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| Year : 2018 | Volume
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| Issue : 2 | Page : 466-469 |
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| Management of Salmonella peritonitis in a patient on peritoneal dialysis without catheter removal |
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Firas Fahad Al-Zahrani1, Hussain Al-Shahrani1, Ashwaq Al-Mohawes1, Abdullah Al-Hwiesh2, Abdusalam Noor2, Ibrahiem Saeed Abdulrahmn2
1 Department of Internal Medicine, Security Force Hospital, Dammam, Saudi Arabia
2 Department of Internal Medicine, Nephrology Division, King Fahd Hospital of the University, University of Dammam, Dammam, Saudi Arabia
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| Date of Web Publication | 10-Apr-2018 |
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 Abstract | | |
Peritoneal dialysis (PD)-associated peritonitis is an important contributor to morbidity and mortality; Gram-positive bacteria constitute the most frequent associated pathogens (45%–60%) followed by Gram-negative bacteria (25%–40%) and fungal infection (3%–6%). Salmonella peritonitis is an extremely rare cause of peritonitis (0.15%). Peritonitis attributed to Salmonella has been reported only in four cases. Herewith, we report a 68-year-old Sudanese female who presented to our PD unit with abdominal pain and diarrhea and was diagnosed to have Salmonella peritonitis. She was managed without catheter removal. To our knowledge, the association between Salmonella peritonitis due to Salmonella enteritidis in a patient on PD managed without catheter removal has been reported in only one case previously.
How to cite this article:
Al-Zahrani FF, Al-Shahrani H, Al-Mohawes A, Al-Hwiesh A, Noor A, Abdulrahmn IS. Management of Salmonella peritonitis in a patient on peritoneal dialysis without catheter removal. Saudi J Kidney Dis Transpl 2018;29:466-9 |
How to cite this URL:
Al-Zahrani FF, Al-Shahrani H, Al-Mohawes A, Al-Hwiesh A, Noor A, Abdulrahmn IS. Management of Salmonella peritonitis in a patient on peritoneal dialysis without catheter removal. Saudi J Kidney Dis Transpl [serial online] 2018 [cited 2022 Mar 7];29:466-9. Available from: https://www.sjkdt.org/text.asp?2018/29/2/466/229290 |
| Introduction | |  |
Bacteria of the genus Salmonella are highly adapted for growth in both humans and animals and cause a wide spectrum of disease. The growth of serotypes Salmonella typhi and Salmonella paratyphi is restricted to human hosts, in whom these organisms cause enteric (typhoid) fever. The remaining serotypes [nontyphoidal Salmonella (NTS)] can colonize the gastrointestinal tracts of a broad range of animals, including mammals, reptiles, birds, and insects and many serotypes are pathogenic to humans, in whom they cause gastroenteritis and can be associated with localized infections and/or bacteremia.[1] Salmonella infections invariably begin with ingestion of organisms, most commonly in contaminated food or water. The infectious dose is 103–106 colony-forming units. Worldwide, there are an estimated 22 million cases of enteric fever, with 200,000 deaths, annually. Herewith, we report a 68- year-old Sudanese female who presented to our peritoneal dialysis (PD) unit with abdominal pain and diarrhea and was diagnosed to have Salmonella peritonitis and was managed successfully without catheter removal.
| Case Report | | |
A 68-year-old Sudanese female was on continuous ambulatory PD (CAPD) for two years for end-stage renal disease secondary to hypertensive nephrosclerosis. She was receiving PD with three exchanges of two liters 1.36% dextrose, and the last fill volume was with two liters of icodextrin. The peritoneal equilibration test revealed a low transporter, and body surface area was 1.7 m2. She was doing well with regular follow-up at the PD unit with no exit-site infection or peritonitis. A week after she returned from Sudan, she developed diffuse abdominal pain, fever, vomiting, and watery diarrhea for three days. Physical examination revealed that the jugular venous pressure was not raised, blood pressure was 110/70 mm Hg, heart rate was 100/min, temperature was 38.5°C, chest auscultation was normal with no crepitations, abdomen was tender on palpation, and lower limbs had no edema.
Laboratory examination showed white blood cell (WBC) count of 13×106, hemoglobin of 11 g/dL, platelet count of 230 k/uL, erythrocyte sedimentation rate of 85, blood urea nitrogen of 35 mg/dL, serum creatinine of 8.5 mg/dL, potassium of 3.3 mEq/L, sodium of 132 mEq/L, bicarbonate of 28 mEq/L, peritoneal effluent was cloudy in appearance with many WBCs, predominantly lymphocytes, and standard aerobic culture and gram stain were performed. Empirical intraperitoneal antibiotics, vancomycin, and ceftazidime, were started. After three days, the culture grew Salmonella enteritidis, and the fecal and blood cultures also showed the same organism. Antibiotic sensitivity testing showed susceptibility of the organism to ciprofloxacin, following which the patient's antibiotic regimen was changed to ciprofloxacin 200 mg intraperitoneal twice daily for three weeks as outpatient without removal of the PD catheter. She responded well with steady improvement of the abdominal pain and diarrhea and repeat peritoneal fluid testing on day 7 after starting antibiotic showed normal WBCs and culture was negative [Table 1]. The patient continued on CAPD for more than a year, and later, she underwent a renal transplantation. | Table 1: Progress of various parameters in the study patient with Salmonella peritonitis.
