Primary Bacterial Peritonitis Research Articles

Primary Bacterial Peritonitis in a Young Man: A Rare Manifestation of Invasive Group A Streptococcal Infection

Primary Bacterial Peritonitis in a Young Man: A Rare Manifestation of Invasive Group A Streptococcal Infection

Evaluation of Percutaneous Peritoneal Drainage Among Patients with High Risk Perforated Peritonitis in Tertiary Care Hospitals

Aim: The aim of this study was to evaluate the effectiveness of percutaneous peritoneal drainage (PPD) as a treatment option for high-risk perforated peritonitis in tertiary care hospitals. Methods: This prospective investigation was conducted at multiple centres including Department of Surgery, Quaid-e-Azam Medical College / Bahawal Victoria Hospital Bahawalpur and Jinnah International Hospital, Abbottabad from August, 2022 to January, 2023. Patients with peritonitis accompanied by shock or who did not respond to initial resuscitative protocols were included in the study. Patients with primary peritonitis or spontaneous bacterial peritonitis and those with a history of multiple previous abdominal surgeries were excluded. The study evaluated the effectiveness of PPD as a treatment option for high-risk perforated peritonitis. Chi Square test was applied to assess association keeping P value < 0.05. Results: The mean age was 54.81±9.2 years, male patients were 66 (57.9%) while female patients were 48 (42.1%). Regarding mortality after PPD 25 (21.9%) patients died, while 15 (13.2%) patients died after definitive surgery. Mortality after PPD was significantly associated with systolic BP < 90 mmHg and comorbid. Conclusion: Based on our study findings, we have determined that percutaneous peritoneal drainage is a crucial procedure that can potentially save lives and lead to improved outcomes in high-risk patients undergoing laparotomy. Moreover, it has the potential to enhance their preoperative condition. Keywords: High risk patients, Primary peritoneal drainage, Perforation peritonitis

A Rare Case of Secondary Streptococcus pyogenes Peritonitis in a Patient With Cirrhosis

CASE REPORT A 42-year-old woman with autoimmune hepatitis with decompensated cirrhosis and ascites presented with 8 days of worsening abdominal pain. She was afebrile with diffuse abdominal tenderness without rebound or guarding and a large umbilical hernia with overlying skin breakdown. Diagnostic paracentesis produced a protein 5.2 g/dL, glucose < 5 mg/dL, lactate dehydrogenase 14,252 U/L, and a white blood cell count of 59,200/μL with 83% polymorphonuclear cells. Cultures grew Streptococcus pyogenes. Imaging showed large ascites communicating with a loculated fluid collection in the umbilical hernia (Figure 1). The loculated collection drained purulent fluid positive for moderate Gram-positive cocci in chains and clusters. Despite 2 weeks of ceftriaxone (2 g) and metronidazole (500 mg), clinical peritonitis with fevers persisted. Repeat paracentesis showed an increase in white blood cells to 82,760/μL. Laparoscopy with peritoneal washout was performed with removal of 6 L of purulent fluid and lysis of dense adhesions and fibrinous exudate (Figure 2). Pathology demonstrated acute fibrinous inflammatory exudate with dense fibrous tissue. Antibiotics were broadened to piperacillin-tazobactam (3.375 g) with improvement, and she was discharged on cefpodoxime (200 mg).Figure 1.: Abdominal and pelvic computed tomography with large volume ascites and loculated fluid collection in the umbilical hernia.Figure 2.: Dense adhesions and fibrinous exudate is seen throughout the peritoneum on laparoscopy.Secondary peritonitis in patients with cirrhosis is uncommon and has a high mortality (53.8%) with appropriate surgical management, so rapid differentiation from primary spontaneous bacterial peritonitis is paramount.1 Runyon's criteria can be used and require 2 of 3 criteria: ascitic fluid protein >1 g/dL, glucose <50 mg/dL, and lactate dehydrogenase greater than normal serum's upper limit. Ascitic fluid growing multiple organisms and clinical failure to respond to appropriate antibiotics are other clues in establishing the diagnosis.2 S. pyogenes peritonitis is rare, limited to case series and reports of individuals without previous underlying liver disease, peritoneal dialysis, or pelvic inflammatory disease. A case series of available evidence until March 2018 identified 30 published cases of S. pyogenes peritonitis in previously healthy individuals. Given female predominance (75%), a hypothesized portal of entry was translocation from the vaginal tract.3 There are 240 cases of culture-positive peritonitis in patients with cirrhosis contained only 2 cases of S. pyogenes, although without case details.4 One case report documented S. pyogenes peritonitis in a patient with cirrhosis with umbilical hernia rupture.5 Given the similarity in the examination, this was considered the likely portal of entry in our patient. This case highlights the challenges in managing secondary peritonitis in patients with cirrhosis, including the importance of early differentiation between primary and secondary peritonitis and successful stepwise management. DISCLOSURES Author contributions: A. Philippou and C. Bowman-Zamora wrote the manuscript. G. Ezaz edited the manuscript and is the article guarantor. Financial disclosure: None to report. Previous presentation: This case was presented at the New York ACP poster presentation; April 8, 2021; Virtual. Informed consent was obtained for this case report.

