COVID 19 Pneumonia and a Rare Form of Fungal Peritonitis in a Patient Survivor on Peritoneal Dialysis

Abstract Peritoneal dialysis (PD) related peritonitis is usually caused by bacteria, but viruses and fungi could also affect the peritoneal membrane and cause cloudy effluent with negative bacterial cultures. We present a case of a PD patient who survived fungal peritonitis caused by Geotrichum klebahnii (March 2015) and COVID-19 pneumonia (April 2021) with peritonitis probably caused by the SARS-CoV-2 virus. The fungal peritonitis followed one episode of exit-site infection and two episodes of bacterial peritonitis treated with a wide-spectrum antibiotic. The patient’s PD catheter was removed immediately upon the diagnosis of fungal peritonitis, and an antifungal treatment was continued for 3 weeks after catheter removal. The new peritoneal catheter was reinserted 8 weeks after complete resolution of peritonitis, and the patient continued treatment with PD. The patient developed severe Covid-19 pneumonia with a sudden appearance of cloudy peritoneal effluent. There was no bacterial or fungal growth on the effluent culture. A PCR test for SARS-CoV-2 in peritoneal effluent was not performed. The peritoneal effluent became transparent with the resolution of the severe symptoms of Covid-19 pneumonia.

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Fungal Peritonitis in Peritoneal Dialysis Patients: Successful Prophylaxis with Fluconazole, as Demonstrated by Prospective Randomized Control Trial

Peritoneal Dialysis International ◽

10.3747/pdi.2008.00189 ◽

2010 ◽

Vol 30 (6) ◽

pp. 619-625 ◽

Cited By ~ 33

Author(s):

César Restrepo ◽

Jose Chacon ◽

Gilberto Manjarres

Keyword(s):

Peritoneal Dialysis ◽

Chronic Kidney Disease Stage ◽

Disease Stage ◽

Oral Antibiotic ◽

Peritoneal Fibrosis ◽

Exit Site Infection ◽

Fungal Peritonitis ◽

Oral Fluconazole ◽

Bacterial Peritonitis ◽

Significant Difference

ObjectivesTo determine whether oral administration of the antifungal fluconazole during the entire period of treatment of bacterial peritonitis (BP), exit-site infection (ESI), or tunnel infection (TI) prevents later appearance of fungal peritonitis (called secondary) in patients with chronic kidney disease stage 5 in a peritoneal dialysis (PD) program.Patients and MethodsAll patients treated in the PD program in RTS Ltda Sucursal Caldas, during the period 1 June 2004 to 30 October 2007 were screened. Patients that had infectious bacterial complications (BP, ESI, TI) were included in a prospective randomized trial to receive or not receive oral fluconazole (200 mg every 48 hours) throughout the time period required by the administration of therapeutic antibiotics via any route. It was evaluated whether the fungal peritonitis complication appeared within 30 – 150 days following the end of antibacterial treatment. Based on local results, the sample size necessary to obtain statistically significant results was determined to be 434 episodes of peritonitis.ResultsThe 434 episodes of peritonitis presented between the previously specified dates and during this same period there were 174 ESI or TI, of which only 52 received oral antibiotic treatment. Information in relation to consumption of antibiotics for purposes other than BP, ESI, and TI was not reliable and thus this variable was excluded. Among the episodes of peritonitis, 402 (92.6%) were of bacterial origin and 32 (7.3%) were mycotic, mainly Candida species [30 (93.75%)]. Of the fungal peritonitis, 14 (43.73%) were primary (without prior use of antibiotics) and 18 (56.25%) were secondary. In the group of patients that received prophylaxis with fluconazole (210 for BP and 26 for ESI or TI), only 3 occurrences of fungal peritonitis were observed within 30 – 150 days of its administration, which is opposite to the group without prophylaxis (210 for BP and 26 for ESI or TI), in which 15 occurrences of fungal peritonitis were detected. Statistical analysis of the group of patients with BP found comparisons of the proportions of those receiving fluconazole (0.92%) or not (6.45%) presented a highly significant difference in favor of prophylaxis ( p = 0.0051, Z = 2.8021). Given that only 1 patient in each group with ESI or TI, with or without prophylaxis, presented the complication fungal peritonitis, it was concluded that this result was not statistically significant. During laparoscopic surgery attempting reintroduction of the peritoneal catheter, it was found that 11 patients had severe adhesions or peritoneal fibrosis leading to obliteration of the peritoneal cavity. In 19 patients, reintroduction of the catheter was possible and the patients returned to PD without consequence.ConclusionIn patients with bacterial peritonitis, administration of prophylactic oral fluconazole throughout the time they received antibiotics significantly prevented the appearance of secondary fungal peritonitis.

