ISPD Guideline 2010

Peritoneal Dialysis International, Vol. 30, pp.
393423
doi:10.3747/pdi.2010.00049
0896-8608/10 $3.00 + .00

Copyright 2010 International Society for Peritoneal Dialysis
ISPD GUIDELINES/RECOMMENDATIONS
PERITONEAL DIALYSIS-RELATED INFECTIONS

RECOMMENDATIONS: 2010 UPDATE
Department of Medicine and Therapeutics,1 Prince of Wales Hospital, The Chinese University of Hong Kong,
Hong Kong; University of Pittsburgh School of Medicine,2 Pittsburgh, PA, USA; Faculdade de Enfermagem,
Nutrio e Fisioterapia,3 Pontifcia Universidade Catlica do Rio Grande do Sul, Brazil; Sanjay Gandhi
Postgraduate Institute of Medical Sciences,4 Lucknow, India; Department of Nephrology,5 Princess Alexandra
Hospital, and School of Medicine, University of Queensland, Brisbane, Australia; Department of Medical
Microbiology,6 Leiden University Medical Center, Leiden, The Netherlands; Centre for Kidney Diseases,7
Mount Elizabeth Medical Centre, Singapore; Section of Infectious Disease,8 Department of Internal Medicine,
University of Missouri-Columbia School of Medicine, Columbia, MO, USA; Pediatric Nephrology
Division,9 University Childrens Hospital, Heidelberg, Germany; Dianet Dialysis Centers,10
Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
eritonitis remains a leading complication of peritoneal dialysis (PD). Around 18% of the infection-related
mortality in PD patients is the result of peritonitis. Although less than 4% of peritonitis episodes result in
death, peritonitis is a contributing factor to death in
16% of deaths on PD. In addition, severe and prolonged
peritonitis can lead to peritoneal membrane failure and
peritonitis is probably the most common cause of technique failure in PD. Peritonitis remains a major cause of
patients discontinuing PD and switching to hemodialysis. Therefore, the PD community continues to focus attention on prevention and treatment of PD-related
infections (19). Peritonitis treatment should aim for
rapid resolution of inflammation and preservation of
peritoneal membrane function.
Recommendations under the auspices of the International Society for Peritoneal Dialysis (ISPD) were first
published in 1983 and revised in 1989, 1993, 1996, 2000,
and 2005 (1013). The previous recommendations inThe authors are members of the ISPD Ad Hoc Advisory Committee on Peritoneal Dialysis Related Infections.
cluded sections on treatment as well as prevention of

peritonitis. In the present recommendations, the Committee focused on the treatment of peritonitis; prevention of PD-related infections will be covered in a separate
ISPD position statement.
The present recommendations are organized into five
sections:
1.
2.
3.
4.
Reporting of peritonitis rate

Exit-site and tunnel infections
Initial presentation and management of peritonitis
Subsequent management of peritonitis (organism
specific)
5. Future research
Perit Dial Int 2010; 30:393423
www.PDIConnect.com
doi:10.3747/pdi.2010.00049
Correspondence to: P.K.T. Li, Department of Medicine and

Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong.
[email protected]
Received 12 February 2010; accepted 27 April 2010.
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393
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Philip Kam-Tao Li,1 Cheuk Chun Szeto,1 Beth Piraino,2 Judith Bernardini,2 Ana E. Figueiredo,3
Amit Gupta,4 David W. Johnson,5 Ed J. Kuijper,6 Wai-Choong Lye,7
William Salzer,8 Franz Schaefer,9 and Dirk G. Struijk10
LI et al.
JULY 2010 VOL. 30, NO. 4
REPORTING OF PERITONITIS RATE

Every program should regularly monitor infection
rates, at a minimum, on a yearly basis (Opinion)
(1416).
Programs should carefully monitor all PD-related
infections, both exit-site infections and peritonitis,
including the presumed cause and cultured organisms, as part of a continuous quality improvement
program.
Causative organisms, their antibiotic sensitivity, and
presumed etiology must be reviewed in a regular fashion by the PD team, including both the nurses and the
physician(s) and, if appropriate, the physician assistant
or nurse practitioner. In this way, interventions can be
implemented if infection rates are rising or unacceptably high. Table 1 provides an easy method to calculate
infection rates. Infection rates for individual organisms
should also be calculated and compared to the literature. The centers peritonitis rate should be no more than
1 episode every 18 months (0.67/year at risk), although
the rate achieved will depend to some extent on the patient population. However, overall rates as low as 1 episode every 41 52 months (0.29 0.23/year) have been
reported, a goal that centers should strive to achieve
(17,18).
394
TABLE 1
Methods for Reporting Peritoneal Dialysis-Related Infections
(Peritonitis, Exit-Site Infections) (16)
1. As rates (calculated for all infections and each organism):
Months of peritoneal dialysis at risk, divided by number
of episodes, and expressed as interval in months between episodes
Number of infections by organism for a time period, divided by dialysis-years time at risk, and expressed as
episodes per year
2. As percentage of patients who are peritonitis free per period of time
3. As median peritonitis rate for the program (calculate peritonitis rate for each patient and then obtain the median of
these rates)
Relapsing peritonitis (see Table 6 for the definition) should
be counted as a single episode.
EXIT-SITE AND TUNNEL INFECTIONS

DEFINITIONS
Purulent drainage from the exit site indicates the

presence of infection. Erythema may or may not represent infection (Evidence) (1922).
An exit-site infection is defined by the presence of
purulent drainage, with or without erythema of the skin
at the catheterepidermal interface. Pericatheter
erythema without purulent drainage is sometimes an
early indication of infection but can also be a simple skin
reaction, particularly in a recently placed catheter or
after trauma to the catheter. Clinical judgment is required to decide whether to initiate therapy or to follow
carefully. A positive culture in the absence of an abnormal appearance is indicative of colonization rather than
infection. Intensification of exit-site cleaning with antiseptics is advised.
A tunnel infection may present as erythema, edema,
or tenderness over the subcutaneous pathway but is
often clinically occult, as shown by sonographic studies (22). A tunnel infection usually occurs in the presence of an exit-site infection but rarely occurs alone.
In the present article, exit-site and tunnel infections
are collectively referred to as catheter infections.
Staphylococcus aureus and Pseudomonas aeruginosa
exit-site infections are very often associated with concomitant tunnel infections and are the organisms that
most often result in catheter infection-related peritonitis; aggressive management is always indicated for
these organisms.

Although many of the general principles could be applied to pediatric patients, recommendations outlined
here focus on PD-related infections in adult patients.
Clinicians who take care of pediatric PD patients
should refer to other sources for detailed treatment regimens and dosages.
These recommendations are evidence based where
such evidence exists. The bibliography is not intended
to be comprehensive as there have been nearly 10 000
references to peritonitis in PD patients published since
1966. The Committee has chosen to include articles that
are more recently published (i.e., after the most recent
recommendation, published in 2005) and those considered key references. These recommendations are not
based solely on randomized controlled trials because
such studies in PD patients are limited. Where there is
no definitive evidence but the group feels there is sufficient experience to suggest a certain approach, this is
indicated as opinion based. The recommendations are
not meant to be implemented in every situation but are
recommendations only. Each center should examine its
own pattern of infection, causative organisms, and sensitivities and adapt the protocols as necessary for local
conditions.
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JULY 2010 VOL. 30, NO. 4
PD-RELATED INFECTIONS RECOMMENDATIONS
TABLE 2
THERAPY FOR EXIT-SITE AND TUNNEL INFECTIONS
Oral Antibiotics Used in Exit-Site and Tunnel Infection
The most serious and common exit-site pathogens are

Staphylococcus aureus and Pseudomonas aeruginosa.
As these organisms frequently lead to peritonitis (Evidence), such infections must be treated aggressively
(7,8,19,2341).
Oral antibiotic therapy is generally recommended,
with the exception of methicillin-resistant S. aureus
(MRSA) (Opinion) (21).
250500 mg b.i.d.
500 mg b.i.d. to t.i.d. (41)
250 mg b.i.d. (29)
500 mg loading dose, then
250 mg b.i.d. or q.d. (30)
Dicloxacillin
500 mg q.i.d.
Erythromycin
500 mg q.i.d.
Flucloxacillin (or cloxacillin)
500 mg q.i.d.
Fluconazole
200 mg q.d. for 2 days,
then 100 mg q.d. (41)
Flucytosine
0.51 g/day titrated to response and serum trough
levels (2550 g/mL) (41)
Isoniazid
200300 mg q.d. (42)
Linezolid
400600 mg b.i.d. (41)
Metronidazole
400 mg t.i.d.
Moxifloxacin
400 mg daily
Ofloxacin
400 mg first day, then
200 mg q.d.
Pyrazinamide
2535 mg/kg 3 times per
week (31)
Rifampicin
450 mg q.d. for <50 kg;
600 mg q.d. for >50 kg
Trimethoprim/sulfamethoxazole 80/400 mg q.d.
b.i.d. = 2 times per day; q.d. = every day; t.i.d. = 3 times per
day; q.i.d. = 4 times daily.
culosis is endemic. Rifampicin should never be given as

monotherapy. It should also be noted that rifampicin is
a potent inducer of drug-metabolizing enzymes and
would reduce the levels of medications such as warfarin,
statins, and anticonvulsants.
Pseudomonas aeruginosa exit-site infections are particularly difficult to treat and often require prolonged
therapy with two antibiotics. Oral fluoroquinolones are
recommended as the first choice, preferably not as
monotherapy since resistance develops rapidly. If
quinolones are given concomitantly with sevelamer,
multivalent cations, such as calcium, oral iron, zinc
preparations, sucralfate, magnesiumaluminum antacids, or milk, chelation interactions may occur that reduce quinolone absorption. Administration of the
quinolone should therefore be separated from these
drugs by at least 2 hours (with the quinolone administered first). If resolution of the infection is slow or if
there is recurrent Pseudomonas exit-site infection, a
second antipseudomonal drug, such as, but not limited
to, IP aminoglycoside, ceftazidime, cefepime, piperacillin, imipenemcilastatin, or meropenem, should be
added.

