Negative Peritonitis Research Articles

Perirectal Abscess: Camouflaged as Culture Negative Peritonitis in a Continuous Ambulatory Peritoneal Dialysis Patient

Perirectal Abscess: Camouflaged as Culture Negative Peritonitis in a Continuous Ambulatory Peritoneal Dialysis Patient

The changing trends of peritoneal dialysis related peritonitis and novel risk factors

Aim: Continuous ambulatory peritoneal dialysis (PD) has become a treatment modality for end stage renal disease with a peak of its use in 1990s. The aim of this study was to examine the peritonitis rates, causative organisms and the risk factors of peritonitis in a large group of patients in our center. Methods: The study was conducted in the Nephrology Department of a University Hospital in Turkey. Patients in the PD programme between January 2000 and January 2006 were included. Cohort-specific and subject specific peritonitis incidence, and peritonitis-free survival were calculated. Causative organisms and risk factors were evaluated. Results: Totally 620 episodes of peritonitis occurred in 440 patients over the six years period. Peritonitis rates showed a decreasing trend through the years (0.79 episodes/patient-year 2000–2003 and 0.46 episodes/patient-year 2003–2006). Cohort-specific peritonitis incidence was 0.62 episodes/patient-years and median subject-specific peritonitis incidence was 0.44 episodes/patient-years. The median peritonitis-free survival was 15.25 months (%95 CI, 9.45–21.06 months). The proportion of gram-negative organisms has increased from 9.8% to 17.3%. There was a significant difference in the percentage of culture negative peritonitis between the first three and the last three years (53.1% vs. 43.2%, respectively). Peritonitis incidence was higher in patients who had been transferred from HD, who had catheter related infection and who had HCV infection without cirrhosis. Conclusions: Our study showed significant trends in the peritonitis rates, causative organisms and antibiotic resistance. Prior HD therapy, catheter related infections and HCV infection were found to be risk factors for peritonitis.

Diagnostic and prognostic role of peritoneal CA 125 in peritoneal dialysis patients presenting with acute peritonitis.

BackgroundCancer antigen 125 (CA125) is made by peritoneal mesothelial cells and can be measured in spent dialysate effluent from peritoneal dialysis (PD) patients. It has been suggested that CA125 is a marker of peritoneal mesothelial cell mass and turnover. As PD CA125 increases during peritoneal inflammation, we wished to determine whether measuring PD CA125 during peritonitis provided additional information in determining outcome of peritonitis.MethodsWe prospectively measured peritoneal CA125 in 127 adult PD patients presenting with 187 acute episodes of PD peritonitis, measuring peritoneal CA125 from a sample of dialysate effluent obtained from a 4 hour 2 litre 13.6 g/l dextrose peritoneal dwell.ResultsMean patient age 60.8 ± 17.1 years, 62.6% male, 33.7% diabetic and the median PD vintage was 22 (11-48) months. 127 patients (66.8%) presented with their first episode of peritonitis, 20% their second episode, 13.2% third or greater. Gram positive bacteria accounted for 64.7% of all peritonitis episodes and Gram negative bacteria 21.1%. Treatment was successful for 151 episodes of PD peritonitis (81.1%). The median PD effluent total WBC was 1240 (430-3660) /ml and serum CRP 67 (20-144) mg/l, with a PD CA125 of 38 (20.3-72.3) IU/l on presentation. There were positive correlations between PD effluent CA125 concentrations and total WBC on presentation (r = 0.41, p = <0.001) and dialysis vintage (r = -0.43, p < 0.001) but not with patient age, diabetic status, or serum CRP.There was no difference in PD effluent CA125 concentrations between Gram positive, and Gram negative peritonitis or between those episodes which responded to treatment, median 38 IU/ml (21-69) vs those with treatment failures 38 IU/ml (15-94).ConclusionWe did not find any additional diagnostic or prognostic benefit for measuring effluent CA125 in PD patients presenting with acute peritonitis compared to standard investigations, including peritoneal WBC and serum CRP. As such our study would not support the routine measurement of peritoneal CA125 during episodes of peritonitis.

