Peritonitis in Pd Patients

8/12/2019 Peritonitis in Pd Patients

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Overview

Peritoneal Dialysis - principles

Anatomy

Physiology

Pathology

Presentations

Management

Key points

www.health.com/
http://www.health.com/http://www.health.com/


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Chronic

Kidney

Disease

Diagnosis

End Stage

Kidney

Disease

Diagnosis

DIALYSIS

HAEMODIALYSIS

PERITONEAL DIALYSIS

TRANSPLANTATION

PALLIATIVE CARESTAGE 1 & 2

Proteinuria plus

eGFR 60+

(to determine eGFR

over 60, hand

calculate GFR using

Cockcroft-Gault

formula)

STAGE 3

eGFR 30-59

ml/min

MODERATE

KIDNEY

DAMAGE

Proteinuria

Care plan

STAGE 5

eGFR


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Peritoneal Dialysis

A form of renal replacement therapy forpatients with end stage kidney disease

Endeavours to replace some of the functions

of the kidney such as Removing waste products

Removing excess fluid

Correcting acid/base imbalances

Correcting electrolyte imbalances

High maintenance form of therapy requiringmeticulous compliance and effort on part ofpatient

www.agingdiscodiva.com
http://www.agingdiscodiva.com/http://www.agingdiscodiva.com/


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IDEAL BODY WEIGHT

IBW

Normotensive (Good BP) 120/70

No signs and symptoms of overload or

dehydration

Set by:

Home Training Staff Royal Perth Hospital

Renal Doctor

Dialysis Staff KSDC


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FLUID ASSESSMENT

Blood pressure

Weight

Chest, SaO2, SOB

OedemaAnkles

Back

Facial

JVP Skin tugor

Symptoms

Nausea,vomiting

Diarrhoea

Dizziness


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FLUID RESTRICTION

800 1000 mls per day

Weigh patient (will be required daily

SAME SCALES and document

which ones)

In hospital, remove jug


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Peritoneal Dialysis

Involves the passage of solutes and water

across a membrane that separates two fluid

containing compartments-blood and dialysate

During dialysis 3 transport processes occursimultaneously

Diffusion

Ultrafiltration

Absorption

http://www.dialyse-45.net/int/info/techniques.htm


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Peritoneal Dialysis

2 types

CAPDcontinuous ambulatory peritoneal

dialysis Involves on average 4 dwells per day of 4-8

hours of 22.5L each

APDautomated peritoneal dialysis

Involves 3-10 exchanges overnight of varyingamounts

Usually but not always a daytime dwell


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Peritoneal Dialysis

Anatomy

Serosal membrane lining the gut

Thought to be the same as the body surface

areausually 1-2 m2

in adult 2 partsvisceral peritoneum lining the organs

(80% or the peritoneal surface area and theparietal peritoneum lining the walls of theabdominal cavity)

Peritoneal blood flow cant be measured butindirectly estimated to be between 50-100mls/min


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Peritoneal Dialysis


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Horizontal disposition of the peritoneum in the lower part of the abdomen.

www.theodora.com/anatomy/the_abdomen.html
http://www.theodora.com/anatomy/the_abdomen.htmlhttp://www.theodora.com/anatomy/the_abdomen.html


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Peritoneal Dialysis

Visceral peritoneum blood supply is from the

superior mesenteric with venous drainage

from the portal system

Parietal peritoneum blood supply is from thelumbar, intercostal and epigastric arteries

while the venous drainage is via the IVC

Main lymphatic drainage is via stomata in the

diaphragmatic peritoneum which drain into

the right lymphatic duct


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Three pore model

Peritoneal capillary is the critical barrier toperitoneal transport

Movement of solute and water movement

across the capillary is mediated by pores ofthree different sizes

Large pores 20-40 nmprotein transport

Small pores 4-6nmsmall solutes eg urea,

creatinine, sodium, potassium, water Ultrapores (aquaporins)


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Three pore model of peritoneal

transport

Kidney International

ISSN: 0085-2538EISSN: 1523-1755

2009 International Society of Nephrology
http://www.isn-online.org/http://www.isn-online.org/


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Peritoneal Transport - Diffusion

Diffusionuraemic solutes and potassiumdiffuse from peritoneal capillary blood into thedialysate. Glucose, lactate, bicarbonate andcalcium diffuse in the opposite direction.

