University of Texas Medical Branch at Galveston spring, TX, United States
Robinder P. Abrol, DO1, Yamam I. Al-Saadi, MD1, Milee M. Patel, DO1, Ronak Gandhi, DO1, Gabriel Reep, MD2 1University of Texas Medical Branch at Galveston, Galveston, TX; 2UTMB, Galveston, TX
Introduction: Spontaneous bacterial Peritonitis (SBP) is an ascitic fluid infection that is potentially life threatening in cirrhotic patients. A diagnosis is confirmed with a polymorphonuclear leukocyte (PMN) count of ≥ 250 and a positive culture in sampled ascites. Current guidelines recommend SBP screening in all admitted cirrhotic patients, and third generation cephalosporins are commonly used in prophylaxis and treatment. With widespread use of antibiotics, a rise in bacterial resistance has been noted. Here we present a case of two resistant SBP infections developing in a patient over two months.
Case Description/Methods: A 52-year-old male with a history of chronic lyme disease requiring multiple antibiotic infusions and recently diagnosed alcoholic hepatitis presented with abdominal pain. Blood workup revealed a total bilirubin of 34.2mg/dL, alanine transaminase of 120U/L, and aspartate transaminase of 244U/L. Paracentesis was performed after vancomycin, cefepime and zosyn were administered at an outside hospital prior to transfer. The ascitic fluid PMN count was 24,492. Ceftriaxone was empirically started, and cultures then identified Escherichia
Coli resistant to amoxicillin-clavulaunate, ampicillin-sulbactam, cefazolin, cefotaxime, and ceftazidime. Ceftriaxone was switched to ertapenem and ultimately levofloxacin. The patient improved clinically and serial paracenteses showed a downtrend in PMNs and no further culture positivity.
The patient then underwent an outpatient paracentesis 12 days later revealing a PMN count of 1,972. He was admitted, and ertapenem was started empirically as per prior hospitalization. Paracentesis was repeated 2 days later yielding a PMN count of 15,853 and the culture grew Enterococcus facieum resistant to ampicillin and vancomycin. Ertapenem was continued during admission and the patient was discharged with linezolid to complete the antibiotic course.
Discussion: SBP is a potentially life threatening infection. Signs and symptoms may be nonspecific. While 3rd generation cephalosporins are commonly used for therapy and prophylaxis, our case sheds light on some of the therapeutic challenges in treating SBP effectively, particularly with regards to potential selection for drug-resistant gram-positive organisms. As resistant organisms and gram-positive organisms are encountered more frequently in SBP, it is imperative that antibiotics are selected and used appropriately.
Disclosures: Robinder Abrol indicated no relevant financial relationships. Yamam Al-Saadi indicated no relevant financial relationships. Milee Patel indicated no relevant financial relationships. Ronak Gandhi indicated no relevant financial relationships. Gabriel Reep indicated no relevant financial relationships.
Robinder P. Abrol, DO1, Yamam I. Al-Saadi, MD1, Milee M. Patel, DO1, Ronak Gandhi, DO1, Gabriel Reep, MD2. P2931 - A Tale of Two Cultures: A Case of a Recurrence of Multi-Drug-Resistant Spontaneous Bacterial Peritonitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.