Peritonitis Related Death - A Retrospective Study Analysing Causative Factors In Chronic Peritoneal Dialysis

Peritunitis is a well-known cause of mortality in perituneal dialysis (PD) patients. This retrospective analysis was first ever done in India, on a total of 127 patients, to disclose the clinical spectrum and risk profile of peritonitis-related mortality. A total of I 00 episodes of peritonitis occurred in 67 people who entered our cbronic perituneal dialysis (CPD) programme from Februsry 2005- March 2013. They were on peritoneal dialysis for 370 I patient-months. Twenty three patients (M8, F IS) died during an episode ofperitonitis(18.1l %). They have been on CPD forameanof29.25±21.98 (range 3 to 132) months, 77 of them were diabetic, 83 hypertensive. Fifty seven percent of those who died were hypertensive (P=0.045). Twenty nine patients had catheter removal for peritonitis which was done between 7-10 days. Co-morbidities present in the 23 patients who had peritonitis related were: diabetes mellitus (IS), hypertension (13), cardiovascular disease (5), Myasthenia Gravis (I). Culture negative peritonitis occurred in 39 episodes. The most common organism isolated were E.coli 7, Mycobacterium tuberculosis 5, Candida species 5. Advanced age, diabetes mellitus and hypertension, left ventricular dysfunction are factors which predisposed to mortality in our patients with peritonitis.

Gangrenous appendicitis presenting as acute abdominal pain in a patient on automated peritoneal dialysis: a case report

IntroductionPresentations of abdominal pain in patients on peritoneal dialysis deserve maximal attention and careful differential diagnosis on admittance to medical care. In this case report a gangrenous appendicitis in a patient on automated peritoneal dialysis is presented.Case presentationWe report the case of a 38-year-old Caucasian man with end-stage renal disease who was on automated peritoneal dialysis and developed acute abdominal pain and cloudy peritoneal dialysate. Negative microbiological cultures of the peritoneal dialysis fluid and an abdominal ultrasonography misleadingly led to a diagnosis of culture negative peritonitis. It was decided to remove the peritoneal catheter but the clinical situation of the patient did not improve. An explorative laparotomy was then carried out; diffuse peritonitis and gangrenous appendicitis were found. An appendectomy was performed. Myocardial infarction and sepsis developed, and the outcome was fatal.ConclusionA peritoneal dialysis patient with abdominal pain that persists for more than 48 hours after the usual antibiotic protocol for peritoneal dialysis-related peritonitis should immediately alert the physician to the possibility of peritonitis caused by intra-abdominal pathology. Not only peritoneal catheter removal is indicated in patients whose clinical features worsen or fail to resolve with the established intra-peritoneal antibiotic therapy but, after 72 hours, an early laparoscopy should be done and in a case of correct indication (intra-abdominal pathology) an early explorative laparotomy.

Peritonitis in children on chronic peritoneal dialysis; experience from a paediatric nephrology centre

Aim To determine variation in clinical manifestations, antibiotic sensitivity, patterns of causative organisms and the outcomes of bacterial peritonitis in children in our institution. Methods This retrospective study population included all those children who developed chronic peritoneal dialysis (CPD) related peritonitis during October 2005–February 2008 at Children Kidney Centre at UHW, Cardiff. The parameters collected were age, presenting symptoms, presence of exit site infection/tunnel infection, nature of peritoneal effluent (PE) at presentation and at 72 h after treatment, type of organism grown, antibiotics sensitivities, response to treatment and outcome. Results Out of 15 patients who were on CPD during 3 years of the study period, 10 patients developed a total of 15 episodes of peritonitis. Risk factors for peritonitis were presence of gastrostomy, use of diapers and exit site infections. Main presenting features were PE with WBC count >100 (87%), abdominal pain and fever (53%), turbid PE and vomiting (40%). Organisms were grown from PE in 13 (86%) episodes and culture was negative in two. Gram positive (GP) organisms accounted for 47%, gram negative (GN) for 27% of episodes and mixed organisms and candida found in one episode each. 86% of GP organisms were sensitive to a glycopeptide and 75% of GN organisms were sensitive to ceftazidime/gentamicin. 10 episodes showed good response to therapy, four episodes improved following removal of PD catheter and one patient died due to Staphylococcus aureus sepsis. Discussion and Conclusions The children with gram negative peritonitis were younger than those who developed gram positive peritonitis. Abdominal pain was common in peritonitis caused by staph aureus, streptococcus and Gram negative organisms. Fever and turbid PE were more likely with Gram negative peritonitis. With appropriate antibiotic therapy, supportive treatment and PD catheter removal where indicated, good clinical improvement was seen in all patients except one (93%). Peritonitis due to staph aureus, pseudomonas and candida were more likely to need PD catheter removal. Those who ultimately need PD catheter removal are more likely to have associated exit site infection, more symptomatic, are culture (effluent) positive and show unsatisfactory response after 72 h of therapy. Strategies to prevent CPD related peritonitis include early detection and treatment of exit site infection, appropriate care of gastrostomy site, optimum placement of PD catheter and avoiding nappy area for catheter exit site in infants. Early detection and prompt initiation of appropriate therapy is essential for a favourable outcome.

