Peritonitis in cirrhotic patients with LeVeen shunts

Six cirrhotic patients are described in whom peritonitis developed from 10 days to 15 months after the insertion of a LeVeen shunt. The presenting clinical features of fever, increasing ascites and deterioration in mental status resembled these previously reported for cirrhotic patients but with spontaneous peritonitis without shunts. Important differences were observed, however, in microbiology, incidence of bacteremia and therapy. Staphylococcus aureus, a rare cause of spontaneous peritonitis, was found in one half of our cases, suggesting that perioperative contamination during shunt placement was an important etiologic factor. All six had concomitant bacteremia which may be attributable to the direct peritoneal-venous connection. Appropriate systemic antimicrobial therapy without shunt removal failed to eradicate the infection irrespective of the patency of the shunt or absence of inflammation at the sites of insertion. Recommended treatment for suspected peritonitis in patients with shunts is systemic antimicrobial therapy with an agent active against staphylococci plus an aminoglycoside, followed by removal of the shunt if the diagnosis is confirmed.