PD+peritonitis

Last reviewed by CRGH Renal Department 2012 Disclaimer - this information is intended to supplement the official Sydney LHD policy, which should always be followed.
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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 <span style="font-family: Arial,sans-serif; font-size: 14px;">Effluent WCC >100, >50% PMNs (after >2h dwell) <span style="font-family: Arial,sans-serif; font-size: 14px;">Organisms seen on gram stain of dialysate effluent <span style="font-family: Arial,sans-serif; font-size: 14px;">Positive culture of effluent fluid

<span style="font-family: Arial,sans-serif; font-size: 14px;">Treatment should be initiated as soon as cultures are taken __<span style="font-family: Arial,sans-serif;">Do not wait __<span style="font-family: Arial,sans-serif;"> for laboratory confirmation when clinical suspicion is high

<span style="color: #ff87b9; font-family: Arial,Helvetica,sans-serif; font-size: 19px;">//Typical organisms// //<span style="font-family: Arial,sans-serif;">S. aureus // <span style="font-family: Arial,sans-serif; font-size: 14px;">Coagulase-negative //Staphylococcus spp.// <span style="font-family: Arial,sans-serif; font-size: 14px;">Enteric gram negative organisms eg //E. coli, Klebsiella, Proteus// //<span style="font-family: Arial,sans-serif;">Enterococcus spp. // //<span style="font-family: Arial,sans-serif;">Pseudomonas // <span style="font-family: Arial,sans-serif; font-size: 14px;">Mixed culture <span style="font-family: Arial,sans-serif; font-size: 14px;">Yeast and other fungi

<span style="font-family: Arial,sans-serif; font-size: 14px;">Empirical treatment needs to cover gram positive and gram negative organisms <span style="font-family: Arial,sans-serif; font-size: 14px;">A proportion of patients will be culture negative.

<span style="color: #ff87b9; font-family: Arial,Helvetica,sans-serif; font-size: 19px;">//Management//
 * 1) <span style="font-family: Arial,sans-serif; font-size: 14px;">Triage the patient (if being seen in the Emergency Department)
 * 2) <span style="font-family: Arial,sans-serif; font-size: 14px;">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) <span style="font-family: Arial,sans-serif; font-size: 14px;">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.
 * <span style="font-family: Arial,sans-serif; font-size: 10pt;">Place 30 mls in yellow top container and send to microbiology for urgent gram stain, culture and sensitivity.
 * <span style="font-family: Arial,sans-serif; font-size: 10pt;">Inoculate 10 mls of effluent into a green top (aerobic) blood culture bottle and send to microbiology for culture and sensitivities.
 * 1) <span style="font-family: Arial,sans-serif; font-size: 14px;">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.
 * <span style="font-family: Arial,sans-serif; font-size: 10pt;">Blood biochemistry (EUC, LFT, CMP, CRP, amylase) and FBC.
 * <span style="font-family: Arial,sans-serif; font-size: 10pt;">Blood cultures if patient is febrile or systemically unwell.
 * <span style="font-family: Arial,sans-serif; font-size: 10pt;">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.
 * 1) <span style="font-family: Arial,sans-serif; font-size: 14px;">Begin empirical treatment according to algorithm below.

<span style="color: #ff87b9; font-family: Arial,Helvetica,sans-serif; font-size: 19px;">//Empirical antibiotic treatment//
 * <span style="font-family: Arial,sans-serif; font-size: 14px;">Empirical treatment should be continued until organism is identified from cultures
 * <span style="font-family: Arial,sans-serif; font-size: 14px;">Review patient history and microbiology results for previous episodes of peritonitis.
 * <span style="font-family: Arial,sans-serif; font-size: 14px;">If relapsing or recurrent peritonitis (within last month) is suspected, notify Nephrologist/Renal Registrar before starting treatment
 * <span style="font-family: Arial,sans-serif; font-size: 14px;">Patients on Automated Peritoneal Dialysis (APD) must be converted to Continuous Ambulatory Peritoneal Dialysis (CAPD) until reviewed by renal team.
 * <span style="font-family: Arial,sans-serif; font-size: 14px;">Administer intra peritoneal (IP) antibiotics according to the protocol shown below and ensure there is a __6 hour dwell time__
 * <span style="font-family: Arial,sans-serif; font-size: 14px;">If fibrin is present and/or the fluid is very turbid, add unfractionated heparin 500 units/L to the PD fluid.
 * <span style="font-family: Arial,sans-serif; font-size: 14px;">Do not use rapid cycles unless specifically ordered by the renal team

