Peritonitis in patients on PD

Background

• Etiology likely 2/2 contamination with pathogenic skin bacteria during exchanges or due to exit-site or tunnel infection
• Usually present with cloudy effluent fluid and abdominal pain but can be present even in the absence of one of these
• 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%
    • • Even if WBC count < 100, presence of > 50% PMNs is still strong evidence of peritonitis in pts with rapid cycle PD

Evaluation

• Culture peritoneal fluid (requires training and equipment, performed by Nephrology)
• Peritoneal cell count with diff, gram stain and culture
• Obtain peripheral blood cultures if there is concern for sepsis

Management

• 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 Vanc and third generation Cephalosporin
• Systemic antibiotics are generally not necessary unless pts have systemic signs of sepsis
• Pts with relapsing, recurrent or repeat peritonitis will likely need catheter removal