Diffusion depends on concentration gradient(maximal at the start), effective peritonealsurface area, intrinsic peritoneal membraneresistance, molecular weight of the solute (egsmall molecules like urea, diffuse morerapidly than larger molecules such ascreatinine)


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Diffusion

www.indiana.edu/.../lecture/lecnotes/diff.html
http://www.indiana.edu/.../lecture/lecnotes/diff.htmlhttp://www.indiana.edu/.../lecture/lecnotes/diff.html


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Peritoneal Transport - Ultrafiltration

Occurs as a consequence of the osmotic gradient between thehypertonic dialysate and the relatively hypotonic peritonealcapillary blood

Driven by high concentration of glucose in dialysate

Depends on;

concentration gradient of the osmotic agent (glucose) peritoneal surface area

hydraulic conductance of the peritoneal membrane

reflection coefficient for the osmotic agent (how effectivelythe osmotic agent diffuses out of the dialysate into theperitoneal capillaries (0-1 is normalthe lower the value the

faster the osmotic gradient is lost. Gluc is 0.3 as opposed toicodextrin which is close to 1)).

Hydrostatic pressure gradientcap press around 20mmversus intraperitoneal pressure around 7mm Hg whichfavours ultrafiltration


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Ultrafiltration

http://www.dialysistips.com/principles.html


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Peritoneal TransportUltrafiltration 2

Depends on; Oncotic pressure gradient which acts to keep fluid in

blood, opposing ultrafiltration (low inhypoalbuminaemic patients so ultrafiltration tends tobe high)

Sievingoccurs when solute moves along with wateracross a semipermeable membrane by convection butsome of the solute is held backsieved. The soluteconcentration in the ultrafiltrate that has passed

through the membrane is lower than the sourcesolution. Different solutes sieve differently rangingfrom 0 (complete sieving) to 1 (no sieving)

Other osmotic agents such as icodextrin with a largereflection coefficient so ultrafiltration is sustained


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Ultrafiltration

http://www.advancedrenaleducation.com/PeritonealDialysis/Ultrafiltration/HowtoAchieveAdequatePDUF/tabid/229/Default.aspx


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Peritoneal TransportFluid

Absorption

Occurs via the lymphatics at constant rate

Typical values for peritoneal fluid absorption

are 1-2 mls/minute

Affected by intraperitoneal hydrostaticpressure

Effectiveness of lymphatics

http://www.fmc-ag.com/gb_2006/en/05/glossar.html


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Peritonitis

Peritoneal Dialysis is a great form of renal

replacement therapy

Peritonitis is a significant complication

Incidence peritonitis episodes varies from 1/9patient-months to 1/53 patient-months

(Grunberg 2005; Kawaguchi 1999)

Our figures pending but are likely to be on

the lower end of the scale
http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005284/bibliography.htmlhttp://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005284/bibliography.htmlhttp://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005284/bibliography.htmlhttp://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005284/bibliography.html


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Peritonitis in PD pts

Risk Factors

Diabetes

Non caucasian

Obesity Temperate climate

Depression

Possibly the peritoneal dialysis

modality but not proven(Huang 2001; Oo 2005).

http://www.diabetesandrelatedhealthissues

.com/
http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005284/bibliography.htmlhttp://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005284/bibliography.htmlhttp://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005284/bibliography.htmlhttp://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005284/bibliography.html


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Significant morbidity

Some mortality - It is estimated that PD-

associated peritonitis results in death in 6%

of affected patients (Troidle 2006).

gymsoap.com
http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005284/bibliography.htmlhttp://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005284/bibliography.html