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One-Port Laparoscopic Technique for Placement of Tenckhoff Peritoneal Dialysis Catheters: Report of Seventy-Nine Procedures

Peritoneal Dialysis International ◽

10.1177/089686080802800613 ◽

2008 ◽

Vol 28 (6) ◽

pp. 622-625 ◽

Cited By ~ 15

Author(s):

Hossein Ashegh ◽

Jalal Rezaii ◽

Khalil Esfandiari ◽

Hassan Tavakoli ◽

Mehdi Abouzari ◽

...

Keyword(s):

Peritoneal Dialysis ◽

Rectus Sheath ◽

Laparoscopic Technique ◽

Exit Site ◽

Exit Site Infection ◽

Catheter Survival ◽

Catheter Migration ◽

Bacterial Peritonitis ◽

Port Site Hernia

Background Laparoscopic techniques for placement of peritoneal dialysis catheters are becoming increasingly popular. In this paper, we report the results of one-port laparoscopic placement of Tenckhoff catheters in 79 patients in our center. Method Videoscopic monitoring was performed via a port inserted in the left upper quadrant and the catheter was placed via a pull-apart sheath through an incision near the umbilicus. The tip and the deep cuff of the catheter were placed into the true pelvis (on the urinary bladder) and into the rectus sheath respectively. A subcutaneous tunnel was created and a point midway on the umbilico-crestal line was selected as the exit site of the catheter. Catheters were capped for 2 weeks before initiation of peritoneal dialysis. Mean duration of the operation was 25 minutes. Results Four patients died during the follow-up period, all due to other medical problems, and 4 patients underwent renal transplantation. During a 48-month follow-up, catheter-related complications were catheter migration (1.3%; month 1), dialysate leakage (1.3%; month 1), port-site hernia (3.8%; after 6 months), exit-site infection (2.5%; months 1 and 9), and bacterial peritonitis (2.5%; after 6 months). Catheter survival was 97.2% in our series. Conclusion We obtained a low complication rate and a high catheter survival rate with this one-port laparoscopic technique.

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Peritonitis and catheter exit-site infection in patients on peritoneal dialysis at home

Revista Latino-Americana de Enfermagem ◽

10.1590/0104-1169.0413.2630 ◽

2015 ◽

Vol 23 (5) ◽

pp. 902-909 ◽

Cited By ~ 2

Author(s):

Ana Cristina Freire Abud ◽

Luciana Kusumota ◽

Manoel Antônio dos Santos ◽

Flávia Fernanda Luchetti Rodrigues ◽

Marta Maria Coelho Damasceno ◽

...

Keyword(s):

Peritoneal Dialysis ◽

Descriptive Analysis ◽

Cross Sectional Study ◽

Site Infection ◽

Exit Site ◽

Peritoneal Catheter ◽

Cross Sectional ◽

Exit Site Infection ◽

Length Of Treatment ◽

At Home

Objective: to analyze the complications related to peritonitis and catheter exit-site infections, in patients on peritoneal dialysis at home.Method: quantitative and cross-sectional study, carried out with 90 patients on peritoneal dialysis at home, in a municipality in the Northeast region of Brazil. For data collection, it was used two structured scripts and consultation on medical records. Descriptive analysis and comparison tests among independent groups were used, considering p<0.05 as level of statistical significance.Results: by comparing the frequency of peritonitis and the length of treatment, it was found that patients over two years of peritoneal dialysis were more likely to develop peritonitis (X²=6.39; p=0.01). The number of episodes of peritoneal catheter exit-site infection showed association with the length of treatment (U=224,000; p=0.015).Conclusion: peritonitis and catheter exit-site infection are associated with the length of treatment.

