Nephrol Dial Transplant (2017) 32: 1283–1284

doi: 10.1093/ndt/gfx226

NDT Digest

Diagnostic and therapeutic approach to peritonitis

Wim Van Biesen1 and Edwina A. Brown2
1
Renal Division, Ghent University Hospital, Ghent, Belgium and 2Imperial College Renal and Transplant Centre, Hammersmith Hospital,

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London, UK

Correspondence and offprint requests to: Wim Van Biesen; E-mail: wim.vanbiesen@ugent.be

|| and/or cloudy dialysis effluent, dialysis effluent white cell

INTRODUCTION
|| count >100/ml (after a dwell time of at least 2 h) with >50% poly-
||
Peritonitis is commonly perceived as a frequent complication of || morphonuclear cells or positive dialysis effluent culture.
peritoneal dialysis (PD). In reality, the incidence of peritonitis is
|| It is obligatory for each centre to have a standardized protocol
||
limited to one episode per 24–48 patient-months (0.25– || to ensure correct sampling of dialysate as rapidly as possible, and
0.5 episodes/year), a number comparable to access-related
|| before therapy is initiated, to allow rapid bacterial identification.
||
infection risk in haemodialysis patients. Peritonitis rates vary || Rates of culture-negative peritonitis should be <15%, to allow
within centres and regions due to centre size, patient training
|| targeted therapy. Inoculation of blood culture bottles with dialy-
||
and local expertise with PD [1]. The impact of peritonitis on the || sate effluent is the preferred technique for bacterial culture [4].
success of PD programmes worldwide is substantial. PD perito-
|| Microbiologists should be aware that slow-growing fastidious
||
nitis is associated with a small increase in mortality in patients || bacteria are not uncommon in PD peritonitis and should adapt
|| their culture techniques accordingly, especially if initial cultures
with multiple comorbidities [2]; more importantly, failure to ||
respond to treatment, with subsequent catheter removal, is a || remain negative after 3 days. The place of more advanced identi-
|| fication techniques such as polymerase chain reaction (PCR) or
significant cause of PD technique failure. ||
Within this NDT Digest, we will briefly discuss the diagnos- || 16S-RNA gene sequencing is unclear in the diagnostic workup of
|| PD-associated peritonitis, and so far studies underpinning their
tic and empiric treatment approach to patients presenting with ||
symptoms of PD-associated peritonitis. || utility in the clinical management of peritonitis are lacking [3].
|| Non-infectious causes of cloudy effluent should be considered,
||
|| although they are rather rare. Chemical peritonitis, e.g. due to
|| high concentrations of glucose degradation products, eosinophilic
DIAGNOSTIC APPROACH ||
|| peritonitis, chylous ascites and malignancies are rare causes of
|| non-infectious cloudy effluent. In patients who have a day off
Patients presenting with cloudy dialysis effluent or abdominal ||
pain should trigger a diagnostic and management pathway (flow- || from PD or who are on automated peritoneal dialysis (APD)
|| with a dry day, cloudy effluent can be observed in the first drain
chart). Systemic features such as vomiting, fever and general ||
unwellness can also be present, particularly in patients who || because of accumulation of peritoneal debris; this should disap-
|| pear after rinsing of the peritoneal cavity with fresh dialysate.
present late. These are more common in patients with vision or ||
cognition problems who do not notice or do not realize the signif- || There is no additional diagnostic value of computed tomography
|| scans of the abdomen unless there is a clear indication for a sec-
icance of cloudy dialysate. The clinical appearance of the patient ||
is important in the decision of whether the patient is seriously ill, || ondary peritonitis, e.g. in patients with signs of cholecystitis, or
|| pancreatitis or when the culture shows multi-bacterial growth. In
and thus needs hospitalization, or the course is more benign and ||
can be managed on an outpatient basis. PD units should have a || the latter case, urgent surgical advice should be considered.
||
protocol to inform patients who to contact and where to go as ||
soon as peritonitis is suspected. The key diagnostic step is to
||
||
obtain a sample of dialysate for microscopy and culture as soon || THERAPEUTIC APPROACH
as possible after presentation. The International Society of
||
||
Peritoneal Dialysis (ISPD) criterion [3] for diagnosis of peritonitis || Appropriate antimicrobial therapy should be started as rapidly
is the presence of at least two of the following: abdominal pain
|| as possible. All centres should develop protocols so that therapy

C The Author 2017. Published by Oxford University Press

V 1283
on behalf of ERA-EDTA. All rights reserved.
 Cloudy effluent
|| ciprofloxacin or fluconazole can be administered orally, but
|| their bioavailability intraperitoneally might vary with inflamma-
||
|| tion and thus sharply decrease when inflammation improves.
|| Antibiotic treatment should be modified once cultures are avail-
White blood cell count and ||
differentiation on effluent || able and the causative organism has been identified. The ISPD
|| peritonitis guidelines provide a useful guide of individual antibi-
||
|| otic dosing [3].
Consider || Although peritonitis is an important complication of PD,
non-infectious > 100 WBC/µl with ||
causes of > 50% polymorphonuclear cells || pharmacokinetics, pharmacodynamics, impact of protein bind-
cloudy effluent ||
|| ing and transperitoneal membrane transport are scarcely inves-
|| tigated. In general, sufficient dwell time should be allowed after
Culture ||
|| intraperitoneal administration, to permit transperitoneal equili-
• Inoculate blood culture bottles with dialysate || bration. Antibiotics should therefore be injected into the day-
||
|| time dwell in APD or into an exchange lasting for a minimum
|| of 6 h on continuous ambulatory peritoneal dialysis.
Start empiric antibiotics
||
|| Vancomycin, gentamicin, cefazolin and ceftazidime can be