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Catheter removal may become necessary ifpt is not responding to antibiotics or ifinfection is fungal. May be temporary orpermanent

Ultrafiltration failure can occur both acutelydue to increases in capillary permeability(Ates 2000; Smit 2004) and in the longerterm resulting in technique failure (Coles2000; Davies 1996).
http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005284/bibliography.htmlhttp://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005284/bibliography.htmlhttp://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005284/bibliography.htmlhttp://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005284/bibliography.htmlhttp://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005284/bibliography.htmlhttp://images.google.com.au/imgres?imgurl=http://www.walkeravenue.com/Health/Kidneys/images_kidneys/Patient_on_peritoneal_Dialysis..png&imgrefurl=http://www.walkeravenue.com/Health/Kidneys/preesrd_education.htm&usg=__pzDOUt8Ria3NEyTSXmUuPHDpAys=&h=270&w=240&sz=16&hl=en&start=2&um=1&tbnid=j2paqOfYjG2_dM:&tbnh=113&tbnw=100&prev=/images%253Fq%253Dperitoneal%252Bdialysis%252Bcatheter%2526hl%253Den%2526sa%253DX%2526um%253D1http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005284/bibliography.htmlhttp://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005284/bibliography.htmlhttp://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005284/bibliography.htmlhttp://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005284/bibliography.htmlhttp://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005284/bibliography.html


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Pathogenesis

1. Potential routes of infection

Intraluminalimproper technique; access tobacteria via the catheter lumen

Periluminalbacteria present on skin surfaceenter the peritoneal cavity via the cathetertract

Transmuralbacteria of intestinal originmigrate through the bowel wall

Haematogenousperitoneum seeded via theblood stream

Transvaginal - ??
http://images.google.com.au/imgres?imgurl=http://www.medionics.com/cather01.jpg&imgrefurl=http://www.medionics.com/catheter.htm&usg=__Ae0nif5kpqg2YbaKTBdYZYjlmOE=&h=480&w=400&sz=29&hl=en&start=5&um=1&tbnid=_nJt38SkW3INeM:&tbnh=129&tbnw=108&prev=/images%253Fq%253Dperitoneal%252Bdialysis%252Bcatheter%2526hl%253Den%2526sa%253DX%2526um%253D1


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Pathogenesis

2. Bacteria laden plaquethe intraperitoneal portionof the catheter is covered with a bacteria ladenplaque - ? Role in pathogenesis of peritonitis

3. Host defencesperitoneal leucocytes critical in

combating bacteria that have entered theperitoneum. Affected by

A. dialysis solution and phhypertonic solutioninhibits activity

B. Calcium levelslow calcium in dialysate inhibits

activity Peritoneal IgG levelslow levels inhibit activity

HIVlittle known effect


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Aetiology

Staph aureus

Coag neg staph (S.Epidermidis)

E coli

Pseudomonas

Sternotropomonas

Candida

Atypical TB
http://images.google.com.au/imgres?imgurl=http://asymptotia.com/wp-images/2008/08/e_coli.jpg&imgrefurl=http://asymptotia.com/category/science/biology/&usg=__RRTS6QDOvMvQ6Bid0HmnJTI7I88=&h=599&w=600&sz=67&hl=en&start=3&um=1&tbnid=dIOpq8M9nmCBdM:&tbnh=135&tbnw=135&prev=/images%253Fq%253De%252Bcoli%2526hl%253Den%2526um%253D1http://swampie.files.wordpress.com/2008/02/staphylococcus-aureus.jpg


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Diagnosis

2 of the following 3 conditions

Symptoms and signs of peritoneal

inflammation (pain, tenderness, guarding,

rebound) Cloudy peritoneal fluid with increased white

cell count (specifically neutrophils)

