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

Peritonitis caused by Listeria monocytogenes and Burkholderia cepacia in a patient on peritoneal dialysis: a case report

Peritoneal dialysis (PD)-associated peritonitis is a major cause of peritoneal dysfunction and failure. The main issue regarding the treatment is whether to remove the catheter surgically or to treat with antibiotics alone. Notably, PD-associated peritonitis is commonly caused by gram-positive cocci, but rarely by Listeria monocytogenes and Burkholderia cepacia. Here, we report a patient diagnosed with PD-associated peritonitis caused by L. monocytogenes and B. cepacia who presented with a fever, abdominal pain, and turbid dialysate and had been receiving PD for over 20 years. After 2 weeks of antibiotic treatment, the catheter in the patient was surgically removed. Culture and pathology results revealed pathogen growth, foreign body granuloma with chronic inflammation, and inflammatory cells with fibroblast infiltration. The patient was switched to hemodialysis. She eventually recovered and was discharged. The patient presented fair health at the 3-month follow-up. In conclusion, sequential dialysate white blood cell count may help clinicians decide the course of treatment and guide the timing of surgical intervention.

Listeria monocytogenes-associated spontaneous bacterial peritonitis in France: a nationwide observational study of 208 cases

BACKGROUND

Listeriosis is a foodborne infection caused by Listeria monocytogenes. Three main forms of listeriosis are well characterised, but little is known about L monocytogenes-associated spontaneous bacterial peritonitis. We used data from the French national surveillance of listeriosis to perform a nationwide retrospective study.

METHODS

All patients with L monocytogenes isolated by culture from a peritoneal fluid sample in France between April 1, 1993, and Dec 31, 2022, were included. Individuals for whom bacterial peritonitis was not confirmed and those who also had another type of invasive listeriosis were excluded. A standardised checklist was used to collect demographic, clinical, and biological data as well as antibiotic treatment and follow-up data. The primary outcome was to determine the characteristics of L monocytogenes-associated spontaneous bacterial peritonitis. We did descriptive analyses and assessed risk factors for 1-month mortality using an exploratory multivariable Cox model analysis.

FINDINGS

Among the 8768 L monocytogenes cases reported, 208 (2%) were patients with L monocytogenes-associated spontaneous bacterial peritonitis. Mean age was 65 years (SD 13), 50 (24%) of 208 patients were female, and 158 (76%) were male (no data on race or ethnicity were available). 200 (98%) of 205 patients with L monocytogenes-associated spontaneous bacterial peritonitis with available data had immunosuppressive comorbidities, including cirrhosis (148 [74%] of 201 with available data), ongoing alcoholism (58 [62%] of 94), and ongoing neoplasia (60 [31%] of 195). Causes of ascites included cirrhosis (146 [70%] of 208), ongoing neoplasia (26 [13%]), end-stage heart failure (13 [6%]), and peritoneal dialysis (11 [5%]). Among those with available data, presentation was pauci-symptomatic and non-specific; only 67 (50%) of 135 patients presented with fever, 49 (37%) of 132 with abdominal pain, and 27 (21%) of 129 with diarrhoea. 61 (29%) of 208 patients were dead at 1 month, 92 (44%) were dead at 3 months, and 109 (52%) were dead at 6 months after diagnosis. Ongoing neoplasia (hazard ratio 2·42 [95% CI 1·05-5·56]; p=0·039), septic shock (8·03 [2·66-24·02]; p=0·0021), and high blood leukocyte count (1·05 [1·00-1·09]; p=0·045) were independently associated with 1-month mortality.

INTERPRETATION

Despite the non-specific and mild presentation of L monocytogenes-associated spontaneous bacterial peritonitis, the outcome is poor and similar to that of neurolisteriosis, and so identification of L monocytogenes in ascitic fluid samples requires urgent parenteral amoxicillin-based treatment to avoid a fatal outcome.

FUNDING

Institut Pasteur, Inserm, and French Public Health Agency.

TRANSLATION

For the French translation of the abstract see Supplementary Materials section.

