1. The document discusses guidelines for the prevention and management of peritonitis from the ISPD 2022 updates. It focuses on key areas such as the standardized definitions of peritonitis, measurement of peritonitis rates, prevention strategies like exit site care and antibiotic prophylaxis, and treatment recommendations. 2. The new guidelines recommend monitoring peritonitis rates and aiming for a rate of less than 0.4 episodes per patient year. Prevention strategies discussed include proper exit site care, antibiotic prophylaxis before catheter placement and invasive procedures, and patient education. 3. Treatment guidelines cover initial antibiotic therapy based on peritonitis type and symptoms, and monitoring response and indications for catheter removal. Overall the document summar

1. Journey through
The road less traveled
Dr Ayman Seddik
Associate Professor of Nephrology
Ain Shams University
89% of
RRT
11% RRT

2. 1-Where are we in PD
map and rule of PD in
RRT
2-ISPD guidelines on
prevention and
management of
peritonitis 2022 UPDATES
Our journey will have 2 stations

4. Ramesh Khanna & Karl D. Nolph
Modalities of renal replacement therapy
Interchangeable, depends on residual renal function

5. Initial assessment
Renal clinic
In hospital
consultation
Transfer to HD
Transplantation
CKD Education
Modality choice
Life planning
Timing of initiation of PD
PD catheter r insertion
Training for PD
Maintenance care
Management of complications
JOURNEY THRU
PD CLINIC

6.  Physicians biased against chronic PD poor
outcome
 Patients have socio-cultural contra-indication
 Infrastructure for chronic PD available in less
than half of dialysis units
 Physicians are not trained for PD

7. WHO ??
WHICH PATIENT TO OFFER PD ??
CONTRAINDICATIONS ??

8.  European Renal Best Practice (ERBP) guidelines &
ISPD guidelines
recommend that all patients be educated about therapy
options, so they can
choose the modality that best suits them
 Initial dialysis modality selection
There is insufficient evidence to support a general preference
of HD
over PD, or vice versa, for medical reasons. Therefore, the
initial
modality choice should be made primarily by the well
informed patient.

9.  MEDICAL
 Prior extensive abdominal
surgery
 LARGE ABDOMINAL WALL HERNIAS
 ILEOSTOMY, COLOSTOMY

10. ❑ Inability to train for PD
❑Limited eyesight
❑Insufficient social and family support
❑Unsafe or limited home living condition

11. Timing of the
start of the
dialysis
Timing of
placement of
PD catheter
Dose of
dialysis to be
targeted
Maintenance
of volume
control
Psychosocial
status and
quality of the
life of the
patient and
their family

12. WHEN??
1) TIME TO INITIATE
2) TIME FOR CATHTER
INSERTION

13.  Clearance or GFR 15ml/min as general guide
 Presence or absence early symptoms and signs of
Uremia
 Other complication of advanced CKD
 Changes in nutritional status and decrease in calorie
intake
 Deterioration in cognitive functioning/quality of life

14.  Best inserted close to time of initiation about 4 to
5 weeks prior to initiation of PD

18. PD DELIVERED MANUALLY OR WITH THE
ASSISTANCE OF THE MACHINE – CYCLER
DESCISION MADE AFTER DISCUSSION
WITH PATIENT AND PATIENTS FAMILY

19.  K/DOQI guidelines suggest minimum Kt/V Urea of 1.7
combining dialysis and endogenous ( residual ) renal
clearances
 Body surface area
 How many exchanges
 Volume of dialysis fluid instilled
 Tonicity of the fluid (GLUCODE CONCENTRATION IN PD FLUID
) is there long DWELL
 Duration of time patient on cycler

20.  CAPD

21.  APD

22.  HIGH DOSE CCPD OR OPTIMIZED

24. THE LONG DAY DWELL

25. • For a single daily exchange for the long
(8- to 16- hour) dwell during continuous
ambulatory peritoneal dialysis (CAPD) or
automated peritoneal dialysis (APD).
• To improve (compared to 4.25%
dextrose) long-dwell ultrafiltration and
clearance of creatinine and urea nitrogen
in patients with high average or greater
transport characteristics, as defined
using the peritoneal equilibration test
(PET).
EXTRANEAL
INDICATIONS

