peritonitis- complication peritoneal dialysis

8/11/2019 Peritonitis- Complication Peritoneal Dialysis

1/9

D IS EASEOF THE MONTH

J A m Soc N ephro l 9 : 195 6-1 96 4. 19 98

P er iton itis a s a C om p lica tion o f P er iton ea l D ia lys is

B E T H P IR A IN O

R ena l E lec tro ly te D iv ision , D epa rtm en t o f M ed ic ine , U n ivers ity o f P ittsbu rgh S choo l o f M ed ic ine , P ittsburgh ,

P ennsy lvan ia .

Periton itis con tinues to be a se rious com plica tion for pa tien ts

on p eriton ea l d ialy sis (P D ). P e rito n itis is o ne o f the m a jo r

cau ses of hosp ita liza tion , accoun tin g fo r 23 % of adm iss ions in

the C A N U S A stud y (1 ) . P e rito n itis is the lead ing cause o f

tech n iqu e fa ilu re and ca the te r lo ss (2 ,3 ). P atien ts w ith frequen t

periton itis a re at

inc rea sed risk o f dy in g , ind ep en den t o f o the r

fac to rs (4 ) . A ltho ugh the ra te s o f p er iton itis h ave dec rea sed

dram atica lly from the incep tio n o f C A P D , rate s abov e 0 .5

ep isod es p er year still com m on ly occur. T he su ccess of th is

d ia ly sis techn iq ue is c losely tied to the ab ility o f the d ia lysis

te am to redu ce th e r isk o f pe rito n itis , and w hen it occu rs ,

m anage th e p atien t app rop ria te ly .

C lin ica l P resen ta t io n

T h e u sua l p resen tatio n o f pe riton itis is abdo m ina l pa in ,

c loud y e ffluen t o r, m ost o f ten , b o th . T h e pa in can ran ge fro m

ex trem e ly sev ere to no nex isten t. In th e inex pe rienced pa tien t,

the absen ce o f p ain m ay lead h im /h e r to ig nore the c lou dy

e ff luen t in itia lly , le ad ing to a d elay in p re sen tatio n and su bse -

quen t trea tm en t. A ll pa tien ts m ust be instruc ted to ca ll im m e-

d ia te ly if the effluen t is ev en s lig h tly c loudy . P eriton itis is

pre sen t if th e w hite b lo od ce ll (W B C ) coun t in th e e fflu en t is

b 00 /p .b o r g reate r , w ith a t le a st 5 0% po lym o rp hon uc lea r ce lls .

I f the spec im en is co llec ted from a sho rt cy cle , an asp ira te from

a dra ined ab dom en , o r ob tain ed from a pa tien t a lready o n

an tib io tics, the percen tag e of po ly m orph onuc lea r cells (i.e.,

m ore th an

5 0 % ) is a m ore

reliab le m ark er fo r pe rito n itis than

the abso lu te num ber o f W B C .

O ccasiona lly , b lood -tin ged e ffluen t w ill b e confused w ith

clo ud in es s, bu t tra ined pe rsonn el can read ily d etec t the d iffer-

en ee . O the r cau se s o f c lou dy e ff luen t inc lude chy lo us ascite s ,

w hich h ave a m ilky ap pearance, in tra -abdo m in al m align ancy ,

d iagno sed b y ce ll cy to log y , an d panc rea titis , w h ich can b e

d iffe ren tia ted by an e fflu en t am yla se lev el o f > 50 U IL . A lso

inc lud ed in the d iffe ren tia l d iagno sis is eo sino ph ilie pe r iton itis ,

w h ich is ra re ly a ssoc ia ted w ith u nusua l fu ng i, bu t m o re o ften is

id io pa th ic ; recen t repo rts sug gest th at tre a tm en t w ith ste ro ids is

e ffec tiv e in reduc ing the ce llu la r ity .

In up to 6% o f the ep isodes o f pe riton itis , th e pa tien t p re-

sen ts w ith abd om ina l pa in bu t has c lea r e ffluen t (5). K o o p m an s

e t a .

rep o rted 60 such ep isodes o f pe rito n itis , a ll w ith pos itive

C orrespo nde nce to D r. B e th P ira ino . P rofessor o f M edic in e. A 9152 S ca ife

H all, 355 0 T errace S tree t. P ittsburg h . P A 1526 1 .

1 046 -66 73 /09 010 - 195 6$ 03.O 0/O

Jo urna l o f th e A m erican Soc ie ty of N ep hro logy

Copyr igh t U 1 998 by the A m erican S oc iety o f N ephro lo gy

cu ltu re s, th at had in itia l e ffluen t W B C co un t les s th an 100 /pA .

In 4 0 ep isod es (67 % ) th e in flam m ato ry respon se w as de layed ,

in 16 ep isodes (27 % ) the eff lu en t ce ll coun t even tua lly reached

30 to

10 0 W B C /pi, an d

in fou r ep iso des (7% ) th e cell coun t

neve r exceed ed 3 0 W B C /p i. T he G ram sta in w as pos itive in

70% of these cases . Th e org an ism w as m ore lik e ly to b e

S ta p h y lo c o cc u s a u re u s com pared to ep isodes o f p eriton itis

w ith a norm a l in f lam m ato ry re sp onse . H a lf o f th e pa tien ts w ith

the im pa ired cell reac tion to pe riton itis had m o re th an o ne such

ep iso de , and in the absen ce o f pe rito n itis had b ow er pe rito neab

m ac rop hage ce ll cou n t than a g rou p of co n tro l pa tien ts . In v iew

of th is study , a ll p atien ts on P D presen tin g w ith ab dom ina l pa in

sho u ld be co nsid ered to have p eriton itis un til p rov en o th erw ise.