395
Exit-site and tunnel infections may be caused by a variety of micro-organisms. Although S. aureus and P. aeruginosa are responsible for the majority of infections,
other bacteria (diphtheroids, anaerobic organisms, nonfermenting bacteria, streptococci, nontuberculous mycobacteria, Legionella, yeasts, and fungi) can also be
involved. Empiric antibiotic therapy may be initiated
immediately. Alternatively, the healthcare team may decide to defer therapy until the results of the exit-site
culture can direct the choice of antibiotic. Microbiological examination should preferably include a combination of microscopy with aerobic and anaerobic culture.
The Gram stain of exit-site drainage and the microbiological culture findings can guide the initial therapy.
Cultures should be taken to the laboratory using appropriate transport materials also allowing anaerobic bacteria to survive. Oral antibiotic therapy has been shown
to be as effective as intraperitoneal (IP) antibiotic
therapy.
Empiric therapy should always cover S. aureus. If the
patient has a history of P. aeruginosa exit-site infections,
empiric therapy should be with an antibiotic that will
cover this organism. In some cases, intensified local care
or a local antibiotic cream may be felt to be sufficient in
the absence of purulence, tenderness, and edema.
Gram-positive organisms are treated with oral penicillinase-resistant (or broad spectrum) penicillin or a
first-generation cephalosporin, such as cephalexin. Dosing recommendations for frequently used oral antibiotics are shown in Table 2 (41). To prevent unnecessary
exposure to vancomycin and thus emergence of resistant organisms, vancomycin should be avoided in the
routine treatment of gram-positive exit-site and tunnel
infections but will be required for MRSA infections.
Clindamycin, doxycycline, and minocycline are sometimes useful for the treatment of community-acquired
MRSA and other organisms; these drugs do not require
dose adjustment for end-stage renal disease. In slowly
resolving or particularly severe S. aureus exit-site infections, rifampicin 600 mg daily may be added, although
this drug should be held in reserve in areas where tuber-
Amoxicillin
Cephalexin
Ciprofloxacin
Clarithromycin
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JULY 2010 VOL. 30, NO. 4
396
INITIAL PRESENTATION AND MANAGEMENT OF

PERITONITIS
CLINICAL PRESENTATION OF PERITONITIS
Peritoneal dialysis patients presenting with cloudy effluent should be presumed to have peritonitis. This is
confirmed by obtaining effluent cell count, differential, and culture (Evidence) (4352).
It is important to initiate empiric antibiotic therapy
for PD-associated peritonitis as soon as possible.
There are potentially serious consequences of peritonitis (relapse, catheter removal, permanent transfer
to hemodialysis, and death) that are more likely to
occur if treatment is not initiated promptly (Opinion).
Patients with peritonitis usually present with cloudy
fluid and abdominal pain; however, peritonitis should
always be included in the differential diagnosis of the
PD patient with abdominal pain, even if the effluent is
clear, as a small percentage of patients present in this
fashion. Other causes, such as constipation, renal or biliary colic, peptic ulcer disease, pancreatitis, and acute
intestinal perforation, should also be investigated in the
PD patient with abdominal pain and clear fluid. Conversely, while patients with peritonitis most often have
severe pain, some episodes are associated with mild or
even no pain. The degree of pain is somewhat organism
specific (e.g., generally less with CoNS and greater with
Streptococcus, gram-negative rods, S. aureus) and can
help guide the clinician in the decision to admit or treat
as an outpatient. Patients with minimal pain can often
be treated on an outpatient basis with IP therapy and
oral pain medication. Those requiring intravenous (IV)
narcotics always require admission for management.
Cloudy effluent will usually represent infectious peritonitis but there are other causes (48). The differential
diagnosis is shown in Table 3. Case reports of sterile peritonitis associated with icodextrin-based dialysis solutions have been reported from Europe (49). Randomized
TABLE 3
Differential Diagnosis of Cloudy Effluent
Culture-positive infectious peritonitis

Infectious peritonitis with sterile cultures
Chemical peritonitis
Eosinophilia of the effluent
Hemoperitoneum
Malignancy (rare)
Chylous effluent (rare)
Specimen taken from dry abdomen

Many organisms can cause exit-site and tunnel infections, including micro-organisms belonging to the normal skin flora, such as corynebacteria (7,32). Therefore,
culture with sensitivity testing is important in determining antibiotic therapy. Close follow-up is necessary to
determine the response to therapy and relapse. Unfortunately, both S. aureus and P. aeruginosa catheter
infections tend to recur; repeating PD effluent cultures 1 2 weeks after the discontinuation of antimicrobial treatment may be useful for risk assessment.
Ultrasonography of the exit site is a useful adjunctive tool in the management of exit-site and tunnel infections (33). A sonolucent zone around the external
cuff over 1 mm thick following a course of antibiotic
treatment and the involvement of the proximal cuff are
associated with poor clinical outcome. In exit-site infections caused by P. aeruginosa, clinical outcome has
been uniformly poor irrespective of the sonographic
findings.
Antibiotic therapy must be continued until the exit
site appears entirely normal. Two weeks is the minimum
length of treatment time; treatment for 3 weeks is probably necessary for exit-site infections caused by P. aeruginosa. If prolonged therapy (e.g., longer than 3 weeks)
with appropriate antibiotics fails to resolve the infection, the catheter can be replaced as a single procedure
under antibiotic coverage (3437). If the cuffs are not
involved, revision of the tunnel may be performed in
conjunction with continued antibiotic therapy. This procedure, however, may result in peritonitis, in which case
the catheter should be removed. Sonography of the tunnel has been shown useful in evaluating the extent of
infection along the tunnel and the response to therapy
and may be used to decide on tunnel revision, replacement of the catheter, or continued antibiotic therapy
(38). In general, catheter removal should be considered
earlier for exit-site infections caused by P. aeruginosa or
if there is tunnel infection.
A patient with an exit-site infection that progresses
to peritonitis, or who presents with an exit-site infection in conjunction with peritonitis with the same organism, will usually require catheter removal. Catheter
removal should be done promptly rather than submitting the patient to prolonged peritonitis or relapsing
peritonitis. The exception is peritonitis due to coagulase-negative staphylococcus (CoNS), which is generally
readily treated. Simultaneous removal and reinsertion
of the dialysis catheter (with a new exit site) is feasible
in eradicating refractory exit-site infections due to
P. aeruginosa (39). In selected cases, cuff shaving may
be considered an alternative to catheter replacement for
tunnel infection (40).
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With this exception, empiric therapy should not be based

on the Gram stain but should cover the usual pathogens,
as discussed below.
The patient should always be questioned in a nonthreatening manner about a break in technique and in
particular whether contamination or disconnection occurred recently. Information about recent exit-site infections and the last (if any) episode of peritonitis should
be obtained. The patient should also be questioned about
any recent endoscopic or gynecological procedures, as
well as the presence of either constipation or diarrhea.
In peritonitis, abdominal tenderness is typically generalized and is often associated with rebound. Localized
pain or tenderness should raise the suspicion of an underlying surgical pathology such as acute appendicitis.
The physical examination of the patient presenting with
peritonitis should always include a careful inspection of
the catheter exit site and tunnel. Any drainage from the
exit site should be cultured along with the effluent. If
the exit site grows the same organism as the effluent
(with the exception of CoNS), then it is very likely that
the origin of the peritonitis is the catheter.
Although an abdominal x-ray image is generally not
necessary, if there is any suspicion of a bowel source,
an abdominal film should be obtained. The presence of
free air under the diaphragm is suggestive of perforation, although it should be noted that a small amount
of IP air is common among PD patients due to inadvertent infusion of air by the patient. Routine peripheral
blood cultures are unnecessary since they are usually
negative but they should be obtained if the patient appears septic.
Some PD patients reside in locations that are remote
from medical facilities and thus cannot be seen expeditiously after the onset of symptoms. These patients also
may not have immediately available microbial and laboratory diagnostic services. Since prompt initiation of
therapy for peritonitis is critical, this necessitates reliance on immediate patient reporting of symptoms to the
center, and then initiating IP antibiotics in the home
setting. Such an approach requires that the patients be
trained in this technique and that antibiotics be kept in
the home. A delay in treatment could be dangerous.
Whenever possible, prior to starting antibiotic, cultures
should be obtained either at a local facility or by having
the patient keep blood-culture bottles at home for use.
Alternatively, the patient may place the cloudy effluent
bag in the refrigerator to slow bacterial multiplication
and white cell killing until they are able to bring in the
sample. The benefit of self-initiated treatment, however,
should be carefully balanced against the potential problems of overdiagnosis and habitual misuse of antibiotics.

