DISEASEOF THE MONTH

J Am Soc Nephrol 9: 1956-1964. 1998

Peritonitis as a Complication of Peritoneal Dialysis
BETH PIRAINO
Renal Electrolyte Division, Department of M edicine, University of Pittsburgh School of M edicine, Pittsburgh,
Pennsylvania.
Peritonitis continues to be a serious complication for patients
on peritoneal dialysis (PD). Peritonitis is one of the major
causes of hospitalization, accounting for 23% of admissions in
the CANUSA study (1). Peritonitis is the leading cause of
technique failure and catheter loss (2,3). Patients with frequent
peritonitis are at increased risk of dying, independent of other
factors (4). Although the rates of peritonitis have decreased
dramatically from the inception of CAPD, rates above 0.5
episodes per year still commonly occur. The success of this
dialysis technique is closely tied to the ability of the dialysis
team to reduce the risk of peritonitis, and when it occurs,
manage the patient appropriately.
Clinical Presentation
The usual presentation of peritonitis is abdominal pain,
cloudy effluent or, most often, both. The pain can range from
extremely severe to nonexistent. In the inexperienced patient,
the absence of pain may lead him/her to ignore the cloudy
effluent initially, leading to a delay in presentation and subse-
quent treatment. All patients must be instructed to call imme-
diately if the effluent is even slightly cloudy. Peritonitis is
present if the white blood cell (W BC) count in the effluent is
b00/p.b or greater, with at least 50% polymorphonuclear cells.
If the specimen is collected from a short cycle, an aspirate from
a drained abdomen, or obtained from a patient already on
antibiotics, the percentage of polymorphonuclear cells (i.e.,
more than 50% ) is a more reliable marker for peritonitis than
the absolute number of W BC.
Occasionally, blood-tinged effluent will be confused with
cloudiness, but trained personnel can readily detect the differ-
enee. Other causes of cloudy effluent include chylous ascites,
which have a milky appearance, intra-abdominal malignancy,
diagnosed by cell cytology, and pancreatitis, which can be
differentiated by an effluent amylase level of >50 UIL. Also
included in the differential diagnosis is eosinophilie peritonitis,
which is rarely associated with unusual fungi, but more often is
idiopathic; recent reports suggest that treatment with steroids is
effective in reducing the cellularity.
In up to 6% of the episodes of peritonitis, the patient pre-
sents with abdominal pain but has clear effluent (5). Koopmans
et a!. reported 60 such episodes of peritonitis, all with positive
Correspondence to Dr. Beth Piraino. Professor of M edicine. A9152 Scaife
Hall, 3550 Terrace Street. Pittsburgh. PA 15261.
1046-6673/09010- 1956$03.O0/O
Journal of the American Society of Nephrology
Copyright U 1998 by the American Society of Nephrology
cultures, that had initial effluent W BC count less than 100/pA.
In 40 episodes (67% ) the inflammatory response was delayed,
in 16 episodes (27% ) the effluent cell count eventually reached
30 to 100 W BC/pi, and in four episodes (7% ) the cell count
never exceeded 30 W BC/pi. The Gram stain was positive in
70% of these cases. The organism was more likely to be
Staphylococcus aureus compared to episodes of peritonitis
with a normal inflammatory response. Half of the patients with
the impaired cell reaction to peritonitis had more than one such
episode, and in the absence of peritonitis had bower peritoneab
macrophage cell count than a group of control patients. In view
of this study, all patients on PD presenting with abdominal pain
should be considered to have peritonitis until proven otherwise.
Etiologies of Peritonitis
The most common microorganisms responsible for perito-
nitis are listed in Table 1 (6,7). M any studies on peritonitis will
list the different organisms as a percentage of the total. This
makes it difficult to compare the results of one study to
another, if the overall rates are dissimilar. For example, in the
two studies shown in the table, the percentages of peritonitis
episodes due to Staphylococcus aureus are 23 and 12% , re-
spectively, yet the actual difference in rates is only 0.04 epi-
sodes per year. It is striking that the rates of coagulase-negative
Staphylococcus are almost identical in the two studies. This
remains the most frequent microorganism responsible for peri-
tonitis in many centers.
