Peritoneal Dialysis Peritonitis

Background 

  • Typically due to contamination with pathogenic skin bacteria 
  • Usually presents with cloudy effluent fluid and abdominal pain, but can 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%

Evaluation 

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

Management 

REQUIRES Nephrology involvement 

  • 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 

Secondary prevention

  • 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

Secondary prevention

  • 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
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