Articles
Diagnosis, treatment and management of UTI in children (D&G) Hospital at Home (H@H) Infant hip clinic referral form Vaccination referral form Assessment and management of babies who are accidentally dropped in hospital DGRI NNU Guideline for Management of Cord Blood Gas Results NNU Admission Criteria Antenatal Drugs for NAS Monitoring Vaccination Referrals from ED Paediatric Antimicrobial Guidance Children’s Services Resolution and Escalation Protocol Blunt Chest Wall Trauma/Rib Fractures Information for Parents Carers of Children Having Investigations in Relation to Unexplained Injuries + Consent form Bruising and Injuries in Babies and Children – Parents Leaflet Multi-Agency Protocol for Injuries to Non-Mobile Children Flowchart for children attending Galloway Community Hospital (GCH) for NAI Follow Up Skeletal Survey Flowchart for children attending DGRI for NAI Follow-Up Skeletal Survey Cognitive Function Conscious Level Kidney Biopsy Complications Parenteral Iron for Non-HD CKD Patients Fracture Management Guidelines (Paediatric) Fracture Management Guidelines (Adult) Management of Hypertension in Acute Stroke Prescribing for CAU Patients Still in ED Hypothermia Deactivation of Implantable Cardioverter Defibrillator Myeloma Croup Care Of Burns In Scotland (COBIS) Paediatric Guidance Management of Epistaxis Sore Throat Differential Diagnosis Dizziness Differential Diagnosis Peritonsillar Abscess/Quinsy Acute Tonsillitis Acute Mastoiditis Otitis Media Otitis Externa Extravasation of IV Amiodarone WoS Paediatric Drooling and Aspiration Guideline Palliative Care – How to Refer Eating Disorders Stroke Care Warfarin Anticoagulation for AF, DVT and PE Molnupiravir MyPsych Foundation Doctors Toolkit Paediatric Febrile Neutropenia Guidance PAEDIATRIC HYPOGLYCAEMIA MANAGEMENT in NON DIABETIC CHILDREN   Paediatric Diabetic Ketoacidosis (DKA) Guideline Child Protection Policies and Procedures (D&G) Management of Acute Behavioural Challenges in Adolescents and Young People presenting to Secondary Care Cancer of Unknown Primary Patients Returning from Interventional Cardiac Procedure Treatment of Malaria Discharging Patients on High Dose Steroids Sotrovimab Paediatric Ketone Correction Guideline Insulin Correction Factor Table (Paediatrics) Management of uncomplicated Henoch-Schonlein Purpura (HSP) in under 16s Management of Hypoglycaemia in Children with Type 1 Diabetes Newly diagnosed diabetic – not in DKA (Walking wounded) Proton Pump Inhibitor Guideline for Neonatal and Paediatrics Stroke – Post Thrombolysis Neonatal Guidelines Gentamicin Prescribing (Paediatrics) Management of Anaphylaxis (Paediatrics) Management of Prolonged Seizures (Convulsive Status Epilepticus) in Children Bronchiolitis Acute Wheeze or Asthma in Paediatrics Conscious Proning Covid-19 Basics Remdesivir Thromboprophylaxis Identifying Patients in the Highest Risk Groups Steroids for Patients with Covid-19 Infection IL-6 Inhibitors – Tocilizumab or Sarilumab Baricitinib Paxlovid (Nirmatrelvir/Ritonavir) Influenza A Inhalers for Adults with Asthma Standard Operating Procedure for AMU Trigger Finger/Thumb Osteoarthritis of the Hand/Thumb Mallet Finger Ganglion Dupuytren’s Contracture De Quervain’s Tenosynovitis Carpal Tunnel Syndrome Prescribing Advice on Admission – Clozapine Prescribing Advice on Admission – Methadone/Buprenorphine Prescribing Advice on Admission – Corticosteroids Prescribing Advice on Admission – Items Not Prescribed by GP Prescribing Advice on Admission – Patients on Chemotherapy Regimes Prescribing Advice on Admission – Medication for Parkinson’s Disease Prescribing Advice on Admission – Insulin Prescribing Advice on Admission Medical Emergencies in Eating Disorders (MEED) Gentamicin & Vancomycin HIV Testing Guidelines Metabolic Syndrome Associated Fatty Liver Disease (MAFLD) Greener Inhaler Prescribing C4 Predischarge Beds Handover Safe and Secure Handling of Medicines