26. CONTRAINDICATIONS
1-Known allergy to cornstarch or
icodextrin
2-Maltose or isomaltose
intolerance
3-Glycogen storage disease
4-Pre-existing severe lactic acidosis

28. Time line for peritoneal dialysis complications
• A) NON INFECTIOUS COMPLICATIONS
• I) Occurring early after surgery
• Pain
• Bleeding
• II) Occurring later after surgery
• Hemoperitoneum
• Poor outflow or inflow
• Leaks
• Migration of the catheter
• Increased IPP (Intra Peritoneal Pressure)
• Hernia
• Pain: infusion and drainage phases
• Eosinophilic peritonitis at start of PD
• sclerosing encapsulating peritonitis
• B)INFECTIOUS COMPLICATIONS
• EXIT SITE INFECTION
• TUNNEL INFECTION
• PERITONITIS
PD
COMPLICATIONS

29. Pain Bleeding
• Management of pain is important
to maintain the patients comfort.
• Avoid or manage severe cough
• Always assess if dressing is clean
and dry
• If bleeding persists, advise the
surgeon
I) Occurring early after surgery

30. Poor Inflow or Outflow
II) Occurring later after surgery
Causes
• Constipation
• Catheter migration
• Catheter obstruction with fibrin, blood
•Omental wrapping

31. II) Occurring later after surgery
Can look dramatic but will usually
settle with time
Can occur with menstrual cycle
May need additional heparin if there
are signs of clots (but usually the
natural anticoagulants from peritoneal
cells will prevent any such problems
HEMOPERITONEIUM

32. II) Occurring later after surgery
Catheter Migration
Predisposing factors Prevention
• Improper implantation or length
• Direction of the subcutaneous
tunnel and “memory” of catheter
may lead to migration of the
catheter.
• Constipation
• Perfect catheter insertion technique
• Avoid and manage constipation

34. Conservative strategies such as
body position change
Laxatives
Flushing with heparinized saline (‘push-and-suck’ manipulation)
Thrombolytic therapy (as per hospital’s protocol eg Urokinase),
Fluoroscopic-guided manipulation using a guidewire
Surgery: will be possible laparoscopically
ISPD GUIDELINES : We recommend that each PD unit should have the
ability to manipulate or reimplant PD catheters when necessary
II) Occurring later after surgery
Catheter Obstruction

35. II) Occurring later after surgery

36. II) Occurring later after surgery
Hernia
The most commonly seen hernias are
incisional, umbilical and inguinal
Incisional hernias may occur when the peritoneal catheter is placed
through the midline instead of the paramedical approach through the
rectus muscle.
Risk factors
Elderly patients
Diabetic patients
Worsened by elevation of intra-peritoneal pressure eg catheter
malfunction problem so drainage is incomplete and pressure rises
driving a leak

37. II) Occurring later after surgery
• Assess and repair before starting PD
• Surgical repair is necessary - hernias should be
corrected either before or at catheter insertion.
• Make sure reduction is possible – if not – then urgent
surgical assessment ( OBSTRUCTED HERNIA )
• Stop PD temporarily around time of surgery ( TEMPORARY
HD )
• Reintroduce PD with low volumes, supine posture,
increase volume gradually over 2 weeks
Hernia MANAGEMENT

38. Causes Management
Infusion
• Solution jet effect on peritoneal
membrane
• Often found to be PD fluid pH
related
• Slower infusion speed
• Use of biocompatible solutions.
• Replacement of catheter if irritating
peritoneal wall
Drainage
• Catheter pressing on peritoneal
membrane or force of ‘suction’
is too strong
• Drain time too prolonged
• Lift up the drainage bag a little,
decreasing gravity
• Ensure PD cycler is not too high
• Tidal modality could be used on
APD

39. II) Occurring later after surgery
Leaks of PD fluid
Site of leaking can be:
• Peri-catheter : leak may be observed directly through the exit site
Illustrations courtesy of John Crabtree, MD

