Peritoneal dialysis (PD)-related peritonitis

[Perit Dial Int 2022;42:110-53]

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Prevention of catheter infections

- Increased risk for S. aureus infections if:

• S. aureus nasal carrier

• diabetic

• immunocompromised.

- Daily application of topical mupirocin cream or ointment at the catheter exit site is recommended to decrease S. aureus exit site infections. Gentamicin cream can be used as an alternative to mupirocin. Triple^® antibiotic ointment (polymyxin, bacitracin, neomycin) is not superior to topical mupirocin.

Prevention of fungal peritonitis

- Antifungal prophylaxis with oral nystatin 500,000 units PO qid or fluconazole 200mg PO q48h for duration of antibiotic therapy plus one week  is recommended for patients requiring antibiotic therapy, regardless of the indication.

Diagnosis

• Submit 5-10 mL of effluent into each of an aerobic and anaerobic blood culture bottle, and 50 mL in a sterile container for Gram stain and culture.

• First cloudy effluent should be submitted to laboratory for cell count and differential.

• Repeat culture not recommended if cell count decreasing and symptomatic improvement.

• Blood cultures if patient is septic or on immunosuppression.

- Diagnosis of PD peritonitis includes at least two of the following:

1. clinical features consistent with peritonitis, e.g. abdominal pain and/or cloudy dialysis effluent

2. dialysis effluent WBC > 0.1 x 10⁹/L (after dwell time of at least 2 hours) with > 50% PMNs

• For APD with rapid cycle treatment, the percentage of PMN >50% is diagnostic even if WBC < 0.1 x 10⁹/L.

3. positive dialysis effluent culture

• If cell count/symptoms not improving, repeat culture within 3 days.

If culture negative peritonitis consider: (1) culture volume too small, (2) prior use of antibiotics, (3) unusual causes of peritonitis: mycobacteria; nocardia, fungi, including lipid-dependent yeast; Legionella spp, slow-growing/fastidious bacteria (e.g. Campylobacter spp, Ureaplasma spp, Mycoplasma spp); enteroviruses. Repeat cell count and differential, Gram stain, and bacterial, fungal and mycobacterial cultures at 3-5 days if culture negative. Consult microbiologist.

Treatment

- Intraperitoneal (IP) administration of antibiotics recommended over IV administration, unless patient is septic.

- Tailor empiric therapy according to C&S results, not Gram stain result. For organism - specific recommendations, see Recommended Therapy of Culture-Directed Infections, Treatment of Culture-proven Peritoneal Dialysis (PD) Peritonitis in Adults.

- For severely symptomatic peritonitis, 1-2 rapid exchanges of peritoneal dialysis solution prior to longer dwell exchange with intraperitoneal (IP) antibiotics, have been shown to provide pain relief.

- Recommend program specific evaluation of local susceptibility patterns.

- Cefazolin + ceftazidime is NOT an optimal empiric regimen for PD peritonitis because:

• the use of 2 cephalosporins may be antagonistic

• cefazolin and aminoglycoside (AG) combinations may be synergistic against organisms such as coagulase negative Staph

• strong association between ceftazidime and selection of ß-lactamase mediated resistance in Enterobacterales (both extended spectrum-ß-lactamase [ESBL] and inducible [AmpC] ß-lactamase).

- Short courses of aminoglycosides for an episode of PD peritonitis do not adversely affect residual renal function.

- Cefepime monotherapy may be considered in patients with pre-existing vestibular/cochlear toxicity.

Cefepime dose:

• intermittent: 1g IP once per day

• continuous: 500mg/L LD, then 125mg/L MD.

- Ciprofloxacin no longer recommended empirically due to unacceptably high resistance and declining effectiveness.

- If no improvement at 48 hours, repeat dialysis effluent cell count and differential, Gram stain, and culture, and evaluate for exit site/tunnel infection.

- Indications for catheter removal:

• refractory (dialysis effluent persistently cloudy or with WBC > 100 x 10⁹/L after 5 days of appropriate antibiotic therapy) peritonitis
  • observation for antibiotic response longer than 5 days is appropriate if effluent WBC is decreasing towards normal
• refractory (unresponsive to ≥ 3 weeks of appropriate antibiotics) exit site and/or tunnel infection
• fungal peritonitis
• mycobacterial peritonitis

- Consider catheter removal for:

• relapsing (occurs within 4 weeks of completion of therapy of a previous episode with same organism or one culture-negative episode) peritonitis

• repeat (occurs more than 4 weeks after completion of therapy of a previous episode with same organism) peritonitis

• recurrent (occurs within 4 weeks after completion of therapy of a previous episode with a different organism) peritonitis

NB:  for relapsing, repeat, recurrent peritonitis, consider simultaneous catheter removal and reinsertion if:

• • PD effluent culture negative
  • WBC < 0.1 x 10⁹/L
  • no exit site/tunnel infection.
• polymicrobial peritonitis (high relapse rate; evaluate for intra-abdominal abscess).

- Cefazolin + AG has been shown to have equivalent efficacy as vancomycin + AG as empiric therapy of PD peritonitis.

Coagulase negative Staph
S. aureus
Enterobacterales

Cefazolin allergy/MRSA colonization

APD = automated peritoneal dialysis

CAPD = continuous ambulatory peritoneal dialysis