Peritoneal dialysis-associated peritonitis

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Background

  • Most common complication of peritoneal dialysis. The patient uses their peritoneum as a dialysis membrane in conjunction with a surgically placed dialysis catheter that penetrates the abdominal wall. Either at night or multiple times during the day peritoneal fluid is infused into the abdomen in an ambulatory setting or at home.
  • Diagnosis of peritonitis usually is made by the patient when a cloudy dialysis effluent is noted, increased abdominal pain or white blood cells (WBCs) in the dialysate

Causative Organisms

Clinical Features

  • Presentation no different from other causes of peritonitis
  • Patients may report a cloudy dialysate

Differential Diagnosis

  • Abdominal pain standard differential also applies to patients with peritoneal dialysis in addition to concern for peritonitis

Dialysis Complications

Cloudy Effluent Differential

  • Culture-positive infectious Peritonitis
  • Infectious peritonitis with sterile cultures
  • Chemical peritonitis
  • Eosinophilia of the effluent
  • Hemoperitoneum
  • Malignancy
  • Chylous effluent (rare)
  • Specimen taken from “dry” abdomen

Evaluation

  • Send dialysate fluid for cell count, Gram stain, culture (if available)
    • Cell count >100/mm with >50% neutrophils most consistent with infection[1]

Special Considerations

There must be dialysis fluid "dwelling" within the patient for adequate fluid collection. If the patient is not "dwelling" then coordination with nephrology is required to infuse fluid to be used to sample the peritoneum. Fluid may be required to "dwell" for a few hours prior to collection.

Management

Empiric Therapy (IP)

10- to 14-day course of intraperitoneal (IP) antibiotics that are administered by the patient on an outpatient basis or IV antibiotics and intraperitoneal for admitted patients

Empiric Tharapy (IV)

Although IP antibiotics are preferred IV antibiotics can be considered with coordination with nephrology for dosing. Coverage should be the same as IP antibiotics [3][4]

Disposition

  • Consultation with nephrology service
  • Depending on patient reliability and level of illness outpatient peritoneal antibiotics or inpatient therapy are therapy options

See Also

External Links

References

  1. ISPD GUIDELINES/RECOMMENDATIONS http://www.ispd.org/guidelines/articles/update/ispdperitonitis.pdf
  2. Li PK, et al: Peritoneal dialysis-related infections recommendations: 2010 update. Perit Dial Int 2010; 30:393 Fulltext
  3. Manley HJ, Bailie GR, Frye RF, McGoldrick MD. Intravenous vancomycin pharmacokinetics in automated peritoneal dialysis patients. Perit Dial Int 2001;21 :378-85
  4. Wong et al. Intravenous Antibiotics with Adjunctive Lavage in Refractory Peritonitis. Intravenous Antibiotics with Adjunctive Lavage in Refractory Peritonitis