E tio log ies o f P er iton itis

T he m ost com m on m ic roo rgan ism s re spo nsib le fo r p er ito -

n itis a re lis ted in T ab le 1 (6 ,7 ). M any stud ies on pe rito n itis w ill

lis t th e d iffe ren t o rgan ism s as a pe rcen tage o f the to ta l. T h is

m ak es it d ifficu lt to co m pare th e re su lts o f on e study to

ano th er , if the ov era ll rate s a re d issim ila r. Fo r exam ple , in th e

tw o stud ie s show n in th e tab le , th e pe rcen tages o f pe riton itis

ep isod es due to S ta p h y lo c o cc u s a u reu s a re 23 an d 1 2% , re -

spectiv ely , ye t th e actu a l d iffe rence in ra tes is on ly 0 .0 4 ep i-

sodes pe r y ear . I t is s tr ik in g th a t the ra te s o f co agu la se -n eg a tiv e

S t a p h y l o c o c c u s are alm ost iden tic al in the tw o stu d ie s. T h is

rem a ins th e m ost frequen t m ic ro o rgan ism respo nsib le fo r pe ri-

ton itis in m any cen ters .

T he lead ing cause o f pe rito n itis con tinues to b e con tam in a-

tio n at th e tim e of the P D exchang e . P e rito n itis du e to sk in

o rgan ism s su ch as coagu la se -nega tive

S taphy lococcus ,

C o ry n e b a cte riu m , B a cillu s sp ec ies, and B ra n h a m e lla ca -

ta rrha l i s

are gene ra lly b e liev ed to be du e to con tam ina tion .

H ow eve r , PD p atien ts m ay a lso h av e o n th eir (unw ashed)

f ingers S tre p to c o c cu s vir id a n s , S ta p h ylo co cc u s a u re u s, m i c r o -

coccus ,

Pr o t e u s

spec ies , K ieb sie lla pn eu m o n iae , E n terobac te r

spec ies ,

E scher ich ia co li,

an d

A cine tobac te r

spec ies (8 ). If the

p a tien t is qu estio ned c lose ly abou t con tam in atio n , the so u rce

m ay becom e o bv io us. F o r ex am ple , a pa tien t from o ur cen ter

h ad frequen t b ou ts o f p er iton itis rela ted to co n tam ina tion ; an

ep isode du e to S trep to coccu s vir idans occurred a fte r perfo r -

m an ee of an ex ch ange w h ile h is g ran dd au gh te r w as in the roo m

w itho u t a m ask . A seco nd ep isod e of p eriton itis fo llow ed an

ex ch an ge in w h ich the pa tien t o ve rh ea ted h is bag , w h ich w as

th en coo led b y runn ing u nd er co ld w ate r . M ille r and F in do n

p erfo rm ed an e leg an t study ex am in ing the leve l o f bacte r ial

con tam ina tion assoc ia ted w ith touch in g the co nnec to r du ring

an exchang e (8 ). T o uch ing th e conn ec tio n afte r h an d w ash ing


2/9

I A m Soc N ephro l 9 :

195 6-1 96 4. 199 8

P e riton iti s a s a C om plica tion of P eritone al D ialys is 19 57

F ig u re 1 . Pro to co ls to p reven t S taphy lococcus aureus peritonitis.

T ab le 1 .

C om m on m icroo rg an ism s cau sing p eriton itis

. .

Microorganism

H olley

et a (6 )

V an B iesen

et ci

(7)

Coagu lase-negat ive S t a p h y l o c o c c u s 0 . 17 0 .1 8

S ta p h y lo c o c c u s a u re u s

0 .13 0 .09

S trep tococcus 0 .04 0 .06

O th er G ram -p ositive < 0 .01 0 .0 2

G r am - n eg a t i v e

0 .09

0 { 1 4 9 } 1 6 b

Po lymierob ial

0 .01

Fungal


3/9

1 958 Journa l o f the A m erican S oc ie ty of N ephro lo gy

J Am Soc Nephrol 9: 1956 1964. 1998

o f e piso de s

reso lved

recu rred ca th e ter lo st died

I

per iton itis w ith in tra -abdom ina l d ise ase

0

a ll o th er ep isod es

F ro m re fe re nc e 24

F igu re 2 .

O utco m e of pe riton itis re la ted to in tra -ab dom ina l

ca tas t rophe .

w ith pe rito n itis (26 -28 ). A n tib io tic p ro phy lax is p rio r to any

proced ure assoc ia ted w ith the risk of periton itis is w arran ted .

R isk F acto rs for Periton itis

M od if iab le r isk fac to rs fo r pe rito n itis a re lis ted in T ab le 2 . In

add ition , ce rta in p atien t popu la tions a re a t h ig her risk fo r

coagu base -n eg ativ e pe riton itis , inc lud in g A frican -A m erican

and na tive A m erican p a tien ts (3 ,29 ,30 ). T h is risk can be m m -

im ized b y us ing a d isconnec t sys tem . A lso a t inc reased risk fo r

periton itis are im m uno sup pressed pa tien ts 1 9). A nd re ws e t a l.

rep o rted tha t th ose receiv ing im m un osu ppre ssive the rap y in th e

past I 2 m on th s o r w ith a d isease p red ispos in g to in fectio n ,

su ch as H IV , h ad a pe riton itis ra te o f 1 .8 ep isod es

p er

pat ien t

yea r com p ared w ith a ra te o f 0 .6 8 ep isodes pe r pa tien t y ear in

o the r pa tien ts (1 9 ) . T h e risk o f S taphy lococcus aureus an d

fung al p er iton itis w as espec ially h igh .

