-
8/9/2019 p24opp
1/9
PERITONITIS
Peritonitis is a serious complication of peritoneal dialysis.
Repeated episodes of peritonitismay be implicated in early failure
of the peritoneal membrane and subsequent failure
of peritoneal dialysis.
Guidelines provide a framework around which an individual
patient's management can bebased, but must be interpreted in light
of the clinical condition of each patient. It is suggestedthat
guidelines be reviewed every year to ensure they remain up to date.
he !edical"irector and attending physicians should make all
medication decisions and approve anyguidelines.
Diagnosis of PD Peritonitis#. $ymptoms and signs of
peritonitis
⇒ %bdominal pain
⇒ &ausea and vomiting
⇒ onstipation or diarrhea⇒ (ever
⇒ Rebound tenderness
⇒ )lood leucocytosis
*. loudy P" fluid with P" +hite cell count #--mm/ 01-2
polymorphonuclearneutrophils is supportive of the diagnosis of
microbial3induced peritonitis4.
0P" fluid is clear and colourless before draining in. P"
effluent should be clear butmay be 5yellow6 in colour. 5loudy6
fluid looks like5Pineapple 7uice6 and it is difficult to read te8t
through the bag.4
auses of cloudy dialysate⇒ Infective peritonitis 3 bacterial,
fungal, ), other
⇒ ulture &egative peritonitis
⇒ $econdary to other intra3abdominal pathology 3 diverticulitis,
appendicitis,
perforated bowel, abscess, transcolonic migration of
catheter
⇒ 9osinophilic peritonitis 3 %symptomatic cloudy dialysate fluid
with #12
eosinophils on differential cell count
BLOODSTAINED PD FLUID$ometimes seen in females during
menstruation is common and harmless. It can also
happen if the small blood vessels in the peritoneum break 0e.g.
lifting something heavy,playing sports4. It usually clears quickly
in a few e8changes but patients should be seen if the fluid is
very bloody or not clearing or they are unwell in any way. Initial
investigationsshould include e8clusion of peritonitis, abdominal
film and consideration of surgical review.
MANAGEMENTPeritonitis is a potentially life3threatening
condition. In the presence of cloudyfluid andor abdominal pain
andor fever prompt initiation of antibiotic therapy
is needed.
-
8/9/2019 p24opp
2/9
#. !easure and record )P 0lying and standing4, pulse and
temperature.*. % sample of the appropriate 0i.e., : hours' dwell
time4 dialysate effluent should be
obtained for laboratory evaluation including a cell count with
differential, Gram stain,and culture.
/. 98amine e8it site; swab if there appears to be e8it site
infection and send for e8it sitewound culture. 98amine tunnel for
evidence of tunnel infection.
:. heck for patient allergies.1. Review recent episodes of
peritonitis and e8it site infections.. ommence empirical
antibiotics per protocol or physician order.?. hoice of final
therapy should always be guided by antibiotic sensitivities.
PROPHYLACTIC ANTIBIOTICS FOLLOWING ACCIDENTAL
TOUCHCONTAMINATION(ollowing a break in sterile technique call
physician for antibiotic orders and change the
patient@s catheter e8tension set before any further e8changes
are performed.
FREUENCY OF CULTURESIt is important to obtain the first cloudy
effluent for culture. he probability of positivediagnostic culture
is greatest from this specimen. Patients should be instructed,
therefore, tobring the first cloudy fluid to the laboratory
immediately. %fter the initial culture, repeateffluent cultures are
not recommended if the cell count is decreasing appropriately and
thepatient is responding symptomatically. If cell counts are either
rising or not decreasingappropriately by / days, repeat cultures
should be taken and management guidelines shouldbe consulted.
INITIAL EMPIRIC ANTIBIOTIC SELECTION
If the effluent sediment Gram stain suggests gram3positive
bacteria, a gram3negativeorganism, or is unavailable, delayed, or
negative for any specific organisms, empiric therapyis indicated
0I$P" GuidelinesRecommendations %dult Peritoneal "ialysis3 Related
Peritonitis reatmentRecommendationsA *--- Bpdate able *4. o
prevent routine use of Cancomycin and thus preventemergence of
resistant organisms, it is recommended that a first3generation
ephalosporin,for e8ample, efaDolin or ephalothin 0# g daily in the
long dwell4, in combination witheftaDidime # g be initiated. hese
antibiotics can be mi8ed in the same dialysate bag aseither loading
or maintenance doses, without significant loss of bioactivity.
0I$P"GuidelinesRecommendations %dult Peritoneal "ialysis3 Related
Peritonitis reatment RecommendationsA *--- Bpdate able/4.
