence of bacterial translocation (BT) in patients with
CNNNA [8,16]. Moreover, Albillos et al. [25] concluded that the def-

23

inition of BT should be extended to include the release of bacterial

products, such as endotoxin and bacterial DNA from viable and
non-viable bacteria.
The results of this study also conrmed that bacterial translocation of DNA is a common event in patients with liver cirrhosis and
CNNNA. BactDNA was detected simultaneously in ascitic uid and
sera in 10 out of 40 (25%) cases of CNNNA. This result approximated that of Vieira et al. [15] who detected bactDNA in 8 out of
28 (28.6%) cases with CNNNA. Fam et al. [16] reported that
bactDNA was detected in the ascitic uid and/or serum in 24 out
of 69 (34.7%) patients with liver cirrhosis and sterile ascites.
BactDNA was also detected simultaneously in the ascitic uid
and serum in 11 patients, in ascitic uid only in another 11 patients and in blood samples only in two patients. El Naggar et al.
[26] detected the presence of bacterial DNA in both serum and
ascitic uid in 12 out of 34 (35.3%) patients with liver cirrhosis
and CNNNA. This nding is in agreement with Such et al. [8] and
Albillos et al. [27] who detected bactDNA simultaneously in the
ascitic uid and sera in 9 out of 28 (32.1%) of patients with CNNNA.
Frances et al. [28] reported that BT is a common event in patients
with advanced and decompensated cirrhosis, because 7 out of 17
(41%) patients showed asymptomatic presence of bacterial DNA
in both blood and ascitic uid. Bruns et al. [17] detected bactDNA
by multiplex PCR in ascitic uid in 8 out of 56 (14.3%) patients with
CNNNA. This lower prevalence may be explained by differences in
the analytical sensitivity of the assays (multiplex PCR vs. singletarget PCR).
In the present study, a total of 20 out of 50 (40%) cases were
diagnosed as ascitic uid infections. SBP was detected in two patients (4%), CNNA was detected in one patient (2%) and bacteriascites was diagnosed in seven patients (14%). Ten patients (20%)
were diagnosed as CNNNA. Sugihara et al. [18] reported that 13
out of 48 (27%) in his study were diagnosed as ascitic uid infections. SBP was detected in 4 (8.3%), CNNA was detected in 5
(10.4%) and bacteriascites was detected in 4 (8.3%) patients.
Kamani et al. [11] reported that the incidence of AFIs in the patients with liver cirrhosis and ascites was 27.7%. SBP constituted
6.5% of AFI while 21.2% had CNNA. Other studies reported higher
incidence of AFI which ranged from 50% to 71% [29,30]. This difference may be due to differences in cirrhotic aetiology [18]. Wang
et al. [31] reported that the in-hospital incidence of SBP was
21.6% in hepatitis B related cirrhosis and 7.3% in hepatocellular
carcinoma.
In the present study, there was no statistically signicant difference of all baseline clinical, serum, and ascitic uid analytical characteristics except for AST; which was signicantly higher in group I
(who had positive ascitic uid culture and/or positive bactDNA in
the ascitic uid and/or serum) than in group II (who had neither
positive ascitic uid culture nor positive bactDNA in the ascitic
uid and serum). However, there was no statistically signicant
difference of all values between patients with CNNNA with
bactDNA and those without bactDNA. Comparison between patients with SBP and patients with CNNA could not be done in this
study because of the low number (only two cases of SBP and one
case of CNNA). Similarly, many other studies did not report any
statistically signicant difference of baseline clinical and haemodynamic parameters among patients with bactDNA and patients
without bactDNA [8,15,17,18]. Fam et al. [16] reported that baseline clinical and haemodynamic investigations did not show any
signicant difference among patients with bactDNA and patients
without bactDNA except for serum creatinine level, which was
higher in patients with bactDNA.
Rapid detection and identication of bacteria in the ascitic uid
is the key to improve the survival of cirrhotic patients with ascitic
uid infection. This aim might be fullled by molecular diagnosis,
which played an increasingly important role in the rapid detection

24

M.S. Mostafa et al. / Arab Journal of Gastroenterology 12 (2011) 2024

and identication of pathogenic organisms in clinical samples

[18].
From this study, it can be concluded that ascitic uid infection is
caused by a variety of Gram positive and Gram negative organisms.
Simultaneous detection of bacterial DNA in the ascitic uid and serum constitutes a molecular evidence of bacterial translocation in
patients with liver cirrhosis and ascites, as previously reported by
Such et al. [8]. Moreover, bacterial DNA could be present in a significant number of patients with culture negative non-neutrocytic
ascites. This nding is not associated with any specic symptom
or sign of infection. Therefore, the early detection of bacterial
DNA in those patients and prompt initiation of prophylactic selective intestinal decontamination might be helpful in overall patients
survival.
Further large-scale studies are recommended to evaluate the
cost-effectiveness of PCR in the detection of bacterial translocation
in patients with liver cirrhosis and ascites in order to initiate early
antibiotic therapy. Nevertheless, PCR of the ascitic uid is recommended to be the gold standard for the diagnosis of ascitic uid
infection. Sequencing of PCR products obtained from the ascitic
uid and/or serum should be considered as a helpful tool in the
identication of the organisms causing ascitic uid infection in
cirrhotic patients.
Conicts of interest
The authors declared that there was no conict of interest.
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