Culture negative still a main problem for PD patient to leave peritoneal dialysis. We try to make patient happy in PD for a life long. If we can cope the peritonitis problem peritoneal membrane will last longer.

1. C U LT U R E N E G AT I V E
P E R I T O N I T I S
K A M O L K H O S I T R A N G S I K U N , M D
2 5 F E B 2 0 1 8

2. H O W T O
•Cope
•Improve
•Prevention

4. K E Y P E R F O R M A N C E I N D E X

5. P E R C E N TA G E O F P E R I T O N I T I S W I T H
C U LT U R E N E G AT I V E
( < 2 0 % )

6. • ร้อยละของการติดเชื้อในผนังช่องท้อง (Peritonitis) ที่เพาะเชื้อไม่ขึ้น
• ตัวตั้ง = จำนวนครั้งของผลการตรวจเพาะเชื้อก่อนให้ยา
ปฏิชีวนะและที่ผลการเพาะเชื้อไม่ขึ้นในรอบ 1 ปี
• ตัวหาร = จำนวนครั้งของ peritonitis ทั้งหมดที่ได้รับการ
ตรวจเพาะเชื้อก่อนให้ยาปฏิชีวนะในรอบ 1 ปี
P E R C E N TA G E O F P E R I T O N I T I S W I T H
C U LT U R E N E G AT I V E

7. ร อ บ เ ว ล า ห นึ่ ง ปี ที่ เ ก็ บ ข้ อ มู ล

8. – J O H N N Y A P P L E S E E D
“Which one is cloudy ?”

9. “ Cloudy effluent with fibrin “

10. C L O U D Y E F F L U E N T
Perit Dial Int 2005; (25):107-131
• Culture-positive infectious peritonitis
• Infectious peritonitis with sterile cultures
• Chemical peritonitis
• Eosinophilia of the effluent
• Hemoperitoneum
• Malignancy (rare)
• Chylous effluent (rare)
• Specimen taken from “dry” abdomen

11. P E R I TO N I T I S
• Peritonitis can occur without cloudy effluent and
can present with other symptoms, such as
abdominal pain, fever, constipation, and diarrhea.
• Likewise, cloudy effluent does not necessarily
indicate infectious peritonitis.
Update on Peritoneal Dialysis: Core Curriculum 2016, Am J Kidney Dis. 2016;67(1):151-164

12. P E R I TO N I T I S
• Defined as the presence of at least 2 of the
following conditions:
• Abdominal pain or tenderness
• Presence of white blood cells in peritoneal
effluent in excess of 100 cells/mL,
comprising at least 50% PMN
• Positive dialysate culture results
PD Related Infections Recommendations: 2010 update, Perit Dial Int : 2010; 30:393 - 423

13. P E R I TO N I T I S
• Defined as the presence of at least 2 of the following
conditions:
• Clinical features consistent with peritonitis, i.e.
abdominal pain and/or cloudy dialysis effluent.
• Dialysis effluent white cell count > 100/μL or > 0.1
x 109/L (after a dwell time of at least 2 hours), with
> 50% polymorphonuclear.
• Positive dialysis effluent culture.
ISPD Peritonitis Recommendations: 2016 Update On Prevention & Treatment; Perit Dial Int 2016; 36(5):481–508

14. A B D O M I N A L PA I N D D X .
1. Peritonitis
2. Exit-site infection
3. Strangulated Hernia
4. Appendicitis
5. Irritable bowel disease

15. D I A G N O S I S O F P E R I T O N I T I S
• PD Fluid White Blood Cell Count and Differential
• Gram Stain
• Culture
• Leukocyte Reagent Strips
• Endotoxin
• Amylase
• DNA Methods
Seminars in Dialysis—Vol 27, No 6 (November–December) 2014 pp. 602–606

