The guidelines of ISPD state that the selection of empiric antibiotics must cover all serious pathogens that are likely to be present, through a first-generation cephalosporin, such as cefazolin or cephalothin, with a second drug for broader Gram-negative coverage (including coverage for Pseudomonas) such as aminoglycoside, ceftazidime, cefepime, or carbapenem. The guidelines of Italian Society of Nephrology state that intra-peritoneal (IP) administration of antibiotic agents is the most effective treatment of PD peritonitis; intermittent administration may be preferred to continuous administration of antibiotic agents in PD peritonitis.
A 65-year-old Caucasian patient, suffering from ADPK, on chronic PD, was admitted to hospital for signs and symptoms of peritonitis. He was started on IP cefazolin and tobramicine and IV ciprofloxacin, but in the next 72 h he worsened vomiting and abdominal pain.AbdomenCTscan showed the presence in the bowels of significant fluid with intense gaseous component (Figure). The PD fluid culture was confirmed to be Pseudomonas Aeruginosa-secreting ESBL.
Due to the severe clinical status, not having yet of susceptibility, we changed the empiric therapy starting intravenous meropenem 500 mg every 8 h a day. The next 24 h, we observed a dramatic clinical improvement with disappearance of abdominal pain and vomiting and recovery of feeding. Having later known the result of the susceptibility pattern, positive for meropenem we began IP therapy with this drug (500 mg/2 L). The antibiotic was continued for 2 weeks and a repeat PD fluid analysis showed a normal cell count and sterile culture.
In Italy the menace of ESBL peritonitis is becoming increasingly common. We stress the need for studies on the efficacy of meropenem in ESBL peritonitis and the best route of administration (IP or parenteral), as well as the need for a revision of the ISPD recommendations, incorporating suggestions for ESBL peritonitis
