1/
75M with ESRD on continuous ambulatory peritoneal dialysis admitted with 1 wk of abd pain and cloudy PD effluent
https://abs.twimg.com/emoji/v2/... draggable="false" alt="🧍" title="Stehende Person" aria-label="Emoji: Stehende Person">VS stable
https://abs.twimg.com/emoji/v2/... draggable="false" alt="🧪" title="Test tube" aria-label="Emoji: Test tube">WBC 5k, 78%N
https://abs.twimg.com/emoji/v2/... draggable="false" alt="🧪" title="Test tube" aria-label="Emoji: Test tube">Effluent: WBC 1537, LDH 55, Glc 20

Empiric tx choice?

#MedTwitter #IDTwitter #NephTwitter
2/
Today’s #tweetorial = PERITONITIS, which can include several different types:
Primary
Secondary
Tertiary
PD-associated

We’ll focus on SBP and PD-associated peritonitis mostly today!
3/
For primary peritonitis, think of spontaneous bacterial peritonitis (SBP) in a pt with liver cirrhosis, ascites

Clinical presentation = acute illness with fever, abd pain. May have altered mental status and hypotension as well.

Other pathogens (eg TB) rare, more indolent
4/
SBP is typically caused by enteric GNRs. Other orgs are less common without risk factors

We won’t dive into secondary/tertiary peritonitis much here, but key https://abs.twimg.com/emoji/v2/... draggable="false" alt="📍" title="Runde Reißzwecke" aria-label="Emoji: Runde Reißzwecke">: these infections are typically polymicrobial, often due to break in intra-abd mucosa (abd abscess, perf viscus)
4/SBP is typically caused by enteric GNRs. Other orgs are less common without risk factorsWe won’t dive into secondary/tertiary peritonitis much here, but key https://abs.twimg.com/emoji/v2/... draggable=: these infections are typically polymicrobial, often due to break in intra-abd mucosa (abd abscess, perf viscus)" title="4/SBP is typically caused by enteric GNRs. Other orgs are less common without risk factorsWe won’t dive into secondary/tertiary peritonitis much here, but key https://abs.twimg.com/emoji/v2/... draggable="false" alt="📍" title="Runde Reißzwecke" aria-label="Emoji: Runde Reißzwecke">: these infections are typically polymicrobial, often due to break in intra-abd mucosa (abd abscess, perf viscus)">
4/SBP is typically caused by enteric GNRs. Other orgs are less common without risk factorsWe won’t dive into secondary/tertiary peritonitis much here, but key https://abs.twimg.com/emoji/v2/... draggable=: these infections are typically polymicrobial, often due to break in intra-abd mucosa (abd abscess, perf viscus)" title="4/SBP is typically caused by enteric GNRs. Other orgs are less common without risk factorsWe won’t dive into secondary/tertiary peritonitis much here, but key https://abs.twimg.com/emoji/v2/... draggable="false" alt="📍" title="Runde Reißzwecke" aria-label="Emoji: Runde Reißzwecke">: these infections are typically polymicrobial, often due to break in intra-abd mucosa (abd abscess, perf viscus)">
5/
How dx peritonitis: https://abs.twimg.com/emoji/v2/... draggable="false" alt="🧪" title="Test tube" aria-label="Emoji: Test tube">Paracentesis

Interpreting ascites fluid is vital. See summary chart for results you would expect with diff types of peritonitis

SBP criteria and the 250 PMN cutoff is a common #TipsForNewDocs! #MedTwitter #GITwitter #medstudenttwitter
6/
https://abs.twimg.com/emoji/v2/... draggable="false" alt="👆" title="Rückhand Zeigefinger nach oben" aria-label="Emoji: Rückhand Zeigefinger nach oben">Notice PD-associated peritonitis has diff dx criteria though: WBC >100 or >50% PMNs (if short dwell, may consider >50% PMNs abnormal even with WBC <100)

https://abs.twimg.com/emoji/v2/... draggable="false" alt="▶️" title="Nach rechts zeigendes Dreieck" aria-label="Emoji: Nach rechts zeigendes Dreieck">May also have different clinical features:
Abd pain
Cloudy effluent/dialysate
Bacteremia+fever less common than SBP
7/
PD-associated inf can be: intraluminal contamination (connect/disconnect cath for exchange), exit site/tunnel infection, visceral (bowel bact)

