01 Diagnosis and Treatment of Peritonitis in PD Patients ECO 33732 PDF

Diagnosis and Treatment of Peritonitis in Peritoneal
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 dialysis-
related 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.
P
eritonitis is an inflammation of the peritoneum, or abdominal cavity lining. It typically has an
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.
Monitoring and reporting of peritonitis rates and outcome evaluation
Peritoneal-dialysis infection (exit-site and peritonitis) rates should be monitored and reported for every
program annually. A goal rate of 1 episode per 18 months (0.67/year) is expected; although, rates of 1
episode per 41-52 months (0.29 0.23/year) are preferred. Additionally, the PD team comprised of
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Diagnosis and Treatment of Peritonitis in Peritoneal Dialysis
Patients
physicians and nurses, should review the presumed etiology, causative organisms and antibiotic
sensitivity of each infection. When infection rates are increasing or undesirably high, interventions should
be employed. The three main methods of reporting infections due to peritoneal dialysis include using
rates, percentages and median rates for each program. Rates may be calculated for individual organisms,
in addition to all infections. Percentages may be reported as how many patients are considered to be free
from peritonitis for a specified amount of time. Median rates may be calculated by taking the median from
a list of individual peritonitis rates.
It is important to monitor and report peritonitis rates, as well as evaluate outcomes. In order to properly
evaluate outcomes, a collection of data for analysis should be performed. The data should include the
date when the culture was collected, any organism identified and subsequent drug therapy utilized. In
addition, the date when the infection resolved should also be included. If another infection occurs, the
recurrent organisms and date of treatment should be noted along with the chosen method of temporary
renal replacement therapy. If the catheter is removed and a new catheter is inserted, the date of each (as
applicable) should be noted. Documentation of potential contributing factors such as break in technique,
exit-site infections, patient factors or tunnel infections, along with the date of re-education and training
should also be completed. The purpose of documentation of data is to evaluate the programs treatment
regimen to ensure best possible outcomes for patients. If the protocol is not effective in treatment and
prevention of peritonitis, it should be reassessed and changes should be implemented to achieve
satisfactory results.
Diagnosis of peritonitis: Signs and symptoms
PD patients could have a clinical presentation consistent with cloudy effluent and abdominal pain, which
can range from mild to severe. The severity of pain can be related to specific organisms (e.g., mild pain
with CoNS and severe pain with gram-negative rods, streptococcus, and S. aureus). The effluent cell
count with differential should be obtained, and if after 2 hours of dwell time, the WBC is greater than
100/L with a minimum of half being polymorphonuclear neutrophilic cells, inflammation is present and
peritonitis is deemed the probable cause. The gram stain should be used to define presence of yeast and
permit initiation of antifungal therapy and timely removal of catheter; however, the gram stain should not
be used for empiric therapy guidance. Sometimes the effluent may be clear despite abdominal pain. The
differential diagnosis should include other causes aside from peritonitis, such as constipation, peptic ulcer
disease, renal or biliary colic, acute intestinal perforation, and pancreatitis
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Patients
Obtaining dialysate cultures and initiating empiric antibiotic treatment
Obtaining the correct microbiological culture from the peritoneal effluent is necessary to identify the
responsible organism, as well as the antibiotic sensitivities. It can also help designate the likely source of
infection and guide appropriate antibiotic selection. Using standard culture technique, culture-negative
peritonitis rates of 10% maximum would be ideal; however, a rate of less than 20% of episodes is
acceptable. It is very important to quickly obtain a bacteriological diagnosis in order to reduce necessary
time for cultures. The diagnosis should be established within 3 days. If the cultures are not positive after
an incubation period of three to five days but an infection is suspected based upon clinical signs and
symptoms, it may be necessary to perform subcultures for an additional 3-4 days in order to reveal slow-
growing bacteria or yeast.
When considering empiric antibiotic treatment, it is important for the selection to encompass gram-
negative and gram-positive organisms concurrently. Additionally, center-specific selection for peritonitis-
causing organisms should be based upon the sensitivities of the local history. Gram-positive antibiotic
options include vancomycin or cephalosporins. Gram-negative coverage may be obtained through the
use of aminoglycosides or third-generation cephalosporins. Microbiological specimens should be
collected as quickly as possible and prior to the initiation of empiric antibiotics. The preferred
administration of antibiotics is intraperitoneal; intermittent and continuous dosing is equally effective (see
below: Intermittent or Continuous Dosing of Antibiotics).
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Patients
Empiric Antibiotic Treatment
After obtaining microbiological specimens for culturing,