Rapid Progression of Invasive Listeria monocytogenes Infection in a Patient With Cirrhosis and Primary Sclerosing Cholangitis on Ustekinumab

We present the case of a 62-year-old immunocompromised man with ulcerative colitis, primary sclerosing cholangitis, and cirrhosis treated with azathioprine and ustekinumab who quickly developed invasive Listeria monocytogenes infection after incidental identification on routine paracentesis. The infection rapidly progressed from bacterial peritonitis to bacteremia and meningitis within three days. Treatment with ampicillin and trimethoprim/sulfamethoxazole was successful. We highlight the increased risk of invasive listeriosis in immunocompromised individuals, including those on biologic therapies, and the importance of considering Listeria as a pathogen from sterile sites even in asymptomatic patients.

Listeria peritonitis in a patient on hemodialysis for end-stage renal disease secondary to lupus nephritis-a case report

Key Clinical Message

Patients with a recent history of peritoneal dialysis catheter removal in the setting of immunosuppression should be monitored for rare Listeria bacterial peritonitis. This infection should be managed with ampicillin and gentamicin.

Abstract

There are scattered reports to date of patients with peritonitis caused by Listeria monocytogenes. Listeria peritonitis is more commonly reported in patients with cirrhosis and those receiving peritoneal dialysis. We present a case of L. monocytogenes peritonitis in a patient with end-stage renal disease due to lupus nephritis actively on hemodialysis months after peritoneal dialysis catheter removal.

Spontaneous bacterial peritonitis caused by Listeria monocytogenes: a rare infection with very high leukocyte counts in ascitic fluid-case report and review of the literature

We present a rare case of Listeria monocytogenes-induced spontaneous bacterial peritonitis (SBP) in cirrhosis. Examination of the patient's peritoneal fluid revealed an extremely high leukocyte count. We suspect, that the patient belongs to 1% of individuals in which Listeria monocytogenes is part of the intestinal flora. Cephalosporins as empiric antibiotics have a Listeria gap. A combination of aminopenicillin and aminoglycoside is recommended. Therefore, early microbiological diagnosis from ascites and blood is essential. Listeria should be considered as a rare cause of SBP, especially in case of very high leukocyte count in peritoneal fluid or lack of response to empiric therapy.

Primary spontaneous listerial peritonitis

A male in his mid-60s with chronic kidney disease, ischemic cardiomyopathy, and nonalcoholic cirrhosis due to congestive hepatopathy presented with fever and abdominal pain for two weeks. He underwent diagnostic paracentesis, which noted an ascitic neutrophil count over 7000/mm³. Gram stain of the ascitic fluid showed Gram-positive cocci. He was diagnosed with spontaneous bacterial peritonitis (SBP) and was started on ceftriaxone. Ascites cultures grew Listeria monocytogenes and antibiotics were changed to ampicillin. He received one week of ampicillin while inpatient and seven weeks of oral amoxicillin, at which point his ascitic neutrophil count was less than 250/mm³. He was continued on suppressive amoxicillin for an additional 14 weeks with no recurrence in over a year after the discontinuation of amoxicillin. Though uncommon, L. monocytogenes should be considered a pathogen causing SBP. Focal listerial infections can be treated with penicillins alone while invasive disease may require the addition of aminoglycosides.

Listerial Spontaneous Bacterial Peritonitis

Spontaneous bacterial peritonitis (SBP) is a severe complication of ascites often seen in advanced hepatic disease that is most commonly caused by Gram-negative bacilli. Here, we report a rare case of Listeria monocytogenes SBP, diagnosed by peritoneal fluid culture and responsive to ampicillin, in a patient with portal hypertension secondary to nodular regenerative hyperplasia. Because Listeria species are resistant to empiric SBP therapies and delays in treatment have been associated with increased mortality, they must be considered in high-risk patients.

