What are the risks of developing peritonitis from Peritoneal Dialysis (PD)?

From the Guidelines

Peritonitis in peritoneal dialysis patients should be treated promptly with empiric antibiotic therapy, avoiding the use of nephrotoxic agents such as aminoglycosides whenever possible, to minimize the risk of further kidney damage and preserve residual kidney function 1. When peritonitis is suspected in a peritoneal dialysis patient, immediate empiric antibiotic therapy should be initiated after obtaining peritoneal fluid for cell count, culture, and Gram stain. The standard treatment includes intraperitoneal antibiotics with coverage for both gram-positive and gram-negative organisms.

Key Considerations

• A typical regimen consists of vancomycin and a cephalosporin, such as ceftazidime, to provide broad-spectrum coverage.
• Treatment should continue for 14-21 days, depending on clinical response and culture results.
• The dialysate should be examined for clearing (becoming less cloudy) and the patient monitored for resolution of abdominal pain and fever.
• If no improvement occurs within 48-72 hours, the catheter may need to be removed.

Prevention Strategies

• Proper exit site care and aseptic technique during exchanges are crucial to prevent peritonitis.
• Prophylactic antibiotics should be considered for invasive procedures to reduce the risk of peritonitis.
• Avoiding the use of nephrotoxic agents, such as aminoglycosides, and nonsteroidal anti-inflammatory drugs (NSAIDs) is essential to preserve residual kidney function 1.

Potential Insults to Residual Kidney Function

• Previous episodes of peritonitis have been associated with faster kidney decline, highlighting the importance of prompt and effective treatment 1.
• The use of aminoglycosides, separate from the rate of peritonitis, has been implicated as an associated factor in kidney decline, emphasizing the need to avoid these agents whenever possible 1.

From the Research

Causes and Complications of Peritonitis

• Peritonitis is a serious complication in patients undergoing automated peritoneal dialysis (APD) that increases morbidity and frequently disqualifies patients from the peritoneal dialysis programme 2.
• The distribution of pathogens is an important outcome determinant, with Gram-negative infections being associated with greater rates of catheter loss and higher death rates 3.
• Peritonitis is a common complication of peritoneal dialysis that is associated with substantial morbidity and mortality, and is the most common reason for transfer to hemodialysis 4.

Prevention and Treatment of Peritonitis

• Prophylactic antibiotics administered before PD catheter insertion, colonoscopy, or invasive gynecologic procedures, daily topical application of antibiotic cream or ointment to the catheter exit site, and prompt treatment of exit site or catheter infection are key measures to prevent PD-associated peritonitis 5.
• Empirical antibiotic therapy, with coverage of both Gram-positive and Gram-negative organisms (including Pseudomonas species), should be started once the appropriate microbiologic specimens have been obtained, with intraperitoneal being the preferred route of administration 5.
• A single dose of 2 g/0.5 g ceftazidime/avibactam led to concentrations that far exceeded the PK/PD targets of both drugs, and a dose of 750/190 mg ceftazidime/avibactam would be sufficient to treat plasma and peritoneal fluid infections in patients undergoing APD 2.
• Intraperitoneal cefepime monotherapy was noninferior to conventional combination therapy for resolution of CAPD-associated peritonitis at day 10 and may be a reasonable alternative first-line treatment 6.

Management and Mistakes to Avoid

• Despite the presence of international guidelines on peritonitis treatment, the evidence base to support optimal peritonitis treatment practices is lacking, leaving the practitioner to rely on clinical experience and extrapolate from across other infection treatment practices 4.
• Common mistakes and misconceptions in the management of peritonitis may compromise treatment success, and suggestions on common controversial aspects of peritonitis management are based on the best available literature 4.
• Catheter removal and temporary hemodialysis support is recommended for refractory, relapsing, or fungal peritonitis, and PD catheter removal should also be considered for refractory exit site or tunnel infections 5.