Vancomycin flushing reaction after intraperitoneal vancomycin: A case report

Vancomycin has been reported to cause vancomycin flushing reaction (VFR), a hypersensitivity reaction that mostly occurs after intravenous administration. The incidence of VFR in a patient receiving intraperitoneal vancomycin is rare. We report a case of a female peritoneal dialysis (PD) patient with a PD-related peritonitis who developed VFR after intraperitoneal administration of 2000 mg vancomycin. Seventy-five minutes after instillation, she developed flushing, a pruritic erythema on the upper body and swelling of the lips. Blood results revealed a vancomycin plasma concentration of 54.8 mg/L and a normal tryptase level. During a relapse of her PD-related peritonitis, vancomycin was successfully reintroduced in a 50% reduced dose. No symptoms of VFR developed, and the corresponding vancomycin plasma concentration was 33.6 mg/L. Intraperitoneal treatment was continued with 500 mg vancomycin every 2-3 days with frequently measured, adequate trough levels ranging from 15-22 mg/L. This case illustrates the risk factors for the development of VFR after intraperitoneal administration of vancomycin, namely a high and concentrated loading dose together with a low body weight, a fast peritoneal transport state and peritonitis. Reintroduction of vancomycin after occurrence of VFR is safe, but a lower loading dose or a slower instillation rate is recommended.

Clinical characteristics and outcomes of peritoneal dialysis (PD)-related peritonitis after colonoscopy

Colonoscopy is known to be associated with peritonitis in peritoneal dialysis (PD) patients. Antibiotic prophylaxis is recommended before colonoscopy. This study aims to investigate the clinical characteristics and outcomes of patients with PD-related peritonitis after colonoscopy. PD patients who were followed up in Pamela Youde Nethersole Eastern Hospital, with colonoscopy done from 1 January 2009 to 31 December 2019, were included for record review retrospectively. During this period, 74 patients underwent 115 colonoscopies. Fourteen patients (12.2%) developed PD-related peritonitis within 1 week after colonoscopy. There was no statistically significant difference in mean age, PD vintage, PD modality and history of PD-related peritonitis between patients with or without colonoscopy-related peritonitis. Polypectomy was more common in patients who developed peritonitis (78.6%) compared to those without peritonitis (35.6%) (p = 0.006). Ten of the 14 PD patients who had colonoscopy-related peritonitis responded to medical treatment while 4 patients required PD catheter removal. Two patients converted to maintenance haemodialysis and two died. Only 33% of Gram-negative bacteria isolated were sensitive to intravenous cefuroxime which was given as prophylactic antibiotic before colonoscopy. In conclusion, the overall risk of PD patients developing peritonitis post colonoscopy was 12.2%. Polypectomy was associated with higher risk of colonoscopy-related peritonitis. Large-scale study is needed to delineate effective antibiotic prophylaxis for colonoscopy-related peritonitis.

Peritoneal Expression of Membrane Complement Regulators Is Decreased in Peritoneal Dialysis Patients with Infected Peritonitis

In peritoneal dialysis (PD) patients, fungi and Pseudomonas aeruginosa are considered important causative microorganisms for peritonitis with poor prognosis. Our objective was to explore expressions of membrane complement (C) regulators (CRegs) and tissue injuries in the peritoneum of patients with PD-related peritonitis, including fungal and Pseudomonas aeruginosa peritonitis. In peritoneal biopsy tissues obtained at PD catheter removal, we investigated the severity of peritonitis-associated peritoneal injuries and the expression of CRegs, CD46, CD55, and CD59 against peritoneal tissues without any episode of peritonitis. In addition, we evaluated peritoneal injuries among fungal and Pseudomonas aeruginosa-peritonitis (P1) and Gram-positive bacterial peritonitis (P2). We also observed deposition of C activation products such as activated C and C5b-9 and measured sC5b-9 in the PD fluid of patients. As a result, the severity of peritoneal injuries correlated inversely with the expression of peritoneal CRegs. Peritoneal CReg expression in peritonitis was significantly reduced compared to no peritonitis. Peritoneal injuries were more severe in P1 than in P2. CReg expression was further decreased and C5b-9 further increased in P1 than in P2. In conclusion, severe peritoneal injuries due to fungal and Pseudomonas aeruginosa-peritonitis decreased CReg expression and increased deposition of activated C3 and C5b-9 in the peritoneum, suggesting that peritonitis, particularly fungal and Pseudomonas aeruginosa-peritonitis, might induce susceptibility to further peritoneal injuries due to excessive C activation.

Peritoneal Catheter Removal for Peritoneal Dialysis-Related Peritonitis Caused by Gram-Negative, Rod-Like Pseudomonas aeruginosa Infection During Antibiotic Therapy for Enterococcus faecalis

Peritonitis is a common complication of peritoneal dialysis (PD) and can result in PD catheter removal, permanent hemodialysis, and, potentially, death. Prediction and prevention of PD-related peritonitis are thus extremely important. In 2016, the International Society for Peritoneal Dialysis published guidelines for patients with peritonitis undergoing PD. The guidelines cover most cases of PD-related peritonitis caused by bacteria and include clear indications for catheter removal. However, difficulties often arise when deciding the timing of catheter removal. When multiple enteric organisms are identified in a culture of dialysis effluent, peritonitis may be caused by intra-abdominal pathology, which is associated with substantial mortality. In such cases, catheter removal is considered. In this report, we describe a case in which, during antibiotic therapy for PD-related peritonitis due to Enterococcus faecalis alone, the patient developed a relapse of peritonitis caused by a newly detected Gram-negative, rod-like Pseudomonas aeruginosa. He required catheter removal because of the possibility of peritonitis recurrence. Although additional study is required, early catheter removal may be effective when a new organism is detected during antibiotic therapy for PD-related peritonitis caused by an organism not meeting the definition of refractory peritonitis.

Brucella Peritonitis in a Patient on Peritoneal Dialysis: Case Report and Literature Review

Peritonitis is the most common complication in patients undergoing peritoneal dialysis (PD). Peritoneal dialysis-related peritonitis caused by Brucella species has been reported in only 7 patients before. Here, we report a further case of Brucella peritonitis. This patient was successfully treated with both intraperitoneal and prolonged oral antibiotics, without removal of the PD catheter. We review relevant literature and make recommendations for the diagnosis and treatment of Brucella PD-related peritonitis from the cumulative published clinical experience.

Intraperitoneal Meropenem for Polymicrobial Peritoneal Dialysis-Related Peritonitis

With the current rise in multiresistant gram-negative bacteria, carbapenems are more frequently used. Surprisingly, limited data exist on the pharmacokinetics of meropenem in peritoneal dialysis (PD)-related peritonitis. We report on the pharmacokinetics of repeated intraperitoneal (IP) meropenem during 21 days as treatment for polymicrobial multiresistent PD-related peritonitis.Our current report supports daily doses of 125 mg/L intraperitoneal meropenem in all bags as an effective and safe modality in the treatment of PD-associated peritonitis with multiresistant microorganisms. No signs of over- or underdosing were found based on serial drug concentration measurements at fixed time points up to 21 days.