Current concepts and future strategies in the antimicrobial therapy of emerging Gram-positive spontaneous bacterial peritonitis

Abstract

Spontaneous bacterial peritonitis (SBP) is the most common infection in end-stage liver disease patients. SBP is defined as an ascitic fluid infection with a polymorphonuclear leucocyte count ≥ 250/mm3 without an evident intra-abdominal surgically treatable source. Several mechanisms contribute to SBP occurrence, including translocation of gut bacteria and their products, reduced intestinal motility provoking bacterial overgrowth, alteration of the gut’s barrier function and local immune responses. Historically, Gram-negative enteric bacteria have been the main causative agents of SBP, thereby guiding the empirical therapeutic choice. However, over the last decade, a worryingly increasing prevalence of Gram-positive and multi-drug resistant (MDR) SBP has been seen. Recently, the microbiological spectrum of SBP seems to have changed in Europe due to a high prevalence of Gram-positive bacteria (48%-62%). The overall proportion of MDR bacteria is up to 22%-73% of cases. Consequently, empirical therapy based on third-generation cephalosporins or amoxicillin/clavulanic acid, can no longer be considered the standard of care, as these drugs are associated with poor outcomes. The aim of this review is to describe, with an epidemiological focus, the evidence behind this rise in Gram-positive and MDR SBP from 2000 to present, and illustrate potential targeted therapeutic strategies. An appropriate treatment protocol should include daptomycin plus ceftaroline and meropenem, with prompt stepdown to a narrower spectrum when cultures and sensitivity data are available in order to reduce both cost and potential antibiotic resistance development.

The pattern of microbial flora in Spontaneous bacterial peritonitis in Cirrhotic patients

“…23 Gram-negative bacteria are the most common culprit when they leak into the blood after overwhelming the quarantine of mesenteric nodes. 24 Subsequently, they settle in the ascitic fluid and lead to spontaneous bacterial peritonitis. 25 Thus most causative organisms belong to intestinal flora 26 , most commonly E. Coli or a Klebsiella is involved.…”

Peculiarities of the phenotype of T-lymphocytes in the dynamics of the postoperating period in patients with peritonite depending on the outcome of disease

“…р 1 -statistically significant differences versus controls; р 2 -statistically significant differences versus patients with WPP before surgery; р 3 -statistically significant differences versus 7 days after surgery patients; р 4 -statistically significant differences versus 14 days after surgery patients. и последующая антибактериальная терапия также вносят значительный вклад в нарушении иммунных механизмов [10]. Так, у обследованных пациентов с РГП независимо от исхода заболевания в дооперационном периоде выявляется снижение абсолютного количества лимфоцитов в крови, уровень которых восстанавливается до контрольных значений только на третьей недели лечения.…”

“…Доказано, что само течение инфекционного процесса в брюшной полости, характер и особенности развития гнойных послеоперацион-ных осложнений определяются не только тяжестью основного заболевания, адекватностью выполненного оперативного вмешательства и полнотой проводимой интенсивной терапии, но и функциональным состоянием иммунной системы [1,10,30]. Установлено, что повышение функциональной активности В-лимфоцитов приводит к затруднению развития антигензависимого перитонита у мышей в эксперименте [25].…”

Choosing the appropriate pharmacotherapy for multidrug-resistant Gram positive infections

“…At standard dosage, low serum drug concentrations have been observed [13]. Because of its bacteriostatic activity, it remains an available option for the management of uncomplicated intra-abdominal infections but not for severe BSIs [14,15].…”