dialysis_peritonitis

suspected peritonitis in peritoneal dialysis patients

introduction

  • patients on peritoneal dialysis are at risk of life threatening peritonitis
  • early recognition and Rx is important and peritonitis should be suspected if either:
    • cloudy effluent
      • an effluent cell count with WBC > 100/μL (after a dwell time of at least 2 hours), with > 50% PMN, is highly suggestive of peritonitis
    • symptoms of peritoneal inflammation such as fever, abdominal pain, vomiting, chills, nausea, abdominal tenderness
    • recent identification of organism on gram stain or culture of peritoneal dialysis effluent

DDx of cloudy effluent

ED Mx of suspected peritonitis

  • this is derived from Western Health Renal Medicine guideline July 20091)2) - YOUR hospital may have it's own policy which differs!

early notification to renal unit

  • contact renal ward / nurse / registrar ASAP upon suspicion of peritonitis to ensure appropriate, timely care
  • early booking of bed under renal ward

early Mx (within 30min of arrival to ED)

  • preferably via renal nurse:
    • perform an in/out flush of the peritoneal cavity with 2L of 1.5% Dialysate with added Heparin 500 IU/L.
    • 1st bag (or fluid sample) sent off for gram stain and culture.
      • a 50ml specimen of dialysate effluent should be collected for micro and culture from the initial drain out.
      • if drainage problems preclude this, the Tenckhoff catheter should be flushed as per hospital policy.
      • a peritoneal fluid sample should be obtained if at all possible before antibiotic therapy commences. If a patient brings in a suitable uncontaminated specimen of peritoneal dialysis fluid from home, a sample of this should also be sent for gram stain and culture.
  • patient assessment:
    • routine observations and clinical appraisal, examining particularly for signs of peritonitis or possible bowel perforation.
    • signs of clinical compromise (for Rx algorithm below) include:
      • systolic BP < 100mmHg, tachycardia, silent or rigid abdomen, hypoxia or acidosis.
  • investigations:
    • Full Blood Examination, Urea & Electrolytes, Amylase, Lipase, Liver function tests, C-reactive protein
    • Blood cultures (2 sets of 2 bottles each, each set from different sites) – if patient unwell
    • Further investigations and treatment according to clinical indications

early empirical antibiotic Rx of peritonitis

  • all loading doses of IP antibiotics, or single daily doses should dwell for a minimum of 6 hours

not clinically compromised and no PH MRSA

  • not allergic to cephalosporins:
    • protocal A:
      • Cephazolin Intra-peritoneal (IP) 20mg/kg bodyweight initial loading in first exchange
      • PLUS Ceftazidime (IP) 20mg/kg bodyweight initial loading dose in first exchange
      • PLUS heparin (IP) 500 IU/L of dialysate IP to be given with every exchange while effluent is cloudy
      • PLUS Nystatin 500,000 units orally: 2 capsules TDS for 10 days.
      • Continue with daily doses of Cephazolin and Ceftazidime at same doses as initial loading in the overnight bag until microbiology results are available.
    • patient may go home if clinically well and be managed as an outpatient. Arrangements must be made via Hospital In The Home for daily administration of IP antibiotics. Patient should be reviewed daily by phone or in person until the peritonitis has settled.
  • allergic to cephalosporins:
    • see protocol C below

clinically compromised or PH MRSA

  • not allergic to cephalosporins:
    • protocol B:
      • vancomycin (IP) 30 mg/kg IP in one bag, usually every 5-7 days but according to serum concentrations.
        • serum concentration to be measured on day 3 initially, then as indicated. Administer additional dose when levels fall below 20 mg/L.
      • PLUS Ceftazidime (IP) 20mg/kg bodyweight initial loading does in first exchange
      • PLUS heparin (IP) 500 IU/L IP to be given while effluent cloudy
      • PLUS Nystatin 500,000 units orally 2 capsules TDS for 10 days
      • Continue with Vancomycin (according to levels) and daily Ceftazidime in the overnight bag until microbiology results are available.
  • allergic to cephalosporins:
    • protocol C:
      • vancomycin (IP) 30 mg/kg IP in one bag, usually every 5-7 days but according to serum concentrations.
        • serum concentration to be measured on day 3 initially, then as indicated. Administer additional dose when levels fall below 20 mg/L.
      • PLUS gentamicin (IP)
        • anuric patient (< 500ml urine/24hrs):
          • load dose: 0.6 mg/kg bodyweight initial loading dose in first exchange
          • maintenance: 0.6 mg/kg bodyweight in the first daily exchange with dosing frequency based on daily serum levels.
        • non-anuric patient (> 500ml urine/24hrs):
          • load dose: 1.5 mg/kg bodyweight initial loading dose in first exchange
          • maintenance: 0.6 mg/kg bodyweight in the first daily exchange with dosing frequency based on daily serum levels.
        • daily Gentamicin levels are required in all patients. Standard trough concentration parameters apply for repeated dosing <2mg/L.

Automated Peritoneal Dialysis (APD) Patients

  • For the 1st 24 hours, the patient should be changed to Continuous Ambulatory Peritoneal Dialysis (CAPD) and standard protocols as above are followed.
  • If there is clinical improvement after 24 hours, reversion to APD with dosing as follows:
    • Intermittent dosing: antibiotic given IP in one exchange daily during the ‘long dwell’ (usually “day bag”) for at least a 6-hour dwell. The following dosages apply.
    • Cephazolin (IP) 20mg/kg bodyweight initial loading in first exchange
    • Ceftazidime (IP) 20mg/kg bodyweight initial loading dose in first exchange
    • vancomycin (IP) 30 mg/kg IP in one bag, usually every 5-7 days, but according to serum concentrations.
      • serum concentration to be measured on day 3 initially, then as indicated. Administer additional dose when levels fall below 20 mg/L.

actions once culture and sensitivities are known

  • fungal species:
    • Remove the Tenckhoff catheter at the earliest convenience. Refer to ID for further Mx guidelines.
  • S. aureus, Pseudomonas sp, multiple organisms or anaerobes:
    • continue Rx for 21 days
  • other organism:
    • continue Rx for 14 days.
  • Empiric antibiotics may be changed once the culture and/or sensitivity result is available.
  • If multiple organisms are present consider intra-abdominal pathology, and patients may require surgical review +/- laparotomy.

failure to respond

  • If effluent fails to clear after 72 hours check culture results to ensure the organism is sensitive to the current treatment protocol.
  • If the effluent fails to clear after 72 hours despite the organism being sensitive to the current treatment protocol, the Tenckhoff catheter should be removed and the patient temporarily transferred to haemodialysis. In general, this should NOT be delayed. Any departure from this policy should be discussed at once with the consultant in charge.
1)
CARI (2004): Treatment of peritoneal dialysis-associated peritonitis in adults
2)
International Society of Peritoneal dialysis (2005) ISPD guidelines/recommendations peritoneal dialysis-related infections Recommendations: 2005 update Peritoneal Dialysis International, Vol. 25, pp. 107–131
dialysis_peritonitis.txt · Last modified: 2019/04/17 09:36 by wh