Peritonitis in patients on PD

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

 

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