Peritonitis in continuous and automated peritoneal dialysis patients - Guideline for the diagnosis and management of

Publication: 17/05/2012  
Last review: 01/07/2017  
Next review: 01/07/2020  
Clinical Guideline
CURRENT 
ID: 2784 
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.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline for the diagnosis and management of peritonitis in continuous and automated peritoneal dialysis patients under the Adult Renal Unit

  • Treatment Algorithm
  • Summary
    Peritonitis in continuous and automated peritoneal dialysis patients

    Clinical features of peritoneal dialysis (PD) peritonitis include:

    • cloudy dialysate
    • abdominal pain
    • fever
    • nausea and diarrhoea
    • PD catheter exit site may show features of an exit site infection

    Initial investigations required
    PD fluid sample for white cell count and microbiology – specialist nurse collection only;
    Exit site swab for culture;
    Blood cultures (only if systemic signs of infection);
    FBC, U&E, CRP.

    Non-Antimicrobial Management
    For heparin use, PD regimen and PD catheter/removal – see full guideline

    Empirical (initial) antimicrobial treatment
    Vancomycin electronic Medicines Compendium information on Vancomycin (given as a single intraperitoneal loading dose dependent on weight, see below). This should be given in a volume of 2 litres dialysate for a minimum six hour dwell. However, it may be given in 1.5 litres of dialysate if larger volumes are not tolerated.
    Patients > 45kg 2g dose of Vancomycin electronic Medicines Compendium information on Vancomycin as above
    Patients < 45kg 1.5g dose of Vancomycin electronic Medicines Compendium information on Vancomycin as above
    AND Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 500mg 12-hourly oral route.

    See full guideline for more details and in case of allergy to these agents.

    Referral criteria for specialist input
    Management of PD peritonitis must be under the supervision of a specialist renal unit with experience of managing peritoneal dialysis patients. All suspected cases presenting elsewhere should be urgently discussed with the Renal Unit for advice about investigation and management. This guideline refers specifically to the adult Renal Unit (which may include those aged 16-18 years who are under the care of the adult unit).

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    Background

    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.

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    Clinical Diagnosis

    Clinical features of peritoneal dialysis (PD) peritonitis include the following in a PD patient:

    • cloudy dialysate
    • abdominal pain
    • fever
    • nausea and diarrhoea.

    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.
    Other causes of cloudy dialysate include:

      • Eosinophilic peritonitis
      • Haemoperitoneum
      • Chemical peritonitis
      • Malignancy
      • Chylous dialysate
      • Specimen from “dry” peritoneal cavity

    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.

    Specialist referral

    • All patients on PD with suspected or possible PD peritonitis require URGENT review by the Renal Unit to allow collection of appropriate samples (which should be collected by renal nurses trained in PD) and management by the multidisciplinary PD team. Where need for review is in doubt, or a patient is too ill for immediate transfer from another site, this should be urgently discussed with the Renal Team for further advice

    Establishing the cause of peritonitis

    • All patients presenting with PD peritonitis should be questioned about any history of a technique error or recent acute illness or symptoms (especially GI, urological).
    • The presence of symptoms and signs of PD catheter exit-site infection should be determined
    • Reassessment of PD technique and follow up home visit is essential following an episode of PD peritonitis, with any necessary supplementary patient training undertaken and further follow up technique assessment performed.

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    Investigation
    1. Recommendation: PD effluent should be investigated in all suspected cases of PD peritonitis; send:
      • 5mL dialysate in EDTA tube for white cell count (WCC) and differential to Haematology
      • 20 mL dialysate for Gram stain and culture to Microbiology
      • 8 mL dialysate into each of a pair of blood culture bottles for culture (i.e. 2 x 8mL samples). See later in this section for interpretation.

