Enterococcus peritonitis is a severe intra-abdominal infection predominantly caused by Enterococcus species. It is a critical concern, especially in patients undergoing peritoneal dialysis (PD), post-surgical individuals, and those with immunosuppressive conditions. This article provides an in-depth review of its pathogenesis, clinical presentation, diagnostic methods, and management strategies.
Pathogenesis and Risk Factors
Enterococcus species, primarily Enterococcus faecalis and Enterococcus faecium, are facultative anaerobic Gram-positive cocci that inhabit the gastrointestinal tract. They become opportunistic pathogens under conditions such as:
- Peritoneal dialysis (PD) – A major predisposing factor due to catheter-related infections.
- Gastrointestinal perforations – Secondary to conditions like diverticulitis, peptic ulcer perforation, or bowel ischemia.
- Post-surgical complications – Following abdominal surgeries, especially in immunocompromised patients.
- Intra-abdominal malignancies – Leading to peritoneal contamination.
- Broad-spectrum antibiotic use – Selects for Enterococcus species, contributing to multidrug-resistant strains.
Clinical Manifestations
Symptoms of Enterococcus peritonitis are often nonspecific but include:
- Severe abdominal pain
- Fever and chills
- Nausea and vomiting
- Abdominal distension
- Cloudy peritoneal dialysis effluent in PD patients
- Hypotension in severe cases
Diagnosis
Early and accurate diagnosis is crucial for effective management. Key diagnostic measures include:
1. Peritoneal Fluid Analysis
- Cell Count & Differential: Elevated white blood cell (WBC) count (>100 cells/mm³ with >50% neutrophils) suggests peritonitis.
- Gram Stain & Culture: Identification of Enterococcus species confirms the diagnosis.
- Lactate & pH Analysis: Increased lactate and decreased pH indicate severe infection.
2. Blood Cultures
Blood cultures should be obtained in systemic infections to assess for bacteremia.
3. Imaging Studies
- Ultrasound or CT scan: Helps identify intra-abdominal abscesses, bowel perforation, or catheter-related complications.
Treatment Strategies
Management of Enterococcus peritonitis requires a combination of antimicrobial therapy, source control, and supportive care.
1. Antibiotic Therapy
Empiric therapy should be guided by local resistance patterns and adjusted based on culture results:
- Empiric Treatment:
- Vancomycin – Preferred for Enterococcus faecium due to potential resistance to beta-lactams.
- Ampicillin – Effective against Enterococcus faecalis if susceptibility is confirmed.
- Linezolid or Daptomycin – Used for vancomycin-resistant Enterococcus (VRE) infections.
- Combination Therapy: Addition of aminoglycosides (e.g., gentamicin) may enhance efficacy in severe cases.
2. Source Control
- Peritoneal Dialysis-Related Peritonitis: Temporary discontinuation of PD and catheter removal if refractory to therapy.
- Surgical Intervention: Required for perforation, abscess formation, or ischemic bowel.
3. Supportive Care
- Intravenous fluids and electrolyte management
- Pain control and antiemetics
- Close hemodynamic monitoring in septic patients
Prognosis and Complications
Without prompt treatment, Enterococcus peritonitis can lead to severe complications, including:
- Sepsis and Multi-Organ Dysfunction Syndrome (MODS)
- Persistent or Recurrent Peritonitis
- Intra-abdominal Abscesses
- End-Stage Renal Disease Progression in PD Patients
Mortality rates vary depending on comorbidities, antibiotic resistance, and timely intervention. Early diagnosis and appropriate therapy significantly improve outcomes.
Prevention Strategies
Preventative measures are essential, particularly in high-risk patients:
- Strict Aseptic Techniques during peritoneal dialysis exchanges.
- Regular Monitoring and Early Antibiotic Therapy for PD-related infections.
- Minimizing Unnecessary Broad-Spectrum Antibiotics to reduce resistant Enterococcus strains.
- Proper Surgical Techniques to prevent postoperative infections.