immediately start the patient on two antibiotics, one
covering Gm (+) and one covering Gm (-) bacteria
Gram (+) Gram (-)
Does patient have penicillin or Aminoglycoside or

cephalosporin allergy? Is patient third generation cephalosporin
seriously ill? Does patient have a (cefepime or ceftazidime).
history of MRSA infection? Is Alternatively use carbapenem, or
there a high rate of MRSA at the a quinolone
care center?
Yes No
Vancomycin First generation

cephalosporin
(cefazolin or
cephalothin)
Allow intraperitoneal antibiotics to dwell for at least 6 hours.

Reevaluate treatment as soon as culture and sensitivity results are obtained.
If no results on day three, treat as culture negative peritonitis.
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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Patients
Specific peritonitis treatment according to culture results
Subsequent to obtaining the results of the culture and sensitivities, it is recommended that the empiric
antibiotic therapy be changed to a narrow spectrum antibiotic to cover the specific organism as
appropriate. Dose adjustments for renally-excreted drugs may be necessary in patients with considerable
residual renal function. The clinical response is used to guide treatment and to determine the length of
therapy. In general, clinical improvement should occur within the first 3 days after antibiotic initiation. In
uncomplicated cases, a total of 14 days is usually an adequate duration, with the antibiotic being
continued 7 days after clearing of effluent. Duration of 3 weeks may be necessary when patients are
slower to respond to therapy, usually in the context of a severe infection often caused by gram-negative
organisms, S. aureus, or enterococcus.
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Patients
Culture Results
Change empiric treatment to reflect

culture and sensitivity results; if no
results on day three, treat as culture
negative peritonitis
Gram (+) Gram (-) Poly-microbial Fungal Culture neg.
Staphylo Coryne Multiple g(+) Multiple g(-) or

coccus bacterium organisms mixed g(+) and
(-) organisms
Streptococcus or
Enterococcus
Candida Other
(Aspergillus,
etc.)
Pseudomonas Stenotrophomonas
Other (E. coli, Proteus,

Klebsiella, etc.)
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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Patients
Gram positive culture
Coagulase-negative staphylococcus (CoNS) is a very common cause of peritonitis and consists of about
20 species that are clinically relevant. The route of infection is mainly due to touch contamination. It is
important for the laboratories to obtain identification of the precise species level whenever possible. This
assists in differentiation between contaminated cultures and true infections. In general, S. epidermidis
responds well to therapy and is rarely associated with catheter infections. Mild pain is a common
symptom and outpatient therapy is typically used. However, when relapsing peritonitis is caused by S.
epidermidis, the catheter is often colonized by biofilm and treatment with catheter replacement in a single
procedure is the best option. Often programs have methicillin-resistant organisms present in high rates
and therefore vancomycin should be used as empiric therapy. Touch contamination and catheter infection
can lead to a severe form of peritonitis caused by Staphylococcus aureus. Vancomycin is the drug of
choice, but rifampicin may be added for up to one week. Teicoplanin can also be used for 3 weeks, where
available.
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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Patients
Gram (+)
Culture
Staphylococcus Corynebacterium Streptococcus or

Enterococcus
Methicillin
resistant S. Give vancomycin Ampicillin-resistant?
aureus? x3 wks
YES NO
YES NO
Vancomycin-resistant Give
Enterococcus? ampicillin5
Continue g(+)
Give coverage
vancomycin based on
or sensitivity. YES NO
teicoplanin1 Stop g(-)
Consider coverage.
adding Consider Give
Give quinupristin/
rifampin2 adding vancomycin
dalfopristin, daptomycin,
rifampin2 or linezolid3
Assess clinical improvement, repeat dialysis effluent cell count and culture at days 3-5
If clinical improvement: If no clinical improvement:

