Pneumococcal peritonitis in adult patients - Report of 64 cases with special reference to emergence of antibiotic resistance

Background: Few data are available regarding pneumococcal peritonitis. We s tudied the clinical characteristics of intra-abdominal infections caused by Streptococcus pneumoniae and its prognosis in relation to antibiotic resis tance. Methods: We reviewed all cases of culture-proved pneumococcal peritonitis. Patients with liver cirrhosis and primary pneumococcal peritonitis were com pared with patients with Escherichia coli peritonitis. Results Between January 1, 1979, and December 31, 1998, we identified 45 ca ses of primary pneumococcal peritonitis in patients with cirrhosis and 19 c ases of secondary (or tertiary) pneumococcal peritonitis. Patients with cir rhosis and primary pneumococcal peritonitis vs those with primary E. coli p eritonitis had more frequent community-acquired infection, 73% vs 47%; pneu monia, 36% vs 2%; and bacteremia, 76% vs 33%; and higher attributable morta lity (early mortality), 27% vs 9% (P < .05 for all). Secondary (or tertiary ) pneumococcal peritonitis was associated with upper or lower gastrointesti nal tract diseases; in most cases, the infection appeared after surgery. A hematogenous spread of S pneumoniae from a respiratory tract infection migh t be the most important origin of peritonitis; also, S pneumoniae might dir ectly reach the gastrointestinal tract favored by endoscopic procedures or hypochlorhydria. There was an increased prevalence of penicillin and cephal osporin resistance up to 30.7% and 17.0%, respectively, although it was not associated with increased mortality rates. Conclusions Primary pneumococcal peritonitis in patients with cirrhosis mor e often spread hematogenously from the respiratory tract and was associated with early mortality. In secondary (and tertiary) pneumococcal peritonitis , a transient gastrointestinal tract colonization and inoculation during su rgery might be the most important mechanisms. Current levels of resistance were not associated with increased mortality rates.