Mycobacterium avium complex-associated peritonitis in a patient on continuous ambulatory peritoneal dialysis

Continuous ambulatory peritoneal dialysis (CAPD)-associated peritonitis remains a major cause of morbidity in the dialysis population. Typically, infection is caused by gram positive bacteria and treated with empiric antibiotics. A subset of patients, however, develop culture negative peritonitis and may be infected with fungal or mycobacterial organisms. We present a case of Mycobacterium avium complex-associated peritonitis in a HIV negative patient on CAPD. Our patient suffered from technique failure and died from unrelated causes before treatment could be completed.

Pulmonary and peritoneal tuberculosis in a CAPD patient

Patients with chronic renal failure have an increased incidence of tuberculosis due to decreased cellular immunity. More than half of the tuberculosis infection in these patients presented with extrapulmonary involvement. Tuberculous peritonitis is an important problem in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). Simultaneous pulmonary and peritoneal tuberculosis is a very rare condition. We describe a 39-year-old man with culture negative CAPD peritonitis. In spite of conventional antimicrobial therapy the patient had persistent fever, weight loss, and night sweats. Approximately after one month from starting treatment, both sputum specimen and peritoneal fluid were positive for mycobacterium. Quadruple therapy for tuberculosis has been started. The response to treatment was promptly. He is still on treatment for six months and receiving CAPD. Tuberculous peritonitis should always be considered when patients on CAPD develop culture negative peritonitis treated with conventional antibiotics without improvement. In addition, the existence of extraperitoneal tuberculosis, especially pulmonary disease must be investigated.

Characterization of human peritoneal dendritic cell precursors and their involvement in peritonitis

Scattered evidence suggests that the human peritoneal cavity contains cells of the dendritic cell (DC) lineage but their characterization is missing. Here, we report that the peritoneal cavity of normal subjects and of stable patients on peritoneal dialysis (PD) contains a population of CD14(+) cells that can differentiate into DCs or macrophages. Within this pool, we characterized a CD14(+)CD4(+) cell subset (2.2% of the peritoneal cells) fulfilling the definition of myeloid DC precursors or pre-DC1 cells. These cells expressed high levels of HLA-DR, CD13, CD33, and CD86, and low levels of CD40, CD80, CD83, CD123, CD209, TLR-2 and TLR-4. These cells retained CD14 expression until late stages of differentiation, despite concomitant up-regulation of DC-SIGN (CD209), CD1a, CD80 and CD40. Peritoneal pre-DC1 cells had endocytic capacity that was down-regulated upon LPS/IFN-gamma stimulation, were more potent allo-stimulators than peritoneal CD14(+)CD4(-/lo) cells and monocyte-derived macrophages, and induced Th1 cytokine responses. More importantly, the number of peritoneal pre-DC1 cells increased during PD-associated peritonitis, with a different profile for Gram positive and Gram negative peritonitis, suggesting that these cells participate in the induction of peritoneal adaptive immune responses, and may be responsible for the bias towards Th1 responses during peritonitis.

Candida parapsilosis peritonitis in patients on CAPD.