Blood Glucose & Steroids IV Fentanyl & Morphine for Acute Pain in Adults Assessment & Management of Acute Pain Hospitalised and Has Coronavirus19 Infection (No suspected Viral Pneumonia Syndrome) Hospitalised Due to Coronavirus19 with Likely Viral Pneumonia Bi-Level NIV S/T Guidelines for CCU Phase Bi-Level NIV S/T Guidelines for ED Phase Adults With Incapacity Premenstrual Syndrome Pelvic USS Boarding Coeliac diagnosis pathway (Adults) Voice clinic Ear Wax Dermatology Squamous Cell Carcinoma (SCC) Malignant Melanoma Basal Cell Carcinoma (BCC) Nipple Discharge Early Cancer Diagnostic Clinic (ECDC) Genetics Referrals Breast Infections Breast Pain Primary Care Prescribing Guidelines Emergency Department Anaesthetics and Chronic Pain Team Respiratory Referrals Chronic Cough Pathway GP Clinical Handbook Test Paediatric Bronchiolitis Early Cancer Diagnosis Clinic (ECDC) Obstetrics & Gynaecology/Medicine Admission Agreement Idiopathic Intrancranial Hypertension Urology Out of Hours Urology Out of Hours Sengstaken/Minnesota Tube for Bleeding Varices Eradication of Helicobacter pylori Transfer from Galloway Community Hospital Repatriation of Patients from Tertiary Hospitals THROMBOPROPHYLAXIS IN PREGNANCY – Appendix 1, Risk factors THROMBOPROPHYLAXIS IN PREGNANCY – Appendix 3, Postnatal assessment & management THROMBOPROPHYLAXIS IN PREGNANCY – Appendix 4 THROMBOPROPHYLAXIS IN PREGNANCY – Appendix 2, Management of women with previous VTE THROMBOPROPHYLAXIS IN PREGNANCY, LABOUR AND THE PUERPERIUM Orthopaedic VTE Risk Assessment Sodium Glucose Transporter 2 Inhibitors (SGLT2i) Cardiology Referrals Vascular Referrals ‘Watershed’ Conditions Myasthenia Gravis Gentamicin in Renal Replacement Therapy Vancomycin in Renal Replacement Therapy REDMAP Poster Realistic Conversations Summary Plan for Deteriorating Health Treatment Escalation Plans Ambulatory Care for Blood and/or Iron Infusion Principles for Light Touch Patients – B2 Clostridiodes difficile Infection Post Astra Zeneca Vaccine Headache Blood Culture Rhabdomyolysis Analgesia Acute Appendicitis Small Bowel Obstruction Elective Admission – Colorectal Surgery Trauma Admissions Post-operative Care Gallstone Disease Vasopressors and Inotropes/Chronotropes Shock Elective Admission – ERCP Elective Admission – Orthopaedics Laxatives Fat Embolism Compartment Syndrome Surgical Post-operative Complications Stoma Diverticular Disease High Dose Steroid Pre-Treatment Checklist Acute Surgical Admissions Level 1 CCU Medical Area Acute Oncology STEMI Thrombolysis Protocol Haemolytic Anaemia Conversion Charts Anticipatory ‘As Required’ Medications Syringe Driver Chart Scottish Palliative Care Guidelines Covid-19 Sick Day Rules for Patients with Primary Adrenal Insufficiency Diabetic Retinopathy Coming Off Benzodiazepines and “Z” Drugs Dental Abscess Facial Trauma – Mandibular Fractures Facial Trauma – Orbital Fractures Facial Trauma – Zygoma Platelet Transfusion Death Certification Parenteral Iron in Adults >18 Years OPAT SBAR (Complex Infections) Mental Health Liaison Team Referrals STEMI Admitting Patients with Tracheostomy/Laryngectomy to DGRI Emergency Laryngectomy Management Emergency Tracheostomy Management Safe Transfer of Patients with Tracheostomy/Laryngectomy within DGRI Other Tracheostomy Documents Systemic Anticancer Therapy Toxicity Haemodialysis Medication Prescribing Breaking Bad News by Telephone End of Life Diabetes Care Adrenal Insufficiency Serotonin Syndrome DGRI Referrals Confirmation of Death Neuroleptic Malignant Syndrome Pulmonary Embolism Deep Vein Thrombosis of Lower Extremities Exacerbation of COPD Contrast Associated AKI Paracetamol Hypertensive Emergencies Staphylococcus aureus Bacteraemia (SAB) Rate Control in AF Common Scenarios Acute Severe Ulcerative Colitis IV Fluid Prescription in Adults Chronic Obstructive Pulmonary Disease Legionnaires Disease Septic Arthritis Guillain-Barré Syndrome Back Pain