Antibiotic prophylaxis for prevention of spontaneous bacterial peritonitis in liver cirrhosis: systematic review.

Spontaneous bacterial peritonitis is a potentially life-threatening infection in patients with liver cirrhosis and ascites. Its prevention is vital to improve prognosis of cirrhotic patients. The main objective of this systematic review was to evaluate what is the most efficacious and safest antibiotic prophylactic strategy. Studies were located by searching PubMed and Cochrane Central Register of Controlled Trials in The Cochrane Library until February 2019. Randomized controlled trials evaluating primary or secondary spontaneous bacterial peritonitis prophylaxis in cirrhotic patients with ascites were included. The selection of studies was performed in two stages: screening of titles and abstracts, and assessment of the full papers identified as relevant, considering the inclusion criteria. Data were extracted in a standardized way and synthesized qualitatively. Fourteen studies were included. This systematic review demonstrated that daily norfloxacin is effective as a prophylactic antibiotic for the prevention of spontaneous bacterial peritonitis in patients with cirrhosis. Once weekly ciprofloxacin was not inferior to once daily norfloxacin, with good tolerance and no induced resistance. Trimethoprim-sulfamethoxazole and norfloxacin have similar efficacy for primary and secondary prophylaxis of spontaneous bacterial peritonitis, however, trimethoprim-sulfamethoxazole was associated with an increased risk of developing an adverse event. Rifaximin was more effective than norfloxacin in the secondary prophylaxis of spontaneous bacterial peritonitis, with a significant decrease in adverse events and mortality rate. Continuous long-term selective intestinal decontamination with norfloxacin is the most widely used prophylactic strategy in spontaneous bacterial peritonitis, yet other equally effective and safe options are available.

GS-015 - Primary spontaneous bacterial peritonitis prophylaxis is associated with greater ICU admission and 30-day mortality compared to secondary spontaneous bacterial peritonitis prophylaxis

GS-015 - Primary spontaneous bacterial peritonitis prophylaxis is associated with greater ICU admission and 30-day mortality compared to secondary spontaneous bacterial peritonitis prophylaxis

Efficacy of taurolockTM in preventing primary bacterial peritonitis in patients undergoing peritoneal dialysis for renal insufficiency: A randomized, multicenter, double-blind study with placebo

Efficacy of taurolockTM in preventing primary bacterial peritonitis in patients undergoing peritoneal dialysis for renal insufficiency: A randomized, multicenter, double-blind study with placebo

The Role of Antibiotics in Acute Abdominal Events

Acute abdominal events are either surgical or medical. Medical events are such as primary bacterial peritonitis and peritonitis secondary to pelvic inflammatory disease, in which usually only antibiotic administration and conservative therapy is enough. Acute abdominal surgical events are those which need surgical intervention to cure, such as acute appendicitis and secondary bacterial peritonitis. It seems that antibiotics are widely used in urgent or emergent abdominal surgical events due to current inflammation, ischemia, gangrene or stasis. In surgical events, Antibiotic administration is either prophylactic or therapeutic.

