Neutrocytic Ascites and Clostridium difficile-associated Diarrhea: Should Patients Be Treated Empirically for Spontaneous Bacterial Peritonitis?

Abstract

Case 1: A 68-year-old woman with cryptogenic cirrhosis presented with new high SAAG neutrocytic ascites (PMN: 421) and Clostridium difficile-associated diarrhea (CDAD). She was treated empirically with oral vancomycin and five days of cefotaxime. Ascitic fluid cultures were negative, and her diarrhea resolved. Case 2: A 58 -year-old woman with hepatitis C cirrhosis presented with high SAAG neutrocytic ascites (PMN: 778) and severe CDAD. She was treated with IV metronidazole and oral vancomycin, as well as cefotaxime. At 48 hours, ascitic fluid cultures were preliminarily negative, and cefotaxime was stopped. Final ascitic fluid cultures remained negative, and she recovered. Discussion: The standard treatment for spontaneous bacterial peritonitis (SBP) is early initiation of antibiotics and albumin after performing a diagnostic paracentesis. However, in CDAD, early discontinuation of broad-spectrum antibiotics is critical. In our two patients, this led to a therapeutic dilemma that required us to consider whether to discontinue antibiotics early in patients undergoing empiric treatment for SBP. Ascites is a common finding in cases of CDAD, up to nearly 80% in some case series (1,2,3,4). The overall specificity of ascites is low, as it may be seen in a variety of conditions (3,4). To our knowledge, this is the first report of a scenario of CDAD in a patient with cirrhosis and ascites with SAAG >1.1, with a high neutrophil count (>250/mL). Conclusion: Cirrhotic patients with CDAD may have culture-negative neutrocytic ascites from colitis alone. Based on our experiences, it may be reasonable to stop empiric treatment of SBP in a patient with high SAAG (>1.1) neutrocytic (>250/mL) ascites, who has confirmed CDAD, if ascitic cultures are negative at 48 hours.