Peritoneal Dialysis as Sole RRT in Severe Paediatric MODS with AKI Stage 3 and Late Stenotrophomonas Maltophilia Bloodstream Infection: PD Prescription Deviation and Neurocritical Complications in a Resource-Limited PICU

Abstract

Background: Multi-organ dysfunction syndrome (MODS) in infants carries mortality exceeding 50% in resource-limited settings. Acute kidney injury (AKI) Stage 3 requiring renal replacement therapy (RRT) is particularly challenging, where continuous RRT (CRRT) is unavailable. Peritoneal dialysis (PD) remains the sole accessible RRT in most sub-Saharan African paediatric intensive care units (PICUs). We report a case of survival from severe sepsis-induced MODS with AKI Stage 3 and ischaemic hepatitis managed with PD as sole RRT, with concurrent documentation of a PD prescription deviation and its quantified clinical impact, followed by late neurocritical complications temporally associated with Stenotrophomonas maltophilia bloodstream infection with suspected, but unconfirmed, catheter association. Case Presentation: A 9-month-old female (7.7 kg) presented with bacterial gastroenteritis, febrile convulsions, and rapid progression to septic shock with MODS. Admission procalcitonin (PCT) was 26.49 ng/mL with a normal white cell count. She required mechanical ventilation for 13 days, three simultaneous vasoactive agents, and PD for AKI Stage 3 with peak creatinine 302.6 μmol/L and peak AST 4274 U/L. A nursing prescription deviation—extending the prescribed 20-minute dwell time to 60 - 120 minutes without authorisation—reduced dialysate exposure by 55% - 60% and delayed the onset of creatinine decline by approximately 48 hours. Following correction, creatinine normalised to 74.5 μmol/L by Day 16, and the PD catheter was removed. PCT at Day 15 was 1.02 ng/mL—a 96% reduction from admission. On Day 18, new severe sepsis developed (PCT 9.28 rising to 52.83 ng/mL), complicated by sepsis-associated coagulopathy suggestive of disseminated intravascular coagulation (DIC; APTT 16.3 seconds), right parietal intracerebral haemorrhage (7.1 × 6.6 cm), bilateral cerebral infarction, and hydrocephalus on CT brain. Blood culture confirmed Stenotrophomonas maltophilia—sensitive only to levofloxacin, resistant to cotrimoxazole, and intrinsically resistant to carbapenems, including meropenem, used for 17 days. Conclusion: This case documents AKI Stage 3 recovery via PD in a resource-limited PICU, a quantified PD prescription deviation, and late Stenotrophomonas bloodstream infection (BSI) with presumed catheter origin causing neurocritical complications—representing a notable triple clinical and patient safety contribution to the literature. Carbapenem stewardship, strict PD dwell time compliance, and early CVC removal are key preventable factors.