Diagnosis and Treatment of Peritonitis in PD Patients

Diagnosis and Treatment of Peritonitis in Peritoneal Dialysis Patients

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The information and reference materials contained in this document are intended solely for the general

education of the reader. It is intended to provide pertinent data to assist you in forming your own

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information provided nor is it intended for treatment purposes and is not a substitute for professional

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The following treatment recommendations provide a summary of best clinical practices based on the

revised guidelines of the International Society of Peritoneal Dialysis (ISPD) issued in 2010. For complete

data, please refer to the original publication by Li PK, Szeto CC, Piraino B, et al. Peritoneal dialysis-

related infections recommendations: 2010 update. Perit Dial Int 30:393-423, 2010. The recommendations

are applicable to adult PD patients. The treatment of peritonitis in pediatric PD patients may be found in

other sources. This article discusses the monitoring and reporting of peritonitis rates, presentation and

initial empiric management of peritonitis and subsequent organism specific management of peritonitis.

Exit-site and tunnel infections are discussed in a separate series of articles on the ADVANCED RENAL

EDUCATION website.

eritonitis is an inflammation of the peritoneum, or abdominal cavity lining. It typically has an

infectious etiology, mainly due to bacteria or fungus. Bacterial infections come from

contamination during peritoneal dialysis and fungal infections may occur subsequent to antibiotic

use. Peritonitis is a major complication of peritoneal dialysis (PD), but only about 4% of episodes result in

death of the patient. However, peritonitis does contribute to the death of approximately 16% of patients on

PD. Peritoneal dialysis contributes to structural changes of the peritoneum and peritonitis is the most

common cause of patients switching from PD to hemodialysis. Peritonitis treatment goals include rapidly

resolving inflammation by eradicating the causative organism(s) and preserving the function of the

peritoneal membrane.

Monitoring and reporting of peritonitis rates and outcome evaluation

Peritoneal-dialysis infection (exit-site and peritonitis) rates should be monitored and reported for every

program annually. A goal rate of 1 episode per 18 months (0.67/year) is expected; although, rates of 1

episode per 41-52 months (0.29 0.23/year) are preferred. Additionally, the PD team comprised of

P


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physicians and nurses, should review the presumed etiology, causative organisms and antibiotic

sensitivity of each infection. When infection rates are increasing or undesirably high, interventions should

be employed. The three main methods of reporting infections due to peritoneal dialysis include using

rates, percentages and median rates for each program. Rates may be calculated for individual organisms,

in addition to all infections. Percentages may be reported as how many patients are considered to be free

from peritonitis for a specified amount of time. Median rates may be calculated by taking the median from

a list of individual peritonitis rates.

It is important to monitor and report peritonitis rates, as well as evaluate outcomes. In order to properly

evaluate outcomes, a collection of data for analysis should be performed. The data should include the

date when the culture was collected, any organism identified and subsequent drug therapy utilized. In

addition, the date when the infection resolved should also be included. If another infection occurs, the

recurrent organisms and date of treatment should be noted along with the chosen method of temporary

renal replacement therapy. If the catheter is removed and a new catheter is inserted, the date of each (as

applicable) should be noted. Documentation of potential contributing factors such as break in technique,

exit-site infections, patient factors or tunnel infections, along with the date of re-education and training

should also be completed. The purpose of documentation of data is to evaluate the programs treatment

regimen to ensure best possible outcomes for patients. If the protocol is not effective in treatment and

prevention of peritonitis, it should be reassessed and changes should be implemented to achieve

satisfactory results.

Diagnosis of peritonitis: Signs and symptoms

PD patients could have a clinical presentation consistent with cloudy effluent and abdominal pain, which

can range from mild to severe. The severity of pain can be related to specific organisms (e.g., mild pain

with CoNS and severe pain with gram-negative rods, streptococcus, and S. aureus). The effluent cell

count with differential should be obtained, and if after 2 hours of dwell time, the WBC is greater than

100/L with a minimum of half being polymorphonuclear neutrophilic cells, inflammation is present and

peritonitis is deemed the probable cause. The gram stain should be used to define presence of yeast and

permit initiation of antifungal therapy and timely removal of catheter; however, the gram stain should not

be used for empiric therapy guidance. Sometimes the effluent may be clear despite abdominal pain. The

differential diagnosis should include other causes aside from peritonitis, such as constipation, peptic ulcer

disease, renal or biliary colic, acute intestinal perforation, and pancreatitis


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Obtaining dialysate cultures and initiating empiric antibiotic treatment