40. Persistant processus vaginalis (a remnant of embryonic
development) : swelling is noted in the groin region –
fluid is moving down the tissue planes until it stops at
the inguinal ligament in the groin
II) Occurring later after surgery
Leaks of PD fluid
CT peritoneography

41. Patient attend ER complain dyspnea increase while doing his PD , decreased UF ,
progresive weight gain
CXR ?
Diagnosis
Leaks of PD fluid
PERITONEO –PLEURAL LEAK

42. Rare, life-threatening complication, mostly after ≥ 6 years on PD, the peritoneum is
massively thickened and calcified, leading to intestinal obstruction)
II) Occurring later after surgery
sclerosing encapsulating peritonitis

43. Dialysis Access remains the Achilles heel of peritoneal
dialysis.
Every year, 10% of PD patients switch to HD. After
infectious-related PD complications, catheter-related
issues are the second most common reason for
technique failure.

44. Infectious complications in PD patients
1-Exit site infection
2- Tunnel infection
3- Peritonitis
PREDICTABLE AND PREVENTABLE

45. Definitions and
measurement of
peritonitis;
Prevention of
peritonitis;
Treatment of
peritonitis: initial and
subsequent;
Monitoring response
to peritonitis
treatment including
indications for
catheter removal
For a better understanding of this guideline, we will focus on
the updates, and we will keep to a few key areas in the new
recommendations:

46. 1-clinical features consistent
with peritonitis: abdominal
pain and/or cloudy dialysis
effluent.
2-dialysis effluent white
blood cell (WBC) count >
100/µL (after a dwell time of
at least 2 h), with > 50%
polymorphonuclear
leukocytes (PMN).
3-positive dialysis effluent
culture
standardized definitions of PD-related peritonitis. ISPD 2022
guidelines
Guideline recommendations: We recommend that peritonitis
should be diagnosed when
at least two of the following are present (1C):
Definitions

47. PD peritonitis is further classified according to
1-causative
organism 2-concomitant
event (e.g.
association with
exit-site/tunnel
infections or
intra-abdominal
pathology)
3-timing
concerning
previous
episodes
4-outcomes.

48. 1-causative
organism

49. • Pre-PD peritonitis is a peritonitis
episode occurring after PD
catheter insertion and prior
initiation of PD (first day of PD
training or PD treatment).
• PD catheter insertion-related
peritonitis is defined as an
episode of peritonitis that occurs
within 30 days of PD catheter
insertion and should be <5% of PD
catheter insertion

50. • Recommended monitoring parameters also
include
• organism-specific peritonitis rates
• antimicrobial susceptibilities
• culture-negative peritonitis.
ISPD peritonitis
guideline recommends
that every PD program
should monitor the
incidence and outcomes
of PD peritonitis at least
annually (1C).
Measurement of peritonitis rate

51. • 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 the 2016
guideline (<0.5 episodes/patient-year).
• The proportion of culture-negative peritonitis should be
less than 15% of all peritonitis episodes (1C).
• percentage of peritonitis-free patients (targeting >80%
peritonitis-free patients per year), and pre-PD peritonitis

52. 4-outcomes.

54. Classification of exit sites
I - perfect
ISPD CATHETER-RELATED INFECTION RECOMMENDATIONS: 2017 UPDATE

55. Classification of exit sites
II- GOOD
ISPD CATHETER-RELATED INFECTION RECOMMENDATIONS: 2017 UPDATE

56. Classification of exit sites
III- Equivocal
ISPD CATHETER-RELATED INFECTION RECOMMENDATIONS: 2017 UPDATE

57. Swelling
2
ISPD 2022 We suggest that exit-site
infection is defined as the presence of
purulent discharge, with or without
erythema of the skin at the catheter-
epidermal interface (not graded).
Most serious
S. aureus and P. aeruginosa. As these
organisms
frequently lead to peritonitis
(Evidence), such
infections must be treated aggressively

58. 2 weeks after missing to treat exit site infection , your patient came to
ER with pain , redness , swelling at the tunnel site

