From the Guidelines
Peritonitis from peritoneal dialysis is a serious complication that can lead to significant morbidity and mortality, and prompt treatment with empiric antibiotic therapy is essential to minimize these complications and preserve peritoneal membrane function. The most common complications of peritonitis from peritoneal dialysis include catheter-related issues, persistent or recurrent infections, peritoneal membrane damage and failure, adhesions and fibrosis, and systemic complications such as sepsis 1.
- Catheter-related issues: Catheter obstruction or malfunction may require catheter replacement.
- Persistent or recurrent infections: Infections can lead to peritoneal membrane damage and failure, reducing the effectiveness of dialysis.
- Peritoneal membrane damage and failure: This can result in reduced ultrafiltration and solute clearance, leading to fluid overload and electrolyte imbalances.
- Adhesions and fibrosis: These can cause compartmentalization, impairing dialysis fluid distribution and reducing the effectiveness of dialysis.
- Systemic complications: Sepsis can be life-threatening if bacteria enter the bloodstream.
Treatment typically involves empiric antibiotic therapy with intraperitoneal administration of antibiotics such as vancomycin (1g IP loading dose, then 25mg/L in each exchange) plus a third-generation cephalosporin or aminoglycoside, adjusted based on culture results for 14-21 days 1. Fungal peritonitis requires antifungal therapy and usually catheter removal. Prevention strategies include proper exit site care, aseptic technique during exchanges, and prophylactic antibiotics for high-risk procedures 1. Early recognition and prompt treatment are essential to minimize these complications and preserve peritoneal membrane function.
According to the most recent and highest quality study, the management of peritonitis from peritoneal dialysis should prioritize prompt antibiotic therapy and source control, with a focus on preserving peritoneal membrane function and preventing systemic complications 1. This approach is supported by the World Journal of Emergency Surgery guidelines, which emphasize the importance of early recognition and treatment of peritonitis to prevent morbidity and mortality 1.
From the Research
Complications of Peritonitis from Peritoneal Dialysis
- 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.
- Peritonitis is associated with substantial morbidity and mortality, and is the most common reason for transfer to hemodialysis 3.
- 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 4.
Management of Peritonitis
- 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 5.
- Intraperitoneal is the preferred route of administration, and antifungal prophylaxis, preferably oral nystatin, should be added to prevent secondary fungal peritonitis 5.
- The duration of antibiotics is usually 2-3 weeks, depending on the specific organisms identified, and catheter removal and temporary hemodialysis support is recommended for refractory, relapsing, or fungal peritonitis 5.
Prevention 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.
- Standardized reporting of peritonitis rates and outcomes can help describe the variability in peritonitis rates and outcomes across facilities, and identify potential peritonitis prevention strategies 6.
- Collaboration and expansion of quality improvement initiatives can lead to dissemination of best practices and reduction in peritonitis incidence 6.