What antibiotics are recommended for peritoneal dialysis (PD) patients with peritonitis?

Antibiotic Recommendations for Peritoneal Dialysis-Associated Peritonitis

The recommended initial antibiotic regimen for peritoneal dialysis-associated peritonitis is intraperitoneal cefazolin (15-20 mg/kg) plus gentamicin (0.6 mg/kg) with a 6-hour dwell time, providing coverage against both gram-positive and gram-negative organisms. 1

Initial Empiric Therapy

First-Line Regimen

• Intraperitoneal (IP) administration:
  • Cefazolin 15-20 mg/kg plus gentamicin 0.6 mg/kg with 6-hour dwell time 1
  • For automated PD patients, administer antibiotics during a daytime dwell 1

Alternative Regimens

• Vancomycin plus ceftazidime: Higher pooled resolution rate (86%) compared to first-generation cephalosporin plus aminoglycosides (66%) or glycopeptides plus aminoglycosides (75%) 2
• Monotherapy options:
  • Oral quinolones or cefepime may be appropriate in select cases 3
  • Amoxicillin/clavulanic acid (1/0.2g IV every 8 hours, followed by 0.5/0.125g PO every 8 hours) 1

Special Considerations

Patient-Specific Factors

• Residual kidney function: Avoid aminoglycosides if possible to preserve residual renal function 1
• Previous antibiotic exposure: Consider broader coverage for patients with:
  • Recent hospitalization (>1 week)
  • ICU stay
  • Corticosteroid use
  • Organ transplantation
  • Baseline pulmonary or hepatic disease 1

Resistance Patterns

• Quinolone prophylaxis: Avoid quinolones for treatment; use cefotaxime or amoxicillin/clavulanic acid instead 1
• MRSA or resistant Enterococcus: Consider newer agents like linezolid, quinupristin/dalfopristin, or daptomycin 3
• Local resistance patterns: Each center should monitor their microbiology trends to guide empiric therapy 3

Administration and Duration

Route of Administration

• IP administration is superior to IV administration for treating PD-associated peritonitis 4
• Continuous and intermittent IP antibiotic dosing schedules have similar efficacy 4

Treatment Duration

• Standard duration: 7-14 days depending on clinical response and culture results 1
• Adjust antibiotics based on culture and sensitivity results when available 1

Monitoring Response

Follow-up Assessment

• Assess clinical response within 48-72 hours 1
• Signs of treatment failure:
  • Persistent fever
  • Worsening abdominal pain
  • Increasing WBC count
  • Development of sepsis or organ dysfunction 1

Repeat Peritoneal Fluid Analysis

• Perform follow-up peritoneal fluid analysis after 48 hours of antibiotic therapy 1
• Treatment failure should be suspected if:
  • Ascitic fluid neutrophil count fails to decrease by at least 25% of pre-treatment value
  • Clinical signs and symptoms worsen 1

Special Situations

Fungal Peritonitis

• Remove PD catheter in addition to antifungal treatment for a minimum of 3 weeks 5
• Transfer patient to hemodialysis 5

Relapsing or Persistent Peritonitis

• Consider catheter removal and replacement rather than urokinase treatment 4
• Catheter removal may be the best treatment for relapsing or persistent peritonitis 4

Prevention Strategies

• Prophylactic antibiotic administration before catheter placement 5
• Adequate patient training and exit-site care 5
• Treatment for S. aureus nasal carriage (mupirocin can reduce exit site infection risk by 46%) 5

The evidence suggests that IP administration of antibiotics with coverage for both gram-positive and gram-negative organisms is essential for effective treatment of PD-associated peritonitis. While cefazolin plus gentamicin is the standard first-line regimen, vancomycin plus ceftazidime may offer superior resolution rates. Treatment should be adjusted based on culture results and clinical response, with careful monitoring for treatment failure.