      Samples for WCC and Gram stain should be requested and processed urgently.
      N.B PD fluid samples should only be taken by appropriately trained nephrology nurses.
      [Evidence level C]

    2. Recommendation: If the diagnosis of peritonitis on presentation is uncertain (e.g. only slightly hazy dialysate), send samples for white cell count only initially; then send the remainder of fluid samples if the white cell count confirms diagnosis of peritonitis.
      [Evidence level C]

    3. A PD catheter exit site swab should be sent from PD patients with peritonitis.
      Results can influence the decision to remove or later replace PD tube.
      [Evidence level C]

    4. Recommendation: Blood samples should be sent for routine biochemistry, CRP and full blood count.
      [Evidence level D]

    5. Recommendation: Blood cultures should not be sent routinely; only if there are features of systemic sepsis (e.g. pyrexia, chills, sweats, rigors, new confusion). Where there are features suggesting severe sepsis assessment and management will involve the Trust sepsis guidelines.
      [Evidence level D]

    [NB – in patients with a suspected primary intra-abdominal pathology, serum amylase may be unreliable in diagnosis of pancreatitis in patients receiving icodextrin dialysate (Extraneal), which results in reduction in measured levels]

    Interpretation of PD effluent analysis

    Recommendation: An elevated dialysate WCC of > 0.1 white cells x 109/litre of which at least 50% are neutrophils is supportive of the diagnosis of peritonitis and the need for immediate initiation of antibiotic treatment.
    [Evidence level B]

    This is the universally agreed diagnostic criteria for diagnosis of PD peritonitis1,2.

    The following should also be noted

    • The same diagnostic criteria apply to diagnosis of APD and CAPD peritonitis. Fluid from short (overnight) dialysis cycles in APD may have misleadingly low WCCs. In equivocal cases a further exchange of minimum 1-2 hour dwell is adequate to obtain further samples for diagnostic white cell counts and Microbiology.
    • Initial drainage of fluid after a period of a dry peritoneal cavity may have an elevated WCC, but predominantly comprised of monocytes. If in doubt a second dialysate sample should be sent for WCC after a further 1-2 hour dwell.

    Recommendation: Monitoring fluid white cell counts

    • After presentation, as a minimum, the patient should be reviewed the following day with repeat fluid WCC, then 3 days after the start of treatment, and every 3 days until completing antibiotics.
    • Review and monitoring must be more frequent
      • if patient is unwell
      • if WCC is rising (including where Day 1 WCC > presentation WCC)
      • peritonitis is slow to respond (clinical decision depending on symptoms and rate of decline of PD fluid WCC).
    • A final dialysate sample, for WCC only, should be sent 1 week after stopping antibiotics following resolution of peritonitis.

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    Treatment
    Non-Antimicrobial Treatment

    Recommendation for use of heparin

    • Heparin 500 units/litre is added to an exchange if visible fibrin is present in the dialysate.

    Recommendations regarding PD regime

    • Patients usually remain on their usual PD modality (CAPD or APD).
    • It may be necessary to interrupt or delay night cycles of APD in order to administer the initial 6 hour dwell containing Vancomycin electronic Medicines Compendium information on Vancomycin.
    • The use of rapid short cycles for initial treatment of peritonitis to “clear turbid effluent” is not beneficial to clearance of infection. However it may occasionally be of use if there is poor dialysate drainage.
    • In the case of loss of ultrafiltration, more frequent, shorter duration glucose fluid exchanges (or icodextrin-containing dialysate for the long dwell in patients not already receiving it) may be considered as alternatives to using more hypertonic glucose solutions.
    • Set change is not routinely required in a patient presenting with peritonitis (unless there is definite recent contamination of set line).

    PD catheter removal or exchange in peritonitis

    • If infection is severe or unresponsive to appropriate antibiotics the PD tube may need to be removed [Evidence level B].
    • This should be considered if there is failure of PD effluent to clear within 5 days of treatment with appropriate antibiotics. This is important to prevent morbidity and to protect the peritoneal membrane, increasing the chance of a successful subsequent return to PD.

