Peritoneal Dialysis Peritonitis

Background

Typically occurs due to contamination with pathogenic skin bacteria during exchanges or due to exit-site/tunnel infection - Usually presents with cloudy effluent fluid and abdominal pain. Can also be asymptomatic
Important history to obtain: recent contamination, accidental disconnection, endoscopic or gynecologic procedure, as well as the presence of constipation or diarrhea
Definitive diagnosis requires 2 of the following:
Clinical features consistent with peritonitis, Positive dialysis effluent culture, Dialysis effluent with WBC > 100 with PMN > 50%

Examine catheter exit site
Culture peritoneal fluid (requires specific technique, done by Nephrology)
Peritoneal cell count with diff, gram stain and culture
- Obtain peripheral blood cultures if there is concern for sepsis

All PD orders, intraperitoneal antibiotics, and prescription adjustments should be directed by ESRD consult service (page them overnight if concerns)
Treatment with intraperitoneal antibiotics should be started immediately after specimens have been obtained if there is high clinical suspicion
Empiric antibiotics regimen should cover both gram-positive and gram-negative organisms, typically with Vancomycin and third generation cephalosporin
Systemic antibiotics are generally not necessary unless pts have systemic signs of sepsis
Patients with relapsing, recurrent or repeat peritonitis will likely need catheter removal

Treatment with intraperitoneal OR IV antibiotics (for any infection requiring > 1 dose of antibiotics) requires prophylaxis for fungal peritonitis with either
- Nystatin 400,000 to 500,000 units orally TID
- Fluconazole 200 mg every other day or 100 mg qdaily
Dialysate should be drained the day of endoscopies or gynecological procedures