Cause Of Spontaneous Bacterial Peritonitis Research Articles

MICROBIOLOGICAL ANALYSIS AND ANTIBIOTIC SUSCEPTIBILITY FOR SPONTANEOUS BACTERIAL PERITONITIS IN HOSPITALIZED PATIENTS WITH AND WITHOUT HEPATITIS C

In individuals with cirrhosis, spontaneous bacterial peritonitis (SBP) is a common and often fatal bacterial infection with ascites. The Pathological accumulation and collection of fluid in the peritoneal cavity is known as ascites. Ascites can be a challenging diagnosis. Individuals with or without underlying hepatitis C may have varying SBP. Antimicrobials are used to treat SBP, however because MDR organisms are present, initial empirical treatment may not be effective. The aim of the present study was to investigate the causative agents of ascites in SBP and to check antibiotic susceptibility of bacterial isolates. In recent study twenty-five SBP patients were prospectively studied. The ascitic fluid was inoculated in to conventional bacterial broth, agar culture and blood culture media. Among all tested bacterial species E. coli was the most isolated bacteria present in 23 samples out of 25. The presence of E.coli was 92% followed by Shigella spp (72%), Salmonella spp (68%), Enterobacter spp (60%), K. aerogenes (52%), S. aureus (32%), S. epidermidis (30%), A. israelii (28%), P. aeruginosa (24%), C. freundii (20%) and S. marcescens (08%). A total of six antibiotics were used to check antibiotic susceptibility pattern of bacterial isolates through disc diffusion method. The used antibiotics were Meropenem, Moxifloxacin, Ciprofloxacin, Ceftriaxone, Cefixime and vancomycin. Our results showed that most of isolated bacterial species were MDR (Multi drug resistant) except E.coli and A.israelii that were sensitive to used antibiotics. Meropenem was the most effective antibiotic against all tested bacterial species. Meropenem showed maximum zone of inhibition against S.auresus (34mm), followed by A. israelii (33mm), P.aeruginosa (32mm), C.freundii (31mm), S.marcescens (28mm), S.epidermidis (27mm), E.coli (26mm), Salmonella spp (23mm), K.aerogenes (21mm), Enterobacter spp (21mm) and Shigella spp (15mm). It is concluded that gram-positive and gram-negative multi-drug resistant bacteria were the most common cause of SBP in patients with and without hepatitis C and meropenem was the most effective antibiotic against all tested isolate

Propensity-score matched analysis shows spontaneous bacterial peritonitis secondary to non O1/non O139 Vibrio cholera infection results in poor outcome

Background and Aim: We analyse clinical course of cirrhotic patients with non-O1/non-O139 Vibrio cholera (NOVC) bacteraemia and/or bacterascites. Methods: Electronic medical records of cirrhotic patients admitted with spontaneous bacterial peritonitis during 2010-2020 were filtered to recruit patients with NOVC isolated in blood or ascites and patients with E. coli bacteraemia/ bacterascites (comparator group). Both the groups were matched a-priori for the date of admission (within 5-days). Baseline parameters and in-hospital outcomes were recorded and compared using non-parametric tests. Both were propensity-matched for baseline parameters (age and Child’s score) and compared for in-hospital outcomes. Results: Of the 2545 patients admitted with spontaneous bacterial peritonitis during the study period, 29 had NOVC isolated (M: F:23:6; Age: 39, 18-54 years; median, range; MELD score: 25, 12-38; Child’s score: 11, 10-12.5) from either blood (26) or ascites (3) or both (8). Of these, 26 isolates were pan-sensitive, and all were sensitive to the initial empirical antibiotic. Fifty-three patients with E. coli isolated (M: F: 43:10; Age: 48, 18-69 MELD score: 25, 20-32; Child’s score:12, 11-13) from blood (31), ascites (17) or both (5) during the similar timeframe were recruited. Of these, 48 isolates were sensitive to empirical antibiotics initially utilised. Overall, 15/ 29 (death: 12; discharge in terminal state: 3) patients with NOVC and 21/53 (death: 19; discharge in terminal state: 2) had an adverse in hospital outcome (p-value: 0.148). On propensity-score matching, 29 comparable E. coli patients (age:41, 18-55 years; MELD score: 24, 19-31; Child’s score: 12, 11-13) had lesser circulatory failure at admission 4(13%) vs 14(49%; p-value:0.1) and significantly lower in-hospital adverse outcome (6/ 29) as compared to NOVC group (15/29; p-value: 0.028). Conclusions: Non-O1/Non-O139 Vibrio cholera, a rare cause of spontaneous bacterial peritonitis, had higher circulatory failure and is associated with significantly higher mortality.

