What is the initial workup and treatment for suspected peritonitis in a patient with a Peritoneal Dialysis (PD) catheter?

From the Guidelines

The initial workup for suspected peritonitis in a peritoneal dialysis (PD) patient should include immediate collection of PD fluid for cell count with differential, Gram stain, and culture before starting antibiotics, as recommended by the 2017 WSES guidelines for management of intra-abdominal infections 1. The diagnosis is typically made when the PD effluent shows cloudiness, the patient has abdominal pain, and the cell count reveals >100 white blood cells/μL with >50% neutrophils. Treatment should begin empirically without waiting for culture results. The recommended empiric antibiotic regimen includes:

• intraperitoneal vancomycin (15-20 mg/kg loading dose, then 15-20 mg/kg every 3-5 days)
• plus a gram-negative coverage agent such as ceftazidime (1-1.5g loading dose, then 1-1.5g daily) or an aminoglycoside. These antibiotics are typically added directly to the dialysate. The dwell time should be at least 6 hours to ensure adequate absorption. Treatment should continue for 14-21 days, with adjustment based on culture results. Pain management with acetaminophen or, if necessary, opioids may be needed. The patient should continue PD exchanges during treatment, though temporary hemodialysis may be required in severe cases. Early treatment is crucial as peritonitis can lead to technique failure, catheter removal, and increased mortality, with mortality rates increasing in patients developing organ dysfunction and septic shock 1. If there's no improvement within 48-72 hours, catheter removal should be considered, especially with fungal peritonitis or certain resistant bacterial infections. It is essential to note that the management of peritonitis in PD patients requires a comprehensive approach, including source control, antibiotic therapy, and supportive care, as outlined in the 2017 WSES guidelines 1.

Some key points to consider in the management of peritonitis in PD patients include:

• The importance of early diagnosis and treatment to prevent complications and improve outcomes
• The need for empiric antibiotic therapy, with adjustment based on culture results
• The role of source control, including catheter removal if necessary
• The importance of supportive care, including pain management and temporary hemodialysis if required
• The need for close monitoring of the patient's condition, with adjustment of treatment as needed to prevent complications and improve outcomes.

Overall, the management of peritonitis in PD patients requires a comprehensive and individualized approach, taking into account the patient's specific needs and circumstances, as well as the latest evidence-based guidelines and recommendations 1.

From the Research

Initial Workup for Suspected Peritonitis in a Patient with a PD Catheter

• The initial workup for suspected peritonitis in a patient with a Peritoneal Dialysis (PD) catheter includes collecting PD effluent specimens for white blood cells count, Gram stain, culture, and sensitivity testing before starting antibiotics 2.
• Clinical presentation and laboratory data, such as cloudy PD fluid and abdominal pain, are used to diagnose peritonitis 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 3.

Empiric Antibiotic Therapy

• Empiric antibiotic therapy should cover both Gram-positive and Gram-negative organisms, including Pseudomonas species, and should be started once the appropriate microbiologic specimens have been obtained 4.
• The preferred route of administration is intraperitoneal 4.
• Antifungal prophylaxis, preferably oral nystatin, should be added to prevent secondary fungal peritonitis 4.

Treatment and Prevention

• The duration of antibiotics is usually 2-3 weeks, depending on the specific organisms identified 4.
• Catheter removal and temporary hemodialysis support is recommended for refractory, relapsing, or fungal peritonitis 4.
• Prophylactic antibiotic administration before PD catheter insertion, 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 4, 5.
• Mupirocin treatment can reduce the risk of exit site infection by 46%, but it cannot decrease the risk of peritonitis due to all organisms 6.

PD Effluent Specimen Collection

• PD effluent specimen collection is an important aspect of managing suspected PD-related peritonitis, and nephrology nurses should follow best practices for collecting these specimens 2.
• There is limited evidence in the PD literature to answer several questions related to PD effluent specimen collection, and nursing practice may vary within and among countries 2.