Approach to managing peritonitis complicating peritoneal dialysis

The 2 most common modalities for peritoneal dialysis are automated peritoneal dialysis (APD) (also called continuous cycler peritoneal dialysis [CCPD]), and continuous ambulatory peritoneal dialysis (CAPD). The recommendations in this topic apply to both APD and CAPD.

In patients with peritonitis complicating peritoneal dialysis, the peritoneal dialysis catheter can usually be kept in situ. Indications for removal of the peritoneal dialysis catheter include:

• refractory peritonitis (defined as failure to respond to appropriate antibiotics within 5 days, or longer if effluent white cell count is decreasing towards normal)
• relapsing, recurrent or repeat episodes of peritonitis
• exit-site or tunnel infection that does not resolve with appropriate antibiotic therapy
• exit-site or tunnel infection that progresses to, or occurs simultaneously with, peritonitis due to the same organism
• fungal or nontuberculous mycobacterial peritonitis.

If the peritoneal dialysis catheter is removed, seek expert nephrology advice on a substitute for peritoneal dialysis.

When treating peritonitis complicating peritoneal dialysis, the intraperitoneal route of administration is preferred for most antibiotics because it delivers high local concentrations. However, most antibiotics are also significantly absorbed after intraperitoneal administration, which may cause systemic effects. Administration of antibiotics via the intraperitoneal route can be either:

• continuous – in which antibiotics are added to each bag of dialysis fluid
• intermittent – in which antibiotics are added to 1 bag of dialysis fluid intermittently (usually once daily).

To be effective, antibiotics should generally stay within the peritoneal cavity for at least 6 hours; however, limited data are available to guide the optimal dwell time. Seek expert nephrology advice to determine which of the following approaches may be most suitable to achieve a minimum 6-hour dwell time of antibiotics:

• for patients using APD¹
  • add antibiotics to a separate 6-hour dwell, which can either be performed by the cycler (called a ‘last fill’) or as a manual continuous APD exchange by the patient (intermittent administration)
  • temporarily switch the patient to CAPD
• for patients using CAPD
  • add antibiotics to each bag, 4 times a day, each with a 6-hour dwell time (continuous administration)
  • add antibiotics to 1 bag per day, with a 6-hour dwell time (intermittent administration).

The choice between intermittent and continuous intraperitoneal administration of antibiotics has not been shown to affect patient outcomes, and is largely a matter of local preference. However, there are some limitations to continuous administration:

• Aminoglycosides (gentamicin or tobramycin) should only be administered intermittently because of increasing concerns about systemic absorption and resultant toxicity with continuous administration.
• Vancomycin should preferably be administered intermittently because the dosage of vancomycin for continuous intraperitoneal administration is poorly defined.
• In patients using APD, continuous administration is logistically difficult because additional exchanges containing antibiotics are needed throughout the day, as well as adding antibiotics to each usual overnight exchange. Additionally, a 6-hour dwell is not achievable overnight because the cycles are 1 to 3 hours.