What is the treatment for Peritoneal Dialysis (PD) peritonitis?

Treatment for Peritoneal Dialysis (PD) Peritonitis

The standard treatment for PD peritonitis consists of empirical intraperitoneal antibiotics that cover both Gram-positive and Gram-negative organisms, with vancomycin and gentamicin being the preferred initial agents, followed by targeted therapy based on culture results for 2-3 weeks.

Initial Assessment and Diagnosis

• Diagnosis is based on at least two of the following:

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

• Obtain dialysate samples for:

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

Empirical Antibiotic Therapy

First-Line Treatment

1. Intraperitoneal (IP) route is superior to intravenous administration 1
   • IP vancomycin (for Gram-positive coverage)
   • IP gentamicin (for Gram-negative coverage including Pseudomonas)

Dosing Options

• Continuous dosing: Add antibiotics to each exchange
• Intermittent dosing: Higher concentration in one exchange daily
  • Both dosing methods show similar efficacy 1, 2

Antifungal Prophylaxis

• Add oral nystatin during antibiotic therapy to prevent secondary fungal peritonitis 3

Targeted Therapy Based on Culture Results

Gram-Positive Organisms (70% of cases) 4

• Continue vancomycin (adjust based on sensitivity)
• Duration: 2-3 weeks

Gram-Negative Organisms (25% of cases) 4

• Continue gentamicin or switch to targeted antibiotic based on sensitivity
• Duration: 2-3 weeks

Fungal Peritonitis (4-5% of cases) 4

• Immediate catheter removal is mandatory
• Antifungal therapy (amphotericin B or fluconazole)
• Duration: 14-21 days after catheter removal 5

Culture-Negative Peritonitis

• Continue empirical therapy for 2 weeks if clinical improvement occurs
• Consider catheter removal if no improvement after 5 days

Special Considerations

Refractory or Relapsing Peritonitis

• Catheter removal is recommended 3, 1
• Temporary hemodialysis support
• Consider simultaneous catheter removal and replacement rather than urokinase treatment 1

Preservation of Residual Renal Function

• Avoid aminoglycosides if equally effective alternatives exist 6
• Consider cephalosporins as alternative if concerned about nephrotoxicity

Peritoneal Membrane Function

• Peritonitis transiently changes the patient to a high transporter and decreases ultrafiltration
• Wait at least 1 month after resolution of peritonitis before obtaining peritoneal clearance measurements 6

Monitoring and Follow-up

• Daily assessment of:

  • Dialysate appearance
  • Abdominal pain
  • Body temperature
  • Dialysate cell count (should show improvement within 48-72 hours)

• Repeat dialysate culture if no clinical improvement after 48 hours

Prevention Strategies

• Prophylactic antibiotics before invasive procedures
• Daily topical antibiotic cream/ointment at catheter exit site
• Prompt treatment of exit site or tunnel infections
• Proper patient training in aseptic technique 6

Important Caveats

• Vancomycin resistance averages around 2% and gentamicin resistance around 8% in PD peritonitis 4
• Long-term use of this regimen has not been shown to increase antimicrobial resistance 4
• Catheter-associated peritonitis requires catheter removal for definitive treatment 5
• Previous episodes of peritonitis are associated with more rapid decline in residual renal function 6

By following this treatment protocol, peritonitis rates have improved significantly over time, with current rates as low as 1 episode per 29 patient-months in some centers 4.