Peritoneal Dialysis–Related Peritonitis | American Society of Nephrology

Dialysis in Late Life: Benefit or Burden
June 5, 2021 0 Comments

Peritonitis is a standard and critical complication of peritoneal dialysis (PD). PD-associated peritonitis is the direct or main contributing explanation for loss of life in >15% of sufferers on PD (1,2). Furthermore, a single episode of extreme peritonitis or a number of peritonitis episodes ceaselessly results in diminished peritoneal ultrafiltration capability and is the most typical explanation for conversion to long-term hemodialysis (3).

Over the previous 30 years, suggestions on the therapy and prevention of PD-associated peritonitis had been revealed and revised recurrently underneath the auspices of the Worldwide Society for Peritoneal Dialysis (ISPD). Within the 2010 model, two units of suggestions had been issued: one on the therapy of PD-associated peritonitis and catheter-related infections (4), and one other on their prevention (5). Within the newest 2016 model, nevertheless, each the therapy and prevention of PD-associated peritonitis had been mixed into one set of suggestions (6), and a separate set of suggestions on catheter-related infections was revealed in 2017 (7). As a result of their focuses are totally different, their particular suggestions will not be fully similar. On this overview, we deal with the prevention and therapy of PD-associated peritonitis.

Reporting of Peritonitis Fee

The ISPD suggestions emphasize that each PD program ought to monitor the PD-associated peritonitis fee at the very least on a yearly foundation (6). The speed ought to be reported because the variety of episode per patient-year however not the variety of patient-months per episode (6). Along with the general peritonitis fee, the peritonitis charges of particular organisms, proportion of peritonitis-free sufferers per yr, and the spectrum of antibiotic resistance ought to be monitored (6). In the course of the calculation of peritonitis fee, relapsing episodes ought to be counted solely as soon as, and all episodes that develop after PD coaching has commenced (not accomplished) ought to be counted (6). Though the suggestions state that the general peritonitis fee ought to be under 0.5 episodes per patient-year, there’s a huge variation within the peritonitis charges reported by totally different nations, in addition to by totally different facilities throughout the similar nation (8). A latest examine exhibits extremely variable charges of adopting the ISPD suggestions throughout totally different facilities, and such variations most likely account for the distinction in an infection danger between PD facilities (9).

Prevention of PD-Related Peritonitis

PD Gear and Coaching.

At the very least 4 randomized, managed trials help using prophylactic antibiotics earlier than PD catheter insertion (6,10). Intravenous vancomycin, cefazolin, gentamicin, and cefuroxime have been examined (10). The optimum selection of antibiotic, nevertheless, shouldn’t be effectively outlined, and ought to be decided by the native spectrum of antibiotic resistance. Apart from prophylactic antibiotics, different points of catheter insertion apply, together with the strategy of catheter placement (mini-laparotomy, laparoscopy, or peritoneoscopy), website of pores and skin incision (midline or lateral), catheter design (e.g., prolonged, presternal, or higher belly catheter), configuration (straight or swan-neck, single or double cuff), and the path of exit website don’t considerably have an effect on the peritonitis fee (11,12). Nonetheless, a big, observational examine means that the double-cuff catheter is related to a discount in peritonitis brought on by Staphylococcus aureus (13).

Disconnect PD programs with a “flush earlier than fill” design are constantly related to a decrease peritonitis fee than the standard spike programs, and are the usual of steady ambulatory peritoneal dialysis (CAPD) apply these days (11,14). There is no such thing as a important distinction in peritonitis fee between numerous disconnect programs (Y-set, double-bag, or luer lock) (11,14), or between CAPD and machine-assisted automated PD (15,16). It’s unsure whether or not the selection of dialysis resolution (standard glucose-based options or biocompatible options with impartial pH and low glucose-degradation product) results in any variations in peritonitis prevalence (17).

Coaching and Nursing Apply.

An excellent PD coaching program would logically decrease the peritonitis fee. It’s typically accepted that PD coaching ought to be performed by nursing employees with the suitable {qualifications} and expertise, and the newest ISPD suggestions for educating PD sufferers and their caregivers ought to be adopted (18,19). Nevertheless, revealed knowledge are restricted, and the important parts of a coaching program that decide the peritonitis fee stay undefined. The continued Focused Training Strategy to Enhance Peritoneal Dialysis Outcomes Trial, to be accomplished in 2023 (20), will assist to make clear the advantage of complete PD coaching packages.

