Spontaneous bacterial peritonitis by Clostridium species and antimicrobial therapy

Spontaneous bacterial peritonitis (SBP) is common in decompensated cirrhosis. Its incidence is 10–30% in patients with ascites and chronic liver disease. Mortality is almost 25% in patients with SBP [1, 2]. We are presenting a very rare case of SBP secondary to Clostridium species.
A 65-year-old man known to have chronic hepatitis C (treatment naive), poly-substance abuse, Child-Pugh C cirrhosis, and gastroesophageal reflux disease (on chronic acid suppression) was admitted due to fever and generalised abdominal pain for 3 days. He had a history of paracentesis three times in the past. He was on ciprofloxacin 500 mg twice daily maintenance because of previous SBP (culture negative neurocytic ascites) for 1 month. Vitals were normal except fever of 101 F. On general physical examination, the patient was cachectic, lethargic, had scleral icterus, gynaecomastia, and spider angiomata on the chest; the abdomen was distended and tender, with dilated veins radiating from the umbilicus. Pulmonary, cardiovascular, and neurological examinations were unremarkable.
Labs showed white blood cells (WBCs) of 12.6 × 109 cells/l, total bilirubin 4.6 mg/dl, international normalised ratio (INR) was 1.67, and serum albumin was 26 g/l. Paracentesis was done and 5.6 l fluid was removed followed by administration of 37.5 g of albumin in three divided doses, fluid analysis showed polymorphonuclear count (PMN) of 12,996 cells/mm3, ascitic fluid albumin of 12 g/l, and glucose of 58 mg/dl (3.2 mmol/l). Ultrasound showed large abdominal ascites, the liver was small, and there was some hepatofugal flow in the main portal vein (Figure 1). Computed tomography (CT) scan of the abdomen revealed massive abdominal and pelvic ascites with a shrunken liver with a nodular undulating contour consistent with liver cirrhosis, splenomegaly was appreciated, and no bowel pathology was noticed (Figure 2).
Intravenous cefotaxime 2 g every 8 h was started empirically, and the ascitic fluid culture was positive for Clostridium species (unspecified microbiologically) in two bottles. Blood cultures were negative for bacteraemia. Stool assay was negative for Clostridium difficile. Intravenous metronidazole 500 mg every 8 h was added. The patient improved clinically on the third day after addition of metronidazole. Repeat paracentesis was done on the fifth day and 1.1 l of ascitic fluid was drained. Fluid analysis revealed a significant decrease in PMN count to 190...


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