    PD catheter removal or exchange is indicated to prevent further episodes in:

    • Relapsing peritonitis (an episode of peritonitis within 4 weeks of completion of treatment of a prior episode with the same organism)
    • Catheter-related peritonitis (peritonitis with an exit-site or tunnel infection with the same organism)

    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.
    [Evidence level C].

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    Empirical Antimicrobial Treatment

    Recommendation: Initial antibiotic treatment of PD peritonitis:
    Administer immediately Vancomycin electronic Medicines Compendium information on Vancomycin and Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin as below until culture results are known (unless known allergy to either agent). This is in keeping with expert recommendations that initial antibiotic regimes should cover Gram positive and Gram negative organisms including Pseudomonas species1,4.Our own audits in Leeds demonstrate that microbial resistance to this standard initial antibiotic regime is uncommon (<5% of episodes).
    [Evidence level C]

    • Vancomycin electronic Medicines Compendium information on Vancomycin (given as a single intraperitoneal (IP) loading dose dependent on weight, see below). This should be given in a volume of 2 litres dialysate for a minimum six hour dwell. However, it may be given in 1.5 litres of dialysate if larger volumes are not tolerated. Give a 2g dose of Vancomycin electronic Medicines Compendium information on Vancomycin as above unless the patient weighs <45kg in which case the dose should be 1.5g dose of Vancomycin electronic Medicines Compendium information on Vancomycin.

    AND

    • Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin
      500mg 12-hourly given by oral route.

      (If there is concern about absorption of oral Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin (e.g. ileus or vomiting), patients should receive intravenous Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 200 mg 12-hourly.

      Absorption of Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin is reduced by sevelamer, calcium compounds, oral iron, zinc, magnesium and milk. It should therefore be given at least 2 hours before any of these.

    Deviations from standard initial antibiotic protocol
    (only in consultation with senior Medical and Microbiological staff)
    Initial antimicrobial regimes may be amended due to:

    • Gram Stain
      • Unusual findings on Gram stain (e.g. multiple organisms or fungi) may occasionally lead to individualised addition to / modification of regime, following senior Medical and Microbiological consultation.
      • Components of the initial regime (i.e. Gram positive and Gram negative cover) must not be omitted on the basis of a positive Gram stain alone, and both should be continued until definitive (i.e. full culture and sensitivity) Microbiology results are available (rather than premature discontinuation of an agent).
    • Recent history of peritonitis or exit-site/tunnel infection with an organism resistant to Vancomycin and ciprofloxacin
    • Possibility of primary intra-abdominal pathology such as diverticular disease (in which case add Metronidazole electronic Medicines Compendium information on Metronidazole for anaerobic cover)
    • Allergy to Vancomycin electronic Medicines Compendium information on Vancomycin and/or Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin (see below)

    Drug allergies to Vancomycin or ciprofloxacin

    • Ciprofloxacin allergy,
      Substitute with IP Gentamicin to provide Gram-negative cover (in addition to Vancomycin electronic Medicines Compendium information on Vancomycin).
    • Vancomycin allergy,
      Substitute with either IP Teicoplanin electronic Medicines Compendium information on Teicoplanin, or in the case of previous anaphylactic reaction to vancomycin, with Linezolid electronic Medicines Compendium information on Linezolid (either IV or oral) following discussion with Microbiology.

    (See Appendix 1 for more specific information on prescribing the following antimicrobials)

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    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)
    [Evidence level D]

    No bacterial growth:
    In most cases this will be due to Gram positive organisms arising from touch contamination and will respond to appropriate antibiotics. If patient is responding to initiation regime, continue vancomycin as for coagulase negative staphylococci and discontinue ciprofloxacin1, 5.

    If culture-negative infection not responding to antibiotics:

      • Consider non-infective causes
      • Consider altering antibiotics suggested by recent positive exit-site culture or recent peritonitis (where possibility this is a relapse)
      • Otherwise may require catheter removal
      • Additional microbiological testing, following discussion with microbiology e.g. mycobacterial culture.