397
trials comparing icodextrin- to glucose-based dialysis

solutions show similar peritonitis risk with the two solutions (5052).
The abdomen should be drained and the effluent carefully inspected and sent for cell count with differential,
Gram stain, and culture. An effluent cell count with
white blood cells (WBC) more than 100/L (after a dwell
time of at least 2 hours), with at least 50% polymorphonuclear neutrophilic cells, indicates the presence of inflammation, with peritonitis being the most likely cause.
To prevent delay in treatment, antibiotic therapy should
be initiated as soon as cloudy effluent is seen, without
waiting for confirmation of the cell count from the laboratory. Patients with cloudy effluent may benefit from
the addition of heparin (500 units/L) to the dialysate
to prevent occlusion of the catheter by fibrin. Heparin
is also usually added in cases of hemoperitoneum. An
experienced observer can differentiate hemoperitoneum from cloudy effluent due to peritonitis. If there is
a question, a cell count with differential should be
performed.
The number of cells in the effluent will depend, in
part, on the length of the dwell. For patients on automated PD (APD) who present during their nighttime
treatment, the dwell time is much shorter than with continuous ambulatory PD (CAPD); in this case, the clinician should use the percentage of polymorphonuclear
cells rather than the absolute number of white cells to
diagnose peritonitis. The normal peritoneum has very
few polymorphonuclear cells; therefore, a proportion
above 50% is strong evidence of peritonitis, even if the
absolute white cell count does not reach 100/L. Patients on APD with a day dwell who present during the
day generally have cell counts similar to those of CAPD
patients and are not difficult to interpret. However, APD
patients without a daytime exchange who present with
abdominal pain may have no fluid to withdraw. In this
case, 1 L of dialysate should be infused and permitted
to dwell a minimum of 1 2 hours, then drained and
examined for turbidity, and sent for cell count with differential and culture. The differential (with a shortened
dwell time) may be more useful than the absolute WBC
count. In equivocal cases, or in patients with systemic
or abdominal symptoms in whom the effluent appears
clear, a second exchange is performed with a dwell time
of at least 2 hours. Clinical judgment should guide initiation of therapy.
Even though the Gram stain is often negative in the
presence of peritonitis, this test should be performed
as the Gram stain may indicate the presence of yeast,
thus allowing for prompt initiation of antifungal therapy
and permitting timely arrangement of catheter removal.
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JULY 2010 VOL. 30, NO. 4
SPECIMEN PROCESSING
Culture-negative peritonitis should not be greater

than 20% of episodes. Standard culture technique is
the use of blood-culture bottles but a large-volume
culture (e.g., culturing the sediment after centrifuging 50 mL of effluent) could further improve the recovery of micro-organisms (Evidence) (5357).
398
positive after the first 24 hours and, in over 75% of cases,

diagnosis can be established in less than 3 days. When
cultures remain negative after 3 5 days of incubation
and clinical suspicion is high, subculture of blood-culture bottles on media with aerobic, anaerobic, and microaerophilic incubation conditions for a further 3 4 days
may help to identify slow-growing bacteria and yeasts
that are undetectable in an automated culture system.
OTHER NOVEL DIAGNOSTIC TECHNIQUES
There is not enough evidence for recommending the

use of novel techniques [such as leukocyte esterase,
broad-spectrum polymerase chain reaction (PCR),
quantitative bacterial DNA PCR] for the diagnosis of
peritonitis (5864).
A number of novel diagnostic techniques have been
explored for the early diagnosis of peritonitis. Park et al.
(58) and Akman et al. (59) reported that leukocyte esterase reagent strip has excellent accuracy for the diagnosis of peritonitis. Various commercially available strips
have been tested to diagnose non-PD peritonitis but the
results vary enormously; more studies are required before this can be applied in a routine setting (60).
Broad-spectrum PCR with RNA sequencing (61) and
quantitative bacterial DNA PCR assays (62) may also
complement culture methods in the diagnosis of CAPD
peritonitis, especially in patients with previous or current antibiotic use. The latter technique may also help
to identify those patients likely to relapse despite apparent clinical improvement with standard antibiotic
therapy (62). Another study suggests that the matrix
metalloproteinase-9 test kit may be a reliable method
for early diagnosis of PD peritonitis (63). The role of rapid
detection of the causative pathogen of peritonitis using
in situ hybridization has also been explored (64).
EMPIRIC ANTIBIOTIC SELECTION
Empiric antibiotics must cover both gram-positive and

gram-negative organisms. The Committee recommends center-specific selection of empiric therapy,
dependent on the local history of sensitivities of organisms causing peritonitis (Opinion). Gram-positive
organisms may be covered by vancomycin or a cephalosporin, and gram-negative organisms by a thirdgeneration cephalosporin or aminoglycoside (Evidence)
(Figure 1) (65105).
Intraperitoneal administration of antibiotics is superior to IV dosing for treating peritonitis; intermittent and

In the ideal situation (e.g., in specialized academic

centers), one could achieve a less than 10% rate of culture-negative peritonitis. Correct microbiological culturing of peritoneal effluent is of utmost importance to
establish the micro-organism responsible. Identification
of the organism and subsequent antibiotic sensitivities
will not only help guide antibiotic selection but, in addition, the type of organism can indicate the possible
source of infection. An optimal culture technique is the
combination of sediment culturing of 50 mL effluent and
bedside inoculation of 5 10 mL effluent in two bloodculture bottles. The specimens should arrive within
6 hours at the laboratory. If immediate delivery to the
laboratory is not possible, the inoculated culture bottles
should ideally be incubated at 37C. When the causative
micro-organism has been established, subsequent
cultures for monitoring may be performed by only inoculating the effluent in blood-culture bottles. Centrifugation of 50 mL peritoneal effluent at 3000g for 15 minutes,
followed by re suspension of the sediment in 3 5 mL of
sterile saline, and inoculation of this material both on
solid culture media and into a standard blood-culture
medium, is a sensitive method to identify the causative
organisms. With this method, less than 5% will be culture negative. The solid media should be incubated in
aerobic, microaerophilic, and anaerobic environments.
Blood-culture bottles can be directly injected with 5
10 mL of effluent if equipment for centrifuging large
amounts of fluid is not available; this method generally
results in a culture-negative rate of 20%. If the patient is
already on antibiotics, removal of antibiotics present in
the specimen may increase the isolation rate.
The speed with which bacteriological diagnosis can
be established is very important. Concentration methods not only facilitate correct microbial identification
but also reduce the time necessary for bacteriological
cultures. Rapid blood-culture techniques (e.g., BACTEC,
Septi-Chek, BacT/Alert; Becton Dickinson) may further
speed up isolation and identification and are probably
the best approach. Two recent prospective studies also
support the routine use of the broth culture technique
(56,57), while the lysiscentrifugation technique needs
further evaluation. The majority of cultures will become
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Patient Education
Start intraperitoneal antibiotics as soon as possible

Allow to dwell for at least 6 hours
Ensure gram-positive and gram-negative coverage*
Base selection on historical patient and center sensitivity patterns as available
Gram-positive coverage:
Either first-generation
cephalosporin or vancomycin
68 hours
Collect data to include

Date of culture, organism identified, drug therapy used
Date infection resolved
Recurrent organisms, date of drug therapy
Method of interim renal replacement therapy
Date of catheter removal
Date of new catheter reinsertion
Documentation of contributing factors
Break in technique, patient factors, exit-site
infections, tunnel infections
Date of reeducation/training
Enter data into catheter management database
Gram-negative coverage:
Either third-generation
cephalosporin or aminoglycoside
Determine and prescribe ongoing antibiotic treatment

Ensure follow-up arrangements are clear or patient admitted
Await sensitivity results
Figure 1 Initial management of peritonitis: *Continued assessment and modification of therapy based on culture and sensitivity
results; refer to subsequent sections for specific organisms cultured. Dwell time of the exchange for intermittent therapy must be
a minimum of 6 hours. Vancomycin may be considered if patient has a history of methicillin-resistant Staphylococcus aureus
colonization/infection, is seriously unwell, or has a history of severe allergy to penicillins and cephalosporins. If the center has an
increased rate of methicillin resistance, vancomycin may also be considered. If the patient is cephalosporin allergic, aztreonam
is an alternative to ceftazidime or cefepime. Vancomycin and ceftazidime are compatible when mixed in a dialysis solution volume
greater than 1 L; however, they are incompatible when mixed in the same syringe or empty dialysis solution bag for reinfusion.
Aminoglycosides should not be added to the same exchange with penicillins as this results in incompatibility.
continuous dosing of antibiotics are equally efficacious

(88).
Therapy is initiated prior to knowledge of the causative organism and should be initiated as soon as possible after appropriate microbiological specimens have
been obtained. The selection of empiric antibiotics must
be made in light of both the patients and the programs
history of micro-organisms and sensitivities. It is important that the protocol cover all serious pathogens that
are likely to be present. For many programs, a first-generation cephalosporin, such as cefazolin or cephalothin,
with a second drug for broader gram-negative coverage
(including coverage for Pseudomonas) will prove suitable. This protocol has been shown to have results
equivalent to vancomycin plus a second drug for gramnegative coverage (77,87). Many programs, however,
have a high rate of methicillin-resistant organisms and
thus should use vancomycin for gram-positive coverage
with a second drug for gram-negative coverage (88).
Gram-negative coverage can be provided with an
aminoglycoside, ceftazidime, cefepime, or carbapenem.
Quinolones should be used for empiric coverage of gramnegative organisms only if local sensitivities support such
use. For the cephalosporin-allergic patient, aztreonam

