ABSTRACT
Peritoneal dialysis (PD) is increasingly being utilized for renal replacement therapy in end stage renal disease (ESRD). Its benefits include lower cost and usage convenience. However’ PD associated peritonitis is a common and serious complication of peritoneal dialysis and a major cause of PD failure. Pasturella multocida is a rare cause of peritonitis but highly specific for domestic pet exposure being the causative factor. We present a case of peritonitis being caused by the contamination of dialysis circuit by a cat. A 55 year old female with ESRD on PD for 3 years presented due to abdominal discomfort’ low grade fever’ nausea’ vomiting’ and rigors for 3 days. PD fluid was obtained for analysis and showed 215 cells/mm3 with 192 neutrophils/mm3’ diagnostic of PD peritonitis. PD fluid culture grew Pasteurella multocida. Given the strong correlation of the organism with cats’ she was questioned about her living situation. She admitted that her daughter’ along with her 13 cats’ had moved in with her recently due to the COVID pandemic. The cats were likely responsible for inadvertent contamination of the PD circuit. She completed a 21 day course of intraperitoneal ceftriaxone with resolution of symptoms and infection. Pasturella multocida is an aerobic gram negative coccobacillus and forms the normal flora of the oral cavity of dogs and cats. Pet bites and scratches to the dialysis tubing can cause translocation of bacteria to the peritoneal cavity causing peritonitis. There are no clinical trials specifically looking at Pasteurella peritonitis but most of the previously reported cases have been known to respond to penicillin’ amoxicillin’ or 3rd generation cephalosporins. This case demonstrates the ever-evolving and vulnerable social situations of many PD patients. It underlies the importance of assessing the home situation at every visit as the source of infection might not be obvious on initial history taking and often requires more careful questioning. Patient education on strict hygiene and keeping pets away from the dialysis room plays a crucial role in preventing re-infection. Pasteurella infection does not necessarily require PD catheter removal if the inciting factor can be removed as in our case.
ABSTRACT
Background: Patients with COVID are more likely to have systemic thrombotic events. Although it has been theorized that those on CRRT also have an increased rate of filter loss due to clotting. If COVID-positive patients are more likely to clot their filter than other patients on CRRT, a more aggressive anticoagulation strategy may be worthwhile. This could result in longer filter lifespan, less circuit down time, which would result in improved clearance, lower costs, less risk of iatrogenic blood loss, and less wasted nursing time. If there is no difference in filter lifespan between COVID positive and negative patients, then more aggressive anticoagulation would result only in added risk without a clear benefit. Methods: We analyzed COVID data on patients in a related unblinded prospective randomized trial, in which patients are assigned to either pre-filter CVVH or CVVHD. The standard treatment protocol at the University of Iowa is to use citrate anticoagulation with a blood flow rate of 200 mL/min and a dose of 25 mL/kg/hr. The primary outcome is average filter life, and secondary outcomes are mortality, intensive care unit LOS, hospital LOS, and renal recovery. Results: A total 30 patients using a total of 90 filters from March 25 to May 20, 2020 were evaluated (Table 1). The average filter life in COVID-positive patients was 37.4 +/- 35.8 compared to 33.1 +/- 26.7 in COVID-negative patients (p = 0.55). However, COVID-19 patients were more likely to receive heparin anticoagulation in addition to citrate. Conclusions: Contrary to other reports, in this retrospective, unadjusted analysis of CRRT patients, the presence of COVID-19 did not decrease average filter life. Further research is needed regarding the appropriate anticoagulation strategy in COVID-19 positive patients.