Obtaining the correct microbiological culture from the peritoneal effluent is necessary to identify the

responsible organism, as well as the antibiotic sensitivities. It can also help designate the likely source of

infection and guide appropriate antibiotic selection. Using standard culture technique, culture-negative

peritonitis rates of 10% maximum would be ideal; however, a rate of less than 20% of episodes is

acceptable. It is very important to quickly obtain a bacteriological diagnosis in order to reduce necessary

time for cultures. The diagnosis should be established within 3 days. If the cultures are not positive after

an incubation period of three to five days but an infection is suspected based upon clinical signs and

symptoms, it may be necessary to perform subcultures for an additional 3-4 days in order to reveal slow-

growing bacteria or yeast.

When considering empiric antibiotic treatment, it is important for the selection to encompass gram-

negative and gram-positive organisms concurrently. Additionally, center-specific selection for peritonitis-

causing organisms should be based upon the sensitivities of the local history. Gram-positive antibiotic

options include vancomycin or cephalosporins. Gram-negative coverage may be obtained through the

use of aminoglycosides or third-generation cephalosporins. Microbiological specimens should be

collected as quickly as possible and prior to the initiation of empiric antibiotics. The preferred

administration of antibiotics is intraperitoneal; intermittent and continuous dosing is equally effective (see

below: Intermittent or Continuous Dosing of Antibiotics).


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Empiric Antibiotic Treatment

After obtaining microbiological specimens for culturing, immediately start the patient on two antibiotics, one covering Gm (+) and one covering Gm (-) bacteria

Does patient have penicillin or cephalosporin allergy? Is patient seriously ill? Does patient have a history of MRSA infection? Is there a high rate of MRSA at the care center?

Gram (+) Gram (-)

Yes No

Vancomycin First generation cephalosporin (cefazolin or cephalothin)

Aminoglycoside or third generation cephalosporin(cefepime or ceftazidime).Alternatively use carbapenem, or a quinolone

Allow intraperitoneal antibiotics to dwell for at least 6 hours.Reevaluate treatment as soon as culture and sensitivity results are obtained.If no results on day three, treat as culture negative peritonitis.

Figure 1: Empiric Antibiotic Treatment. Modified from: Li PK, Szeto CC, Piraino B, et al. Peritoneal

dialysis-related infections recommendations: 2010 update. Perit Dial Int 30:393-423, 2010


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Specific peritonitis treatment according to culture results

Subsequent to obtaining the results of the culture and sensitivities, it is recommended that the empiric

antibiotic therapy be changed to a narrow spectrum antibiotic to cover the specific organism as

appropriate. Dose adjustments for renally-excreted drugs may be necessary in patients with considerable

residual renal function. The clinical response is used to guide treatment and to determine the length of

therapy. In general, clinical improvement should occur within the first 3 days after antibiotic initiation. In

uncomplicated cases, a total of 14 days is usually an adequate duration, with the antibiotic being

continued 7 days after clearing of effluent. Duration of 3 weeks may be necessary when patients are

slower to respond to therapy, usually in the context of a severe infection often caused by gram-negative

organisms, S. aureus, or enterococcus.


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Culture Results

Gram (-)Gram (+) Poly-microbial Culture neg.Fungal

Staphylococcus

Streptococcus or Enterococcus

Corynebacterium

Pseudomonas

Other (E. coli, Proteus, Klebsiella, etc.)

Stenotrophomonas

Multiple g(+) organisms

Multiple g(-) or mixed g(+) and (-) organisms

Candida Other (Aspergillus, etc.)