Anaesthetics – Unscheduled Procedures Requests Hyperglycaemia & Steroids Variable Rate Insulin Infusion Decompensated Liver Disease Fast Atrial Fibrillation – ACP Hyperkalaemia Contraindications to MRI Magnetic Resonance Imaging Bleeding with Other Antithrombotics In-patient Hyperglycaemia Management Anaemia (Management) – ACP Suspected NSTEMI – ACP Guidance on Chaperones Compulsory Admission and Treatment Radiology Immediate Discharge Letter Alcohol Withdrawal Fentanyl Patches in the Last Days of Life Care in the Last Days of Life Low Molecular Weight Heparin Interstitial Lung Disease Haematinic Testing Thromboprophylaxis for Non-Covid Patients Lung Cancer Osteoporosis Heart Failure Fluid Replacement in AKI Death & The Procurator Fiscal Thrombophilia Screening Neutropenic Sepsis Acute Vertigo Aortic Dissection Antithrombotics in Hip Fracture Transient Global Amnesia Hypomagnesaemia Hypophosphataemia Oxygen Therapy Falls – ACP Falls Acute Asthma Oncology Contact Details & General Advice Reversal of Warfarin Lumbar Puncture, Antiplatelet & Anticoagulant Drugs Antithrombotics & Surgery Non ST Elevation MI (NSTEMI) Suspected Acute Coronary Syndrome Antibiotics and the Kidney Acute Upper GI Bleeding (AUGIB) Pericardiocentesis Pleural Effusion Spontaneous Pneumothorax Acute Diarrhoea Iron Deficiency Anaemia Hyperthyroidism Gout Giant Cell Arteritis Pacemakers Clinical Suspicion PE – ACP Community Acquired Pneumonia (CAP) Management of Urinary Symptoms Acute Kidney Injury (AKI) SSRI Poisoning Immobility Autopsies Indications for Echocardiography Bradycardia Suspected Meningitis Hypernatraemia Diarrhoea – ACP Suspected Meningitis – ACP Blood Transfusion Brain Tumours Newer Antidiabetic Drugs Parkinson’s Disease Major Haemorrhage Protocols (DGRI & GCH) Major Haemorrhage Stroke Thrombolysis Pneumothorax – ACP Heart Failure – ACP Suspected Anaphylaxis Anaphylaxis – ACP The AMB Score – ACP Transient Loss of Consciousness (TLOC) – ACP Bell’s Palsy – ACP Suspected Sepsis Lumbar Puncture Hypokalaemia Gentamicin Dosing Transient Loss of Consciousness Urinary Tract Infection Urethral Catheterisation Vancomycin Dosing Hyponatraemia Narrow Complex Tachycardia Hypocalcaemia New Onset Type 1 Diabetes – ACP Paracentesis for Tense Ascites – ACP Idiopathic Intracranial Hypertension – ACP Other Funny Turns Hypoglycaemia Hypoglycaemia – ACP Management of Transfusion Reactions Hypercalcaemia Haematemesis – ACP Anti-Platelet Therapy in Coronary Heart Disease Unfractionated Heparin Infusion Anaemia (Investigation) – ACP Delirium Suspected Seizure – ACP Headache – ACP Community Acquired Pneumonia – ACP Cellulitis Dyspepsia Management of Acute AF Rhythm Control in AF Atrial Fibrillation Kidney Transplantation Massive Pulmonary Embolism Head and Neck Injury Diabetic Ketoacidosis Switching from VRII Insulin Pumps Diabetes Mellitus Aspirin Digoxin Poisoning Tricyclic Antidepressants Opiates Benzodiazepines Gut Decontamination Deliberate Self Harm Acute Liver Failure Asymptomatic Raised Transaminases (ALT & AST) Nutritional Support in Adults Refeeding Syndrome Parenteral Nutrition Crohn’s Disease Acute Pancreatitis Abdominal Aortic Aneurysms Malignant Spinal Cord Compression Post Splenectomy Sepsis Ascites in Cirrhosis Alcohol Related Liver Disease Hepatitis C Symptom Control Suspected Variceal Bleeding Severe Headache Status Epilepsy in Adults Lower Gastrointestinal Bleeding Functional & Social Assessment Breathlessness with Abnormal CXR Polymyalgia Rheumatica Rheumatoid Arthritis Ureteric Colic & Renal Stones Intravascular Catheter Related Blood Stream Infection Care of Vascular Access Urinary Incontinence Peritoneal Dialysis Related Peritonitis The First Seizure Hypertension Ventricular Tachycardia Cardiogenic Shock Complicating Acute Coronary Syndrome Telemetry The Diabetic Foot Subcutaneous Insulin Diabetes and Acute Coronary Syndrome Hyperosmolar Hyperglycaemic State Multiple Sclerosis Coma
 