Forty years of peritoneal dialysis Listeria peritonitis: Case and review

Infections with Listeria monocytogenes (LM) are very uncommon and severe especially in immunocompromised people. We report a continuous cycling peritoneal dialysis (CCPD) patient who presented initially disseminated listeriosis with peritonitis. He was successfully treated with intraperitoneal and intravenous ampicillin but died unfortunately from a cardiorespiratory arrest due to food inhalation. It is the 20th case of such peritonitis mentioned among PD patients and the first reported in Belgium. This case illustrates the importance of a systematic approach to get quick diagnosis and effective antibiotic readjustment. Empiric therapy is not effective on Listeria which is naturally resistant to cephalosporins and poorly sensitive to vancomycin. Ampicillin is the first-line antibiotic. In case of penicillin allergy, trimethoprim-sulfamethoxazole or erythromycin can be used successfully. Identification of LM serotype has a prognostic value. PD educative programmes should recommend to avoid unpasteurized dairy products to prevent listeriosis.

Intraperitoneal ampicillin treatment for peritoneal dialysis- related peritonitis with Listeria monocytogenes - a case report

BACKGROUND

Peritoneal dialysis (PD)-related peritonitis is a rare but serious complication and is associated with increased morbidity and mortality rates. It is most commonly caused by Staphylococcus aureus or Staphylococcus epidermidis, but infection with Listeria monocytogenes may also occur. Recommendations for antibiotic treatment of a Listeria infection are currently based on a small number of case reports and suggest the administration of ampicillin. But unlike vancomycin or gentamicin, for ampicillin the route of application, the dosage, and the duration of treatment have not yet been established. We report a case in which PD-associated peritonitis due to Listeria infection was treated with ampicillin administered intravenously and intraperitoneally, separately and in combination.

CASE PRESENTATION

A 72-year-old man with chronic kidney disease stage 5 dialysis (CKDG5D) secondary to hypertension and diabetes was hospitalised in April 2020 because of PD-related peritonitis caused by a Listeria infection. In accordance with the results of resistance tests, the patient was treated with intravenous ampicillin at a dosage of 6 g twice daily. After initial treatment the leukocyte count in the PD effluent had decreased substantially, but it was permanently reduced only with the addition of intraperitoneal ampicillin (4 g daily). Efficient serum concentrations of ampicillin were determined for both routes of administration, intravenous and intraperitoneal.

CONCLUSION

This is the first case report demonstrating that PD-related peritonitis due to Listeria monocytogenes infection can be treated with intraperitoneal ampicillin and monitored by the determination of peripheral serum concentrations of ampicillin.

Bacterial meningitis in Finland, 1995-2014: a population-based observational study

OBJECTIVES

Bacterial meningitis remains an important cause of morbidity and mortality worldwide. Its epidemiological characteristics, however, are changing due to new vaccines and secular trends. Conjugate vaccines against Haemophilus influenzae type b and Streptococcus pneumoniae (10-valent) were introduced in 1986 and 2010 in Finland. We assessed the disease burden and long-term trends of five common causes of bacterial meningitis in a population-based observational study.

METHODS

A case was defined as isolation of S. pneumoniae, Neisseria meningitidis, Streptococcus agalactiae, Listeria monocytogenes or H. influenzae from cerebrospinal fluid and reported to national, population-based laboratory surveillance system during 1995-2014. We evaluated changes in incidence rates (Poisson or negative binomial regression), case fatality proportions (χ²) and age distribution of cases (Wilcoxon rank-sum).

RESULTS

During 1995-2014, S. pneumoniae and N. meningitidis accounted for 78% of the total 1361 reported bacterial meningitis cases. H. influenzae accounted for 4% of cases (92% of isolates were non-type b). During the study period, the overall rate of bacterial meningitis per 1 00 000 person-years decreased from 1.88 cases in 1995 to 0.70 cases in 2014 (4% annual decline (95% CI 3% to 5%). This was primarily due to a 9% annual reduction in rates of N. meningitidis (95% CI 7% to 10%) and 2% decrease in S. pneumoniae (95% CI 1% to 4%). The median age of cases increased from 31 years in 1995-2004 to 43 years in 2005-2014 (p=0.0004). Overall case fatality proportion (10%) did not change from 2004 to 2009 to 2010-2014.