Change empiric treatment to reflect culture and sensitivity results; if no results on day three, treat as culture negative peritonitis

Figure 2: Culture Results. Modified from: Li PK, Szeto CC, Piraino B, et al. Peritoneal dialysis-related

infections recommendations: 2010 update. Perit Dial Int 30:393-423, 2010


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Gram positive culture

Coagulase-negative staphylococcus (CoNS) is a very common cause of peritonitis and consists of about

20 species that are clinically relevant. The route of infection is mainly due to touch contamination. It is

important for the laboratories to obtain identification of the precise species level whenever possible. This

assists in differentiation between contaminated cultures and true infections. In general, S. epidermidis

responds well to therapy and is rarely associated with catheter infections. Mild pain is a common

symptom and outpatient therapy is typically used. However, when relapsing peritonitis is caused by S.

epidermidis, the catheter is often colonized by biofilm and treatment with catheter replacement in a single

procedure is the best option. Often programs have methicillin-resistant organisms present in high rates

and therefore vancomycin should be used as empiric therapy. Touch contamination and catheter infection

can lead to a severe form of peritonitis caused by Staphylococcus aureus. Vancomycin is the drug of

choice, but rifampicin may be added for up to one week. Teicoplanin can also be used for 3 weeks, where

available.

Peritonitis caused by streptococcus and enterococcus may have originated from the gastrointestinal tract,

mouth, touch contamination, or exit site and tunnel infection. Severe pain is commonly associated with

this type of peritonitis. Ampicillin is the drug of choice, provided that the organism is susceptible. Addition

of an aminoglycoside, such as gentamicin, for synergy against enterococcus is useful provided there is no

high-level antibiotic resistance. Recent hospitalization and previous antibiotic therapy are risk factors

associated with peritonitis caused by vancomycin-resistant Enterococcus (VRE). Amipicillin may be used

for VRE if it is susceptible, and linezolid, quinupristin/dalfopristin, and daptomycin are alternative choices.

Corynebacterium may be difficult to identify as pathogens due to normal colonization of the skin. This

species is not a common cause of peritonitis, but does pose significant risks such as relapse, repeat

peritonitis, removal of catheter, hospitalization, transfer to permanent hemodialysis and death. Treatment

usually consists of vancomycin therapy for up to 3 weeks and removal of catheter within 1 week of onset

of infection, to prevent transfer to permanent hemodialysis.


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Corynebacterium

Assess clinical improvement, repeat dialysis effluent cell count and culture at days 3-5

Gram (+)Culture

Staphylococcus

Methicillin resistant S. aureus?

YES NO

Continue g(+) coverage based on sensitivity.Stop g(-) coverage. Consider adding rifampin2

Give quinupristin/ dalfopristin, daptomycin, or linezolid3

Streptococcus or Enterococcus

Ampicillin-resistant?

YES NO

Vancomycin-resistant Enterococcus?

YES NO

Give vancomycin

Give vancomycin x3 wks

If clinical improvement:Continue antibiotics and reevaluate for exit-site or occult tunnel infection, abdominal abscess, catheter colonization, etc.

If no clinical improvement: Reculture and evaluate

Continue for: S. aureus and Enterococcus 21 days; Other Staph and Strep: 14 days

If no improvement after 5 days on appropriate antibiotics, remove catheter6

If exit-site or tunnel infection exists, catheter removal should be seriously considered4

Give ampicillin5

Give vancomycin or teicoplanin1Consider adding rifampin2


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Figure 3: Gram-positive culture. Modified from: Li PK, Szeto CC, Piraino B, et al. Peritoneal dialysis-

related infections recommendations: 2010 update. Perit Dial Int 30:393-423, 2010 1 If vancomycin-resistant S. aureus, use linezolid, daptomycin, or quinupristin/dalfopristin; 2 consider oral

rifampin 600 mg/day (in single or split dose) for 5-7 days (450 mg/day if body weight < 50 kg), especially if

patient is infected with methicillin-resistant S. aureus. Limit use to 5-7 days; 3 If linezolid is used for

vancomycin-resistant enterococcus, bone marrow suppression has been noted after 10-14 days; 4 Allow a

minimum rest period of 3 weeks before reinitiating peritoneal dialysis; 5 Consider adding an

aminoglycoside for synergy, however, do not mix in same bag; 6 The duration of antibiotic therapy

following catheter removal and timing or resumption of peritoneal dialysis may be modified depending on

the clinical course.

Gram negative culture

Pseudomonas aeruginosa is another common cause of severe peritonitis. It is also often associated with

a catheter infection, and therefore removal of the catheter is recommended for better outcomes. P.

aeruginosa is linked to increased frequency of hospitalizations and transfer to permanent hemodialysis. It

is important to always use two antibiotics with two different mechanisms to ensure complete eradication of

the organism.

