What are the guidelines for managing peritoneal dialysis (PD)-related infections?

From the Guidelines

Peritoneal dialysis patients with suspected peritonitis should immediately collect a dialysate sample for cell count, Gram stain, and culture, then start empiric antibiotic therapy with intraperitoneal vancomycin (15-30 mg/kg) plus a third-generation cephalosporin like ceftazidime (1-1.5g) or an aminoglycoside, as recommended by recent guidelines 1. The management of peritonitis in peritoneal dialysis patients is crucial to prevent technique failure and transfer to hemodialysis.

• Key aspects of peritonitis management include:
  • Empiric antibiotic therapy with coverage for both Gram-positive and Gram-negative organisms
  • Collection of dialysate samples for cell count, Gram stain, and culture to guide antibiotic therapy
  • Adjustment of antibiotic therapy based on culture results
  • Consideration of catheter removal for refractory infections, fungal peritonitis, or tunnel infections Recent studies have highlighted the importance of appropriate empiric antibiotic therapy in the management of intra-abdominal infections, including peritonitis in peritoneal dialysis patients 1.
• The recommended empiric regimen includes intraperitoneal vancomycin (15-30 mg/kg) plus a third-generation cephalosporin like ceftazidime (1-1.5g) or an aminoglycoside.
• The choice of antibiotic therapy should be guided by regional epidemiological data and resistance profiles, as well as the results of microbiological testing 1. In addition to antibiotic therapy, other aspects of peritonitis management are important, including:
• Prevention of peritonitis through strict infection control protocols, such as hand hygiene and exit site care
• Early recognition and treatment of peritonitis to prevent complications and improve outcomes
• Consideration of the potential for multidrug-resistant organisms (MDROs) in patients with healthcare-associated infections, and adjustment of antibiotic therapy accordingly 1.

From the Research

Peritoneal Dialysis Infection Guidelines

• Peritoneal dialysis (PD) is associated with a high risk of infection of the peritoneum, subcutaneous tunnel, and catheter exit site 2
• The reported overall rate of PD-associated infection is 0.24-1.66 episodes/patient/year, with quality standards demanding an infection rate < 0.67 episodes/patient/year on dialysis 2
• Gram-positive cocci, such as Staphylococcus epidermidis and Staphylococcus aureus, are the most frequent aetiological agents of PD-associated peritonitis worldwide 2

Diagnosis and Management

• Empiric antibiotic therapy must cover both gram-positive and gram-negative organisms 2
• The use of systemic vancomycin and ciprofloxacin administration is a simple and efficient first-line protocol antibiotic therapy for PD peritonitis, with a success rate of 77% 2
• For fungal PD peritonitis, it is now standard practice to remove PD catheters in addition to antifungal treatment for a minimum of 3 weeks and subsequent transfer to hemodialysis 2
• A proportional meta-analysis showed that the association of a glycopeptide plus ceftazidime is superior to other regimens for initial treatment of PD peritonitis 3

Prevention of PD-Associated Infections

• Prophylactic antibiotic administration before catheter placement, adequate patient training, exit-site care, and treatment for S. aureus nasal carriage should be employed to prevent PD-associated infections 2
• Mupirocin treatment can reduce the risk of exit site infection by 46%, but it cannot decrease the risk of peritonitis due to all organisms 2
• The uptake of interventions to prevent PD-associated infections in clinical practice around the world remains inconsistent, despite evidence for their efficacy 4

Antibiotic Utilization

• A retrospective study in Malaysia found that the most common first-line empirical antibiotic combinations used for CAPD-related peritonitis were ceftazidime/cefazolin, followed by cefepime/cefazolin and ceftazidime/cloxacillin 5
• Vancomycin was the most frequently prescribed antibiotic for definitive therapy, followed by amikacin, meropenem, and ampicillin 5
• Ciprofloxacin was among the least prescribed definitive antibiotics, but had the highest therapeutic intensity 5
• A study comparing cefepime monotherapy to vancomycin and netilmicin therapy found that cefepime was a simple, safe, and cost-effective alternative for the treatment of CAPD-associated bacterial peritonitis 6