    [Evidence level .B.]

    Coagulase negative staphylococci
    Continue intermittent intraperitoneal (IP) Vancomycin electronic Medicines Compendium information on Vancomycin dwells according to blood levels at 3 day intervals (see info later) and stop oral ciprofloxacin1.
    [Evidence level C.]

    Staphylococcus aureus (methicillin susceptible, MSSA)
    Continue Vancomycin electronic Medicines Compendium information on Vancomycin (as in coagulase negative staphylococci regime). There should be a low threshold for adding oral Rifampicin electronic Medicines Compendium information on Rifampicin (300mg 12-hourly) orally after confirming sensitivity with results server or Microbiology unless very rapid clinical response1,6
    [Evidence level C]

    Staphylococcus aureus (methicillin resistant, MRSA)
    Continue Vancomycin electronic Medicines Compendium information on Vancomycin (as in coagulase negative staphylococci regime). There should be a low threshold for adding oral Rifampicin electronic Medicines Compendium information on Rifampicin (300mg 12-hourly) orally after confirming sensitivity with results server or Microbiology unless very rapid clinical response1,6
    [Evidence level C]

    Enterococcal infection
    Consider addition of Gentamicin where inadequate response to initial antibiotics1.
    [Evidence level C]

    Gram negative infection (other than Pseudomonas)
    If patient is responding, continue oral Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin and give no further vancomycin.
    If unsatisfactory response, change to, or add, other IP antibiotic according to sensitivities (and discuss with seniors) 1.
    [Evidence level C]

    Pseudomonas
    Should be treated with two agents with activity against the cultured organism [1, 7]. This is usually

    [Evidence level B]

    Fungal infections

    • The PD catheter should be removed promptly.
    • A minimum of 2 weeks of appropriate antifungal treatment is required from after the time of catheter removal.
    • We recommend initial treatment of fungal PD peritonitis pending identification and sensitivity results as follows: Anidulafungin as initial treatment (200mg loading dose, then 100mg daily, intravenously). Treatment may be adjusted according to sensitivity
    • Individual cases always require discussion with the Consultant Nephrologist and Microbiologists and anidulafungin will require a Microbiology prescription code.

    [Evidence level D]

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    Duration of Treatment
    • Minimum duration of treatment with appropriate antibiotics is 14 days1.
    • Antibiotic treatment should also continue until PD fluid WCC has been persistently <0.1 white cells x 109/litre for at least 7 days.
      Thus total duration of treatment may be extended beyond 14 days if infection is slow to respond and time to normalisation of PD white cell count is >7 days, but should never be less than 14 days.

    [Evidence level C.]

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    Switch to oral agent(s)

    Most treatment is IP, oral agents may be advised as adjuncts for specific pathogens, see directed antimicrobial section.

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    Treatment Algorithm

    Initial Management of Suspected PD Peritonitis

    Suspected PD peritonitis
    Cloudy dialysate and/or abdominal pain

    Specimens for Microbiology/Haematology/Chemical Pathology
    (PD fluid suitable for WCC estimation after minimum 1 hour dwell)

    • 5ml for white cell count (WCC) and differential (in EDTA tube to Haematology)

    Samples (await initial WCC if disgnosis uncertain):

    • 20ml dialysate in blood culture bottles to Microbiology for culture sensitivity
    • Exit-site swab and routine biochemistry (inc CRP) and FBC
    Peritonitis confirmed by WCC >0.1 x 109/litre of which at least 50% are neutrophils

    Initiate antibiotics

    May be modified in event of allergy, recent peritonitis, positive exit-site cultures,
    or if initial Gram stain suggests fungal infection or primary intra-abdominal pathology (see later).