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Persistent exit-site infection in peritoneal dialysis – An unrecognized window to abdominal viscera

Peritoneal Dialysis International ◽

10.1177/0896860820920134 ◽

2020 ◽

Vol 40 (5) ◽

pp. 513-514

Author(s):

Ana Teresa Domingos ◽

Anabela Malho Guedes ◽

Filipa Brito Mendes ◽

Joana Vidinha ◽

Idalecio Bernardo ◽

...

Keyword(s):

Peritoneal Dialysis ◽

Catheter Removal ◽

Exit Site ◽

Peritoneal Catheter ◽

Neoplastic Tissue ◽

Exit Site Infection ◽

Persistent Infections ◽

Well Differentiated ◽

Untreatable Pain ◽

Tomography Scan

Exit-site (ES) infection is a common complication in peritoneal dialysis (PD). Pseudomonas spp. is particularly difficult to treat, and catheter removal should be considered in persistent infections. The authors present a chronic ES infection resistant to directed antibiotic therapy in which catheter salvage was not possible. Removal was very difficult due to the presence of white sponge-like tissue with petrous consistency surrounding the catheter, all the way into the peritoneum. Histology revealed well-differentiated adenocarcinoma infiltrates. Abdominal computed tomography scan revealed a solid pancreatic (tail) lesion, nodular images on the greater epiploon, an adnexal lesion and a hepatic solid lesion, consistent with metastasis. The patient was referred for palliative care but maintained PD until untreatable pain and deterioration of general status aroused. Somewhere along the course of a chronic ES infection, the peritoneal catheter (and inflammation) was the metastatic path of an unknown pancreatic cancer, with neoplastic tissue reaching the skin. Catheter removal was crucial for diagnosis.

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Repeat exit site infection in peritoneal dialysis patient with polycythemia vera – a case report

BMC Infectious Diseases ◽

10.1186/s12879-021-06342-x ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Edyta Gołembiewska ◽

Kazimierz Ciechanowski

Keyword(s):

Pseudomonas Aeruginosa ◽

Peritoneal Dialysis ◽

Case Report ◽

Polycythemia Vera ◽

Significant Risk ◽

Renal Amyloidosis ◽

Site Infection ◽

Exit Site ◽

Exit Site Infection ◽

First Case

Abstract Background Infectious complications of peritoneal dialysis (PD) remain a common cause of catheter loss and discontinuation of PD. Exit site infection (ESI) constitutes a significant risk factor for PD-related peritonitis and determination of predisposing states is relevant. We here present a case of repeat ESI due to Pseudomonas aeruginosa in a PD patient with skin changes in the course of polycythemia vera (PV). Case presentation A 73-year-old PD patient with chronic kidney disease secondary to renal amyloidosis and ankylosing spondylitis, presented to the nephrology unit with signs of ESI. In 2006 he was diagnosed with PV and since then has was successfully treated with hydroxyurea; however, he reported recurrent episodes of developing skin nodules in the course of the disease. Exit site swab yielded Pseudomonas aeruginosa and the infection developed in the ulcerated PV nodule that appeared in exit site 2 weeks earlier. Patient was treated with intraperitoneal amikacin and oral ciprofloxacin, however, due to neurological complications, the treatment had to be interrupted and finally catheter was removed. Similar episode of ESI with Pseudomonas aeruginosa developed in the patient two years earlier and also required catheter removal. Conclusion This is the first case report demonstrating the development of ESI on the polycythemia vera skin lesion in this area. Skin manifestations of PV might be a predisposing factor to ESI in PD patients.

