ORIGINAL INVESTIGATION Pneumococcal Peritonitis in Adult Patients Report of 64 Cases With Special Reference to Emergence of Antibiotic Resistance Olga Capdevila, MD; Roman Pallares, MD; Imma Grau, MD; Fe Tubau, MD; Josefina Lin˜ares, MD; Javier Ariza, MD; Francisco Gudiol, MD Background: Few data are available regarding pneu- tis was associated with upper or lower gastrointestinal mococcal peritonitis. We studied the clinical character- tract diseases; in most cases, the infection appeared af- istics of intra-abdominal infections caused by Strepto- ter surgery. A hematogenous spread of S pneumoniae from coccus pneumoniae and its prognosis in relation to a respiratory tract infection might be the most impor- antibiotic resistance. tant origin of peritonitis; also, S pneumoniae might di- rectly reach the gastrointestinal tract favored by endo- Methods: We reviewed all cases of culture-proved pneu- scopic procedures or hypochlorhydria. There was an mococcal peritonitis. Patients with liver cirrhosis and pri- increased prevalence of penicillin and cephalosporin re- mary pneumococcal peritonitis were compared with pa- sistance up to 30.7% and 17.0%, respectively, although tients with Escherichia coli peritonitis. it was not associated with increased mortality rates. Results: Between January 1, 1979, and December 31, Conclusions: Primary pneumococcal peritonitis in pa- 1998, we identified 45 cases of primary pneumococcal tients with cirrhosis more often spread hematogenously peritonitis in patients with cirrhosis and 19 cases of sec- from the respiratory tract and was associated with early ondary (or tertiary) pneumococcal peritonitis. Patients mortality. In secondary (and tertiary) pneumococcal peri- with cirrhosis and primary pneumococcal peritonitis vs tonitis, a transient gastrointestinal tract colonization and those with primary E coli peritonitis had more frequent inoculation during surgery might be the most impor- community-acquired infection, 73% vs 47%; pneumo- tant mechanisms. Current levels of resistance were not nia, 36% vs 2%; and bacteremia, 76% vs 33%; and higher associated with increased mortality rates. attributable mortality (early mortality), 27% vs 9% (P,.05 for all). Secondary (or tertiary) pneumococcal peritoni- Arch Intern Med. 2001;161:1742-1748 TREPTOCOCCUS PNEUMONIAE is a most likely route of peritoneal fluid infec- common pathogen that causes tion.6,7,22,23 In some patients, a respiratory high morbidity and mortality tract focus is not clinically apparent, and, around the world.1,2 It is the in these cases, the gastrointestinal tract has most common cause of com- been hypothesized to be a source of pneu- Smunity-acquired pneumonia and the sec- mococci.7,22,24 However, pneumococci are ond most common cause of purulent men- soluble in bile salts,5 and, therefore, it is un- ingitis,3-5 but intra-abdominal pneumococcal likely that S pneumoniae can grow in the nor- infections are rarely found.6-9 mal gastrointestinal tract. Primary (or spontaneous) bacterial On the other hand, secondary in- peritonitis occurs mainly in patients with tra-abdominal infection (secondary peri- liver cirrhosis and is usually caused by tonitis) is due to the spread of gastroin- gram-negative bacilli.10-12 It is thought that testinal or genitourinary microorganisms in most cases the enteric microorganism into the peritoneal space from loss of in- gains access to the peritoneal cavity with- tegrity of the mucosal barrier. These are out loss of integrity of the intestinal wall often polymicrobial infections and through a mechanism of bacterial trans- can take the form of generalized perito- location.12-20 In addition, gram-negative nitis or localized peritonitis (localized bacteria can occasionally reach the peri- abscesses).14,15,22 toneal cavity by a hematogenous route To date, only anecdotal cases of adult From the Infectious Disease from a distant primary focus (eg, a uri- patients with secondary pneumococcal peri- Service (Drs Capdevila, nary tract infection).21 tonitis have been reported,25-28 and some of Pallares, Grau, Ariza, and Primary pneumococcal peritonitis in them were associated with appendici- Gudiol) and Microbiology 29,30 Service (Drs Tubau and patients with cirrhosis is usually associ- tis. The mechanism of the pneumococ- Lin˜ares), Hospital de Bellvitge ated with a respiratory tract infection such cus that causes these infections is not clear and University of Barcelona, as pneumonia, and, in this case, the blood- because it is not found in the gastrointes- Barcelona, Spain. stream (hematogenous spreading) is the tinal tract. (REPRINTED) ARCH INTERN MED/ VOL 161, JULY 23, 2001 WWW.ARCHINTERNMED.COM 1742 ©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 PATIENTS AND