PD peritonitis Flashcards
How to diagnose PD peritonitis?
**2/3 **
a. clinical features
b. dialysis effluent:
>50% polymorphonucleus cells
>100/uL WBC
>0.1 x 10*9/L WBC (after 2hrs dwell)
c. +ve effluent culture
ISPD guideline 2022
What is
culture -ve peritonitis?
Full diagnosis criteria (1/2) however no organism identified.
Causes of culture -ve peritonitis
Mx & Treatment duration
- recent abx exposure
- inadequate sample
- slow growing atypical organism (fungal/TB)
*4. eusinophilic peritonitis - chemical peritonitis (icodextrin) *
mx:
1. if NG after3/7, then repeat cell count + special culture
2. cont initial tx - duration: 2/52
infectious, non infectious
what is the peritonitis rate recommended?
should be** no more than 0.40 episode per year at risk**
diagnosis of fungal PD peritonitis
- PD effluent culture
- PD effluent galactomannan
- Serum Galactomannan
- 65.2% sensitivity
- 85% specificity
Antibiotics for PD peritonitis
- Emperic abx **(IP) **:
Gram pos coverage: 1st gen cephalosporin / vancomycin
Gram neg: 3rd gen **cephalosporin / aminoglycoside
Cefepime: monotherapy **
Aminoglycoside
- cant be use os monotherapy
- +post abx effect (exhibit [ ] dependent activity even below MIC
- suggest for intermittent daily dosing IP
- SE: irrevesible ototoxicity
- RF: elderly / episodes of peritonitis / cumulative dose of amikacin / vancomycin
- prevention: oral NAC 600mg bd, avoid prolonged / repeated use
- culture guided therapy
- Adjunct therapy
- heparin 500u/L IP - prevent fibrin clog
- pain mx: analgesic / rapid cycler (augmented peritoneal lavage)
- IP urokinase + rifampicin (following CONS inf) : prevent biofim formation esp in refractory (not proven)
ISPD guideline: PD peritonitis 2022
Mx of PD peritonitis as in-pt
- hemodynamic instability /shock
- persistent severe symptoms
- fluid overloaded
- poor social support
- inability to provide IP abx as outpt
Complication of PD peritonitis
1. Fluid overload
- increase inflammation > vasodilatation > increase effective peritoneal surface area > increase transfer rate > faster absorption of glucose > early osmotic equilibration > transient loss of UF capacity
- —high transporter
- use icodextrin
**2. increase protein loss
- intraabdominal abscesses / systemic seeding **
Refractory PD peritonitis
Failure of PD effluent to clear after 5 days of appropiate abx
indication for catheter removal
- refractory PD peritonitis
- systemic / clinical deterioration
- fungal / TB
- Peritonitis + exit site/ tunnel
- Intrabd collection / perforated bowel
Pattern of treatment outcome
1. Early responses
2. delayed response: gradual decline of effluent WBC but still above 100/uL on D5 *
3. treatment failure: not cure by abx, change modality to HD temporarily of permanent / peritonitis related death*
**4.medical cure: **complete resolution with NONE of the cx (relapse / recurrent / removal / death / transfer to HD > 30 days
PD catheter insertion - related peritonitis
episode of peritonitis that occur within 30days of insertion
aim: **< 5% of insertion **
IPSD PD peritonitis 2022
Reporting, monitoring and measuring
monitor:
1. PD related peritonitis rate (after PD commencement)
2. antimicrobial susceptibility of organism
3. culture negative peritonitis
4. peritonitis outcome
5. mean time to 1st peritonitis episode
6. % of pt with peritonitis free (aim: >80% / year)
Peritonitis rate reporting
number of episodes per patient-year
Aim: < 0.4 episodes per pt-year
**Culture negative **peritonitis rate reporting
reported as
**% of all peritonitis episodes per unit time **
Aim: < 15% of all peritonitis episode
Specific definition following peritonitis
- Refractory
- recurrent: different organism, within 4/52 of abx completion
- relapsing: same organism, with 4/52 of completion abx
- repeat: same organism, > 4/52 of abx completion
PD contamination
- DRY contamination
- contamination outside a closed PD system - WET contamination
- contamination with an open system, either dialysate is infused after contamination / cath set left open for extended period
- + prophylatic abx
- change sterile transfer set
- PD effluent send for cell count + culture
How to reduce the peritonitis rate in your center?
- systemic prophylatic abx per cath insertion: IV cefazolin / cefuroxime / genta / vanco
- exit side care: topical abx, proper PD cath immobilization , avoid mechanical stress
- proper training and re-training (both staff and pt)
- pre-procedures prophylactic abx
- no domestic pet / prevent zoonotic infection
- avoid HYPOkalemia / constipation- bacterial translocation
- Avoid H2 rec antagonist - suppress gastric acidity
- Avoid constipation
- anti-fungal prophylaxis
- oral nystatin 500k u qid
- oral fluconazole 200mg eod
(during abx therapy) - revisit on environmental RF: PD fluid / hospital air / water contamination
- *choose pt wisely
ISPD guideline PD peritonitis 2022
Balance solution
Icodextrin
Balance solution :
more biocomplatible
Icodextrin
7.5% glucose polymer
Fungal peritonitis
- identification of organism
- removal of cath
- antifungal 2 weeks post removal
- reinsertion after 4 week min
chemical peritonitis
- symptoms
- cell counts > 100-3500 white cells per uL (predominant mononuclear)
- sterile culture
causes:
icodextrin
mx:
stop icodextrin
re-challenge 2-4 weeks
stop if recur
