Peritonitis in continuous and automated peritoneal dialysis patients - Guideline for the diagnosis and management of
|Last review: 01/07/2017|
|Next review: 01/07/2020|
|Approved By: Improving Antimicrobial Prescribing Group|
|Copyright© Leeds Teaching Hospitals NHS Trust 2017|
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
Guideline for the diagnosis and management of peritonitis in continuous and automated peritoneal dialysis patients under the Adult Renal Unit
Peritonitis in continuous and automated peritoneal dialysis patients
Clinical features of peritoneal dialysis (PD) peritonitis include:
Initial investigations required
Empirical (initial) antimicrobial treatment
Referral criteria for specialist input
Peritoneal dialysis (PD), comprising CAPD and APD, is a major modality for treatment of patients with end-stage renal failure. It involves infusion of dialysis fluid into the peritoneal cavity via a permanent catheter. Peritonitis is one of the major complications of PD and can lead to severe acute and long-term effects. Infections may arise through contamination during the dialysis procedure, spread of infection from the catheter exit site from the abdominal wall, and through intra-abdominal sources such as infection with enteric organisms. The varied pathogenesis and involvement of an indwelling medical device (PD catheter) mean that a wide variety of microorganisms can cause PD peritonitis. Staphylococci (Including Staphylcoccus aureus and coagulase negative staphylococci) are a common cause but Gram negative bacteria including Pseudomonas species may also be involved.
“Secondary peritonitis”, resulting from perforation of intestine or a primary focus of infection in another intra-abdominal organ, requires a different antimicrobial approach and usually surgical input and should be managed according to LTHT guideline for management of intra-abdominal infection of unknown cause.
The following document describes the standard protocol for treatment of peritonitis in patients on CAPD and APD in the adult Renal Unit in Leeds.
It is essential that the protocol is routinely followed, and that any necessary deviations are discussed with the Renal and Microbiology consultants and PD nursing staff to allow a consistent approach and a rational approach to future revision of the protocol.
Clinical features of peritoneal dialysis (PD) peritonitis include the following in a PD patient:
The PD catheter exit site may show features of an associated exit site infection (including purulent exudate, erythema and tenderness).
Rarely PD peritonitis may present as abdominal pain with clear dialysate. In this situation other causes of abdominal pain should be sought, but a subsequent dialysis dwell will yield cloudy dialysate with an increased dialysate white cell count (WCC) in a patient who does have peritonitis.
An elevated dialysate white cell count (WCC) of > 0.1 white cells x 109/litre of which at least 50% are neutrophils is supportive of the diagnosis of peritonitis- see investigation section below.
Note that the differential white cell count from automated analysis may indicate a relative lower proportion of white cells as neutrophils, than accurate manual counts, so do not withhold antibiotic treatment on the basis of WCC differential where there is an elevated WCC but <50% neutrophils, unless there is also reason to suspect this is not an infection (e.g. a sample from dry peritoneal cavity or borderline total white cell count).
Patients with generalised peritonism or severe sepsis – may have secondary peritonitis and require surgical assessment and should be assessed as according to the Trust sepsis guideline.
Establishing the cause of peritonitis
Recommendation for use of heparin
Recommendations regarding PD regime
PD catheter removal or exchange in peritonitis
PD catheter removal or exchange is indicated to prevent further episodes in:
In these situations it is appropriate to perform simultaneous removal of the PD catheter and insertion of a new catheter on the contralateral side of the abdomen. This must only be performed after the dialysate WCC has normalised and the procedure must be performed with cover by an antibiotic active against the infecting organism (including on-going continuation/conclusion of the course of antibiotics for the episode of peritonitis). (See PD catheter insertion protocol).
If the catheter is removed rather than replaced (e.g. if the infection does not resolve with appropriate antibiotics), the patient may require temporary haemodialysis (if required, follow current protocol for decolonisation prior to HD line insertion). However, it is sometimes possible to hold without dialysis, with careful biochemical and clinical monitoring of the patient until a new PD catheter is inserted, if they have sufficient residual renal function. In cases where direct catheter exchange is performed, PD should ideally be withheld for 7-10 days to allow catheter healing. If there is insufficient residual renal function to allow this, PD is started earlier (timing determined by biochemistry and clinical features), using reduced volume dialysis exchanges and a “dry day” in APD patients3.
|Empirical Antimicrobial Treatment|
Recommendation: Initial antibiotic treatment of PD peritonitis:
Deviations from standard initial antibiotic protocol
Drug allergies to Vancomycin or ciprofloxacin
(See Appendix 1 for more specific information on prescribing the following antimicrobials)
|Directed Antimicrobial Treatment (when microbiology results are known)|
Recommendation: Antimicrobial therapy should be reviewed and amended as necessary when microbiology results are available (see recommendations below)
No bacterial growth:
If culture-negative infection not responding to antibiotics:
[Evidence level .B.]
