Peritoneal Dialysis-Related Infection

Exit-site and tunnel infections

ü Defined as presence of purulent drainage with or without erythema of skin at catheter-epidermal interface.

ü Oral antibiotic therapy is generally recommended, except MRSA

ü Pseudomonas aeruginosa exit-site infections required two antibiotics: Oral fluoroquinolones and either IP aminoglycoside, ceftazidime, cefepime, piperacillin, imipenem cilastatin or meropenem.

ü Continue antibiotic therapy until exit site appears entirely normal, minimum length of treatment time is 2 weeks. Infections caused by P. aeruginosa may need 3 weeks, and earlier catheter removal should be considered.

Peritonitis

ü  Peritoneal dialysis patients presenting with cloudy effluent should be presumed to have peritonitis. This is confirmed by obtaining effluent cell count, differential, and culture.

ü Important to initiate empiric antibiotic therapy for PD-associated peritonitis as soon as possible to prevent serious consequences such as relapse, catheter removal, permanent transfer to hemodialysis,   and death.

ü Bacteremia is uncommon in peritoneal dialysis-associated peritonitis. Infection is usually localized in the peritoneum and few cell layers lining the peritoneal cavity and intra-abominal viscera.

ü Empiric antibiotics must cover both gram-positive and gram-negative organisms.

ü IP administration is superior to IV dosing for treating peritonitis; intermittent and continuous dosing of antibiotics are equally efficacious.

Indications for catheter removal:

• Relapsing peritonitis
• Refractory peritonitis
• Refractory catheter infections
• Fungal or mycobacterial peritonitis
• Peritonitis occurring in association with intra-abdominal pathology

References:

1. ISPD Guidelines / Recommendations. Peritoneal Dialysis-Related Infections Recommendatins: 2010 Update.

2. UpToDate. Microbiology and therapy of peritonitis in continuous peritoneal dialysis. http://www.uptodate.com