Professional Documents
Culture Documents
Dialysis Patients
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
conclusions and making decisions. This document should not be considered an endorsement of the
information provided nor is it intended for treatment purposes and is not a substitute for professional
evaluation and diagnosis. Additionally, this information is not intended to advocate any indication, dosage
or other claim that is not covered, if applicable, in the FDA-approved label.
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 dialysisrelated 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.
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.
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Gram (+)
Gram (-)
Aminoglycoside or
third generation cephalosporin
(cefepime or ceftazidime).
Alternatively use carbapenem, or
a quinolone
Yes
No
Vancomycin
First generation
cephalosporin
(cefazolin or
cephalothin)
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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Culture Results
Change empiric treatment to reflect
culture and sensitivity results; if no
results on day three, treat as culture
negative peritonitis
Gram (+)
Staphylo
coccus
Gram (-)
Coryne
bacterium
Poly-microbial
Multiple g(+)
organisms
Fungal
Culture neg.
Multiple g(-) or
mixed g(+) and
(-) organisms
Streptococcus or
Enterococcus
Candida
Pseudomonas
Other
(Aspergillus,
etc.)
Stenotrophomonas
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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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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Gram (+)
Culture
Staphylococcus
Corynebacterium
Streptococcus or
Enterococcus
Methicillin
resistant S.
aureus?
Give vancomycin
x3 wks
Ampicillin-resistant?
YES
YES
NO
NO
Vancomycin-resistant
Enterococcus?
Give
vancomycin
or
teicoplanin1
Consider
adding
rifampin2
Continue g(+)
coverage
based on
sensitivity.
Stop g(-)
coverage.
Consider
adding
rifampin2
YES
Give
ampicillin5
NO
Give quinupristin/
dalfopristin, daptomycin,
or linezolid3
Give
vancomycin
Assess clinical improvement, repeat dialysis effluent cell count and culture at days 3-5
If clinical improvement:
Continue antibiotics and reevaluate for exitsite or occult tunnel infection, abdominal
abscess, catheter colonization, etc.
If exit-site or tunnel
infection exists, catheter
removal should be
seriously considered4
If no clinical improvement:
Reculture and evaluate
If no improvement after 5
days on appropriate
antibiotics, remove catheter6
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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;
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;
aminoglycoside for synergy, however, do not mix in same bag;
Consider adding an
following catheter removal and timing or resumption of peritoneal dialysis may be modified depending on
the clinical course.
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
Adjust antibiotics to
sensitivity pattern;
ceftazidime or
cefepime may be
indicated
Stenotrophomonas
Exit site
infection?
YES
NO
Remove
catheter and
continue
antibiotics on
temporary HD1
Assess clinical improvement, repeat dialysis effluent cell count and culture at days 3-5
If no clinical improvement by 5
days on appropriate antibiotics,
remove catheter
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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;
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
Polymicrobial
Fungal
Multiple g(+)
organisms
Multiple g(-) or
mixed g(+/-)
organisms
Continue
antibiotics
based on
sensitivities
for a
minimum of
21 days
Change to
metronidazole +
ampicillin,
ceftazidime, or
aminoglycoside;
continue for 14
days
If exit-site
or tunnel
infection is
present,
remove
catheter1
Obtain surgical
assessment2.
If laparotomy
indicates intraabdominal
pathology
/abscess,
remove the
catheter1.
Day 3: If no
improvement in
differential or
clinical
assessment,
consider special
culture technique
for unusual
causes (i.e. viral,
fungi, bacteria,
etc.)
Remove catheter1
Other
(Aspergillus,
etc.)
Candida
species
Give
echinocandins
Give
amphotericin
B3 and
flucytosine4
Day 3: If
improvement in
differential or
clinical
assessment,
continue
therapy for 14
days
Once
susceptibility
results are
available,
amphotericin B
can be replaced
by echinocandins
or azoles;
continue
flucytosine5
Reculture is positive
Reculture is negative
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The duration of antibiotic therapy following catheter removal and timing or resumption of peritoneal
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.
Concentration
Stability (days)
Storage temperature
Vancomycin
25 mg/L
28
RT
Gentamicin
8 mg/L
14
---
500 mg/L
RT
14
Refrigerated
RT
Refrigerated
Cefazolin
Ceftazidime
125 mg/L
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.
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;
Icodextrin-
containing dialysis solutions are compatible with vancomycin, cefazolin, ampicillin, cloxacillin, ceftazidime,
gentamicin and amphotericin; 3 Heparin reduces stability. RT: room temperature.
CAPD IP Dosing1
Intermittent
Continuous
Automated PD IP Dosing
Intermittent
(per exchange,
once daily)
2 mg/kg
Tobramycin
0.6 mg/kg
LD 8, MD 4
Gentamicin, netilmicin
0.6 mg/kg
LD 8, MD 4
Cephalosporins
Cephalothin,
cephradine
Cefazolin
15 mg/kg
LD 500, MD 125
15 mg/kg
LD 500, MD 125
Aminoglycosides
Amikacin
Cefepime
LD 25, MD 12
1000mg
LD 500, MD 125
Ceftazidime
1000-1500 mg
LD 500, MD 125
Ceftizoxime
1000mg
LD 250, MD 125
Amoxicillin
Ampicillin, oxacillin,
nafcillin
Azlocillin
No data
LD 250-500, MD 50
No data
MD 125
No data
LD 500, MD 250
Ampicillin/sulbactam
2 g every 12 hrs
LD 1000, MD 100
LD 50000 units
MD 25000 units
Penicillins
Penicillin G
No data
Quinolones
Ciprofloxacin
No data
LD 50, MD 25
Aztreonam
No data
LD 1000, MD 250
Daptomycin
No data
LD 100, MD 20
Others
Linezolid
Teicoplanin
Vancomycin
(Dose depends on
serum trough levels)
Imipenem/cilastin
TMP/SMZ
Quinupristin/dalfopristin
LD 400, MD 20
15-30 mg/kg
every 5-7 days 2
LD 1000, MD 25
1g twice daily
LD 250, MD 50
Antifungals
Amphotericin B
Fluconazole
Not applicable
200 mg IP every
24-48 hrs
1.5
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 dialysisrelated 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
continuous ambulatory peritoneal dialysis. LD: loading dose. MD: maintenance dose.
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.
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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