Spontaneous bacterial peritonitis due to Listeria monocytogenes: importance of enrichment culture

Current Status and Prospects of Spontaneous Peritonitis in Patients with Cirrhosis

Spontaneous bacterial peritonitis (SBP) is a common cirrhotic ascites complication which exacerbates the patient's condition. SBP is caused by gram-negative bacilli and, to a lesser extent, gram-positive cocci. Hospital-acquired infections show higher levels of drug-resistant bacteria. Geographical location influences pathogenic bacteria distribution; therefore, different hospitals in the same country record different bacteria strains. Intestinal changes and a weak immune system in patients with liver cirrhosis lead to bacterial translocation thus causing SBP. Early diagnosis and timely treatment are important in SBP management. When the treatment effect is not effective, other rare pathogens should be explored.

Review article: spontaneous bacterial peritonitis--bacteriology, diagnosis, treatment, risk factors and prevention

BACKGROUND

Spontaneous bacterial peritonitis (SBP) is a severe and often fatal infection in patients with cirrhosis and ascites.

AIM

To review the known and changing bacteriology, risk factors, ascitic fluid interpretation, steps in performing paracentesis, treatment, prophylaxis and evolving perspectives related to SBP.

METHODS

Information was obtained from reviewing medical literature accessible on PubMed Central. The search term 'spontaneous bacterial peritonitis' was cross-referenced with 'bacteria', 'risk factors', 'ascites', 'paracentesis', 'ascitic fluid analysis', 'diagnosis', 'treatment', 'antibiotics', 'prophylaxis', 'liver transplantation' and 'nutrition'.

RESULTS

Gram-positive cocci (GPC) such as Staphylococcus, Enterococcus as well as multi-resistant bacteria have become common pathogens and have changed the conventional approach to treatment of SBP. Health care-associated and nosocomial SBP infections should prompt greater vigilance and consideration for alternative antibiotic coverage. Acid suppressive and beta-adrenergic antagonist therapies are strongly associated with SBP in at-risk individuals.

CONCLUSIONS

Third-generation, broad-spectrum cephalosporins remain a good initial choice for SBP treatment. Levofloxacin is an acceptable alternative for patients not receiving long-term flouroquinolone prophylaxis or for those with a penicillin allergy. For uncomplicated SBP, early oral switch therapy is reasonable. Alternative antibiotics such as pipercillin-tazobactam should be considered for patients with nosocomial SBP or for patients who fail to improve on traditional antibiotic regimens. Selective albumin supplementation remains an important adjunct in SBP treatment. Withholding acid suppressive medication deserves strong consideration, and discontinuing beta-adrenergic antagonist therapy in patients with end-stage liver disease and resistant ascites is standard care. Liver transplant evaluation should be undertaken for patients who develop SBP barring contraindications.

Listeria monocytogenes as a cause of spontaneous bacterial peritonitis: a rare entity

Listeria is an uncommon cause of spontaneous bacterial peritonitis (SBP) in the United States. Listeria should be suspected as a cause of SBP when the patient has diphtheria-like organisms on ascitic/blood cultures, iron overload/hemochromatosis, exposure to farm animals, or poor response to empiric therapy within 48–72 h. Diagnosis of SBP is made if the ascitic fluid shows polymorphonuclear cell count >250 cells/mm³ without an intra-abdominal source of infection. Ampicillin with or without an aminoglycoside is the treatment of choice. Trimethoprim-sulfamethoxazole is recommended for prophylaxis in patients with a previous episode of Listeria SBP.

Listeria monocytogenes peritonitis: presentation, clinical features, treatment, and outcome

BACKGROUND

Spontaneous bacterial peritonitis (SBP) is a serious complication in cirrhotic patients. Gram (-) (E. coli, Klebsiella pneumoniae), and Gram (+) (Streptococci, Staphylococci) bacteria are most frequently cultured from patients'ascites. Listeria monocytogenes (Lm) is scarcely reported as a causative agent.

OBJECTIVE

Our objective is to describe Lm peritonitis as a clinical entity, including its presentation, clinical features, treatment, and the potential factors that might affect survival outcome.

DATA SOURCES

MEDLINE, Scholar.Google, Scopus databases, including English, Spanish, French, and German language papers published between 1966 and June 2011, and reference lists.

DATA EXTRACTION

investigators abstracted details about medical history, disease presentation, laboratory data, treatment and outcome.

DATA SYNTHESIS

One-hundred and twenty-eight cases with known survival outcome--eighty-six cirrhotics, seventeen individuals undergoing continuous ambulatory peritoneal dialysis and another twenty-five with other or no underline condition were reviewed. An additional number of twenty-five cases with unknown outcome were searched in Listeria studies published from 1990 to 2009 and were only used for calculating worldwide distribution.

CONCLUSION

Cirrhotics, mostly alcoholics, presented with fever and abdominal pain. Those who succumbed had significantly higher peripheral WBC count (15622 vs. 8155 cells/mm(3), p = 0.01) and (%) polymorphonuclear cells in differential count (83.3 vs. 71%, p = 0.001). Higher mortality was experienced in those with comorbidities, and those who presented with encephalopathy. Lower mortality was experienced in patients on continuous ambulatory peritoneal dialysis. Ascites was neutrocytic in 86% of the samples. In the sum of the cases mortality was 27.3%, with significantly highest rates in the elderly, in patients with bacteremia, immunosuppression, hematological malignancies, and lowest rates in those who presented with abdominal pain and in diabetics (type I or II). The latter observation was surprising and could be considered a single fortuitous fact. Initial appropriate treatment was associated with significantly better outcome (p = 0.002) than inappropriate; combination therapy with an aminoglycoside was superior to monotherapy (p = 0.038).

The high prevalence of Listeria monocytogenes peritonitis in cirrhotic patients of an Egyptian Medical Center

BACKGROUND

Spontaneous bacterial peritonitis (SBP) is a potentially lethal complication of cirrhosis. It is probably the most characteristic infectious complication of cirrhosis.

AIM

The aim of this study was to evaluate the bacterial and fungal causes of SBP in Egyptian population. Furthermore to predict the occurrence of rare pathogen like Listeria monocytogenes in those patients.

MATERIALS AND METHODS

The study included 100 patients with end stage liver disease associated with ascites. Patients were suspected to have SBP. The ascitic fluids were subjected to full cytological and microbiological study.

RESULTS

The peritoneal fluid cytological study revealed that 50 samples had cell counts >250 cells/mm(3). 37 samples had growth and 13 samples had no growth (CNNA). The distribution of isolated pathogens was Gram positive cocci 48.8% followed by L. monocytogenes 24.4%, Gram negative bacilli 12.2% and Mycobacterium tuberculosis 7.3. The cells counts associated with listeria culture were 475 cells/mm(3) with sensitivity 70% and specificity 68%.

CONCLUSION

The study highlights the prevalence of microorganisms in Egyptian patients with liver cirrhosis associated with ascites. It reflects the occurrence of L. monocytogenes as an important pathogen of such clinical situation. Other rare pathogens like M. tuberculosis are not uncommon in those patients.