Demonstration of bacteria on gram stain or

culture


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Diagnosissymptoms and signs

Abdo pain most common but in a PD pt

suspect peritonitis if general malaise,

nausea, vomiting or diarrhoea

Dont be blinded by the PD These pts get other pathology

EG. Strangulated hernia, withdrawal from

steroids (if they stop taking meds suddenly

and they happen to be on steroids), rupturedviscus, ulcers, perforations etc

EXAMINE THE PATIENT
http://images.google.com.au/imgres?imgurl=http://www.pain-free.eu/userdata/Image/pain_free/Abdominal%252520pain_3811288.jpg&imgrefurl=http://www.pain-free.eu/Abdominal%252520Pain&usg=__p1msd23yoqHs-4Tb3I-IWj4jLP0=&h=512&w=384&sz=118&hl=en&start=2&um=1&tbnid=Bt9s55cQzugywM:&tbnh=131&tbnw=98&prev=/images%253Fq%253Dabdo%252Bpain%2526hl%253Den%2526um%253D1


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Diagnosissymptoms and signs

PercentageSymptoms

Abdo pain 95

Nausea and vomiting 30

Fever 30

Chills 20

Constipation or diarrhoea 15

Signs

Cloudy peritoneal fluid 99

Abdo tenderness 80

Rebound tenderness 10-50Increased temperature 33

Blood leucocytosis 25

CRP 100 but can be delayed

Daugirdas JT et al 2007 p 419


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Peritoneal fluid culture

Send the whole bag

Label it (preferable with textalabel can sweat off)

Let the lab know it is coming

Ask for urgent gram stain and cell count and ask this

to be telephoned to you. Be aware that the gramstain may be negative in 50% of cases of subsequentculture proven peritonitis

Also ask for M/C/S and fungal cultures

Follow up the culture Do a full septic workup each timeincluding blood

cultures
http://images.google.com.au/imgres?imgurl=http://www.diabetesmonitor.com/images/dialys.gif&imgrefurl=http://www.diabetesmonitor.com/b120.htm&usg=__H_l97wjRow--D2Rm8Ait6oCqJXM=&h=274&w=252&sz=12&hl=en&start=65&um=1&tbnid=0bp7SVgbuiBJyM:&tbnh=113&tbnw=104&prev=/images%253Fq%253Dperitoneal%252Bdialysis%252Bbag%2526ndsp%253D18%2526hl%253Den%2526sa%253DN%2526start%253D54%2526um%253D1


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Peritonitis

Common things occur commonly and

peritonitis is unfortunately common in our

population of PD patients

BUT Dont lose sight of the bigger picture and

these patients can suffer from any other

pathologyalways keep an open mind
http://www.youthwithanopenmind.com/images/openmind_print_logo.gif


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Peritonitis Management

Broad spectrum coverage

Vancomycin (2.5g if more than 60kg / 2 g if 60kg orless)

Gentamicin (200mg if more than 60kg / 140mg if 60kg

or less) IP is better than IV (confirmed on large Cochrane

review April 2009)

Await culture. If gram positive, then repeat the vancdose in 1 week. If gram negative then usually

ceftriaxone 1g intraperitoneally daily for 14 days Things to note; if pseudomonas tube is very often lost.

May need to consider adding a second antibiotic suchas daily ciprofloxacin

PERITONITIS MANAGEMENT


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Initial symptoms may include;

diarrhoea, vomiting, nausea,

abdominal pain, mental confusion or feeling unwell

COLLECT DRAINED BAG

*Seeadditional resources (pink section) for drainage instructions* Send entirebag for urgent MC&S (including WCC differential) and Fungal elements. ****

Must cc KRSS ****

Intraperitoneal (IP) Antibiotics (see Procedures)Give BOTH

Gentamycin 160mgs if 60kgs or less

(gramve organisms) 200mg if > 60kgs

AND

Vancomycin - 2gms if 60kgs or less

(gram +ve organisms) 2.5grams if > 60kgs

Give both in a 2L 2.3%bag

Dwell in the abdomen for minimum 6 hours(Consult microbiologist if Vanc or Gent allergy)

must be able to read newspaper print through the

bag

LOOK FOR OTHER CAUSES

Call PD Coordinator or

Renal GP

ATTENTION:Vanc and Gent provide some coverage while

awaiting sensitivities.****Further antibiotics WILL be required ****

If Staph/gram +ve, give IP Vancomicin again on Day 7

If gram negative, refer to sensitivities, but

usually 14 days of IP Ceftriaxone1gmYOU MUSTfollow up the MC & S 48 hours after initial IP treatment.