17. Ann Lab Med 2012;32:119-125 http://dx.doi.org/10.3343/alm.2012.32.2.119

18. Ann Lab Med 2012;32:119-125 http://dx.doi.org/10.3343/alm.2012.32.2.119

19. D N A E X T R A C T I O N M E T H O D S
Journal of Clinical Microbiology 2014; Volume 52;Number 4 p. 1217–1219, doi:10.1128/JCM.03106-13

20. Journal of Clinical Microbiology 2014; Volume 52;Number 4 p. 1217–1219, doi:10.1128/JCM.03106-13

21. Pediatrics International (2005) 47, 523–527

22. U R I N E S T R I P T E S T F O R D X P E R I T O N I T I S
http://www.nearmedic.ru/upload/files/Doc_389_578.pdf Pediatrics International (2005) 47, 523–527

23. Journal of Clinical Laboratory Analysis 18:224–230 (2004)

24. Journal of Clinical Laboratory Analysis 18:224–230 (2004)

25. Journal of Clinical Laboratory Analysis 18:224–230 (2004)

26. N O V E L D I A G N O S T I C T E C H N I Q U E S
ISPD Peritonitis Recommendations: 2016 Update On Prevention & Treatment; Perit Dial Int 2016; 36(5):481–508

27. ISPD Peritonitis Recommendations: 2016 Update On Prevention & Treatment; Perit Dial Int 2016; 36(5):481–508

28. ISPD Peritonitis Recommendations: 2016 Update On Prevention & Treatment; Perit Dial Int 2016; 36(5):481–508

29. ISPD Peritonitis Recommendations: 2016 Update On Prevention & Treatment; Perit Dial Int 2016; 36(5):481–508

30. S P E C I M E N P R O C E S S I N G - 1 / 2
• Standard culture technique is the use of
blood-culture bottles.
• Blood-culture bottles can be directly
injected with 5 – 10 mL of effluent
Perit Dial Int 2010; 30:393–423Philip Li, Perit Dial Int 2016; 35:481-508

31. S P E C I M E N P R O C E S S I N G - 2 / 2
• A large-volume culture
• Culturing the sediment
after centrifuging 50 mL
of effluent.
Perit Dial Int 2010; 30:393–423Philip Li, Perit Dial Int 2016; 35:481-508

32. I N I T I A L M A N A G E M E N T O F P E R I T O N I T I S
Initial management of peritonitis
Start intraperitoneal antibiotics as soon as possible
Allow to dwell for at least 6 hours Ensure gram-positive and gram-negative
coverage* Base selection on historical patient and center sensitivity patterns
as available
Gram-positive coverage:
Gram-negative coverage:
Either first-generation Either
third-generation cephalosporin
or vancomycin†
Gram-negative coverage: Either
third-generation cephalosporin‡
or aminoglycoside
Determine and prescribe ongoing antibiotic treatment Ensure follow-up
arrangements are clear or patient admitted Await sensitivity results
Adapt from Perit Dial Int 2010; 30:393–423
0-6 hr
6-8 hr

33. I N I T I A L M A N A G E M E N T O F P E R I T O N I T I S
ISPD Peritonitis Recommendations: 2016 Update On Prevention & Treatment; Perit Dial Int 2016; 36(5):481–508

34. ISPD Peritonitis Recommendations: 2016 Update On Prevention & Treatment; Perit Dial Int 2016; 36(5):481–508

35. ISPD Peritonitis Recommendations: 2016 Update On Prevention & Treatment; Perit Dial Int 2016; 36(5):481–508

36. Chow KM, Clin J Am Soc Nephrol 1: 768–773, 2006.

37. O V E R A L L P E R I T O N I T I S
565 episodes of peritonitis in 280 PD patients
Treatment success
465 episodes (82%)
Treatment failure
100 episodes (18%)
Aug 2001 - July 2005
70 - required catheter removal
30 - peritonitis related dead within 2 weeks
Diagnosis of peritonitis ( 2 of 3 )
- Abdominal pain or cloudy PD effluent
- Leucocytosis in PD effluent ( WBC > 100/ mm 3 )
- Positive Gram stain or culture from effluent
Chow KM, Clin J Am Soc Nephrol 1: 768–773, 2006.
IP Cefazolin & Ceftazidime
Prophylactic Nystatin 500,000 U x 3 times daily
IV antibiotics - in patient seemed septic clinically

38. Chow KM, Clin J Am Soc Nephrol 1: 768–773, 2006.

39. Chow KM, Clin J Am Soc Nephrol 1: 768–773, 2006.

40. 3 1,000
Chow KM, Clin J Am Soc Nephrol 1: 768–773, 2006.

