None listed
Conditions
Brief summary
Spontaneous bacterial peritonitis or in short ‘SBP’ is a life threatening bacterial infection within the excessive abdominal fluid that accumulates in patients with advanced liver cirrhosis. SBP if discovered or treated late can cause prolonged hospitalisation and even death. The key to treatment of SBP is early detection or prophylactic antibiotic use to prevent its occurrence. It is well known that prophylactic antibiotic use can prevent SBP occurrence but can be associated with side effects of the antibiotics and development of multi-resistant bacteria. Current research to date has limited information on which patients may best benefit from prophylactic antibiotics and there is lack of consensus between experts in this field. The theory behind development of SBP is through the concept called bacterial translocation. The passage of pathogenic bacteria from the inside of the gut through the bowel wall barrier into the gut tissue leads to eventual infective process. One of the key changes that contribute to development of SBP in context of advanced liver cirrhosis is the change that occurs in the gut barrier. Patients with liver cirrhosis have increased permeability or ‘leakiness’ of the gut barrier, thereby allowing pathogenic bacteria to leak across the barrier into the tissue space. This is often compounded by the abnormal overgrowth of pathogenic gut flora in patients with liver cirrhosis. We propose that by determining which patients with liver cirrhosis have highly abnormal gut permeability will allow us to predict who will best benefit from prophylactic antibiotics. We hypothesize that individuals with high gut permeability are most at risk of SBP and would have the most benefit of prophylactic antibiotic use. There has been long standing safe method of measuring gut permeability in children with many different gut disorders since 1980 by measuring two different types of ingested sugars, namely rhmanose and lactulose on a blood or urine test. The test allows measurement of the ingested sugars which crosses the gut barrier into the blood or urine at a set time to determine the functionality of the barrier. The study aims to recruit patients with advanced liver cirrhosis and examine their gut permeability by using this dual sugar test. Subsequently patients with abnormal permeability will be randomised to antibiotics or no antibiotic prophylaxis in a controlled trial to observe its benefit.
Interventions
All participants will undergo dual sugar solution (rhamnose/lactulose + mannitol) ingestion. The solution contains 7.5 mL of lactulose (Duphalac®; Solvay Pharmaceuticals, Pymble, New South Wales, Australia), 1g L-rhamnose monohydrate (minimum 99%, diluted in 2 mL water; Sigma) and 1g of mannitol. This is followed by a blood test 4 hours after which is then taken to the laboratory for analysis. The plasma concentrations of lactulose, rhamnose and mannitol is determined using High Performance Liqu
All participants will undergo dual sugar solution (rhamnose/lactulose + mannitol) ingestion. The solution contains 7.5 mL of lactulose (Duphalac®; Solvay Pharmaceuticals, Pymble, New South Wales, Australia), 1g L-rhamnose monohydrate (minimum 99%, diluted in 2 mL water; Sigma) and 1g of mannitol. This is followed by a blood test 4 hours after which is then taken to the laboratory for analysis. The plasma concentrations of lactulose, rhamnose and mannitol is determined using High Performance Liquid Chromatography (Centre for Paediatric and Adolescent Gastroenterology, Children, Youth and Women’s Health Service) and the result expressed as dual sugar ratios (lactulose/rhamnose; lactulose/mannitol). This will determine the gut permeability. Participants determined as having increased permeability will undergo concealed randomisation to either intervention or no intervention. Intervention arm will received oral administration of Trimethoprim/Sulfamethoxazole 160mg/800mg tablet daily or oral administration of Ciprofloxacin 500mg tablet daily (if allergic to trimethoprim/sulfamethoxazole) for 6 months with standard care. Adherence to the medications will be reviewed by monthly contact with the participant either by phone call or face to face consultation. Non-intervention arm will received standard care only. The standard care is defined as usual practice in optimising lifestyle in patients with liver cirrhosis such as absolute alcohol abstinence, high protein and no added salt diet and regular exercise. There is concurrent medical treatment with diuretics to reduce ascites and regular blood test monitoring for electrolyte derangement and renal function. Patients with refractory or diuretic intolerant ascites will receive regular ascitic drain to control their symptoms at set intervals. Patient who develop complications such as gastrointestinal bleed (variceal bleed) or infection will received prompt care with hospital protocol care for gastrointestinal bleed and appropriate targeted antibiotics as required.
Sponsors
Gastroenterology Department, The Queen Elizabeth hospital
Study design
Allocation
Randomised controlled trial
Intervention model
Parallel
Primary purpose
Prevention
Masking
Open (masking not used)
Eligibility
Sex/Gender
All
Age
18 Years to 75 Years
Healthy volunteers
No
Inclusion criteria
- Patients with established diagnosis of liver cirrhosis of any aetiology - Clinically detectable large volume ascites - Child-Pugh score of B or C liver cirrhosis - Increased gut permeability Participants subsequently found to have normal gut permeability will not be randomised but will be followed from enrolment for 6 months for both primary and secondary outcomes.
Exclusion criteria
- Previous history or current history of bacterial peritonitis - Current use of antibiotics - Non-steroidal anti-inflammatory drug (NSAIDs) use which is known to increase intestinal permeability - Gastrointestinal disease that affects permeability including inflammatory bowel disease, coeliac disease, irritable bowel syndrome, gastrointestinal bleeding or acute gut inflammation - Active alcohol abuse of more than 40g/day for male and 20g/day for female - Lack of capacity to consent for the study
Outcome results
None listed