polymicrobial peritonitis suggests perforation

Primary peritonitis (isolated infection within the peritoneum) is a common and serious complication of peritoneal dialysis and presents unique diagnostic and management challenges in this patient population. The presence of polymicrobial organisms and Candida in peritoneal fluid cultures and an incomplete response to initial sepsis management raises concern for secondary peritonitis, infection due to an underlying intraabdominal process that has spread to the peritoneum. Repeat CT scanning of the abdomen revealed extensive intraperitoneal free air, and laparotomy demonstrated a perforation at the site of the patient’s prior gastrojejunal anastomosis (Figure 1 and Figure 2) (choice C is correct).

There is substantial variation in the reported rates of primary peritonitis in centers that perform peritoneal dialysis, with guideline-based recommendations suggesting a program goal of no more than 0.5 episodes per year. Common prevention measures to minimize the risk of primary peritonitis include use of perioperative antibiotics immediately prior to catheter insertion; a “flush before fill” technique that clears the peritoneal catheter prior to dialysate instillation; and a robust training program on proper sterile technique for nurses, patients, and families performing the procedure. There are no clear data favoring one insertion technique (percutaneous, laparoscopic, open surgical) or catheter type to minimize the risk of infection. Interestingly, a significant proportion of peritonitis episodes are associated with invasive interventional procedures, prompting the suggestion that antibiotic prophylaxis should be considered prior to colonoscopy and invasive gynecologic procedures in addition to wet contamination (infusion of peritoneal dialysate fluid after potential contamination).1234

Footnotes

  1. SEEK Questionnaires ↩

  2. Toprak H, Yilmaz TF, Yurtsever I, et al. Multidetector CT findings in gastrointestinal tract perforation that can help prediction of perforation site accurately. Clin Radiol. 2019;74(9):736.e1-736.e7. PubMed ↩

  3. Li PK, Szeto CC, Piraino B, et al. ISPD peritonitis recommendations: 2016 update on prevention and treatment. Perit Dial Int. 2016;36(5):481-508. PubMed ↩

  4. ISPD peritonitis recommendations: 2016 update on prevention and treatment. Perit Dial Int. 2018;38(4):313. PubMed ↩