Intraperitoneal ampicillin treatment for peritoneal dialysis- related peritonitis with Listeria monocytogenes - a case report

The Use of Intraperitoneal Ampicillin in a Patient With Enterococcus faecalis Peritonitis

Introduction: Peritoneal dialysis (PD) - associated peritonitis is a serious complication of peritoneal dialysis (PD). The 2022 International Society of Peritoneal Dialysis (ISPD) guidelines do not recommend intraperitoneal (IP) ampicillin for treatment of Enterococcal PD - associated peritonitis. To date, there is no in vivo data to support use of IP ampicillin for the treatment of Enterococcus faecalis. Case Description: A 69-year-old man with a past medical history of end stage kidney disease (ESKD) requiring continuous cycling peritoneal dialysis (CCPD) was admitted to the hospital and treated for peritonitis with E. faecalis. The patient's CCPD prescription was 2.5% Dianeal with 5 total exchanges. IP ampicillin was added to the first 4 exchanges and additional ampicillin was added to the last fill. The patient successfully completed the treatment course with clinical cure. Discussion: The use of IP ampicillin for E. faecalis peritonitis is controversial and previously lacked compelling clinical evidence for or against its use. This case demonstrates treatment of peritonitis using a modified dosing strategy with ampicillin added to each CCPD exchange and last fill. The loss of ampicillin antimicrobial activity reported in vitro with E. faecalis was not supported by this case.

Peritoneal dialysis-related Listeria monocytogenes peritonitis treated with both intravenous and intraperitoneal ampicillin

Listeria monocytogenes is a ubiquitous bacterium and opportunistic pathogen for immunocompromised patients. Peritoneal dialysis-related L. monocytogenes peritonitis is a rare clinical presentation, with a total of 23 cases reported to date and an overall mortality rate of 17.3%. The current report describes a case of peritoneal dialysis-related L. monocytogenes peritonitis in a woman in her 60s on long-term immunosuppressive therapies for a prior renal transplant. We treated this patient successfully with intraperitoneal ampicillin (125 mg/L in dialysate), in addition to intravenous ampicillin (1 g every 12 hours) for 10 days and subsequent oral amoxicillin 500 mg every 12 hours to complete a total 21-day course of therapy. This treatment regimen was informed by a literature review of pre-existing case studies, which demonstrated considerable variability in recommended antimicrobial dosing and frequency. A summary of this literature review is included in the current case report.

ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment

Peritoneal dialysis (PD)-associated peritonitis is a serious complication of PD and prevention and treatment of such is important in reducing patient morbidity and mortality. The ISPD 2022 updated recommendations have revised and clarified definitions for refractory peritonitis, relapsing peritonitis, peritonitis-associated catheter removal, PD-associated haemodialysis transfer, peritonitis-associated death and peritonitis-associated hospitalisation. New peritonitis categories and outcomes including pre-PD peritonitis, enteric peritonitis, catheter-related peritonitis and medical cure are defined. The new targets recommended for overall peritonitis rate should be no more than 0.40 episodes per year at risk and the percentage of patients free of peritonitis per unit time should be targeted at >80% per year. Revised recommendations regarding management of contamination of PD systems, antibiotic prophylaxis for invasive procedures and PD training and reassessment are included. New recommendations regarding management of modifiable peritonitis risk factors like domestic pets, hypokalaemia and histamine-2 receptor antagonists are highlighted. Updated recommendations regarding empirical antibiotic selection and dosage of antibiotics and also treatment of peritonitis due to specific microorganisms are made with new recommendation regarding adjunctive oral N-acetylcysteine therapy for mitigating aminoglycoside ototoxicity. Areas for future research in prevention and treatment of PD-related peritonitis are suggested.