The leading cause of peritonitis continues to be contamina-
tion at the time of the PD exchange. Peritonitis due to skin
organisms such as coagulase-negative Staphylococcus,
Corynebacterium, Bacillus species, and Branhamella ca-
tarrhalis are generally believed to be due to contamination.
However, PD patients may also have on their (unwashed)
fingers Streptococcus viridans, Staphylococcus aureus, micro-
coccus, Proteus species, Kiebsiella pneumoniae, Enterobacter
species, Escherichia coli, and Acinetobacter species (8). If the
patient is questioned closely about contamination, the source
may become obvious. For example, a patient from our center
had frequent bouts of peritonitis related to contamination; an
episode due to Streptococcus viridans occurred after perfor-
manee of an exchange while his granddaughter was in the room
without a mask. A second episode of peritonitis followed an
exchange in which the patient overheated his bag, which was
then cooled by running under cold water. M iller and Findon
performed an elegant study examining the level of bacterial
contamination associated with touching the connector during
an exchange (8). Touching the connection after hand washing
I Am Soc Nephrol 9: 1956-1964. 1998 Peritonitis as a Complication of Peritoneal Dialysis 1957
Figure 1. Protocols to prevent Staphylococcus aureus peritonitis.
Table 1. Common microorganisms causing peritonitis
. .
Microorganism
Holley
et a/. (6)
Van Biesen
et c i/. (7)
Coagulase-negative Staphylococcus 0. 17 0.18
Staphylococcus aureus 0.13 0.09
Streptococcus 0.04 0.06
Other Gram-positive <0.01 0.02
Gram-negative 0.09
0#{149}16b
Polymierobial 0.01
Fungal <0.01
Culture-negative 0. 1 1 0.20
Total rate 0.56c 0.73
a Rates provided as episodes per year at risk.
b Pseudomonas accounted for 0.06.
C Rates do not add to total due to rounding.
using ehlorhexidine followed by thorough drying reduced the
numbers of bacteria reaching the peritoneal cavity to <5. In
contrast, absence of hand washing resulted in considerably
higher numbers of organisms on the connection, and wet hands
resulted in the transport of up to 4500 organisms. Proper
training of the patient in aseptic technique is obviously critical
in reducing peritonitis from contamination.
Fifteen to 20% of peritonitis episodes are due to catheter
infections, with Staphylococcus aureus and Pseudomonas
aeruginosa accounting for the great majority (9). Patients at
greatest risk for Staphylococcus aureus catheter-related peri-
tonitis are those who are Staphylococcus aureus carriers
(10,1 1). Approximately one-half of PD patients are Staphylo-
coccus aureus nasal carriers ( 1 1 , 1 2). Staphylococcus aureus in
the nose is transmitted to the hands; Boelaert et al. found that
75% of dialysis patients with Staphylococcus aureus in their
nares had Staphylococcus aureus on their hands, in contrast to
. Reference 15: daily exit site
mupirocin
1 0% of dialysis patients without nasal carriage ( 1 3). From the
hands, the Staphylococcus aureus is quickly transmitted to the
catheter exit site and/or to the connection port at the time of an
exchange. This risk factor is important to recognize, because
the risk of Staphylococcus aureus peritonitis can be consider-
ably reduced by prophybaxis for Staphylococcus aureus ear-
riage (14,15) (Figure 1). Several different approaches have
been identified (15-18). Either at the time the catheter is placed
or, ideally, before placement, the nose should be cultured, and,
if positive, the patient should be treated with intranasal mupi-
rocin. Once training begins, mupirocin can be used at the exit
site as part of routine care, or the intranasal course can be
repeated monthly. Patients who have three negative nose cub-
tures are at very low risk for infection and do not require
prophylaxis, unless immunosuppressed (12,19).
