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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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