0(or more on medication selection please see I$P"
GuidelinesRecommendations %dult Peritoneal "ialysis3 Related Peri
tonitisreatment RecommendationsA *--- Bpdate httpAwww.ispd.org4
SAMPLE! PERITONITIS MEDICATION GUIDELINES
IP Cancomycin single dose, dwell
-
8/9/2019 p24opp
3/9
&oteA iproflo8acin should be taken * hours before calcium
and iron preparations 0e.g.ums, Phoslo4 as they interfere with
absorption.
SAMPLE! Peritonitis Protocol
linical diagnosis of P" peritonitis, no e8it site, no tunnel
infection
9mpirical treatment
Fral iproflo8acin 1-- mg bidFR IP Gentamicin -.
-
8/9/2019 p24opp
4/9
may be accompanied by pain and the presence of a scab, but
crusting alone is not indicativeof infection
C'roni# E%it&Site Infe#tions may be the result of an
untreated or inadequately treatedacute infection. It may also be a
sequela of a resolved acute infection, which recurs after
withdrawal of antibiotic therapy. $ymptoms of chronic infection
are similar to those of acuteinfections; however, e8uberant
granulation tissue is more common both e8ternally and in thesinus.
Granulation tissue at the e8ternal e8it is sometimes covered by a
large stubborn crustor scab. Pain, erythema, and swelling are
frequently absent in chronic infection.
An E($i)o#a* E%it Site is defined as purulent andor bloody
drainage only in the sinus thatcannot be e8pressed outside,
accompanied by regression of the epithelium and theoccurrence of
slightly e8uberant granulation tissue in the sinus. 9rythema may be
presentbut with a diameter less than twice the width of the
catheter. Pain, swelling, and e8ternaldrainage is absent 0wardowski
and Prowant, #???4. !ost, but not all, tunnelinfections occur in
association with e8it3site infections. ere the risk for
subsequentperitonitis is increased.
Tra$+ati,e- E%it Site appearances depend on the intensity of the
trauma and the timeinterval until e8amination. ommon features are
pain, bleeding, scab, and deterioration ofe8it appearance.
Pat'ogens! $taph. %ureus is responsible for the ma7ority of
e8it3site and tunnel infections.Pseudo. %eruginosa is much less
common, but like $taph. %ureus is difficult to eradicate
andfrequently leads to peritonitis if catheter removal is delayed.
$taph. 9pidermidis is a relativelyinfrequent cause of tunnel
infection in contrast to peritonitis. Fther gram3positive
organisms,other gram3negative bacilli, and, rarely, fungi account
for the remaining infections.
E%it&Site C$*t$res! within * : weeks after catheter
implantation, bacteria coloniDe almostall e8it sites. Positive
cultures from normal3appearing e8it sites indicate coloniDation,
notinfection. +henever possible, the cultures should be taken from
the e8udate 0wardowskiand Prowant #??
-
8/9/2019 p24opp
5/9
olley KG, (oulkes K, !ers %, +illard ". Bltrasound as a tool in
the diagnosis and management of e8it3site infections inpatients
undergoing %P". %m K Lidney "is #?>?; #:A*###
-
8/9/2019 p24opp
6/9
-
8/9/2019 p24opp
7/9
Hngklslgfs
Lngls
Nlsmg
HkgsLsnkg
Lknlkg
Lnf
kjnsf
S
Mg
Knvxdgvd
Jjfd
Bnxdlgvd
Lklks
KjkjCh
Fhtfvj
Vnvj
Fdxfd
Gfxgfxg
Bchbb
Hcbcv
Nvjvjj
Jvhcvn
Hvh
vgnb
-
8/9/2019 p24opp
8/9
jvbmfkhskjbfna
mnbjmsgvs
hjhsvfjs
kbjhnsf
nkbkl
vcjsbkfkf bjvskv
bjhbfks
kbbvsz
lkbjfs
lkbfjs
kjkfvkjsf
bhjfvs;f
nbfkvs
fkbsklf
bfkjbks
bjbkfsfkjnszlf
nkjfblzs
nmszgvsd
bzbvkz
nkjnvzc
;nlvs
Lnknlsf
Sf
Lhvbhls
!lhkz
Lk
Nlnfls
Jlfsa
Kfks
!nbkjfbksdf
kjasa
kkfs
hzf
"j#
nkfs
;jlfzaHdg
sttg
hsg
jfjgfj
khkh$
hfhd
hfhf
hkghkfhd
jfggsab
cgdm
gjgfj
-
8/9/2019 p24opp
9/9
jfhgghgjbkjnlk
