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
patients 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):S631.
Twardowski ZJ, Prowant BF. Classification of normal and diseased exit sites. Perit Dial Int 1996b; 16(Suppl 3):S3250.
Plum J, Sudkamp S, Grabensee B. Results of ultrasound-assisted diagnosis of tunnel infections in CAPD. Am J Kidney Dis
1994; 23:99104.

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; 14:21116.

Reviewed: 06-2011

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