Difficult cases: Peritonitis with recurrence of symptoms during initial antibiotic treatment

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Difficult cases Peritonitis with recurrence of
symptoms during initial antibiotic treatment

• Aleksandra Zurowska
• Department Paediatric Nephrology, Gdansk
  University Medical School

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Case report

• Peter K. d.o.b. 12 10 1992
• Diagnosis
• Nail-patella syndrome - proteinuria ? 6 yrs
  NS
• ? 7.5 yrs ESRD
• 05.2000 Renal replacement therapy
• double cuff straight Tenckoff catheter
• mode of dialysis CCPD wet day
• infectious complications
• 10 2000 peritonitis following
  appendectomy
• (Pseudomonas aer.,
  Proteus)
• 02 2001 peritonitis ( Klebsiella
  pneumoniae)
• 04 2001 ESI, peritonitis

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Initial manifestation

• Day 1 severe abdominal pain, nausea,temp.36.7C
• purulent exsudate from exit site
• clear effluent, effluent cell
  count 200/mm³
• culture of dialysate performed
• swab from exit site taken
• laboratory results CRP 125, WBC
  10,1
• 
  Neutrophils 57, Lymphocytes 25
• Initial diagnosis ESI, gastritis suspected
• Management oral clindamycin started,
• gastroscopy discussed
  

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Initial manifestation cont.

• Day 2 general malaise
• fever 38C
• severe abdominal pain
• effluent cell count 200/mm³

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Diagnosis of peritonitis

• Peritonitis ISPD pediatric guidelines
• PDI 200020610
• i. cloudy effluent
• ii. cytosisgt 100/mm³
• ii. gt 50 PMN in differential cell count

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DSS- disease severity score (range 0-5) JASN
199910136
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Standardized scoring system for exit site
(0-10)JASN 199910136
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Initial diagnosis

• Peritonitis - DSS 2 (0-5)
• Exit-site infection 2 points (0-10)
• Risk factors present
• Young age
  -
• Fever
  -
• Severe abdominal pain
• Exit site infection
  /-
• Previous MRSA infection -

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Treatment protocol
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Initial management

• Intermittent vancomycin
• Continuous ceftazidime
• 0ral nystatin

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Culture results

• Corynebacterium - at exit site resistant to
  clindamycin, sensitive to cephalosporins and
  glycopeptides
• S.aureus - methicillin sensitive

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Initial response to treatment Day 3

• Complete resolution of symptoms DSS0
• Improvement of general status
• Temp 36.9C
• No abdominal pain
• Effluent cell count 64/mm³
• Effluent culture negative (BACTALERT) gt48hrs
  treatment

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Treatment modification Day 3

• Continuation of i.p. vancomycin as monotherapy
• Discontinuation of ceftazidime

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Recurrence of symptoms

• Day 7 recurrent abdominal pain
• Day 10 fever 37.8C
• clear effluent
• effluent cell count 200/mm³
• CRP 308
• WBC 20.0/µL Neutrophils 78

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Differential diagnosis of early recurrence
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Bulion culture result

• Initial culture from Day 1
• Gram negative rod Providentia stuartii
• In vitro sensitivity
• S ampicillin, cephalosporins, imipenem,
  aminoglycosides, ciprofloxacin, cotrimoksazol
• All further bulion cultures positive

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Providentia infections

• No reports on Providentia peritonitis in humans
• Genus Providentia is closely related to genera
  Proteus and Morganella. It includes species
  P.stuartii, rettgeri, alcalifaciens,rustigianii
  of which the most common species responsible for
  human infection is P.stuartii
• P.stuartii is extremely common in patients with
  indwelling urinary catheters ( due to an adhesin
  MR/K)
• P.stuartii and retgerri are causes of
  travellers diarrhea and urinary tract infection,
  respiratory tract infection usually of slight
  symptomatology.
• Patients with burns are at high risk of
  Provid. infection
• Bloodstream infections have 6-33 mortality
  rate

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Modification of treatment

• intermittent Vancomycin continued
• Continuous Ceftazidime added

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Response to treatment at 48 hrs

• Day 12
• Improvement but low grade fever and intermittent
  abdominal pain continues
• Effluent cell count 100/mm³
• Culture result
• Pseudomonad Stenotrophomonas maltofilia
• S aminoglycosides, cotrimoksazol
• R cephalosporins, imipenem
• Day 14 Blood tinged effluent

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Stenotrophomonas maltophilia

• Stenotrophomonas is a common environmental
  saprophyte. Previuosly known as Pseudomonas
  maltophilia or Xanthomonas maltophilia. It is a
  non fermentive, aerobic gram negative rod. Unlike
  pseudomonas it has low virulence and is regarded
  as an opprtunistic pathogen which affects
  patients with debilitating disease, compromised
  immune system or with indwelling catheters.
• Reports on Stenotrophomonas peritonitis in PD
  patients
• Szeto Am J Med. 2002113728 6 cases (
  broad spectrum antibiotics)
• Machura Adv.Per Dialysis 20052163 1 case
  (water contamination)
• Baek Korean J Med. 200419104 5 cases
  (all with diabetes mellitus)
• Taylor PDI 199919259. 7 episodes (all
  community acquired)
• Treatment Difficult to treat due to resistance
  to betalactams and aminoglycosides. Most strains
  are susceptible to trimetoprim- sulfametoaoxazole
  - the treatment of choice

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Abdominal x-ray

• Malpositioned entrapped catheter
• probably causing bowel wall ischaemia (
  recurrent right upper quadrant abdominal pain)
  and transmural migration of colonic bacteria

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Management

• Repositioning of catheter
• Continuation of treatment with
• vancomycin 3 weeks
• ceftazidime 3 weeks
• netilmycin 3 weeks

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Outcome

• Resolution of symptoms next day following
  catheter repositioning DSS0
• No further relapse
• No catheter replacement

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Final outcome

• Final outcome Recovery with further loss of
  ultrafiltration
• 3 months later transfer to HD due to technique
  failure

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Polymicrobial peritonitis in patients on chronic
peritoneal dialysis

• Polymicrobial peritonitis is traditionally
  thought to be a serious complication of PD
  accounting for up to 2- 9 of peritonitis
  episodes in studies of adult population and has
  been associated with intraabdominal or
  gastrointestinal pathology ( intraabdominal
  catastrophies).In children scarce information.
• NAPRTCS no information on number of
  polymicrobial peritonitis
• MEPPS 2.4 polymicrobial
• ISPD guidelines recommend surgical
  exploration fpr polymicrobial peritonitis but
  there is evidence that this does not reflect
  clinical practise.
• Holley Am J Kidney Dis 199219162 39 episodes
• Kiernan Am J Kidney Dis 199525461 80 cases
• Kim Am J Kidney Dis 2000 361000 43 cases
• Szeto Am J Med. 2002113728 140 cases

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Causes of polymicrobial peritonitis

• Intraabdominal pathology lt 10
• surgical pathology 5, catastrophic
  surgical pathology a rare cause
• Report on a cases of bowel perforation
  during peritoneoscopy for insertion of catheter
  Am J Kidney Dis 2003421270
• Contamination of dialysis system
• a/ exit site infections/tunnel infections
  Kim ( mainly G)
• b/ outbreak of polymicrobial peritonitis in
  dialysis ward during external wall
• renovation of the unit Cheng PDI
  200121296
• c/ report of a child who developed PMP from
  oral contamination due to
• chewing on her catheter
• Transmigration of bacteria through an intact
  intestinal wall
• It has been postulated that it is more
  frequent in patients following broad spectrum
  antibiotics?