399
06 hours
Immediately report cloudy effluent,

abdominal pain, and/or fever to PD unit
Save drained cloudy dialysate and bring
to clinic
Treatment will be adding intraperitoneal
antibiotics for up to 3 weeks
Report worsening symptoms or persistent
cloudiness to PD unit
Schedule retraining for technique issues
Outcomes Evaluation
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JULY 2010 VOL. 30, NO. 4
400
broad for routine application and should be considered

only for highly resistant cases. The increased isolation
rate of gram-negative rods (Enterobacteriaceae, Acinetobacter species, and Pseudomonas species) resistant to
carbapenems is of increasing concern (97).
Monotherapy is also possible. In a randomized trial,
imipenem/cilastatin (500 mg IP with a dwell of 6 hours,
followed by IP 100 mg per 2 L dialysis solution) was as
effective in curing peritonitis as was cefazolin plus ceftazidime in CAPD patients (98). Cefepime (2 g IP load
with a dwell time of >6 hours, followed by 1 g/day IP for
9 consecutive days) was as effective as vancomycin plus
netilmicin in another randomized trial of CAPD-related
peritonitis (69).
Quinolones (oral levofloxacin 250 mg daily, or oral
pefloxacin 400 mg daily) appear to be an acceptable alternative to aminoglycosides for gram-negative coverage (94,99,100) and do reach adequate levels within the
peritoneum, even with cycler PD (101). In another study,
oral ofloxacin alone (400 mg, followed by 300 mg daily)
was equivalent to cephalothin 250 mg/L for all CAPD
exchanges, in combination with tobramycin 8 mg/L
(102). However, resolution of S. aureus may prove to be
slow with the use of ciprofloxacin alone and it is not the
ideal drug (103).
In the early days of PD, mild cases of peritonitis such
as those caused by S. epidermidis were treated effectively
with oral cephalosporin therapy (104). If the organism
is sensitive to methicillin and first-generation cephalosporin, then this approach is still possible if, for some
reason, IP or IV antibiotic therapy is not feasible. Oral
therapy is not suitable for more severe cases of peritonitis. No role has been shown for routine peritoneal lavage or use of urokinase (88), although one or two rapid
exchanges often help to relieve pain, and continuous
peritoneal lavage (for 24 48 hours) is often used for
patients with septic shock and grossly turbid PD effluent. In a recent randomized control trial of 88 patients,
IP urokinase had no significant benefit as an adjunct
therapy in the treatment of bacterial peritonitis resistant to initial antibiotic therapy (105).
DRUG DELIVERY AND STABILITY
Vancomycin, aminoglycosides, and cephalosporins

can be mixed in the same dialysis solution bag without
loss of bioactivity. However, aminoglycosides should not
be added to the same exchange with penicillins because
of chemical incompatibility (although aminoglycoside
and cephalosporin can be added to the same bag). For
any antibiotics that are to be admixed, separate syringes
must be used for adding the antibiotics. Even though

is an alternative to ceftazidime or cefepime for gramnegative coverage if aminoglycosides are not used. Antibiotic resistance may develop with empiric use of
extended-spectrum cephalosporins and quinolones. Resistance should be monitored, especially for enterococci,
staphylococci, yeasts, and gram-negative organisms
such as Pseudomonas species, Escherichia coli, Proteus
species, Providencia species, Serratia species, Klebsiella
species, and Enterobacter species, but catheter removal
should not be delayed until the result of antibiotic resistance testing is available.
While an extended course of aminoglycoside therapy
may increase the risk for both vestibular and ototoxicity, short-term use appears to be safe and inexpensive
and provides good gram-negative coverage. Gentamicin
given in once-daily dosing (40 mg IP in 2 L) is as effective as dosing in each exchange (10 mg/2 L, IP, in 4 exchanges/day) for CAPD peritonitis (89,90). There does
not appear to be convincing evidence that short courses
of aminoglycosides harm residual renal function (65,91).
Repeated or prolonged courses (e.g., longer than
2 weeks) of aminoglycoside therapy are probably not advisable if an alternative approach is possible. If an
aminoglycoside is used for the initial gram-negative coverage, intermittent dosing is strongly encouraged and
prolonged courses of longer than 3 weeks should be
avoided.
Either ceftazidime or cefepime is an appropriate alternative for gram-negative coverage. Cefepime is not
broken down by many of the beta-lactamases that are
currently produced by gram-negative bacilli worldwide
so, theoretically, it has better coverage than ceftazidime.
In addition to the above combinations, a variety of
regimens have been tested in prospective trials, with
acceptable results (92). In a randomized control study
of 102 patients, IP cefazolin plus netilmicin and cefazolin
plus ceftazidime had similar efficacy as empirical treatment for CAPD peritonitis (93). In CAPD patients with
residual renal function, significant but reversible reduction in residual renal function and 24-hour urine volume
could occur after an episode of peritonitis, despite successful treatment by antibiotics. However, the effect of
both regimens on residual renal function is similar (93).
Other combination therapy may also be effective. A
recent study showed that systemic vancomycin and ciprofloxacin administration might also be an effective firstline antibiotic therapy (94). Lima et al. (95) reported
satisfactory response rates with ciprofloxacin plus
cefazolin as the empirical regimen for peritonitis. Meropenem plus tobramycin followed by meropenem plus vancomycin is another regimen recently reported to have
reasonable success (96), but this combination is too
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INTERMITTENT OR CONTINUOUS DOSING OF ANTIBIOTICS:

SPECIAL CONSIDERATIONS FOR APD PATIENTS
Little is known about intermittent dosing requirements in patients treated with APD. The optimal ratio of
antibiotic concentration and MIC value of a bacterium
depends on various variables, such as bacterial species,
presence of postantibiotic effect, and duration of antibiotic concentration above MIC value. The Committee
agrees that IP dosing of antibiotics for peritonitis is preferable to IV dosing in CAPD, since IP dosing results in
very high local levels of antibiotics. For example, 20 mg/L
IP gentamicin is well above the MIC of sensitive organisms. The equivalent dose of gentamicin given IV would
result in much lower IP levels. The IP route has the added
advantage that it can be done by the patient at home
after appropriate training and it avoids venipuncture.
Monitoring of drug levels for aminoglycosides and vancomycin is recommended if toxicity is suspected.
Intraperitoneal antibiotics can be given in each exchange (i.e., continuous dosing) or once daily (i.e., intermittent dosing) (109114). In intermittent dosing,
the antibiotic-containing dialysis solution must be
allowed to dwell for at least 6 hours to allow adequate
absorption of the antibiotic into the systemic circulation. Most antibiotics have significantly enhanced absorption during peritonitis (e.g., IP vancomycin is about
50% absorbed in the absence of peritonitis but closer to
90% in the presence of peritonitis), which permits subsequent reentry into the peritoneal cavity during ensuing exchanges of fresh dialysis solution. Table 4 provides
doses for both continuous and intermittent administration for CAPD, where there is information available.
There are insufficient data on whether continuous
dosing is more efficacious than intermittent for firstgeneration cephalosporins. A once-daily IP cefazolin
dose of 500 mg/L results in acceptable 24-hour levels in
the dialysis fluid in CAPD patients (111). An extensive
body of evidence exists for the efficacy of intermittent
dosing of aminoglycosides and vancomycin in CAPD but
less for APD. Table 5 provides dosing recommendations
for APD where such data exist or sufficient experience
can allow a recommendation to be made. A randomized
trial in children that included both CAPD and APD patients found that intermittent dosing of vancomycin/
teicoplanin is as efficacious as continuous dosing (65).
Intraperitoneal vancomycin is well absorbed when given
in a long dwell and subsequently crosses again from the
blood into the dialysate with fresh exchanges.
Rapid exchanges in APD, however, may lead to inadequate time to achieve IP levels. There are fewer data
concerning efficacy of first-generation cephalosporins

401
vancomycin and ceftazidime are compatible when added

to dialysis solutions (1 L or higher), they are incompatible if combined in the same syringe or added to an empty
dialysate bag for reinfusion into the patient. This approach is not recommended.
Antibiotics should be added using sterile technique:
placing povidone iodine, rubbing with alcohol 70% stripe,
or chlorhexidine on the medication port for 5 minutes
prior to insertion of the needle through the port. Dwell
time of the exchange must be a minimum of 6 hours.
Data suggest that some antibiotics are stable for variable times when added to dextrose-containing dialysis
solution. Vancomycin (25 mg/L) is stable for 28 days in
dialysis solution stored at room temperature, although
high ambient temperatures will reduce the duration of
stability. Gentamicin (8 mg/L) is stable for 14 days but
the duration of stability is reduced by admixture of heparin. Cefazolin (500 mg/L) is stable for at least 8 days at
room temperature or for 14 days if refrigerated; addition of heparin has no adverse influence. Ceftazidime is
less stable: concentrations of 125 mg/L are stable for
4 days at room temperature or 7 days refrigerated, and
concentrations of 200 mg/L are stable for 10 days if refrigerated. Cefepime is stable in dialysis solution for
14 days if the solution is refrigerated (106).
These data are derived from duration of stability studies. It is possible that the agents are stable for longer
periods; more research is needed to identify the optimal
stability conditions for antibiotics added to dialysis solutions. Icodextrin-containing dialysis solutions are
compatible with vancomycin, cefazolin, ampicillin, cloxacillin, ceftazidime, gentamicin, and amphotericin
(107). Nonetheless, data on the stability of individual
antibiotics in various new PD solutions are limited. Clinicians should remain alert to new studies in this area.
In a recent retrospective study of 613 patients,
Blunden et al. (108) confirmed that dosing recommendation for vancomycin in CAPD and APD patients produces adequate serum concentrations of the antibiotics
in the vast majority (over 85%) of patients. In contrast,
the currently recommended dosing regimen of gentamicin resulted in high levels for more than 50% patients,
but switching gentamicin to ceftazidime at day 5 appeared safe and limited aminoglycoside exposure. In this
study, increasing vancomycin and gentamicin concentrations did not appear to improve cure rates (108).
Since standard microbiological tests [e.g., minimum inhibitory concentration (MIC) test] do not account for
the unique factors of PD peritonitis, and IP antibiotics
act primarily locally, checking of antibiotic levels in peripheral blood should be used for the detection of toxicity rather than a proof of efficacy.
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TABLE 4
Intraperitoneal Antibiotic Dosing Recommendations for CAPD Patientsa
Continuous
(mg/L; all exchanges)
2 mg/kg
0.6 mg/kg
LD 25, MD 12
LD 8, MD 4
15 mg/kg
1000 mg
10001500 mg
1000 mg
LD 500, MD 125
LD 500, MD 125
LD 500, MD 125
LD 250, MD 125
ND
ND
ND
ND
LD 250500, MD 50
MD 125
LD 500, MD 250
LD 50000 units, MD 25000 units
ND
LD 50, MD 25
ND
ND
LD 1000, MD 250
LD 100, MD 20
Oral 200300 mg q.d.

