Extended spectrum beta lactamase peritonitis: Time for innovation?
A-seven-year-old boy on CAPD presented with fever, vomiting, and pain in the abdomen. Peritonitis was suspected based on the clinical signs as well as the cloudy PD fluid effluent. This was confirmed by PD fluid cytology, which showed a cell count of 1020/ml with 92% neutrophils. He was started on intraperitoneal (IP) ceftazidime and vancomycin, but failed to show any signs of clinical improvement. At 72 h, the PD fluid culture was confirmed to be Klebsiella pneumoniae (KP)-secreting ESBL (confirmed by the double disk synergy test). Culture sensitivity showed it to be resistant to not only cephalosporins, but also to imipenem, ciprofloxacin, and aminoglycosides. It was sensitive only to meropenem, polymixin, gatifloxacin, and trimethoprim []. As none of the sensitive antibiotics were featured in the ISPD recommended list of IP antibiotics, he was started on intravenous meropenem along with oral co-trimoxazole. The child showed excellent response, becoming asymptomatic in 72 h. The antibiotic was continued for 2 weeks and a repeat PD fluid analysis showed a normal cell count and sterile culture. At the 12 month follow-up, the child continues to be successfully managed on CAPD, with no significant change in his membrane character as per his repeat Peritoneal Equilibration test (PET) results.