A WCC > 100 confirms peritonitis.If the patient is not improving within 24 hrs, or any other concerns, contact PD coordinator

CLEAR BAG CLOUDY BAG


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Peritonitis Mx

CAPD/APD

Drain abdomen and send bag off with path

request as above

Change the transfer set completely followingusual aseptic techniques

Load 2.3% 2 litre dialysate bag (use 1.5% bag

if patient hypotensive) with Vancomycin and

Gentamicin as per above guideline Infuse bag into peritoneum

6 hour dwell


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Peritonitisfungal infection

If fungal organisms are seen on gram stain,

or cultured, it is unlikely you will be able to

save the tube

Once the tube is colonized, the only cure isremoval of tube, peritoneal rest (pt on

Haemodialysis for a few months) and then

start from scratch


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Peritonitis

If you think that the patient has peritonitis but youthink they have life threatening sepsis eghypotension, tachycardia, fever (or no fever as maynot be able to mount an immune response), alteredconscious state etc, your patient is likely to require IV

broad spectrum antibiotics. Ring the microbiologiston call. Dont wait to get IP regime in. That can go inwhile you are making calls and obtaining results.

Antibiotics must be given within 1 hour ofpresentationit is an emergency.

I usually ring SCGH as they maintain a 24 hourconsultant micro roster 93463333 but remember allour patients who require transfer must go to RoyalPerth Hospital as they are under the RPH consultant


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Peritonitis

Patients can have dual pathology

Eg it is not uncommon for patients to have

peritonitis, delay treatment, splint their

abdomen and get pneumonia. This needs tobe treated as per the normal guidelines for

pneumonia
http://images.google.com.au/imgres?imgurl=http://www.med-ed.virginia.edu/courses/rad/cxr/web%252520images/rul-pneumonia-pa.jpg&imgrefurl=http://www.med-ed.virginia.edu/courses/rad/cxr/pathology3chest.html&usg=__BmCnP3nxpkWKlbnd5ognWKNQVQg=&h=450&w=400&sz=19&hl=en&start=2&um=1&tbnid=VQ6GGqACl7HlpM:&tbnh=127&tbnw=113&prev=/images%253Fq%253Dpneumonia%2526hl%253Den%2526um%253D1


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Peritonitis

Additives to bags

Vancomycin, aminoglycosides andcephalosporins are safe to mix in the samebag

Aminoglycosides are incompatible withpenicillins

Vancomycin is stable for 28 days in dialysate(normal room temp)

Cefazolin is stable for 8 days

Gentamicin is stable for 14 days

Heparin added decreases duration of stability


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Peritonitis

Often get formation of fibrin clots which

increases risk of catheter block

May need to add 500units of heparin to 1 or 2

bags a day until fibrin clots decrease Constipation is commonyou may need to

stop the calcium based phosphate binders

temporarily but better off using aperients

early and preventing the need to alter routinemeds
http://images.google.com.au/imgres?imgurl=http://tell.fll.purdue.edu/JapanProj/FLClipart/Medical/constipation.gif&imgrefurl=http://tell.fll.purdue.edu/JapanProj/FLClipart/Medical.html&usg=__AvCBbR8wMo-cqxSEMPJ5YJZCHTA=&h=1355&w=1782&sz=35&hl=en&start=6&um=1&tbnid=BFROXmxKGYw-zM:&tbnh=114&tbnw=150&prev=/images%253Fq%253Dconstipation%2526hl%253Den%2526um%253D1


