Case Presentation: A 64-year-old female with decompensated alcoholic liver cirrhosis was admitted to the hospital for lower abdominal pain. The initial paracentesis polymorphonuclear (PMN) leukocyte count was 149 cells/mm3, but the patient was found to have E. coli urinary tract infection. During the course of her treatment, the patient developed pancreatitis and her hepatic encephalopathy worsened. She developed septic shock due to aspiration pneumonia and was transferred to the ICU. Due to her decompensation, infectious workup was repeated including paracentesis. PMN count was 12 cells/mm3, but the body fluid culture turned positive on day two and resulted as vancomycin-resistant Enterococcus (VRE). The patient had already been on IV piperacillin-tazobactam and vancomycin, and the patient completed a 7 day course with IV piperacillin-tazobactam which did not cover the VRE. After completion of the antibiotic, the patient developed acute kidney injury (AKI) and the paracentesis was repeated to rule out SBP. The PMN count was 43 cells/mm3 and the body fluid culture did not have any growth. Her AKI was believed to be HRS and despite aggressive measures, the patient ultimately passed away in the ICU.

Discussion: Bacterascites is defined as patients with ascites PMN count less than 250/mm3 and a positive bacterial culture. SBP is established with PMN count greater than 250/mm3 [1]. The presentation of SBP is variable and a delay in starting antimicrobial therapy can lead to increased mortality [2]. It is beneficial to isolate a microorganism from ascites so that antibiotic susceptibility results may guide antibiotic therapy. It is important to recognize that this patient never received adequate treatment for the positive culture, but the decision was made to complete treatment to prevent the progression of SBP. A small prospective study showed that 38% of the time the bacterascites resulted in SBP, but 62% of the time the bacterascites did not develop neutrocytosis without any antibiotic treatment [3].

Conclusions: Our case demonstrates its importance in distinguishing between SBP versus bacterascites. A repeat paracentesis is needed to assess for the progression to SBP or to confirm that the positive culture was a contaminant. Also, our case highlights the importance of antibiotic stewardship as the exposure to the unnecessary antibiotic could have attributed to the renal injury leading to further decompensation. Early recognition could lead to a reduction in antibiotic resistance, improve patient outcomes, and reduce cost for the patient.