Predictors of Short-Term Mortality Following First Episode of Spontaneous Bacterial Peritonitis in Hospitalized Cirrhotic Patients.

Background and aimsSpontaneous bacterial peritonitis (SBP) is an important cause of morbidity and mortality in patients with cirrhosis. This study aimed to identify the factors impacting morbidity and short-term mortality in a cohort of patients with cirrhosis following an index episode of SBP.MethodsIn a retrospective study of hospitalized cirrhotic cohort, 333 patient records were reviewed. Demographic, clinical, and laboratory, as well as radiological characteristics of the patient population were analyzed on day 1 of admission. The diagnosis of cirrhosis was based on the combination of laboratory, clinical, and radiological features. The diagnosis of SBP was established by abdominal paracentesis in the presence of cellular, biochemical, and microbiological features consistent with SBP. All independent variables were analyzed to generate a predictive model of mortality by using the Cox proportional hazards regression analysis (adjusted for age and gender).ResultsA total of 61 cirrhotic patients with ascites and a first episode of SBP were identified. The overall mortality among hospitalized patients was 19.7% and was associated with longer length of stay (12.6 vs. 7.6 days; p=0.01). Patient cohorts with multiple antibiotic resistant bacteria as a cause of SBP had a significantly higher mortality compared to those with other bacterial phenotypes (p=0.03). Multivariate analyses showed that a model for end-stage liver disease (MELD) score (hazard ratio [HR]=1.29; 95% CI: 1.10 to 1.92; p=0.023), Child-Turcotte-Pugh score (HR=1.23; 95% CI: 1.05 to 1.82; p=0.027), and acute kidney injury (HR=2.09; 95% CI: 1.41 to 3.47; p=0.01) were the predictors of mortality from SBP.ConclusionSBP predicts in-hospital mortality in cirrhotic patients. In addition to multiple antibiotic resistant bacteria, thresholds of both hepatic and renal injury independently predict adverse outcomes.

S2541 Spontaneous Bacterial Peritonitis Secondary to Listeria monocytogenes in an Immunosuppressed Patient With Lymphocytic Predominance Ascitic Fluid

INTRODUCTION: Spontaneous bacterial peritonitis (SBP) is a common complication among patients with cirrhosis and ascites. It is associated with lower survival of 40% at 1 year after the initial episode. Enteric gram-negative bacteria, including Escherichia coli and Klebsiella pneumonia are the most common bacteria causing SBP in these patients, but SBP caused by gram-positive bacteria is increasing. Listeria monocytogenes, a gram-positive rod shaped bacteria, is an unusual cause of SBP in the United States. We describe a patient with cirrhosis and neutropenia who presented with SBP caused by Listeria. CASE DESCRIPTION/METHODS: A 70-year-old female with history of cirrhosis due to autoimmune hepatitis presented to the ER with severe weakness and vomiting. She denied abdominal pain, fever, chills or diarrhea. Laboratory tests were significant for WBC of 0.92thou/mcl, absolute neutrophil count of 0.4thou/mcl, lactic acid at 14.9 mmol/L and creatinine level at 2.45mg/dl. MELD-Na score was 31. Abdominal ultrasound showed large amount of ascites and paracentesis was performed. Ascites fluid studies showed WBC of 37/mm3 with 1.0% neutrophils, 83% of lymphocytes, PMNs of 0.37/mm3, 10% mesothelial cells and macrophages 6%. She was empirically started on cefepime 2g, meropenem 500 mg and vancomycin 1.25g while awaiting cultures. Ascitic fluid culture grew Listeria monocytogenes. Blood cultures and urine culture were negative. She was admitted to ICU, received volume resuscitation with Ringer lactate solution, albumin infusion, and stress-doses of steroids along with vasopressors for two days. Repeated ascitic fluid culture after 7 days showed no growth. She completed antibiotics for 14 days. Patient underwent liver transplantation and had uneventful recovery. DISCUSSION: Listeria is a facultative anaerobe that it is transmitted feco-orally from contaminated food or animal products. Neonates, elderly and immunosuppressed patients are at higher risk to Listeria infection. It is well known to cause gastroenteritis and meningitis, but it is an uncommon cause of SBP. Third generation cephalosporin antibiotics are standard empiric therapy for SBP but it does not cover for uncommon bacteria like Listeria. Lymphocytic predominance in the ascitic fluid in our patient may be secondary to neutropenia however, there are a few reported cases of Listeria causing nonneutrocytic bacterascites. Antibiotic therapy for SBP with third generation cephalosporins may need to be reevaluated in cirrhotic patients with severe neutropenia.

