Peritoneal Dialysis–Associated Peritonitis

Abstract

Peritonitis is a common and severe complication in peritoneal dialysis (PD). Detailed recommendations on the prevention and treatment of PD-associated peritonitis have been published by the International Society for Peritoneal Dialysis (ISPD), but there is a substantial variation in clinical practice among dialysis units. Prophylactic antibiotics administered before PD catheter insertion, colonoscopy, or invasive gynecologic procedures, daily topical application of antibiotic cream or ointment to the catheter exit site, and prompt treatment of exit site or catheter infection are key measures to prevent PD-associated peritonitis. When a patient on PD presents with clinical features compatible with PD-associated peritonitis, empirical antibiotic therapy, with coverage of both Gram-positive and Gram-negative organisms (including Pseudomonas species), should be started once the appropriate microbiologic specimens have been obtained. Intraperitoneal is the preferred route of administration. Antifungal prophylaxis, preferably oral nystatin, should be added to prevent secondary fungal peritonitis. Once the PD effluent Gram stain or culture and sensitivity results are available, antibiotic therapy can be adjusted accordingly. A detailed description on the dosage of individual antibiotic can be found in the latest recommendations by the ISPD. The duration of antibiotics is usually 2–3 weeks, depending on the specific organisms identified. Catheter removal and temporary hemodialysis support is recommended for refractory, relapsing, or fungal peritonitis. In some patients, a new PD catheter could be inserted after complete resolution of the peritonitis. PD catheter removal should also be considered for refractory exit site or tunnel infections. After the improvement in clinical practice, there is a worldwide trend of reduction in PD-associated peritonitis rate, supporting the use of PD as a first-line dialysis modality.

An analysis of the “Half-Perc” versus open surgical placement method for a peritoneal dialysis catheter: a non-inferiority cohort study

“…PD-related infections including peritonitis and exit-site/tunnel infections remain major complication that can lead to technical failure or even death [ 22 ]. There are many studies suggesting that the prevention of peritonitis is necessary for the improvement of catheter survival as well as the long-term success of peritoneal dialysis [ 23 ]. Overall, we observed less episodes/patients-year of peritonitis and exit-site infection in the “Half-Perc” group during 365 days follow-up time, but both complications were not statistically different.…”

Hyperuricemia Predicts Residual Diuresis Decline in Peritoneal Dialysis Patients

“…Several mechanisms could explain the negative effect of hyperuricemia on RD in PD patients. First, it has been demonstrated that the number of peritonitis episodes are associated with RRF reduction [5,19,23]. Considering the fact that peritoneal clearance dominates in SUA balance and peritonitis is a significant risk factor for structural and functional alterations in the peritoneal membrane in PD patients, an increased risk of RD decline might be observed in patients with hyperuricemia [23,24].…”

“…First, it has been demonstrated that the number of peritonitis episodes are associated with RRF reduction [5,19,23]. Considering the fact that peritoneal clearance dominates in SUA balance and peritonitis is a significant risk factor for structural and functional alterations in the peritoneal membrane in PD patients, an increased risk of RD decline might be observed in patients with hyperuricemia [23,24]. Second, it has been postulated that a high SUA level induces systemic and intraperitoneal inflammation [15,18,25].…”

IL-17A as a Potential Therapeutic Target for Patients on Peritoneal Dialysis

“…Peritonitis, an infection within the peritoneal cavity mainly caused by bacteria, is the most frequent complication of PD [ 160 ]. Measures to limit infection risk and to ensure prompt and appropriate investigation and treatment have lowered peritonitis rates and improved outcomes, but peritonitis remains a major determining factor in mortality and in adverse outcomes, including peritoneal inflammation and membrane failure [ 161 ]. The immune response to infectious peritonitis is initially characterized by neutrophil recruitment, with subsequent transition to monocyte predominance [ 162 ].…”