Relapsing CAPD peritonitis with rapid peritoneal sclerosis due to ...

Nephrol Dial Transplant ( 1997) 12: 821–822

Nephrology Dialysis Transplantation

Case Report

Relapsing CAPD peritonitis with rapid peritoneal sclerosis due to Haemophilus influenzae C. G. Chew, A. R. Clarkson and R. J. Faull Renal Unit, Royal Adelaide Hospital, Adelaide, South Australia

Key words: CAPD peritonitis; Haemophilus influenzae

Introduction Infective peritonitis is a major complication of continuous ambulatory peritoneal dialysis (CAPD) which causes significant morbidity and mortality. Recurrent episodes of peritonitis are associated with fibrosis of the peritoneal membrane, and eventually loss of dialysis efficiency and failure of the technique. The microorganisms usually infecting the peritonal fluid are often skin commensals, reflecting the most common mode of contamination. However, the implications of the identity of the organism vary dramatically, because certain organisms are particularly likely to cause recurrent peritonitis and/or rapid membrane fibrosis/dialysis failure (e.g. fungal peritonitis, Staphylococcus aureus). We now report a case of CAPD peritonitis secondary to an organism which has rarely been associated with this condition (Haemophilus influenzae). The added significance of this case is that the patient suffered two rapid recurrences 1 month apart of the peritonitis, resulting in rapid and severe scarring of the peritoneal membrane that necessitated conversion to haemodialysis.

Case report A 41 year old Australian Aboriginal female with endstage renal failure secondary to diabetic nephropathy was commenced on CAPD in January 1996. Despite careful education she was poorly compliant with many aspects of self-care, including her medications, fluid management, and diet. Consequently she remained hypertensive and on two occasions was admitted to hospital for acute management of fluid overload. She Correspondence and offprint requests to: Dr C. G. Chew, Renal Unit, Royal Adelaide Hospital, North Tce, Adelaide 5000, South Australia.

also continued to smoke cigarettes, but there was no clinical evidence of chronic airways limitation. She had her first episode of CAPD peritonitis in April 1996. An urgent Gram stain of the dialysate was negative, and according to our standard protocol she was provisionally treated with intraperitoneal cephalothin (200 mg per bag after 1 g loading dose). The next day the peritoneal effluent grew Haemophilus influenzae type b, which was fully sensitive, including to cephalothin, gentamicin and ampicillin. The cephalothin was continued, but gentamicin (12 mg per 2-litre bag after loading dose of 2 mg/kg ) was added the following day as there had been little resolution of the peritonitis. This had good effect over the next 2 days, and the patient was discharged to complete a 14-day course of intraperitoneal cephalothin and gentamicin as an outpatient. The source of the H. influenzae was not identified, and specifically there was no evidence for an infectious source elsewhere, including a normal chest X-ray. Blood cultures performed prior to the commencement of the antibiotics were also negative. A throat swab was, however, not performed. Poor visual acuity from diabetic retinopathy necessitated close proximity of the patient’s nasophrynx to the cap during bag exchanges, and her sterile technique in general was substandard. She was admitted a month later with a further episode of H. influenzae peritonitis, which subsided quickly with intraperitoneal cephalothin and gentamicin. The following month, peritonitis due to the same organism recurred once more, and after microbiological advice she was treated with intraperitoneal amoxycillin (100 mg per 2-litre bag) and oral ciprofloxacin (250 mg b.d.). Again the peritonitis resolved quickly, and like the first two episodes there was no clinical evidence of infection elsewhere and no bacteraemia detected. The long-term outcome of the latter antibiotic regimen could not be assessed because 1 month later the patient accidentally removed the Tenckhoff catheter. She underwent a laparoscopy with the intention of replacing the catheter, but the peritoneal cavity was found to be so severely scarred that safe insertion would have been impossible and viability for

© 1997 European Renal Association–European Dialysis and Transplant Association

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adequate dialysis doubtful, so she was switched to haemodialysis.

Discussion Haemophilus influenzae is a rare causative agent of CAPD peritonitis. A literature search showed only two published case reports in this setting [1,2] although there have been other reports of primary haemophilus peritonitis in children [3 ] and adults with ascites [4 ]. Neither relapsing peritonitis nor rapid peritoneal sclerosis were features in the two case reports of CAPD peritonitis. The cause of the frequent relapses in this patient remains uncertain, but her previous pattern of behaviour suggests that poor compliance with self administration of the antibiotics could have been a factor. Nevertheless, on each occasion the dialysate had completely and rapidly cleared with the combination antibiotic therapy before the patient was discharged from hospital. An alternative explanation is that H. influenzae colonized the Tenckhoff catheter to cause the recurrent infections. The poor outcome in this patient also raises the question of the most appropriate antibiotic regimen. The 2 weeks of combination intra-

C. G. Chew et al.

peritoneal cephalothin and gentamicin was inadequate, and the damage may have already been established by the time a combination of amoxycillin and ciprofloxacin was initiated. Maxwell et al. [2 ] successfully treated a patient with a similar infection with intravenous cefotaxime followed by oral ciprofloxacin until the fever subsided. Ferrari and Dasgupta [1 ] treated their patient with gentamicin and then ampicillin with a good result. Alternatively, our experience suggests that infection from this organism confers a poor prognosis and perhaps early removal of the Tenckhoff catheter may have been necessary to preserve the integrity of the peritoneal membrane.

References 1. Ferrari R, Dasgupta MK. A case of CAPD peritonitis due to Haemophilus influenzae. Perit Dial Int 1993; 13 (4): 323–324 2. Maxwell PH, Abbott J, Koffman CG. Haemophilus influenzae as a rare cause of CAPD peritonitis. J Infect 1993; 26( 3): 340–341 3. Chang MJ, Cantori G. Primary peritonitis due to Haemophilus influenzae type b in a previously healthy child. J Clin Microbiol 1983; 18 (3): 725–726 4. Stephens CG, Meadows JG, Kerkering TM et al. Spontaneous peritonitis due to Haemophilus influenzae in an adult. Gastroenterology 1979; 77( 5): 1088–1090 Received for publication: 16.12.96 Accepted: 18.12.96