ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment

Peritoneal dialysis (PD)-associated peritonitis is a serious complication of PD and prevention and treatment of such is important in reducing patient morbidity and mortality. The ISPD 2022 updated recommendations have revised and clarified definitions for refractory peritonitis, relapsing peritonitis, peritonitis-associated catheter removal, PD-associated haemodialysis transfer, peritonitis-associated death and peritonitis-associated hospitalisation. New peritonitis categories and outcomes including pre-PD peritonitis, enteric peritonitis, catheter-related peritonitis and medical cure are defined. The new targets recommended for overall peritonitis rate should be no more than 0.40 episodes per year at risk and the percentage of patients free of peritonitis per unit time should be targeted at >80% per year. Revised recommendations regarding management of contamination of PD systems, antibiotic prophylaxis for invasive procedures and PD training and reassessment are included. New recommendations regarding management of modifiable peritonitis risk factors like domestic pets, hypokalaemia and histamine-2 receptor antagonists are highlighted. Updated recommendations regarding empirical antibiotic selection and dosage of antibiotics and also treatment of peritonitis due to specific microorganisms are made with new recommendation regarding adjunctive oral N-acetylcysteine therapy for mitigating aminoglycoside ototoxicity. Areas for future research in prevention and treatment of PD-related peritonitis are suggested.

The Impact of Peritonitis on Peritoneal and Systemic Acid-Base Status of Patients on Continuous Ambulatory Peritoneal Dialysis

Objective

To assess the possible effects of peritonitis on peritoneal and systemic acid-base status.

Design

pH, pCO2, lactate, and total leukocyte and differential count were simultaneously determined in the overnight dwell peritoneal dialysis effluent (PDE) and arterial blood in noninfected patients (controls) and on days 1, 3, and 5 from the onset of peritonitis.

Setting

University multidisciplinary dialysis program.

Patients

Prospective analysis of 63 peritonitis episodes occurring in 30 adult CAPD patients in a single center.

Results

In controls, mean (±SD) acid-base parameters were pH 7.41 ±0.05, pCO2 43.5±2.6 mm Hg, lactate 2.5±1.5 mmol/L in the PDE, and pH 7.43±0.04, PaCO2 36.8±3.8 mm Hg, lactate 1.4±0.7 mmol/L in the blood. In sterile (n=6), gram-positive (n=34), and Staphylococcus aureus (n=9) peritonitis PDE pH's on day 1 were, respectively, 7. 29±0.07, 7. 32±0.07, and 7.30±0.08 (p<0.05 vs control). In gram -negative peritonitis (n=14) PDE pH was 7.21 ±0.08 (p<0.05 vs all other groups). A two-to-threefold increase in PDE lactate was observed in all peritonitis groups, but a rise in pCO2 was only seen in gram -negative peritonitis. Acid-base profile of PDE had returned to control values by day 3 in sterile, gram -positive and Staphylococcus aureus peritonitis and by day 5 in gramnegative peritonitis. Despite a slight increase in plasma lactate on the first day of peritonitis, arterial blood pH was not affected by peritonitis.

Conclusion

PDE pH is decreased in continuous ambulatory peritoneal dialysis (CAPD) peritonitis, even in the absence of bacterial growth. In gram-negative peritonitis, PDE acidosis is more pronounced and prolonged, and pCO2 is markedly increased. Arterial blood pH is not affected by peritonitis.

