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Therapeutic Discussion – Peritonitis
Basic Pathophysiology
Severe & prolonged peritonitis can lead to peritoneal membrane failure ( catheter removal, permanent transfer to HD & 1090 on day 3 = independent prognostic marker for treatment failure
Recurrent, relapsing, repeat peritonitis = worse outcome
Exit-site & Tunnel Infections – purulent drainage from exit site indicates presence of infection; erythema may or may not represent infection
- most serious & common pathogens = S. aureus & Pseudomonas aeruginosa
- IP abx as effective as PO abx
- Empiric therapy should always cover S. aureus and P. aeruginosa if hx of exit-site infection
- Clindamycin, doxycycline, minocycline are sometimes useful or tx of CA-MRSA
|CC. HPI, |What are the symptoms of peritonitis? |
|Subjective |Cloudy effluent & abdominal pain (pain lesss w/ CoNS & greater w/ streptococcus, GN rods, S. aureus) |
|findings |Generalized abdominal tenderness with rebound |
| |↓ pain with CoNS (i.e. S. epidermidis) |
| |↑ pain with streptococcus, enterococcus, S. aureus |
|PMHx |What are the risk factors for peritonitis? |
| |Constipation/diarrhea |
|Social Hx |What are lifestyle risk factors for peritonitis? |
| |Break in aseptic technique; contamination or disconnection |
|Objective |How do we diagnose peritonitis? |
| |Cloudy effluent; effluent cell count, differential and culture |
| |Vitals |Vitals: ↑ temp; ↓ BP; ↑ HR ( or normal |
| |Physical Exam |CNS: confusion |
| | |HEENT: / |
| | |CVS: / |
| | |Resp: / |
| | |GI: guarding; general diffuse pain; |
| |Investigations |Lab |↑ WBC, ↑ neuts |
| | |Micro |Effluent: WBC > 100 after a dwell of > 2 hrs; 50% polymorphonuclear neutrophilic cells |
| | | |Gram stain to check for yeast |
Goals of therapy
Eradicate bacteria
Rapid resolution of inflammation and preservation of peritoneal membrane function
Treatment alternatives and duration
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Peritonitis
Non-pharm ( no evidence for rapid exchanges as it delays initiation of abx therapy
Initiate antibiotics as soon as cloudy effluent seen and CBC sent off
Addition of heparin (500 U/L) to dialysate to prevent occlusion of catheter by fibrin
If yeast – catheter removal
Empiric abx must cover both GP-bacteria & GN-bacteria
- IP > IV dosing
- Repeated/prolonged (> 2 wks) courses of AMG therapy are probably not advisable if alternatives possible
- Genatmicin given in OD (40 mg IP in 2L) [intermittent dosing] as effective as dosing in each exchange (10 mg/2L IP, in 4 exchanges/day) [continuous dosing]
- Cefazolin has not been compared in terms of intermittent and continuous dosing; success rates have been similar in many different trials
** vancomycin, AMG, cephalosporins can be mixed in the same dialysis solution bag w/o loss of bioactivity
** AMG cannot be added to same exchange with penicillins ( chemically incompatible
Refractory Peritonitis
Removal of catheter to protect peritoneal membrane for future use
Polymicrobial Peritonitis
Multiple enteric organisms (esp. anaerobes) – risk of death increased & surgical evaluation needed
May be an intra-abdominal pathology – diverticulitis, cholecystitis, ischemic bowel, appendicitis, etc.
Fungal Peritonitis
Should be strongly suspected after recent abx treatment for bacterial peritonitis
Catheter removal indicated immediately after fungi are identified
- RCT looked at prophylactic fluconazole ( decreased rates of developing fungal peritonitis
- At IH patients will be put on prophylaxis if they are going to be put on long-term abx or have a hx of fungal peritonitis and will be receiving abx
Monitoring Parameters: Efficacy and toxicity
Efficacy
Improvements in symptoms/effluent within 48 hrs
Extended course AMG (> 2 weeks) - ↑ risk of vestibular and ototoxicity (short-term = safe)
Monitoring of drug levels for AMG and vanco recommended if drug toxicity suspected
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Minimum treatment duration = 2 weeks, but will likely require 3 weeks
> 3 wk treatment ( consider catheter replacement
Consider earlier replacement if infection with P. aeruginosa
Strep/Enterococci = Ampicillin IP +/- AMG (for enterococci)
Pseudomonas = 2 abx and treat for 3 weeks or > 2 wks if catheter removed
- Repeat cell count & culture at days 3-5
Imipenem has also been studies – 1 g BID
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