The empiric therapy of PD-associated Peritonitis, according ISPD guidelines, must encompass 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. Italian Society of Nephrology guidelines state that intraperitoneal (IP) administration of antibiotic agents is the most effective treatment and the intermittent administration may be preferred to continuous administration of antibiotic agents in PD- associated peritonitis.
A 65‑year‑old Caucasian patient, suffering from autosomal dominant polycystic kidney disease, on chronic PD, was admitted to hospital for signs and symptoms of peritonitis (fever, abdominal pain, cloudy PD fluid effluent, a cell count of 9950/ml). He was started on IP cefazolin and tobramicine and IV ciprofloxacin, but in the next 72 h he worsened vomiting and abdominal pain. Abdominal CT scan [Figure 1] showed the presence in the bowels of significant fluid with intense gaseous component. The PD fluid culture was confirmed to be ESBL secreting Pseudomonas aeruginosa. 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. We observed a dramatic clinical improvement in the next 24 hours with disappearance of abdominal pain and vomiting and recovery of feeding. Having later known the result of the susceptibility pattern, positive for meropenem (minimum inhibitory concentration 0.25), 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.
The guidelines of International Society for PD state that empiric antibiotic therapy must cover all serious pathogens that are likely to be present. In Italy the menace of ESBL peritonitis is becoming increasingly common. ESBL-producer bacterial pathogens are frequently insensitive to a first-generation cephalosporins or aminoglycosides. Following this report we highlight on the need for studies on the efficacy of meropenem in ESBL peritonitis and the best route of administration (IP or parenteral).
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