<span style="font-family: Arial,sans-serif; font-size: 8pt;">Gentamicin 80 mg once daily IP || **<span style="font-family: Arial,sans-serif; font-size: 8pt;">Outpatient Management ** <span style="font-family: Arial,sans-serif; font-size: 8pt;">If patient not admitted follow up should be arranged as below || <span style="font-family: Arial,sans-serif; font-size: 8pt;">Gentamicin 40mg once daily IP || <span style="font-family: Arial,sans-serif; font-size: 8pt;">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) <span style="font-family: Arial,sans-serif; font-size: 8pt;">No Gentamicin || <span style="font-family: Arial,sans-serif; font-size: 8pt;">No clinic visit required. <span style="font-family: Arial,sans-serif; font-size: 8pt;">Phone F/U by PD staff || <span style="font-family: Arial,sans-serif; font-size: 8pt;">Gentamicin according to level || <span style="font-family: Arial,sans-serif; font-size: 8pt;">Patient to attend PD clinic for review and gentamicin level ||
 * <span style="font-family: Arial,sans-serif; font-size: 8pt;">Day 1 || <span style="font-family: Arial,sans-serif; font-size: 8pt;">Cephalothin 1gram once daily IP
 * <span style="font-family: Arial,sans-serif; font-size: 8pt;">Day 2 || <span style="font-family: Arial,sans-serif; font-size: 8pt;">Cephalothin 1 gram once daily IP
 * <span style="font-family: Arial,sans-serif; font-size: 8pt;">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) ** ||
 * <span style="font-family: Arial,sans-serif; font-size: 8pt;">Day 3 || <span style="font-family: Arial,sans-serif; font-size: 8pt;">Cephalothin 1 gram once daily IP
 * <span style="font-family: Arial,sans-serif; font-size: 8pt;">Day 4 || <span style="font-family: Arial,sans-serif; font-size: 8pt;">Cephalothin 1 gram once daily IP
 * <span style="font-family: Arial,sans-serif; font-size: 8pt;">Day 5 || <span style="font-family: Arial,sans-serif; font-size: 8pt;">As above || <span style="font-family: Arial,sans-serif; font-size: 8pt;">As required ||

<span style="font-family: Arial,sans-serif; font-size: 14px;">NB Gentamicin should only be administered for a __maximum of 3 doses__. <span style="font-family: Arial,sans-serif; font-size: 14px;">For culture negative peritonitis, treat with Cephalothin alone for 3 weeks.

<span style="color: #ff87b9; font-family: Arial,Helvetica,sans-serif; font-size: 19px;">//Organism-specific antibiotic treatment// <span style="font-family: Arial,sans-serif; font-size: 14px;">All episodes of peritonitis should be treated for a minimum of __3 weeks__ in total <span style="font-family: Arial,sans-serif; font-size: 14px;">The use of prophylactic nystatin oral drops is recommended <span style="font-family: Arial,sans-serif; font-size: 8pt;">NB: DO NOT MIX with gentamicin. <span style="font-family: Arial,sans-serif; font-size: 8pt;">Ampicillin and gentamicin must be administered in separate PD bags. || <span style="font-family: Arial,sans-serif; font-size: 8pt;">125mg/L IP in each bag || <span style="font-family: Arial,sans-serif; font-size: 8pt;">Aim level 15; dose when trough <20. || <span style="font-family: Arial,sans-serif; font-size: 8pt;">* Treatment with gentamicin for >3 days should only be prescribed after discussion with Nephrologist and the patient’s cumulative gentamicin exposure is assessed <span style="font-family: Arial,sans-serif; font-size: 14px;">Recommended only for MRSA/MRSE patients
 * **<span style="font-family: Arial,sans-serif; font-size: 8pt;">Ampicillin **
 * **<span style="font-family: Arial,sans-serif; font-size: 8pt;">Cephalothin/cephazolin ** || <span style="font-family: Arial,sans-serif; font-size: 8pt;">1gram IP once daily ||
 * **<span style="font-family: Arial,sans-serif; font-size: 8pt;">Ciprofloxacin ** || <span style="font-family: Arial,sans-serif; font-size: 8pt;">500mg PO bd ||
 * **<span style="font-family: Arial,sans-serif; font-size: 8pt;">Cefepime ** || <span style="font-family: Arial,sans-serif; font-size: 8pt;">1gram IP once daily ||
 * **<span style="font-family: Arial,sans-serif; font-size: 8pt;">Gentamicin* ** || <span style="font-family: Arial,sans-serif; font-size: 8pt;">40-80 mg IP daily based on levels (trough<1) ||
 * **<span style="font-family: Arial,sans-serif; font-size: 8pt;">Metronidazole ** || <span style="font-family: Arial,sans-serif; font-size: 8pt;">400 mg PO tds ||
 * **<span style="font-family: Arial,sans-serif; font-size: 8pt;">Vancomycin ** || <span style="font-family: Arial,sans-serif; font-size: 8pt;">1-2 grams IP based on levels