 
In this section Close
Home | Articles | Renal | Peritoneal Dialysis Related Peritonitis

Peritoneal Dialysis Related Peritonitis

Last updated 18th November 2024

Definitions

  1. Peritoneal dialysis associated peritonitis is diagnosed when at least 2 of the following are present:
    • Clinical features consistent with peritonitis, i.e. abdominal pain and/or cloudy dialysis effluent
    • Dialysis effluent white cell count > 100/microlitres or > 0.1 x 109/L (after a dwell time of at least 2 hours), with more than 50% polymorphonuclear leucocytes
    • Positive dialysis effluent culture
  2. ***We recommend that PD patients presenting with cloudy effluent be presumed to have peritonitis and treated as such until the diagnosis can be confirmed or excluded***
  3. Relapsing peritonitis is defined as further episode of peritonitis caused by the same organism (or sterile culture), occurring within 4 weeks of completing antibiotic therapy for peritonitis. 
  4. Repeat peritonitis is a further episode of peritonitis more than 4 weeks after completing antibiotics, with the same organism. 
  5. Recurrent peritonitis is a further episode of peritonitis caused by a different organism, occurring within 4 weeks of completing antibiotics for peritonitis. 
  6. Outcome following an episode of peritoneal dialysis related peritonitis an outcome must be documented on SERPR. Outcomes are classified as:
    • Cure defined as resolution of evidence of peritonitis following antimicrobial therapy and without the need for catheter removal.
    • Peritoneal dialysis catheter removal.
    • Patient death This includes patients who die within 28 days of presentation of peritonitis even if the effluent WCC had cleared. 

Diagnosis (Day 0)

The following should be performed:

  1. Initial Assessment:
    • Routine observations (temperature, BP, pulse rate)
    • PD effluent to bacteriology for URGENT white cell count, Gram stain and culture and sensitivity
    • Check CRP and consider blood cultures if febrile
  2. Record details of the initial assessment, including urgent white cell count result, in the case notes (or clinical portal) and clinical history on SERPR.
  3. Consider predisposing factors:
    • Exit site or tunnel infection
    • Break in sterile dialysis procedure or equipment (without subsequent administration of prophylactic antibiotics)
    • Diverticulosis or other bowel disease

Initial Antimicrobial Therapy (Day 0)