15 mg/kg
LD 400, MD 20
1530 mg/kg every 57 days
LD 1000, MD 25
NA
200 mg IP every 2448 hours
1.5
2 g every 12 hours
LD 1000, MD 100
1 g b.i.d.
LD 250, MD 50
25 mg/L in alternate bagsb
Oral 960 mg b.i.d.
ND = no data; q.d. = every day; NA = not applicable; IP = intraperitoneal; b.i.d. = 2 times per day; LD = loading dose in mg/L; MD =
maintenance dose in mg/L.
a For dosing of drugs with renal clearance in patients with residual renal function (defined as >100 mL/day urine output), dose
should be empirically increased by 25%.
b Given in conjunction with 500 mg intravenous twice daily.
TABLE 5
Intermittent Dosing of Antibiotics in Automated Peritoneal Dialysis
Drug
IP dose
Cefazolin
Cefepime
Fluconazole
Tobramycin
Vancomycin
20 mg/kg IP every day, in long day dwell (112)

1 g IP in 1 exchange per day
200 mg IP in 1 exchange per day every 2448 hours
LD 1.5 mg/kg IP in long dwell, then 0.5 mg/kg IP each day in long dwell (112)
LD 30 mg/kg IP in long dwell; repeat dosing 15 mg/kg IP in long dwell every 35 days (aim to keep serum trough
levels above 15 g/mL)
IP = intraperitoneal; LD = loading dose.

402

Aminoglycosides
Amikacin
Gentamicin, netilmicin, or tobramycin
Cephalosporins
Cefazolin, cephalothin, or cephradine
Cefepime
Ceftazidime
Ceftizoxime
Penicillins
Amoxicillin
Ampicillin, oxacillin, or nafcillin
Azlocillin
Penicillin G
Quinolones
Ciprofloxacin
Others
Aztreonam
Daptomycin (115)
Linezolid (41)
Teicoplanin
Vancomycin
Antifungals
Amphotericin
Fluconazole
Combinations
Ampicillin/sulbactam
Imipenem/cilastin
Quinupristin/dalfopristin
Trimethoprim/sulfamethoxazole
Intermittent
(per exchange, once daily)
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nificance (125). There was, however, a significant decrease in the incidence and proportion of antibioticrelated fungal peritonitis in the nystatin group (125).
The Work Group recognizes that nystatin is not available in some countries and that there are few data on
the efficacy and potential problem of fluconazole prophylaxis. Each PD program must examine its history of
fungal peritonitis and decide whether such a protocol
might be beneficial.
Studies of IP urokinase failed to show any benefit of
urokinase over placebo with respect to complete cure in
persistent peritonitis, or primary response to treatment
in the setting of resistant peritonitis (105,126,127).
Similarly, catheter removal and relapse rates were not
affected by treatment with urokinase, either in the setting of persistent peritonitis or on initiation of fibrinolytic therapy at the time peritonitis was diagnosed. In
contrast, one randomized control study showed that
simultaneous catheter removal and replacement was
superior to urokinase in reducing recurrent episodes of
peritonitis (128).
One, small, randomized control trial reported that the
use of IP immunoglobulin provides significant improvement in laboratory parameters (especially dialysate leukocyte count), but that there was no effect on the rate
of treatment failure or relapse (129).
SUBSEQUENT MANAGEMENT OF PERITONITIS
ADJUNCTIVE TREATMENTS
Once culture results and sensitivities are known, antibiotic therapy should be adjusted to narrowspectrum agents as appropriate. For patients with
substantial residual renal function (e.g., residual glomerular filtration rate 5 mL/minute/1.73 m2), the
dose of antibiotics that have renal excretion may need
to be adjusted accordingly (Opinion).
The majority of fungal peritonitis episodes are preceded by courses of antibiotics (116118). Fungal prophylaxis during antibiotic therapy may prevent some
cases of Candida peritonitis in programs that have high
rates of fungal peritonitis (119124). A number of studies have examined the use of prophylaxis, either oral
nystatin or a drug such a fluconazole, given during antibiotic therapy to prevent fungal peritonitis, with
mixed results. Programs with high baseline rates of fungal peritonitis found such an approach to be beneficial, while those with low baseline rates did not detect
a benefit. In a recent observational study, the fungal
peritonitis rate of the nystatin group was slightly lower
than that of the control group (0.011 vs 0.019/patientyear) but the difference did not reach statistical sig-
Few data exist that provide dosing recommendations

for patients treated with APD. Extrapolation of data from
CAPD to APD may result in significant underdosing of APD
patients for two reasons: First, intermittent administration to any exchange other than a prolonged daytime
exchange would prevent an adequate proportion of the
dose from being absorbed into the systemic circulation,
but this problem can be avoided by ensuring a minimum
of 6 hours dwell during the daytime. Second, data exist
that suggest APD may result in higher peritoneal clearances of antibiotics than is the case with CAPD (85). This
would result in reduced dialysate concentrations, reduced serum concentrations, and the possibility of prolonged intervals during a 24-hour period when dialysate
concentrations are less than the MIC for susceptible

403
given intermittently for peritonitis, particularly for the

patient on a cycler. For patients given a daytime exchange of a cephalosporin only, the nighttime IP levels
are below the MIC of most organisms. This raises a concern that biofilm-associated organisms may survive and
result in subsequent relapsing peritonitis. Until a randomized trial with large numbers is done, adding firstgeneration cephalosporin to each exchange would
appear to be the safest approach.
The Committee agrees that vancomycin can be given
intermittently for patients on APD, even though there
are few studies. However, a randomized European trial
in children showed that intermittent dosing of vancomycin or teicoplanin (and many of the children were on
APD) was as effective as continuous dosing. Generally, a
dosing interval of 4 5 days will keep serum trough levels above 15 g/mL but, in view of the variability of losses
due to residual renal function and peritoneal permeability, it is best to obtain levels. Intraperitoneal levels of
vancomycin after the initial dose will always be lower
than serum levels of vancomycin; therefore, the serum
levels need to be kept higher than would be otherwise
indicated (75). Re-dosing is appropriate once serum vancomycin levels go below 15 g/mL.
Whether or not patients on a cycler need to convert
temporarily to CAPD or lengthen the dwell time on the
cycler is unclear at present. It is not always practical to
switch patients from APD to CAPD, especially if the patient is treated as an outpatient, since the patient may
not have supplies for CAPD and may not be familiar with
the technique. Resetting the cycler in such cases to permit a longer exchange time is an alternative approach;
however, it has not been well studied. Further research
is needed in this area.
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REFRACTORY PERITONITIS
Refractory peritonitis, defined as failure of the

effluent to clear after 5 days of appropriate antibiotics, should be managed by removal of the catheter to
protect the peritoneal membrane for future use (Evidence) (3,130132).
Refractory peritonitis is the term used for peritonitis
treated with appropriate antibiotics without resolution
after 5 days (see Table 6 for terminology).
A recent retrospective study that had a validation
group of patients from another center showed that peritoneal dialysate white cell count 1090/mm3 on day 3
was an independent prognostic marker for treatment
failure after adjustment for conventional risk factors
(hazard ratio 9.03) (132). Catheter removal is indicated
to prevent morbidity and mortality due to refractory peritonitis and to preserve the peritoneum for future PD
(Table 7). If the organism is the same as that of the preceding episode, strong consideration should be given to
TABLE 7
Indications for Catheter Removal for Peritoneal
Dialysis-Related Infections
Refractory peritonitis
Relapsing peritonitis
Refractory exit-site and tunnel infection
Fungal peritonitis
Catheter removal may also be considered for
Repeat peritonitis
Mycobacterial peritonitis
Multiple enteric organisms
replacing the catheter after PD effluent becomes clear.

The primary goal in managing peritonitis should always
be the optimal treatment of the patient and protection
of the peritoneum, not saving the catheter. Ideally, attempts should be made at the laboratory to identify the
causative micro-organism to the exact species level (e.g.,
S. epidermidis, S. hominis, or a species other than CoNS).
Prolonged attempts to treat refractory peritonitis are
associated with extended hospital stay, peritoneal membrane damage, increased risk of fungal peritonitis, and,
in some cases, death. Death related to peritonitis defined as death of a patient with active peritonitis, or
admitted with peritonitis, or within 2 weeks of a peritonitis episode should be a very infrequent event. The
risk of death is highest with peritonitis due to gramnegative bacilli and fungus.
RELAPSING, RECURRENT, AND REPEAT PERITONITIS
Treatments of relapsing, recurrent, or repeat peritonitis represent distinct clinical entities that portend
a worse outcome (particularly for recurrent peritonitis). Stronger consideration should be given to timely
catheter removal (Opinion) (133).
TABLE 6
Terminology for Peritonitis
Recurrent
Relapsing
Repeat
Refractory
Catheter-related peritonitis
An episode that occurs within 4 weeks of completion of therapy of a prior episode but with a different organism
An episode that occurs within 4 weeks of completion of therapy of a prior episode with the same
organism or 1 sterile episode
An episode that occurs more than 4 weeks after completion of therapy of a prior episode with the
same organism
Failure of the effluent to clear after 5 days of appropriate antibiotics
Peritonitis in conjunction with an exit-site or tunnel infection with the same organism or 1 site
sterile
Relapsing episodes should not be counted as another peritonitis when calculating peritonitis rates; recurrent and repeat episodes
should be counted.
404

organisms. Table 5 lists the most commonly used antibiotics that have been studied in APD and provides dosing
recommendations. Patients who are high transporters
and those with high dialysate clearances may have a more
rapid removal of some antibiotics. Adjustments in dosing for such patients are not yet known but the clinician
should choose the side of higher dosing.
Within 48 hours of initiating therapy, most patients
with PD-related peritonitis will show considerable clinical improvement. The effluent should be visually inspected daily to determine if clearing is occurring. If
there is no improvement after 48 hours, cell counts and
repeat cultures should be done. Antibiotic removal techniques may be used by the laboratory on the effluent in
an attempt to maximize culture yield.
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A recent retrospective study showed that relapsing

and recurrent peritonitis episodes are caused by different species of bacteria and probably represent two distinct clinical entities (133). Recurrent peritonitis
episodes have a worse prognosis than relapsing episodes.
COAGULASE-NEGATIVE STAPHYLOCOCCUS
Coagulase-negative staphylococcus, especially S. epidermidis, is still a very common organism in many programs, usually denotes touch contamination, generally
responds well to antibiotic therapy, and is seldom related
to a catheter infection. Most patients with S. epidermidis
Other Gram-Positive Organisms, Including Coagulase-Negative Staphylococcus, on Culture
Continue gram-positive coverage based on sensitivities