Spontaneous Bacterial Peritonitis due to Actinomyces Mimicking a Perforation of the Proximal Jejunum

Patient: Female, 42Final Diagnosis: Spontaneous pelvic-abdominal peritonitis due to actinomycesSymptoms: Abdominal distension • abdominal pain • acute abdomen • fever • intermenstrual bleeding • nausea • sepsis • septic shockMedication: —Clinical Procedure: —Specialty: SurgeryObjective:Unusual clinical courseBackground:Pelvic-abdominal actinomycosis is a rare chronic condition caused by an anaerobic, gram-negative rod-shaped commensal bacterium of the Actinomyces species. When Actinomyces becomes pathogenic, it frequently causes a chronic infection with granulomatous abscess formation with pus. Due to diversity in clinical and radiological presentation, actinomycosis can easily be mistaken for several other conditions. Peritonitis without preceding abscess formation caused by Actinomyces species has been described in only few cases before in literature.Case report:We report a case of spontaneous pelvic-abdominal peritonitis with presence of pneumoperitoneum and absence of preceding abscesses due to acute actinomycosis mimicking a perforation of the proximal jejunum in a 42-year-old female with an intra-uterine contraceptive device in place. Explorative laparotomy revealed 2 liters of odorless pus but no etiological explanation for the peritonitis. The intra-uterine contraceptive device was removed. Cultivation showed growth of Actinomyces turicensis. The patient was successfully treated with penicillin.Conclusions:In the case of primary bacterial peritonitis or lower abdominal pain without focus in a patient with an intrauterine device in situ, Actinomyces should be considered as a pathogen.

Non-perforation tension pneumoperitoneum resulting from primary non-aerobic bacterial peritonitis in a previously healthy middle-aged man: a case report

BackgroundTension pneumoperitoneum is a rare surgical emergency in which free intraperitoneal gas accumulates under pressure. The known sources of free gas are perforated hollow viscera. We believe this is the first published case of a tension non-perforation pneumoperitoneum secondary to anaerobic gas production. This occurred in a background of primary non-aerobic bacterial peritonitis, which developed in an immunocompetent adult man.Case presentationA previously healthy 45-year-old Bulgarian man presented with a 3-week history of abdominal pain. He displayed signs of shock, peritonitis, and abdominal compartment syndrome. A plain abdominal X-ray showed the pathognomonic “saddlebag sign” with his liver displaced downwards and medially. An emergency laparotomy released pressurized gas, accompanied by 3100 mL of foamy pus. A sudden hemodynamic deterioration occurred soon after decompression. The sources of infection and tension pneumoperitoneum were not found. The peritoneal exudate sample did not recover aerobes. A laparostomy was created and three planned re-operations were performed. During the second re-laparotomy we placed an intraperitoneal silo and his abdomen was closed with skin sutures. Definitive fascial closure was achieved through separation of his two rectus muscles from their posterior sheaths. He was discharged in good health on the 25th postoperative day.ConclusionsOur case provides evidence supporting the theory that anaerobic infection may underlie the etiology of tension pneumoperitoneum. Prior to decompressive laparotomy the patient should receive an intravenous volume bolus to compensate for possible hypotension. If laparostomy leads to lateralization of the rectus muscles with a gap of 6 cm or less, the posterior part of the components separation technique is effective in achieving fascial closure. We present an original classification of tension pneumoperitoneum defining it as primary or secondary.Electronic supplementary materialThe online version of this article (doi:10.1186/s13256-016-0945-0) contains supplementary material, which is available to authorized users.

Is there a role for probiotics in liver disease?

Intestinal microbiota plays an important role in health and disease. Alteration in its healthy homeostasis may result in the development of numerous liver disorders including complications of liver cirrhosis. On the other hand, restoration and modulation of intestinal flora through the use of probiotics is potentially an emerging therapeutic strategy. There is mounting evidence that probiotics are effective in the treatment of covert and overt hepatic encephalopathy, as well as in the prevention of recurrence of encephalopathy. The beneficial effect of probiotics also extends to liver function in cirrhosis, nonalcoholic fatty liver disease, and alcoholic liver disease. On the other hand, data associating probiotics and portal hypertension is scanty and conflicting. Probiotic therapy has also not been shown to prevent primary or secondary spontaneous bacterial peritonitis. Larger clinical studies are required before probiotics can be recommended as a treatment modality in liver diseases.

