PERITONITIS Peritonitis is a serious complication of peritoneal dialysis. Repeated episodes of peritonitis may be implicated in early failure of the peritoneal membrane and subsequent failure of peritoneal dialysis. Guidelines provide a framework around which an individual patient's management can be based, but must be interpreted in light of the clinical condition of each patient. It is suggested that guidelines be reviewed every year to ensure they remain up to date. The Medical Director and attending physicians should make all medication decisions and approve any guidelines. Diagnosis of PD Peritonitis 1. Symptoms and signs of peritonitis Abdominal pain Nausea and vomiting Constipation or diarrhea Fever Rebound tenderness Blood leucocytosis 2. Cloudy PD fluid with PD White cell count >100/mm3 (>50% polymorphonuclear neutrophils is supportive of the diagnosis of microbial-induced peritonitis). (PD fluid is clear and colourless before draining in. PD effluent should be clear but may be “yellow” in colour. “Cloudy” fluid looks like “Pineapple juice” and it is difficult to read text through the bag.) Causes of cloudy dialysate Infective peritonitis - bacterial, fungal, TB, other Culture Negative peritonitis Secondary to other intra-abdominal pathology - diverticulitis, appendicitis, perforated bowel, abscess, transcolonic migration of catheter Eosinophilic peritonitis - Asymptomatic cloudy dialysate fluid with >15% eosinophils on differential cell count BLOODSTAINED PD FLUID Sometimes seen in females during menstruation is common and harmless. It can also happen if the small blood vessels in the peritoneum break (e.g. lifting something heavy, playing sports). It usually clears quickly in a few exchanges but patients should be seen if the fluid is very bloody or not clearing or they are unwell in any way. Initial investigations should include exclusion of peritonitis, abdominal film and consideration of surgical review. MANAGEMENT Peritonitis is a potentially life-threatening condition. In the presence of cloudy fluid and/or abdominal pain and/or fever prompt initiation of antibiotic therapy is needed. 1. Measure and record BP (lying and standing), pulse and temperature. 2. A sample of the appropriate (i.e., > 4 hours' dwell time) dialysate effluent should be obtained for laboratory evaluation including a cell count with differential, Gram stain, and culture. 3. Examine exit site; swab if there appears to be exit site infection and send for exit site wound culture. Examine tunnel for evidence of tunnel infection. 4. Check for patient allergies. 5. Review recent episodes of peritonitis and exit site infections. 6. Flush peritoneum per protocol or physician order. 7. Change catheter extension set. 8. Commence empirical antibiotics per protocol or physician order. 9. Choice of final therapy should always be guided by antibiotic sensitivities. PROPHYLACTIC ANTIBIOTICS FOLLOWING ACCIDENTAL TOUCH CONTAMINATION Following a break in sterile technique call physician for antibiotic orders and change the patient’s catheter extension set before any further exchanges are performed. FREQUENCY OF CULTURES It is important to obtain the first cloudy effluent for culture. The probability of positive diagnostic culture is greatest from this specimen. Patients should be instructed, therefore, to bring the first cloudy fluid to the laboratory immediately. After the initial culture, repeat effluent cultures are not recommended if the cell count is decreasing appropriately and the patient is responding symptomatically. If cell counts are either rising or not decreasing appropriately by 3 days, repeat cultures should be taken and management guidelines should be consulted. INITIAL EMPIRIC ANTIBIOTIC SELECTION If the effluent sediment Gram stain suggests gram-positive bacteria, a gram-negative organism, or is unavailable, delayed, or negative for any specific organisms, empiric therapy is indicated (ISPD Guidelines/Recommendations Adult Peritoneal Dialysis- Related Peritonitis Treatment Recommendations: 2000 Update Table 2). To prevent routine use of Vancomycin and thus prevent emergence of resistant organisms, it is recommended that a first-generation Cephalosporin, for example, Cefazolin or Cephalothin (1 g daily in the long dwell), in combination with Ceftazidime 1 g be initiated. These antibiotics can be mixed in the same dialysate bag as either loading or maintenance doses, without significant loss of bioactivity. (ISPD Guidelines/Recommendations Adult Peritoneal Dialysis- Related Peritonitis Treatment Recommendations: 2000 Update Table 3). (For more on medication selection please see ISPD Guidelines/Recommendations Adult Peritoneal Dialysis- Related Peritonitis Treatment Recommendations: 2000 Update http://www.ispd.org) SAMPLE: PERITONITIS MEDICATION GUIDELINES IP Vancomycin single dose, dwell 6hours 1.5g if <60 kg body weight 2.0g if >60 kg body weight Ciprofloxacin 500mg PO BID x 4 days IP Heparin 1000 units per exchange 4 days (continue until bags clear and no fibrin clots present) Note: Ciprofloxacin should be taken 2 hours before calcium and iron preparations (e.g. Tums, Phoslo) as they interfere with absorption. SAMPLE: Peritonitis Protocol Clinical diagnosis of PD peritonitis, no exit