Stop gram-negative coverage
Assess clinical improvement, repeat dialysis effluent cell count and culture at days 35
Clinical improvement
(symptoms resolve; bags clear):
Continue antibiotics;
Reevaluate for exit-site or occult
tunnel infection, intra-abdominal
abscess, catheter colonization, etc.
Duration of therapy: 14 days
No clinical improvement
(symptoms persist; effluent remains cloudy):
Reculture & evaluate*
No clinical improvement by 5 days on

appropriate antibiotics: remove catheter
Peritonitis with exit-site or tunnel infection:

Consider catheter removal
Figure 2 Coagulase-negative staphylococcus (CoNS; Staphylococcus epidermidis): *CoNS can sometimes lead to relapsing peritonitis, presumably due to biofilm involvement. The duration of antibiotic therapy following catheter removal and timing of
resumption of peritoneal dialysis may be modified depending on clinical course.
405
Coagulase-negative staphylococcus peritonitis, including S. epidermidis, is due primarily to touch contamination, is generally a mild form of peritonitis,
and responds readily to antibiotic therapy but can
sometimes lead to relapsing peritonitis due to biofilm
involvement. In such circumstances, catheter replacement is advised (Evidence) (Figure 2) (37,134136).
peritonitis have mild pain and often can be managed as

outpatients. In some programs, and depending on the
precise species involved, there is a very high rate of methicillin resistance (>50%); therefore, these programs may
wish to use vancomycin as empiric therapy. The PD program should inquire of the laboratory the definition of
resistance based on MIC levels and, ideally, molecular
data (e.g., the presence of the mecA gene). Methicillin
resistance of staphylococci is defined as the presence of
the mecA gene and indicates that the organism is considered resistant to all beta-lactam-related antibiotics, including penicillins, cephalosporins, and carbapenems.
Every effort should be made to avoid inadequate levels
that may lead to relapsing peritonitis. The Committee feels
the existing data are inadequate to recommend intermittent dosing of first-generation cephalosporins and, until
more data are available, continuous dosing may be preferable. Ideally, repeated cell counts and cultures of the
effluent should guide the therapy but 2 weeks of therapy
is generally sufficient. The patients technique should be
reviewed to prevent recurrence.
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STREPTOCOCCUS AND ENTEROCOCCUS
In general, streptococcal peritonitis is readily curable

by antibiotics but enterococcal peritonitis tends to be
severe and is best treated with IP ampicillin when the
organism is susceptible (Opinion) (Figure 3) (140,141).
If vancomycin-resistant enterococcus (VRE) is ampicillin susceptible, ampicillin remains the drug of
choice; otherwise, linezolid or quinupristin/dalfopristin should be used to treat VRE peritonitis
(Opinion).
Streptococcal and enterococcal peritonitis generally
cause severe pain. Ampicillin 125 mg/L in each exchange
is the preferred antibiotic. An aminoglycoside (given
once daily IP as 20 mg/L) may be added for synergy for
enterococcal peritonitis. Addition of gentamicin is potentially useful only if there is no laboratory evidence of
high-level resistance to the antibiotic. Since enterococci
are frequently derived from the gastrointestinal tract,
intra-abdominal pathology must be considered but touch
contamination as a source is also possible. The microbiology laboratory should optimize techniques to recognize the presence of other bacterial species (e.g.,
anaerobic species) that can lead to more suspicion of an
406
intra-abdominal focus. The patients technique should

be reviewed as well.
Peritonitis with enterococci or streptococci may also
derive from infection of the exit site and tunnel, which
should be carefully inspected. Some streptococcal species originate from the mouth; assessment of dental hygiene could be considered in these cases. Isolated
infections with viridans streptococci have been reported
to be associated with slower response, poor outcome, and
higher rates of recurrence (142). In contrast, a recent
report from the Australian Registry showed that isolated
streptococcal peritonitis tends to respond well to antibiotic therapy (141). A report of 116 episodes of enterococcal peritonitis from the ANZDATA Registry observed
that this condition was generally more severe and had
worse outcomes than other forms of gram-positive peritonitis (143). Moreover, it was reported that other pathogenic organisms were isolated in addition to Enterococcus
species in approximately half of all cases of enterococcal
peritonitis, and that the recovery of other organisms was
associated with very high rates of catheter removal
(52%), permanent transfer to hemodialysis (52%), and
death (6%). Timely removal of the PD catheter within
1 week of the onset of refractory enterococcal peritonitis
was associated with a significant reduction in the risk of
permanent transfer to hemodialysis (74% vs 100%).
Increased infection rates are reported for amoxicillinor ampicillin-resistant Enterococcus faecium (ARE) but
data on the incidence in PD infections are lacking (144).
VRE has been reported and is seen most often in conjunction with recent hospitalization and prior antibiotic
therapy. Vancomycin-resistant E. faecium has been reported but remains uncommon in PD patients. Limited
data are available regarding the appropriate management of VRE peritonitis (145148). If VRE is ampicillin
susceptible, ampicillin remains the drug of choice.
Linezolid or quinupristin/dalfopristin should be used to
treat VRE peritonitis. Another recent report on two cases
of VRE peritonitis suggests that IP daptomycin may also
be effective (115) but the dosing and pharmacokinetics
need further studies. Quinupristin/dalfopristin, however, may not be active against E. faecalis isolates. Bone
marrow suppression usually occurs after 10 14 days of
linezolid therapy and more prolonged therapy can also
result in neurotoxicity. It is unclear if the catheter must
be removed for VRE peritonitis but, if the peritonitis does
not resolve readily, this certainly should be done.
STAPHYLOCOCCUS AUREUS
Staphylococcus aureus causes severe peritonitis. Although it may be due to touch contamination, it is

Coagulase-negative staphylococci consist of at least

20 clinically relevant species that are sometimes difficult to identify by automated systems and therefore require a molecular approach by 16S DNA sequencing. If
facilities are available, identification to the exact species level may be useful as some CoNS can cause serious
infections (e.g., S. schleiferi, S. lugdunensis, S. warneri)
and it may help to differentiate contaminated cultures
from true infections. The introduction of matrix-assisted
laser desorption/ionization-time of flight mass spectrometry (MALDI-TOF) techniques for routine bacterial
identification in several European countries enables microbiologists to recognize correctly the spectra of various species of CoNS (137,138). A recently performed
comparative study between MALDI-TOF and two rapid
identification automates for identification of 234 CoNS
isolates, representing 20 different species, revealed significantly better performance of MALDI-TOF (139).
Relapsing S. epidermidis peritonitis suggests colonization of the intra-abdominal portion of the catheter
with biofilm and is best treated by replacing the catheter (128). This can be done under antibiotic coverage
as a single procedure once the effluent clears with antibiotic therapy. Often, hemodialysis can be avoided by
using either supine PD or low volumes for a short period
of time.
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Enterococcus/Streptococcus on Culture
Discontinue starting antibiotics*

Start continuous ampicillin 125 mg/L each bag; consider adding aminoglycoside for Enterococcus
If ampicillin resistant, start vancomycin;

If vancomycin-resistant enterococcus, consider quinupristin/dalfopristin, daptomycin, or linezolid
Duration of therapy:
14 days (Streptococcus)
21 days (Enterococcus)

Peritonitis with exit-site or tunnel infection:

Consider catheter removal
Figure 3 Enterococcus or Streptococcus peritonitis: *Choice of therapy should always be guided by sensitivity patterns. If linezolid
is used for vancomycin-resistant enterococcus, bone marrow suppression has been noted after 10 14 days. The manufacturers
precaution label states that these antibiotics should not be mixed together in the same solution container. Physicians own judgment is necessary. The duration of antibiotic therapy following catheter removal and timing of resumption of peritoneal dialysis
may be modified, depending on clinical course.
often due to catheter infection. Staphylococcal peritonitis with concurrent exit-site or tunnel infection
is unlikely to respond to antibiotic therapy without
catheter removal (Evidence) (Figure 4) (5,23,149).
Rifampicin could be considered as an adjunct for the
prevention of relapse or repeat S. aureus peritonitis
but the enzyme-inducer effect of rifampicin should
be considered in patients taking other medications
(Opinion) (150).
If the organism is S. aureus, very careful attention
must be paid to the exit site and tunnel of the catheter,
as the mode of entrance of this organism is often via the
catheter, although touch contamination is another
source. If the episode occurs in conjunction with an exit-
site infection with the same organism, then often the

infection will prove to be refractory and the catheter
must be removed. After a rest period off PD (generally a
minimum of 2 weeks), PD can be tried again.
If the strain of S. aureus cultured is methicillin resistant then the patient must be treated with vancomycin.
Such infections are more difficult to resolve. Compared
with methicillin-sensitive S. aureus peritonitis, MRSA
peritonitis has been reported to be independently predictive of an increased risk of permanent transfer to hemodialysis (odds ratio 2.11) (151). Rifampicin 600 mg/
day orally (in single or split dose) can be added to the IP
antibiotics but therapy with this adjunctive antibiotic
should be limited to 1 week, as resistance often develops with longer courses. If the patient is considered at

