Spontaneous bacterial peritonitis in an adult patient with nephrotic syndrome

Spontaneous Bacterial Peritonitis in an Adult Patient with Minimal Change Disease

Patient: Male, 60-year-old

Final Diagnosis: Peritonitis

Symptoms: Abdominal pain • edema of lower extermities

Medication: —

Clinical Procedure: —

Specialty: Nephrology

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.

Citrobacter peritonitis: two cases and review of the literature

One of the uncommon gram negative organisms causing peritonitis in peritoneal dialysis patients is Citrobacter. Because of this organism's resistant nature, treatment for Citrobacter peritonitis may be difficult, and removal of the catheter may be necessary in refractory cases. Here we present 2 cases of peritonitis caused by this organism and fully treated with antibiotics. The literature contains only a limited number of reports on Citrobacter peritonitis, mostly case reports or portions of general papers about the microbiological spectrum of peritonitis in the relevant units. Until enough data about this micro-organism have been accumulated to map out an approach, it is wise to individualize treatment by watching the response of the patient during the wait for the antibiogram result and not to hesitate to remove the catheter if the clinical situation deteriorates.

Citrobacter freundii peritonitis and tunnel infection in a patient on continuous ambulatory peritoneal dialysis

The clinical course of a patient on continuous ambulatory peritoneal dialysis who developed peritonitis and tunnel infection due to an unusual pathogen, Citrobacter freundii, is described. The patient did not respond well to antibiogram-based therapy (intravenous meropenem and intraperitoneal gentamicin) and removal of the catheter was required.

Spontaneous bacterial peritonitis

Spontaneous bacterial peritonitis (SBP) is a bacterial infection of ascitic fluid in patients with decompensated cirrhosis. The modifier 'spontaneous' distinguishes this from surgical peritonitis. The infecting organisms are usually enteric gram-negatives which have translocated from the bowel. Symptoms of infection occur in most patients with SBP, including fever, abdominal pain, mental status changes, and ileus. A high index of suspicion should exist for SBP in patients with cirrhosis and ascites. Diagnostic abdominal paracentesis can be undertaken with minimal risk and should be performed in all patients admitted to the hospital, during times of worsening clinical appearance, or when gastrointestinal bleeding occurs. The ascitic fluid polymorphonuclear cell count is the most sensitive test in evaluating for infection. Cultures of the ascitic fluid are helpful in identifying the organism and are best performed by bedside injection of blood culture bottles. Ascites total protein, lactate dehydrogenase, and glucose levels can assist in distinguishing SBP from secondary peritonitis. Empirical therapy is recommended after paracentesis if suspicion for infection exists. Cefotaxime is the best-studied antibiotic for this purpose and has excellent penetration into ascites with no nephrotoxicity. Prophylaxis should be limited to high-risk settings. Mortality rates in SBP have declined dramatically, largely due to earlier detection and improved therapy.

Citrobacter freundii and fatal neutropenic enterocolitis following adjuvant chemotherapy for breast cancer

Neutropenic enterocolitis is increasingly being recognized as a life-threatening complication of chemotherapy, mainly for haematological and lymphoproliferative malignancies. It is under-recognized clinically, with the diagnosis often being made on post-mortem examination. Although active medical management is generally preferred, surgical intervention may be indicated. We report a case of fatal neutropenic enterocolitis, secondary to Citrobacter freundii, following adjuvant chemotherapy for breast cancer. We also review the literature, examining the aetiology, diagnosis and management of this often fatal entity.

Spontaneous bacterial peritonitis in a patient with nephrogenic ascites during an episode of acute renal transplant rejection

Spontaneous bacterial peritonitis (SBP) is a primary infection of asci tes without signs of perforation or penetration. It occurs most often in patients with liver cirrhosis but can also be diagnosed in patients with ascites from other causes. We report a kidney transplant recipient who developed nephrogenic ascites during an episode of acute rejection. The patient complained of fever, abdominal tenderness, and loose stools and showed all of the signs of peritonitis on physical examination. The patient's serum creatinine was elevated, and Duplex sonography of the graft was highly suggestive for acute rejection. Ascites puncture was performed. The ascitic fluid contained 4,000 leukocytes per microliter. No source of infection was detected, so the diagnosis of SBP was made. The patient was treated with ciprofloxacin intravenously and received low-dose steroid pulse therapy. The ascites culture grew Staphylococcus aureus that was highly sensitive to ciprofloxacin. The patient recovered rapidly. We could avoid laparotomy, which is associated with high mortality in patients suffering from SBP. No relapses of SBP occurred. Renal function has improved and remained stable.

Ascites in Nephrotic syndrome. Incidence, patients' characteristics, and complications

The pathophysiology of ascites in patients with cirrhosis is complex and includes increases in hepatic sinusoidal pressure, the formation of hepatic and splanchnic lymph, renal sodium retention, and hypoalbuminemia. However, the role of hypoalbuminemia in ascites formation is controversial. Evaluating ascites in hypoalbuminemic patients with nephrotic syndrome could add to our understanding of the role of hypoalbuminemia in ascites development. We conducted a retrospective analysis of 52 adults and 21 children with nephrotic syndrome who were hospitalized in the Hadassah University Hospital on Mount Scopus during 1981-1994. There was a significant difference in the prevalence of ascites between pediatric (52%) and adult patients (23%) (p = 0.024). Pediatric patients had lower serum albumin levels than adults (1.70 +/- 0.08 g/dl vs. 2.10 +/- 0.07 g/dl, p = 0.001). Adult patients with ascites had lower serum albumin levels than adult patients without ascites (1.80 +/- 0.13 g/dl vs. 2.20 +/- 0.07 g/dl, p = 0.01). This difference was not found in pediatric patients. Temporary fluctuations in liver enzymes (up to four times the upper limit of normal for transaminases) were evident in five patients from the pediatric group with ascites, whereas all pediatric patients without ascites had completely normal liver enzymes (p = 0.035). Among the 12 adult patients with ascites, seven had liver disease (three with cirrhosis and four with amyloidosis), and two had right-sided congestive heart failure. Among the 40 adult patients without ascites, only four had liver disease (amyloidosis). The plasma albumin levels of the patients with amyloidosis without ascites were higher than patients with amyloidosis with ascites (1.90 +/- 0.10 g/dl vs. 1.50 +/- 0.07 g/dl, p = 0.03). Two patients with nephrotic syndrome and ascites (one without liver disease) had episodes of spontaneous bacterial peritonitis. Ascites in nephrotic syndrome is more common in children than in adults. Although in most pediatric patients ascites formation is probably a common manifestation of the general fluid retention, in most adult patients with nephrotic syndrome ascites can be attributed to both hypoalbuminemia and the presence of liver disease or congestive heart failure, with increased hepatic sinusoidal pressure.