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| Discussion | | |
The incidence of NTS is highest during the rainy season in tropical climates and during the warmer months in temperate climates, coinciding with the peak in food-borne outbreaks. The morbidity and mortality rates associated with NTS are highest among the elderly, infants, and immunocompromised individuals, including those with hemoglobinopathies, human immunodeficiency virus infection, or infections that cause blockade of the reticuloendothelial system.[1],[2],[3] Unlike S. typhi and S. paratyphi, whose only reservoir is humans, NTS can be acquired from multiple animal reservoirs. Transmission is most commonly associated with animal food products, especially eggs, poultry, undercooked ground meat, dairy products, and fresh produce contaminated with animal waste.[4],[5] Infection with NTS most often results in gastroenteritis indistinguishable from that caused by other enteric pathogens. Nausea, vomiting, and diarrhea occur 6–48 h after the ingestion of contaminated food or water. Patients often experience abdominal cramping and fever (38°C–39°C; 100.5°F–102.2°F). Diarrheal stools are usually loose, nonbloody, and of moderate volume. However, large volume of watery stools, bloody stools, or symptoms of dysentery may occur. Rarely, NTS causes pseudoappendicitis or an illness that mimics inflammatory bowel disease. Up to 10% of untreated patients with typhoid fever excrete S. typhi in the feces for up to three months, and 1%–4% develop chronic asymptomatic carriage, shedding S. typhi in either urine or stool for >1 year. Chronic carriage is more common among women, infants, and persons who have biliary abnormalities or concurrent bladder infection with Schistosoma haematobium. The anatomic abnormalities associated with the latter conditions presumably allow prolonged colonization.[6],[7]
After reviewing the literature, we found four other reported cases of Salmonella peritonitis in PD patients [Table 2]. | Table 2: Treatment modality and catheter outcome in the four reported cases of Salmonella peritonitis.
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In the first case, the PD catheter was removed after recurrence of peritonitis on day 19, and the patient was transferred to hemodialysis. In the second case, the first episode of peritonitis was treated with intraperitoneal cefazolin and netilmicin. After two weeks, an additional three-week course of oral amoxicillin was given. For the second episode of peritonitis, trimethoprim–sulfamethoxazole was given for two weeks. Subsequently, the patient was treated with ciprofloxacin 500 mg once daily for three months, without removal of the PD catheter.
In the third case, the patient was treated with intraperitoneal ceftriaxone, and the PD catheter was removed on day 13 of treatment. The patient received intravenous ceftriaxone therapy for four weeks.
In the fourth case, the PD catheter was removed on the fifth day of treatment, and the patient was switched to hemodialysis.[8],[9],[10],[11]
We conclude that the initial treatment of Salmonella peritonitis in a patient on CAPD should include at least a quinolone or a third-generation cephalosporin and should be followed according to peritoneal effluent cultures. Removal of the PD catheter is not routinely necessary for the treatment of uncomplicated Salmonella peritonitis.
| Acknowledgment | | |
The authors are pleased to express their thanks and appreciation to the staff nurses in the PD unit at the King Fahad University Hospital, Al Khobar, for their valuable support regarding patient care.
Conflict of interest: None declared.
| References | | |
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| 7. | Pullinger GD, Paulin SM, Charleston B, et al. Systemic translocation of Salmonella enterica serovar Dublin in cattle occurs predominantly via efferent lymphatics in a cell-free niche and requires type III secretion system 1 (T3SS-1) but not T3SS-2. Infect Immun 2007;75:5191-9. [ PUBMED] |
| 8. | Chiu YL, Huang JW, Hsueh PR, Wu KD, Chu TS. CAPD-related peritonitis due to Salmonella enteritidis in a patient with SLE. Am J Kidney Dis 2005;46:e21-3. [ PUBMED] |
| 9. | Mølbak K, Baggesen DL, Aarestrup FM, et al. An outbreak of multidrug-resistant, quinolone-resistant Salmonella enterica serotype typhimurium DT104. N Engl J Med 1999;341: 1420-5. |
| 10. | Swanson SJ, Snider C, Braden CR, et al. Multidrug-resistant Salmonella enterica serotype typhimurium associated with pet rodents. N Engl J Med 2007;356:21-8. [ PUBMED] |
| 11. | Locatelli A, Quiroga MA, De Benedetti L, et al. Treatment of recurrent and resistant CAPD peritonitis by temporary withdrawal of peritoneal dialysis without removal of the catheter. Adv Perit Dial 1995;11:176-8. [ PUBMED] |
Correspondence Address:
Dr. Firas Fahad Al-Zahrani
Department of Internal Medicine, Security Force Hospital, Dammam
Saudi Arabia
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DOI: 10.4103/1319-2442.229290 PMID: 29657222 
[Table 1], [Table 2] |
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