407
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Staphylococcus aureus on Culture
Continue gram-positive coverage based on sensitivities*

Stop gram-negative coverage, assess exit site again
If methicillin resistant, adjust coverage to vancomycin or teicoplanin

Add rifampin 600 mg/day orally (in single or split dose) for 57 days (450 mg/day if BW <50 kg)
at least 21 days
Reculture & evaluate

Peritonitis with exit-site or tunnel infection may prove to be refractory

and catheter removal should be seriously considered.
Allow a minimum rest period of 3 weeks before reinitiating PD
Figure 4 Staphylococcus aureus peritonitis: *If vancomycin-resistant S. aureus, linezolid, daptomycin, or quinupristin/dalfopristin
should be used. Teicoplanin can be used in a dose of 15 mg/kg every 5 7 days. In areas where tuberculosis is endemic, rifampicin use for treatment of S. aureus should be restricted. Refractory is defined as failure to respond to appropriate antibiotics
within 5 days. The duration of antibiotic therapy following catheter removal and timing of resumption of peritoneal dialysis may
be modified depending on clinical course. BW = body weight; PD = peritoneal dialysis.
high risk to have asymptomatic tuberculosis, rifampicin

should be used with caution in order to preserve this drug
for treatment of tuberculosis.
Vancomycin may be administered as 15 30 mg/kg
body weight IP, with a maximum dose of 2 g. A typical
protocol for a patient 50 60 kg is vancomycin 1 g IP
every 5 days. Ideally, the timing of repetitive dosing
should be based on trough levels and is likely to be every
3 5 days. The dosing interval is dependent on residual
renal function and patients should receive another dose
once trough serum levels reach 15 mg/mL. Teicoplanin,
where available, can be used in a dose of 15 mg/kg body
weight every 5 7 days. Data for children suggest that
this approach is successful for both CAPD and APD. Treatment should be for 3 weeks (115,148).
408
In a recent review of 245 cases of S. aureus peritonitis, episodes that were treated initially with vancomycin
had a better primary response rate than those that were
treated with cefazolin (98.0% vs 85.2%, p = 0.001) but
the complete cure rate was similar (150). Adjuvant
rifampicin treatment for a period of 5 7 days was associated with a significantly lower risk for relapse or repeat S. aureus peritonitis than was treatment without
rifampicin (21.4% vs 42.8%). In this study, recent hospitalization was a major risk factor for methicillin resistance. However, it should be noted that rifampicin is a
potent inducer of drug-metabolizing enzymes and would
reduce the levels of many medications. Similarly, an
evaluation of 503 cases of staphylococcal peritonitis in
Australia found that the initial empiric antibiotic choice

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JULY 2010 VOL. 30, NO. 4
between vancomycin and cephazolin was not associated

with any significant differences in subsequent clinical
outcomes (151).
Unfortunately, prolonged therapy with vancomycin
may predispose dialysis patients to infections with
vancomycin-resistant S. aureus and should be avoided
whenever possible. If vancomycin-resistant S. aureus
peritonitis develops, linezolid, daptomycin, or quinupristin/dalfopristin could be considered.
CORYNEBACTERIUM PERITONITIS
Like CoNS, Corynebacterium species belong to the

natural flora of the skin and are therefore difficult to
recognize as pathogens. Previously, Corynebacterium
was thought to have little pathogenic potential in man.
However, reporting of infections due to Corynebacterium
has increased over the past few decades, in large part
due to improved recognition of the clinical relevance of
Corynebacterium species. In a retrospective study, recurrent Corynebacterium peritonitis was common after a
2-week course of antibiotics, but recurrent episodes can
usually be cured with a 3-week course of IP vancomycin
(152). Another large, retrospective, observational cohort study of 82 episodes of Corynebacterium peritonitis by the ANZDATA Registry (153) demonstrated that
Corynebacterium peritonitis not infrequently resulted in
relapse (18%), repeat peritonitis (15%), hospitalization
(70%), catheter removal (21%), permanent transfer to
hemodialysis (15%), and death (2%). The overall cure
rate with antibiotics alone for a median period of 2 weeks
was 67%. In individuals requiring catheter removal for
refractory peritonitis, those who had their catheters removed more than 1 week after the onset of Corynebacterium peritonitis had a significantly higher risk of
permanent transfer to hemodialysis than those who had
their catheters removed within 1 week (90% vs 43%).
Ideally, coryneform bacteria should be identified to the
species level. As for CoNS, further attempts should be
made to analyze the exact role of the gingival species
because the group Corynebacterium actually encompasses at least 46 different species.
CULTURE-NEGATIVE PERITONITIS
If a program has a rate of culture-negative peritonitis greater than 20%, then the culture methods should
be reviewed and improved (Opinion) (Figure 5)

(154,155).
Cultures may be negative for a variety of technical or
clinical reasons. The patient should always be queried
on presentation about use of antibiotics for any reason,
as this is a known cause of culture-negative peritonitis
(155). If there is no growth by 3 days, repeat cell count
with differential should be obtained. If the repeat cell
count indicates that the infection has not resolved, special culture techniques should be used for the isolation
of potential unusual causes of peritonitis, including
lipid-dependent yeast, mycobacteria, Legionella, slow
growing bacteria, Campylobacter, fungi, Ureaplasma,
Mycoplasma, and enteroviruses. This will require coordination with the microbiology laboratory.
In clinical practice, a large proportion of culturenegative peritonitis episodes are caused by gram-positive organisms (e.g., due to touch contamination), while
the causative organism is not identified for technical
reasons. If the patient is improving clinically, the initial
therapy can be continued. Duration of therapy should
be 2 weeks if the effluent clears rapidly. If, on the other
hand, improvement is inadequate by 5 days, catheter
removal should be strongly considered. A recent review
of 435 episodes of culture-negative peritonitis found that
this condition was significantly more likely to be cured
by antibiotics alone (77% vs 66%) and less likely to be
complicated by hospitalization (60% vs 71%), catheter
removal (12% vs 23%), permanent transfer to hemodialysis (10% vs 19%), or death (1% vs 2.5%) compared
with culture-positive peritonitis (155).
PSEUDOMONAS AERUGINOSA PERITONITIS
Pseudomonas aeruginosa peritonitis, similar to S. aureus peritonitis, is often related to a catheter infection
and in such cases catheter removal will be required. Two
antibiotics should always be used to treat P. aeruginosa peritonitis (Evidence) (Figure 6) (25,156,157).
Pseudomonas aeruginosa peritonitis is generally severe and often associated with infection of the catheter.
If catheter infection is present or has preceded peritonitis, catheter removal is necessary. Antibiotics must be
continued for 2 weeks while the patient is on hemodialysis. A large retrospective study of 191 episodes of
Pseudomonas peritonitis recently confirmed that
Pseudomonas peritonitis is associated with greater frequencies of hospitalization, high rates of catheter removal, and permanent transfer to hemodialysis but not
with increased death rates. Prompt catheter removal and

409
Corynebacterium is an uncommon but significant

cause of peritonitis and exit-site infection. Complete
cure with antibiotics alone is possible in many patients
(Opinion) (152,153).
LI et al.
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PDI
Culture Negative on Days 1 & 2
Continue initial therapy
Day 3: culture still negative

Clinical assessment
Repeat PD fluid white cell count and differential
Infection not resolving:

Special culture technique for unusual causes (e.g., viral,
mycoplasma, mycobacteria, Legionella). Consider fungi
Continue initial therapy for 14 days
Now culture positive
Adjust therapy according to

sensitivity patterns
Duration of therapy based on
organism identified
Still culture negative
Clinical improvement:
Continue antibiotic
14 days
after 5 days:
Remove catheter*
Continue antibiotics for at least

14 days after catheter removal
Figure 5 Culture-negative peritonitis: *The duration of antibiotic therapy following catheter removal and timing or resumption
of peritoneal dialysis (PD) may be modified depending on clinical course.
use of two antipseudomonal antibiotics are associated

with better outcomes (157).
Occasionally, P. aeruginosa peritonitis occurs in the
absence of a catheter infection. An oral quinolone can
be given as one of the antibiotics for P. aeruginosa peritonitis. Alternative drugs include ceftazidime, cefepime,
tobramycin, or piperacillin. Should piperacillin be
preferred, its dose is 4 g IV every 12 hours in adults. Piperacillin cannot be added to the dialysis solution in conjunction with aminoglycosides.
Every effort to avoid P. aeruginosa peritonitis should
be made by replacing the catheter for recurrent, relapsing, or refractory exit-site infections with P. aeruginosa
prior to the development of peritonitis. In such cases,
the catheter can be replaced as a single procedure;
410
whereas, if peritonitis develops, the catheter must be

removed and the patient taken off PD for a period of time.
In many such cases, permanent peritoneal membrane
damage may have occurred.
OTHER SINGLE GRAM-NEGATIVE MICRO-ORGANISMS
CULTURED
Single-organism gram-negative peritonitis may be

due to touch contamination, exit-site infection, or
transmural migration from constipation, diverticulitis, or colitis (Evidence) (Figure 7) (6,158165).
If a single gram-negative organism, such as E. coli,
Klebsiella, or Proteus, is isolated, the antibiotic to be