Micro reflects this as pathogens often gram positive (bacterial skin contaminant). See chart/ref below
https://pubmed.ncbi.nlm.nih.gov/17080112/ ">https://pubmed.ncbi.nlm.nih.gov/17080112/...
8/
On to management, detailshttps://abs.twimg.com/emoji/v2/... draggable="false" alt="👇" title="Rückhand Zeigefinger nach unten" aria-label="Emoji: Rückhand Zeigefinger nach unten">
https://abs.twimg.com/emoji/v2/... draggable="false" alt="🔹" title="Kleine blaue Raute" aria-label="Emoji: Kleine blaue Raute">Why 5d? Here is RCT that comp& #39;d 5 v 10d of cefotax in SBPhttps://abs.twimg.com/emoji/v2/... draggable="false" alt="➡️" title="Pfeil nach rechts" aria-label="Emoji: Pfeil nach rechts">both grps similar cure, recurrent inf, mort https://pubmed.ncbi.nlm.nih.gov/2019378/ 

https://pubmed.ncbi.nlm.nih.gov/2019378/&... class="Emoji" style="height:16px;" src=" https://abs.twimg.com/emoji/v2/... draggable="false" alt="🔹" title="Kleine blaue Raute" aria-label="Emoji: Kleine blaue Raute">Many ctrs have diff approach to f/u paras, good topic to discuss with your GI colleagues @BIDMC_GI @javiervg0902
8/On to management, detailshttps://abs.twimg.com/emoji/v2/... draggable=https://abs.twimg.com/emoji/v2/... draggable="false" alt="🔹" title="Kleine blaue Raute" aria-label="Emoji: Kleine blaue Raute">Why 5d? Here is RCT that comp& #39;d 5 v 10d of cefotax in SBPhttps://abs.twimg.com/emoji/v2/... draggable="false" alt="➡️" title="Pfeil nach rechts" aria-label="Emoji: Pfeil nach rechts">both grps similar cure, recurrent inf, mort https://pubmed.ncbi.nlm.nih.gov/2019378/&... class="Emoji" style="height:16px;" src=" " title="8/On to management, detailshttps://abs.twimg.com/emoji/v2/... draggable="false" alt="👇" title="Rückhand Zeigefinger nach unten" aria-label="Emoji: Rückhand Zeigefinger nach unten">https://abs.twimg.com/emoji/v2/... draggable="false" alt="🔹" title="Kleine blaue Raute" aria-label="Emoji: Kleine blaue Raute">Why 5d? Here is RCT that comp& #39;d 5 v 10d of cefotax in SBPhttps://abs.twimg.com/emoji/v2/... draggable="false" alt="➡️" title="Pfeil nach rechts" aria-label="Emoji: Pfeil nach rechts">both grps similar cure, recurrent inf, mort https://pubmed.ncbi.nlm.nih.gov/2019378/&... class="Emoji" style="height:16px;" src=" " class="img-responsive" style="max-width:100%;"/>
9/
Management of PD-assoc& #39;d peritonitis is different.

Did you know that there are ISPD guidelines?
https://abs.twimg.com/emoji/v2/... draggable="false" alt="🥔" title="Kartoffel" aria-label="Emoji: Kartoffel">For catheter inf: https://journals.sagepub.com/doi/pdf/10.3747/pdi.2016.00120
https://journals.sagepub.com/doi/pdf/1... class="Emoji" style="height:16px;" src=" https://abs.twimg.com/emoji/v2/... draggable="false" alt="🥔" title="Kartoffel" aria-label="Emoji: Kartoffel">For peritonitis:
https://journals.sagepub.com/doi/pdf/10.3747/pdi.2016.00078">https://journals.sagepub.com/doi/pdf/1...
9/Management of PD-assoc& #39;d peritonitis is different. Did you know that there are ISPD guidelines?https://abs.twimg.com/emoji/v2/... draggable=For catheter inf: https://journals.sagepub.com/doi/pdf/1... class="Emoji" style="height:16px;" src=" " title="9/Management of PD-assoc& #39;d peritonitis is different. Did you know that there are ISPD guidelines?https://abs.twimg.com/emoji/v2/... draggable="false" alt="🥔" title="Kartoffel" aria-label="Emoji: Kartoffel">For catheter inf: https://journals.sagepub.com/doi/pdf/1... class="Emoji" style="height:16px;" src=" ">
9/Management of PD-assoc& #39;d peritonitis is different. Did you know that there are ISPD guidelines?https://abs.twimg.com/emoji/v2/... draggable=For catheter inf: https://journals.sagepub.com/doi/pdf/1... class="Emoji" style="height:16px;" src=" " title="9/Management of PD-assoc& #39;d peritonitis is different. Did you know that there are ISPD guidelines?https://abs.twimg.com/emoji/v2/... draggable="false" alt="🥔" title="Kartoffel" aria-label="Emoji: Kartoffel">For catheter inf: https://journals.sagepub.com/doi/pdf/1... class="Emoji" style="height:16px;" src=" ">
9/Management of PD-assoc& #39;d peritonitis is different. Did you know that there are ISPD guidelines?https://abs.twimg.com/emoji/v2/... draggable=For catheter inf: https://journals.sagepub.com/doi/pdf/1... class="Emoji" style="height:16px;" src=" " title="9/Management of PD-assoc& #39;d peritonitis is different. Did you know that there are ISPD guidelines?https://abs.twimg.com/emoji/v2/... draggable="false" alt="🥔" title="Kartoffel" aria-label="Emoji: Kartoffel">For catheter inf: https://journals.sagepub.com/doi/pdf/1... class="Emoji" style="height:16px;" src=" ">
10/
Despite https://abs.twimg.com/emoji/v2/... draggable="false" alt="👆" title="Rückhand Zeigefinger nach oben" aria-label="Emoji: Rückhand Zeigefinger nach oben">guidelines, theres variability. Here is a chart w/recs for tx by org + dosing charts

