Infection prevention in PD strategies วภิ าภทั ร ชูจร หน่วยไตเทยี ม รพ.มหาราชนครศรีธรรมราช
Outline 1. Definitions and measurement of peritonitis; 2. Prevention of peritonitis; 3. Treatment of peritonitis: initial and subsequent; 4. Monitoring response to peritonitis treatment including indications for catheter removal
ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment
Peritonitis • One of the most serious complications faced by patients utilizing PD for kidney replacement therapy. • Peritonitis is the most common PD-related infection and contributes to approximately increased acute care utilization, technique failure, transfer to hemodialysis, and sometimes even death.
Definitions and measurement of peritonitis • At least two of the following three condition(1C) Clinical features consistent with peritonitis (i.e. abdominal pain +/- cloudy dialysis effluent) Dialysis effluent WBC > 100/μL (after a dwell time of at least 2 hours), with > 50% PMN Positive dialysis effluent culture
Measuring, monitoring and reporting peritonitis • Every PD program should monitor the incidence and outcomes of PD peritonitis at least annually (1C). • Recommended monitoring parameters also include organism-specific peritonitis rates, antimicrobial susceptibilities, and culture-negative peritonitis (1C). • Peritonitis rate should be calculated as the number of episodes per patient per year at risk (years counted from PD initiation). • The guideline recommends an achievable goal of <0.4 episodes/patient-year, a lower target than 2016 guideline (<0.5 episodes/patient-year). • Culture-negative peritonitis should be less than 15% of all peritonitis episodes (1C).
Prevention of peritonitis
Primary Prevention • Catheter placement: systemic prophylactic antibiotics be administered immediately prior to catheter placement (1A). • Perioperative intravenous antibiotic such as; cefuroxime, gentamicin, vancomycin and cefazolin
Exit-site care • Daily topical ATB cream or ointment • Immobilization and avoidance of mechanical stress on the exit site • Prompt treatment of exit-site/ tunnel infection
Contamination of PD system • Prophylactic antibiotics after wet contamination of the PD system to prevent peritonitis (2D). • Examples of wet contamination include leaks from dialysate bags, leaks or breaks in tubing proximal to the tubing clamp, breach of aseptic technique or touch contamination of the connection during a PD exchange.
Contamination of PD system • The common practice is thus change of a sterile transfer set. • A PD effluent should preferably be obtained for cell count and culture. • Monitored closely for an extended period. • One dose of intraperitoneal (IP) cefazolin is option.
Invasive gastrointestinal and gynaecological procedures Peritonitis rate • After endoscopic or invasive gynaecological procedures, ranging from 26.9% to 38.5%. • After colonoscopy ranged between 3.4% and 8.5%. • After gastroscopy range from 1.2% to 3.9%.
Invasive gastrointestinal and gynaecological procedures • Antibiotic prophylaxis prior to colonoscopy (2C) and invasive gynaecological procedure (2D). • Antibiotic prophylaxis include cephalosporins (such as ceftriaxone or ceftazidime), amoxicillin–clavulanate, ampicillin– sulbactam, ampicillin plus aminoglycoside. • Drainage of PD fluid to keep the abdomen empty before endoscopic gastrointestinal and invasive or instrumental gynaecological procedures (2D).
Training Programs and Monitoring • PD exchange technique and knowledge be regularly reassessed and updated, with an emphasis on direct inspection of practice of PD technique (1C).
Training Programs and Monitoring
Training Programs
Home visit
Domestic Pets and Zoonotic Infections • PD patients take extra precautions to prevent peritonitis if domestic pets are kept (1C). • Pets not be allowed in the room where PD exchange takes place, and where dialysis tubing, equipment and machine are stored (2A).
Dietary and Medication Effects • Avoidance and treatment of hypokalemia may reduce the risk of peritonitis (2C). • Avoiding or limiting the use of histamine-2 receptor antagonists may prevent enteric peritonitis (2C).
Secondary Prevention • To prevent fungal peritonitis, we recommend that anti-fungal prophylaxis be co-prescribed whenever PD patients receive an antibiotic course, regardless of the indication for that antibiotic course (1B).
Treatment of peritonitis: initial and subsequent
Initial presentation and management of peritonitis • If peritonitis is suspected, the guideline recommends that PD effluent be tested for cell count, differential gram stain, and culture (1B). • PD patients presenting with cloudy effluent should be presumed to have peritonitis and treated as such until the diagnosis can be confirmed or excluded (1C).
Drain an effluent: Cell count and differential, gram stain, culture dwell time ⩾ 2 hr WBC > 100 PMN > 50% PMN > 50% (WBC, may < 100)
Without daytime exchange Present with abdominal pain no fluid to withdrawn
1 L of dialysate should be infused dwell time : 1-2 hr drain and examined for turbidity and sent for cell count with differential and culture.
Dosage of antibiotics • IP antibiotics be the preferred route of administration unless the patient has features of systemic sepsis (1B). • IP aminoglycoside be administered as daily intermittent dosing. • Prolonged courses of IP aminoglycoside be avoided (1C).
Dosage of antibiotics • Adjunctive oral N-acetylcysteine therapy may help to prevent aminoglycoside toxicity (2B). • There is insufficient evidence to make a recommendation as to whether patients on APD should be temporarily switched to CAPD during treatment of peritonitis (Not Graded).
Antibiotic delivery and stability • Compatible: Gentamicin with cefazolin Gentamicin with vancomycin Ceftazidime with cefazolin Ceftazidime with vancomycin • Incompatible: × Aminoglycosides with penicillins
Coagulase-negative Staphylococcus Peritonitis • Treated with IP cephalosporin or vancomycin, according to susceptibility, for a period of 2 weeks (2C).
Drug Tuberculous peritonitis Isoniazid Dosing Oral 5 mg/kg daily (maximum dose Rifampicin 300 mg daily)382 Oral 450 mg daily for BW <50 kg; Pyrazinamide 600 mg daily for BW ≥50 kg Levofloxacin Ofloxacin Oral 30 mg/kg three times weekly Ethambutol Moxifloxacin Oral 250 mg every 48 h Pyridoxine Oral 200 mg daily375 Oral 15 mg/kg every 48 h382 Oral 400 mg daily234,235 Oral 50–100 mg daily375,382
4. Monitoring response to peritonitis treatment including indications for catheter removal • Antibiotic therapy be adjusted once results and sensitivities are known (1C). • A higher dialysis effluent WBC count, >1090/µL or >1000/µL on day 3, correlate with the likelihood of treatment failure.
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