Peritonitis due to Gram-negative bacilli may be the result of
contamination, catheter infection, or may come from the
bowel. Treatment of constipation with enemas, diarrhea, and
gastric acid inhibitors may predispose to enterie peritonitis
(20-22). Although frank bowel perforation is distinctly un-
common (23), Harwell et al. reported that enterie peritonitis
was associ? ed with underlying intra-abdominal pathology
such as eholeeystitis, isehemic colitis, and appendicitis in one-
third of patients (24). Because few of these episodes resolved
with antibiotic therapy alone (Figure 2), early recognition
followed by laparotomy is critical to decrease the risk of death.
latrogenie peritonitis could be classified under bacteremia,
enteric, or gynecologie categories, but is listed separately to
emphasize this unusual but important (potentially preventable)
cause of peritonitis. It is well recognized that peritonitis may
follow cobonoseopy with polypeetomy, endoscopy with sele-
rotherapy, and dental procedures (24-26). Vaginal leak of
dialysate, the use of intrauterine devices, endometrial biopsy,
and hysteroseopy with polypeetomy have all been associated
U no prophylaxis o prophylaxis
S aureus peritonitis, episodes/y
0 Reference 16: rifampin 600 mg qd
for 5 days every 12 weeks
0 Reference 17: intranasal
mupirocin bid for 5 days every
month in nasal carriers
. Reference 18: intranasal
mupirocin tid for 7 days for each
positive nose culture
RefiS Refl6 Ref 17
*p < 0.001, no prophylaxis versus prophylaxis
Ref 18
1958 Journal of the American Society of Nephrology J Am Soc Nephrol 9: 1956-1964. 1998
% of episodes
resolved recurred catheter lost died
I peritonitis with intra-abdominal disease 0 all other episodes
From reference 24
Figure 2. Outcome of peritonitis related to intra-abdominal catastrophe.
with peritonitis (26-28). Antibiotic prophylaxis prior to any
procedure associated with the risk of peritonitis is warranted.
Risk Factors for Peritonitis
M odifiable risk factors for peritonitis are listed in Table 2. In
addition, certain patient populations are at higher risk for
coagubase-negative peritonitis, including African-American
and native American patients (3,29,30). This risk can be mm-
imized by using a disconnect system. Also at increased risk for
peritonitis are immunosuppressed patients ( 1 9). Andrews et al.
reported that those receiving immunosuppressive therapy in the
past I 2 months or with a disease predisposing to infection,
such as HIV, had a peritonitis rate of 1 .8 episodes per patient
year compared with a rate of 0.68 episodes per patient year in
other patients (19). The risk of Staphylococcus aureus and
fungal peritonitis was especially high.
Evaluation
Upon presentation, a rapid assessment of the patient should
include questions on breaks in technique, recent procedures
that may have led to peritonitis, change in bowel habits, prior
Table 2. Factors associated with decreased risk of peritonitis
Prophylactic antibiotics at time of catheter placement
2-cuffed catheter (versus one-cuff catheter)
Downward pointing tunnel
Twin bag connection system
Treatment of Staphylococcus aureus carriage
peritonitis, and catheter infection history. The exit site and
tunnel should be closely examined for evidence of infection. In
addition, the patients abdomen should be drained, and the
effluent sent for cell count with differential, Gram stain, and
culture. The cell count with differential will confirm the pres-
ence of peritonitis. Centrifuging 10 ml of effluent results in a
positive Gram stain of the infected sediment in 93% of epi-
sodes (3 1 ). The culture should be obtained by placing 5 ml in
each of two tryptie soy broth blood culture bottles (aerobic and
anaerobic); Lye et al. found that the rate of culture-negative
peritonitis was reduced from 42 to 25% by this technique (32).
In addition to inadequate culture techniques, culture-negative
peritonitis may also be due to the presence of antibiotics, so the
patient should be questioned closely about recent antibiotic use
(33). In one-third of culture-negative peritonitis episodes, re-
culturing will result in identification of an organism (34).
