HOME
Last reviewed by CRGH Renal Department 2012
Disclaimer - this information is intended to supplement the official Sydney LHD policy, which should always be followed.

This is a common complication of peritoneal dialysis
ISPD guidelines suggest infection rates should be no more than 1 episode every 18 months
Many units achieve much better results
Links: Sydney LHD policy CARI Guidelines ISPD Guidelines Sydney LHD policy

Typical presentation
Fever (T>37.5)
Abdominal pain and/or rebound tenderness
Cloudy dialysate effluent
PD effluent UA positive for leucocytes

No all patients present with all symptoms.
Maintain a high index of suspicion for this diagnosis in all PD patients

Diagnosis
At least 1 symptom
Effluent WCC >100, >50% PMNs (after >2h dwell)
Organisms seen on gram stain of dialysate effluent
Positive culture of effluent fluid

Treatment should be initiated as soon as cultures are taken
Do not wait for laboratory confirmation when clinical suspicion is high

Typical organisms
S. aureus
Coagulase-negative Staphylococcus spp.
Enteric gram negative organisms eg E. coli, Klebsiella, Proteus
Enterococcus spp.
Pseudomonas
Mixed culture
Yeast and other fungi

Empirical treatment needs to cover gram positive and gram negative organisms
A proportion of patients will be culture negative.

Management
  1. Triage the patient (if being seen in the Emergency Department)
  2. When peritonitis is suspected the peritoneum should be drained immediately and the fluid inspected (patient may have presented with a previous cloudy bag). If the fluid is turbid or cloudy proceed as below.
  3. Peritoneal fluid collection. PD effluent must be collected prior to starting antibiotics. Aseptically collect 40 ml sample of peritoneal dialysis fluid via the collection port on the drainage bag. If the patient brings the previous drained bag and it is cloudy then collect specimen from that bag.
    • Place 30 mls in yellow top container and send to microbiology for urgent gram stain, culture and sensitivity.
    • Inoculate 10 mls of effluent into a green top (aerobic) blood culture bottle and send to microbiology for culture and sensitivities.
  4. Other specimens required:Contact the Renal Consultant or Renal Registrar on call. Do not wait for micro results in patients where the index of suspicion is high.
    • Blood biochemistry (EUC, LFT, CMP, CRP, amylase) and FBC.
    • Blood cultures if patient is febrile or systemically unwell.
    • Exit site swab if there is any sign of infection eg crusting, exudate, erythema, tenderness. N.B. If patient uses Medihoney on exit site remove with dry gauze prior to swabbing.
  5. Begin empirical treatment according to algorithm below.

Empirical antibiotic treatment
  • Empirical treatment should be continued until organism is identified from cultures
  • Review patient history and microbiology results for previous episodes of peritonitis.
  • If relapsing or recurrent peritonitis (within last month) is suspected, notify Nephrologist/Renal Registrar before starting treatment
  • Patients on Automated Peritoneal Dialysis (APD) must be converted to Continuous Ambulatory Peritoneal Dialysis (CAPD) until reviewed by renal team.
  • Administer intra peritoneal (IP) antibiotics according to the protocol shown below and ensure there is a 6 hour dwell time
  • If fibrin is present and/or the fluid is very turbid, add unfractionated heparin 500 units/L to the PD fluid.
  • Do not use rapid cycles unless specifically ordered by the renal team

Day 1
Cephalothin 1gram once daily IP
Gentamicin 80 mg once daily IP
Outpatient Management
If patient not admitted follow up should be arranged as below
Day 2
Cephalothin 1 gram once daily IP
Gentamicin 40mg once daily IP
Patient to attend PD clinic for review. If patient is stable load PD bag for day 3 and instruct patient on use (see appendix 3)
NB: If OP review required on a Sunday, patient will need to see renal registrar in the renal ward (6east 1 at RPAH and 4N at CRGH)
Day 3
Cephalothin 1 gram once daily IP
No Gentamicin
No clinic visit required.
Phone F/U by PD staff
Day 4
Cephalothin 1 gram once daily IP
Gentamicin according to level
Patient to attend PD clinic for review and gentamicin level
Day 5
As above
As required

NB Gentamicin should only be administered for a maximum of 3 doses.
For culture negative peritonitis, treat with Cephalothin alone for 3 weeks.

Organism-specific antibiotic treatment
All episodes of peritonitis should be treated for a minimum of 3 weeks in total
The use of prophylactic nystatin oral drops is recommended
Ampicillin
NB: DO NOT MIX with gentamicin.
Ampicillin and gentamicin must be administered in separate PD bags.
125mg/L IP in each bag
Cephalothin/cephazolin
1gram IP once daily
Ciprofloxacin
500mg PO bd
Cefepime
1gram IP once daily
Gentamicin*
40-80 mg IP daily based on levels (trough<1)
Metronidazole
400 mg PO tds
Vancomycin
1-2 grams IP based on levels
Aim level 15; dose when trough <20.
* Treatment with gentamicin for >3 days should only be prescribed after discussion with Nephrologist and the patient’s cumulative gentamicin exposure is assessed
Recommended only for MRSA/MRSE patients

Fungal peritonitis
Immediate catheter removal is recommended
Discuss management with Nephrologist/Renal Registrar
Recommended initial treatment fluconazole 200mg po daily
Antifungal treatment should continue for 10 days after catheter removal

Relapsing peritonitis
Peritonitis within 1 month of previous episode with same organism
May need prolonged antibiotic treatment
Consider treatment with single dose Vancomycin after standard protocol
Must be discussed with the Nephrologist prior to initiating
In some cases catheter removal should be discussed

Patient follow up
  • The PD Training Unit must be notified of any patient with confirmed or suspected peritonitis so that correct patient follow up can be scheduled.
  • If patient is seen in hospital please send discharge summary with patient or fax to PD unit.
  • The Peritoneal Dialysis Unit is part of the State Wide Renal Services (SWRS) incorporating Concord Hospital and Royal Prince Alfred Hospital and is located at Building 12, Missenden Rd, Camperdown.
  • Contact details
    • Working Hours Monday to Saturday 8am-4pm (02) 9515 3525
    • Fax (02) 9515 3502
    • After Hours (02) 9515 3531 Please leave a message on the message bank clearly stating the date, name of patient, treatment plan and follow-up
  • After hours information can also be obtained by contacting the relevant renal ward:
    • Concord Hospital 4 North extension 76420
    • Royal Prince Alfred Hospital 6 East 1 extension 57704
    • Renal Registrar or Consultant on-call at either hospital