CONCLUSIONS

Substantial decreases in bacterial meningitis were associated with infant conjugate vaccination against pneumococcal meningitis and secular trend in meningococcal meningitis in the absence of vaccination programme. Ongoing epidemiological surveillance is needed to identify trends, evaluate serotype distribution, assess vaccine impact and develop future vaccination strategies.

Unusual Listeria monocytogenes peritonitis in peritoneal dialysis patient with liver cirrhosis: a case report and review of literature

Spontaneous Listeria peritonitis is well described in liver failure, but is uncommon in peritoneal dialysis patients. Atypical cases where peritonitis symptoms develop after systemic manifestations are rare and challenging for diagnostic. A 57-year-old peritoneal dialysis patient with history of ethylic cirrhosis was admitted after epileptic seizure. On admission, patient was soporous without signs of peritonitis and meningitis. Patient's peritoneal effluent was clear, with normal leukocytes. Cranial CT scan showed no abnormalities. Laboratory exams revealed positive inflammatory syndrome. Despite antibiotic therapy, next day, symptoms aggravated with coma development. Peritoneal effluent became cloudy and its leukocyte count rose up. Effluent microscopy revealed Gram-positive bacilli. Patient was started with intraperitoneal Vancomycin and Amikacin. Patient's clinical condition deteriorated with lethal outcome. Post-mortem analysis of effluent and blood culture showed growth of L. monocytogenes. Apart from idiopathic etiology, goat-milk curd, that patient had started consuming 10 days before admission, could theoretically be considered as possible infection vehicle. L. monocytogenes peritonitis in peritoneal dialysis patients is rare, but must be considered in immunocompromised or patients with concomitant liver failure, especially after Gram-positive bacilli identification in peritoneal effluent. In case of suspiscion of Listeria peritonitis, Ampicillin should be initiated, because bacteria often poorly respond to currently recommended empiric regimens.

Peritonitis as the First Presentation of Disseminated Listeriosis in a Patient on Peritoneal Dialysis—a Case Report

Infections with Listeria monocytogenes are uncommon but serious, with mortality rate approaching 30% in cases of systemic involvement despite first-line therapy. They are usually caused by ingestion of contaminated foods, but spontaneous infections have also been described. Listeria monocytogenes is a rare cause of peritonitis, and most of the published cases are in patients with cirrhosis and ascites. There are a few reported cases of Listeria peritonitis associated with peritoneal dialysis (PD), primarily isolated peritonitis.

If detected early, Listeria peritonitis can be successfully treated with ampicillin, alone or in combination with gentamicin. Vancomycin has been listed as a second-line agent. However, it has been associated with treatment failure.

In this case report, we present a patient who developed disseminated listeriosis, with peritonitis as the first manifestation of disseminated infection. This case illustrates the importance of having a high index of suspicion for L. monocytogenes if patients deteriorate despite empiric therapy for PD-associated peritonitis and serves as a further example demonstrating the inadequate coverage of vancomycin for L. monocytogenes.

Antibiotic treatment and mortality in patients with Listeria monocytogenes meningitis or bacteraemia

