From the Guidelines
For a peritoneal dialysis (PD) patient with peritonitis who is unable to drain PD fluid, immediate intervention is necessary to prevent severe complications and improve outcomes in terms of morbidity, mortality, and quality of life. The first step is to administer broad-spectrum antibiotics empirically, typically vancomycin (15-20 mg/kg loading dose) plus a third-generation cephalosporin like ceftazidime (1-1.5 g daily) or an aminoglycoside, adjusted for residual renal function, as recommended by recent guidelines 1. These should be given intravenously since the peritoneal route is compromised. The drainage issue must be addressed urgently as it indicates catheter malfunction, which could be due to fibrin plugs, catheter displacement, or omental wrapping. Initial management includes flushing the catheter with heparinized saline (500 units/mL) using gentle pressure. If unsuccessful, radiological evaluation with a plain abdominal X-ray or CT scan should be performed to assess catheter position, as suggested by the World Journal of Emergency Surgery 1. Surgical intervention may be necessary if conservative measures fail, potentially involving catheter manipulation, replacement, or temporary hemodialysis while treating the peritonitis. The patient should be monitored closely for signs of sepsis or deteriorating clinical status. Drainage problems during peritonitis are particularly concerning because the infected fluid needs to be removed to resolve the infection and prevent complications like adhesions, loculations, and membrane damage that could permanently compromise PD as a treatment modality. Key considerations in managing such patients include:
- Prompt initiation of appropriate antibiotic therapy
- Urgent addressing of the drainage issue to prevent further complications
- Close monitoring for signs of sepsis or clinical deterioration
- Consideration of surgical intervention if necessary, based on the most recent and highest quality evidence available 1.
From the Research
Treatment Options for Peritoneal Dialysis Patients with Peritonitis
For a peritoneal dialysis (PD) patient with peritonitis who is unable to drain PD fluid, several treatment options are available:
- The use of intraperitoneal (IP) cefazolin and gentamicin as initial treatment for primary PD peritonitis, as shown in a study published in 2001 2.
- Systemic administration of vancomycin and ciprofloxacin as a first-line treatment protocol for PD peritonitis, as evaluated in a multicenter study published in 2004 3.
- Intraperitoneal vancomycin plus either oral moxifloxacin or intraperitoneal ceftazidime for the treatment of PD-related peritonitis, as compared in a randomized controlled pilot study published in 2017 4.
Considerations for Treatment
When choosing a treatment option, several factors should be considered:
- The type of microorganism causing the peritonitis, as different antibiotics may be more effective against specific types of bacteria 5.
- The potential for antibiotic resistance, as some microorganisms may be resistant to certain antibiotics 6.
- The ease of administration and potential side effects of the antibiotics, as some patients may have difficulty with intraperitoneal administration or may experience adverse reactions to certain medications 3, 4.
Antibiotic Regimens
Different antibiotic regimens may be used to treat PD peritonitis, including:
- Cefazolin and gentamicin, which have been shown to be effective in treating primary PD peritonitis 2.
- Vancomycin and ciprofloxacin, which have been evaluated as a first-line treatment protocol for PD peritonitis 3.
- Vancomycin and moxifloxacin or ceftazidime, which have been compared in a randomized controlled pilot study for the treatment of PD-related peritonitis 4.