Peritoneal dialysis-associated peritonitis

Background

• Most common complication of peritoneal dialysis. The patient sues 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

• Staphylococcus aureus or Staphylococcus epidermidis are the most common causes of infection with gram-negative enteric organisms also contributing. There is also an increased risk of MRSA related infections.

Clinical Features

• Presentation no different from other causes of peritonitis

Differential Diagnosis

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

Dialysis Complications

• Dialysis-associated hypotension
• Dialysis disequilibrium syndrome
• Air embolism
• Missed dialysis (pulmonary edema)

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

Workup

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

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

• 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 Therapy (IP)

• Vancomycin 30mg/kg loading followed by 0.6 mg/kg IP daily PLUS
• Ceftazidime 1g IP daily OR
• Gentamycin 0.6mg/kg daily

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

Disposition

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

See Also

• Dialysis complications