Single Gram-negative organisms (for example, Klebsiella, E.coli, or Proteus) that cause peritonitis may

originate from exit-site infections, touch contamination or a bowel source (constipation, colitis or

diverticulitis). Although treatment should be based upon sensitivity results, it is important to consider

these organisms may be present in the biofilm state, which can lead to treatment failure. This occurs

because the organisms are significantly less sensitive than laboratory results may indicate. For risk

reduction of recurrence and relapse, it is suggested that two antibiotics should be used.

Stenotrophomonas is an infrequent cause of peritonitis that has limited sensitivity to antibiotics. Previous

use of fluoroquinolones, carbapenems, and third and fourth-generation cephalosporins is associated with

infection caused by this organism. Treatment with two drugs for 3-4 weeks is recommended provided the

patient is improving clinically: oral minocycline or trimethoprim/sulfamethoxazole, and intraperitoneal (IP)

ticarcillin/clavulanate.


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Gram (-)Culture

Pseudomonas StenotrophomonasOther (E. coli, Proteus, Klebsiella, etc.)

Give two antibiotics with different mechanisms (i.e. oral quinolone, ceftazidime, cefepime, tobramycin, piperacillin)

Exit site infection?

Remove catheter and continue antibiotics on temporary HD1

YES NO

Assess clinical improvement, repeat dialysis effluent cell count and culture at days 3-5

Adjust antibiotics to sensitivity pattern; ceftazidime or cefepime may be indicated

Give two antibiotics with different mechanisms based on sensitivity pattern (i.e. oral TMP/SMZ2, IP ticarcillin/clavulanate, oral minocycline)

If clinical improvement, continue therapy for:Pseudomonas: 21 daysStenotrophomonas: 21-28 daysOther: 14-21 days

If no clinical improvement by 5 days on appropriate antibiotics, remove catheter


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Figure 4: Gram-negative culture. Modified from: Li PK, Szeto CC, Piraino B, et al. Peritoneal dialysis-

related infections recommendations: 2010 update. Perit Dial Int 30:393-423, 2010

1 Antibiotics must be continued for 2 weeks while the patient is on hemodialysis; however, the duration of

antibiotic therapy following catheter removal and timing or resumption of peritoneal dialysis may be

modified depending on clinical course; 2 TMP/SMZ is preferred. TMP/SMZ: Trimethoprim and

Sulfamethoxazole.

Polymicrobial, fungal and culture negative peritonitis

Multiple Gram positive organisms come from contamination or infections of the catheter. This type of

peritonitis should resolve with antibiotic therapy and only when the catheter is the infection source, is

removal indicated. This type of peritonitis has a superior prognosis compared to when multiple enteric

organisms are the cause. In this case, pathology may arise from an intra-abdominal source such as

diverticulitis, ischemic bowel, cholecystitis, or appendicitis. A computed tomographic (CT) scan or

laparotomy may be useful to identify an abdominal cause. Antibiotics such as metronidazole plus

ampicillin, an aminoglycoside, or ceftazidime are recommended.

A serious complication that can occur subsequent to an episode of bacterial peritonitis treated with

antibiotics is fungal peritonitis. Approximately 25% of fungal peritonitis episodes result in death. The

catheter should be removed as soon as possible to decrease risk of death. Flucytosine and amphotericin

B can be used empirically for infections caused by Candida species, while echinocandins such as

caspofungin, anidulafungin, and micafungin, are recommended for Aspergillus. Combination therapy with

casposfungin and amphotericin has been used effectively, as well as caspofungin alone. Amphotericin B

may be replaced by an echinocandin, fluconazole, voriconazole or posaconazole when indicated by

culture and sensitivity results. Azoles should be used only when sensitivities are available due to

emerging resistance. The prevention of fungal peritonitis may be achieved by the use of antifungal

prophylaxis during antibiotic treatment, as it is commonly associated with antibiotic use. However, this

therapeutic decision has only been demonstrated to be beneficial in programs that have high fungal

peritonitis baseline rates. Optional agents for fungal prophylaxis include fluconazole and nystatin,

although there is limited data on fluconazole use.