Continue antibiotics and reevaluate for exit- Reculture and evaluate
site or occult tunnel infection, abdominal
abscess, catheter colonization, etc.
Continue for: S. aureus If exit-site or tunnel If no improvement after 5

and Enterococcus 21 infection exists, catheter days on appropriate
days; Other Staph and removal should be antibiotics, remove catheter6
Strep: 14 days seriously considered4
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Patients
Figure 3: Gram-positive culture. Modified from: Li PK, Szeto CC, Piraino B, et al. Peritoneal dialysis-
related infections recommendations: 2010 update. Perit Dial Int 30:393-423, 2010
1 2
If vancomycin-resistant S. aureus, use linezolid, daptomycin, or quinupristin/dalfopristin; 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
3
patient is infected with methicillin-resistant S. aureus. Limit use to 5-7 days; If linezolid is used for
vancomycin-resistant enterococcus, bone marrow suppression has been noted after 10-14 days; 4 Allow a
5
minimum rest period of 3 weeks before reinitiating peritoneal dialysis; Consider adding an
6
aminoglycoside for synergy, however, do not mix in same bag; The duration of antibiotic therapy
following catheter removal and timing or resumption of peritoneal dialysis may be modified depending on
the clinical course.
Gram negative culture
Pseudomonas aeruginosa is another common cause of severe peritonitis. It is also often associated with
a catheter infection, and therefore removal of the catheter is recommended for better outcomes. P.
aeruginosa is linked to increased frequency of hospitalizations and transfer to permanent hemodialysis. It
is important to always use two antibiotics with two different mechanisms to ensure complete eradication of
the organism.
Single Gram-negative organisms (for example, Klebsiella, E.coli, or Proteus) that cause peritonitis may
originate from exit-site infections, touch contamination or a bowel source (constipation, colitis or
diverticulitis). Although treatment should be based upon sensitivity results, it is important to consider
these organisms may be present in the biofilm state, which can lead to treatment failure. This occurs
because the organisms are significantly less sensitive than laboratory results may indicate. For risk
reduction of recurrence and relapse, it is suggested that two antibiotics should be used.
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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Patients
Gram (-)
Culture
Pseudomonas Other (E. coli, Proteus, Stenotrophomonas

Klebsiella, etc.)
Give two antibiotics with Give two antibiotics with

different mechanisms (i.e. different mechanisms based
oral quinolone, Adjust antibiotics to
on sensitivity pattern (i.e.
ceftazidime, cefepime, sensitivity pattern;
oral TMP/SMZ2, IP
tobramycin, piperacillin) ceftazidime or
ticarcillin/clavulanate, oral
cefepime may be
minocycline)
indicated
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 clinical improvement, continue therapy for: If no clinical improvement by 5

Pseudomonas: 21 days days on appropriate antibiotics,
Stenotrophomonas: 21-28 days remove catheter
Other: 14-21 days
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Patients
Figure 4: Gram-negative culture. Modified from: Li PK, Szeto CC, Piraino B, et al. Peritoneal dialysis-
related infections recommendations: 2010 update. Perit Dial Int 30:393-423, 2010
1
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
2
modified depending on clinical course; TMP/SMZ is preferred. TMP/SMZ: Trimethoprim and
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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Patients
Culture-negative peritonitis rates should be less than 20% for all programs. If this is not the case, then
review of culture methods is needed for improvement. Negative cultures may be observed due to clinical
or technical reasons. For example, antibiotic use of any kind can produce a negative culture. Some
organisms are difficult to diagnose in routine culture. When under clinical consideration, atypical causes
of peritonitis can be determined by using special culture techniques. Unusual causes include lipid-
dependent yeast, mycobacteria, Legionella, Campylobacter, slow-growing bacteria, fungi, enteroviruses,
Ureaplasma, and Mycoplasma. Initial therapy may be continued for 2 weeks if clinical improvement is
noted and the effluent clears quickly. However, if improvement is not observed in 5 days, catheter
removal is recommended.
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Patients
Poly- Culture
Fungal
microbial Negative
Multiple g(+) Multiple g(-) or Days 1-2: If culture is Remove catheter1