59. Cloudy bag = peritonitis
Flush with rapid exchange wash the
peritoneum then Antibiotics as per unit
protocol immediately in a 6 hour dwell
2.27% ,
Use first cloudy bag if possible – make sure
patient
brings it send for cell count , culture

60. Primary Prevention
• Catheter Placement - Prophylactic Antibiotic
• In the guideline, there is only one 1A recommendation, which can
be found both in the 2017 and 2022 ISPD guidelines: that systemic prophylactic
antibiotics be administered before catheter placement.
• Four randomized trials support this recommendation, including cefuroxime
(Wikdahl et al, NDT 1997), Gentamicin, vancomycin, and Cefazolin versus no
treatment (Lye et al, Scand J Urol Nephrol 1992; Gadallah et al, AJKD 2000).
Prevention of peritonitis

61. Contamination of PD System
• We suggest prophylactic antibiotics after
wet contamination of the PD system to
prevent peritonitis (2D).
• We suggest advice be sought
immediately from the treatment team if
contamination during PD exchange is
noted (Not Graded).
Guideline
recommendations:
ISPD 2022 Peritonitis Guideline

63. Invasive gastrointestinal and gynecological procedures
• We suggest antibiotic prophylaxis prior to colonoscopy
(2C) and invasive gynecological procedure (2D).
• We suggest drainage of PD fluid to keep the abdomen
empty before endoscopic gastrointestinal and invasive
or instrumental gynecological procedures (2D).
Guideline
recommendations:
ISPD 2022 Peritonitis Guideline
GI procedures, i.e. colonoscopy, without antibiotic prophylaxis, has a
peritonitis incidence of 3.4 to 8.5%

64. Training Programs and Monitoring
• We suggest that the characteristics of an
optimal PD training programme (how, how
long, where, when and by whom) remain
uncertain (2C).
• We recommend that PD exchange technique
and knowledge be regularly reassessed and
updated, with an emphasis on direct
inspection of practice of PD technique (1C).
Guideline
recommendations:
ISPD 2022 Peritonitis Guideline

65. Review postoperative instructions with patient:
• Maintain clean, dry, securely taped sterile dressing
• Protect site from gross contamination and wetness
• Immobilize catheter
• Practice good hand hygiene .
• Avoid heavy lifting, stair climbing, straining, and constipation until
catheter is healed (2 to 6 weeks)
• Notify PD unit in case of blood or other drainage, pain or
tenderness, trauma to abdomen
Restrict dressing changes following implantation
to experienced PD staff
Prevention of complications
PATIENT EDUCATION FOR EARLY CATHTER CARE

66. Optimal long-term peritoneal catheter management focuses on maintaining a healthy exit site
and catheter track. Catheter survival of greater than 80% at one year
•ongoing assessment of the exit-site
• institution of antibiotic prophylaxis
•early identification and treatment of exit-site problems
•prevention of contamination
•immobilization of the catheter to protect from trauma.
ISPD 2022 recommends one of the following:
• Gentamicin 0.1% cream daily at exit-site effective in reducing both gram-positive and
gram-negative infections
• Mupirocin cream or ointment daily at exit-site effective in reduction of gram-positive
infections
• Apply to skin around catheter site only, not catheter

68. Domestic Pets and Zoonotic Infections
• We recommend PD patients take extra precautions
to prevent peritonitis if domestic pets are kept (1C).
• We suggest pets not be allowed in the room where
PD exchange takes place, and where dialysis tubing,
equipment and machine are stored (2A).
Guideline
recommendations:
ISPD 2022 Peritonitis Guideline

69. Dietary and Medication Effects
•We suggest that avoidance
and treatment of
hypokalemia may reduce the
risk of peritonitis (2C).
Guideline
recommendations:
ISPD 2022 Peritonitis Guideline

70. 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).
Guideline
recommendations:
ISPD 2022 Peritonitis Guideline

71. • 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).
initial management for
PD patients presenting
with a clinical diagnosis
ISPD 2022 Peritonitis Guideline