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Culture-negative peritonitis rates should be less than 20% for all programs. If this is not the case, then

review of culture methods is needed for improvement. Negative cultures may be observed due to clinical

or technical reasons. For example, antibiotic use of any kind can produce a negative culture. Some

organisms are difficult to diagnose in routine culture. When under clinical consideration, atypical causes

of peritonitis can be determined by using special culture techniques. Unusual causes include lipid-

dependent yeast, mycobacteria, Legionella, Campylobacter, slow-growing bacteria, fungi, enteroviruses,

Ureaplasma, and Mycoplasma. Initial therapy may be continued for 2 weeks if clinical improvement is

noted and the effluent clears quickly. However, if improvement is not observed in 5 days, catheter

removal is recommended.


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Poly-microbial Fungal

Culture Negative

Multiple g(+) organisms

Multiple g(-) or mixed g(+/-) organisms

Candida species

Other (Aspergillus, etc.)

Continue antibiotics based on sensitivities for a minimum of 21 days

If exit-site or tunnel infection is present, remove catheter1

Change to metronidazole + ampicillin, ceftazidime, or aminoglycoside; continue for 14 days

Obtain surgical assessment2. If laparotomy indicates intra-abdominal pathology/abscess, remove the catheter1.

Give amphotericin B3 and flucytosine4

Once susceptibility results are available, amphotericin B can be replaced by echinocandins or azoles; continue flucytosine5

Give echinocandins

Days 1-2: If culture is negative, continue initial therapy

Day 3: If culture is still negative, repeat PD fluid white cell count and differential, then perform clinical assessment

Day 3: If no improvement in differential or clinical assessment, consider special culture technique for unusual causes (i.e. viral, fungi, bacteria, etc.)

Reculture is positive Reculture is negative

Adjust therapy according to sensitivity patterns; duration of therapy should be based on organism(s)

Continue antibiotics for at least 14 days. Remove catheter1 if no improvement after 5 days

Day 3: If improvement in differential or clinical assessment, continue therapy for 14 days

Remove catheter1


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Figure 5: Polymicrobial, Fungal or Culture Negative. Modified from: Li PK, Szeto CC, Piraino B, et al.

Peritoneal dialysis-related infections recommendations: 2010 update. Perit Dial Int 30:393-423, 2010.

1 The duration of antibiotic therapy following catheter removal and timing or resumption of peritoneal

dialysis depends on the clinical course; 2 Hypotension, sepsis, lactic acidosis, or elevation of peritoneal

amylase should raise immediate concern for surgical peritonitis; 3 IP use of amphotericin causes

chemical peritonitis and pain, while IV leads to poor peritoneal bioavailability; 4 Flucytosine requires

monitoring of serum concentrations to avoid bone marrow toxicity (goal trough 25-50 g/mL and

transiently not greater than 100 g/mL); 5 Azole resistance is emerging, if azole is used treatment should

be continued orally with flucytosine 1000mg and fluconazole 100-200 mg daily for an additional 10 days

after catheter removal.

Drug Dosing and Stability

Drugs that can be admixed in one dialysis solution bag include aminoglycosides, vancomycin, and

cephalosporins; however, chemical incompatibility exists between penicillins and aminoglycosides and

therefore should not be mixed. The use of separate syringes is necessary for admixture of antibiotics into

the same bag, in conjunction with sterile technique. When dialysis solutions contain dextrose, the time of

stability of added antibiotics is variable (Table 1).

Antibiotic Stability1 in Dextrose-Containing2 Dialysis Solutions

Antibiotic Concentration Stability (days) Storage temperature

Vancomycin 25 mg/L 28 RT

Gentamicin 8 mg/L 14 ---

8 RT Cefazolin 500 mg/L

14 Refrigerated

4 RT Ceftazidime 125 mg/L

7 Refrigerated

Ceftazidime 200 mg/L 10 Refrigerated

Cefepime 100 g/L 14 Refrigerated


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Table 1: Antibiotic Stability in Dextrose-Containing Dialysis Solutions. Modified from: Li PK, Szeto CC,

Piraino B, et al. Peritoneal dialysis-related infections recommendations: 2010 update. Perit Dial Int

30:393-423, 2010. 1 It is possible that these antibiotics are stable for longer periods; more research is

needed to identify the optimal stability conditions for antibiotics added to dialysis solutions; 2 Icodextrin-

containing dialysis solutions are compatible with vancomycin, cefazolin, ampicillin, cloxacillin, ceftazidime,

gentamicin and amphotericin; 3 Heparin reduces stability. RT: room temperature.

