Infectious complication in peritoneal dialysis

2.  Peritonitis
 Exit site infections
 Tunnel Infections

3. Incidence
 1.1 -1.3 episodes per-patient year in the US I 1980s and early
1990s
 Rate has fallen 0.2 to 0.6 per-patient year
Hand book of dialysis fifth edition

4.  Seventy episodes of bacterial peritonitis occurred in 45
patients (0.17 episodes/patient-year), and 123 ESI/TI
occurred in 60 patients (0.29 episodes/patient-year).
A survey of peritonitis and exit-site and/or tunnel infections in Japanese children on PD
Pediatric Nephrology June 2006, Volume 21, Issue 6, pp 828–834

5.  A prospective study of 501 peritonitis episodes in 44 pediatric
dialysis centers located in 14 countries that examined peritonitis
etiology, efficiency of opinion-based management guidelines, and
final outcomes.
 Between October 2001 and December 2004, a total of 548
peritonitis episodes were recorded in 392 pediatric patients, that
is, 1.4±0.8 episodes per patient
Worldwide variation of dialysis-associated peritonitis in children
Kidney InternationalVolume 72, Issue 11, 1 December 2007, Pages 1374-1379

6. PATHWAYS OF INFECTION
 Intraluminal
 Periluminal
 Bowel source
 Hematogenous
 Transvaginal
HOST DEFENSES
 Dialysis solution pH and
osmolality
 Peritoneal dialysis calcium
levels

7. Gram positive organisms
 40- 50%
 S aureus
 Coagulase negative
staphylococcal
Gram negative organisms
20-30%
 pseudomonas
 Ecoli
Fungi ~ 2-4%
Mycobacterium ~ 1%
Polymirobial growth 10%
Culture negative 15%
Handbook of dialysis 5th edition

8. •Culture-negative
incidence varied
significantly from 11%
in North America to
67% in Mexico
•Argentina and North
America had the
highest rate of Gram-
negative episodes.
Worldwide variation of dialysis-associated peritonitis in children
Kidney InternationalVolume 72, Issue 11, 1 December 2007, Pages 1374-1379

9. At least two of the following three findings
1. Sign and symptoms' of peritoneal inflammation
2. Cloudy peritoneal fluid with an elevated peritoneal fluid
count (>100/mcL) with 50% neurtrophils
2. Demonstration of bacteria in peritoneal effluent by gram
stain or culture
Li PK, Szeto CC, Piraino B, de Arteaga et al. ISPD peritonitis recommendations: 2016 update on prevention
and treatment. Perit Dial Int. 2016;36:481–508

10.  Abdominal pain – 79 - 88 %
 Fever (greater than 37.5ºC) – 29 - 53 %
 Nausea or vomiting – 31 - 51 %
 Cloudy effluent – 84 percent
 Hypotension – 18 %
Clinical manifestations and diagnosis of peritonitis in peritoneal dialysis: Uptodate
Author: John M Burkart, MD

11.  Peritoneal fluid for cell count and differential, gram
stain and culture.
 Complete blood count and blood cultures.

14. CONSENSUSGUIDELINES FORTHE PREVENTIONANDTREATMENTOF CATHETER-RELATED INFECTIONS
AND PERITONITIS IN PEDIATRIC PATIENTS RECEIVING PERITONEAL DIALYSIS: 2012 UPDATE

17.  The loading dose:
CAPD IP or IV
APD  IV or IP peritoneal dwell left in place for atleast 4-
6hr
 Maintenance antimicrobial dose
Doses added in each exchange or intermittent dose once
daily
APD CAPD or added to day time dwell
APD on day dry schedule CAPD or low volume day time
dwell time
APD  higher doses

19.  The recommendation of increasing dose by 25%in patient with
residual renal function is removed from the latest version
 IP aminoglycoside should preferably be administered as daily
intermittent dosing
 Treatment of IP aminoglycoside for over 3 weeks should be
avoided
 Vancomycin should also be administered intermittently.Trough
vancomycin level >15 μg/mL.
The new ISPD peritonitis guideline Cheuk Chun Szeto Renal ReplacementTherapyv olume 4,
Article number: 7 (2018)

20.  Vancomycin should not be given into amino-acid based
solution
 When used in combination, they should preferably be
injected to different bags of PD solution
 Tobudic S, PoepplW, Kratzer C,Vychytil A, Burgmann H. Comparative in vitro antimicrobial activity of
vancomycin, teicoplanin, daptomycin and ceftobiprole in four different peritoneal dialysis fluids. Eur J Clin
Microbiol Infect Dis. 2012;31:1327–34

21.  Temporary use of hypertonic exchanges and short dwell
times may be needed to maintain adequate fluid removal
 Screening for malnutrition
 Blood glucose monitoring with appropriate adjustments of
insulin dosage

22.  Perforated ulcer
 Pancreatitis
 Appendicitis
 Diverticulitis

23.  Oral nystatin or fluconazole be considered at the time of
antibiotic administration
 Accidental intraluminal contamination
 Before invasive dental procedures
 Before procedures involving the gastrointestinal or
genitourinary tract

25. Incidence : ~1 episode in every
24-48 patient-months
Etiology: S.aureus, P, aeruginosa
Pathogenesis: Nasal carriage of
S. aureus is risk factor

27. Uncomplicated catheter exit-site infections
Oral antibiotic therapy
 score of 4 or greater
 2 or greater with pathogenic organism on culture
 no tunnel involvement
 Duration2 -3 weeks

28. Catheter tunnel infections
Oral, intraperitoneal, or intravenous
 If MRSA is the causative agent, intraperitoneal or
intravenous glycopeptide therapy is indicated.
 Duration should be 2 – 4 weeks .

29.  Systemic prophylactic antibiotics immediately prior to
catheter insertion
 Antibiotic prophylaxis before other invasive procedures
 Catheter exit site care with daily topical application of
antibiotic (mupirocin or gentamicin) cream or ointment.
 Prompt treatment of exit site and tunnel infection
 Disconnect systems with a “flush before fill” design be
used for CAPD