Severe peritonitis due to Streptococcus viridans following adjustable gastric banding

Periprocedural Peritonitis Prophylaxis: A Summary of the Microbiology and the Role of Systemic Antimicrobials

Background

Peritonitis is a leading complication of peritoneal dialysis (PD). One strategy that the International Society for Peritoneal Dialysis (ISPD) has used to help mitigate the morbidity and mortality associated with peritonitis is through prevention, including antibiotic prophylaxis utilization in high-risk situations. The aim of this study is to summarize our current understanding of postprocedural peritonitis and discuss the existing data behind periprocedural antibiotic prophylaxis, focusing primarily on PD catheter insertion, dental procedures, colonoscopies, upper endoscopies with gastrostomy, and gynecologic procedures.

Summary

The ISPD currently recommends intravenous antibiotics prior to PD catheter insertion, colonoscopies, and invasive gynecologic procedures, though prophylaxis has only demonstrated benefit in a prospective, randomized control setting for PD catheter insertion. However, multiple retrospective studies exist that support the use of antibiotic prophylaxis for the other 2 procedures. No specific antibiotic regimen has been established as most optimal to prevent peritonitis for any of the 3 procedures. Antibiotic coverage should include the Enterobacteriaceae family, as well as Gram-positive organisms commonly found on the skin flora for PD catheter insertion, anaerobes for colonoscopies, and common organisms from the urogenital flora in gynecologic procedures. Additionally, the ISPD currently recommends oral amoxicillin prior to dental procedures. There is currently no ISPD recommendation to provide antibiotic prophylaxis prior to an upper endoscopy with or without gastrostomy, though this is a potential area for research.

Key Messages

PD patients are at high risk for developing peritonitis after typical procedures. Antibiotic prophylaxis is a potential strategy that the ISPD utilizes to prevent these infections. However, further research needs to be done to determine the optimal antibiotic regimen.

Clinical features and outcome of postoperative peritonitis following bariatric surgery

Background

We assessed the clinical features and outcome of morbidly obese patients admitted to the intensive care unit (ICU) for management of postoperative peritonitis (POP) following bariatric surgery (BS).

Methods

In a prospective, observational, surgical ICU cohort, we compared the clinical features, empiric antibiotic therapy, and prognosis of BS patients with those developing POP after conventional surgery (cPOP).

Results

Overall, 49 BS patients were compared to 134 cPOP patients. BS patients were younger (45 ± 10 versus 63 ± 16 years; p < 0.0001), had lower rates of fatal underlying disease (39 vs 64 %; p = 0.002), and the same SOFA score at the time of reoperation (8 ± 4 vs 8 ± 3; p = 0.8) as the cPOP patients. BS patients had higher proportions of Gram-positive cocci (48 vs 35 %; p = 0.007) and lower proportions of Gram-negative bacilli (33 vs 44 %; p = 0.03), anaerobes (4 vs 10 %; p = 0.04), and multidrug-resistant strains (20 vs 40 %; p = 0.01). Despite higher rates of adequate empiric antibiotic therapy (82 vs 64 %; p = 0.024) and high de-escalation rates (67 % in BS cases and 51 % in cPOP cases; p = 0.06), BS patients had similar reoperation rates (53 vs 44 %; p = 0.278) and similar mortality rates (24 vs 32 %; p = 0.32) to cPOP patients. In multivariate analysis, none of the risk factors for death were related to BS.

Conclusions

The severity of POP in BS patients resulted in high mortality rates, similar to the results observed in cPOP. Usual empiric antibiotic therapy protocols should be applied to target multidrug-resistant microorganisms, but de-escalation can be performed in most cases.

Viridans streptococci in peritoneal dialysis peritonitis: clinical courses and long-term outcomes

BACKGROUND

The clinical courses and long-term outcomes of viridans streptococcus (VS) peritoneal dialysis (PD) peritonitis remain unclear.

METHODS

We conducted a retrospective analysis of all PD patients in a single center with gram-positive cocci (GPC) peritonitis between 2005 and 2011, and divided them into 3 groups: VS, other streptococci and other GPC (apart from VS). Clinical characteristics and outcomes of the VS group were compared with the other streptococci and other GPC groups, with prognostic factors determined.

RESULTS

A total of 140 patients with 168 episodes of GPC peritonitis (44% of all peritonitis) were identified over 7 years. Among these, 18 patients (13%) developed VS peritonitis, while 14 patients (10%) developed other streptococcal peritonitis. Patients with VS peritonitis had a high cure rate by antibiotic alone (94%), despite a high polymicrobial yield frequency (28%). We found that VS peritonitis carried a lower risk of Tenckhoff catheter removal and relapsing episodes than other GPC peritonitis (6% vs 11%), and a lower mortality than other streptococci peritonitis (0% vs 7%). However, after the index peritonitis episodes, VS, other streptococci, and other GPC group had a significantly increased peritonitis incidence compared with the period before the index peritonitis (all p < 0.01). Patients with VS peritonitis had a significantly higher incidence of refractory peritonitis compared with other streptococci or other GPC peritonitis in the long term (both p < 0.01).

CONCLUSIONS

VS poses a higher risk of subsequent refractory peritonitis after the index episode as compared with other streptococcal or GPC peritonitis. It might be prudent to monitor the technique of these patients with VS peritonitis closely to avoid further peritonitis episodes.