Intermittent or Continuous Dosing of Antibiotics: Special Considerations for APD

It is well known that the preferred method of dosing antibiotics in peritonitis is intraperitoneal (IP). IP

dosing is favored over intravenous (IV) dosing because the local levels that can be achieved are higher

with IP. Additionally, IP route is advantageous because the patient can perform it at home after adequate

training. It also avoids venipuncture necessary for IV access. Optional dosing regimens of IP antibiotics

include once daily (intermittent) or per each exchange (continuous). The antibiotic must dwell for a

minimum of 6 hours to ensure adequate absorption.

There are few antibiotic dosing recommendations for APD patients and when given equivalent doses as

CAPD patients, significant under-dosing could occur. This can be due to rapid exchanges, where there is

not enough time given for the antibiotic to be absorbed in the systemic circulation. This can be avoided by

utilizing the 6 hour dwell time. Refer to Table 2 for dosing recommendations for CAPD and APD, where

evidence exists. The debate between increased efficacies of continuous dosing versus intermittent dosing

is still lacking evidence. It is a concern that with quick exchanges in APD there is inadequate time for

achievement of IP levels. The possibility of biofilm-associated organisms is raised when there are only

daytime exchanges of a single cephalosporin, resulting in IP levels that are below MIC at nighttime. It is

unclear at this time if patients on a cycler should convert to CAPD temporarily or reset the cycler to permit

a longer exchange time. Another consideration is the practicality of switching patients on APD to CAPD,

since necessary supplies or training may not be accessible to the patient.

Additional data support that APD leads to increased peritoneal clearance of antibiotics when compared to

CAPD, which results in dialysate concentrations lower than the MIC for sensitive organisms. Clinicians

should choose the higher end of the dosing range for patients that have a rapid removal of antibiotics.

Clinical improvement should be seen within 48 hours as a clearing of effluent; if there is no improvement,

a repeat cell count and culture is necessary.


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Antibiotic Dosing Regimens

Medication CAPD IP Dosing1 Automated PD IP Dosing

Aminoglycosides

Intermittent (per exchange,

once daily)

Continuous (mg/L, all exchanges)

Intermittent (per exchange, once daily)

Amikacin 2 mg/kg LD 25, MD 12

Tobramycin 0.6 mg/kg LD 8, MD 4 LD 1.5 mg/kg IP in long dwell, then 0.5 mg/kg IP daily in long dwell Gentamicin, netilmicin 0.6 mg/kg LD 8, MD 4 Cephalosporins Cephalothin, cephradine 15 mg/kg LD 500, MD 125

Cefazolin 15 mg/kg LD 500, MD 125 20 mg/kg IP in long day dwell Cefepime 1000mg LD 500, MD 125 1 g IP in 1 exchange daily Ceftazidime 1000-1500 mg LD 500, MD 125 Ceftizoxime 1000mg LD 250, MD 125 Penicillins Amoxicillin No data LD 250-500, MD 50 Ampicillin, oxacillin, nafcillin No data MD 125

Azlocillin No data LD 500, MD 250 Ampicillin/sulbactam 2 g every 12 hrs LD 1000, MD 100

Penicillin G No data LD 50000 units MD 25000 units

Quinolones Ciprofloxacin No data LD 50, MD 25 Others Aztreonam No data LD 1000, MD 250 Daptomycin No data LD 100, MD 20 Linezolid Oral 200-300 mg daily Teicoplanin 15 mg/kg LD 400, MD 20 Vancomycin (Dose depends on serum trough levels)

15-30 mg/kg every 5-7 days 2 LD 1000, MD 25

LD 30 mg/kg IP in long dwell; repeat dosing 15 mg/kg IP in long dwell every

3-5 days Imipenem/cilastin 1g twice daily LD 250, MD 50 TMP/SMZ Oral 960 mg BID

Quinupristin/dalfopristin 25 mg/L in alternate bags3

Antifungals Amphotericin B Not applicable 1.5

Fluconazole 200 mg IP every 24-48 hrs 200 mg IP in 1 exchange per day every

24-48 hours


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Table 2: Antibiotic dosing regimens. Based on: Li PK, Szeto CC, Piraino B, et al. Peritoneal dialysis-

related infections recommendations: 2010 update. Perit Dial Int 30:393-423, 2010. 1 Dosing of drugs in patients with residual renal function (defined as >100mL/day urine output), should be

empirically increased by 25%; 2 Vancomycin should be re-dosed if serum trough levels fall below 15

g/mL; 3 Given in conjunction with 500 mg quinupristin/dalfopristin intravenous twice daily. CAPD:

continuous ambulatory peritoneal dialysis. LD: loading dose. MD: maintenance dose.

