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Peritonitis is a common complication of Peritoneal dialysis and can result in significant morbidity and occasionally requires change to hemodialysis modality for renal replacement therapy. Common organisms are gram positive organisms; however gram-negative organisms can contribute as well. One of the rare causes of PD Peritonitis is Neisseria Cinerea,a gram-negative organism which is a common commensal in nasal and oropharyngeal areas.
Case presentation
Our patient was a 78 -year-old female on continuous ambulatory peritoneal dialysis for the last three and half years, who developed abdominal pain and found to have peritonitis. According to the patient this is her first episode of peritonitis she had since starting dialysis. She denies any change in the technique and denied any irritation or discharge from catheter exit site. CT scan of abdomen was performed which did not show any acute abdomen. She had been following exit site cares religiously and examination of exit site do not have any discharge but there was slight tenderness.
Laboratory data revealed normal white blood count, low hemoglobin, and normal platelet count. Serum electrolytes were normal while blood urea nitrogen and creatinine were elevated, as expected. The peritoneal dialysate (PD) fluid analysis revealed a WBC count of 2997 cells/microL, with 51% predominant neutrophils. Peritoneal fluid Gram stain revealed 2+ WBC, and no organisms were seen.
The patient was started initially on empiric intraperitoneal vancomycin and cefipime. When PD fluid culture grew Neisseria cinerea, antibiotics were broadened to intraperitoneal ceftriaxone 2 gm IV q 24 hrs and Ciprofloxacin 500 mg PO q 24 hrs for double coverage of Neisseria species.
We did request sensitivities on the Neisseria cinerea, but they are not routinely run on this organism and will be a send out so expecting that it will take at least 1 week, if not more. Given the uncertainty of the resistance patterns for this particular Neisseria species, we continued double coverage until we have sensitivities. Also, we continued fungal prophylaxis with fluconazole for the duration of antibiotics. We decided that if she has clinical improvement with concurrent reflection of improvement in the peritoneal fluid on fluid analysis, we would plan to treat with intraperitoneal ceftriaxone and PO ciprofloxacin for total of 3 weeks. But if there is no improvement, then we will need to plan for removal of the peritoneal catheter.
Cell count decreased to 300 cells/microL after 48 hrs. Repeat cell count from the peritoneal fluid remained normal and repeat peritoneal fluid culture was negative and she completed both antibiotics for a total of 21 days and remained asymptomatic. On follow up, she did not have any further episodes of PD peritonitis since this event.
Take home points
Neisseria Cinerea is a common commensal in nasal and oropharyngeal secretions and can result in PD peritonitis.
Usually needs double antibiotic coverage with cephalosporin and macrolide.
Occasionally might need PD catheter removal if no response to antibiotics.
Recognize that fastidious organisms, such as Neisseria species, can cause culture-negative peritonitis and the lack of response to standard first-line therapy should alert clinicians to the possibility of these rare organisms causing peritonitis.
