What is the treatment for peritonitis related to peritoneal dialysis (PD)?

Treatment of Peritoneal Dialysis-Related Peritonitis

The treatment for peritoneal dialysis (PD)-related peritonitis requires immediate empiric antibiotic therapy with intraperitoneal vancomycin and gentamicin, along with catheter management and supportive care.

Diagnosis and Initial Assessment

• Diagnosis is based on:

  • Cloudy dialysate fluid
  • Abdominal pain
  • Fever
  • Dialysate white cell count >100/μL with >50% neutrophils
  • Positive dialysate culture

• Obtain dialysate samples for:

  • Cell count with differential
  • Gram stain
  • Culture and sensitivity testing

Antimicrobial Therapy

Initial Empiric Treatment

1. First-line therapy: Intraperitoneal (IP) vancomycin plus gentamicin 1

   • Vancomycin: Loading dose of 15-20 mg/kg IP, then maintenance based on levels
   • Gentamicin: 0.6 mg/kg IP daily

2. Alternative regimen: Glycopeptide (vancomycin or teicoplanin) plus ceftazidime 2

   • This combination has shown superior resolution rates (86%) compared to first-generation cephalosporins plus aminoglycosides (66%)

Targeted Therapy (After Culture Results)

• Gram-positive infections (70% of cases):

  • Continue vancomycin for 14-21 days
  • Consider switching to first-generation cephalosporin if organism is sensitive

• Gram-negative infections (25% of cases):

  • Continue gentamicin or switch to targeted therapy based on sensitivities
  • Treatment duration: 14-21 days

• Fungal peritonitis (4-5% of cases):

  • Immediate catheter removal 3
  • Systemic antifungal therapy with fluconazole or amphotericin B for 2-3 weeks

Catheter Management

• Initial approach: Maintain catheter in place during antibiotic treatment

• Indications for catheter removal:

  • Fungal peritonitis (immediate removal) 3
  • Refractory peritonitis (no improvement after 5 days of appropriate antibiotics)
  • Relapsing peritonitis
  • Tunnel or exit-site infection with same organism

• After catheter removal and resolution of peritonitis, a new catheter may be placed after at least 2 weeks 3

Monitoring Response

• Assess dialysate effluent clarity daily
• Repeat dialysate cell count at 48-72 hours
• Expect improvement within 48 hours (decreasing pain, clearing dialysate, falling WBC count)
• If no improvement after 48-72 hours:
  • Repeat cultures
  • Consider catheter removal
  • Consider broadening antibiotic coverage

Special Considerations

• Aminoglycoside use: Consider alternative antibiotics for prolonged therapy to preserve residual kidney function 3
• Intraperitoneal vs. intravenous: IP administration is superior to IV for treating PD peritonitis 4
• Duration: 14-21 days of therapy is standard; longer courses may be needed for severe or complicated infections

Prevention Strategies

• Exit-site care with daily cleaning
• Proper hand hygiene and aseptic technique during exchanges
• Prophylactic antibiotics for invasive procedures
• Regular monitoring of catheter function 5

Common Pitfalls to Avoid

1. Delayed treatment: Empiric therapy should begin immediately after obtaining cultures, without waiting for results
2. Inadequate dosing: Ensure proper loading doses of antibiotics to achieve therapeutic levels quickly
3. Premature catheter removal: Try appropriate antibiotics first unless fungal peritonitis is present
4. Neglecting residual kidney function: Consider nephrotoxicity of antimicrobials, especially with prolonged aminoglycoside use
5. Insufficient duration: Incomplete treatment can lead to relapse or recurrence

The evidence supports intraperitoneal administration of antibiotics as superior to intravenous administration, with glycopeptides showing optimal efficacy for complete cure of peritonitis 4. Prompt initiation of appropriate antimicrobial therapy and proper catheter management are essential for reducing morbidity and mortality associated with PD-related peritonitis.