Guideline for the Management of Peritonitis

Prevention Strategies

Important General Points

Clinical Presentation

Assessment

Diagnosis

Treatment

Treatment in the First 48 hours

Eosinophilic Peritonitis

Recurrent Peritonitis

Fungal Peritonitis

Indications for Removal of the Catheter

After the Catheter has been Removed

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For the complete guideline see Peritoneal Dialysis International 2010;30:393-423.

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Prevention Strategies

• PD units should undertake regular audit of their peritonitis and exit-site infection rates, including causative organism, treatment and outcomes. They should enter into active dialogue with their microbiology department and infection control team to develop optimal local treatment and prevention protocols
• For children on manual PD the flush-before-fill dialysis delivery systems should be used
• Caregivers or patients should undergo regular review of their technique, at least once every 6 months, or more frequently if indicated, such as after an episode of PDrelated infection or after a significant interruption of the caregiver performing the PD. They should receive intensified training if their technique is below standard
• Administer prophylactic antibiotics
  • after accidental intraluminal or touch contamination: intraperitoneal vancomycin 25 mg/L
  • before invasive dental procedures: amoxicillin 50 mg/ kg PO, maximum 2 g
  • before procedures involving the gastrointestinal or genitourinary tract and associated with a high risk of bacteraemia: cefoxitin or cefotaxime 25 mg/kg, max 2 g.

Important General Points

• Symptoms and outcome are usually worse with Staphylococcus aureus and gram-negative infections and fungi
• Prolonged use of antibiotics may result in fungal peritonitis. Use oral nystatin at the time of antibiotic administration to reduce the risk of fungal peritonitis
• Treatment should be aimed at preservation of the peritoneal membrane rather than the catheter.

Clinical Presentation

• Cloudy dialysate fluid ± (menstruating girls may develop cloudy or blood-stained PD fluid)
• Abdominal pain ±
• Fever ±
• History of line break / contamination ±
• Septic shock ±
• Increased vomiting ± (especially noted in babies)
• Non-specific signs and symptoms (especially noted in babies).

Assessment

• Send a single bag of PD fluid effluent for cell count and differential, Gram stain and MC&S. Also ask for an eosinophil count if the white blood cell count is >100 x 10⁶ /litre

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NB: Unless child’s clinical presentation requires urgent action, ensure the effluent has been dwelling for a minimum of 2-4 hours before collecting the sample, to improve culture yield

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• Blood investigations: FBC and differential, CRP
• Blood cultures if clinically indicated
• Assess PD exit site and send swab for MC&S. If infected, order abdominal ultrasound to exclude tunnel infection.

Diagnosis

Features strongly suggestive of peritonitis include peritoneal fluid analysis (uncentrifuged specimen and dwell time of >2 hours) revealing:

• WBC >100 x 10⁶ /litre or
• WBC >50-100 x 10⁶ /litre and clinical features suggestive of peritonitis
• In both the above cases treatment should be initiated
• Negative Gram stain does not exclude peritonitis.

In doubtful cases when there are:

• 50 -100 WBC x 10⁶ /litre and the patient is asymptomatic, repeat specimen culture in 4-6 hours
• WBC in peritonitis are usually >50% neutrophils. If the differential count is predominantly lymphocytes fungal peritonitis should be considered
• Positive PD culture usually develops in 24 hours.

Treatment

• Methicillin resistant organisms (MRSA) will require systemic treatment (e.g. vancomycin) and will need to comply with local infection control policies
• Initial treatment regimens for peritonitis should include cover for bacterial gram-positive and gram-negative organisms including Pseudomonas species until the result of culture and antibiotic sensitivities are obtained
• Intraperitoneal administration of antibiotics is superior to IV dosing for treating peritonitis; intermittent and continuous dosing of antibiotics are equally efficacious
• Once culture results and sensitivities are known, antibiotic therapy should be adjusted as appropriate
• For patients with substantial residual renal function (e.g., residual glomerular filtration rate 5 mL/minute/1.73 m² ), the dose of antibiotics must be adjusted accordingly
• Treatment guidelines are from the peritoneal dialysisrelated infections recommendations at www.PDIconnect.com.

