Peritoneal Dialysis-Associated Peritonitis

Abstract

Peritonitis is a common and severe complication in peritoneal dialysis (PD). Detailed recommendations on the prevention and treatment of PD-associated peritonitis have been published by the International Society for Peritoneal Dialysis (ISPD), but there is a substantial variation in clinical practice among dialysis units. Prophylactic antibiotics administered before PD catheter insertion, colonoscopy, or invasive gynecologic procedures, daily topical application of antibiotic cream or ointment to the catheter exit site, and prompt treatment of exit site or catheter infection are key measures to prevent PD-associated peritonitis. When a patient on PD presents with clinical features compatible with PD-associated peritonitis, empirical antibiotic therapy, with coverage of both Gram-positive and Gram-negative organisms (including Pseudomonas species), should be started once the appropriate microbiologic specimens have been obtained. Intraperitoneal is the preferred route of administration. Antifungal prophylaxis, preferably oral nystatin, should be added to prevent secondary fungal peritonitis. Once the PD effluent Gram stain or culture and sensitivity results are available, antibiotic therapy can be adjusted accordingly. A detailed description on the dosage of individual antibiotic can be found in the latest recommendations by the ISPD. The duration of antibiotics is usually 2-3 weeks, depending on the specific organisms identified. Catheter removal and temporary hemodialysis support is recommended for refractory, relapsing, or fungal peritonitis. In some patients, a new PD catheter could be inserted after complete resolution of the peritonitis. PD catheter removal should also be considered for refractory exit site or tunnel infections. After the improvement in clinical practice, there is a worldwide trend of reduction in PD-associated peritonitis rate, supporting the use of PD as a first-line dialysis modality.

Keywords: Antibiotic; Infection; Peritonitis; dialysis; end-stage renal disease; microbiology; peritoneal dialysis.

Figure 1.

Algorithm for the management of peritoneal dialysis-related peritonitis. ^aClinical evaluation includes routine history, physical examination, examination of exit site and catheter tunnel, collection of PDE for cell count, differential count, Gram stain, and bacterial culture. ^bThe choice of empirical antibiotics coverage should be on the basis of patient history and center sensitivity patterns. ^cIn centers with a high prevalence of Gram-negative peritonitis, empirical Gram-negative coverage may be continued for culture negative peritonitis episodes. ^dNeed to screen for S. aureus carrier. ^eNeed to use vancomycin or other appropriate agents if enterococci identified. ^fGive two effective antibiotics according to sensitivity; also apply to Stenotrophomonas and other Pseudomonas-like species. ^gConsider surgical problem; in addition to Gram-negative coverage, consider metronidazole and vancomycin. ^hEspecially for peritonitis episodes caused by S. aureus or Pseudomonas species. CNSS, coagulase negative staphylococcal species; IP, intraperitoneal; PDE, peritoneal dialysis effluent.