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

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 3 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.

CT Abdominal Scan

Perform only if necessary as part of the abdominal pain workup, to rule-out other (secondary) causes of peritonitis

CT WITHOUT IV contrast Patients are dependent on small amounts of residual renal function and thus risk of contrast outweighs benefits



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

Catheter removal/exchange is usually only done if IP antibiotics fail (fungal, pseudomonal), and should be done in consultation with a nephrologist[3]

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 [4][5]

Disposition

In consultation with nephrology service: Depending on patient reliability and level of illness, outpatient peritoneal antibiotics vs. inpatient therapy



See Also

References