S1502 A Rare Case of Raoultella planticola-Associated Spontaneous Bacterial Peritonitis in a Patient With Decompensated Cirrhosis

INTRODUCTION: Raoultella planticola (RP) is a rare human pathogen, the incidence and prevalence of which is likely underreported due to its frequent misidentification as a Klebsiella species. To our knowledge, three cases have been reported of RP causing peritoneal infections. We present a case of RP causing spontaneous bacterial peritonitis (SBP) in a patient with decompensated cirrhosis, the first case of RP infection in a patient with cirrhosis secondary to nonalcoholic steatohepatitis (NASH). CASE DESCRIPTION/METHODS: 53-year-old female patient with cirrhosis, presented with ascites and abdominal pain. Medical history is significant for multiple sclerosis, gastric bypass surgery, breast cancer status post lumpectomy, chemo and radiation 10 years prior, with recent diagnosis of cirrhosis due to NASH (biopsy confirmed). On presentation, the patient was afebrile, markedly hypotensive, hypokalemic, neutropenic (WBC 2.84), anemic, thrombocytopenic, and with lactic acidosis. CT scan was notable for cirrhotic morphology, known innumerable hepatic lesions (biopsy negative for malignancy), as well as large volume ascites with a nodular omentum. Patient underwent diagnostic and therapeutic paracentesis with removal of 4 liters of ascitic fluid. Fluid analysis revealed WBC count of 4,524 with 98% neutrophil predominance and a polymorphonuclear leukocyte count greater than 250. Cytology was negative for malignancy. The patient was started on metronidazole and fluoroquinolone based therapy and later switched to Vancomycin and Meropenem for broad spectrum coverage. Cultures from the ascitic fluid returned positive for RP. Antibiotics were narrowed to Aztreonam on day 4 to complete a 7-day course of treatment. Subsequent collection of ascitic fluid revealed 228 WBC per mcL and fluid differential of 16% neutrophils indicating good response to Aztreonam with resolution of SBP. DISCUSSION: RP is an extremely rare cause of SBP even in immunocompromised patients. Risk factors include heavy alcohol abuse, seafood consumption, diabetes, and chemotherapy. Our patient is unique in that she had clear evidence of RP in ascitic fluid and is the only documented cirrhotic patient with RP cultured in ascitic fluid with no known alcohol abuse history or history of peritoneal dialysis. Given that our patients peritoneal fluid was positive for RP alone, it is likely that the isolate was the pathogenic cause of SBP rather than a colonizing organism.

Carbapenem vs. Third-Generation Cephalosporin for Spontaneous Bacterial Peritonitis

Due to widespread use of antibiotics, multidrug-resistant organisms have emerged as causes of spontaneous bacterial peritonitis (SBP). Typically,

Listeria monocytogenes as a Cause of Spontaneous Bacterial Peritonitis

Spontaneous bacterial peritonitis is a common and often serious complication of long standing ascites in the presence of advanced liver disease. We report a case of a 74-year-old woman with alcoholic cirrhosis admitted to our emergency department with a 1-week history of diffuse abdominal pain and increased abdominal perimeter. On physical examination, she had a significant abdominal distention and a positive fluid wave consistent with ascites. A diagnosis of spontaneous bacterial peritonitis was made and empiric therapy with ceftriaxone was started but the patient’s condition worsened. Four days later Listeria monocytogenes was detected in peritoneal fluid culture and ampicillin was initiated according to in vitro sensibility test. The patient completed 14 days of treatment with clinical and laboratory improvement. Listeria is an uncommon cause of spontaneous bacterial peritonitis. Clinicians should be aware of the uncommon agents of spontaneous bacterial peritonitis, mainly when there is not a proper response to therapy. J Med Cases. 2019;10(9):257-259 doi: https://doi.org/10.14740/jmc3358

