MEDizzy - A 35-year-old woman with hypertensive kidney disease

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Disorders of the Kidney and Urinary Tract

A 35-year-old woman with hypertensive kidney disease progresses to end-stage renal disease. She was initiated on peritoneal dialysis 1 year ago and has done well with relief of her uremic symptoms. She is brought to the emergency department with fever, altered mental status, difuse abdominal pain, and cloudy dialysate. Her peritoneal fuid is withdrawn through her catheter and sent to the laboratory for analysis. The f uid white blood cell count is 125/μL with 85% polymorphonuclear neutrophils. Which organism is most likely to be found on the culture of the peritoneal fuid?

ExplanationThe major complication of peritoneal dialysis therapy is peritonitis, although other complications include catheter-associated non peritonitis infections, peritonitis, although other complications include catheter-associated nonperitonitis infections, weight gain, metabolic derangements, and residual uremia. Peritonitis is usually a result of a failure of the sterile technique during the exchange procedure. Transvisceral infection from the bowel is much less common. Because of the high dextrose used in dialysate, there is a conducive environment for the development of bacterial infection. This can be diagnosed by the presence of >100/μL leukocytes with >50% polymorphonuclear cells on microscopy. Cloudy dialysate and abdominal pain are the most common symptoms. The most commonly isolated bacteria are skin fora such as Staphylococcus. Gram-negative organisms, fungi, and mycobacteria have also been described. A Cochrane review (Wiggins KJ et al: Cochrane Database Syst Rev 1:CD005284, 2008) concluded that intraperitoneal administration of antibiotics was more effective than intravenous administration and that adjunctive treatment with urokinase or peritoneal lavage offers no advantage. Intraperitoneal vancomycin is common initial empiric therapy. In cases where peritonitis is due to hydrophilic gram-negative rods (e.g., Pseudomonas spp.) or yeast, antimicrobial therapy is usually not sufficient, and catheter removal is required to ensure complete eradication of infection.