This is just part of the management though, #NephTwitter likely has other tips. Shout-out to @BID_NephFellows for their expertise + #PharmTwitter friends to help w/IP abx dosing!
10/Despite https://abs.twimg.com/emoji/v2/... draggable=guidelines, theres variability. Here is a chart w/recs for tx by org + dosing chartsThis is just part of the management though, #NephTwitter likely has other tips. Shout-out to @BID_NephFellows for their expertise + #PharmTwitter friends to help w/IP abx dosing!" title="10/Despite https://abs.twimg.com/emoji/v2/... draggable="false" alt="👆" title="Rückhand Zeigefinger nach oben" aria-label="Emoji: Rückhand Zeigefinger nach oben">guidelines, theres variability. Here is a chart w/recs for tx by org + dosing chartsThis is just part of the management though, #NephTwitter likely has other tips. Shout-out to @BID_NephFellows for their expertise + #PharmTwitter friends to help w/IP abx dosing!">
10/Despite https://abs.twimg.com/emoji/v2/... draggable=guidelines, theres variability. Here is a chart w/recs for tx by org + dosing chartsThis is just part of the management though, #NephTwitter likely has other tips. Shout-out to @BID_NephFellows for their expertise + #PharmTwitter friends to help w/IP abx dosing!" title="10/Despite https://abs.twimg.com/emoji/v2/... draggable="false" alt="👆" title="Rückhand Zeigefinger nach oben" aria-label="Emoji: Rückhand Zeigefinger nach oben">guidelines, theres variability. Here is a chart w/recs for tx by org + dosing chartsThis is just part of the management though, #NephTwitter likely has other tips. Shout-out to @BID_NephFellows for their expertise + #PharmTwitter friends to help w/IP abx dosing!">
10/Despite https://abs.twimg.com/emoji/v2/... draggable=guidelines, theres variability. Here is a chart w/recs for tx by org + dosing chartsThis is just part of the management though, #NephTwitter likely has other tips. Shout-out to @BID_NephFellows for their expertise + #PharmTwitter friends to help w/IP abx dosing!" title="10/Despite https://abs.twimg.com/emoji/v2/... draggable="false" alt="👆" title="Rückhand Zeigefinger nach oben" aria-label="Emoji: Rückhand Zeigefinger nach oben">guidelines, theres variability. Here is a chart w/recs for tx by org + dosing chartsThis is just part of the management though, #NephTwitter likely has other tips. Shout-out to @BID_NephFellows for their expertise + #PharmTwitter friends to help w/IP abx dosing!">
11/
Lastly, what are indications for PD catheter removal?
https://abs.twimg.com/emoji/v2/... draggable="false" alt="✳️" title="Stern mit 8 Strahlen" aria-label="Emoji: Stern mit 8 Strahlen">Refractory perit
https://abs.twimg.com/emoji/v2/... draggable="false" alt="✳️" title="Stern mit 8 Strahlen" aria-label="Emoji: Stern mit 8 Strahlen">Relapsing perit
https://abs.twimg.com/emoji/v2/... draggable="false" alt="✳️" title="Stern mit 8 Strahlen" aria-label="Emoji: Stern mit 8 Strahlen">Refractory catheter inf
https://abs.twimg.com/emoji/v2/... draggable="false" alt="✳️" title="Stern mit 8 Strahlen" aria-label="Emoji: Stern mit 8 Strahlen">Fungal peritonitis

