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Kidney International (2015) 88, 1455; doi:10.1038/ki.2015.79
Polymicrobial peritonitis in a peritoneal dialysis
patient
A. Laurain1, N. Degand2, C. Raffaelli3 and Olivier Moranne1
1
Service de Néphrologie-Dialyse-Transplantation, Centre Hospitalier Universitaire Pasteur, Nice, France; 2Service de Bactériologie, Centre
Hospitalier Universitaire Pasteur, Nice, France and 3Service de Radiologie, Centre Hospitalier Universitaire de Nice, Nice, France
Correspondence: Olivier Moranne, Service de Néphrologie-Dialyse-Transplantation, Centre Hospitalier Universitaire Pasteur, 30 Avenue de la
Voie Romaine, Nice 06100, France. E-mail: moranne.o@chu-nice.fr
Figure 1 | Bag of dialysate fluid. Brown dialysate fluid
secondary to colic perforation.
A 95-year-old man with end stage kidney disease on
continuous ambulatory peritoneal dialysis (CAPD) was
admitted to the hospital for abdominal pain and diarrhea.
Physical examination was notable for hypotension (BP
77/42 mm Hg), a hypothermia (35°5C), and diffuse abdom-
inal pain. Laboratory investigations revealed leukocytosis
(15 × 109/l neutrophils), normal liver enzymes, and elevated
C-reactive protein (276 mg/l). Dialysate fluid was turbid and
dirty and bacteriological analysis revealed high leukocyte
count (3000 leukocytes/mm3) with 86% neutrophils. Perito-
neal fluid cultures revealed Clostridium perfringens. Blood
cultures and stool examination were negative. Initial treat-
ment consisted of intraperitoneal piperacillin and cefazolin.
On the basis of antibiotic susceptibility testing intraperitoneal
piperacillin was continued and intravenous metronidazole
was administered with clinical improvement and negative
Kidney International (2015) 88, 1455
nephrology image
Figure 2 | Abdominal computed tomography with contrast
media. Computed tomography with contrast media (LIGHT
SPEED PRO 32, General Electric, Milwaukee, USA). It shows
intraperitoneal liquid (*) and gas along left colon (arrow).
dialysis fluid cultures. Ten days later, brown dialysate fluid
(Figure 1) was seen with positive cultures, this time with
Acinetobacter junii and Enterococcus faecium. An abdominal
computed tomography scan performed showed a faecal
peritonitis with colic perforation (Figure 2). The patient was
not felt to be a surgical candidate on account of his poor
candidacy for major abdominal surgery. Despite resuscitation
and antibiotics, the patient died.
Polymicrobial peritonitis or specific bacteria such as
Clostridium perfringens may suggest diverticulitis and/or bowel
perforation in CAPD patients, and the diagnosis should be
confirmed with appropriate imaging studies. The incidence of
bowel perforation is 1–10% and mortality can be high, up to
46%. Diverticular disease and catheter perforation are the usual
causes. Although some cases may be conservatively managed,
surgical intervention is usually the only corrective therapy.
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