Refractory, Relapsing, Recurrent, and Repeat Peritonitis

The 2010 ISPD Guidelines give the following definitions:

Refractory peritonitis results when there is failure of the effluent to clear after 5 days of appropriate

antibiotics. Relapsing peritonitis can be defined by an episode that occurs within 4 weeks of completion of

a therapy of a prior episode with the same organism or 1 sterile episode. Recurrent peritonitis refers to an

episode that occurs within 4 weeks of completion of therapy of a prior episode but with a different

organism. Repeat peritonitis occurs more than 4 weeks after completion of therapy of a prior episode with

the same organism. Catheter-related peritonitis is in conjunction with an exit-site or tunnel infection with

the same organism or 1 site sterile.

When peritonitis rates are calculated, relapsing episodes are not considered another peritonitis episode;

however, repeat and recurrent episodes are counted.

Catheter removal is indicated in refractory and relapsing peritonitis, refractory exit-site and tunnel

infections, and fungal peritonitis. It may also be considered for repeat peritonitis, mycobacterial peritonitis,

and multiple enteric organisms. In the case of relapsing peritonitis, once the effluent is cleared, the

catheter can be removed and replaced in a single procedure with use of antibiotic coverage. It is

recommended that a time period of 2-3 weeks be utilized between catheter removal and reinsertion when

cases are refractory or fungal.

Refractory peritonitis should be managed by removing the catheter to protect the peritoneal membrane

for future use. The catheter may be replaced after infection resolution, provided that both the previous

and current episode is caused by the same organism. The primary goal of peritonitis treatment is to focus

on the patient and protect the peritoneum, not to save the catheter. Severe episodes of peritonitis may


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prevent patients from returning to PD. Adhesions may prevent catheter reinsertion or the peritoneal

membrane may have been permanently damaged, thus no longer able to be used for PD. Prolonged

treatment attempts lead to longer hospital stays, damage to the peritoneum, greater risk for fungal

infection, and potentially death. Death should be very infrequent, and risk is highest with fungus and

gram-negative bacilli as causative organisms.

Worse outcomes are associated with recurrent, relapsing and repeat peritonitis and catheter removal

should be performed in a timely manner. It is common for relapsing and recurrent episodes to be caused

by a different bacterial species. Recurrent episodes are associated with a worse prognosis.

Prevention of Further Peritonitis

An analysis should always be performed to determine the cause of the peritonitis episode, as well as any

interventions against reversible risk factors in prevention of further episodes. Touch contamination is a

common cause, and whenever necessary, the patient should be retrained to ensure proper technique for

further prevention. Additional information regarding prevention of peritonitis will be discussed in detail in

another chapter.

Patient Education

Patient should immediately report to the PD nurse any symptoms of abdominal pain, cloudy effluent, or

fever. The cloudy dialysate fluid should be drained and saved to be brought to the clinic for analysis. The

patient should understand that treatment involves antibiotic therapy for approximately 3 weeks. Upon

completion of therapy, the patient should report any persistent cloudiness or worsening symptoms to the

PD nurse. Retraining to address technique issues should also be scheduled.

Conclusion

In summary, this article discussed the presentation and initial empiric management of peritonitis,

subsequent organism specific management of peritonitis, and monitoring and reporting of peritonitis rates.

The main symptoms of peritonitis include abdominal pain and cloudy dialysate. Empiric antibiotic therapy

should be given as soon as samples are taken for culture. Upon receiving results of culture and


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sensitivity, empiric therapy should be tailored to the most narrow spectrum antibiotic as appropriate and

should be continued for up to 3 weeks depending on clinical response. The goals of treatment of

peritonitis include rapid resolution of inflammation by eradication of causative organism and preservation

of peritoneal membrane function. Monitoring and reporting peritonitis rates, as well as evaluating

outcomes of peritonitis treatment are important to ensure patients are receiving the best possible

treatment.

Diagnosis and Treatment of Peritonitis in PD Patients

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