  1. The aim of initial therapy is to provide cover against both gram positive and negative organisms.  Vancomycin provides gram positive cover. Ceftazidime provides gram negative cover. Antibiotics should be given via an intraperitoneal route.  Details of alternative antibiotics for patients with confirmed allergies to these antibiotics are provided below.
  2. All intermittent (bolus) intraperitoneal (IP) dosages of antibiotics should be administered via peritoneal dialysis exchanges with a minimum dwell time of 6 hours. IP antibiotics are compatible with Icodextrin (Extraneal) dialysis fluid.
  3.  The loading dosages of intraperitoneal vancomycin and ceftazidime are as follows:
  4.  Vancomycin – 30mg/Kg body weight to a maximum of 3g intraperitoneally in a minimum 6hr dwell. 
  5. Use a vancomycin prescription chart to record doses administered and subsequent vancomycin levels. Doses given should also be documented in HEPMA. If a patient has a confirmed allergy to vancomycin then daily IP teicoplanin should be used instead. See page 7.
  6. Ceftazidime – 1.5 g intraperitoneally in a minimum 6 hr dwell. Administer daily
  7.  If the patient has an allergy to ceftazidime or has had a previous known Clostridium difficile infection then aztreonam should be used instead. See page 7.
  8. Treatment should start immediately after the effluent white cell count is found to be greater than 100/μl. Automated Peritoneal Dialysis (APD) patients require a continuous ambulatory peritoneal dialysis (CAPD) exchange, with antibiotics added.
  9. Note:  APD patients do not need to convert to CAPD but, if peritonitis is severe enough to require inpatient stay APD patients should be converted to CAPD.

Management on Day 1

  1. The following should be done:
    • Routine observations (temperature, BP, pulse rate)
    • Record white cell count on overnight or long day dwell dialysate effluent in the case notes (or clinical portal) and on SERPR.
    • Administer 1.5g ceftazidime intraperitoneally in a long dwell (use aztreonam intraperitoneally if previous c.difficle infection or ceftazidime allergy – see below
    • See below if teicoplanin is being used instead of vancomycin.
    • Prescribe Nystatin 1 mL (100,000 Units) QDS for the duration of treatment to prevent fungal peritonitis.

Management on Day 2  

  1. Routine observations (temperature, BP, pulse rate)
  2. Record white cell count on overnight or long day dwell dialysate effluent in the case notes (or clinical portal) and on SERPR.
  3. Check serum CRP and white cell count.
  4. Administer 1.5 g ceftazidime IP in a long dwell. (use aztreonam intraperitoneally if previous C.difficle infection or ceftazidime allergy – see below)
  5. If residual renal function >5ml/min, check vancomycin level after 48hrs. Vancomycin and aminoglycoside levels fall more quickly in patients with residual urinary output. Patients with significant residual renal function will require more frequent monitoring of serum vancomycin levels.
  6. Give vancomycin 15 mg/kg IP into long dwell when level <20mg/l (note different level to that used in haemodialysis). If level <10mg/l discuss with pharmacist/doctor as dose may require to be altered.
  7. See below if teicoplanin is being used instead of vancomycin.

Management on Day 3

  1. The following should be done:
    • Routine observations (temperature, BP, pulse rate)
    • Record white cell count on overnight dialysate effluent in the case notes (or clinical portal) and on SERPR.
    • Check serum CRP and white cell count.
    • Check vancomycin levels if residual renal function less than 5ml/min. Give vancomycin 15mg/kg IP into long dwell when level less than 20mg/l.
    • Review bacteriology and clinical response (serial results of effluent WCC, CRP and serum vancomycin level)
    • Review antibiotic regimen with microbiology results and in consultation with microbiology team
  2. If gram positive organism:
    • Continue vancomycin 15mg/kg intraperitoneally (minimum 6 hour dwell) when vancomycin level falls below 20mg/l (See below) if teicoplanin is being used instead of vancomycin)
  3. If gram negative organism:
    • Continue ceftazidime daily dosing, 1.5g intraperitoneally (minimum 6 hour dwell). Use aztreonam if ceftazidime allergy or previous c.difficle infection (see below)
  4. If multiple gram negative organisms and/or anaerobes:
    • Consider surgery (likely intra-abdominal pathology)
    • Add metronidazole
  5. If culture negative:
    • Continue vancomycin (or teicoplanin) and ceftazidime (or aztreonam)
  6. If no clinical improvement:
    • Most patients should be improving by 48 hours
  7. If not responding by 72 hours, consider:
    • Check of antimicrobial sensitivities
    • Tunnel infection or exit site infection (commonly Gram positive) 
    • Unusual organism – treat as per microbiology advice 
    • Catheter removal if dialysate WCC not decreasing
    • Fungal infection – arrange catheter removal
    • Recurrent Staphylococcus Aureus or persistent coagulase negative staphylococcus (from PD fluid) – add rifampicin 600 mg/day. NB rifampicin has many drug interactions see British National Formulary (BNF).