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Peritonitis

Fluid regimes

Depends whether patient is overloaded orunderloaded

Can usually continue normal regime but tailor to

patient If BP low, use 1.5% bags x 4 a day

If BP high use 2.3% bags, minimum of 4 a day

Aim for BP 120/

APD pts can continue on APD or if needed canconvert temporarily to CAPDin Broome withresources this should not be necessary


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Peritonitis

Can get changes in the permeability of the peritoneal

membrane

Permeability to water, glucose and proteins is

increased

Rapid glucose absorption from the dialysis solutionreduces amount of ultrafiltration and can result in fluid

overload

May need high glucose concentration dialysate with

shorter dwells Hyperglycaemia is common

Protein loss is increased in peritonitis so patients will

need high protein supplements


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Peritonitis

Dont forget secondary causes of peritonitis

Perforated gastric or duodenal ulcer

Pancreatitis

Appendicitis Diverticulitis

PID

Talk to the surgeon if you are not sure


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Peritonitis

You dont necessarily have to admit the

patient

Admission dictated by symptoms and distress

and often social circumstances up here

blogs.southshorenow.ca/louise/cms.ich.ucl.ac.uk/website/imagebank/images
http://blogs.southshorenow.ca/louise/http://cms.ich.ucl.ac.uk/website/imagebank/imageshttp://cms.ich.ucl.ac.uk/website/imagebank/imageshttp://blogs.southshorenow.ca/louise/


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Peritonitis - bugs

StaphVancomycin and repeat in 1 week

Patients should have nasal carriage treated withmupirocin bd for 5 days and then once a week of bdfor 5 days once a month

Gram NegsIP Ceftriaxone for 2 weeks andconsider repeating the dose of gentamicin after aweek or adding oral ciprofloxacin to the regime

Pseudomonas difficult to treat

Sternotrophomonasusually requires 2 antibiotics

and usually for 4 weeks Campylobacter not that commonresponds to

gentamicin


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Peritonitis

Culture negative disease

If cell count less than 50 x 106unlikely toperitonitis

If higher white cell count, then repeat empirictherapy

Make sure lab is doing cultures for AFBs andfungus

If not improving consider legionella,

campylobacter, ureaplama, mycoplasma,enteroviruses, fungus, histoplasmacapsulatum


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Peritonitis

Fungal peritonitis

Predisposing factors

Prior antibiotic use especially if not full treatment

Immunosuppressive therapy HIV

Malnutrition

Low albumin

Diabetes


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Peritonitis

Fungal peritonitis

We tend to try and save the tube by giving

antifungals but guidelines recommend prompt

removal of catheter, conversion tohaemodialysis for a few weeks and then start

from scratch

Penetration of antifungals to peritoneum other

than with IP administration, is poor
http://images.google.com.au/imgres?imgurl=http://www.kaiscience.com/thumbimage.php%253Fid%253D79&imgrefurl=http://www.kaiscience.com/ph_79-Soil_fungus_condiophore_and_conidia_Trichoderma_sp._Copyright_Dennis_Kunkel_Microscopy&usg=__e64sTlCXU05-V6zgOTb1b3hMiDQ=&h=353&w=300&sz=25&hl=en&start=2&um=1&tbnid=i5lgwUzM0td0QM:&tbnh=121&tbnw=103&prev=/images%253Fq%253Dfungus%252Bmicroscopy%2526hl%253Den%2526um%253D1


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Peritonitis

Refractory disease

Defined as disease that is treated with

appropriate antibiotics for 5 days without

improvement Catheter removal necessary to reduce

morbidity and preserve peritoneum

Increased with gram neg bugs


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Peritonitis

Relapsing disease

Peritonitis with the same organism within 4 weeks of stoppingtherapy

Usually Staph epidermidis or a gram negative organism

If pseudomonas or gram negatives, remove the catheter

If staph, may be able to rescue with repeat vancomycin weeklyfor a month or may be able to remove the tube andsimultaneously insert a new tube (as opposed to any otherorganism where a 2 month peritoneal rest is required)