Spontaneous Bacterial Peritonitis

Spontaneous bacterial peritonitis (SBP) is defined as bacterial infections that occur in patients with cirrhosis and ascites without any significant intraperitoneal infection, accounting for approximately 10-30% of bacterial infections in hospitalized patients. SBP develops in patients with liver cirrhosis because bacterial translocations are increased by changes in the intestinal bacteria and mucosal barriers. In addition, the decreased host immune response cannot remove the bacteria and their products. The most common cause of SBP is Gram-negative bacteria, such as Escherichia coli and Klebsiella species, and infections by Gram-positive bacteria are increasing. SBP is diagnosed by the presence of >250 polymorphonuclear leukocyte/mm3 in ascites after paracentesis. If SBP is diagnosed, empirical antibiotic therapy should be started immediately. Empirical antibiotic treatment should distinguish between community acquired infections and nosocomial infections. Cirrhotic patients with gastrointestinal bleeding or low ascitic protein concentrations should consider primary prevention and those who recover from SBP should consider secondary prevention. This review describes the pathophysiology, diagnosis, treatment, and prevention of SBP.

Spontaneous Bacterial Peritonitis (SBP) as a Rare Complication of Invasive Listeriosis: A Closer Look at Empiric SBP Coverage

Introduction: Listeria monocytogenes is an anaerobic gram-positive rod that is transmitted from contaminated food or animal products. Listeriosis is a rare but deadly disease with approximately 1600 cases per year and mortality rate of approximately 16%. Rarely, listeria has been shown to cause spontaneous bacterial peritonitis (SBP), with approximately 50 cases reported in literature. We present a rare case of invasive listeriosis manifesting with bacteremia, pericarditis, and spontaneous bacterial peritonitis. Case Report: A 58-year old female with past medical history of decompensated alcoholic cirrhosis and poorly controlled diabetes presented with a one week history of shortness of breath and dyspnea on exertion. Initial workup revealed severe pericarditis with early cardiac tamponade physiology and patient underwent urgent pericardiocentesis and pericardial window procedures. Following the procedure, the patient developed fevers and abdominal pain. Blood cultures were obtained and paracentesis was performed that revealed an absolute neutrophil count of 15,700 cells/mm3. The patient was empirically started on a third generation cephalosporin for empiric SBP coverage. Subsequently she developed high fevers and worsening sepsis and blood and peritoneal fluid cultures both grew listeria monocytogenes. Antimicrobial therapy was switched to piperacillin-tazobactam with progressive clinical improvement. The patient was discharged to rehab facility after a one month hospitalization and finished a prolonged treatment course with trimethoprim-sulfamethoxazole. Upon further questioning she did admit to frequently eating soft cheeses and deli meats; however, no absolute source of infection was identified. Discussion: Listeria often results in self-limited gastroenteritis in normal hosts, but may manifest with severe invasive disease in immunocompromised or pregnant patients. Listeria has been infrequently reported as a cause of SBP and is often associated with poor clinical outcomes in these cases. Empiric coverage for spontaneous bacterial peritonitis usually involves a third generation cephalosporin to provide coverage for enterobacteriaceae such as E. Coli or Klebsiella species. In our patient, conventional SBP empiric coverage failed to appropriately treat her infection and the patient clinically worsened. Atypical organisms such as listeria may circumvent empiric SBP coverage, making clinical suspicion for these organisms paramount in select cases.

Spontaneous Bacterial Peritonitis Caused by Listeria monocytogenes

Introduction: Diagnosis of SBP is made if the ascitic fluid shows polymorph nuclear cell count more than 250 cells/mm. Listeria monocytogenes, is an uncommon cause of SBP in the United States. Case Presentation: Patient is a 57-year-old man with a past medical history significant for non-Hodgkin's lymphoma diagnosed three years prior to hospital presentation status post six rounds of Rituximab, Cyclophosphosphamide, Doxorubicin Hydrochloride, Vincristine Sulfate and Prednisone therapy. He presented to the hospital secondary to generalized weakness, consistent temperature of 99.2 Fahrenheit and chills. He had a tunneled indwelling peritoneal catheter for recurrent ascites secondary to peritoneal metastasis. During presentation his vitals were temperature: 98.2 F, heart rate of 101 beats/ min, BP 84/40 mmHg while on norepinephrine, and saturating at 94% on 2 L of nasal cannula. His abdomen was distended, tense with ascites and tender to palpation. His laboratory results were as noted in Table 1. Evaluation with a CT abdomen and pelvis showed moderate ascites and small bilateral pleural effusion. His serum-ascites albumin gradient was 1.3. He was further worked up for an infectious etiology with thoracentesis and peritoneal tap. He was found to have listeria bacteremia as well as positive pleural and ascites cultures for listeria. He initially had received an empiric dose of ceftriaxone and gentamicin, but was transitioned to ampicillin and gentamicin once listeria was identified in the peritoneal fluid and blood cultures. After 7 days of treatment with ampicillin, he remained afebrile with resolution of general weakness and myalgia. He was discharged on ampicillin 2g intravenous every 4 hours for a total of 14 days of treatment. At the time of discharge his repeat blood and peritoneal cultures remained sterile.Table: Table. Laboratory resultsDiscussion: SBP caused by listeria monocytogenes should be considered when there is an inappropriate response to treatment in the first 48-72 hours with patients treated for SBP. Third generation cephalosporin are commonly used for treatment of SBP, however these antibiotics do not have a reliable action against listeria. Ampicillin with or without an aminoglycoside is the treatment of choice. In conclusion listeria is a rare but potentially fatal cause of spontaneous bacterial peritonitis. This case emphasizes the importance of looking beyond meningitis when approaching listeriosis in immunocompromised hosts.

