S2648 Spontaneous Peritonitis and When to Escalate Therapy From Bacterial to Fungal: A Case Report and Review of the Literature

Abstract

INTRODUCTION: Spontaneous bacterial peritonitis (SBP) is a disease seen in patients with decompensated liver cirrhosis and can be deadly. Clear diagnostic criteria have been established with ascites showing >250 PMNs/mm at which point of time empiric antibiotic therapy should be initiated. Spontaneous fungal peritonitis (SFP) can present similarly to SBP, yet the diagnosis is often delayed and outcomes are poor. We present a case of a patient with SFP was misdiagnosed as SBP, followed but criteria that can distinguish those at high risk for SFP for whom early antifungal therapy could be considered. CASE DESCRIPTION/METHODS: A 67 yr old man with a history of decompensated NASH cirrhosis, CKDIII and diabetes presented to our hospital with acute kidney injury and abdominal pain, after having been discharged 2 weeks prior for a C. difficile infection and ascites requiring paracentesis. Signs and symptoms on arrival suggested spontaneous bacterial peritonitis with abdominal distension and tenderness and ceftriaxone was started empirically. Nephrology was consulted for kidney injury and diagnosed hepatorenal syndrome type 1. His initial paracentesis ascites fluid showed >4000 PMNs/mm3, confirming SBP. On day 2 he underwent hemodialysis and developed altered mental status, respiratory distress and hypotension and was emergently transferred to the ICU for intubation and antibiotic escalation to vancomycin, cefepime and metronidazole for septic shock. At 48 hours he underwent second paracentesis for which ascites fluid showed 3600 PMNs/mm3, suggesting failure of SBP therapy. Candida glabrata grew from initial paracentesis culture on day 3 and empiric micafungin was initiated. By day four with worsening clinical status and dismal prognosis, he was made comfort care after discussion with family. DISCUSSION: Effective medical therapy has been established for SBP, but such is lacking for spontaneous fungal peritonitis (SFP). In cases where SBP therapy fails, SFP should be seriously considered. Mortality for SFP remains significant at 50–100%, thought to be due to the delay in culture-based fungal therapy initiation. Literature suggests antifungal initiation at 48 hours does little to change initial prognosis and thus earlier initiation should be sought when possible. Ascitic fluid fungal PCR should be pursued for early diagnosis when SFP is suspected. We will present criteria that can delineate patients at high risk for SFP so that early empiric antifungal therapy can be initiated in attempt to improve overall prognosis.