A decision must be made about whether to hospitalize the
patient. This will depend on the severity of the peritonitis, and
the need for intravenous analgesia and fluids. Because the
disconnect systems have primarily diminished peritonitis due
to less virulent organisms such as coagulase-negative Staphy-
lococcus, as opposed to Gram-negative and Staphylococcus
aureus, a high proportion of the patients will require admission
(23).
Initial Treatment
Often, the clinician does not know the causative organism
when antibiotic therapy is ordered. Therefore, the initial ther-
apy should be active against the most commonly offending
organisms, including Staphylococcus (both coagulase-negative
J Am Soc Nephrol 9: 1956-1964. 1998 Peritonitis as a Complication of Peritoneal Dialysis 1959
I Increase dosing frequency based on serum and/or dialysate levels.
and -positive), Streptococcus, and Gram-negative bacilli. In the
absence of clinical data suggestive of bowel perforation, an-
aerobic coverage is generally not given initially. Coverage for
fungus should be implemented immediately only if the Gram
stain is positive for yeast.
The Ad Hoc treatment guidelines of 1996 recommended
using a first-generation cephalosporin, in combination with
gentamicin for the initial therapy (35) (Table 3). This change
from the prior recommendation for vancomyein in conjunction
with Gram-negative coverage was due to the increasing mci-
denee of vaneomycin-resistant enterocoecus and the fear that
this resistance will be transferred to staphylococci, leaving us
with no drugs to treat these infections. Indeed, peritonitis due
to vancomycin-resistant Staphylococcus has been reported
(36).
Lai et al. reported on the results of once daily intraperitoneal
cefazolin and gentamicin, with subsequent modification of
therapy as needed, for treatment of peritonitis (37). It is im-
portant to note that episodes of peritonitis related to catheter
infection were excluded from this study. All I 9 episodes of
Gram-positive peritonitis resolved. Three episodes of Staphv-
lococcus epidermidis were resistant in vitro to both gentamicin
and cephabosporin, yet responded in vivo to these antibiotics,
presumably due to the high local concentration in one ex-
change each day. These data, therefore, support the Ad Hoe
Committee s recommendations.
Unfortunately, data from other dialysis programs suggest
that use of a first-generation cephabosporin for initial therapy
may result in a considerable number of untreated or made-
quately treated patients. Vas et al. reported that cefazolin (1.5
g intraperitoneally once daily for 3 wk) resulted in resolution of
only 45% of episodes of peritonitis due to methicillin-resistant
coagulase-negative Staphylococci (38). This was in contrast to
a 73% response during the historical period for which vanco-
mycin (2 g intraperitonealby once weekly for three doses) was
used. The proportion of Staphylococci with methicillin resis-
tance is reported to range from 33 to 67% (7,39). W e have
found an increase in methicillin-resistant eoagulase-negative
Staphylococci in our program, as shown in Figure 3. Using the
Ad Hoc 1996 recommendations for initial therapy, Van Biesen
noted that only 76.5% patients with Gram-positive infections
and 8 1 % of patients with Gram-negative infections would have
Table 3. Ad Hoc 1996 guidelines for initial therapy (35)
been effectively treated, based on sensitivities (7). These au-
thors propose an alternative approach, shown in Table 4, which
would provide I 00% coverage of Gram-positive organisms and
87.5% coverage of Gram-negative organisms.
W ithin 2 to 3 d, the organism is usually identified and
sensitivities are available. Subsequent therapy is chosen to
provide narrow coverage with the least toxicity. Dosing sched-
ules for some commonly used antibiotics are given in Table 5.
Guidelines by organism are provided below. If the culture is
negative, generally the aminoglycoside is stopped and a single
drug such as a first-generation cephabosporin or vaneomycin is
continued alone.
Coagulase-Negative Staphylococcus Peritonitis
These patients often do not require hospitalization, because
the pain is less severe than that due to other organisms (23).