Coagulase negative staphylococci
Staphylococcus aureus (methicillin susceptible, MSSA)
Staphylococcus aureus (methicillin resistant, MRSA)
Gram negative infection (other than Pseudomonas)
[Evidence level B]
[Evidence level D]
|Duration of Treatment|
[Evidence level C.]
|Switch to oral agent(s)|
Most treatment is IP, oral agents may be advised as adjuncts for specific pathogens, see directed antimicrobial section.
Initial Management of Suspected PD Peritonitis
Doses of oral medication used in treatment of PD peritonitis:
This guideline aims to provide a clear and easily applied strategy for diagnosis of peritonitis and initiation of antibiotic therapy in both continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD) patients, whether treatment is performed as an inpatient or outpatient. It also describes subsequent treatment following definitive culture results for common infections. Management must be under the supervision of the specialist Leeds Renal Unit Unit and applies to managing adult peritoneal dialysis patients (or those aged 16-18 years) under their care.
|Clinical condition:||Peritoneal dialysis peritonitis|
|Target patient group:||Any patient with suspected or confirmed peritoneal dialysis peritonitis|
|Target professional group(s):||Secondary Care Doctors
- Li PK-T, Szeto CC, Piraino B et al. ISPD peritonitis recommendations: 2016 update on prevention and treatment. Peritoneal Dialysis International 2016; 36: 481-508
- Gould IM, Casewell MW. The laboratory diagnosis of peritonitis during continuous ambulatory peritoneal dialysis. J Hosp Infect 1986; 7: 155-160
- Posthuma N, Borgstein PJ, Eijsbouts Q, ter Wee PM. Simultaneous peritoneal dialysis catheter insertion and removal in catheter-related infections without interruption of peritoneal dialysis. Nephrol Dial Transplant 1998; 13:700-703
- Woodrow G, Davies S. Renal Association Clinical Practice Guideline on Peritoneal Dialysis. Nephron Clin Pract 2011; 118 (Suppl 1): c287-310
- Fahim M, Hawley CM, McDonald SP et al. Culture-negative peritonitis in peritoneal dialysis patients in Australia: predictors, treatment, and outcomes in 435 cases. Am J Kidney Dis 2010; 55: 790-797
- Szeto CC, Chow K-M, Ching-Ha B et al. Staphylococcus aureus peritonitis complicates peritoneal dialysis: review of 245 consecutive cases. Clin J Am Soc Nephrol 2007; 2: 245-251
- Siva B, Hawley CM, McDonald SP et al. Pseudomonas peritonitis in Australia: predictors, treatment, and outcomes in 191 cases. Clin J Am Soc Nephrol 2009; 4: 957-64
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other)
Improving Antimicrobial Prescribing Group
LHP version 1.0
- An initial dose of 2g (or 1.5g if <45kg body weight) is administered i.p. in a long dwell (in 2 litres dialysate for minimum of 6 hours, though this volume may be lower if 2 litre dwells not tolerated).
- Blood Vancomycin levels must be checked every 3 days. Further doses (same as initial dose based) should be given at 3 day intervals if indicated according to blood levels (see below) until the end of course.
- Clearance of Vancomycin after single i.p. loading dose varies with differing residual function. Maintenance of therapeutic blood levels is crucial for successful eradication of infection.
Vancomycin level and subsequent dosing
Do not give vancomycin and repeat blood test in a further 3 days
Give Vancomycin 2g i.p. (or 1.5g if <45kg body weight) as before and repeat blood test in a further 3 days
- An initial dose of 15mg/kg is administered I.P in a long dwell (in 2 litres dialysate for minimum of 6 hours).
- Further doses are administered at 3 day intervals.
Teicoplanin levels do not need to be monitored routinely if the patient is clinically responding to Teicoplanin . If the patient is deteriorating then please discuss with Microbiology about the need to send levels or whether a change to another antibiotic (e.g Linezolid ) may be more appropriate. The Microbiologists must be told about patients who are receiving Teicoplanin and in whom an organism has been isolated from the PD fluid. This is because extra susceptibility tests may need to be performed on any Gram-positive organisms grown.
- Gentamicin may be used once daily in the long dwell only (day dwell for APD and overnight dwell for CAPD).
- Levels of Gentamicin should initially be measured 48-72 hours after starting regular treatment, and thereafter as necessary (typically every 48 hours).
- Aminoglycosides have a prolonged post-antibiotic antibacterial effect associated with high local concentrations in the infused dialysis fluid. This allows effective treatment with intermittent intraperitoneal dosing (daily, but in long dwell only)
- It is not necessary to achieve “therapeutic” systemic levels and the regular initial IP. dose should not be increased above initial dose if blood levels are “sub-therapeutic”.
- Aminoglycoside toxicity (such as ototoxicity or loss of residual renal function often results from prolonged or repeated courses rather than short term high levels.
- Aminoglycosides (e.g. Gentamicin) should be avoided if possible if the patient has received a course in the previous 3 months except where bacterial cultures suggest that this is essential.
- Level < 2mg/L - Continue with same dose, do not increase dose.
- Level > 2mg/L - subsequent doses should be reduced (but not omitted) to avoid toxicity.
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