1/
75M with ESRD on continuous ambulatory peritoneal dialysis admitted with 1 wk of abd pain and cloudy PD effluent
VS stable
WBC 5k, 78%N
Effluent: WBC 1537, LDH 55, Glc 20
Empiric tx choice?
#MedTwitter #IDTwitter #NephTwitter
75M with ESRD on continuous ambulatory peritoneal dialysis admitted with 1 wk of abd pain and cloudy PD effluent



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!
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
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
: these infections are typically polymicrobial, often due to break in intra-abd mucosa (abd abscess, perf viscus)
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

5/
How dx peritonitis:
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
How dx peritonitis:

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/
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)
May also have different clinical features:
Abd pain
Cloudy effluent/dialysate
Bacteremia+fever less common than SBP


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/
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/
8/
On to management, details
Why 5d? Here is RCT that comp'd 5 v 10d of cefotax in SBP
both grps similar cure, recurrent inf, mort https://pubmed.ncbi.nlm.nih.gov/2019378/
Many ctrs have diff approach to f/u paras, good topic to discuss with your GI colleagues @BIDMC_GI @javiervg0902
On to management, details




9/
Management of PD-assoc'd peritonitis is different.
Did you know that there are ISPD guidelines?
For catheter inf: https://journals.sagepub.com/doi/pdf/10.3747/pdi.2016.00120
For peritonitis:
https://journals.sagepub.com/doi/pdf/10.3747/pdi.2016.00078
Management of PD-assoc'd peritonitis is different.
Did you know that there are ISPD guidelines?


https://journals.sagepub.com/doi/pdf/10.3747/pdi.2016.00078
10/
Despite
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!
Despite

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!
11/
Lastly, what are indications for PD catheter removal?
Refractory perit
Relapsing perit
Refractory catheter inf
Fungal peritonitis
Strongly consider with:
Mycobact or polymicrobial inf
Association with intra-abd pathology
Lastly, what are indications for PD catheter removal?




Strongly consider with:


12/
PD-assoc'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's case/review fr initial poll. Don't forget pet-associated PD-peritonitis if you have an unusual bug! https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7081570/
PD-assoc'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's case/review fr initial poll. Don't forget pet-associated PD-peritonitis if you have an unusual bug! https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7081570/