A Rare Case of Non-typhoidal Salmonella SBP Leading to Empyema in Decompensated Cirrhosis

Introduction: Spontaneous bacterial peritonitis (SBP) is a common infection seen in cirrhotic patients, with bacterial translocation as a major mechanism of pathogenesis. Salmonella typhimurium is a gram negative non-typhoidal bacteria, which has been reported as an unusual cause of SBP in immunocompromised patients. We report a rare case of a salmonella empyema secondary to SBP in a decompensated cirrhotic. Case Report: A 63 year old Caucasian male with a history of cirrhosis secondary to chronic hepatitis C virus (HCV) was admitted with ascites and leukocytosis (WBC of 25.9 x109 per liter). Paracentesis revealed a WBC of 1196 (39% PMN's), consistent with a diagnosis of SBP. The patient was admitted and treated with intravenous albumin and antibiotics. Gram stain and culture of the ascitic fluid were negative. He clinically improved and was discharged on oral antibiotics after three days of hospitalization. Approximately one week later, the patient returned to the emergency department with progressive shortness of breath. He was hypoxic and had a significant leukocytosis (WBC of 19 x109 per liter). His abdominal exam was benign without any reoccurrence of ascites, but chest imaging demonstrated a right sided pleural effusion (Image 1 and Image 2). Thoracentesis was performed, which was consistent with an empyema. Gram stain of the pleural fluid showed gram negative rods and cultures grew non-typhoidal salmonella typhimurium (Image 3). Discussion: Non-typhoidal Salmonella is a rare cause of SBP that has been previously reported in the literature. Published case reports show an association of SBP with immunocompromised states such as malignancy, chemotherapy and organ transplant recipients. While a few cases of nontyphoidal Salmonella empyemas have been seen in the literature, this is the first reported case of SBP implicated as the cause of a Salmonella empyema. While a rare pathogen, Salmonella should be recognized as a cause of SBP in decompensated cirrhosis, especially in patients who are immunocompromised.

56-Year-Old-Man With Fever, Altered Mental Status, and Abdominal Pain

56-Year-Old-Man With Fever, Altered Mental Status, and Abdominal Pain

Monomicrobial Non-Neutrocytic Bacteriascites due to Salmonella enteritidis : A Case Report and Literature Review

Spontaneous bacterial peritonitis (SBP) is diagnosed on the basis of neutrophilic leukocytosis in peritoneal fluid. In monomicrobial non-neutrocytic bacteriascites (MNB), bacterial cultures are positive in absence of neutrophilic leukocytosis (polymorphonuclear neutrophil (PMN) < 250/mm 3 ). Salmonella is an uncommon cause of SBP and only one other case of Salmonella MNB has been reported. We report such a case of Salmonella MNB. A 70-year-old man with diabetes mellitus and cirrhosis was brought to the ED with irritability and confusion for 2 days. He had recovered from a diarrheal illness 3 days prior to presentation. Examination was notable for tachycardia, tachypnea, confusion, and ascites with diffuse abdominal tenderness. Pertinent investigations included creatinine 1.38 mg/dL, ammonia 142 mMol/L, and lactic acid 5.3 mMol/L. Diagnostic paracentesis revealed a nucleated cell count of 33/mm 3 . He was admitted to MICU for hepatic encephalopathy and severe sepsis and started on empiric vancomycin and cefepime. Salmonella enteritidis was isolated in the ascitic fluid culture on day 4. Repeat paracentesis was indicated but could not be performed because he was transferred to another hospital. Infection secondary to non-typhoidal Salmonella usually presents as a self-limited gastrointestinal disease. The diagnosis of MNB is made when ascitic fluid culture is positive but fluid PMN count is < 250/mm 3 . Thirty-eight percent of patients with MNB eventually progress to SBP, while in the rest, this represents spontaneous colonization resolving without antibiotic treatment. Mechanism of infection is translocation of bacteria across intestinal cells into the peritoneum, increasing according to the Child-Pugh classification. Treatment is recommended if patients continue to have positive ascitic fluid cultures on subsequent paracentesis or if they develop local or systemic signs of infection. MNB is a potentially life-threatening condition with mortality similar to SBP. Clinicians must follow ascitic fluid culture even when fluid PMN count is < 250/mm 3 . J Med Cases. 2016;7(8):351-353 doi: http://dx.doi.org/10.14740/jmc2575w