Treatment in the First 48 hours

If there are only local signs or minor systemic illness use both intraperitoneal vancomycin and amikacin until Gram stain or culture of PD fluid is available:

• Vancomycin 25 mg/L IP
• Amikacin 25 mg/L IP
• Heparin 200 u/L IP
• Nystatin oral suspension 100,000 iu bd for the duration of antibiotic treatment.

If severe systemic illness, initially use both IV vancomycin and amikacin until Gram stain and culture is available. Initial doses of parenteral antibiotics:

• Vancomycin 10 mg/kg IV stat
• Amikacin 15 mg/kg IV stat
• Modify treatment according to results of culture and sensitivity
• In most cases, discharge home is possible after 3-4 days of treatment
• Continue treatment at home with bags spiked with antibiotics and heparin, prepared by experienced nursing staff every 48 hours
• Treatment should be continued for 14 days for culture positive and culture negative peritonitis, and 21 days for Staph aureus
• If the PD fluid WBC is persistently >100 x 10⁶ /litre reassess the exit site and repeat fluid and exit site MC & S.

Eosinophilic Peritonitis

• Should be considered in an asymptomatic patient with cloudy dialysate and when >10% of WBC in PD fluid consists of eosinophils
• It is usually benign and resolves spontaneously over 2 to 6 weeks
• Most occur after catheter insertion or during the treatment phase of peritonitis
• May be associated with peripheral blood eosinophilia
• Treat with oral anti-histamines
• Rarely, it may occur in association with fungal and parasitic infections.

Recurrent Peritonitis

Consider risk factors

• Revisit the exchange technique and consider burn out
• Tenckhoff catheter, exit site or tunnel infection - swab the exit site and obtain an ultrasound scan of the tunnel
• May need a further course of oral antibiotics (up to 6 weeks) according to sensitivities
• An infected superficial cuff can be exteriorised and shaved. If the inner cuff is involved it will need catheter replacement
• Staph. aureus infection: Take a nasal swab for Staph carriage for both carers and patient. If positive use intranasal mupirocin (Bactroban) bd for one week.

Fungal peritonitis

Children at risk

• Frequent broad-spectrum antibiotic usage
• Gastrostomy (but no significant relationship).

Treatment

• Start treatment with fluconazole 12 mg/kg IV once daily for 48 hrs decreasing to 6 mg/kg/ day (max dose 200 mg daily) for a total of at least 2 weeks. Then continue with oral fluconazole for further 4 weeks
• Most Candida albicans are sensitive to fluconazole. If not responding, change to liposomal amphotericin B 1mg/kg as a daily IV dose (monitor cultures for sensitivities)
• Catheter removal as soon as possible
• Start HD until PD can be reinitiated. Preferably rest the peritoneum for 3 months if possible.

Indications for removal of the catheter

• Severe intra-abdominal sepsis and septic shock
• Exit site or tunnel infection due to the same organism as that causing the peritonitis
• A recurrence with the same organism within 4 weeks of stopping therapy (i.e. relapsing peritonitis)
• Persistently raised WCC after 3 to 4 days if the infection is severe, or 7 days if the infection is mild
• The child remains symptomatic after 3 to 4 days.

After the catheter has been removed

• Antibiotics should be continued for a minimum 5 to 7 days
• A new catheter can be inserted at a minimum of one week after all clinical evidence of peritonitis has subsided, providing Staphylococcus aureus carriage has been eliminated and any infection in the catheter tunnel has resolved
• Ideally, the peritoneum should be rested for 4 weeks (3 months for fungal peritonitis)
• If there has been a tunnel infection with abdominal wall sepsis, catheter replacement needs to be delayed until this has healed.

Click here for the pdf.

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Van Biljon I, Bhimma R, Gajjar P, McCulloch M, Nourse P. Guideline for Chronic Dialysis in Children in South Africa. South African Renal Society; 2015.