Invasive Listeria monocytogenes infections carry a high mortality despite antibiotic treatment. The rareness of the infection makes it difficult to improve antibiotic treatment through randomized clinical trials. This observational study investigated clinical features and outcome of invasive L. monocytogenes infections including the efficacy of empiric and definitive antibiotic therapies. Demographic, clinical and biochemical findings, antibiotic treatment and 30-day mortality for all episodes of L. monocytogenes bacteraemia and/or meningitis were collected by retrospective medical record review in the North Denmark Region and the Capital Region of Denmark (17 hospitals) from 1997 to 2012. Risk factors for 30-day all-cause mortality were assessed by logistic regression. The study comprised 229 patients (median age: 71 years), 172 patients had bacteraemia, 24 patients had meningitis and 33 patients had both. Significant risk factors for 30-day mortality were septic shock (OR 3.0, 95% CI 1.4-6.4), altered mental state (OR 3.6, 95% CI 1.7-7.6) and inadequate empiric antibiotic therapy (OR 3.8, 95% CI 1.8-8.1). Cephalosporins accounted for 90% of inadequately treated cases. Adequate definitive antibiotic treatment was administered to 195 patients who survived the early period (benzylpenicillin 72, aminopenicillin 84, meropenem 28, sulfamethoxazole/trimethoprim 6, and piperacillin/tazobactam 5). Definitive antibiotic treatment with benzylpenicillin or aminopenicillin resulted in a lower 30-day mortality in an adjusted analysis compared with meropenem (OR 0.3; 95% CI 0.1-0.8). In conclusion, inadequate empiric antibiotic therapy and definitive therapy with meropenem were both associated with significantly higher 30-day mortality.

Laboratory diagnostics of spontaneous bacterial peritonitis

The term peritonitis indicates an inflammatory process involving the peritoneum that is most frequently infectious in nature. Primary or spontaneous bacterial peritonitis (SBP) typically occurs when a bacterial infection spreads to the peritoneum across the gut wall or mesenteric lymphatics or, less frequently, from hematogenous transmission in combination with impaired immune system and in absence of an identified intra-abdominal source of infection or malignancy. The clinical presentation of SBP is variable. The condition may manifest as a relatively insidious colonization, without signs and symptoms, or may suddenly occur as a septic syndrome. Laboratory diagnostics play a pivotal role for timely and appropriate management of patients with bacterial peritonitis. It is now clearly established that polymorphonuclear leukocyte (PMN) in peritoneal fluid is the mainstay for the diagnosis, whereas the role of additional biochemical tests is rather controversial. Recent evidence also suggests that automatic cell counting in peritoneal fluid may be a reliable approach for early screening of patients. According to available clinical and laboratory data, we have developed a tentative algorithm for efficient diagnosis of SBP, which is based on a reasonable integration between optimization of human/economical resources and gradually increasing use of invasive and expensive testing. The proposed strategy entails, in sequential steps, serum procalcitonin testing, automated cell count in peritoneal fluid, manual cell count in peritoneal fluid, peritoneal fluid culture and bacterial DNA testing in peritoneal fluid.

[A case of spontaneous bacterial peritonitis caused by Listeria monocytogenes]

Spontaneous bacterial peritonitis (SBP) is a life-threatening complication in patients with ascites caused by advanced liver disease. While gram negative bacteria, such as Escherichia coli and Klebsiella pneumonia are the common pathogens, Listeria monocytogenes has been recognized as a very rare pathogen. Empirical treatment with third generation cephalosporins does not provide adequate antibiotics coverage against L. monocytogenes. Diagnosis is often delayed as it requires confirmation from ascitic fluid culture. Herein, we describe the first case of SBP caused by L. monocytogenes in a patient with advanced alcoholic liver cirrhosis in Korea. Clinicians should be aware of the atypical pathogens, especially in patients with inadequate response to empirical antibiotics.

The complex microbiota of raw milk

Here, we review what is known about the microorganisms present in raw milk, including milk from cows, sheep, goats and humans. Milk, due to its high nutritional content, can support a rich microbiota. These microorganisms enter milk from a variety of sources and, once in milk, can play a number of roles, such as facilitating dairy fermentations (e.g. Lactococcus, Lactobacillus, Streptococcus, Propionibacterium and fungal populations), causing spoilage (e.g. Pseudomonas, Clostridium, Bacillus and other spore-forming or thermoduric microorganisms), promoting health (e.g. lactobacilli and bifidobacteria) or causing disease (e.g. Listeria, Salmonella, Escherichia coli, Campylobacter and mycotoxin-producing fungi). There is also concern that the presence of antibiotic residues in milk leads to the development of resistance, particularly among pathogenic bacteria. Here, we comprehensively review these topics, while comparing the approaches, both culture-dependent and culture-independent, which can be taken to investigate the microbial composition of milk.