Primary Bacterial Septic Peritonitis in Cats: 13 Cases

The purpose of this paper is to describe the signalment, clinical signs, laboratory results, culture results, and response to treatment for primary septic peritonitis in cats. This is a retrospective study of 12 client-owned animals. Medical records were reviewed for clinical findings, laboratory results, microbial culture results, radiographic findings, diagnosis, treatment, and outcome. The overall mortality rate for this group of cats was 31%, consistent with previous reports of septic peritonitis in cats. All cats that were both bradycardic and hypothermic on presentation did not survive. Other clinicopathological findings were consistent with previously reported cases of septic peritonitis in cats. Results suggest that clinicopathological findings and outcomes in cats with primary septic peritonitis are similar to those in cats with septic peritonitis from a determined cause. A specific mechanism of inoculation has yet to be determined, but an oral source of bacteria is suggested for cats with primary bacterial septic peritonitis.

The Utility of Evaluating Low Serum Albumin Gradient Ascites in Patients With Cirrhosis

Serum-ascites albumin gradient (SAAG) has been used extensively in the diagnostic workup of patients with ascites. A SAAG level of <1.1 g/dl is usually thought of as a result of nonportal hypertension etiologies, including malignancies, tuberculous peritonitis, and nephrotic syndrome. However, the predictive value of a low SAAG in patients with existing cirrhosis in whom the pretest probability of portal hypertension is high is not clear. We identified all patients with a SAAG of <1.1 g/dl during a 5-year period at a single large veterans affairs medical center. Cirrhosis was defined by clinical, histological, and radiological features. Nonportal hypertension causes of low SAAG were identified, including bacterial peritonitis, peritoneal carcinomatosis, nephrogenous ascites, tuberculous peritonitis, chylous ascites, and pancreatic ascites. We identified 92 patients (76 with cirrhosis and 16 with no cirrhosis) with ascites and a SAAG of <1.1 g/dl. Of the 76 patients with cirrhosis, only 29 (38%) had an identifiable cause, most commonly primary bacterial peritonitis (11, 38%), followed by peritoneal carcinomatosis or malignant ascites (8, 28%) and nephrotic syndrome (5, 17%). There were 47 patients with cirrhosis and a low SAAG for whom no etiology was identified. Thirty-three patients underwent a repeat paracentesis, 24 (73%) of whom changed to a high SAAG. On the other hand, the 16 patients with no cirrhosis had significantly lower SAAG (0.66 vs. 0.81), and most (12, 75%) had an identifiable cause of ascites. Evaluation of a SAAG <1.1 g/dl in patients with known cirrhosis has low yield and is less likely to be helpful than that in patients without cirrhosis. A repeat paracentesis as part of the workup is recommended. Further studies of low SAAG cutoffs are needed.

Primary bacterial peritonitis in dogs and cats: 24 cases (1990–2006)

To determine clinical characteristics of primary bacterial peritonitis (infection of the peritoneal cavity with no identifiable intraperitoneal source of infection) and compare characteristics of primary and secondary peritonitis in dogs and cats. Retrospective case series. 24 (primary peritonitis) and 60 (secondary peritonitis) client-owned dogs and cats. Data from medical records of dogs and cats with primary and secondary peritonitis were reviewed for descriptive information regarding primary peritonitis and for comparison between the 2 forms of peritonitis. 15 dogs and 9 cats met inclusion criteria for primary peritonitis, and 49 dogs and 11 cats met inclusion criteria for secondary peritonitis. The most common historical findings in dogs and cats with primary and secondary peritonitis were lethargy, vomiting, and anorexia. Dogs with secondary peritonitis more often developed peritoneal exudates than those with primary peritonitis, and dogs with primary peritonitis were more often infected with gram-positive bacteria than those with secondary peritonitis. No difference in outcome was detected between all animals with primary versus secondary peritonitis; however, dogs with secondary peritonitis treated with surgery were more commonly discharged than those with primary peritonitis treated with surgery. Differences in primary and secondary peritonitis related to historical, physical examination, and clinical laboratory findings; bacteriologic findings; peritoneal effusion characteristics; and outcome were detected. However, larger case numbers are needed before alternative recommendations, such as avoidance of surgery, can be made.

