Diagnosis and management of enteric disease and abdominal catastrophe in peritoneal dialysis patients with peritonitis

Abstract

Peritoneal dialysis (PD)-associated peritonitis rates have decreased significantly in recent years, especially Staphylococcus epidermidis and Staphylococcus aureus infections. Rates of gram-negative, polymicrobial, and fungal peritonitis have remained steady. The reported mortality of gram-negative and polymicrobial peritonitis varies widely (4%-50%). Most likely, the reason for this variability is that prognosis depends on the underlying etiology more than the specific microorganisms isolated. Gram-negative, polymicrobial, and fungal infection have variable association with documented visceral disease, and the highest mortality occurs in reports with the highest prevalence of intra-abdominal pathology. The odds ratio of death in PD patients with documented abdominal catastrophe and peritonitis is reported to be 20:1 compared with all other causes. Further reductions in PD-associated peritonitis mortality are likely to depend on earlier diagnosis and better management of intra-abdominal pathology. Presentation with hypotension, sepsis, lactic acidosis, and/or elevation of peritoneal fluid amylase should raise immediate concern for "surgical" peritonitis. Suspicion for visceral disease should also be high in patients with gram-negative, polymicrobial, and fungal infection or those who fail to improve rapidly as judged by clinical signs and symptoms, cell counts, and repeat cultures. Nonlocalizing physical examination and negative or nonspecific results of abdominal computed tomography do not rule out serious intra-abdominal disease. Immediate initiation of broad antibiotic coverage including for anaerobic infection is indicated when bowel pathology is suspected. Urgent surgical consultation, with active discussion and participation by the nephrologist, is advisable when visceral pathology is suspected and the patient is unstable or fails to improve rapidly.