site, no tunnel infection Empirical treatment Oral Ciprofloxacin 500 mg bid OR IP Gentamicin 0.6mg/kg/day if vomiting) IP Vancomycin 2g(>60 kg) 1.5g (<60 kg) single dose (then review) IP Heparin 1000u in each exchange Gram positives inc. Enterococcus, Staph After Cultures received: Pseudomonas, yeast, mixed gram negative and culture negative (Special cases, see detailed protocols/call for specific orders) Stop Ciprofloxacin/Gentamicin Give day 7 Vancomycin, same dose If Staph aureus: • Consider Rifampicin and/or Flucloxacillin • give day 7 and 14 Vancomycin. Gram negatives (except Pseudomonas) 14 days oral Ciprofloxacin. No further Vancomycin If recurrent Staph epidermidis: • give day 7 and 14 vancomycin. Laboratory Follow up 1. Day four of therapy: Repeat cell counts and differential Repeat routine culture and sensitivity Confirm sensitivies Ideal specimen is overnight dwell More laboratory tests may be ordered PRN patient's status 2. Four days after completion of therapy Final cell count and differential Final routine cultures EXIT SITE INFECTION An exit site infection is defined by the presence of purulent drainage with or without erythema of the skin at the catheter-epidermal interface. Exit-site and tunnel infections are important because they may lead to refractory or relapsing peritonitis and subsequent catheter loss. Acute Exit-Site Infection is defined as purulent and/or bloody drainage from the exit site, which may be associated with erythema, tenderness, exuberant granulation tissue, and edema (Twardowski and Prowant, 1996b). The erythema is more than twice the catheter diameter and there is regression of the epithelium in the sinus. An acute catheter infection may be accompanied by pain and the presence of a scab, but crusting alone is not indicative of infection Chronic Exit-Site Infections may be the result of an untreated or inadequately treated acute infection. It may also be a sequela of a resolved acute infection, which recurs after withdrawal of antibiotic therapy. Symptoms of chronic infection are similar to those of acute infections; however, exuberant granulation tissue is more common both externally and in the sinus. Granulation tissue at the external exit is sometimes covered by a large stubborn crust or scab. Pain, erythema, and swelling are frequently absent in chronic infection. An Equivocal Exit Site is defined as purulent and/or bloody drainage only in the sinus that cannot be expressed outside, accompanied by regression of the epithelium and the occurrence of slightly exuberant granulation tissue in the sinus. Erythema may be present but with a diameter less than twice the width of the catheter. Pain, swelling, and external drainage is absent (Twardowski and Prowant, 1996b). The equivocal infected exit site represents low-grade infection. Although some equivocal exits improve spontaneously, most progress to overt infection if untreated. Tunnel Infection is defined as erythema, edema, and/or tenderness over the subcutaneous pathway, and may be characterized by intermittent or chronic, purulent, bloody, or gooey drainage which discharges spontaneously or after pressure on the cuff. Tunnel infections are often occult (Plum et al., 1994) and can sometimes be detected by ultrasonography of the subcutaneous pathway (Plum et al., 1994; Holley et al., 1989). Most, but not all, tunnel infections occur in association with exit-site infections. Here the risk for subsequent peritonitis is increased. Traumatized Exit Site appearances depend on the intensity of the trauma and the time interval until examination. Common features are pain, bleeding, scab, and deterioration of exit appearance. Pathogens: Staph. Aureus is responsible for the majority of exit-site and tunnel infections. Pseudo. Aeruginosa is much less common, but like Staph. Aureus is difficult to eradicate and frequently leads to peritonitis if catheter removal is delayed. Staph. Epidermidis is a relatively infrequent cause of tunnel infection in contrast to peritonitis. Other gram-positive organisms, other gram-negative bacilli, and, rarely, fungi account for the remaining infections. Exit-Site Cultures: within 2 – 4 weeks after catheter implantation, bacteria colonize almost all exit sites. Positive cultures from normal-appearing exit sites indicate colonization, not infection. Whenever possible, the cultures should be taken from the exudate (Twardowski and Prowant 1996a, 1996c). Cultures should only be taken from abnormal-looking exit sites Selected Readings International Society Of Peritoneal Dialysis http://www.ispd.org ISPD Guidelines/Recommendations Adult Peritoneal Dialysis- Related Peritonitis Treatment Recommendations: 2000 Update Twardowski ZJ, Prowant BF. Exit-site study methods and results. Perit Dial Int 1996a; 16(Suppl 3):S6–31. Twardowski ZJ, Prowant BF. Classification of normal and diseased exit sites. Perit Dial Int 1996b; 16(Suppl 3):S32–50. Plum J, Sudkamp S, Grabensee B. Results of ultrasound-assisted diagnosis of tunnel infections in CAPD. Am J Kidney Dis 1994; 23:99–104. Holley JG, Foulkes CJ, Mers AH, Willard D. Ultrasound as a tool in the diagnosis and management of exit-site infections in patients undergoing CAPD. Am J Kidney Dis 1989; 14:211–16. Reviewed: 06-2011