Leukotriene inhibitors in combination with steroids: potential role in the development of primary bacterial peritonitis

Leukotrienes play a role in inflammation, and their participation in airway inflammation and bronchoconstriction in patients with severe asthma can be ameliorated by a new class of drugs known as leukotriene modulators. The role of leukotrienes in increasing vascular permeability in experimental peritonitis and in inducing chemotaxis of inflammatory cells has recently been documented. Steroids have been incriminated in the development of bacterial translocation in animal models in association with the suppression of mucosal immunity. The development of spontaneous bacterial peritonitis is recognized in cirrhotic patients with ascites and in those with nephrotic syndrome. The onset of bacterial peritonitis in the absence of these predisposing conditions or other underlying cause, such as perforated viscus, is termed 'primary bacterial peritonitis', and has never been described in asthmatic patients. We present an asthmatic patient who developed primary bacterial peritonitis while receiving a leukotriene modulator in combination with prednisolone therapy. The hypothesis that leukotriene receptor blockade might predispose to the development of primary bacterial peritonitis in patients receiving steroid therapy is discussed.

Laparoscopic Diagnosis and Management of Primary Bacterial Peritonitis

Primary bacterial peritonitis is a rare condition occurring, by definition, in patients without an underlying cause as is otherwise observed in patients with perforated viscus, pre-existing ascites, or nephrosis. The diagnosis is usually made at laparotomy. Laparotomy, however, is often associated with significant morbidity and wound complications. We report a case of primary bacterial peritonitis diagnosed at laparoscopy that was managed successfully by laparoscopic peritoneal lavage and appropriate antibiotic therapy with expeditious recovery. This is yet another argument for the application of laparoscopy in the management of generalized peritonitis.

Bacteremic Streptococcus bovis infections at a university hospital, 1992-2001.

The association of Streptococcus bovis biotypes with types of clinical infection and underlying malignancies has rarely been reported in Taiwan. The aim of this study was to characterize the clinical features and microbiological characteristics of patients with S. bovis bacteremia. From January 1992 to December 2001, 62 patients with S. bovis bacteremia were treated at National Taiwan University Hospital. Their demographic characteristics, clinical features, results of imaging studies, pathological findings, and laboratory data were retrospectively analyzed. Antimicrobial susceptibilities were determined using the agar dilution method and biotypes were determined using the API 20 Strep system. The majority of cases (76%) occurred during the 1996-1997 and 1999-2000 periods. Thirty five patients were male, and the mean age of the 62 patients was 61 years. Underlying diseases included malignancies (40%), cardiac diseases (27%), diabetes mellitus (24%), and liver cirrhosis (21%). Fifty two percent (n = 32) of patients presented with primary bacteremia and 24% (15) with definite or possible infective endocarditis. Thirteen percent (8) presented with hepatobiliary infections (acute cholecystitis and biliary tract infection). Ten patients (16%) had polymicrobial bacteremia. All of the concomitant pathogen(s) were Gram-negative rods, among which Escherichia coli predominated. The mortality rate on day 30 of illness was 21%. High Acute Physiology and Chronic Health Evaluation (APACHE) II score on the day of positive blood culture was associated with high mortality. Among the 19 patients (31%) who underwent colonoscopy, 9 (47%) had colonic lesions (tubular adenomas or carcinomas). Of the 26 patients (41%) who underwent echocardiography, 14 (54%) had vegetation in the valves. Of the 47 S. bovis isolates examined for biotypes, 37 (79%) were biotype II (29 of biotype II/2 and 8 of biotype II/1) and 10 (21%) were biotype I. The majority of isolates causing primary bacteremia (92%), hepatobiliary infections (100%) and primary bacterial peritonitis (100%) were biotype II, while 67% of isolates associated with infective endocarditis were biotype I. All isolates were susceptible to penicillin. Infective endocarditis should be highly suspected in patients with bacteremia due to S. bovis biotype I. Investigations for intra-abdominal foci other than the colon should be undertaken in patients with bacteremia caused by S. bovis biotype II. Due to the increasing number of S. bovis bacteremia patients at the hospital and unknown origins of about 50% of bacteremia cases, the need for colonoscopy and echocardiography in each case and biotyping of each blood isolate should be emphasized.

