How should peritonitis be prevented and treated?
A team-based, multifaceted approach to continuous quality improvement with regular audit of infection rates and outcomes is essential to improving peritonitis rates. Training and retraining of both patients and nurse patient-educators is a cornerstone of this effort.
A number of peritonitis episodes are the result of direct extension of an infection associated with the exit site, in particular when the infecting organism at the exit site is either S. aureus or P. aeruginosa . All BDPs in reducing exit site infections will decrease peritonitis episodes. Another measure to reduce peritonitis is “flush before fill” connectology, a technology that washes any bacteria introduced at the tubing–catheter interface during an exchange into the drainage bag rather than into the patient’s peritoneum. Avoidance of constipation reduces the risk of peritonitis by attenuating transmigration of enteric bacteria across the bowel wall.
Observational studies have suggested benefits in draining the peritoneum dry and providing appropriate prophylactic antibiotics prior to dental, gastrointestinal, and genitourinary procedures. Adequate 25-hydroxyvitamin D levels have also been associated with lower peritonitis rates.
Once a presumptive diagnosis of peritonitis is made, prompt treatment with antibiotics capable of covering both gram-negative and gram-positive organisms is implemented. Although antibiotics can be given orally or intravenously, intraperitoneal (IP) administration has the benefit of providing immediate delivery of bacteriocidal concentrations of antibiotics. PD fluid culture results should then help narrow the spectrum and guide the duration of antimicrobial therapy. Attention to achieving a consistent mean inhibitory concentration (MIC) of antibiotics in the PD fluid, particularly if the patient is receiving APD or if intermittent antibiotic therapy is being used, is critical to successful treatment. Continuous rather than intermittent antibiotic therapy should ensure that a therapeutic MIC is achieved. While intermittent vancomycin dosing appears to be acceptable, it is prudent to obtain serum levels to ensure adequate MIC levels, particularly in the presence of significant RKF. Serum vancomycin levels should be kept >15 mmg/mL.
The signs and symptoms of peritonitis usually resolve within 48 hours after appropriate antimicrobial therapy. Persistent pain, cloudy fluid, and elevation of peritoneal fluid white blood cell (WBC) count should prompt reevaluation of the infectious cause and whether antibiotic therapy is suitable. Peritonitis refractory to treatment, defined as failure of the effluent to clear within 5 days of appropriate antibiotic therapy, should result in removal of the catheter. The ISPD has published guidelines for the prevention, diagnosis, and treatment of peritonitis.