42. P D F L U I D C U LT U R E R E P O R T E D

43. ISPD Peritonitis Recommendations: 2016 Update On Prevention & Treatment; Perit Dial Int 2016; 36(5):481–508

44. ISPD Peritonitis Recommendations: 2016 Update On Prevention & Treatment; Perit Dial Int 2016; 36(5):481–508

45. ISPD Peritonitis Recommendations: 2016 Update On Prevention & Treatment; Perit Dial Int 2016; 36(5):481–508

46. ISPD Peritonitis Recommendations: 2016 Update On Prevention & Treatment; Perit Dial Int 2016; 36(5):481–508

47. ISPD Peritonitis Recommendations: 2016 Update On Prevention & Treatment; Perit Dial Int 2016; 36(5):481–508
S U G G E S T
S U G G E S T
S U G G E S T
S H O U L D
W O U L D
S H O U L D
S H O U L D
I S P D 2 0 1 6

48. ISPD Peritonitis Recommendations: 2016 Update On Prevention & Treatment; Perit Dial Int 2016; 36(5):481–508

49. ISPD Peritonitis Recommendations: 2016 Update On Prevention & Treatment; Perit Dial Int 2016; 36(5):481–508

50. • In cases of culture negative peritonitis with persistent
peritoneal leukocytosis and a lack of neutrophilia
fungal or tubercule peritonitis should be considered.
Perit Dial Int 25(3):207–222, 2005

51. • In cases of culture negative peritonitis with persistent
peritoneal leukocytosis and a lack of neutrophilia
fungal or tubercule peritonitis should be considered.
Perit Dial Int 25(3):207–222, 2005

52. T U B E R C U L O U S P E R I T O N I T I S
• Testing for mycobacterial DNA via polymerase chain
reaction methods is useful, particularly in the detection
and early treatment of Mycobacterium tuberculosis,
but may be prone to false positive and false negative
results.
• Measuring adenosine deaminase or T-cell based
assays have the potential be useful when TB is
suspected but these methods have not been studied
extensively in the PD population.
Seminars in Dialysis—Vol 27, No 6 (November–December) 2014 pp. 602–606

53. T U B E R C U L O U S P E R I T O N I T I S
• Though sensitivity of acid fast staining is poor.
• When considering mycobacterial peritonitis, biopsy of
the peritoneum or omentum by laporoscopy should
be pursued; direct tissue examination for acid fast
bacilli is most likely to yield confirmatory results and
allow for early treatment if AFB staining is not positive.
Seminars in Dialysis—Vol 27, No 6 (November–December) 2014 pp. 602–606

54. ISPD Peritonitis Recommendations: 2016 Update On Prevention & Treatment; Perit Dial Int 2016; 36(5):481–508

55. ISPD Peritonitis Recommendations: 2016 Update On Prevention & Treatment; Perit Dial Int 2016; 36(5):481–508

56. R E F R A C T O RY P E R I T O N I T I S
Perit Dial Int 2010; 30:393–423

57. M.Krishnan et al: PDI 2002; 573-581
485
episodes
399 episodes were
analyzed
53 episodes
C/S negative
33 episodes
Fungal
peritonitis
• Retrospective study, single study
• Collected all episodes of peritonitis occurring
between March 1995 an July 2000.