Evaluat ion

U po n p re sen ta tion , a rap id a sse ssm en t o f th e pa tien t sh ou ld

inc lu de questio ns on breaks in techn ique , recen t p roced ures

tha t m ay have led to pe riton itis , ch ange in b ow e l hab its , p rio r

T a b le 2 . F ac to rs assoc iated w ith dec rea sed risk o f p eriton itis

P roph y lactic an tib io tic s a t tim e o f cath ete r p lacem en t

2 -cu ffed ca the te r (versus on e-cu ff ca th ete r)

D ow nw ard p o in tin g tun ne l

T w in bag co nnec tion sy stem

T reatm en t o f S ta phy lococcus au reus car r iage

p er iton itis , and ca the te r in fec tion h is to ry . T h e ex it s ite an d

tu nne l sho u ld be c lose ly ex am ined fo r ev idence o f in fec tion . In

add ition , the p atien ts ab dom en sho u ld be dra ined , and the

e fflu en t sen t fo r cell cou n t w ith d iffe ren tia l, G ram stain , an d

cu ltu re. T he cell cou n t w ith d iffe ren tia l w ill con firm th e p re s-

en ce o f p eriton itis . C en trifug ing 10 m l o f e ffluen t resu lts in a

p ositiv e G ram sta in o f the in fec ted sed im en t in 93 % o f ep i-

sodes (3 1 .

T h e cu ltu re sh ou ld be ob tain ed by p lac in g

5

m l in

each o f tw o tryp tie so y b ro th b loo d cu ltu re bo ttle s (ae rob ic and

an ae rob ic ) ; L ye et a l. fo und tha t the ra te o f cu ltu re -nega tive

pe rito n itis w as red uced from 42 to 2 5% by th is techn iq ue (3 2 ) .

In add ition to inadequ ate cu ltu re tech n iqu es, cu ltu re -n eg a tive

pe rito n itis m ay a lso b e d ue to the p resen ce o f an tib io tics , so th e

pa tien t sho u ld be q uestion ed c lose ly abo u t recen t an tib io tic u se

(3 3). In one-th ird of cu ltu re-n ega tive perito n itis ep isodes , re -

cu ltu r ing w ill re su lt in id en tific a tion o f an organ ism (34 ).

A dec is ion m ust b e m ad e abou t w h eth e r to hosp ita lize the

pa tien t. T h is w ill d ep en d on th e seve rity o f the pe rito n itis , an d

the need fo r in trav en ous ana lgesia an d flu ids. B ecause th e

d isconnect sys tem s h av e prim arily d im in ished periton itis d ue

to le ss v iru len t o rgan ism s such as co agu la se -n eg a tive S taphy -

l o c o c c u s , as o pposed to G ram -neg ative an d S taphy lococcus

a u r e u s ,

a h ig h pro portion o f the pa tien ts w ill requ ire ad m issio n

(23 ) .

In itia l T rea tm en t

O ften , the c lin ic ian d oes no t kno w the cau sa tive o rgan ism

w h en an tib io tic the rap y is o rde red . T h ere fo re , the in itia l the r-

ap y sh ou ld b e ac tive aga ins t th e m o st com m only o ffen d in g

organ ism s, inc lu d ing S t a p h y l o c o c c u s ( bo th c oa gu la se -n eg at iv e


4/9

J A m So c N ephro l 9 : 19 56-19 64 . 1998

P eriton itis as a C o m plic atio n of P erito nea l D ia lys is 1 959

I

Inc rease d osing frequen cy based on serum and /o r d ia lysa te leve ls.

a nd - po si ti ve ), S trep tococcus , an d G ram -nega tive bac illi. In the

absence of clin ica l da ta su ggestive of b ow el p erfo ra tion , an-

aerob ic cov erag e is genera lly no t g iven in itia lly . C overage for

fu ngu s shou ld be im plem en ted im m ed ia tely on ly if th e G ram

s ta in is po sitive fo r yeast.

T h e A d H o c trea tm en t gu id elin es o f 199 6 recom m en ded

u sing a first-gen eration

cepha losporin , in com bina tion w ith

gen tam ic in fo r th e in itia l th erap y

(35 ) (T ab le 3 ). T h is ch an ge

from th e prio r reco m m end atio n fo r van co m ye in in con ju nc tion

w ith G ram -n eg a tive cov erage w as due to the increas in g

m ci -

denee o f vaneom ycin -res istan t en terocoecus an d the fea r tha t

th is res istance w ill be tran sfe rred to staphy loco cc i, leav in g u s

w ith no dru gs to treat th ese in fec tions . Indeed , periton itis due

t o v an co m yc in -r es is ta nt S t a p h y l o c o c c u s

has been reported

(36 ) .

La i et a l. rep o rted o n the re su lts o f o nce da ily in trape riton eal

ce fazo lin an d

gen tam ic in , w ith subsequen t m o difica tion of

the rapy as need ed , fo r trea tm ent o f periton itis (37 ). It is im -

p ortan t to no te that ep isodes of periton itis re la ted to ca the ter

in fec tion w ere exc luded fro m th is s tu dy . A ll I 9 ep isodes of

G ram -po sitive periton itis reso lved . T hree ep isodes of S t a p h v -

lo co c cu s e p id erm id is w ere re sis ta nt in vitro to b o th gen tam ic in

an d cephabo spo rin , ye t respon ded

in v ivo

to the se an tib io tic s ,

p resum ably d ue to the h igh local con cen tra tion in one ex -

ch an ge each d ay . T h ese da ta , the re fo re , sup port the A d H o e

C om mittee s recom mend atio ns.

