Peritoneal dialysis-associated peritonitis
From IDWiki
Background
Microbiology
- Gram-positive bacteria (45%)
- Gram-negative bacteria (15%), especially if underlying GI pathology
- Mixed bacterial (1-2%)
- Fungal (1%), particularly Candida
- Tuberculosis (<1%)
Pathophysiology
- Acquired from catheter, exit site, dialysate fluid, or transmural migration
Epidemiology
- On average one episode per patient per year
Clinical Manifestations
- Peritonitis, with diffuse abdominal pain and tenderness and cloudy or purulent dialysate
- Often afebrile
- Dialysate may have elevated WBCs >100 cells/mcL with >50% neutrophils
Diagnosis
- Aspirate dialysate, then centrifuge and inoculate into blood culture bottles (for both aerobic and anaerobic organisms)
Management
- Empiric treatment should cover coagulase-negative staphylococci and gram-negatives, so vancomycin plus ceftriaxone or ceftazidime would be reasonable
- Intraperitoneal antibiotics are preferred unless systemic infection or bacteremia
- May attempt to salvage the catheter, especially for less virulent organisms like coagulase-negative staphylococci
- Indications for catheter removal include
- Difficult-to-treat organisms (Candida, Staphylococcus aureus, resistant Gram-negatives like Pseudomonas or Stenotrophomonas)
- Bowel perforation
- Relapse with same organism within a month
- Clinical failure despite 5 days of appropriate antibiotics
- Exit site infection
- Duration 14 to 21 days, or 1 week after catheter removal
Further Reading
- ISPD Peritonitis Recommendations: 2016 Update on Prevention and Treatment. Perit Dial Int. 2016;36:481. doi: 10.3747/pdi.2016.00078
- ISPD Catheter-Related Infection Recommendations: 2017 Update. Perit Dial Int. 2017;37:141-154. doi: 10.3747/pdi.2016.00120
- Focuses on exit site infections