Primary and secondary peritonitis: an update.

Intraabdominal infections are commonly encountered in clinical practice and represent a major cause of morbidity and mortality. The most common etiology is contamination of the peritoneal space by endogenous microflora secondary to loss of integrity of the gastrointestinal tract which results in secondary peritonitis. Primary peritonitis or spontaneous bacterial peritonitis is less common and usually occurs in the presence of ascites without an evident source of infection. Peritonitis associated with chronic ambulatory peritoneal dialysis is not discussed in this review. This review summarizes the significant progress which has been made with regard to primary and secondary peritonitis in the last two decades. The review emphasizes the issues of etiology, pathogenesis, microbiology, diagnosis, medical treatment and prevention.

Hypothesis: Compartmentalization of cytokines in intraabdominal infection

Although the proximal role of systemic cytokines in the infectious-inflammatory cascades is well recognized, the magnitude and meaning of its intraperitoneal levels in peritonitis have received little attention. We hypothesized that in peritonitis a significant and clinically relevant cytokine-mediated inflammatory response is compartmentalized in the peritoneal cavity. MEDLINE was used to search the literature for all articles dealing with experimental, primary, and secondary bacterial peritonitis and cytokines. Bacterial peritonitis is associated with an immense intraperitoneally compartmentalized cytokine response, with plasma levels of cytokines representing only the tip of the iceberg. Although certain amount of cytokines may be beneficial to the peritoneal defense mechanisms, higher levels correlate with adverse outcome. Thus it is plausible to look at acute peritonitis as initially a combined infective (microorganism) and inflammatory (cytokines) process. The clinical significance of the distinction between peritoneal inflammation and infection and the relevance of our findings to the stratification and treatment of peritonitis are discussed. Current surgical and antibiotic therapy for peritonitis is able to clear the peritoneal cavity of infective concentration of bacteria, but many patients continue to die of an uncontrolled activation of the inflammatory cascade. We suggest that one potential venue for therapeutic progress is the modulation of the compartmentalized peritoneal inflammatory response.

Post-traumatic primary bacterial peritonitis

Post-traumatic primary bacterial peritonitis

The role of I and B in peritonitis associated with the nephrotic syndrome of childhood.

Children with nephrotic syndrome (NS) are susceptible to bacterial infections, including primary bacterial peritonitis. Immunologic abnormalities associated with NS include low serum levels of the complement proteins I and B of the alternative complement pathway. We developed a novel and highly sensitive enzyme immunoassay using murine MAb to I and B to quantitate urinary concentrations of these proteins. We studied 22 patients with minimal change NS, including seven with a history of peritonitis (1.6 +/- 0.3 episodes, mean +/- SEM) and 15 without such a history. The two groups did not differ significantly in age, sex, race, age at onset of disease, or duration of disease. Children with minimal change NS complicated by peritonitis had 1) increased urinary excretion of both I (p < 0.05) and B (p < 0.05) in relapse versus remission, 2) greater excretion of I in both relapse (p < 0.01) and remission (p < 0.05) compared with patients without peritonitis, 3) greater excretion of B in relapse compared with patients without peritonitis (p < 0.05), and 4) decreased plasma levels of I compared with patients without peritonitis and controls (p < 0.01) and decreased plasma levels of B compared with controls. Increased urinary excretion of I correlated with decreased plasma levels of I (r = 0.88, p < 0.001). These data support our initial hypothesis that depressed plasma concentrations of these proteins of the alternative complement pathway may predispose patients with minimal change NS to peritonitis and that urinary loss of these proteins is a tenable mechanism.