primary peritonitis in PD patients only need 50 neutrophils

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The clinical diagnosis of primary peritonitis in these patients requires consistent clinical features (abdominal pain, cloudy dialysis effluent), a dialysis effluent WBC count >100/μL (0.10 × 109/L) with greater than 50% neutrophils (obtained after a dwell time of ≥2 h), and a positive fluid culture. Infections can be due to either gram-positive or gram-negative organisms, and initial antibiotic management is often based on the initial fluid Gram stain, with heavy emphasis on intraperitoneal administration in stable patients. Recommendations when systemic infection is present include both gram-positive (vancomycin or first-generation cephalosporin) and gram-negative (third-generation cephalosporin or aminoglycoside) coverage based on prior cultures and local antibiogram sensitivities until cultures return. Peritoneal permeability typically increases during an episode of peritonitis, and temporary use of hypertonic exchanges with short dwell times or initiation of hemodialysis may be necessary until the infection is controlled.

Clinical response to therapy is typically rapid, and antibiotics should be narrowed based on culture results within 48 h. Patients without clinical response should have repeat peritoneal fluid cultures, with effluent WBC count >1,090/μL (1.09 × 109/L), a prognostic marker of treatment failure in one retrospective study. Refractory peritonitis is defined as failure of the peritoneal dialysis effluent to clear after 5 days of appropriate antibiotics and should prompt a systematic evaluation for causes of secondary peritonitis and consideration of peritoneal dialysis catheter removal. Continued treatment of refractory peritonitis with prolonged antibiotics has been associated with extended hospital stay, peritoneal membrane damage, and increased mortality.

Addition of antifungal coverage is appropriate in this situation, but current Infectious Diseases Society of America recommendations are to use an echinocandin (micafungin, not fluconazole) as first-line treatment for nonneutropenic patients with significant systemic infection. Although de-escalation of vancomycin may be appropriate in the absence of methicillin-resistant S aureus, this will not address the underlying source of clinical deterioration in this case. Removal of the patient’s peritoneal dialysis catheter is indicated in the setting of both refractory and fungal peritonitis but should only be performed in conjunction with exploratory laparotomy so that the underlying cause of secondary peritonitis can be identified and addressed.123456

Footnotes

  1. SEEK Questionnaires ↩

  2. ISPD peritonitis recommendations: 2016 update on prevention and treatment. Perit Dial Int. 2018;38(4):313. 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. Pappas PG, Kauffman CA, Andes DR, et al. Clinical practice guideline for the management of candidiasis: 2016 update by the Infectious Diseases Society of America. Clin Infect Dis. 2016;62(4):e1-e50. PubMed ↩

  5. Perl J, Fuller DS, Bieber BA, et al. Peritoneal dialysis-related infection rates and outcomes: results from the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) [published online ahead of print January 10, 2020]. Am J Kidney Dis. doi: 10.1053/j.ajkd.09.016. PubMed ↩

  6. 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 ↩