From the Guidelines
The most appropriate next step for this 70-year-old woman on peritoneal dialysis presenting with abdominal pain, fever, abdominal tenderness, and leukocytosis is to immediately evaluate for peritoneal dialysis-associated peritonitis. This should begin with obtaining peritoneal fluid for cell count, Gram stain, and culture, as peritonitis is a serious complication of peritoneal dialysis that can lead to catheter loss, transfer to hemodialysis, and increased mortality if not promptly treated 1. The clinical presentation of fever, abdominal pain, and leukocytosis in a PD patient strongly suggests peritonitis and requires immediate intervention to prevent complications. Some key points to consider in the management of peritonitis include:
- Empiric antibiotic therapy should be initiated promptly, typically with intraperitoneal antibiotics that cover both gram-positive and gram-negative organisms, such as vancomycin and a third-generation cephalosporin like ceftazidime 1.
- The cloudy dialysate should be drained and the patient should continue more frequent exchanges with antibiotics added to the dialysate.
- The diagnosis is confirmed if the peritoneal fluid white blood cell count exceeds 100/μL with at least 50% neutrophils.
- Patients with diffuse peritonitis should undergo an emergency surgical procedure as soon as is possible, even if ongoing measures to restore physiologic stability need to be continued during the procedure 1.
- Where feasible, percutaneous drainage of abscesses and other well-localized fluid collections is preferable to surgical drainage.
- For hemodynamically stable patients without evidence of acute organ failure, an urgent approach should be taken, with intervention delayed for as long as 24 h if appropriate antimicrobial therapy is given and careful clinical monitoring is provided. It is essential to prioritize the patient's morbidity, mortality, and quality of life when making treatment decisions, and to consider the most recent and highest-quality evidence available 1.
From the Research
Patient Presentation
The patient is a 70-year-old woman with renal failure, on peritoneal dialysis (PD), presenting with:
- Abdominal pain
- Fever (hyperthermia) of 39 C (102.2 F)
- Abdominal tenderness
- Leukocytosis with a leukocyte count of 18,000/mm3
- Recent peritoneal dialysis treatment 2 hours prior to presentation
Differential Diagnosis
Given the patient's symptoms and history, the differential diagnosis includes:
- Peritonitis, which is a common complication of peritoneal dialysis 2, 3, 4, 5
- Fungal peritonitis, which can have similar clinical features to bacterial peritonitis 3
- Clostridioides difficile associated peritonitis, which can present with diarrhea and cloudy dialysate 6
Appropriate Next Steps
The most appropriate next steps would be to:
- Obtain a sample of the peritoneal dialysis effluent for cell count, culture, and Gram stain to guide antibiotic therapy 4, 5
- Initiate empirical antibiotic therapy, taking into account the possibility of fungal or Clostridioides difficile infection 3, 4, 6
- Consider the use of broad-spectrum antibiotics, such as a combination of a first- and third-generation cephalosporin, or alternative regimens as recommended by the International Society for Peritoneal Dialysis 4, 5
- Monitor the patient closely for signs of improvement or deterioration, and adjust the treatment plan as needed 3, 4, 5, 6