Randomized Controlled Trial on Adjunctive Lavage for Severe Peritonitis

Background:In severe peritoneal dialysis (PD)-related peritonitis, patients' response to antibiotic can be poor. We postulated that adjunctive lavage may improve the outcome in severe cases by enhancing the removal of bacteria and inflammatory cells from the peritoneum.Methods:Severe PD peritonitis was defined as poor clinical response to empirical cefazolin/ceftazidime and a PD effluent (PDE) leukocyte count > 1,090/mm³ on day 3. Enrolled patients were randomized into either the lavage group (n = 20) or control group (n = 20). In the lavage group, continuous lavage by an automated PD machine from day 3 to 5 or 6 was performed, whereas the usual PD schedule was maintained in the control group. The primary outcome was treatment success. Post hoc analysis was also performed to compare the outcome between subgroups with different severity.Results:Baseline parameters were similar in the lavage and control groups, including PDE leukocyte count on day 3 (4,871/mm³ vs 4,143/mm³, p = 0.46). Treatment success rates were high in both groups (75% vs 70%, p = 0.72). C-reactive protein (CRP) on day 3 was found to be the only predictor of treatment failure and was used to stratify all patients into tertiles of severity. Whilst a significant decline in treatment success was evident across the tertiles of increasing CRP in the control group (100% vs 85.7% vs 28.6%, p = 0.005), treatment success was relatively maintained in the lavage group (85.7% vs 71.4% vs 66.7%, p = 0.43).Conclusions:Adjunctive lavage did not improve the overall outcome, although it may be beneficial for the more severe peritonitis patients who have high CRP.

Treatment for peritoneal dialysis-associated peritonitis

BACKGROUND

Peritonitis is a common complication of peritoneal dialysis (PD) that is associated with significant morbidity including death, hospitalisation, and need to change from PD to haemodialysis. Treatment is aimed to reduce morbidity and recurrence. This is an update of a review first published in 2008.

OBJECTIVES

To evaluate the benefits and harms of treatments for PD-associated peritonitis.

SEARCH METHODS

For this review update we searched the Cochrane Renal Group's Specialised Register to March 2014 through contact with the Trials Search Co-ordinator using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE and EMBASE, and handsearching conference proceedings.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs assessing the treatment of peritonitis in PD patients (adults and children). We included any study that evaluated: administration of an antibiotic by different routes (e.g. oral, intraperitoneal (IP), intravenous (IV)); dose of an antibiotic agent; different schedules of administration of antimicrobial agents; comparisons of different regimens of antimicrobial agents; any other intervention including fibrinolytic agents, peritoneal lavage and early catheter removal.

DATA COLLECTION AND ANALYSIS

Multiple authors independently extracted data on study risk of bias and outcomes. Statistical analyses were performed using the random effects model. We expressed summarised treatment estimates as a risk ratio (RR) with 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) with 95% CI for continuous outcomes.

MAIN RESULTS

We identified 42 eligible studies in 2433 participants: antimicrobial agents (36 studies); urokinase (4 studies), peritoneal lavage (1 study), and IP immunoglobulin (1 study). We did not identify any optimal antibiotic agent or combination of agents. IP glycopeptides (vancomycin or teicoplanin) had uncertain effects on primary treatment response, relapse rates, and need for catheter removal compared to first generation cephalosporins, although glycopeptide regimens were more likely to achieve a complete cure (3 studies, 370 episodes: RR 1.66, 95% CI 1.01 to 2.72). For relapsing or persistent peritonitis, simultaneous catheter removal and replacement was better than urokinase at reducing treatment failure rates (RR 2.35, 95% CI 1.13 to 4.91) although evidence was limited to a single small study. Continuous and intermittent IP antibiotic dosing schedules had similar treatment failure and relapse rates. IP antibiotics were superior to IV antibiotics in reducing treatment failure in one small study (RR 3.52, 95% CI 1.26 to 9.81). Longer duration treatment (21 days of IV vancomycin and IP gentamicin) had uncertain effects on risk of treatment relapse compared with 10 days treatment (1 study, 49 patients: RR 1.56, 95% CI 0.60 to 3.95) although may have increased ototoxicity.In general, review conclusions were based on a small number of studies with few events in which risk of bias was generally high; interventions were heterogeneous, and outcome definitions were often inconsistent. There were no RCTs evaluating optimal timing of catheter removal and data for automated PD were absent.

AUTHORS' CONCLUSIONS

Many of the studies evaluating treatment of PD-related peritonitis are small, out-dated, of poor quality, and had inconsistent definitions and dosing regimens. IP administration of antibiotics was superior to IV administration for treating PD-associated peritonitis and glycopeptides appear optimal for complete cure of peritonitis, although evidence for this finding was assessed as low quality. PD catheter removal may be the best treatment for relapsing or persistent peritonitis.Evidence was insufficient to identify the optimal agent, route or duration of antibiotics to treat peritonitis. No specific antibiotic appears to have superior efficacy for preventing treatment failure or relapse of peritonitis, but evidence is limited to few trials. The role of routine peritoneal lavage or urokinase is uncertain.