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• Keep a registry of peritonitis cases in your centre || mixed with dialysate solutions and are stable for at least 24–
with microbial cultures and sensitivity patterns and
||
|| 48 h, and even longer, allowing preparation of a dialysate bag in
adapt antimicrobial therapy accordingly || the centre or by a nurse for self-administration by the patient
• Take into account pharmacokinetics, ||
pharmacodynamics and compatibility with || later on. However, there is concern about mixing vancomycin
dialysate solutions
|| and ceftazidime, and vancomycin might not be stable in alkal-
||
|| ized solutions.
|| Some centres will administer heparin (500 units/L) to avoid
||
Gram positive covering: Gram negative covering: || clotting of the catheter by fibrin, and some centres will use one
Vancomycin 30 mg/kg IP + Gentamicin 1 mg/kg IP || instillation of urokinase to avoid biofilm formation, although
or Cefazolin 1.5 g IP or Ceftazidime 1.5 g IP ||
|| evidence to support these practices is lacking.
• Allow a dwell time of at least 6 hours for equilibration
|| Under normal conditions, signs of inflammation (cloudy efflu-
||
• Avoid mixing vancomycin in alkaline solutions || ent and cell count) should substantially improve in the first 3
NDT DIGEST

• Aim at trough levels for Vancomycin of > 15 µg/ml || days for a non-complicated peritonitis episode. If after 5 days the
||
|| dialysate has not become clear, further diagnostic workup should
FIGURE 1: Flowchart for management of patients presenting with || be done and catheter removal should be considered. After a short
cloudy effluent. ||
|| recovery period on haemodialysis, PD can be successfully
|| resumed after reinsertion of the catheter in most cases [8].
||
||
covers the most frequent causative organisms of peritonitis ||
||
(both Gram negative and Gram positive) in that centre or || REFERENCES
region [5]. With that aim, all centres should register antimicro- ||
|| 1. Rocha A, Rodrigues A, Teixeira L et al. Temporal trends in peritonitis rates,
bial resistance in peritonitis. A recent Cochrane review revealed || microbiology and outcomes: the major clinical complication of peritoneal
that no combination of antimicrobial agents has proven superi- ||
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ority in the management of peritonitis [6]. Most centres will || 2. Boudville N, Kemp A, Clayton P et al. Recent peritonitis associates with mor-
nowadays opt for a regimen with intraperitoneal administration || tality among patients treated with peritoneal dialysis. J Am Soc Nephrol 2012;
||
of vancomycin and an aminoglycoside in the first dwell. This || 23: 1398–1405
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|| 3. Li PK, Szeto CC, Piraino B et al. ISPD Peritonitis recommendations: 2016
|| update on prevention and treatment. Perit Dial Int 2016; 36: 481–508
with this combination, the strong post-antimicrobial effect of || 4. Alfa MJ, Degagne P, Olson N et al. Improved detection of bacterial growth in
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||
|| continuous ambulatory peritoneal dialysis effluent by use of BacT/Alert FAN
comycin. Single administrations of aminoglycosides (e.g. genta- || bottles. J Clin Microbiol 1997; 35: 862–866
micin 1 mg/kg) do not impact residual renal function [7].
|| 5. Van Biesen W, Vanholder R, Vogelaers D et al. The need for a center-tailored
|| treatment protocol for peritonitis. Perit Dial Int 1998; 18: 274–281
Vancomycin can be added to each bag in low doses (30 mg/kg ||
|| 6. Campbell D, Mudge DW, Craig JC et al. Antimicrobial agents for preventing
loading dose, maintenance 1.5 mg/kg per bag) or intermittently || peritonitis in peritoneal dialysis patients. Cochrane Database Syst Rev 2017; 4:
(30 mg/kg every 5–7 days depending on residual renal function || CD004679
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and dialysis clearance). It is strongly advisable to monitor van- || 7. Baker RJ, Senior H, Clemenger M et al. Empirical aminoglycosides for perito-
comycin serum levels to ensure adequate serum trough levels || nitis do not affect residual renal function. Am J Kidney Dis 2003; 41: 670–675
|| 8. Cho Y, Badve SV, Hawley CM et al. Peritoneal dialysis outcomes after tempo-
(aim for minimum of 15 lg/mL to avoid emerging || rary haemodialysis transfer for peritonitis. Nephrol Dial Transplant 2014; 29:
vancomycin resistance). ||
|| 1940–1947
There is no clear advantage to administering antibiotics ||
intravenously. In mild cases, antimicrobial agents such as || Received: 24.4.2017; Editorial decision: 23.5.2017
||
||
||

1284 W. Van Biesen and E.A. Brown