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Management of Culture-negative Peritonitis

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Dr Sandeep Mahajan, New Delhi    27 December 2018

  • Culture-negative peritonitis (CNP) - Dialysate effluent culture is negative but clinical signs and symptoms are otherwise consistent with peritonitis.
  • Peritonitis is diagnosed if ≥2 of the following are present: Consistent clinical features (abdominal pain or cloudy effluent); Peritoneal fluid white count >100 cells/mm3 (after dwell time of at least 2 hours) and neutrophils ≥50%; Positive effluent culture.
  • PDF culture techniques - Recommend blood-culture bottle as preferred technique for bacterial culture of PD effluent; Suggest that sampling and culture methods be reviewed and improved if more than 15% of peritonitis episodes are culture-negative.
  • CNP treatment guidelines - Suggest that negative effluent cultures warrant a repeat dialysis effluent WBC count with differential; If resolving at day 3, discontinuing aminoglycoside therapy and continuing treatment with Gram-positive coverage for 2 weeks is suggested; If not resolving at day 3, special culture techniques should be considered for isolation of unusual organisms; Duration of therapy 2 weeks if responsive (most are Gram-positive); Suboptimal response at day 5: treat as refractory peritonitis.
  • CNP is common in our country. There is an urgent need to adopt better culture techniques.
  • It is usually caused by Gram-negative bacteria resistant to cephalosporins and associated with poor outcomes.
  • CNP - Our protocol: Empirical treatment with IP vancomycin and amikacin (depends on previous exposure); Monitor response; Indication of response: PDF clearing up in 3 days, >50% drop in TLC and subsidence of fever and abdominal pain; If poor response at day 3: Step up the potency (add meropenem), re-culture PDF, look for TB/fungus; If response positive: Duration of therapy 21 days.
  • Close monitoring of clinical and peritoneal cellular response is essential. Duration of therapy for 21 days should be recommended.

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