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    Treatment Failure

    See empirical and directed antimicrobial sections or discuss with microbiology

    Audit
    The unit’s peritonitis data will be audited on an annual basis. Key audit measures are:

    • Peritonitis rate (guidelines suggest that a rate of less than 1 episode / 18 patient treatment months is obtained)
    • Rate of culture negative infections (guidelines suggest that inability to culture the responsible organism should occur in less than 20% of episodes)
    • Cure rate of peritonitis with preservation of catheter and continuation of PD
    • Relapse / recurrence rate
    • Antibiotic sensitivity/resistance

    Antibiotic doses
    Doses of IP. antibiotics:

     

    Intermittent
    (once daily in long dwell)

    Continuous
    (in all dialysate exchanges)

    Aztreonam electronic Medicines Compendium information on Aztreonam

    1000mg

    250mg/L of dialysate

    Ceftazidime electronic Medicines Compendium information on Ceftazidime

    1000-1500mg

    125mg/L of dialysate

    Gentamicin

    0.6mg/kg (body weight), then adjusted by levels – see above

    N/A

    Cefuroxime electronic Medicines Compendium information on Cefuroxime

    2g

    150mg/L of dialysate

    Doses of oral medication used in treatment of PD peritonitis:

    • Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 500mg 12-hourly
    • Rifampicin electronic Medicines Compendium information on Rifampicin 300mg 12-hourly
    • Linezolid electronic Medicines Compendium information on Linezolid 600mg 12-hourly (following discussion with Microbiology – an antibiotic code will be required).

    Patients treated with Rifampicin electronic Medicines Compendium information on Rifampicin require monitoring of liver function tests and CSM advises that weekly FBC is required due to haematological side-effects in patients treated with Linezolid electronic Medicines Compendium information on Linezolid.

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    Provenance

    Record: 2784
    Objective:

    Aims

    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.

    Objectives

    • To provide evidence-based recommendations for appropriate diagnosis and investigation of peritonitis in CAPD/APD patients.
    • To provide evidence-based recommendations for appropriate non-antimicrobial management of peritonitis in CAPD/APD patients.
    • To provide evidence-based recommendations for appropriate empirical and directed antimicrobial therapy of peritonitis in CAPD/APD patients.
    • To recommend appropriate dose, route of administration and duration of antimicrobial agents.
    • To advise in the event of antimicrobial allergy.
    • To set-out criteria for referral to specialists.
    Clinical condition: Peritoneal dialysis peritonitis
    Target patient group: Any patient with suspected or confirmed peritoneal dialysis peritonitis
    Target professional group(s): Secondary Care Doctors
    Pharmacists
    Adapted from:

    Evidence base

    References

    1. 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
    2. Gould IM, Casewell MW. The laboratory diagnosis of peritonitis during continuous ambulatory peritoneal dialysis. J Hosp Infect 1986; 7: 155-160
    3. 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
    4. Woodrow G, Davies S. Renal Association Clinical Practice Guideline on Peritoneal Dialysis. Nephron Clin Pract 2011; 118 (Suppl 1): c287-310
    5. 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
    6. 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
    7. 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

    Evidence levels:
    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)

    Approved By

    Improving Antimicrobial Prescribing Group

    Document history

    LHP version 1.0

    Related information

    Appendix 1

    Antibiotic Information

    Vancomycin prescription

    • 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 electronic Medicines Compendium information on 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 electronic Medicines Compendium information on 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

    • >20mg/L
      Do not give vancomycin and repeat blood test in a further 3 days
    • <20mg/L
      Give Vancomycin electronic Medicines Compendium information on Vancomycin 2g i.p. (or 1.5g if <45kg body weight) as before and repeat blood test in a further 3 days

    Teicoplanin prescription

    • 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 electronic Medicines Compendium information on Teicoplanin levels do not need to be monitored routinely if the patient is clinically responding to Teicoplanin electronic Medicines Compendium information on 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 electronic Medicines Compendium information on Linezolid) may be more appropriate. The Microbiologists must be told about patients who are receiving Teicoplanin electronic Medicines Compendium information on 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 prescription

    • 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.

    Gentamicin levels

    • 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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