Cefazolin or cephalothin should be changed to vaneomyein if
the organism is methicillin-resistant (38). Although vaneomy-
cm is often given weekly, this may lead to underdosing in
many patients, especially those with residual renal function.
Low trough levels in the dialysate increases the risk of relaps-
ing peritonitis (40). W e prefer the use of 30 mg/kg vaneomycin
intraperitoneally (maximum of 2 g) in the initial exchange,
which is allowed to dwell for a minimum of 6 h, with one-half
of this dose repeated in 4 to 5 d. Before the second dose, a
blood level is measured, which in outpatients is not back before
redosing, but the value guides the timing of the third dose,
usually about 5 d later. These three doses then provide antibi-
otie coverage for a minimum of 2 wk.
Staphylococcus Aureus Peritonitis
Patients with Staphylococcus aureus peritonitis often have
severe abdominal pain and generally require hospitalization. If
Staphylococcus aureus exit site or tunnel infection is present,
the catheter should be removed without delay (9). If there is no
clinically obvious tunnel infection, an ultrasound of the tunnel
to confirm the absence of involvement is helpful, as catheter
infections may be occult (41 ). Peritonitis associated with a
catheter infection will prove to be either refractory or relapsing
(9,42). The course can be deceptive because the episode may
appear to resolve with clearing of the effluent, yet the effluent
culture remains positive with recrudescence of full-blown peri-
Treatment Protocol Urine Output <500 mb/d
Ur Ou t
In the first exchange
cefazolin or eephalothin 500 mg/L, or 15 mg/kg 25% increase
gentamicin 0.6 mg/kg I .5 mg/kg
Subsequent therapy
cefazolin or cephalothin 125 mg/L. each exchange, or 500 mg/L,
one exehange/d
25% increase
gentamicin 0.6 mg/kg, one exehange/d 0.6 mg&ga
80-Sl 82-83 84-85 86-87 88-89 90-91 92-93 94-95
year
1960 Journal of the American Society of Nephrology J Am Soc Nephrol 9: 1956-1964. 1998
Coagulase negative staphylococcus
peritonitis, episodes I year
0.5
0.4
0.3
0.2
0.1
0
Figure 3. Rates of coagulase-negative Staphylococcus peritonitis over time.
Table 4. Empiric treatment of peritonitis, Van Biesen
approach (7)a
Initial therapy
vancomyein 15 mg/kg single dose IP
gentamicin 1 .5 mg/kg for urine output >500 mb/d,
0.5 mg/kg for urine output <500
ml/d
After 24 hours
outpatient ciprofloxacin 500 mg twice a day
inpatient eeftazidime 250 mg IP/exehange, and
ciprofloxacin 50 mg/exchange
IP, intraperitoneally.
tonitis once the antibiotics are stopped (42). If the exit site and
tunnel are normal, then the presumption is that the episode is
due to touch contamination (usually in a patient who is a
Staph locoecus aureus nasal carrier), and antibiotic treatment
is often successful. The aminoglycoside is discontinued. If the
organism is methieiblin-sensitive, then methicilbin or a cepha-
losporin may be used, and if methicillin-resistant, vaneomycin
or clindamycin is prescribed. Rifampin, 600 mg/d, may be
added.
Streptococcus Peritonitis
The source for peritonitis due to Streptococcus species (non-
enterococcus) may be the respiratory tract (either transient
bacteremia or absence of a mask during an exchange), the skin
(touch contamination), or the bowel (43). Consistent with this,
the incidence of Streptopcoccus viridans has decreased with
use of the disconnect systems. Streptococcus (especially group
A and group B) causes severe peritonitis and may quickly
Table 5. Intraperitoneal antibiotic dosages for adults (35)
Drug Intraperitoneal Dose
Ampicillin 1 25 mgIL continuously
Ampieillin/sulbaetam I g/L load, then 100 mg/L
continuously
Cefazolin and cephalothin 500 mg/L load, then I 25 mgfL
continuously
Ceftazidime 1000 mg/exchange, once daily
Gentamicin and tobramycin 0.6 mg/kg, once daily
Impipenem/cilistat 500 mg/L load. then 200 mg/L
continuously
Vaneomycin 1 5 to 30 mg/kg every 5 to 7 d
result in death. Therefore, treatment must be implemented
rapidly. Ampicillin appears to be more effective than vaneo-
mycin (43).