Twenty-four episodes of C. parapsilosis peritonitis in 23 patients on continuous ambulatory peritoneal dialysis (CAPD) over 6 years were reviewed. Clinical manifestations and laboratory findings were similar to those of other pathogens. All started treatment with intravenous amphotericin B. In six cases it was attempted to maintain a peritoneal catheter in situ, but removal became essential to relieve fungal peritonitis. Of the patients who developed peritonitis, 15 episodes (62.5%) continued the CAPD program. Nine cases could not resume CAPD because of death in 4, patient preference in 2, and abdominal adhesion in 3. Antifungal treatment alone was ineffective in most cases. It was found that peritonitis developing after gram negative bacterial peritonitis and the use of fluconazole after catheter removal were associated with CAPD discontinuation. It was suggested that C. parapsilosis peritonitis in CAPD patients should be treated with rapid catheter removal, particularly those with fungal peritonitis who had prior gram negative peritonitis.

Outcomes of single organism peritonitis in peritoneal dialysis: Gram negatives versus gram positives in the Network 9 Peritonitis Study

The use of the "peritonitis rate" in the management of patients undergoing peritoneal dialysis is assuming importance in comparing the prowess of facilities, care givers and new innovations. For this to be a meaningful outcome measure, the type of infection (causative pathogen) must have less clinical significance than the number of infections during a time interval. The natural history of Staphylococcus aureus, pseudomonas, and fungal peritonitis would not support that the outcome of an episode of peritonitis is independent of the causative pathogen. Could this concern be extended to other more frequently occurring pathogens? To address this, the Network 9 Peritonitis Study identified 530 episodes of single organism peritonitis caused by a gram positive organism and 136 episodes caused by a single non-pseudomonal gram negative (NPGN) pathogen. Coincidental soft tissue infections (exit site or tunnel) occurred equally in both groups. Outcomes of peritonitis were analyzed by organism classification and by presence or absence of a soft tissue infection. NPGN peritonitis was associated with significantly more frequent catheter loss, hospitalization, and technique failure and was less likely to resolve regardless of the presence or absence of a soft tissue infection. Hospitalization and death tended to occur more frequently with enterococcal peritonitis than with other gram positive peritonitis. The outcomes in the NPGN peritonitis group were significantly worse (resolution, catheter loss, hospitalization, technique failure) compared to coagulase negative staphylococcal or S. aureus peritonitis, regardless of the presence or absence of a coincidental soft tissue infection. Furthermore, for the first time, the poor outcomes of gram negative peritonitis are shown to be independent of pseudomonas or polymicrobial involvement or soft tissue infections. The gram negative organism appears to be the important factor. In addition, the outcome of peritonitis caused by S. aureus is worse than that of other staphylococci. Thus, it is clear that all peritonitis episodes cannot be considered equivalent in terms of outcome. The concept of peritonitis rate is only meaningful when specific organisms are considered.

Major reduction of CAPD peritonitis after the introduction of the twin-bag system

In recent years an impressive decrease in the incidence of CAPD-related peritonitis was observed in our centre, from 1.4 in the mid-eighties to 0.4 per patient year in 1991. In order to analyse which factors were most responsible for this decline, the present study was performed. From the start of our CAPD programme in 1982 until September 1991, 100 patients were enrolled. For each patient, time elapsed from catheter insertion until first peritonitis episode was recorded. Outcome was measured as the peritonitis-free interval in days. The following variables have been evaluated: age, gender, type of catheter, type of system, presence of diabetes mellitus, leakage, break-in period, presence of an exit-site infection, and performing surgeon. Data were analysed first by Kaplan-Meier product-limit estimate of survival (peritonitis-free interval). Thereafter Cox proportional hazard analysis was applied to the data, providing a conditional probability of peritonitis at each moment during follow-up, given a certain combination of risk factors. Our results show that the system, in conjunction with the type of catheter, was a decisive factor in the decline of the peritonitis rate in our centre. Patients on the twin-bag system (twin-bag group) showed a significant increase in the peritonitis-free interval in comparison with patients using other systems (non-twin bag group). Among the other variables analysed, only diabetes mellitus appeared to be relatively important. Episodes of culture negative peritonitis were more frequently observed in the twin-bag group, compared to the non-twin bag group. In absolute numbers Staph. non-aureus was the micro-organism most effectively reduced.

Early diagnosis of gram-negative peritonitis in continuous ambulatory peritoneal dialysis patients with the Lymulus amebocyte lysate assay.

