Treatment of Peritoneal Dialysis-Related Peritonitis
Initiate empirical intraperitoneal antibiotic therapy immediately after obtaining peritoneal fluid samples, using a combination that covers both Gram-positive organisms (including Pseudomonas) and Gram-negative organisms. 1
Empirical Antibiotic Regimen
The optimal initial treatment is intraperitoneal glycopeptide (vancomycin or teicoplanin) plus ceftazidime, which achieves superior resolution rates (86%) compared to first-generation cephalosporin plus aminoglycoside (66%) or glycopeptide plus aminoglycoside (75%). 2 This combination provides:
- Gram-positive coverage (including methicillin-resistant Staphylococcus aureus) via glycopeptide 1, 2
- Gram-negative coverage (including Pseudomonas species) via ceftazidime 1, 2
- Higher complete cure rates (RR 1.66) compared to first-generation cephalosporins 2
Route of Administration
Administer antibiotics via the intraperitoneal route rather than intravenous, as IP administration is superior to IV for treating PD-associated peritonitis (RR 3.52 for treatment failure reduction). 3 Ceftazidime can be incorporated into dialysis fluid at 250 mg per 2 liters of dialysate. 4
Dosing Considerations
For patients with normal renal function on PD:
- Loading dose: 1 gram ceftazidime IP 4
- Maintenance: 500 mg every 24 hours IP 4
- Glycopeptide: Dose according to local protocols (typically vancomycin 15-30 mg/kg IP every 5-7 days) 5
Both continuous and intermittent IP dosing schedules achieve similar outcomes. 3
Duration of Therapy
Treat for a minimum of 2 days after signs and symptoms resolve, though complicated infections require longer therapy. 4 Standard duration is typically 14-21 days, though evidence shows uncertain benefit of extended 21-day courses over 10-day regimens. 3
Indications for Catheter Removal
Remove the PD catheter and transfer to temporary hemodialysis in the following situations: 1
- Refractory peritonitis (no clinical improvement after 5 days of appropriate antibiotics)
- Recurrent peritonitis (repeat episode within 4 weeks)
- Fungal peritonitis (catheter removal is mandatory with minimum 3 weeks antifungal therapy) 5
- Refractory exit-site or tunnel infections 1
For relapsing or persistent peritonitis, simultaneous catheter removal and replacement is superior to urokinase therapy (RR 2.35 for reducing treatment failure). 3
Culture-Directed Therapy Adjustments
Once culture results are available:
Gram-Positive Organisms
- Continue glycopeptide or de-escalate to first-generation cephalosporin if susceptible 2, 6
- For resistant organisms (MRSA, VRE), consider linezolid, daptomycin, or quinupristin/dalfopristin 6
Gram-Negative Organisms
- Continue ceftazidime or adjust based on susceptibilities 2
- For ESBL-producing organisms, consider carbapenems 6
- Oral fluoroquinolones may be considered for ease of administration in selected cases 6
Fungal Peritonitis
- Immediate catheter removal is mandatory 5
- Administer systemic antifungal therapy for minimum 3 weeks 5
- Transfer to hemodialysis 5
Critical Pitfalls to Avoid
- Do not delay antibiotic initiation while awaiting culture results 1
- Avoid aminoglycosides in patients with residual renal function when possible, as they may accelerate loss of residual kidney function 3
- Do not mix ceftazidime with aminoglycosides in the same solution due to potential interaction 4
- Monitor for ototoxicity with prolonged aminoglycoside or vancomycin therapy 3
- Reassess residual renal function after peritonitis episodes, as they significantly impact remaining kidney function 1
Monitoring and Follow-Up
- Peritoneal fluid should clear within 5 days of appropriate therapy; if not, consider catheter removal 1
- Peritonitis temporarily converts patients to high transporter status, affecting ultrafiltration and clearance measurements 1
- Each dialysis unit should monitor peritonitis rates (target <0.67 episodes/patient/year) and causative organisms to guide local protocols 1, 5