Cosmatos Alexandre, McCormick Brendan, Blew Brian, Brown Pierre Antoine
Faculty of Medicine, University of Ottawa, ON, Canada.
Division of Nephrology, Department of Medicine, University of Ottawa, ON, Canada.
Can J Kidney Health Dis. 2023 Feb 17;10:20543581231156854. doi: 10.1177/20543581231156854. eCollection 2023.
Clear guidelines currently exist regarding antibiotic prophylaxis for patients on peritoneal dialysis (PD) prior to common diagnostic procedures. However, these guidelines do not include patients with subcutaneously embedded PD catheters who are awaiting PD initiation although both these populations share a great deal of risk factors for infections. Issues regarding antibiotic prophylaxis and avoidable infections are bound to keep occurring if physicians are not conscious of the risks of infections shared by all patients suffering from renal failure.
Two weeks after a saline infusion sonohysterography (SIS), a 48-year-old woman with chronic kidney disease (CKD) G5 ND, type 2 diabetes, a subcutaneously embedded PD catheter, and prior abnormal uterine bleeding presented to the emergency department complaining of nausea, vomiting, diarrhea, weakness, and abdominal pain. The patient received no antibiotic prophylaxis prior to her SIS.
The final diagnosis of peritonitis was established after acute kidney injury, gastroenteritis, and small bowel obstruction were considered and ruled out. A delay in the final diagnosis occurred because of the complex presentation, the fact that the patient had not yet initiated PD, and the presence of concomitant anion gap metabolic acidosis and an acute elevation of the patient's creatinine.
The patient was started on broad-spectrum intravenous antibiotics when the diagnosis of peritonitis was established. Insulin and intravenous bicarbonate infusions were used to correct the patient's anion gap metabolic acidosis. Surgical debridement of the necrotic subcutaneous tissue and removal of the embedded PD catheter were necessary.
The patient's infection resolved completely as did her anion gap metabolic acidosis. The patient had to transfer permanently from PD to hemodialysis for her renal replacement therapy.
This case report serves as a good reminder that physicians should keep in mind the possibility of peritonitis in patients with embedded PD catheters. As these patients are also at risk of infections, antibiotic prophylaxis should be used in patients with embedded catheters in the same way it is used for PD patients prior to obstetrical, gynecological, or gastrointestinal procedures.
目前对于腹膜透析（PD）患者在进行常见诊断程序前的抗生素预防已有明确指南。然而，这些指南并未涵盖那些皮下埋置了PD导管但尚未开始进行PD的患者，尽管这两类人群都有大量感染风险因素。如果医生没有意识到所有肾衰竭患者共有的感染风险，那么抗生素预防和可避免感染的问题必然会不断出现。
在进行盐水灌注超声子宫输卵管造影（SIS）两周后，一名48岁患有慢性肾脏病（CKD）G5 ND、2型糖尿病、皮下埋置PD导管且既往有异常子宫出血史的女性因恶心、呕吐、腹泻、虚弱和腹痛前往急诊科就诊。该患者在进行SIS前未接受抗生素预防。
在排除急性肾损伤、肠胃炎和小肠梗阻后，最终确诊为腹膜炎。由于临床表现复杂、患者尚未开始进行PD、存在阴离子间隙代谢性酸中毒以及患者肌酐急性升高，导致最终诊断延迟。
确诊腹膜炎后，患者开始接受广谱静脉抗生素治疗。使用胰岛素和静脉输注碳酸氢盐来纠正患者的阴离子间隙代谢性酸中毒。有必要对坏死的皮下组织进行手术清创并取出埋置的PD导管。
患者的感染以及阴离子间隙代谢性酸中毒均完全得到解决。患者不得不永久性地从PD转为血液透析进行肾脏替代治疗。
本病例报告很好地提醒医生应牢记皮下埋置PD导管患者发生腹膜炎的可能性。由于这些患者也有感染风险，对于埋置导管的患者，应像对PD患者在进行产科、妇科或胃肠道手术前一样使用抗生素预防。