The treatment of peritonitis in continuous ambulatory peritoneal dialysis patients is empiric until the bacteriological results are available. The Lymulus amebocyte lysate assay (LAL) is a very sensitive method for the detection of endotoxin, a structural component of gram-negative bacteria. We performed the LAL assay in a prospective study in 36 consecutive episodes of peritonitis. The LAL assay was positive in all 10 episodes of gram-negative peritonitis (100% specificity). Treatment directed specifically against gram-negative or -positive infection was started based on the LAL assay result. In 26 episodes with LAL-negative test, a gram-positive bacterium was cultured in 23 episodes, in 1 there was fungal infection and 2 were sterile. In summary: the LAL assay is a rapid (1 h) and sensitive method for the differentiation of gram-positive or -negative peritonitis and enables starting an immediate and more appropriate antibiotic therapy.

Limulus amoebocyte lysate assay in the diagnosis of peritonitis in patients receiving continuous ambulatory peritoneal dialysis.

To evaluate the Limulus amoebocyte lysate (LAL) assay for differentiating Gram positive from Gram negative peritonitis in patients receiving continuous ambulatory peritoneal dialysis (CAPD). One hundred and six patients with suspected peritonitis were studied. LAL assay was performed by adding 0.1 ml of CAPD fluid to 0.1 ml of LAL reagent and incubating in a heating block for 60 minutes at 37 degrees C. The sensitivity of the reaction was determined by: (i) diluting endotoxin in distilled water and used (filter sterilised) peritoneal dialysis fluid; and (ii) diluting a broth culture of E coli used in peritoneal dialysis fluid. A positive LAL assay was defined as the constant stability of the clot through an inversion of 180 degrees. Compared with bacterial culture, the LAL assay had a sensitivity of 65% and a specificity of 98%. The sensitivity of microscopy compared with culture of Gram negative organisms was 76%; overall sensitivity of microscopy in comparison was 80%. The Gram stain was more sensitive than has previously been reported; the LAL assay was specific but insensitive for the diagnosis of CAPD peritonitis. There was a correlation between reduced leucocyte count and culture; this was reduced in cases from which Gram negative organisms had been isolated. It is recommended that laboratories evaluate their Gram stain procedure to improve its sensitivity because the LAL assay is not a satisfactory substitute.

Recurrent Culture Negative Peritonitis Cured with Hemicolectomy

Recurrent Culture Negative Peritonitis Cured with Hemicolectomy

Tuberculous Peritonitis in a CAPD Patient Cured Without Catheter Removal: Case Report, Review of the Literature, and Guidelines for Treatment and Diagnosis

Tuberculous peritonitis in the chronic peritoneal dialysis patient carries a high mortality, which may reflect the diagnostic delay that is often encountered in these cases. Accordingly, a high index of suspicion and an aggressive diagnostic approach (which may include laparoscopic biopsy) should be applied to the patient with persistent culture negative peritonitis. One of the first continuous ambulatory peritoneal dialysis (CAPD) cases involving tuberculous peritonitis successfully treated without interruption of dialysis or removal of the peritoneal dialysis catheter is reported. The literature is reviewed to provide diagnostic and therapeutic guidelines in dealing with this serious infection.

Staphylococcus Aureus Nasal Carriage, Exit-Site Infection and Catheter Loss in Patients Treated with Continuous Ambulatory Peritoneal Dialysis (CAPD)

Over a three-year period, 217 episodes of bacterial peritonitis occurred in 183 patient years. Thirty-seven episodes were due to Staphylococcus aureus and 19 (51%) of these required removal of the catheter to eradicate infection. This compared with catheter loss in 4/63 (6.3%) coagulase negative staphylococci infections (p less than 0.001); 7/67 (9.5%) culture negative peritonitis (p less than 0.001); and 10/30 (33.3%) episodes due to gram-negative organisms (p less than 0.05). Over half (51.3%) the episodes due to S. aureus were associated with exit-site infections, and this rose to 100% (10/10) with recurrent peritonitis (p less than 0.01). A prospective analysis of nasal carriage and exit-site infections due to S. aureus was carried out in 87 patients. Exit-site infections were present in 21 (24%), almost entirely due to different strains as judged by sensitivity patterns and phage typing. Nasal carriage, defined as two positive swabs within the study period, was present in 20 (23%) patients. Fourteen (70%) of these had exit-site infections due to the same strain as that isolated from the nose, whereas no patient grew different strains from either site. Nasal carriage increased the risk of infection sixfold (p less than 0.001).