organisms mixed g(+/-) negative, continue
organisms initial therapy
Continue Change to Day 3: If culture is still Other Candida

antibiotics metronidazole + negative, repeat PD (Aspergillus, species
based on ampicillin, fluid white cell count etc.)
sensitivities ceftazidime, or and differential, then
for a aminoglycoside; perform clinical Give Give
minimum of continue for 14 assessment echinocandins amphotericin
21 days days B3 and
flucytosine4
If exit-site Obtain surgical Day 3: If no Day 3: If Once

or tunnel assessment2. improvement in improvement in susceptibility
infection is If laparotomy differential or differential or results are
present, indicates intra- clinical clinical available,
remove abdominal assessment, assessment, amphotericin B
catheter1 pathology consider special continue can be replaced
/abscess, culture technique therapy for 14 by echinocandins
remove the for unusual days or azoles;
catheter1. causes (i.e. viral, continue
fungi, bacteria, flucytosine5
etc.)
Reculture is positive Reculture is negative
Adjust therapy according to sensitivity Continue antibiotics for at least 14 days.

patterns; duration of therapy should be Remove catheter1 if no improvement
based on organism(s) after 5 days
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Patients
Figure 5: Polymicrobial, Fungal or Culture Negative. Modified from: Li PK, Szeto CC, Piraino B, et al.
Peritoneal dialysis-related infections recommendations: 2010 update. Perit Dial Int 30:393-423, 2010.
1
The duration of antibiotic therapy following catheter removal and timing or resumption of peritoneal
2
dialysis depends on the clinical course; Hypotension, sepsis, lactic acidosis, or elevation of peritoneal
3
amylase should raise immediate concern for surgical peritonitis; IP use of amphotericin causes
4
chemical peritonitis and pain, while IV leads to poor peritoneal bioavailability; 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.
Drug Dosing and Stability
Drugs that can be admixed in one dialysis solution bag include aminoglycosides, vancomycin, and
cephalosporins; however, chemical incompatibility exists between penicillins and aminoglycosides and
therefore should not be mixed. The use of separate syringes is necessary for admixture of antibiotics into
the same bag, in conjunction with sterile technique. When dialysis solutions contain dextrose, the time of
stability of added antibiotics is variable (Table 1).
Antibiotic Stability1 in Dextrose-Containing2 Dialysis Solutions
Antibiotic Concentration Stability (days) Storage temperature

Vancomycin 25 mg/L 28 RT
Gentamicin 8 mg/L 14 ---
Cefazolin 500 mg/L 8 RT
14 Refrigerated
Ceftazidime 125 mg/L 4 RT
7 Refrigerated
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
1
30:393-423, 2010. It is possible that these antibiotics are stable for longer periods; more research is
2
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.
Intermittent or Continuous Dosing of Antibiotics: Special Considerations for APD
It is well known that the preferred method of dosing antibiotics in peritonitis is intraperitoneal (IP). IP
dosing is favored over intravenous (IV) dosing because the local levels that can be achieved are higher
with IP. Additionally, IP route is advantageous because the patient can perform it at home after adequate
training. It also avoids venipuncture necessary for IV access. Optional dosing regimens of IP antibiotics
include once daily (intermittent) or per each exchange (continuous). The antibiotic must dwell for a
minimum of 6 hours to ensure adequate absorption.
There are few antibiotic dosing recommendations for APD patients and when given equivalent doses as
CAPD patients, significant under-dosing could occur. This can be due to rapid exchanges, where there is
not enough time given for the antibiotic to be absorbed in the systemic circulation. This can be avoided by
utilizing the 6 hour dwell time. Refer to Table 2 for dosing recommendations for CAPD and APD, where
evidence exists. The debate between increased efficacies of continuous dosing versus intermittent dosing
is still lacking evidence. It is a concern that with quick exchanges in APD there is inadequate time for
achievement of IP levels. The possibility of biofilm-associated organisms is raised when there are only
daytime exchanges of a single cephalosporin, resulting in IP levels that are below MIC at nighttime. It is
unclear at this time if patients on a cycler should convert to CAPD temporarily or reset the cycler to permit
a longer exchange time. Another consideration is the practicality of switching patients on APD to CAPD,
since necessary supplies or training may not be accessible to the patient.
Additional data support that APD leads to increased peritoneal clearance of antibiotics when compared to
CAPD, which results in dialysate concentrations lower than the MIC for sensitive organisms. Clinicians
should choose the higher end of the dosing range for patients that have a rapid removal of antibiotics.
Clinical improvement should be seen within 48 hours as a clearing of effluent; if there is no improvement,
a repeat cell count and culture is necessary.
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Antibiotic Dosing Regimens
Medication CAPD IP Dosing1 Automated PD IP Dosing

