Unsuspected infection is infrequent in asymptomatic outpatients with refractory ascites undergoing therapeutic paracentesis

OBJECTIVE: Large-volume paracentesis is a safe and effective means of treat ing patients with refractory ascites. However, there is limited information regarding the need for ascitic fluid studies in asymptomatic outpatients p resenting for therapeutic paracentesis. The aim of this prospective study w as to define the incidence and natural history of peritoneal fluid infectio n in asymptomatic outpatients undergoing therapeutic paracentesis. METHODS: Over a 13-month period, 118 therapeutic paracenteses were performe d in 29 outpatients with decompensated cirrhosis (Child-Pugh class B = 38%, C = 62%). After a brief medical history and physical examination, ascitic fluid cell count with differential and culture were obtained from all parti cipating subjects. Seven (24%) of the subjects were receiving norfloxacin p rophylaxis, accounting for antibiotic coverage during 40% of the procedures performed. The clinical course and outcome of study subjects during a mean follow-up of 137 days was reviewed. RESULTS: All 118 (100%) of the ascitic fluid samples demonstrated absolute neutrophil counts of <250/mm(3) (mean = 6.5 +/- 22.5 pmn/mm(3). Asymptomati c bacterascites was identified from three of the 118 (2.5%) fluid samples, but all of these subjects spontaneously recovered without treatment or sequ elae. During follow-up, six episodes of symptomatic or hospital-associated peritoneal fluid infection were identified in study participants, emphasizi ng the importance of fluid studies in other clinical settings. CONCLUSIONS: Although further studies are needed, the routine culture of as citic fluid in asymptomatic outpatients with refractory ascites requiring t herapeutic paracentesis may not be necessary when there is a low index of s uspicion for occult infection. In circumstances of clinical uncertainty, ho wever, obtaining ascitic fluid cell counts with differential is recommended to insure patient safety. (C) 1999 by Am. Coll. of Gastroenterology.