Sometimes can use urokinase to strip the biofilm (bacteria

entrapped in fibrin in the peritoneal membrane) in relapsingdiseaselast resort but worth a go


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Peritonitis

20% of episodes temporally associated with

exit site and tunnel infections (Piraino et al

2005)

Treat exit site infections if red and purulent Swab it

Start Flucloxacillin empirically and change or

add ciprofloxacin if gram neg

Exit sites are another whole topic
http://images.google.com.au/imgres?imgurl=http://userweb.port.ac.uk/~norrismj/antimicrobial_agents/images/flucloxacillin.jpg&imgrefurl=http://userweb.port.ac.uk/~norrismj/antimicrobial_agents/Penicillins.html&usg=__NEub6FBelfkHq1UjbvLBqOviCfc=&h=192&w=256&sz=8&hl=en&start=6&um=1&tbnid=2slNyhkigq4NjM:&tbnh=83&tbnw=111&prev=/images%253Fq%253Dflucloxacillin%2526hl%253Den%2526um%253D1


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Peritonitis

Prevention

Good technique

Hygiene

Mupirocin Exit site care

Anchor tape
http://images.google.com.au/imgres?imgurl=http://www.homedialysis.org/images/resources/tom/presternal2.jpg&imgrefurl=http://www.homedialysis.org/resources/tom/200507/&usg=__d63G_ug_2drZP4ljNbQ4eVUxMKM=&h=329&w=219&sz=17&hl=en&start=2&um=1&tbnid=uaKvWtG2nO5aoM:&tbnh=119&tbnw=79&prev=/images%253Fq%253Dsite:www.homedialysis.org%252Banchor%252Btape%252Bin%252Bperitoneal%252Bdialysis%2526hl%253Den%2526um%253D1


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Cochrane Review 2009

Implications for practiceAt the present time broad spectrum antibiotics should be initiated at thetime a diagnosis of peritonitis is made. When choosing antibiotics theside-effect profile, local drug resistance patterns and previous antibioticuse and infection history in the individual concerned should beconsidered. In cases of recurrent peritonitis dialysis catheters shouldbe removed rather than using intraperitoneal urokinase.

Currently available evidence from RCTs is inadequate in many areas

of clinical practice important in the management of PD-associatedperitonitis. This is a limiting factor in the provision of definitivetreatment guidelines.


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Cochrane Review 2009

Implications for researchFurther studies are required to establish the most effective treatment for peritoneal dialysis-associated peritonitis. An essential feature of such studies is inclusion of enough patients toensure adequate power to assess meaningful long and short term outcomes. Short termoutcomes should extend beyond whether cure is achieved without catheter removal, forexample duration of systemic inflammation. Study of long-term outcomes should includepermanent transfer to haemodialysis, development of ultrafiltration failure patient death andlate recurrent episodes of peritonitis beyond four weeks from the original episode.

Specific interventions that would be of value include early versus late catheter removal.Studies designed to study infections due to specific organisms would also be valuable. Anexample is a study of glycopeptide versus cephalosporin therapy in peritonitis due tocoagulase negative Staphylococcal species. The majority of studies have included patientson CAPD rather than APD hence studies designed to test the efficacy of antibiotics in APDare required. This is particularly applicable to studies of intermittent versus continuousdosing when cycler dwell times may well influence pharmacokinetics.Future research should be conducted using standard definitions, with inclusion ofinformation about factors that may influence the response to therapy such as prophylaxis

regimens and dialysis solutions used. Current ISPD guidelines provide a comprehensive listof requirements for future studies that should be referred to when designing studies.


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Take home points

Have a high index of suspicion

Use the remote area manual

Always let KRSS know of episode

Copy all results to KRSS

Dont hesitate to ask if you are not sure KRSS team, KRSS GP, Renal GP,

Nephrologist

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Peritonitis in Pd Patients

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