Enterococeal peritonitis is severe, responds slowly to anti-
bioties, and carries an increased risk of death (23,43). In the
Network 9 Peritonitis Study. peritonitis due to enterococcus
resulted in death in 7.4% of the episodes (23). Peritonitis due
to enterococeus, compared with Streptococcus viridans perito-
nitis, occurs in older patients and is likely spread from the
bowel. The incidence has not fallen with the use of disconnect
systems. Fortunately, vancomycin-resistant enterococeal
(VRE) peritonitis, with a reported mortality rate of 55% , is still
rare (44). VRE peritonitis is associated with prior use of both
cephalosporins and vaneomycin, as well as hospitalization.
Treatment is problematic. Troidle et al. used ehloramphenieol,
mostly unsuccessfully (44). W e have had one ease of VRE
peritonitis at the University of Pittsburgh, in a patient with a
failed renal transplant given three weekly doses of vancomycin
J Am Soc Nephrol 9: 1956-1964, 1998 Peritonitis as a Complication of Peritoneal Dialysis 1961
for culture-negative peritonitis; she did well with prompt cath-
eter removal and institution of quinupristin/dalfopristin, an
experimental drug. Stool carriage of VRE is still uncommon in
PD patients, perhaps because PD is a home dialysis modality
(39).
Gram-Negative Peritonitis
Once the organism is identified and sensitivities are known,
the antibiotic therapy is adjusted to minimize use of amino-
glycosides as much as possible, in view of the risk of vestibular
toxicity. Alternatives to aminoglyeosides, such as ceftazidime
and quinolones, should be used whenever possible. An alter-
native approach has been to use a low dose of aminoglyeoside
in one exchange per day, which provides high local levels
during the period of the dwell, yet very low systemic levels.
Lai et al. treated 14 Gram-negative peritonitis episodes with
gentamicin, 20 mg/L in one exchange per day intraperitoneally,
combined with 500 mgfL in the same exchange of cefazolin
(37). For the eight non-Pseudornonas Gram-negative organ-
isms, only two infections due to Acinetobacter species required
alteration in therapy, and all resolved. Baibie et al. used 0.6
mg/kg in one exchange of gentamicin (in combination with an
initial dose of vancomycin) with resolution of two-thirds of the
episodes of non-Pseudomonas Gram-negative peritonitis (45).
The nonresponders included Acinetobacter and Alcaligenes
species. Acinetobacter peritonitis is difficult to treat, and two
antibiotics should be used to treat this organism.
Pseudomonas aeroginosa peritonitis is frequently associated
with a tunnel infection, which may be occult. Should the
effluent culture reveal a Pseudoinonas infection, the subeuta-
neous tunnel should be examined carefully, and if it appears
normal, ultrasonography should be performed to further assess
possible tunnel involvement. If the tunnel is involved, the
catheter should be promptly removed, as resolution with anti-
biotic therapy is highly unlikely (9). If there is no tunnel
infection, Pseudomonas aeroginosa will usually resolve with
aminoglycoside therapy (generally given as 5 to 8 mg/L in each
exchange) and the addition of a second agent active against
Pseudomonas. Of note, in a recent article from Belgium, 7% of
patients with peritonitis died (3 of 42) from sepsis; two of these
patients had Pseudornonas peritonitis (7).
In view of the results of a recent article by Harwell et al. , in
every case of peritonitis due to enterie organisms, intra-abdom-
inal pathology underlying the infection should be considered
(24). This can be evaluated with a computed tomography scan
of the abdomen. Early surgical consultation should be consid-
ered, as prompt laparotomy may decrease the risk of death.