58. M.Krishnan et al: PDI 2002; 573-581
399 episodes
317
episodes
Successful
82 episodes
Non-
resolved
9 Died 73
transferred
to HD
❑ Mean number of days in
which cell count > 100/µL
▪ Successful gr : 4.8+3.3 days
VS [p < 0.0001]
▪ Non-resolved : 7.4+1.4 days
❑ PD cell count > 100/µL for > 5
days
▪ Nonresolution rate 45.6%
VS [p=0.001]
▪ Resolution rate 4.2%

59. Chow KM, Clin J Am Soc Nephrol 1: 768–773, 2006.

60. Chow KM, Clin J Am Soc Nephrol 1: 768–773, 2006.

61. C U LT U R E N E G AT I V E P E R I T O N I T I SCulture-negative peritonitis:
After Culture negative on Day 3
Clinical assessment
Repeat PDF cell diff & count
Infection Resolving
Patient resolving
clinically
Continue initial
therapy for 14 days
Infection Not Resolving
Patient resolving clinically
Consider special culture technique
Now culture positive
consider specific Rx
Still Culture
negative
No clinical
improvement after 5
days
remove catheter
Clinical improvement:
continue antibiotics
14 days
Adapted from Perit Dial Int 2010; 30:393–423

62. C U LT U R E N E G AT I V E P E R I T O N I T I S

63. C O N T I N U O U S Q U A L I T Y I M P R O V E M E N T
Perit Dial Int. 2012 Jul-Aug; 32(4): 476–478.

64. P E R I T O N I T I S S U R V I VA L K I T
K A M O L K H O S I T R A N G S I K U N , M D
J A N U A RY 2 0 1 8

65. ห ลั ก ก า ร แ ล ะ เ ห ตุ ผ ล
• การติดตามการเพาะเชื้อที่ไม่พบเชื้อ เป็นดัชนีสำคัญในการวัด
ประสิทธิภาพการทำงานของหน่วย
• การรักษาผู้ป่วยที่มีการติดเชื้อที่ไม่พบเชื้อมีผลต่อผลลัพธ์การ
รักษา
• เพื่อยกศักยภาพสำหรับพยาบาลวิชาชีพในการดูแลผู้ป่วย

70. http://learn.chm.msu.edu/vibl/content/differential/index.html

73. ก า ร ป ร ะ ชุ ม ค รั้ ง แ ร ก
2 3 ม ก ร า ค ม 2 5 6 1

74. อ ธิ บ า ย ค ว า ม เ ป็ น ม า

78. H O W T O
•Cope
•Improve
•Prevention

79. PeritonitisInfectionRisk

80. R I S K FA C TO R S F O R P E R I TO N I T I S
• Non- medical condition
• Socioeconomic status
• Personal hygienic care
• Medical condition
• Patient associated condition eg. co-morbid disease
• System associated condition eg. connection system
Textbook of Peritoneal dialysis; ISBN 978-974-16-5787-2, p. 269

81. P R E V E N T I O N - P D R E L AT E D I N F E C T I O N S
• Catheter placement
• Exit-site care
• Connection methods
• Training methods
• Antibiotic prophylaxis procedure
• Prevention bowel source of infection
• Prevention of fungal peritonitis
Perit Dial Int 2005; 25:107–131

82. M O D I F I A B L E R I S K FA C TO R S F O R
P E R I TO N I T I S
• Hypoalbuminemia
• Hypokalemia
• Constipation
• Vitamin D insufficiency
• Depression
Piraino, Perit Dial Int 2011; 31(6):614-630
• Prolonged antibiotics
• Medical procedures
• Exit-site colonization
and infections
• Technique errors

83. C A U S E O F C U LT U R E N E G AT I V E
• Most cases of culture-negative peritonitis in PD
patients can be explained by
• Recent antibiotic therapy
• Technical problems during effluent culture.
Perit Dial Int. 2012 Jul-Aug; 32(4): 476–478.

84. R D U - R AT I O N A L D R U G U S E

85. Thank You
Kamol Khositrangsikun, MD.
25 กุมภาพันธ์ 2561 - Novotel Baxter Scientia