What is the recommended treatment for peritonitis in patients on Peritoneal Dialysis (PD), following International Society for Peritoneal Dialysis (ISPD) guidelines?

ISPD Peritonitis Management Summary

Definition and Diagnostic Criteria

Peritoneal dialysis-associated peritonitis is diagnosed when at least 2 of 3 criteria are met: cloudy peritoneal effluent, abdominal pain, and peritoneal fluid white blood cell count >100/μL with >50% polymorphonuclear cells. 1

• This represents a diffuse bacterial infection of the peritoneum, typically caused by a single organism, occurring in patients with a PD catheter 1
• Diagnostic specimens should be obtained when the patient is clinically stable and at least 1 month after resolution of any previous peritonitis episode 1

Prevention Strategies

Key preventive measures include:

• Prophylactic antibiotics before PD catheter insertion, colonoscopy, or invasive gynecologic procedures 2
• Daily topical antibiotic cream or ointment application to the catheter exit site 2
• Prompt treatment of exit site or tunnel infections 2
• Management of modifiable risk factors including domestic pet exposure, hypokalaemia, and histamine-2 receptor antagonist use 3

Empirical Antibiotic Treatment

Start empirical intraperitoneal antibiotics covering both Gram-positive and Gram-negative organisms (including Pseudomonas species) immediately after obtaining microbiologic samples. 1, 2

Route and Administration

• Intraperitoneal administration is superior to intravenous administration for treating PD-associated peritonitis 4
• Continuous and intermittent IP antibiotic dosing schedules have similar efficacy 4
• Maintain adequate antimicrobial drug levels throughout treatment 5

Antibiotic Selection

• IP glycopeptides (vancomycin or teicoplanin) combined with coverage for Gram-negative organisms are recommended for empirical therapy 4
• Glycopeptide regimens achieve higher complete cure rates compared to first-generation cephalosporins (RR 1.66) 4
• Adjust therapy once Gram stain or culture and sensitivity results become available 2

Antifungal Prophylaxis

• Add oral nystatin prophylaxis to prevent secondary fungal peritonitis 2

Treatment Duration

• Standard treatment duration is 2-3 weeks depending on the specific organism identified 2
• Longer duration (21 days) versus shorter courses (10 days) show uncertain benefits for relapse prevention 4

Indications for Catheter Removal

Catheter removal with temporary hemodialysis support is mandatory for: 1, 2

• Refractory peritonitis (failure to improve after 5 days of appropriate antibiotics)
• Relapsing peritonitis (recurrence within 4 weeks with same organism)
• Fungal peritonitis
• Refractory exit-site or tunnel infections

For relapsing or persistent peritonitis, simultaneous catheter removal and replacement is superior to urokinase therapy (RR 2.35 for reducing treatment failure) 4

Quality Targets (2022 ISPD Update)

• Overall peritonitis rate should be ≤0.40 episodes per year at risk 3
• ≥80% of patients should remain peritonitis-free per year 3
• Each unit must monitor peritonitis rates, causative organisms, and develop strategies to understand reasons for peritonitis 1

Post-Peritonitis Management

• Reevaluate residual renal function after each peritonitis episode as it can have significant negative impact 1
• Peritonitis temporarily converts patients to high transporter status and decreases ultrafiltration, which can affect clearance calculations 1
• Wait at least 1 month after resolution before performing diagnostic tests 1

Special Considerations

Enteric Peritonitis

• Bacterial translocation from the intestine is the probable mechanism in peritonitis associated with diarrhea, especially with enteric organisms 1
• Consider secondary bacterial peritonitis and perform abdominal CT imaging if suspected 6

Adjunctive Therapies

• Oral N-acetylcysteine may be considered to mitigate aminoglycoside ototoxicity 3
• Routine peritoneal lavage has uncertain benefit 4

Common Pitfalls to Avoid

• Do not delay empirical antibiotic therapy while awaiting culture results 1, 2
• Do not omit antifungal prophylaxis during antibiotic treatment 2
• Do not continue antibiotics beyond appropriate duration without clear indication as this increases toxicity risk without proven benefit 4
• Do not delay catheter removal for refractory, relapsing, or fungal peritonitis as this increases morbidity and mortality 1, 2