After PD coaching is accomplished, a house go to by PD nurse is efficacious in detecting unexpected sensible issues with dwelling dialysis (6). Nevertheless, the advantage of dwelling go to on peritonitis danger has not been formally examined. Along with the preliminary coaching, retraining ought to be thought of after peritonitis or catheter an infection episodes; any change in dexterity, imaginative and prescient, or psychological acuity; change in provider or connection system; extended hospitalization; or interruption of PD due to different causes (6). Early research recommend {that a} steady high quality enchancment (CQI) program within the PD heart could assist to scale back peritonitis charges (6,21). Nationwide CQI packages have been discovered to sustainably cut back peritonitis charges (22). An in depth description on the group of CQI packages is past the scope of this overview. Nonetheless, a multidisciplinary staff that runs CQI packages ought to meet and overview efficiency metrics recurrently (6).

Exit Website and Catheter Infections.

Exit website and catheter tunnel infections are an essential danger issue of PD-associated peritonitis (23). Their early detection and immediate antibiotic therapy are logical steps to attenuate the danger of subsequent peritonitis (6). The correct care of catheter exit website performs a pivotal function in prevention. Every day topical software of antibiotic cream or ointment to the catheter exit website is advisable (6), and mupirocin cream or ointment ought to be the agent of selection (24). Every day software of mupirocin cream or ointment to the pores and skin across the exit website reduces the speed of S. aureus exit website an infection and doubtless decreases the speed of peritonitis (24,25). Intranasal mupirocin is efficient for decreasing S. aureus exit website an infection, however not peritonitis (26). Extreme quantities of topical mupirocin immediately utilized onto the polyurethane or silicone catheter floor could cause catheter erosion (27). Sufferers have to be educated concerning the correct methodology of software.

Topical gentamicin is an affordable different to mupirocin for exit website care (28), however the proof appears much less sturdy. Gentamicin gives a bonus over mupirocin in facilities with a excessive fee of exit website an infection by Gram-negative organisms, however the opportunity of gentamicin resistance, which impacts the selection of antibiotic for peritonitis therapy, is a particular concern. Different different methods, comparable to topical antibacterial honey (29) or triple ointment (polymyxin, bacitracin, and neomycin) (30), have been examined, however none is proven to be superior than topical mupirocin. Usually, common systemic antibiotic prophylaxis shouldn’t be advisable. Though intermittent oral rifampicin reduces the speed of S. aureus peritonitis (31), rifampicin resistance, adversarial results, and drug interactions are all critical issues.

Different Modifiable Danger Elements.

Many different modifiable danger components for PD peritonitis have been reported (8), however their absolute danger (e.g., cirrhosis, polycystic kidney illness, left ventricular help system, neutropenia throughout chemotherapy) will not be effectively outlined, and interventions to solely only a few have been proved to scale back peritonitis danger. Peritonitis typically follows invasive endoscopic procedures (e.g., colonoscopy, hysteroscopy) in sufferers on PD (32). Prophylactic systematic antibiotic earlier than colonoscopy or invasive gynecologic procedures ought to be thought of (6). Though the optimum antibiotic routine is unknown, intravenous ampicillin with or with out aminoglycoside or metronidazole is mostly used (10). The efficacy of prophylactic antibiotic given intraperitoneally earlier than different invasive procedures shouldn’t be proved. Prophylactic antibiotics must also be thought of after moist contamination or different breaches in method (5), however there is no such thing as a broadly accepted routine (6). Though it’s a frequent apply to alter the extension tubings after contact contamination, revealed proof is restricted. Constipation, enteritis, and hypokalemia are related to an elevated danger of peritonitis by enteric organisms (6,8), and these circumstances deserve therapy on their very own proper.

Secondary Prevention.

Most fungal peritonitis episodes are preceded by means of systemic antibiotics (6,33). Randomized, managed trials and a scientific overview present that using both oral nystatin or fluconazole throughout antibiotic remedy reduces the danger of secondary fungal (particularly Candida) peritonitis (6,10). In nations the place nystatin is accessible, it ought to be the popular selection as a result of it has no systematic impact or drug interactions. Antifungal prophylaxis may additionally cut back the danger of fungal peritonitis when a affected person on PD receives systemic antibiotics for nonperitonitis infections (10), however this apply doesn’t appear to be broadly adopted.

After every episode of peritonitis, a root trigger evaluation ought to be carried out to find out the etiology and potential interventions to stop additional episodes (6). For instance, change method ought to be reviewed after peritonitis episodes brought on by contact contamination, and alternative of PD catheter ought to be thought of after relapsing or repeat peritonitis episodes (6). The important thing measures for the prevention of PD-associated peritonitis are summarized in Desk 1.