Polymicrobial Peritonitis and Intra-Abdominal
Abscesses
Approximately 6% of all episodes of peritonitis will have
multiple organisms (46). If only Gram-positive organisms are
present, the patient generally does well, with resolution of the
infection with antibiotic therapy in the absence of catheter
infection. However, if multiple enteric organisms grow from
the culture, intra-abdominal pathology must be considered,
which requires surgical exploration. This is especially true if an
anaerobe grows in culture. M etronidazole, 500 mg intrave-
nously every 8 h, should be added to the other antibiotics.
Intra-abdominal abscesses occur in < 1 % of peritonitis epi-
sodes. These are more common with Pseudotnonas aerugi-
nosa, Candida albicans, and polymierobial peritonitis, and
require drainage. Computed tomography scan of the abdomen
is useful to evaluate the patient.
Fungal Peritonitis
Fungal peritonitis accounts for 3% of all episodes (47).
Usually the patient has severe abdominal pain, and the effluent
W BC count is high. Gram stain is often helpful in establishing
the diagnosis early. Candida is by far the most common
organism. Risk factors include frequent peritonitis. immuno-
suppression, and antibiotic therapy. At our institution, the
catheter is removed as soon as the diagnosis is established. In
an uncontrolled trial, Goldie et al. found that 1 5% of patients
in whom the catheter was removed within 1 wk of diagnosis
died, in contrast to 50% when the catheter was left in place
(47). Therapy with fluconazole (200 mg orally each day),
flucytosine (I g orally each day), and, if necessary, amphoter-
iein, should be continued after catheter removal for at least an
additional 10 d. The catheter can be reinserted, but a waiting
period of 1 to 2 mo is advisable. Approximately 10% of
patients will have peritoneal fibrosis making PD no longer an
option.
Peritonitis due to M ycobacterium
Tubereubous peritonitis occurs more frequently in Asia than
in W estern countries, but may become more common in view
of the current epidemic of myeobaeteria infections. As with
other microorganisms, the effluent W BC are predominately
polymorphonuelear cells. Because the effluent acid-fast bacil-
lus stain is generally negative and there is usually no tubercu-
bus disease elsewhere, the diagnosis may be difficult (48).
Ultrafiltration failure may occur but is not inevitable. Therapy
should consist of three drugs (isoniazid, rifampicin, and pyra-
zinamide) for 9 to 1 2 mo. Reportedly, the catheter does not
always require removal (48).
Refractory and Relapsing Peritonitis
Refractory peritonitis is defined as an episode in which there
is no improvement 5 d after appropriate antibiotic therapy is
initiated. There may be apparent resolution of the episode with
antibiotic therapy, but a cell count will often show persistence
of an abnormal inflammatory response. Recurrent or relapsing
peritonitis is defined as a second episode of peritonitis with the
same organism as the first within 2 wk of stopping antibiotics.
Refractory and relapsing peritonitis may be due to a catheter
infection, which may not be clinically apparent. In every ease
of relapsing and refractory peritonitis, the catheter subeutane-
ous tunnel should be examined clinically, and, if it appears
normal, an ultrasonographie examination should be performed.
Recurrent peritonitis, in the absence of a tunnel infection,
may be due to sequestration of bacteria (most often coagulase-
negative Staphylococcus) in the biofilm surrounding the intra-
1962 Journal of the American Society of Nephrology J Am Soc Nephrol 9: 1956-1964. 1998
I Exception is if organism is coagulase-negative Staphv/ococcus.