U n fo rtun a te ly , d ata fro m o the r d ia ly sis p rog ram s sugg est

tha t use o f a firs t-g en era tion cep habo sporin fo r in itia l the rapy

m ay resu lt in a cons id erab le num ber of u n treated or m ade-

q ua tely treated pa tien ts. V as e t a l. repor ted tha t ce fazo lin (1 .5

g in traperitonea lly o nce da ily fo r 3 w k) resu lted in reso lu tion of

on ly 45 % of ep isodes o f pe rito n itis d ue to m e th ic illin -re sis tan t

coagu lase-negat ive S t a p h y l o c o c c i

(3 8). T h is w as in co n trast to

a 73% respo nse during the h is to rica l period fo r w h ich vanco-

m ycin (2 g in traperitonea lby o nce w eek ly fo r th ree do ses) w as

used . T he propo rtio n o f S t a p h y l o c o c c i w ith m e th ic illin re sis-

tance is rep o rted to range from 33 to 67 % (7 ,39 ) . W e have

foun d an inc rea se in m eth icillin -res is tan t eo agu la se -n eg a tive

S t a p h y l o c o c c i in ou r program , as sh ow n in F ig u re 3 . U sing th e

A d H o c 19 96 recom m en da tions fo r in itia l th erapy , V an B ie sen

no ted th at o n ly 7 6 .5% patien ts w ith G ram -pos itive in fec tions

an d 8 1 % of p atien ts w ith G ram -nega tive in fec tions w ou ld have

T a b le 3 .

A d H oc 1 996 gu id e line s fo r in itia l the rapy (35 )

been effective ly treated , based on sens itiv ities (7 ). T hese au -

tho rs p ropo se an a lterna tive ap proach , sho w n in T ab le 4 , w h ich

w ou ld p rov ide I 00 % cove rag e o f G ram -pos itive o rgan ism s and

87 .5% cov erag e o f G ram -nega tive organ ism s.

W ith in 2 to 3 d , th e org an ism is usua lly iden tif ied and

sen sitiv itie s a re ava ilab le. S ubseq uen t th e rap y is cho sen to

pro v ide narrow coverage w ith th e least tox ic ity . D os ing sch ed -

u les fo r som e com m o nly used an tib io tics are g iv en in T ab le

5.

Guidel ines by organ ism are pro v ided be low . If th e cu ltu re is

nega tive , genera lly the am ino g lycoside is s topped and a sin g le

dru g such as a first-genera tion ceph ab osp orin or vaneom y cin is

con tinued a lon e.

Coagulase-Negat ive Staphy lococcus Peritonit is

T h ese p atien ts o ften do no t req u ire ho sp ita liza tion , because

the pa in is les s seve re than th at due to o the r o rgan ism s (23) .

C e fazo lin o r ceph alo th in sh ou ld b e chang ed to vaneom ye in if

the o rg an ism is m e th ic illin -re sis tan t (38 ). A ltho ugh v aneom y -

cm is o ften g iv en w eek ly , th is m ay lead to u nde rdosin g in

m any pa tien ts , e sp ec ia lly th ose w ith re sidu al rena l fun ctio n .

L ow tro ugh lev els in the d ia lysa te inc rea se s the r isk o f relap s-

ing pe rito n itis (40 ) . W e prefe r the u se o f 30 m g/k g vaneom yc in

in traperitonea lly (m axim um of 2 g) in the in itia l exchange ,

w hich is a llo w ed to dw ell fo r a m in im um of 6 h , w ith one-h alf

of th is d ose repea ted in 4 to

5

d . B e fo re th e seco nd do se , a

b lo od leve l is m easu red , w h ich in ou tp atien ts is n o t back b efo re

redo sing , bu t the v a lu e gu ides the tim ing of th e th ird dose ,

usua lly abo u t

5

d la te r. T hese th ree doses then prov id e an tib i-

o tie coverage for a m in im um of 2 w k.

S ta ph y loco ccus A u reu s

Peritonitis

P a tien ts w ith S ta p h y lo c o c cu s a u r eu s p eriton itis o ften have

severe abdom ina l p a in and genera lly requ ire h osp ita liza tion . If

S ta p h y lo co cc u s a u re u s ex it site o r tu nne l in fec tio n is p resen t,

the cath e ter shou ld be rem o ved w ithou t d elay (9 ). If the re is no

c lin ica lly obv iou s tunn el in fec tio n , an u ltrasoun d o f the tunne l

to con firm the ab sen ce o f invo lvem en t is he lp fu l, as ca the ter

in fec tion s m ay be occu lt (41 .