<span style="color: #ff87b9; font-family: Arial,Helvetica,sans-serif; font-size: 19px;">//Fungal peritonitis// <span style="font-family: Arial,sans-serif; font-size: 14px;">Immediate catheter removal is recommended <span style="font-family: Arial,sans-serif; font-size: 14px;">Discuss management with Nephrologist/Renal Registrar Recommended initial treatment fluconazole 200mg po daily <span style="font-family: Arial,sans-serif; font-size: 14px;">Antifungal treatment should continue for 10 days after catheter removal

<span style="color: #ff87b9; font-family: Arial,Helvetica,sans-serif; font-size: 19px;">//Relapsing peritonitis// <span style="font-family: Arial,sans-serif; font-size: 14px;">Peritonitis within 1 month of previous episode with same organism <span style="font-family: Arial,sans-serif; font-size: 14px;">May need prolonged antibiotic treatment <span style="font-family: Arial,sans-serif; font-size: 14px;">Consider treatment with single dose Vancomycin after standard protocol <span style="font-family: Arial,sans-serif; font-size: 14px;">Must be discussed with the Nephrologist prior to initiating <span style="font-family: Arial,sans-serif; font-size: 14px;">In some cases catheter removal should be discussed

<span style="color: #ff87b9; font-family: Arial,Helvetica,sans-serif; font-size: 19px;">//Patient follow up//
 * <span style="font-family: Arial,sans-serif; font-size: 14px;">The PD Training Unit must be notified of __any__ patient with confirmed or suspected peritonitis so that correct patient follow up can be scheduled.
 * <span style="font-family: Arial,sans-serif; font-size: 14px;">If patient is seen in hospital please send discharge summary with patient or fax to PD unit.
 * <span style="font-family: Arial,sans-serif; font-size: 14px;">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.
 * <span style="font-family: Arial,sans-serif; font-size: 14px;">Contact details
 * **<span style="font-family: Arial,sans-serif; font-size: 10pt;">Working Hours **<span style="font-family: Arial,sans-serif; font-size: 10pt;"> Monday to Saturday 8am-4pm **(02) 9515 3525**
 * **<span style="font-family: Arial,sans-serif; font-size: 10pt;">Fax (02) 9515 3502 **
 * **<span style="font-family: Arial,sans-serif; font-size: 10pt;">After Hours (02) 9515 3531 **<span style="font-family: Arial,sans-serif; font-size: 10pt;">Please leave a message on the message bank clearly stating the date, name of patient, treatment plan and follow-up
 * <span style="font-family: Arial,sans-serif; font-size: 14px;">After hours information can also be obtained by contacting the relevant renal ward:
 * <span style="font-family: Arial,sans-serif; font-size: 14px;">Concord Hospital 4 North extension 76420
 * <span style="font-family: Arial,sans-serif; font-size: 14px;">Royal Prince Alfred Hospital 6 East 1 extension 57704
 * <span style="font-family: Arial,sans-serif; font-size: 14px;">Renal Registrar or Consultant on-call at either hospital