abdominal portion of the catheter. Inadequate treatment of
peritonitis predisposes to this complication. There are two
options: fibrinobytic therapy or catheter replacement. Uroki-
nase, 5000 U in 5 ml of normal saline injected into the catheter
with the abdomen drained and allowed to dwell for 2 h, is
successful in 29 to 67% of patients with recurrent peritonitis
(49,50). This procedure has been primarily used on patients
with recurrent coagulase-negative Stapkvlococcus peritonitis,
and should be reserved for those recurrent episodes of perito-
nitis for which tunnel infection has been excluded as a cause by
careful examination using ultrasonography. Alternatively, if
the peritoneal cell count can be suppressed to less than 100
W BC/pi. then the catheter can be safely replaced at one
setting. allowing the avoidance of hemodialysis in many pa-
tients (50,5 1 ). One of the most common problems in managing
peritonitis is delay in removing the catheter in episodes that are
not responding or that are likely to result in relapsing perito-
nitis. Table 6 lists examples in which catheter removal is often
necessary.
Prevention of Peritonitis
Prevention of peritonitis is a key component of a successful
PD program, and is based on collaboration between patient, the
nurses, and the physician. Decreasing risk from contamination
is highly dependent on both patient selection and training
techniques. The nurses should reinforce the concepts of steril-
ity and compulsiveness in performing the exchange, even after
the initial training is completed. The best connection technol-
ogy, the twin bag system. should be chosen for continuous
ambulatory PD patients, and for cycler patients who must do
multiple spikes, use of the Compact Assist Device (Baxter
Healthcare Corp., Deerfield, IL) is helpful in reducing the risk
of infection. Each program must monitor and periodically
review cases of peritonitis to identify problem areas. Patients
with high peritonitis rates should be encouraged to transfer
permanently to hemodialysis.
The risk of Staphylococcus aureus peritonitis and catheter
infections can be reduced by monitoring and treating for nasal
carriage (Figure 1 ). W e found that prophylaxis with mupirocin
at the exit site resulted in a reduction in Staphylococcus aureus
exit site infections and related peritonitis episodes (16). These
results have been recently confirmed by Thodis et a!. (52). This
protocol is well accepted by the patients, who use a Q-tip to
place a thin smear of mupiroein around the catheter exit site
after bathing. One tube lasts for approximately 2 mo. This
method should not be used with polyurethane catheters, which
Table 6. Episodes of peritonitis for which catheter removal
is appropriate
Peritonitis associated with same organism causing exit site
or tunnel infection
Fungal peritonitis
Relapsing or refractory peritonitis
Peritonitis associated with intra-abdominab pathology
may be damaged. Alternative approaches are intranasal mupi-
rocin for Staphylococcus aureus nasal carriage. In the multi-
center European trial, this reduced Staphylococcus aureus
catheter infections but not peritonitis (I 7). Perez-Fontan et al.
found a reduction in both Stapk lococcus aureus catheter in-
fections and peritonitis with a course of intranasal mupirocin
for each positive nose culture (18). Rifampin has also been
shown to reduce both Staphylococcus aureus catheter infee-
tions and peritonitis rates, but is associated with side effects in
12% ofpatients (14-16).
Prophylaxis with nystatin, given to the patient taking anti-
biotics, successfully reduces the risk of andida peritonitis
(53). Additional studies will be needed to identify those pa-
tients who would benefit most from such prophylaxis. This
may prove to be patients at high risk for fungal peritonitis,
including those with frequent bacterial peritonitis. on pro-
longed courses of antibiotics or with impaired immune sys-
tems.
Procedure-related causes of peritonitis may be decreased by
asking the patient to inform the dialysis center before extensive
dental work, cobonoseopy, and endometrial biopsies. W e be-
lieve that antibiotic prophylaxis should be given for all such
procedures. In addition, the abdomen should be drained prior to
pelvic and colonie procedures. Aggressive treatment of consti-
pation may result in enterie peritonitis; therefore, every effort
should be made to prevent constipation in the PD patient.
In conclusion, peritonitis remains one of the most serious
problems facing the PD patient and PD health care worker.
Reducing rates of peritonitis can be achieved by careful patient
selection and training, use of the best connection technology,
and screening for and treating nasal carriage. Once peritonitis
occurs, the treatment should be prompt. There should be no
hesitation to remove the catheter if this appears to be appro-
priate.
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