P erito n itis a ssoc ia ted w ith a

ca the ter in fectio n w ill p rov e to be e ithe r re frac to ry o r re lapsin g

(9 ,42). T he course can be decep tive b ecause th e ep isode m ay

appea r to re so lve w ith c lea r ing of the e fflu en t, ye t th e e ff luen t

cu ltu re rem ain s po sitive w ith rec ru descen ce o f fu ll-b low n pe ri-

Trea tm ent Pro to co l U r in e O utpu t < 5 0 0 m b/d

U rO u

In the firs t exchang e

ce fazo lin o r eeph alo th in 500 m g /L , o r 15 m g /kg

25 % inc rease

gen tam ic in

0 .6 m g/kg I .5 m g / k g

S ubsequen t the rapy

ce fazo lin o r ceph alo th in

125 m g /L . each ex change , o r 50 0 m g/L ,

o ne e xe ha ng e/d

2 5% in crease

gen tam ic in 0 .6 m g /k g , o ne exehang e/d

0 .6 m g& g a


5/9

8 0 -S l 82 - 83 84- 85 86 - 87 88 -89 90 -91 92 - 93

94-95

year

1960 Journ a l o f the A m erican Soc ie ty of N eph ro logy

J A m S oc N ephro l 9 : 195 6-196 4 . 1 998

C o agu la se nega tive staph y loco ccus

pe riton itis , ep isodes I y ea r

5

4

0.3

0.2

1

F igure 3 . R ate s o f c oa gu la se -n eg ativ e S taphy lococcus periton itis o ver tim e .

T a b le 4 . E m p ir ic trea tm ent o f periton itis, V an B iesen

approach

(7)a

In itia l the rap y

vancom yein

15 m g /kg s ing le d ose IP

g en tam ic in 1 .5

m g /kg fo r u rine ou tp u t > 5 00 m b/d ,

0. 5

m g/kg fo r u rine ou tpu t < 5 00

m l / d

After 24 hours

o u tpa tien t c ip ro floxac in

500 m g tw ice a day

inp a tien t ee f taz id im e 25 0 m g IP /exehang e, and

c ip ro f loxac in 50 m g /ex ch ange

IP ,

in t raper i tonea l ly .

ton itis o nce the an tib io tic s a re stop ped (42 ) . If the ex it s ite and

tun ne l a re no rm a l, then the p re sum p tion is tha t the ep isod e is

d ue to tou ch co n tam in atio n (usu a lly in a pa tien t w h o is a

S ta ph locoecus aureus n asa l carr ier), and an tib io tic trea tm en t

is o ften successfu l. T he am inog ly co side is d iscon tinued . I f the

organ ism is m eth ie ib lin -sensitive , th en m eth ic ilb in or a cepha-

losp orin m ay b e used , an d if m eth ic illin -res is tan t, vaneom ycin

o r clin dam yc in is p re scr ibed . R ifam pin , 6 00 m g/d , m ay be

ad d ed .

Streptococcus

Peritonit is

T he source fo r pe r ito n itis d ue to S trep tococcus spec ies (n on-

en te rococcus) m ay be the resp ira to ry trac t (e ithe r tran sien t

bac te rem ia o r ab sence o f a m ask du rin g an exchange ) , the sk in

( touch con tam ina tion ) , o r th e bo w e l (43 ). C onsis ten t w ith th is ,

the in cid en ce o f

S trep topcoccus v irida ns

has dec rea sed w ith

use of the d isco nnec t sys tem s. S t r e p t o c o c c u s (e spec ially g rou p

A an d grou p B ) causes seve re p eriton itis an d m ay qu ick ly

T a b le 5 . In trap er iton ea l an tib io tic d osages fo r ad u lts (35 )

D rug

In traperitonea l D ose

Ampici l l in

1 25 m gIL con tin uou sly

A m pie i l l in /su lbae tam

I g /L load , then 1 00 m g /L

con t inuous ly

C efazo lin an d cepha lo th in

50 0

m g/L load , th en I 25 m gfL

con t inuously

C eftazid im e 100 0 m g /exchange , on ce d a ily

G en tam ic in and

to b ram ycin 0 .6 m g/kg , on ce da ily

Im pipenem /c i l i s ta t 50 0 m g /L load . then 2 00 m g/L

con t inuous ly

V an eo m y c i n

1 5 to 30 m g /kg eve ry

5

to 7 d

re su lt in death . T he re fo re , trea tm en t m u st be im p lem en ted

rap id ly . A m pic illin app ears to b e m o re effec tive than vaneo-

m y cin (4 3).

Enterococeal periton itis is severe , responds slow ly to an ti-

b io ties , and carries an increased risk of dea th (23 ,43 ). In the

N etw ork 9 P eriton itis S tudy . p er iton itis d ue to en te rococcu s

re su lted in dea th in 7 .4 % o f the

ep iso des (23 ). P eriton itis d ue

to en te roco ceus, co m p ared w ith S tre p to c o c c u s v ir id a n s peri to -

n itis , o ccu rs in o lder pa tien ts and is like ly spread from the

bow e l. T he in cid en ce h as no t fa llen w ith the u se o f d is co nnec t

sys tem s. Fo rtuna te ly , van co m ycin -resis tan t en te ro co cea l

(V R E ) pe rito n itis , w ith a reported m ortality ra te o f

55 ,

is s till

ra re (4 4 ). V R E p eriton itis is a sso c iated w ith p rio r use o f bo th

ceph alo spo rin s and v an eo m y cin , a s w e ll a s ho sp ita liz atio n .

T reatm en t is p rob lem a tic . T ro id le e t a l. u se d e hl or am p he ni eo l,

m ostly un succes sfu lly (4 4 ) . W e hav e had o ne ease o f V R E

perito n itis a t th e U n iv ersity of P ittsb urgh , in a pa tien t w ith a

fa iled rena l transp lan t g iv en th ree w eek ly doses o f vancom yc in


6/9

J A m S oc N ep hro l 9 : 1 956-1 964 , 19 98

P er iton itis as a C o m plica tion of P erito nea l D ia lys is 1 961

fo r cu ltu re -nega tive p eriton itis ; she d id w e ll w ith p rom pt cath -

e te r rem o va l an d ins titu tion of qu inu pristin /da lfopr is tin , an

expe rim en ta l d rug . S too l ca rr iage o f V R E is s till uncom m on in

P D p atien ts , p e rhaps because P D is a ho m e d ia lysis m oda lity

(39) .