Strongly consider with:
https://abs.twimg.com/emoji/v2/... draggable="false" alt="✳️" title="Stern mit 8 Strahlen" aria-label="Emoji: Stern mit 8 Strahlen">Mycobact or polymicrobial inf
https://abs.twimg.com/emoji/v2/... draggable="false" alt="✳️" title="Stern mit 8 Strahlen" aria-label="Emoji: Stern mit 8 Strahlen">Association with intra-abd pathology
11/Lastly, what are indications for PD catheter removal?https://abs.twimg.com/emoji/v2/... draggable=Refractory perithttps://abs.twimg.com/emoji/v2/... draggable="false" alt="✳️" title="Stern mit 8 Strahlen" aria-label="Emoji: Stern mit 8 Strahlen">Relapsing perithttps://abs.twimg.com/emoji/v2/... draggable="false" alt="✳️" title="Stern mit 8 Strahlen" aria-label="Emoji: Stern mit 8 Strahlen">Refractory catheter infhttps://abs.twimg.com/emoji/v2/... draggable="false" alt="✳️" title="Stern mit 8 Strahlen" aria-label="Emoji: Stern mit 8 Strahlen">Fungal peritonitisStrongly consider with: https://abs.twimg.com/emoji/v2/... draggable="false" alt="✳️" title="Stern mit 8 Strahlen" aria-label="Emoji: Stern mit 8 Strahlen">Mycobact or polymicrobial infhttps://abs.twimg.com/emoji/v2/... draggable="false" alt="✳️" title="Stern mit 8 Strahlen" aria-label="Emoji: Stern mit 8 Strahlen">Association with intra-abd pathology" title="11/Lastly, what are indications for PD catheter removal?https://abs.twimg.com/emoji/v2/... draggable="false" alt="✳️" title="Stern mit 8 Strahlen" aria-label="Emoji: Stern mit 8 Strahlen">Refractory perithttps://abs.twimg.com/emoji/v2/... draggable="false" alt="✳️" title="Stern mit 8 Strahlen" aria-label="Emoji: Stern mit 8 Strahlen">Relapsing perithttps://abs.twimg.com/emoji/v2/... draggable="false" alt="✳️" title="Stern mit 8 Strahlen" aria-label="Emoji: Stern mit 8 Strahlen">Refractory catheter infhttps://abs.twimg.com/emoji/v2/... draggable="false" alt="✳️" title="Stern mit 8 Strahlen" aria-label="Emoji: Stern mit 8 Strahlen">Fungal peritonitisStrongly consider with: https://abs.twimg.com/emoji/v2/... draggable="false" alt="✳️" title="Stern mit 8 Strahlen" aria-label="Emoji: Stern mit 8 Strahlen">Mycobact or polymicrobial infhttps://abs.twimg.com/emoji/v2/... draggable="false" alt="✳️" title="Stern mit 8 Strahlen" aria-label="Emoji: Stern mit 8 Strahlen">Association with intra-abd pathology" class="img-responsive" style="max-width:100%;"/>
12/
PD-assoc& #39;d peritonitis is more complex than fits in this thread, a recent publ thinking about management: https://www.sciencedirect.com/science/article/pii/S2590059520301321

Here& #39;s">https://www.sciencedirect.com/science/a... case/review fr initial poll. Don& #39;t forget pet-associated PD-peritonitis if you have an unusual bug! https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7081570/">https://www.ncbi.nlm.nih.gov/pmc/artic...
12/PD-assoc& #39;d peritonitis is more complex than fits in this thread, a recent publ thinking about management: https://www.sciencedirect.com/science/a... case/review fr initial poll. Don& #39;t forget pet-associated PD-peritonitis if you have an unusual bug! https://www.ncbi.nlm.nih.gov/pmc/artic...
12/PD-assoc& #39;d peritonitis is more complex than fits in this thread, a recent publ thinking about management: https://www.sciencedirect.com/science/a... case/review fr initial poll. Don& #39;t forget pet-associated PD-peritonitis if you have an unusual bug! https://www.ncbi.nlm.nih.gov/pmc/artic...
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