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Background/aims: The most rational treatment of moderate ascites is spironolactone alone or in combination with furosemide. However, it is unknown which of these two treatment schedules is preferable., Methods: One hundred nonazotemic cirrhotic patients with moderate ascites were randomly assigned to be treated with spironolactone and furosemide (Group 1: 50 patients) or with spironolactone alone (Group 2: 50 patients). If no response was obtained, the doses of diuretics were increased up to 400 mg/day of spironolactone and 160 mg/day of furosemide. In patients of group 2 not responding to 400 mg/day of spironolactone, furosemide was added. In cases with an excessive response, the dosage of diuretics was reduced., Results: The response rate (98% in Group 1 vs. 94% in Group 2), the rapidity of ascites mobilization and the incidence of complications induced by diuretic therapy was similar in both groups. The need to reduce the diuretic dosage was significantly higher in Group 1 than Group 2 (68% vs. 34%; P=0.002)., Conclusions: In the treatment of moderate ascites, spironolactone alone seems to be as safe and effective as spironolactone associated with furosemide. Since spironolactone alone requires less dose adjustment, it would be more suitable for treating ascites on an outpatient basis.

Background/aims: Intestinal bacterial translocation is common in cirrhotic rats with spontaneous bacterial peritonitis, and it is thought to play a major pathogenic role. There has so far been no evidence for clonality between bacteria isolated from intestine and ascites. This study aimed to use molecular epidemiology techniques to show that spontaneous bacterial peritonitis is due to translocated intestinal bacteria., Methods: Samples of ascitic fluid, portal blood, mesenteric lymph nodes and ileal contents from healthy (n=10) and ascitic cirrhotic rats with (n=12) or without (n=15) spontaneous bacterial peritonitis were cultured. In six infected rats, DNA macrorestriction fragments of 30 bacterial isolates [Escherichia coli (n=13), Enterococcus faecalis (n=12) and Proteus mirabilis (n=5)] from ascites (n=8), mesenteric lymph nodes (n=7), portal blood (n=6), and ileal flora (n=9) were compared., Results: Bacterial translocation was more frequent in animals with (58%) than in those without spontaneous bacterial peritonitis (20%, p=0.049) or controls (10%, p=0.026). The same bacterial strain was simultaneously isolated in ascites and in mesenteric lymph nodes and/or ileum in 7/8 (87%) instances. The identity rate for bacteria present in both ascites and mesenteric lymph nodes was 80% (4/5). Likewise, identity was demonstrated in 3/4 instances of bacteria found in both ascites and portal blood., Conclusions: These results indicate that spontaneous bacterial peritonitis in cirrhotic rats is mainly due to intestinal bacteria translocated to mesenteric lymph nodes. Portal blood could be a less frequent route.

Background/aims: Selective intestinal decontamination with norfloxacin is widely used to prevent spontaneous bacterial infections in cirrhosis. The study was performed to compare the spontaneous bacterial peritonitis occurring in patients with and without prophylactic norfloxacin., Methods: Two hundred and twenty-nine consecutive episodes of spontaneous bacterial peritonitis, (193 in patients without (Group A) and 36 in patients with norfloxacin prophylaxis (Group B)), were retrospectively analyzed. In 100 episodes (86 and 14, respectively), the responsible organism was isolated in ascitic fluid., Results: Clinical and laboratory data at diagnosis were comparable in both groups. There were marked differences (p < 0.001) between group A and B in the frequency of peritonitis caused by gram-negative (67.4% vs. 14.3%) and gram-positive (30.2% vs. 78.6%) bacteria. There were three polymicrobial episodes. Bacteria resistant to cefotaxime and gram-negative bacilli resistant to quinolones were isolated in ascitic fluid in nine (seven in Group A and two in Group B) and three episodes (all in Group A), respectively. No differences in the course of infection and patient survival were observed between groups., Conclusions: Spontaneous bacterial peritonitis in patients with and without prophylaxis with norfloxacin are not different in clinical features, response to treatment and prognosis. Spontaneous bacterial peritonitis caused by gram-negative organisms resistant to quinolones is extremely uncommon in patients with cirrhosis receiving prophylactic norfloxacin.