72. We recommend that IP antibiotics be the preferred route of
administration as long as the compatibility and stability of the IP
antibiotics allow, unless the patient has features of systemic sepsis (1B).
• We suggest that IP aminoglycoside be administered as daily intermittent dosing (2B).
• We recommend that prolonged courses of IP aminoglycoside be avoided (1C).
We suggest that adjunctive oral N-acetylcysteine therapy may help to
prevent aminoglycoside ototoxicity (2B).
• There is insufficient evidence to make a recommendation as to whether patients on APD
should be temporarily switched to CAPD during the treatment of peritonitis (Not Graded).
ISPD 2022 Peritonitis Guideline

73. Treatment of peritonitis: initial and subsequent
ISPD 2022 Peritonitis Guideline

74. Prescribing high-quality goal-directed PD
In 2020, the ISPD published practice recommendations for
prescribing high-quality goal-directed
These recommendations represented a paradigm shift from the conventional, non-
evidence-based and potentially harmful practice of prescribing PD to achieve so-
called ‘dialysis adequacy’ based primarily on the unvalidated and imprecise
surrogate measure of small solute clearance.
• Instead, the new guidelines advocate a tailored, shared decision-making model. Such a PD plan
should be developed by the person receiving PD in collaboration with their care team to ensure the
delivery of high-quality PD that helps the patient to achieve their expressed, personal goals of care,
and is informed by careful assessment of (in descending order of priority) patient-reported outcome
measures (such as QOL and symptom burden), clinical measures (such as fluid status) and, to a much
lesser extent, surrogate measures (such as RKF, bone mineral disorder parameters, nutritional
indices, peritoneal membrane function and small solute clearance)

75. Worldwide, approximately 11% of patients on dialysis receive peritoneal dialysis
(PD).
Whilst PD may offer more autonomy and freedom compared with hemodialysis,
infection, hospitalization, symptom burden, and patient/caregiver burnout and
fatigue remain as major challenges to the success of PD.
To some extent, this may be due to the inconsistency, heterogeneity, and lack of
patient-prioritized outcomes reported in trials in patients on PD.
The aim of the Standardised Outcomes in Nephrology-Peritoneal Dialysis (SONG-PD)
study is to establish a core outcome set for trials in patients on PD based on the
shared priorities of all stakeholders; which can help to improve the contribution of
trials to shared-decision making.

76. https://songinitiative.org/projects/song-pd/

78.  Evaluating candidacy for PD is a MULTI-DISCIPLINARY task
 Timing of initiation of PD requires close assessment and follow
up by the Nephrologist and Renal team
 PLACEMENT of catheter is best done about 4 to 5
weeks prior to anticipated initiation of PD as to allow 2
weeks of healing and 2 to 3 weeks of training

79.  Catheter care is best done according to a SET PROTOCOL
 Adequate and complete training for PD is critical

 Primary and secondary prevention of complications is
important for patient catheter and technique
 Early serious problems can usually be addressed without
permanently discontinuing PD
 Comprehensive care of the PD patient starts early
 Providing high quality goal directed PD therapy is the target
for ongoing trials

80. THANK
YOU

81. APPENDIX :
IP antibiotic dosing recommendations for
treatment of peritonitis.

83. Group Antibiotic
Intermittent (1 exchange
daily for at least 6 h)
Continuous (all
exchanges)
Aminoglycosides Amikacin 2 mg/kg daily173 Not advised
Aminoglycosides Gentamicin 0.6 mg/kg daily174,175 Not advised
Aminoglycosides Netilmicin 0.6 mg/kg daily165 Not advised
Aminoglycosides Tobramycin 0.6 mg/kg daily Not advised
Group Antibiotic
Intermittent (1 exchange
daily for at least 6 h)
Continuous (all
exchanges)
Cephalosporins Cefazolin 15 mg/kg daily (for long dwell)176,177 LD 500 mg/L, MD 125 mg/Ld 168,179
Cephalosporins 20 mg/kg daily (for short dwell)178,176
Cephalosporins Cefepime 1000 mg daily LD 500 mg/L, MD 125 mg/Ld 168
Cephalosporins Cefoperazone No data LD 500 mg/L, MD 62.5–125 mg/L180
Cephalosporins Cefotaxime 500–1000 mg daily181 no data
Cephalosporins Ceftazidime 1000–1500 mg daily (for long dwell) LD 500 mg/L, MD 125 mg/Ld 168,182
Cephalosporins 20 mg/kg daily (for short dwell)178
Cephalosporins Ceftriaxone 1000 mg daily183 No data