Clinical Features and Outcomes of Spontaneous Bacterial Peritonitis Caused by Streptococcus pneumoniae: A Matched Case-Control Study.

Streptococcus pneumoniae is a well-known cause of spontaneous bacterial peritonitis (SBP) in cirrhotic patients. However, little information is available regarding clinical characteristics and outcomes of SBP caused by S. pneumoniae. It has been suggested that spontaneous pneumococcal peritonitis (SPP) often spreads hematogenously from concomitant pneumococcal pneumonia, and is associated with a higher rate of mortality.During the period between January 1997 and December 2013, 50 SPP cases were identified. These cases were then age/sex-matched with 100 patients with SBP due to causes other than S. pneumoniae (controls).SPP accounted for 4.3% (50/1172) of all culture-proven SBPs. The baseline Child-Pugh class, etiology of cirrhosis, and model for end-stage liver disease scores were comparable for the 2 groups. SPP patients were more likely than control patients to have a community-acquired infection (90.0% vs. 76.0%; P = 0.04), concurrent bacteremia (84.0% vs. 59.0%; P = 0.002), and to present with variceal bleeding (10.0% vs. 1.0%; P = 0.02). None of the study patients had pneumococcal pneumonia. The most common initial empirical therapy for both groups was third-generation cephalosporins (96.0% vs. 91.0%; P = 0.34) which was active against a significantly higher proportion of the cases than of the controls (97.8% vs. 78.7%; P = 0.003). Thirty-day mortality was significantly lower in the case group than in the control group (10.0% vs. 24.0%; P = 0.04).SPP was not associated with pneumococcal pneumonia and showed lower mortality than SBP caused by other organisms. However, the present study was constrained by the natural limitations characteristic of a small, retrospective study. Therefore, large-scale, well-controlled studies are required to demonstrate the influence of SPP on mortality, which was marginal in the present study.

Infection spontanée du liquide d’ascite au cours de la cirrhose

Spontaneous bacterial peritonitis (SBP) is a severe complication occurring in patients with cirrhosis, and is associated with high mortality. Liver transplantation should be considered after a first episode of SBP. Gram-negative bacilli are the major cause of SBP, however there is an increasing trend of Gram-positive cocci related SBP. Management includes empirical antibiotic treatment and albumin infusion. The choice of antibiotics depends on the site of acquisition (community-acquired vs nosocomial or health-care associated infection) and local resistance profile, due to the emergence of drug-resistant bacteria. Secondary prophylaxis is recommended after resolution of SBP and reduces recurrence and mortality. Primary prophylaxis in patients with low protein ascites (<15 g/L) should be restricted to patients with severe cirrhosis awaiting for liver transplantation.

First report of Kocuria marina spontaneous peritonitis in a child

BackgroundSpontaneous bacterial peritonitis (SBP) is a rare affection in the pediatric population. It usually occurs when concurrent conditions are present, such as nephrotic syndrome, peritoneal dialysis or liver disease. We report a case of spontaneous bacterial peritonitis due to Kocuria marina in a 2-year-old child with no underlying risk factor. This is both the first description of an infection caused by this rare pathogen in a child and the first reported case of primary peritonitis caused by K. marina in a patient with no predisposing condition.Case presentationA 2 year-old boy presented to the Pediatric Emergency Department with clinical signs of peritonitis. Laparoscopic surgical exploration confirmed purulent, generalized peritonitis without perforation. Culture of the peritoneal fluid revealed the presence of Kocuria marina, a Gram-positive coccoid environmental bacteria. After peritoneal lavage and appropriate antibiotic treatment, the patient improved and was discharged without sequel.ConclusionThe present report illustrates the first clinical presentation of Kocuria marina SBP in a child with no underlying risk factor. Although never previously described in healthy patients, this pathogen may therefore be considered as a possible cause of SBP in a child. This unusual finding extends the spectrum of infectious diseases caused by Kocuria marina beyond the scope of the previously described susceptible population.Electronic supplementary materialThe online version of this article (doi:10.1186/s12879-014-0719-5) contains supplementary material, which is available to authorized users.