Desk 1.

Key measures for the prevention of PD-associated peritonitis

Administration of PD-Related Peritonitis


The analysis of PD-associated peritonitis requires any two of the next options: (1) medical options according to peritonitis, i.e., belly ache or cloudy dialysis effluent; (2) dialysis effluent white cell rely >100/μl (after a dwell time of at the very least 2 hours), with >50% neutrophils; and (3) constructive dialysis effluent tradition (6). Nevertheless, immediate medical analysis and early initiation of antibiotic remedy are key to profitable therapy. Due to this fact, sufferers presenting with cloudy effluent ought to be presumed to have peritonitis and handled as such till the analysis is confirmed or excluded (6). At any time when peritonitis is suspected, PD effluent ought to be examined for cell rely, differential, Gram stain, and bacterial tradition (6). Blood tradition bottle kits are the popular method for bacterial tradition (6). If speedy supply of the inoculated tradition bottles to the laboratory shouldn’t be potential, they need to be incubated at 37°C. Different effluent focus methods could additional improve the yield, however are cumbersome to make use of. There’s inadequate proof for different novel laboratory methods (e.g., reagent strip or molecular-based exams) (6).

Empirical Antibiotic Remedy.

As soon as the suitable microbiologic specimens have been obtained, empirical antibiotic remedy ought to be began (6). No single antibiotic routine has been proved to be superior than the others, and the selection ought to be center-specific (34). The essential precept is to supply satisfactory protection of each Gram-positive and Gram-negative organisms, together with Pseudomonas species. The present suggestions are vancomycin or first-generation cephalosporin for Gram-positive organism protection, and third-generation cephalosporin or aminoglycoside for Gram-negative organism protection (6). The selection of vancomycin versus first-generation cephalosporin ought to rely upon the prevalence of methicillin-resistant organisms in every heart.

Intraperitoneal administration of antibiotics is the popular route until there are options of systemic sepsis (6). When there’s a foreseeable delay in administering intraperitoneal antibiotics, nevertheless, the systemic route ought to be used as a short lived measure in order to make sure a immediate therapy (35). Vancomycin, aminoglycosides, and cephalosporin may be blended in the identical dialysis resolution bag (36). Nevertheless, vancomycin and ceftazidime are incompatible if mixed in the identical syringe for injection (6). The advisable dosages of antibiotics are summarized within the newest ISPD suggestions (6), however a lot of them are on the premise of medical expertise quite than pharmacokinetic research. The dosage of many antibiotics must be adjusted for sufferers with substantial residual kidney perform (4,6). A hard and fast generic dosage for all sufferers could clarify the commentary that residual kidney perform is related to therapy failure (37).

Intraperitoneal antibiotics may be given as steady (in every change) or intermittent dosing (6). Intermittent dosing is usually potential as a result of many antibiotics have substantial systemic absorption throughout peritonitis, which allow reentry into the peritoneal cavity in subsequent PD cycles. When given intermittently, the antibiotic-containing PD resolution ought to dwell for at the very least 6 hours to permit satisfactory absorption. For β-lactams, each steady and intermittent intraperitoneal dosing are cheap choices, however steady dosing has a theoretical benefit as a result of the bactericidal exercise is time-dependent (i.e., the discount in bacterial density is proportional to the time above minimal inhibitory focus), and ought to be the popular routine (6). Nevertheless, intermittent dosing is usually efficient and stands out as the solely possible routine when the affected person requires helpers or well being care guests to manage the antibiotics, or in sufferers on automated PD who couldn’t be transformed to CAPD quickly (6).

In contrast to β-lactams, intraperitoneal vancomycin is extra generally administered intermittently each 4–5 days. The serum vancomycin stage ought to be saved >15 μg/ml to keep up efficacy (38). Intraperitoneal aminoglycoside can also be ideally administered as day by day intermittent dosing (6). Brief-term aminoglycoside remedy doesn’t speed up the lack of residual kidney perform (39), however extended or repeated publicity is related to vestibular toxicity (40) and ought to be averted.

Sufferers on automated PD who develop peritonitis could swap quickly to CAPD, in order to facilitate intraperitoneal antibiotics remedy, however conversion shouldn’t be at all times possible for pragmatic causes (6). For sufferers who stay on automated PD, the intermittent intraperitoneal dosing ought to be given within the day dwell (6). Sadly, there’s a substantial information hole concerning the antibiotic dosing for the therapy of peritonitis in automated PD. As a result of extrapolation of pharmacokinetic knowledge from CAPD to automated PD could lead to important underdosing in sufferers on automated PD (6), a better day by day dose is usually required.