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Exit-Site Infection during Continuous and Cycling Peritoneal Dialysis in Children

Peritoneal Dialysis International ◽

10.1177/089686089001000108 ◽

1990 ◽

Vol 10 (1) ◽

pp. 31-35 ◽

Cited By ~ 18

Author(s):

Maurice Levy ◽

J. Williamson Balfe ◽

Dennis Geary ◽

Sue Fryer-Keene ◽

Robert Bannatyne

Keyword(s):

Peritoneal Dialysis ◽

Site Infection ◽

Exit Site ◽

Exit Site Infection ◽

Daily Dialysis ◽

Pseudomonas Species ◽

Before And After ◽

Species Being ◽

Catheter Replacement

A 10-year retrospective review of pediatric patients on peritoneal dialysis showed that 50 of 83 had 132 episodes of exit-site infection (ESI). Thirty-nine episodes were purulent. The most prevalent organism was Staphylococcus aureus. Staphylococcus epidermidis was also common, usually occurring in purulent infections. Gramnegative organisms were responsible for 23 ESls, with Pseudomonas species being the most common. Age, sex, concomitant primary disease type, length of training, dressing techniques, quality of daily dialysis technique, use of diapers, and pyelostomies did not affect the incidence of ESI. However, 40% of children with a skin infection from other sites had associated peritoneal catheter ESI. Thirty-eight episodes of ESI in 28 patients resulted in peritonitis; the main organisms involved were Staphylococcus and Pseudomonas species. Catheters were replaced in 13 patients with peritonitis, but there was no difference in the incidence of ESI before and after catheter replacement.

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P1198CATHETER-RELATED INFECTIONS DUE TO SERRATIA SPECIES IN PATIENTS RECEIVING PERITONEAL DIALYSIS

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfaa142.p1198 ◽

2020 ◽

Vol 35 (Supplement_3) ◽

Author(s):

Christy Au ◽

Jasper Chan ◽

Terence Yip ◽

Desmond Yap ◽

Daniel Tak Mao Chan

Keyword(s):

Peritoneal Dialysis ◽

Medical Therapy ◽

Chronic Haemodialysis ◽

Exit Site ◽

Exit Site Infection ◽

2Nd Generation ◽

Queen Mary Hospital ◽

Skin Abnormalities ◽

Tract Involvement ◽

Antibiotics Susceptibility

Abstract Background and Aims Serratia species can cause catheter-related infections in peritoneal dialysis (PD) patients but data on this clinical entity remains limited. This study aims to investigate the clinical characteristics, antibiotics susceptibility/resistance profiles and treatment outcomes of Serratia catheter-related infections in PD patients. Method We retrospectively reviewed all PD patients who were followed up at Queen Mary Hospital and Tung Wah Hospital, Hong Kong between 2004 to 2017. Patients with Serratia exit site infection (ESI) or peritonitis were included for analysis. Results One hundred and seventy-three patients with Serratia catheter-related infections were included. 161 patients had ESI, of which 10 (6.2%) progressed to tunnel tract involvement and 11 (6.8%) developed PD peritonitis. Skin abnormalities surrounding the exit site were present in 58 patients (36%), and 40 patients (24.8%) were hospitalized within 1 month prior to Serratia ESI. 142 patients (88.2%) with ESI responded to medical therapy alone, and repeat ESI occurred in 56 patients (34.7%) at a median of 12 months. Twenty-two patients had Serratia peritonitis, which accounted for 1% of peritonitis during the study period. Concomitant intra-abdominal pathologies were detected in 12 patients (54.5%). Ten patients (45.5%) responded to medical treatment while the remaining 12 (54.5%) required catheter removal. Nine patients (36.4%) failed PD resumption and switched to chronic haemodialysis. Repeat peritonitis occurred in two patients at 2 months and 3 years after the initial episode respectively. While Serratia species in PD patients are generally susceptible to aminoglycosides, carboxy-/ureido-penicillins and carbapenems, they exhibit substantial rates of resistance to ampicillin, and 1st- and 2nd-generation cephalosporins. Conclusion Serratia ESI responds favourably to medical therapy and seldom progresses to tunnel tract infection or peritonitis. Serratia peritonitis is associated with considerable risk of catheter loss and peritoneal failure.