The burden of extended-spectrum β-lactamase-producing Enterobacteriaceae in patients with cirrhosis.

Patients with cirrhosis have high susceptibility to bacterial infections [1]; 24 % of patients admitted to the hospital for an acute decompensation of cirrhosis have bacterial infection [2]. The most common infection is spontaneous bacterial peritonitis (SBP) [1, 2]. It is well known that SBP is caused by Gram-negative bacteria such as Escherichia coli or Klebsiella pneumoniae originating from the intestinal lumen [3]. The translocation of intestinal bacteria is a crucial step in the process leading to SBP [1, 4]. Little is known about underlying mechanisms that explain bacterial translocation [4]. During the last 30 years the mortality of SBP has decreased from 70 to 30 % [3]. This was the result of large use of a strategy which includes high index of suspicion leading to diagnosis paracentesis, diagnosis of SBP based on neutrophil count C250/mL in the ascitic fluid and subsequent rapid initiation (before results of culture) of wide spectrum, non-nephrotoxic antibiotics (e.g., third generation cephalosporins) against Enterobacteriaceae (E. coli, K. pneumonia) which are the most common causes of SBP [3]. In the late 1990s mortality of SBP was further decreased to 10 % with the combined use of empiric antibiotics and the intravenous administration of human albumin [5]. This beneficial effect was related to a significant decrease in the development of kidney failure (known as hepatorenal syndrome, HRS) [5]. Today, SBP remains the most common trigger of infection-induced acute-onchronic liver failure (ACLF) [2]. ACLF whichever its trigger, is characterized by the failure(s) of organs (including kidney, cerebral, liver, coagulation, circulation and lungs) and high risk of death depending on the number of failing organs [2]. Due to the severity of SBP, efforts have been made to prevent this complication. In patients who survive an episode of SBP long-term prophylaxis with the fluoroquinolone norfloxacin significantly decreases the risk of recurrent SBP [3]. The impact on survival is unknown. In patients with low ascitic fluid protein levels (\1.5 g/dL) but without a prior episode of SBP the efficacy of primary prophylaxis using a fuoroquinolone is still unclear. One trial has shown that norfloxacin significantly decreased the risk for developing a first episode of SBP [6], a finding that was not confirmed in another trial with ciprofloxacin [7]. Recently, an increasing number of cases of SBP due to extended spectrum b-lactamase (ESBL)-producing E. coli, K. pneumonia have been reported in Asia [8–11] and Europe [12–16]. Some risk factors for SBP caused by ESBL-producing bacteria Enterobacteriaceae have been identified including the in-hospital acquisition of infection [10–15], long-term norfloxacin prophylaxis [13], use of blactams within the last 3 months [13], and infection by multiresistant bacteria in the last 6 months [13]. ESBLproducing strains are resistant not only to third-generation cephalosporins, amoxicillin-clavulanic acid but also to quinolones and trimethoprim-sulfamethoxazole [13]. R. Moreau (&) Inserm UMR_S 1149, Centre de Recherche sur l’Inflammation (CRI), Inserm et Universite Paris-Diderot, Paris 7 – Site Bichat, 16 Rue Henri Huchard, 75890 Paris Cedex 18, France e-mail: Richard.moreau@inserm.fr

Non-typhoidal salmonella: an unusual cause of spontaneous bacterial peritonitis in decompensated cirrhosis

Salmonella typhimurium, a non-typhoidal salmonella, is an unusual cause of spontaneous bacterial peritonitis (SBP). It is usually reported in asymptomatic patients with normal or high ascitic fluid protein levels with underlying immunosuppression, as high opsonic activity in the ascitic fluid of these patients protects them from the usual organisms causing spontaneous bacterial peritonitis, unless they are exposed to a particularly virulent organism like salmonella. We report a case of culture-proven non-typhoidal salmonella in a patient with decompensated cirrhosis, with low protein and without any underlying immunosuppression, and no other source to explain its origin.