Treatment for peritoneal dialysis-associated peritonitis

BACKGROUND

Peritonitis is a common complication of peritoneal dialysis (PD) and is associated with significant morbidity. Adequate treatment is essential to reduce morbidity and recurrence.

OBJECTIVES

To evaluate the benefits and harms of treatments for PD-associated peritonitis.

SEARCH STRATEGY

We searched the Cochrane Renal Group's specialised register, the Cochrane Central Register of Controlled Trials (CENTRAL, in The Cochrane Library), MEDLINE, EMBASE and reference lists without language restriction. Date of search: February 2005

SELECTION CRITERIA

All randomised controlled trials (RCTs) and quasi-RCTs assessing the treatment of peritonitis in peritoneal dialysis patients (adults and children) evaluating: administration of an antibiotic(s) by different routes (e.g. oral, intraperitoneal, intravenous); dose of an antibiotic agent(s); different schedules of administration of antimicrobial agents; comparisons of different regimens of antimicrobial agents; any other intervention including fibrinolytic agents, peritoneal lavage and early catheter removal were included.

DATA COLLECTION AND ANALYSIS

Two authors extracted data on study quality and outcomes. Statistical analyses were performed using the random effects model and the dichotomous results were expressed as relative risk (RR) with 95% confidence intervals (CI) and continuous outcomes as mean difference (WMD) with 95% CI.

MAIN RESULTS

We identified 36 studies (2089 patients): antimicrobial agents (30); urokinase (4), peritoneal lavage (1) intraperitoneal (IP) immunoglobulin (1). No superior antibiotic agent or combination of agents were identified. Primary response and relapse rates did not differ between IP glycopeptide-based regimens compared to first generation cephalosporin regimens, although glycopeptide regimens were more likely to achieve a complete cure (3 studies, 370 episodes: RR 1.66, 95% CI 1.01 to 3.58). For relapsing or persistent peritonitis, simultaneous catheter removal/replacement was superior to urokinase at reducing treatment failure rates (1 study, 37 patients: RR 2.35, 95% CI 1.13 to 4.91). Continuous IP and intermittent IP antibiotic dosing had similar treatment failure and relapse rates. IP antibiotics were superior to IV antibiotics in reducing treatment failure (1 study, 75 patients: RR 3.52, 95% CI 1.26 to 9.81). The methodological quality of most included studies was suboptimal and outcome definitions were often inconsistent. There were no RCTs regarding duration of antibiotics or timing of catheter removal.

AUTHORS' CONCLUSIONS

Based on one study, IP administration of antibiotics is superior to IV dosing for treating PD peritonitis. Intermittent and continuous dosing of antibiotics are equally efficacious. There is no role shown for routine peritoneal lavage or use of urokinase. No interventions were found to be associated with significant harm.

Treatment of peritoneal dialysis-associated peritonitis: a systematic review of randomized controlled trials

BACKGROUND

Peritonitis frequently complicates peritoneal dialysis. Appropriate treatment is essential to reduce adverse outcomes. Available trial evidence about peritoneal dialysis peritonitis treatment was evaluated.

SELECTION CRITERIA FOR STUDIES

The Cochrane CENTRAL Registry (2005 issue), MEDLINE (1966 to February 2006), EMBASE (1985 to February 2006), and reference lists were searched to identify randomized trials of treatments for patients with peritoneal dialysis peritonitis.

INTERVENTIONS

Trials of antibiotics (comparisons of routes, agents, and dosing regimens), fibrinolytic agents, peritoneal lavage, and intraperitoneal immunoglobulin.

OUTCOMES

Treatment failure, relapse, catheter removal, microbiological eradication, hospitalization, all-cause mortality, and adverse reactions.