84. Group Antibiotic
Intermittent (1 exchange
daily for at least 6 h)
Continuous (all
exchanges)
Penicillins Penicillin G No data LD 50,000 unit/L, MD 25,000 unit/L13
Penicillins Amoxicillin No data MD 150 mg/L184
Penicillins Ampicillina 4 gm daily185 MD 125 mg/L186
Penicillins
Ampicillin/sulbacta
m
LD 1000 mg/500 mg, MD 133.3 mg/66.7
mg187,188
Penicillins
Piperacillin/tazobac
tam
No data LD 4 gm/0.5 gm, MD 1 gm/0.125 gm189
Penicillins
Ticarcillin/clavulani
c acid
No data LD 3 gm/0.2 gm, MD 300 mg/20 mg/L190

86. Group Antibiotic
Intermittent (1 exchange
daily for at least 6 h)
Continuous (all
exchanges)
Antifungal Fluconazole
IP 150–200 mg every 24 to 48 h215,216 (oral route
is preferred: see Table 6)
No data
Antifungal Voriconazole
IP 2.5 mg/kg daily217 (oral route is preferred:
see Table 6)
No data

87. APPENDIX :
Systemic antibiotic dosing recommendations for
treatment of peritonitis.

88. group Drug Dosing
Antibacterial Amoxicillin Oral 500 mg thrice daily219
Antibacterial Ciprofloxacin Oral 500–750 mg daily220
Antibacterial Oral 750 mg BD for CCPD221
Antibacterial Clarithromycin Oral 250 mg BD222,223
Antibacterial Colistin
IV 300 mg loading (for critically ill patients), then 60–200
mg dailyb224-226
Antibacterial Dalbavancin IV 1500 mg over 30 min single dose227
Antibacterial Daptomycin IV 4–6 mg/kg every 48 h228
Antibacterial Ertapenema IV 500 mg daily229
Antibacterial Levofloxacin Oral 250 mg daily230 or 500 mg every 48 h
Antibacterial Linezolid IV or oral 600 mg BD231,232 for 48 h, then 300 mg BD233
Antibacterial Moxifloxacin Oral 400 mg daily234,235
Antibacterial Rifampicin
Oral or IV 450 mg daily for BW <50 kg; 600 mg daily for BW
≥50 kg
Antibacterial
Ticarcillin/clavulanic
acid
IV 3 gm/0.2 gm every 12 h
Antibacterial Tigecycline IV 100 mg loading, then 50 mg every 12 h236,237
Antibacterial
Trimethoprim/sulfametho
xazole
Oral 160 mg/800 mg BD238,239

89. group Drug Dosing
Anti-fungal
Amphotericin B
desoxycholate
IV 0.75–1.0 mg/kg/day over 4–6 h240
Anti-fungal
Amphotericin B
(liposomal)
IV 3–5 mg/kg/day241,242
Anti-fungal Anidulafungin IV 200 mg loading, then 100 mg daily243,244
Anti-fungal Caspofungin IV 70 mg loading, then 50 mg daily243
Anti-fungal Fluconazole Oral 200 mg loading, then 100 mg daily240
Anti-fungal Flucytosine Oral 1 gm daily240
Anti-fungal Isavuconazole
Oral or IV 200 mg every 8 h for 6 doses (48 h) loading,
then 200 mg daily
Anti-fungal Micafungin IV 100 mg daily243,245
Anti-fungal Posaconazole
Oral tablet 300 mg every 12 h loading for two doses, then
300 mg daily246
Anti-fungal Voriconazole Oral 200 mg every 12 h