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Modification of the percutaneous approach to peritoneal dialysis catheter placement under peritoneoscopic visualization: clinical results in 78 patients.

Journal of the American Society of Nephrology ◽

10.1681/asn.v31103 ◽

1992 ◽

Vol 3 (1) ◽

pp. 103-107

Author(s):

N S Nahman ◽

D F Middendorf ◽

W H Bay ◽

R McElligott ◽

S Powell ◽

...

Keyword(s):

Peritoneal Dialysis ◽

Catheter Placement ◽

Seldinger Technique ◽

First Episode ◽

Dialysis Access ◽

Peritoneal Dialysis Catheter ◽

Exit Site ◽

Exit Site Infection ◽

Percutaneous Approach ◽

Tunnel Infection

The placement of percutaneous peritoneal dialysis catheters under direct peritoneoscopic visualization is a relatively new technique for establishing peritoneal dialysis access. In this study, in which a modification of the Seldinger technique was used to facilitate the placement of the peritoneoscope, the experience with 82 consecutive catheterization procedures in 78 patients is reported. In 2 (2.4%) of 82 catheterization procedures, we were unable to enter the peritoneal cavity but experienced no other complications unique to the percutaneous approach. Of the 80 successful catheterization procedures, 76 represented first-time catheter placement and constituted a population subjected to life-table analysis examining catheter survival rates, the time to first cutaneous exit site or s.c. tunnel infection, and the time to first episode of peritonitis. After a follow-up period of 50.1 patient yr, 11 catheters were lost because of catheter dysfunction. Other clinical complications included peritoneal fluid leaks at the cutaneous exit site in 11 instances (0.22/patient yr), cutaneous exit site infection in 7 instances (0.14/patient yr), s.c. tunnel infection in 2 instances (0.04/patient yr), and 34 episodes of peritonitis (0.68/patient yr). The results of this study demonstrate that the suggested modification of the percutaneous placement of peritoneal dialysis catheters, under peritoneoscopic visualization, is a viable method for establishing peritoneal access.

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Selective Infracolic Omentecomy and Fixation Reduces Complications after Laparoscopic Assisted Peritoneal Dialysis Catheter Placement

10.33169/surg.gsoaoj-i-103 ◽

2018 ◽

Vol I (1) ◽

pp. 06-11

Author(s):

Andries Ryckx

Keyword(s):

Peritoneal Dialysis ◽

Catheter Placement ◽

P Value ◽

Peritoneal Dialysis Catheter ◽

Dialysis Catheter ◽

Exit Site ◽

Exit Site Infection ◽

Catheter Survival ◽

Catheter Obstruction ◽

Infracolic Omentectomy

Introduction Peritoneal dialysis (PD) as a treatment for patients with end-stage renal disease (ESRD) provides a competitive alternative to hemodialysis (HD). Long-term catheter survival remains challenging and techniques are not standardized. Advanced laparoscopic placement with fixation and omentectomy might increase catheter survival. The goal of our study was to evaluate if selective infracolic omentectomy and fixation reduced complications after CAPD catheter placement. Materials and Methods A prospective database of patients with CAPD catheter placement from March 2004 to March 2015 was analyzed. All procedures were performed laparoscopically assisted and under general anesthesia by a single surgeon. 78 patients were included, there were no exclusion criteria. Statistical analysis was performed with SPSS. Fisher exact test and log-rank test with calculation of P-value was executed. P-value of <0.05 was considered significant. Results Of the 78 patients who underwent catheter placement, 53 (68%) were males and 25 (32%) were females. The mean age was 54 (ranged from 13 to 88 years). Selective infracolic omentectomy was performed in 32 patients if the momentum reached beyond the promontory. Non-resorbable sutures to fix the catheter were applied in 33 patients. The average duration of peritoneal dialysis was 21 months (range from ten days to 84 months). Omentectomy significantly reduced the incidence of catheter obstruction (3 vs. 11%, P=0.028) but not of catheter dislocation (19 vs. 30%, P=0.101). Omentectomy did not significantly increase the incidence of peritonitis (22 vs. 31%,P=0.133) or exit-site infection (16vs 17%, P=0.238). Catheter fixation with non-resorbable sutures reduced catheter dislocation (21 vs. 23%, P=0.226) and catheter obstruction( 12 vs.17%,P=0.223) with a significant reduction of peritonitis (15 vs. 29%, P=0.044) and no effect on exit-site infection (15 vs. 17%,P=0.251). Conclusion Laparoscopic PD catheter placement with selective omentectomy and fixation of the catheter to the abdominal wall is safe and feasible and leads to fewer complications. Key words: peritoneal, dialysis, catheter, complications, laparoscopy, omentectomy.

