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Peritoneal dialysis-associated peritonitis
From WikEM
Contents
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
- Staphylococcus aureus or Staphylococcus epidermidis most common
- Gram-negative enteric organisms.
- Increased risk of MRSA related infections
Clinical Features
- Presentation no different from other causes of peritonitis
- Including abdominal pain, fever and rebound tenderness
- 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
- 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
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
- Vancomycin 30mg/kg loading followed by 0.6 mg/kg IP daily PLUS[2]
- 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 [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
- ↑ ISPD GUIDELINES/RECOMMENDATIONS ../docss/ispdperitonitis.pdf
- ↑ Li PK, et al: Peritoneal dialysis-related infections recommendations: 2010 update. Perit Dial Int 2010; 30:393 Fulltext
- ↑ Manley HJ, Bailie GR, Frye RF, McGoldrick MD. Intravenous vancomycin pharmacokinetics in automated peritoneal dialysis patients. Perit Dial Int 2001;21 :378-85
- ↑ Wong et al. Intravenous Antibiotics with Adjunctive Lavage in Refractory Peritonitis. Intravenous Antibiotics with Adjunctive Lavage in Refractory Peritonitis