G ram -N egative P eriton itis

O nce the

organ ism is iden tified an d sens itiv itie s a re kno w n ,

the an tib io tic the rap y is ad jus ted to m in im ize use o f am ino -

g lycos ides as m u ch as p oss ib le, in v iew o f the risk of ves tib u lar

tox ic ity . A lte rna tiv es to am ino g lyeosid es , such as ceftaz id im e

and qu ino lon es , sho u ld be used w henever poss ib le . A n alte r-

na tive app ro ach has b een to use a low dose o f am inog lyeoside

in one exchang e per day , w hich prov id es h igh loca l leve ls

during the p e riod o f th e dw e ll, ye t v ery lo w sy stem ic leve ls .

L ai

e t a l.

tre a ted 14 G ram -nega tive p eriton itis ep isodes w ith

gen tam icin , 20 m g/L in one ex ch ange per day in traperitonea lly ,

com bined w ith 500 m g fL in th e sam e ex ch an ge of cefazo lin

(37). Fo r the e igh t

n o n - Ps e u d o r n o n a s

G ram -n eg ative o rgan-

ism s, o n ly tw o infec tion s due to Ac i n e t o b a c t e r spec ies requ ired

a lte ratio n in the rapy , and a ll re so lved . B a ib ie

e t a l.

used 0 .6

m g/kg in one ex ch an ge of gen tam icin (in com bina tion w ith an

in itia l dose of vancom ycin ) w ith reso lu tion of tw o-th irds of the

ep iso des of n o n - Ps e u d o m o n a s G ram -n eg a tive perito n itis (4 5).

T h e n onre spon de rs inc lud ed Ac i n e t o b a c t e r an d A lca l igenes

spec ies . A cine tobac te r periton itis is d ifficu lt to trea t, and tw o

an tib io tics sho u ld be used to treat th is o rgan ism .

P seud om onas aero g inosa pe riton itis is freq uen tly as soc iated

w ith a tu nne l in fec tion , w hich m ay be occu lt. S hou ld the

e ff luen t cu ltu re revea l a P seudo inonas in fec tion , the sub eu ta -

n eous tun ne l shou ld be exam in ed care fu lly , and if it app ea rs

n o rm a l, u ltra sono grap hy sh ou ld be p erfo rm ed to fu r the r assess

p oss ib le tu nne l inv o lvem ent. If the tu nne l is invo lved , th e

cath ete r shou ld be pro m p tly rem oved , as re so lu tio n w ith an ti-

b io tic th e rapy is h igh ly un like ly (9 ) . If the re is n o tun ne l

in fect ion ,

P seudo m o nas aerog inosa w ill usu a lly reso lve w ith

am inog ly co side therapy (genera lly g iv en as 5

to 8 m g /L in each

ex ch an ge ) an d th e add itio n o f a seco nd agen t ac tiv e aga inst

P seudomonas .

O f n o te , in a recen t a r ticle from B e lg ium , 7% of

p a tien ts w ith perito n itis d ied (3 of 42) from sepsis ; tw o of these

p a tien ts had P seudornonas pe rito n itis (7 ) .

In v iew of the re su lts o f a recen t a r ticle by H arw e ll e t a l. in

eve ry case o f p e riton itis du e to en te rie o rg an ism s, in tra-abdo m -

in al pa tho logy und erly in g the in fec tion shou ld be co nside red

(24 ) . T his can be eva lua ted w ith a com p uted tom o graphy scan

o f the abd om en . E a rly su rg ical con su lta tion sho u ld b e con sid -

ered , as prom pt laparo tom y m ay d ecrease the risk of dea th .

Po lym icrob ia l P er iton it is and In tra -A bdom ina l

Absces ses

A pprox im ately 6% o f a ll ep iso des of periton itis w ill have

m ultip le o rgan ism s (4 6) . If on ly G ram -p ositive o rg an ism s a re

presen t, the pa tien t genera lly does w ell, w ith reso lu tion of the

in fec tion w ith an tib io tic the rapy in the absence of ca the te r

in fec tion . H o w eve r , if m u ltip le en ter ic o rg an ism s grow fro m

th e cu ltu re , in tra -abd om in al p ath o log y m ust be cons ide red ,

w hich requ ires su rg ical exp lo ration . T h is is espec ia lly tru e if an

anaerob e g ro w s in cu ltu re . M e tron id azo le , 5 00 m g in trav e-

n ous ly every 8 h , sho u ld be add ed to the o ther an tib io tics .

In tra -abd om in al ab scesses occu r in < 1 % of p e riton itis ep i-

sodes . T hese are m o re com m on w ith P seudo tn onas a erug i-

n osa , C and id a a lb icans , and po lym ie rob ia l pe rito n itis , an d

req u ire dra inage . C o m puted to m ography scan of the abd om en

is

use fu l to eva lua te the p atien t.

F unga l P er iton it is

F ung al pe r iton itis accou n ts fo r 3% of all ep isod es (47 ) .