Management from Day 4 Onwards

  1. Continue vancomycin (or teicoplanin) and ceftazidime (or aztreonam) or change antibiotic therapy depending on bacteriology results.
  2. Review interval at the PD unit will depend on progress and the need to monitor WCC of effluent and serum levels of antibiotics

Management to minimise complications

  1. Treatment Duration
    • Duration of treatment depends on clinical response and is usually at least 14 days. Longer duration of treatment (21 days) is required for more severe infections caused by Staphylococcus Aureus and Gram negative organisms.
  2. Ultrafiltration
    • Ultrafiltration may be affected by peritonitis.  PD regimens may need altered to maintain adequate fluid removal. Icodextrin (Extraneal) is useful in maintaining net ultrafiltration volumes. Occasionally heparin (500 units/litre) may need to be added to the PD fluid, if there is fibrin in the effluent.
  3. Catheter Removal
    • Consider catheter removal after a first episode of recurrent peritonitis .
    • If catheter removal is required, appropriate IV or oral antibiotics and/or antifungal drugs should continue to be prescribed. 

Alternative Antibiotics

  1. Treatment should be standardised and in line with these guidelines wherever possible. A comprehensive list of alternative antibiotics is available via ISPD.  The use of non-standard anti-microbial therapy is best discussed with senior medical and microbiology staff.
  2. Use of Intra-Peritoneal Teicoplanin
    • Teicoplanin has gram positive organism cover and should be used in place of vancomycin where there is a documented vancomycin allergy.
    • Teicoplanin Dosing Regimen:
      • Day 0 400mg IP once only
      • Day 1-7 20mg/litre into each exchange
      • Day 8-14 20mg/litre into alternate exchanges
      • Day 15-21 20mg/litre into overnight exchanges
    • It is recommended to use 200mg vials and reconstitute with 3ml water provided then further dilute with 2ml sodium chloride injection. This gives 200mg in 5ml which is 40mg/ml. Then inject 1ml in each 2 litre exchange.
    • Once reconstituted – vial stable for 24hr. In the event that only 400mg vials of teicoplanin are available: reconstitute as above but only inject 0.5ml into each 2 litre exchange.
  3. Use of Intra-Peritoneal Aztreonam
    • Aztreonam has gram negative organism cover and should be used in place of ceftazidime where there is a documented ceftazidime allergy or when the patient has a history of a previous c.difficle infection.
    • Aztreonam Dosing Regimen:
      • Day 0 – 21 Administer 2g daily intraperitoneally in a minimum 6 hour dwell
  4. Use of Intra-Peritoneal Gentamicin
    • Gentamicin should only be used in conjunction with advice from senior medical and microbiology staff. 
    • Gentamicin Dosing Regimen:
      • Intermittent – (in 2 litre exchange with a dwell time of at least 6 hours) Dosage – One exchange a day – 0.6 mg/kg body weight for 14 days Dosage monitoring – to avoid toxicity serum gentamicin levels should be monitored at 24 hours and 48 hours along with effluent WCC and culture. Further dose may be required if level is < 2, the result should be interpreted in the light of the time period between dose and blood level.

(Contamination of PD system – prophylactic antibiotics (Vancomycin 1g + Ceftazidime 1.5g IP or Teicoplanin if allergic to vancomycin or Aztreonam if allergic to penicillin) should be administered after wet contamination of the PD system to prevent peritonitis.)

Links

Content Updated by Dr Elaine Rutherford & Dr Thalakunte Muniraju. Adapted with permission from NHS GGC Guidelines 2018.