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The Effect of Exit-Site Antibacterial Honey versus Nasal Mupirocin Prophylaxis on the Microbiology and Outcomes of Peritoneal Dialysis-Associated Peritonitis and Exit-Site Infections: A Sub-Study of the Honeypot Trial

Peritoneal Dialysis International ◽

10.3747/pdi.2014.00206 ◽

2015 ◽

Vol 35 (7) ◽

pp. 712-721 ◽

Cited By ~ 8

Author(s):

Lei Zhang ◽

Sunil V. Badve ◽

Elaine M. Pascoe ◽

Elaine Beller ◽

Alan Cass ◽

...

Keyword(s):

Peritoneal Dialysis ◽

Site Infection ◽

Control Groups ◽

Exit Site ◽

Exit Site Infection ◽

Gram Negative ◽

Nasal Mupirocin ◽

And Control ◽

Technique Failure ◽

Culture Negative

Background The HONEYPOT study recently reported that daily exit-site application of antibacterial honey was not superior to nasal mupirocin prophylaxis for preventing overall peritoneal dialysis (PD)-related infection. This paper reports a secondary outcome analysis of the HONEYPOT study with respect to exit-site infection (ESI) and peritonitis microbiology, infectious hospitalization and technique failure. Methods A total of 371 PD patients were randomized to daily exit-site application of antibacterial honey plus usual exit-site care ( N = 186) or intranasal mupirocin prophylaxis (in nasal Staphylococcus aureus carriers only) plus usual exit-site care (control, N = 185). Groups were compared on rates of organism-specific ESI and peritonitis, peritonitis-and infection-associated hospitalization, and technique failure (PD withdrawal). Results The mean peritonitis rates in the honey and control groups were 0.41 (95% confidence interval [CI] 0.32 – 0.50) and 0.41 (95% CI 0.33 – 0.49) episodes per patient-year, respectively (incidence rate ratio [IRR] 1.01, 95% CI 0.75 – 1.35). When specific causative organisms were examined, no differences were observed between the groups for gram-positive (IRR 0.99, 95% CI 0.66 – 1.49), gram-negative (IRR 0.71, 95% CI 0.39 – 1.29), culture-negative (IRR 2.01, 95% CI 0.91 – 4.42), or polymicrobial peritonitis (IRR 1.08, 95% CI 0.36 – 3.20). Exit-site infection rates were 0.37 (95% CI 0.28 – 0.45) and 0.33 (95% CI 0.26 – 0.40) episodes per patient-year for the honey and control groups, respectively (IRR 1.12, 95% CI 0.81 – 1.53). No significant differences were observed between the groups for gram-positive (IRR 1.10, 95% CI 0.70 – 1.72), gram-negative (IRR: 0.85, 95% CI 0.46 – 1.58), culture-negative (IRR 1.88, 95% CI 0.67 – 5.29), or polymicrobial ESI (IRR 1.00, 95% CI 0.40 – 2.54). Times to first peritonitis-associated and first infection-associated hospitalization were similar in the honey and control groups. The rates of technique failure (PD withdrawal) due to PD-related infection were not significantly different between the groups. Conclusion Compared with standard nasal mupirocin prophylaxis, daily topical exit-site application of antibacterial honey resulted in comparable rates of organism-specific peritonitis and ESI, infection-associated hospitalization, and infection-associated technique failure in PD patients.

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