U sua lly the pa tien t has severe abdom ina l p ain , and the effluen t

W B C coun t is h igh . G ram sta in is o f ten he lp fu l in e stab lish ing

th e d iag nos is ea rly . Cand ida is by fa r th e m ost com m on

o rgan ism . R isk facto rs in clud e frequ en t periton itis. im m un o-

suppression , and an tib io tic the rapy . A t o ur in stitu tion , the

ca the te r is rem ov ed as soon as th e

d iag nos is is es tab lished . In

an u ncon tro lled tr ia l, G o ld ie e t a l. foun d tha t 1

5

o f p atie nts

in

w ho m the cath ete r w as rem oved w ith in 1 w k of d iagno sis

d ied , in con tras t to 50% w hen the ca the te r w as le ft in p lace

(47) . T herapy w ith f lucon azo le (200 m g o ra lly each d ay ),

f lucy tos ine

( I g o ra lly each day ), an d , if n ecessa ry , am pho ter-

ie in , sho u ld be con tinued afte r cathe te r rem o va l fo r a t least an

add itiona l 1 0 d . T he ca the te r can be rein se rted , b u t a w a iting

pe riod of 1 to 2 m o is ad v isab le . A pp ro x im a te ly 10% of

pa tien ts w ill have peritonea l fib rosis m aking P D n o lo nger an

option.

P eriton itis d ue to

My c obac t e r i um

Tubereubous perito n itis occu rs m o re frequ en tly in A sia than

in W es tern co un tr ie s , bu t m ay becom e m ore com m on in v iew

o f th e cu rren t ep idem ic o f m yeobae te ria in fec tions. A s w ith

o the r m ic ro o rg an ism s, the e ffluen t W B C are p redo m ina te ly

po lym orpho nue lea r ce lls. B ecause the effluen t ac id -fast bac il-

lus sta in is genera lly nega tiv e and there is usua lly no tubercu-

bus d isease e lsew here , the d iagno sis m ay be d ifficu lt (48 ).

U ltra f iltra tion fa ilu re m ay occur bu t is n o t inev itab le . T he rapy

sh ou ld co nsist o f th ree d rug s (iso n iazid , rifam pic in , and py ra -

z inam ide ) fo r 9 to 1 2 m o. R epo rted ly , the ca the te r do es no t

a lw ays requ ire rem ova l (48).

R efractory and R elap sin g P er iton it is

R efrac to ry pe rito n itis is de fin ed as an ep isod e in w hich the re

is no im p rovem ent

5

d afte r ap p ro p riate an tib io tic the rapy is

in itia ted . T here m ay b e ap paren t reso lu tio n of the ep iso de w ith

an tib io tic the rapy , b u t a ce ll coun t w ill o ften sho w persis ten ce

of an abn orm a l in f lam m ato ry re spo nse . R ecu rren t o r relaps in g

periton itis is defined as a seco nd ep iso de of periton itis w ith the

sam e organ ism as the first w ith in 2 w k of sto pp in g an tib io tics .

R efrac to ry and re lap sing periton itis m ay be d ue to a ca the ter

in fec tion , w h ich m ay n o t be c lin ically ap pa ren t. In eve ry ease

o f re lapsin g and re frac to ry pe riton itis , th e ca the ter su beu tane -

ou s tunn el sh ou ld be exam in ed c lin ica lly , an d , if it appea rs

no rm al, an u ltra son ograph ie exam in atio n sho u ld be pe rfo rm ed .

R ecurren t pe rito n itis , in the absence o f a tu nn el in fec tio n ,

m ay be du e to sequestra tion of b ac te ria (m ost o ften coagu lase -

nega t ive S t a p h y l o c o c c u s ) in the b io film surro und ing the in tra -


7/9

1 962 Journ al

of the A m e rica n S o cie ty of N ep hro logy

J

A m

S oc N eph ro l 9 : 1956 -1964 . 1 998

I

E xcep tion is if o rg an ism is coagu lase-nega tiv e S taphv /ococcus .

abdo m ina l p o rtion o f the cath ete r . Inad eq ua te trea tm en t o f

pe r iton itis p red ispo ses to th is com p lica tio n . T h ere are tw o

op tions : fib rino by tic the rap y or ca the te r rep lacem en t. U ro k i-

n a se , 50 00 U in 5 m l o f norm a l sa line in jected in to the ca the ter

w ith the abd om en drained and allow ed to dw ell fo r 2 h , is

successfu l in 29 to 67% o f pa tien ts w ith recurren t perito n itis

(49 ,50 ) . Th is procedure has been p rim ar ily used on p atien ts

w ith recu rren t co ag u la se -neg ativ e

S tapkv lococcus

peritonitis,

and sh ou ld be reserved fo r tho se recu rren t ep iso des o f p erito -

n itis fo r w h ich tun ne l in fec tion h as b een exc luded as a cau se by

ca re fu l exam ina tion

u sing u ltrasono graphy . A lte rna tiv ely , if

th e p eriton ea l ce ll cou n t can b e su ppre ssed to le ss than

10 0

W B C /pi. th en th e cathe te r can be safe ly rep laced a t one

setting . a llow in g the avo id ance o f h em o dia ly sis in m any pa-

tients (50 ,5 1

.

O ne of the m ost co m m o n p rob lem s in m anag ing

periton itis is de lay in rem ov in g the ca the te r in ep isod es tha t a re

no t re spo nd in g o r tha t are lik e ly to re su lt in relaps ing p erito -

n itis. T ab le 6 lists exam ples in w hich ca the te r rem ova l is o ften

necessa ry .