METHODS culture (for S pneumoniae [case patients] or E coli [control patients]) were present, and without any clinical or radio- SETTING AND STUDY DESIGN logic data suggesting a surgically treatable intra- abdominal focus. The present study was carried out in Bellvitge Hospital, a Secondary (or tertiary) pneumococcal peritonitis was 1000-bed teaching hospital for adult patients in Barce- diagnosed in a patient with a localized or diffuse suppura- lona, Spain. It serves approximately 1 million people and tive intra-abdominal process together with a positive cul- admits more than 26000 patients per year. This hospital ture for S pneumoniae and in whom an intra-abdominal, sur- does not have pediatrics and obstetrics departments. gically treatable source was detected (or in whom the We reviewed the clinical and microbiological data of infection appeared after surgery). all patients who had a diagnosis of diffused or localized We considered a hospital-acquired peritoneal infec- peritonitis and a peritoneal sample that was positive for S tion (either primary or secondary peritonitis) when the epi- pneumoniae. These patients were admitted to Bellvitge sode occurred 48 hours after hospital admission (or ap- Hospital between January 1, 1979, and December 31, peared after surgery) and it was not in the incubated period. 1998, and most of them had been cared for and included Community-acquired infection was considered when it was in a protocol of invasive pneumococcal infections by one evident on hospital admission or within the first 48 hours. of us (R.P.). Pneumonia was considered (definitive diagnosis) in Patients with liver cirrhosis and primary pneumococ- a patient with signs or symptoms of a lower respiratory tract cal peritonitis (case patients) were compared with patients infection and a new pulmonary infiltrate on chest radiog- with cirrhosis and primary peritonitis due to E coli (control raphy, together with bacteremia or positive culture from a patients). For each case patient we selected a control patient lower respiratory tract sample (eg, pleural fluid). We also according to the nearest date of positive culture. If a case or considered pneumonia (presumptive diagnosis) in pa- control patient had more than 1 episode of primary perito- tients with clinical and radiographic findings compatible nitis, only the first episode was considered. with pneumonia, with a positive sputum sample or no res- piratory tract samples available for culture (all of our pa- STUDY VARIABLES AND DEFINITIONS tients had concomitant positive ascitic fluid cultures for ei- ther S pneumoniae or E coli). The diagnosis of liver cirrhosis was established using In all patients, demographic characteristics, clinical find- clinical, laboratory, and exploratory findings and did ings, and laboratory and medication data were obtained from not require a liver biopsy with histologic confirmation. hospital records or from previous data recorded in the pro- The stage of cirrhosis was determined by the criteria of tocol of invasive pneumococcal infections. Pugh et al.34,35 Previous hospitalization was defined as admission to Primary peritonitis in a patient with cirrhosis was con- any hospital during the previous 6 months. sidered when clinical findings together with biochemical data of peritoneal inflammation and a positive ascitic fluid Continued on next page There have been reported cases of primary and sec- abdominal pneumococcal isolates represented 4.3% of a to- ondary pneumococcal peritonitis in prepubertal girls and tal of 1476 S pneumoniae strains isolated from clinical speci- in postpubertal healthy women, mainly post partum, af- mens (all sterile fluid samples; sputum samples were not ter an abortion, after gynecologic procedures, or associ- included). Comparing 1979 to 1988 with 1989 to 1998, ated with intrauterine device use.25-28,31 It is well known the percentage of pneumococcal isolates from abdominal that S pneumoniae can colonize in the vagina and an as- samples vs the total number of sterile fluid samples was 3.6% cending infection can occur.32,33 In children, coloniza- (22/604) and 4.8% (42/872), respectively (P=.27). tion in the genitourinary tract with S pneumoniae occurs Of 64 patients with intra-abdominal pneumococ- because of inadequate hygiene or orogenital sexual cal infections, 45 with liver cirrhosis had primary pneu- abuse.24,29,30 In these patients, when no apparent puru- mococcal peritonitis and the remaining 19 had second- lent foci in the genitourinary tract is found, such cases ary (or tertiary) pneumococcal peritonitis. are usually called primary peritonitis.32 The main objectives of the present study were (1) to PRIMARY PNEUMOCOCCAL PERITONITIS describe different types of intra-abdominal