A 49-year-old woman had been
diagnosed as having diabetes mellitus for 15 years and
end-stage renal disease for 2 years. She started to undergo
intermittent hemodialysis for the first 6 months, which was
subsequently switched to peritoneal dialysis (PD) after
receipt of adequate education and training for PD. She ever
suffered from several episodes of bacterial peritonitis for
which she received courses of complete antibiotic therapy
without complication. The day before she came back to the
monthly PD clinic, she experienced a low-grade fever and mild
abdominal pain. The effluent became cloudy, although the
catheter exit site was clean without erythematous skin change
or discharge. The results of laboratory tests on the day of PD
clinic were also suggestive of peritonitis (please see the
laboratory result), and vancomycin and a third-generation
cephalosporin were begun empirically. A few days later, she
was free of symptoms and the effluent became clear. However, a
new fever and abdominal pain developed and the effluent became
cloudy two weeks after she completed the previous course of
antibiotic treatment. The results of laboratory tests were
suggestive of recurrent peritonitis; dialysate effluent
contained 150 white blood cells/mm3 and 70% of the white blood
cells were polymorphonuclear neutrophils. Despite therapy with
vancomycin and a third-generation cephalosporin, high fever,
abdominal pain and presence of cloudy effluent persisted.
Meanwhile, the oral hypoglycemic agents failed to effectively
control her blood glucose at the usually prescribed doses. She
also exhibited chills, tachycardia and peripheral coldness.
Under the impression of uncontrolled PD-related peritonitis
and sepsis, she was admitted for further management.
< Laboratory and Image
Study >
1. CBC and differential count
Day after admission |
WBC K/μL |
Hgb g/dL |
Hct % |
Plt K/μL |
Band % |
Seg % |
Eos % |
Lym % |
PD clinic |
9.98 |
10.3 |
30.5 |
460 |
0 |
88 |
0.2 |
2.5 |
Admission day 1 |
15.54 |
9.6 |
28.8 |
470 |
0 |
92 |
3.6 |
2.5 |
Admission day 3 |
10.98 |
9.8 |
29.8 |
440 |
0 |
87 |
4.0 |
2.2 |
Admission day 7 |
9.03 |
10.1 |
30.7 |
460 |
0 |
82 |
2.0 |
2.3 |
2.
Biochemistry
Day after admission |
BUN mg/dl |
Cre mg/dl |
Na mmol/l |
K mmol/l |
GOT U/l |
PD clinic |
75 |
8.5 |
141 |
4.8 |
29 |
Admission day 3 |
77 |
8.3 |
138 |
4.6 |
30 |
3. Tests for
Dialysate
Day after admission |
appearance |
WBC count (/mm3) |
PMN % |
Gram stain |
Bacterial culture |
Fungus culture
|
PD clinic |
cloudy |
220 |
70 |
+ |
MSSA |
- |
Admission day 1 |
cloudy |
365 |
80 |
yeast-like organism |
- |
Candida albicans |
Admission day 5 |
mildly cloudy |
150 |
69 |
- |
- |
- |
Admission day 7 |
clear |
101 |
55 |
- |
- |
- | Note:
MSSA: methicillin-resistant Staphylococcus aureus
4. Blood culture Admission day 1:
bacterial: negative; C. albicans: positive
5. CXR: mildly enlarged heart size and
clear lung fields
< Course and Treatment
>
On admission, she was empirically
treated with intraperitoneal and intravenous vancomycin and a
third-generation cephalosporin. Fluconazole 200 mg was
administered by intraperitoneal as well as intravenous route.
After the culture results were available that grew C.
albicans, anti-bacterial agents were discontinued and
fluconazole was continued based on the microbiological
susceptibility. PD catheter was removed and she was placed on
intermittent hemodialysis. After two weeks of intravenous
fluconazole, the patient was afebrile and was discharged with
oral fluconazole for two more weeks.
< 病例分析
>
Peritoneal dialysis (PD)
peritonitis是在PD病人非常常見的併發症。然而大多PD peritonitis
是源自細菌感染,相對而言,黴菌性PD peritonitis 則不常見。當PD病患出現以下三項臨床表現時,必須要懷疑有PD
peritonitis: 發燒、腹痛及混濁的透析液。但是發燒、腹痛在成年病患並不是一定會出現,而混濁的透析液則是 PD
peritonitis 一定會出現的表現。當懷疑一位病患有PD
peritonitis時,除了必要的病史及理學檢查外,還必須要立即採取透析液做Gram stain、cell count
及微生物的培養。當一位PD病患的透析液中發現: >100 white blood cells/mm3
及 > 50% 的 polymorphonuclear neutrophils 時,就確定此病患有PD peritonitis。若是黴菌性PD
peritonitis,則偶爾可在透析液中發現 eosinophil 比例升高。有時即使確有PD peritonitis,但Gram stain還是可能呈現陰性,儘管如此
Gram stain 仍然一定要做,因為
Gram stain 不只可以篩檢細菌,還可篩檢是否有黴菌的存在。由於黴菌性PD peritonitis 的高死亡率及須立即拔管,所以
Gram stain
可爭取時效,而不需等待培養報告。因此當懷疑 PD peritonitis 時,Gram stain 是所有病患都必要的檢查。當懷疑 PD
peritonitis 時,即使 Gram stain
呈現陰性,但還是要先針對革蘭性陰性及陽性菌給予經驗性抗生素。至於抗黴菌藥物,由於發生率不高,因此並不是 PD
peritonitis
的第一線藥物。
黴菌性 PD peritonitis
常發生在病患之前有過抗細菌性抗生素的療程,或本身的疾病使患者易發生黴菌性PD peritonitis,如 diabetes
mellitus 等。對於黴菌性 PD peritonitis,由於發生數不如細菌性 PD
peritonitis,所以至今並未有大規模的前瞻性研究,文獻多局限於病例報告或回顧性研究,因此經驗不多,而治療以專家經驗為主。根據
International Society for Peritoneal Dialysis’ 2005 Guideline
Update,初期治療可以考慮使用腹內注射 amphotericin B 直到得到培養結果,因為 amphotericin
B 的腎毒性較大,雖然PD病患已接受透析,但仍需盡量保存殘存腎功能,且會造成疼痛及有產生 chemical
peritonitis 的疑慮,因此也有文獻指出優先使用 fluconazole 或 voriconazole,而不建議
amphotericin B。藥物治療同時必須伴隨透析管路的移除。腹內注射及靜脈注射藥物劑量可考慮200
mg,而之後可換成每天口服 flucytosine 1000 mg 及 fluconazole 100至200
mg,共十天。但也有文獻建議至少2至4星期。
在黴菌性 PD peritonitis
的治療除了抗黴菌藥物外,還包括管路的移除才算完整。表一則亦列出其他需移除管路的情況。一旦確認是黴菌性 PD
peritonitis
時,就必須要將透析管移除,由於死亡率高達25%,因此並不需為了保存管路而冒險,主要的考量除了高死亡率之外,也在於盡量保存腹膜功能。至於管路移除之後,需隔多久才可再植入新管,目前並無定論。經驗上,在拔除舊管後,至少需等待2至3星期的時間。
Table 1. Indications for Catheter Removal for
Peritoneal Dialysis-Related Infections
Refractory peritonitis Relapsing peritonitis
Refractory exit-site and tunnel infection Fungal
peritonitis Consider catheter removal if not responding to
therapy Mycobacterial peritonitis Multiple enteric
organisms
< References
>
- Peritoneal Dialysis International, Vol. 25, pp.
107–131, 2005.
- Comprehensive Clinical Nephrology 2nd edition
|