Intermittent Continuous Intermittent
(per exchange, (mg/L, all exchanges) (per exchange, once daily)
Aminoglycosides once daily)
Amikacin 2 mg/kg LD 25, MD 12
Tobramycin 0.6 mg/kg LD 8, MD 4 LD 1.5 mg/kg IP in long dwell, then 0.5
mg/kg IP daily in long dwell
Gentamicin, netilmicin 0.6 mg/kg LD 8, MD 4
Cephalosporins
Cephalothin,
cephradine 15 mg/kg LD 500, MD 125
Cefazolin 15 mg/kg LD 500, MD 125 20 mg/kg IP in long day dwell
Cefepime 1000mg LD 500, MD 125 1 g IP in 1 exchange daily
Ceftazidime 1000-1500 mg LD 500, MD 125
Ceftizoxime 1000mg LD 250, MD 125
Penicillins
Amoxicillin No data LD 250-500, MD 50
Ampicillin, oxacillin,
No data MD 125
nafcillin
Azlocillin No data LD 500, MD 250
Ampicillin/sulbactam 2 g every 12 hrs LD 1000, MD 100
LD 50000 units
Penicillin G No data
MD 25000 units
Quinolones
Ciprofloxacin No data LD 50, MD 25
Others
Aztreonam No data LD 1000, MD 250
Daptomycin No data LD 100, MD 20
Linezolid Oral 200-300 mg daily
Teicoplanin 15 mg/kg LD 400, MD 20
Vancomycin LD 30 mg/kg IP in long dwell; repeat
15-30 mg/kg
(Dose depends on LD 1000, MD 25 dosing 15 mg/kg IP in long dwell every
every 5-7 days 2
serum trough levels) 3-5 days
Imipenem/cilastin 1g twice daily LD 250, MD 50
TMP/SMZ Oral 960 mg BID
25 mg/L in
Quinupristin/dalfopristin
alternate bags3
Antifungals
Amphotericin B Not applicable 1.5
200 mg IP every 200 mg IP in 1 exchange per day every
Fluconazole
24-48 hrs 24-48 hours
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Table 2: Antibiotic dosing regimens. Based on: Li PK, Szeto CC, Piraino B, et al. Peritoneal dialysis-
related 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
2
empirically increased by 25%; Vancomycin should be re-dosed if serum trough levels fall below 15
3
g/mL; Given in conjunction with 500 mg quinupristin/dalfopristin intravenous twice daily. CAPD:
continuous ambulatory peritoneal dialysis. LD: loading dose. MD: maintenance dose.
Refractory, Relapsing, Recurrent, and Repeat Peritonitis
The 2010 ISPD Guidelines give the following definitions:

Refractory peritonitis results when there is failure of the effluent to clear after 5 days of appropriate
antibiotics. Relapsing peritonitis can be defined by an episode that occurs within 4 weeks of completion of
a therapy of a prior episode with the same organism or 1 sterile episode. Recurrent peritonitis refers to an
episode that occurs within 4 weeks of completion of therapy of a prior episode but with a different
organism. Repeat peritonitis occurs more than 4 weeks after completion of therapy of a prior episode with
the same organism. Catheter-related peritonitis is in conjunction with an exit-site or tunnel infection with
the same organism or 1 site sterile.
When peritonitis rates are calculated, relapsing episodes are not considered another peritonitis episode;
however, repeat and recurrent episodes are counted.
Catheter removal is indicated in refractory and relapsing peritonitis, refractory exit-site and tunnel
infections, and fungal peritonitis. It may also be considered for repeat peritonitis, mycobacterial peritonitis,
and multiple enteric organisms. In the case of relapsing peritonitis, once the effluent is cleared, the
catheter can be removed and replaced in a single procedure with use of antibiotic coverage. It is
recommended that a time period of 2-3 weeks be utilized between catheter removal and reinsertion when
cases are refractory or fungal.
Refractory peritonitis should be managed by removing the catheter to protect the peritoneal membrane
for future use. The catheter may be replaced after infection resolution, provided that both the previous
and current episode is caused by the same organism. The primary goal of peritonitis treatment is to focus
on the patient and protect the peritoneum, not to save the catheter. Severe episodes of peritonitis may
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Patients
prevent patients from returning to PD. Adhesions may prevent catheter reinsertion or the peritoneal
membrane may have been permanently damaged, thus no longer able to be used for PD. Prolonged
treatment attempts lead to longer hospital stays, damage to the peritoneum, greater risk for fungal
infection, and potentially death. Death should be very infrequent, and risk is highest with fungus and
gram-negative bacilli as causative organisms.
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.
Prevention of Further Peritonitis
An analysis should always be performed to determine the cause of the peritonitis episode, as well as any
interventions against reversible risk factors in prevention of further episodes. Touch contamination is a
common cause, and whenever necessary, the patient should be retrained to ensure proper technique for
further prevention. Additional information regarding prevention of peritonitis will be discussed in detail in
another chapter.
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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P/N 101349-01 Rev 00 11/2010
Patients
sensitivity, empiric therapy should be tailored to the most narrow spectrum antibiotic as appropriate and
should be continued for up to 3 weeks depending on clinical response. The goals of treatment of
peritonitis include rapid resolution of inflammation by eradication of causative organism and preservation
of peritoneal membrane function. Monitoring and reporting peritonitis rates, as well as evaluating
outcomes of peritonitis treatment are important to ensure patients are receiving the best possible
treatment.
19 / 19
P/N 101349-01 Rev 00 11/2010

01 Diagnosis and Treatment of Peritonitis in PD Patients ECO 33732 PDF

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Diagnosis and Treatment of Peritonitis in Peritoneal

Monitoring and reporting of peritonitis rates and outcome evaluation

Diagnosis of peritonitis: Signs and symptoms

Obtaining dialysate cultures and initiating empiric antibiotic treatment

Empiric Antibiotic Treatment

After obtaining microbiological specimens for culturing,

Gram (+) Gram (-)

Does patient have penicillin or Aminoglycoside or

Vancomycin First generation

Allow intraperitoneal antibiotics to dwell for at least 6 hours.

Specific peritonitis treatment according to culture results

Change empiric treatment to reflect

Gram (+) Gram (-) Poly-microbial Fungal Culture neg.

Staphylo Coryne Multiple g(+) Multiple g(-) or

Other (E. coli, Proteus,

Gram positive culture

Staphylococcus Corynebacterium Streptococcus or

If clinical improvement: If no clinical improvement:

Continue for: S. aureus If exit-site or tunnel If no improvement after 5

Gram negative culture

Pseudomonas Other (E. coli, Proteus, Stenotrophomonas

Give two antibiotics with Give two antibiotics with

If clinical improvement, continue therapy for: If no clinical improvement by 5

Polymicrobial, fungal and culture negative peritonitis

Multiple g(+) Multiple g(-) or Days 1-2: If culture is Remove catheter1

Continue Change to Day 3: If culture is still Other Candida

If exit-site Obtain surgical Day 3: If no Day 3: If Once

Reculture is positive Reculture is negative

Adjust therapy according to sensitivity Continue antibiotics for at least 14 days.

Drug Dosing and Stability

Antibiotic Stability1 in Dextrose-Containing2 Dialysis Solutions

Antibiotic Concentration Stability (days) Storage temperature

Intermittent or Continuous Dosing of Antibiotics: Special Considerations for APD

Antibiotic Dosing Regimens

Medication CAPD IP Dosing1 Automated PD IP Dosing

Refractory, Relapsing, Recurrent, and Repeat Peritonitis

The 2010 ISPD Guidelines give the following definitions:

Prevention of Further Peritonitis

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