Peritoneal dialysis-associated peritonitis

Background
  • Most common complication of peritoneal dialysis. The patient uses their peritoneum as a dialysis membrane in conjunction with a surgically placed dialysis catheter that penetrates the abdominal wall. Either at night or multiple times during the day peritoneal fluid is infused into the abdomen in an ambulatory setting or at home.
  • Diagnosis of peritonitis usually is made by the patient when a cloudy dialysis effluent is noted, increased abdominal pain or white blood cells (WBCs) in the dialysate

Causative Organisms

Clinical Features
  • Presentation no different from other causes of peritonitis
  • Patients may report a cloudy dialysate

Differential Diagnosis
  • Abdominal pain standard differential also applies to patients with peritoneal dialysis in addition to concern for peritonitis

Dialysis Complications

Cloudy Effluent Differential
  • Culture-positive infectious Peritonitis
  • Infectious peritonitis with sterile cultures
  • Chemical peritonitis
  • Eosinophilia of the effluent
  • Hemoperitoneum
  • Malignancy
  • Chylous effluent (rare)
  • Specimen taken from “dry” abdomen

Evaluation
  • Send dialysate fluid for cell count, Gram stain, culture (if available)
    • Cell count >100/mm3 with >50% neutrophils most consistent with infection[1]

Special Considerations

There must be dialysis fluid "dwelling" within the patient for adequate fluid collection. If the patient is not "dwelling" then coordination with nephrology is required to infuse fluid to be used to sample the peritoneum. Fluid may be required to "dwell" for a few hours prior to collection.

CT Abdominal Scan

Perform only if necessary as part of the abdominal pain workup, to rule-out other (secondary) causes of peritonitis

  • CT WITHOUT IV contrast
    • Patients are dependent on small amounts of residual renal function and thus risk of contrast outweighs benefits

Management

Empiric Therapy (IP)
10- to 14-day course of intraperitoneal (IP) antibiotics that are administered by the patient on an outpatient basis or IV antibiotics and intraperitoneal for admitted patients
  • Vancomycin 30mg/kg loading followed by 0.6 mg/kg IP daily PLUS[2]
  • Ceftazidime 1g IP daily OR
  • Gentamycin 0.6mg/kg daily
  • Catheter removal/exchange is usually only done if IP antibiotics fail (fungal, pseudomonal), and should be done in consultation with a nephrologist[3]

Empiric Tharapy (IV)

Although IP antibiotics are preferred IV antibiotics can be considered with coordination with nephrology for dosing. Coverage should be the same as IP antibiotics [4][5]

Disposition
  • In consultation with nephrology service:
    • Depending on patient reliability and level of illness, outpatient peritoneal antibiotics vs. inpatient therapy

See Also

References
  1. ISPD GUIDELINES/RECOMMENDATIONS http://www.ispd.org/guidelines/articles/update/ispdperitonitis.pdf
  2. Li PK, et al: Peritoneal dialysis-related infections recommendations: 2010 update. Perit Dial Int 2010; 30:393 Fulltext
  3. Akoh JA. Peritoneal dialysis associated infections: An update on diagnosis and management. World J Nephrol. 2012 Aug 6; 1(4): 106–122.
  4. Manley HJ, Bailie GR, Frye RF, McGoldrick MD. Intravenous vancomycin pharmacokinetics in automated peritoneal dialysis patients. Perit Dial Int 2001;21 :378-85
  5. Wong et al. Intravenous Antibiotics with Adjunctive Lavage in Refractory Peritonitis. Intravenous Antibiotics with Adjunctive Lavage in Refractory Peritonitis
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