Prev en tion of P er iton it is

P reven tion o f pe riton itis is a key com pon en t o f a su ccessfu l

P D pro gram , an d is based on co llab o ra tio n be tw een p a tien t, th e

nurses, and th e ph ysic ian . D ecreas ing risk from con tam ina tion

is

h igh ly depend en t o n bo th pa tien t se lectio n and tra in ing

techn iq ues. T h e nurse s sho u ld re in fo rce the concep ts o f ste ril-

ity an d com pu ls iveness in p erfo rm ing the exchange , even a fter

th e in itia l tra in ing is co m ple ted . T he best conn ec tion tech no l-

og y , the tw in bag sy stem . sho u ld b e chosen for con tinuo us

am bu la to ry P D patien ts, and for cyc le r pa tien ts w ho m ust do

m ultip le sp ikes, use of the C om p ac t A ss is t D ev ice (B ax te r

H ea lth ca re C orp ., D ee rf ie ld , IL ) is he lp fu l in red uc ing the risk

o f in fec tion . E ach pro gram m ust m o n ito r and pe rio d ica lly

rev iew cases of periton itis to iden tify prob lem areas. P atien ts

w ith h igh pe riton itis ra te s sh ou ld be encou raged to tran sfe r

p erm anen tly to hem o d ia lysis .

T h e risk o f S ta p h y lo c o c c u s a u re u s pe rito n itis an d ca the ter

in fec tio ns can be redu ced by m o nito rin g an d trea ting for nasa l

ca rriage (F igu re 1

.

W e fou nd th a t p rop hy lax is w ith m up iroc in

a t the ex it s ite re su lted in a reduc tion in

S taphy lococcus aureus

ex it s ite in fec tions and re la ted p e riton itis ep isodes (1 6 ) . T hese

resu lts have b een recen tly co nfirm ed by T hod is e t a . (5 2 ) .

This

pro to co l is w e ll accep ted by the p atien ts , w ho use a Q -tip to

p lace a th in sm ear o f m up iroe in a ro und the ca the ter ex it s ite

a fte r ba th in g . O ne tu be la sts fo r ap prox im ate ly 2 m o . T h is

m e tho d sh ou ld no t b e used w ith po lyu re thane ca the te rs , w h ich

T a b le 6 . Ep isodes of periton itis fo r w hich cathe te r rem ova l

i s a pp ro pr ia te

P erito n itis a sso cia ted w ith sam e organ ism causin g ex it s ite

o r tu nne l in fec tion

F un ga l pe riton itis

R e lapsing o r re frac to ry pe riton itis

P er iton itis assoc ia ted w ith in tra -abdo m in ab pa tho logy

m ay be dam aged . A lte rn ative approaches are in tranasa l m upi-

roc in fo r S ta phy lococcus aureu s nasa l ca rriage . In the m ulti-

c en te r E uropean tr ia l, th is red uced S taph ylococcus au reus

ca the te r in fectio ns bu t no t pe rito n itis (I 7 ). P e rez -F o n tan e t a l.

fou nd a redu ctio n in bo th S ta p k lo co c cu s a u r eu s ca the te r in -

fectio ns an d pe rito n itis w ith a course o f in tranasa l m up iroc in

fo r each po sitive no se cu ltu re (18 ) . R ifam pin has a lso been

show n to redu ce bo th

S taphy lococcus aureus

ca the ter in fee-

tion s and perito n itis rates , b u t is assoc ia ted w ith s id e effec ts in

1 2% ofpa tien ts (14 -16).

P rop hy lax is w ith n ysta tin , g iv en to the pa tien t tak in g an ti-

b io tics , successfu lly redu ces the risk of and ida peritonitis

(53 ) . A dd itiona l stu d ie s w ill b e needed to id en tify th ose pa-

tien ts w ho w ould benefit m ost f rom such p roph y lax is . T h is

m ay prove to be p atien ts a t h ig h risk fo r fun ga l pe rito n itis ,

in c lud in g those w ith frequen t b acte r ial pe r iton itis . on p ro -

lo nged co urses o f an tib io tic s o r w ith im pa ired im m une sys-

t em s .

P ro ced ure-re la ted cause s o f pe riton itis m ay b e dec rea sed b y

ask ing the pa tien t to in fo rm the d ia lysis cen te r b efo re ex tens ive

den ta l w ork , cob ono seopy , and en dom etr ia l b iop sies . W e b e-

liev e th at an tib io tic p roph y lax is sh ou ld be g iv en fo r a ll such

p rocedures . In add itio n , the abdo m en sho u ld be dra ined pr io r to

p e lv ic an d co lon ie procedu res . A ggress ive treatm ent o f con sti-

p a tion m ay re su lt in en te r ie p e riton itis ; the re fo re, eve ry effo rt

shou ld be m ad e to p reven t con stipa tion in the P D p atien t.

In con clu sion , pe rito n itis rem a ins on e of the m os t se r ious

p ro b lem s fac ing th e P D pa tien t and P D hea lth care w o rk er .

R ed uc ing ra tes o f p er iton itis can be ach ieved b y ca re fu l p atien t

se lec tion and train ing , use of th e best conn ec tion techno logy ,

an d screen ing fo r and trea ting nasa l ca rriage . O nce pe rito n itis

occu rs , th e treatm en t sho u ld be prom p t. T h e re sh ou ld b e no

h esita tion to rem o ve th e ca the te r if th is appears to b e ap pro-

priate .

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C A PD p er ito nitis . P en t D ia l mt 15 : 2 69-2 71 , 199 5


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