Peritonitis in children with nephrotic syndrome

In a retrospective review of 214 children with nephrotic syndrome seen at Children's Medical Center and Parkland Memorial Hospital in Dallas throughout the 20-year period from 1967 to 1986, 62 cases of primary peritonitis were identified in 37 patients (17.3% rate). Streptococcus pneumoniae was the major pathogen, accounting for 38% of the cases. An additional 27% of patients had negative culture results but were clinically responsive to penicillin. Gram-negative organisms were cultured from only 3% of patients; 5% were caused by alpha-streptococci and 2% each by enterococcus and anaerobes. In 23% of cases the cause was unknown. Our findings differ from the recent trend in the literature in which Gram-negative organisms associated with these infections are increasingly implicated. The incidence and bacteriology of peritonitis do not appear to have changed significantly during the 20-year period. Clinically, peritonitis was characterized by abdominal pain (98%), fever (95%), rebound tenderness (85%), and nausea and vomiting (71%). A total of 79% of patients were either in relapse or receiving steroid therapy at the time peritonitis was diagnosed; 13% had infiltrates visible on their chest radiographs. Based on our data, it seems reasonable to initiate antimicrobial therapy in nephrotic children with suspected peritonitis using a combination of penicillin plus either an aminoglycoside or a cephalosporin. This regimen should continue until culture results are available, unless Gram-positive diplococci are identified in a Gram-stained specimen of peritoneal fluid, in which case penicillin alone should suffice.