Adjunctive Measures.

Most sufferers with PD-associated peritonitis could possibly be managed as outpatients. The choice of hospital admission depends upon the medical severity, hemodynamic standing, and sometimes sensible concerns of therapy. Antifungal prophylaxis, ideally oral nystatin, ought to be given together with antibiotic remedy (6). Intraperitoneal heparin is often added when the PD effluent is cloudy, in order to stop catheter occlusion by fibrin. As well as, cautious blood glucose monitoring is advisable in sufferers with diabetes as a result of glucose absorption from the PD resolution could also be elevated throughout peritonitis. Peritoneal protein loss can also be elevated throughout peritonitis and malnutrition could develop shortly.

Subsequent Administration.

As soon as the PD effluent Gram stain or tradition outcomes are recognized, antibiotic remedy ought to be adjusted (6). Usually, if Gram-positive organisms are recognized, antibiotic protection for Gram-negative micro organism (i.e., aminoglycoside or third-generation cephalosporin) could possibly be stopped, and vice versa as soon as sensitivities can be found. PD effluent leukocyte counts and bacterial tradition ought to be carried out once more 2–3 days after antibiotic remedy, particularly when there is no such thing as a medical enchancment. PD effluent leukocyte rely >1090/µl on day 3 could predict therapy failure (41).

The present ISPD suggestions present an in depth description on the therapy of peritonitis episodes brought on by particular organisms (6). In essence, if the medical response is passable, peritonitis brought on by coagulase-negative staphylococci, streptococci, or culture-negative episodes ought to be handled for two weeks (6). For culture-negative episodes, it stays controversial whether or not the antibiotic for Gram-negative protection ought to be discontinued. The present suggestions state that if aminoglycoside is used because the empirical Gram-negative protection, it ought to be stopped to attenuate the danger of ototoxicity from repeated publicity (6), though a small examine has advised that N-acetylcysteine could stop aminoglycoside-related ototoxicity (42).

For the therapy of peritonitis episodes brought on by S. aureus, enterococci, Corynebacterium species, Gram-negative bacilli (Pseudomonas or non-Pseudomonas species), and polymicrobial peritonitis, efficient antibiotics ought to be continued for 3 weeks. As a result of enterococci have intrinsic resistance to cephalosporin, and ampicillin is quickly inactivated when given intraperitoneally (43), enterococcal peritonitis ought to be handled with intraperitoneal vancomycin until there may be vancomycin resistance (6). In contrast to different bacterial causes, Pseudomonas peritonitis ought to be handled with two efficient antibiotics with totally different mechanisms of motion (e.g., gentamicin or oral ciprofloxacin with ceftazidime or cefepime) (6,44,45). If a number of enteric organisms are recognized from PD effluent and when there is no such thing as a immediate medical response to empirical antibiotics, surgical analysis ought to be obtained instantly, and metronidazole ought to be used with vancomycin and both an aminoglycoside or ceftazidime (6). In distinction, if a number of Gram-positive organisms are recognized from the PD effluent, antibiotic therapy alone is often efficient (46). Normal antituberculous chemotherapy is extremely efficient for peritonitis brought on by Mycobacterium tuberculosis. The therapy routine for nontuberculous mycobacterial peritonitis shouldn’t be effectively outlined, however catheter removing is often wanted.

Extreme Episodes.

The indications of PD catheter removing are summarized in Desk 2. Particularly, refractory peritonitis episode is now outlined as failure of the effluent to clear after 5 days of applicable antibiotics (6), whereas relapsing peritonitis refers back to the episode that happen inside 4 weeks of completion of remedy of a previous episode with the identical organism or being tradition adverse (6). Recurrent peritonitis refers to an episode that happens inside 4 weeks of completion of remedy of a previous episode however with a special organism (6), whereas repeat peritonitis refers to an episode that happens >4 weeks after completion of remedy of a previous episode with the identical organism (6).

Desk 2.

Indications for catheter removing

After catheter removing for fungal or refractory peritonitis, efficient antibiotics ought to be continued for an additional 2 weeks (6,47). Insertion of a brand new PD catheter and return to PD is usually potential (47,48), however ought to be carried out at the very least 2 weeks after catheter removing and full decision of peritoneal signs (6). PD catheter must also be eliminated for refractory exit website or tunnel infections (6). If there is no such thing as a concomitant peritonitis (or after PD effluent has cleared up from the concomitant episode), a brand new PD catheter could possibly be inserted concurrently and PD could possibly be continued (7).

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