RESULTS

36 eligible trials were identified: 30 trials (1,800 patients) of antibiotics; 4 trials (229 patients) of urokinase; 1 trial of peritoneal lavage (36 patients); and 1 trial of intraperitoneal immunoglobulin (24 patients). No superior antimicrobial class was identified. In particular, glycopeptides and first-generation cephalosporins were equivalent (3 trials, 387 patients; relative risk [RR], 1.84; 95% confidence interval [CI], 0.95 to 3.58). Simultaneous catheter removal/replacement was superior to urokinase at decreasing treatment failures (1 trial, 37 patients; RR, 2.35; 95% CI, 1.13 to 4.91). Continuous and intermittent intraperitoneal antibiotic dosing were equivalent regarding treatment failure (4 trials, 338 patients; RR, 0.69; 95% CI, 0.37 to 1.30) and relapse (4 trials, 324 patients; RR, 0.93; 95% CI, 0.63 to 1.39). One trial showed superiority of intraperitoneal antibiotics over intravenous therapy.

LIMITATIONS

The method quality of trials generally was suboptimal and outcome definitions were inconsistent. Small patient numbers led to inadequate power to show an effect. Interventions, such as optimal duration of antibiotic therapy, were not evaluated.

CONCLUSIONS

Trials did not identify superior antibiotic regimens. Intermittent and continuous antibiotic dosing are equivalent treatment strategies.

Conservative management of polymicrobial peritonitis complicating peritoneal dialysis--a series of 140 consecutive cases

PURPOSE

Because polymicrobial peritonitis is believed to be caused by bowel perforation in peritoneal dialysis patients, surgical exploration is often recommended. However, there is recent evidence that antibiotic therapy may be a safe alternative.

METHODS

We studied 140 consecutive episodes of dialysis-related polymicrobial peritonitis from January 1995 to June 2001. All episodes were treated primarily with intraperitoneal antibiotics. When there was no response, the Tenckhoff catheter was removed, usually after about 10 days of treatment. Laparotomy was performed only when there was clinical suspicion of surgical pathology.

RESULTS

Ninety patient-episodes (64%) responded to antibiotics alone by day 10; 56 patients (40%) had complete cure with no relapse in 4 months. Nine patients (6%) died within 2 days. Laparotomy was performed in 8 patients who did not respond by day 10, but only 3 had underlying surgical disease (strangulated hernia, ischemic colitis, and colonic cancer). In a multivariate logistic regression analysis, age and the presence of fungus, anaerobes, or Pseudomonas species in the dialysis fluid were independent predictors of poor primary response; and presence of fungus was the only independent predictor of failure to cure in 4 months.

CONCLUSION

Most patients with dialysis-related polymicrobial peritonitis responded to antibiotic therapy, and surgical exploration was needed only in a few patients. A careful examination of isolated organisms may help in identifying patients who need Tenckhoff catheter removal or surgical intervention.

Peritoneal dialysis. Prevention and control of infection

In spite of the reduction in peritonitis and catheter-related infection rates in patients undergoing peritoneal dialysis, these infections remain major sources of morbidity and transfer to haemodialysis. Touch contamination at the time of doing the exchanges is still a major cause of peritonitis and leads to Gram-positive organisms (coagulation-negative staphylococcus) being the most common pathogens. Newer exchange techniques have reduced this incidence but the more serious pathogens (Staphylococcal aureus, pseudomonas and fungi) remain a major problem. Treatment has to be immediate, and hence empirical, giving adequate cover for both Gram-positive and Gram-negative organisms. The use of vancomycin as an initial antibacterial has been discontinued because of the problem of vancomycin-resistant enterococcus. Recent guidelines advocate the use of a first generation cephalosporin combined with ceftazidime (if the urine output is >100 ml/day) or an aminoglycoside in anuric patients. Subsequent therapy changes are made upon bacterial isolation and sensitivities. Vancomycin is reserved for methicillin-resistant staphylococcus. Peritoneal catheter-related infections (exit site and tunnel) are predominantly caused by S. aureus and pseudomonal organisms and can be difficult to eradicate. Tunnel infections invariably involve the catheter dacron cuffs and therefore are more likely to lead to peritonitis; in this situation catheter removal is the treatment of choice. Treatment of exit-site infections is with oral antibacterials (penicillinase-resistant penicillins, cefalexin). Vancomycin is avoided if possible. The identification that nasal carriage of S. aureus predisposes to exit-site and tunnel infections has led to prophylactic regimens to combat this problem. Mupirocin applied at the exit site leads to a reduction in catheter-related infections and peritonitis.