Spontaneous bacterial peritonitis with a very high leukocyte count in ascitic fluid caused by Haemophilus influenzae

We report on a case of spontaneous bacterial peritonitis (SBP) due to Haemophilus influenzae (H. influenzae) in an elderly patient with alcoholic cirrhosis. The patient presented with a 5 day history of fever, cough, and fatigue. Abdominal paracentesis revealed a very high neutrophil count (134,800 cells/μL). Secondary peritonitis and abdominal abscess were ruled out. Peritoneal fluid culture displayed the growth of H. influenzae. The patient was treated with ceftriaxone and showed signs of improvement. Eventually, the patient died due to septic shock caused by other organisms. H. influenzae is a very rare cause of SBP. This case report demonstrates that (1) H. influenzae should be considered a potential cause of SBP, and (2) a very high leukocyte count in ascitic fluid can be found in patients with SBP.

Spontaneous Bacterial Peritonitis Caused by Nontypeable Haemophilus influenzae in a Previously Healthy Child

To the Editors: Spontaneous bacterial peritonitis (SBP) is an infection of the peritoneum without obvious intra-abdominal cause.1 Most episodes of SBP develop in patients with cirrhosis, but has also been observed in congestive heart failure, nephrotic syndrome, fulminant hepatic failure and alcoholic and viral hepatitis.2 SBP developing in healthy individuals is rare.2Haemophilus influenzae is a rare cause of SBP in normal children and has been assumed to originate from a respiratory source.3 Only 3 cases of SBP caused by H. influenzae have been reported.4–6 However, SBP caused by nontypeable H. influenzae biotype ІІ in otherwise healthy child has never been reported. A 13-year-old previously healthy boy presented to the emergencyroom with 8 days of abdominal pain, fever, diarrhea and vomiting. He reported recent symptoms of upper respiratory tract infection. His temperature was 38°C, the abdomen was tense and tender with signs of peritoneal inflammation. The white blood cell count was 26.9 K/μL (80.8% segmented cells). C-reactive protein was 24.6 mg/L. Ultrasound showed a localized inflammatory mass in the right lower abdomen. The child was considered to have advanced appendicitis taken to surgery. He received preoperatively intravenous amoxicillin and clavulanic acid, metronidazole and netilmicin. Intraoperatively, the abdominal cavity contained 1000 mL of purulent peritoneal fluid, which was Gram stained and cultured for aerobic and anaerobic organisms. The appendix was normal, whereas the omentum was inflamed and edematous with ischemic lesions distally. Appendectomy was performed, and the ischemic portion of the omentum was removed. The peritoneal cavity was irrigated with isotonic crystalloid solution until the returns were clear, and the wound was closed primarily. There were no surgical complications. Histopathology of the appendix and the omentum was normal. The peritoneal fluid culture grew a nontypeable H. influenzae, biotype ІІ, susceptible to amoxicillin and clavulanic acid. The diagnosis of SBP due to H. influenzae was established. The patient received 10 days of antibiotic therapy and recovered completely. The signs and symptoms of SBP are nonspecific. Approximately 10% of the patients are asymptomatic.1 The diagnosis is established by examination of the ascitic fluid. The polymorphonuclear leukocyte count in the fluid exceeds 250 cells/mm³, and peritoneal cultures yield the pathogen.1 Empiric antimicrobial therapy is started, as soon as infection is suspected.2 Preoperatively, diagnosis of SBP in previously healthy children is difficult because of the suspicion of secondary peritonitis undergo laparotomy. The present report demonstrates that SBP due to H. influenzae, although a rare condition in children with no underlying disease, should be considered as a possibility in children with acute abdominal pain, especially if following infection of the respiratory tract. Early diagnosis of SBP, caused by H. influenzae in otherwise normal children, is essential for effective treatment and improved outcome. Anastasia Dimopoulou, MD Department of Pediatric Surgery Children’s Hospital of Penteli Athens, Greece Dimitra Dimopoulou, MD Department of Internal Medicine University Hospital of Heraklion Crete, Greece Efstratios, Christianakis, MD Dimitrios Bourikas, MD Ioannis Alexandrou, MD Department of Pediatric Surgery Children’s Hospital of Penteli Athens, Greece George, Samonis, MD Department of Internal Medicine University Hospital of Heraklion Crete, Greece