Spontaneous Bacterial Peritonitis Caused by Listeria monocytogenes Associated with Ascitic Fluid Lymphocytosis: A Case Report and Review of Current Empiric Therapy
Spontaneous bacterial peritonitis (SBP) is a potentially deadly complication of ascites. We describe a case of SBP caused by Listeria monocytogenes in a patient with alcoholic cirrhosis. This was associated with the unusual finding of ascitic fluid lymphocytosis, which previously had only been associated with tuberculoid or malignant ascites. Given increasing rates of cefotaxime-resistant SBP alongside the possibility of Listeriosis, the use of cefotaxime as first-line therapy in SBP should be reevaluated. 1. Introduction Spontaneous bacterial peritonitis is the most common life-threatening infectious complication of cirrhosis, affecting between 10 and 30% of cirrhotic patients hospitalized for ascites [1]. Hospital mortality rates range from 10 to 30%, with the development of progressive renal impairment being the strongest predictor of mortality [2]. SBP is thought to result from increased bacterial translocation across gastrointestinal mucosa combined with diminished host immunity in cirrhotic patients [2]. Enteric gram-negative bacteria are the most common cause of SBP, with E. coli and Klebsiella responsible for more than half of SBP cases [3]; however there is a recent evidence for increasing prevalence of SBP caused by gram-positive cocci [4]. In addition, cases of SBP caused by Candida, anaerobes, and Listeria have been reported [3]. Intravenous cefotaxime is considered standard of care for empiric therapy for SBP after it was demonstrated superior to ampicillin-amikacin [5]. However, recent studies suggest that cefotaxime resistance is increasingly common [4]. Other studies show that empiric amoxicillin-clavulanic acid or ciprofloxacin may be equally effective in select patients [6, 7]. Appropriate selection of empiric antibiotics is essential as absolute mortality rates in patients not covered by the initial antibiotic therapy were 20% higher than in patients with appropriate coverage [8]. Cefotaxime-resistant bacteria that can cause SBP include extended-spectrum beta-lactamase (ESBL) producing gram-negative rods, Enterococci, anaerobes, and Listeria [9]. Fewer than 5 cases of Listeria SBP have been reported in the United States. 2. Case Report This patient is a 62-year-old Caucasian male with a history of alcoholic cirrhosis and ascites who presented with one month of increasing abdominal distention and discomfort. His distention had been worsening since his last paracentesis one-month prior. He was afebrile and otherwise asymptomatic on presentation. Prior to this hospitalization, he had undergone 8 therapeutic large-volume paracenteses over
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