Peritonitis

Abstract

The first clinical case is that of a child with renal hypo-dysplasia and several nonrenal comorbidities and on peritoneal dialysis since the neonatal period. He underwent two abdominal interventions due to intestinal necrosis plus repeated peritoneal catheter replacements. At the age of 2 years, he experienced a methicillin-resistant Staphylococcus aureus (MRSA) peritonitis originated from an exit-site/tunnel infection caused by the same organism. Peritonitis was effectively cured with intraperitoneal vancomycin, while persistent and antibiotic-resistant exit-site and tunnel infection was treated with local debridement and curettage, unroofing of the subcutaneous tunnel, and extrusion and shaving of the external Dacron cuff of the catheter. In this small child, local, conservative surgery was performed as an alternative to catheter removal taking into account his history of repeated catheter replacements and high operative risk.

The second clinical case initially presented as an almost ordinary case of peritonitis in an apparently not-at-risk 4-year-old child who had been on peritoneal dialysis for 26 months. On day 3 of treatment, culture results showed that peritonitis was caused by a strain of Candida parapsilosis, whose occurrence and growth could have been facilitated by repeated, short courses of antibiotic treatment of recurrent urinary tract infections in a child with complex urinary tract abnormalities. After 2 days of treatment with fluconazole and no clinical improvement, the peritoneal catheter was removed, and fluconazole was replaced by caspofungin, by which the fungal infection was effectively treated. Serial determinations of 1-3-β-D-glucan in serum and peritoneal fluid, together with concomitant evaluation of clinical conditions and microbiology, were helpful to assess response to therapy and to optimize the timing of peritoneal catheter replacement.