Peritoneal Dialysis Related Peritonitis

Definition of peritonitis:
Peritonitis in patients undergoing peritoneal dialysis denotes inflammation of the peritoneum. This results in an increase in the number of white blood cells, leading to cloudiness of the peritoneal dialysis fluid when drained out of the peritoneum. The cloudiness is almost invariably present, should be seen as the earliest detector of infection. The majority of patients will also complain of abdominal pain and/or tenderness.
The triad of symptoms is:

  • Pain
  • Fever
  • Cloudy Bag

 All peritoneal dialysis patients with suspected or confirmed Peritoneal Dialysis (PD) peritonitis should be notified to the renal team.

Administration of Antibiotic therapy:
Where there is suspicion of peritonitis, samples must be taken for white cell count, microscopy (gram stain), culture, and sensitivity. Immediately following the taking of samples, empirical antibiotic therapy should be administered that provides both gram-positive and gram-negative cover.Do not wait for confirmation of results or WCC before administering the first doses of antibiotic therapy.

The patient’s history of infection and any available sensitivity results must be considered when selecting initial therapy. Intraperitoneal (IP) administration of antibiotics for treating peritonitis is superior to intravenous administration and intermittent dosing is equally efficacious as continuous administration.

Antibiotic choices should be based on sensitivities when results are available.(Click here) for the full policy.

Severity(classification)

1st line oral/iv antibiotics

Allergy to first line treatment

A/B/C

Minor to severe life threatening infection

Review doses in renal impairment

CIPROFLOXACIN 500mg po stat* followed by 500mg bd
plus 
VANCOMYCIN 2g IP stat**. Remain indwell for 6-8 hours
(repeat IP Vancomycin 2g in overnight exchange on day 5 if indicated)
Patients who usually undertake automated PD should perform a manual exchange to facilitate administration of antibiotics by this route.

Treatment duration: typically 10 days

Not applicable

Other allergies  

  • If allergic to ciprofloxacin give Gentamicin 40mg IP stat. Remain indwell for 6-8 hours.
    Inject into a 2-litre dialysis bag and drain into the peritoneum. IP gentamicin should be given once daily.
  • 
  • If allergic to Vancomycin discuss with consultant microbiologist

Treatment duration: typically 10 days

 

 IV to Oral Switch
(explanatory notes)

Discuss with consultant microbiologist

*The calcium and aluminium salts are often prescribed for dialysis patients as a phosphate binder. They bind and prevent the absorption of ciprofloxacin. Therefore stop the calcium or aluminium based phosphate binder  whilst on ciprofloxacin treatment. Renagel® and Renvela® may be continued normally as they do not contain calcium or aluminium.

**Each 1000mg vial of vancomycin should be reconstituted with 20mls of water for injection and drawn up into a 20ml syringe. The vancomycin should be added to the PD fluid through the additive port on the PD bag.

Last reviewed: 10/02/14

For guidance on the administration of intravenous antibiotics click here
(GHNHSFT intranet)