Infection resolving
Patient improvement clinically
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JULY 2010 VOL. 30, NO. 4
Pseudomonas Species on Culture
Without catheter infection (exit-site/tunnel)
Give 2 different antibiotics acting in different ways

that organism is sensitive to, e.g., oral quinolone,
ceftazidime, cefepime, tobramycin, piperacillin
at least 21 days
Catheter removal*
q
Continue oral and/or systemic
antibiotics for at least 2 weeks

Figure 6 Pseudomonas peritonitis. *The duration of antibiotic therapy following catheter removal and timing or resumption of
peritoneal dialysis may be modified depending on clinical course.
used can be chosen based on sensitivities, safety, and

convenience. A fluoroquinolone or cephalosporin may
be indicated based on in vitro sensitivity testing. Unfortunately, organisms in the biofilm state may be considerably less sensitive than the laboratory indicates (160),
which may account for the high proportion of treatment
failures even when the organism appears to be sensitive
to the antibiotic used (161). A recent retrospective study
of 210 cases suggested that recent antibiotic therapy is
the major risk factor for antibiotic resistance; exit-site
infection, and probably recent antibiotic therapy, is associated with poor therapeutic response (163). The SPICE
organisms (Serratia, Pseudomonas, and indol-positive
organisms such as Providencia, Citrobacter, and
Enterobacter) seem to have a particularly high risk of
relapse. One retrospective study suggests that two antibiotics may reduce the risk of relapse and recurrence
compared to single-agent therapy (163). Outcomes of
these infections are worse than gram-positive outcomes
and are more often associated with catheter loss and
death. Single-organism gram-negative peritonitis may
be due to touch contamination, exit-site infection, or

possibly a bowel source, such as constipation, colitis, or
transmural migration. Often the etiology is unclear. Response of gram-negative peritonitis in pediatric PD patients treated with empiric IP ceftazidime is often
suboptimal (164).
The isolation of a Stenotrophomonas organism,
while infrequent, requires special attention since it
displays sensitivity to only a few antimicrobial agents
(158,165). Prior therapy with carbapenems, fluoroquinolones, and third- or fourth-generation cephalospor ins usually precedes Stenotrophomonas
infections. Infection with this organism is generally
not as severe as with Pseudomonas and is usually not
associated with an exit-site infection. Therapy for
Stenotrophomonas peritonitis is recommended for 3
4 weeks if the patient is clinically improving. Treatment
with two drugs (chosen based on the sensitivities) is
recommended: the most effective agents are usually
oral trimethoprim/sulfamethoxazole, IP ticarcillin/
clavulanate, and oral minocycline.

411
Assess clinical improvement, repeat dialysis

effluent cell count and culture at days 35
With catheter infection (exit-site/

tunnel) current or prior to peritonitis
LI et al.
JULY 2010 VOL. 30, NO. 4
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Single Gram-Negative Organism on Culture*
Other
E. coli, Proteus, Klebsiella, etc.
Stenotrophomonas
Treat with 2 drugs with differing mechanisms

based on sensitivity pattern (oral trimethoprim/
sulfamethoxazole is preferred)


1421 days
No clinical improvement by
5 days on appropriate antibiotics
(symptoms persist; effluent remains
cloudy): remove catheter
2128 days
Figure 7 Other single gram-negative organism peritonitis: *Choice of therapy should always be guided by sensitivity patterns.
POLYMICROBIAL PERITONITIS
If multiple enteric organisms are grown, particularly

in association with anaerobic bacteria, the risk of
death is increased and a surgical evaluation should
be obtained (Evidence) (Figure 8) (166169).
Peritonitis due to multiple gram-positive organisms
will generally respond to antibiotic therapy (Evidence)
(4,170173).
In cases of multiple enteric organisms, there is a possibility of intra-abdominal pathology such as diverticulitis, cholecystitis, ischemic bowel, appendicitis, etc.
Presentation with hypotension, sepsis, lactic acidosis,
and/or elevation of peritoneal fluid amylase level should
raise immediate concern for surgical peritonitis (174).
A rapid Gram staining of the effluent may lead to the
recognition of a mixed bacterial population suggestive
for an intestinal origin. In this setting where the intestines are felt to be the source, the therapy of choice is
metronidazole in combination with ampicillin and ceftazidime or an aminoglycoside in the recommended
doses. The catheter may need to be removed, particularly if laparotomy indicates intra-abdominal pathology
412
and, in that case, antibiotics should be continued via the

IV route. Antibiotics can be tried, however, and in some
cases the catheter may not need to be removed. Computed tomographic (CT) scan may help identify intraabdominal pathology but a normal CT scan does not
eliminate the possibility of intra-abdominal pathology
as a source.
Polymicrobial peritonitis due to multiple gram-positive organisms more common than that due to enteric
organisms has a much better prognosis (175). The
source is most likely contamination or catheter infection; the patients technique should be reviewed and the
exit site carefully examined. Polymicrobial peritonitis
due to contamination generally resolves with antibiotics without catheter removal, unless the catheter is the
source of the infection.
FUNGAL PERITONITIS
Fungal peritonitis is a serious complication and should

be strongly suspected after recent antibiotic treatment for bacterial peritonitis. Catheter removal is indicated immediately after fungi are identified by
microscopy or culture (Evidence) (116118,176).

Adjust antibiotics to sensitivity pattern. Cephalosporin

(ceftazidime or cefepime) may be indicated
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JULY 2010 VOL. 30, NO. 4
Polymicrobial Peritonitis: Days 13
Multiple gram-negative organisms or

mixed gram-negative/gram-positive:
Consider GI problem
Multiple gram-positive organisms

Touch contamination
Consider catheter infection
Change therapy to metronidazole

in conjunction with ampicillin,
ceftazidime, or aminoglycoside
Continue therapy based on sensitivities
Without exit-site or tunnel

infection:
continue antibiotics
In case of laparotomy indicating

intra-abdominal pathology/
abscess: remove catheter*
With exit-site or tunnel

infection:
remove catheter*
minimum 21 days based
on clinical response
Continue antibiotics: 14 days

Figure 8 Polymicrobial peritonitis: *The duration of antibiotic therapy following catheter removal and timing or resumption of
peritoneal dialysis may be modified depending on clinical course. GI = gastrointestinal.
Prolonged treatment with antifungal agents to determine response and to attempt clearance is not encouraged. Fungal peritonitis is serious, leading to death of
the patient in approximately 25% or more of episodes
(116,117). Some evidence suggests that prompt catheter
removal poses a lesser risk of death. A recent Australian
report analyzed 162 episodes of fungal peritonitis retrospectively (176): Candida albicans and other Candida
species were the most frequently isolated fungi. Compared with other micro-organisms, fungal peritonitis was
associated with higher rates of hospitalization, catheter
removal, transfer to hemodialysis, and death (176). Initial therapy may be a combination of amphotericin B and
flucytosine, until the culture results are available with
susceptibilities. An echinocandin (e.g., caspofungin or
anidulafungin), fluconazole, posaconazole, or voriconazole may replace amphotericin B based on species
identification and MIC values. Intraperitoneal use of
amphotericin causes chemical peritonitis and pain; IV
use leads to poor peritoneal bioavailability. Voriconazole
or posaconazole are alternatives for amphotericin B
when filamentous fungi have been cultured. Neither of
them can be used alone for Candida peritonitis (with

catheter removal). Voriconazole at a dose of 200 mg IV
twice daily for 5 weeks after catheter removal has been
used successfully (177). Posaconazole at 400 mg twice
daily for 6 months has been used successfully for the
treatment of liposomal amphotericin B-resistant PDrelated Mucor peritonitis (178). Echinocandins (e.g.,
caspofungin, micafungin, and anidulafungin) have been
advocated for the treatment of fungal peritonitis attributable to Aspergillus and non-responding non-albicans
Candida, and in patients intolerant to other antifungal
therapies (179). Caspofungin has been used successfully
as monotherapy (70 mg IV loading dose, then 50 mg
daily) (180) or in combination with amphotericin (181).
If flucytosine is used, regular monitoring of serum
concentrations is necessary to avoid bone marrow toxicity. Generally, trough serum flucytosine concentrations
should be 25 50 g/mL and transiently not greater than
100 g/mL (41). Emergence of resistance to the azoles
has occurred, thus indicating the importance of sensitivities where available. Therapy with these agents
should be continued orally with flucytosine 1000 mg and

413
Obtain urgent surgical assessment
LI et al.
JULY 2010 VOL. 30, NO. 4
fluconazole 100 200 mg daily for an additional 10 days

after catheter removal. The withdrawal of oral flucytosine from many countries and the price of many new antifungal agents will affect local protocols.
PERITONITIS DUE TO MYCOBACTERIA
Mycobacteria are an infrequent cause of peritonitis

and can be difficult to diagnose. When under clinical
consideration, special attention must be paid to culture techniques. Treatment requires multiple drugs
(Evidence) (23,182192).
414
ments are used for specif ic mycobacteria (e.g.,

M. haemophilum). Repeat microscopic smear examination and culture of dialysis effluent is mandatory for better yield in suspected cases of mycobacterial peritonitis.
Exploratory laparotomy or laparoscopy with biopsy of the
peritoneum or omentum should be considered in patients
in whom the diagnosis is being considered. When a Ziehl
Neelsen technique reveals the presence of acid-fast rods,
and if facilities are available, a molecular test (e.g., PCR)
should be applied directly on the pellet to diagnose
M. tuberculosis infection.
The treatment protocol for M. tuberculosis peritonitis
should be based on general protocols for treatment of
tuberculosis. The patient should be investigated for pulmonary disease and other extrapulmonary locations.
Since streptomycin, even in reduced doses, may cause
ototoxicity after prolonged use, it should generally be
avoided. Similarly, ethambutol is not recommended because of the high risk of optic neuritis in end-stage renal
disease. Treatment is started with four drugs: rifampicin, isoniazid, pyrazinamide, and ofloxacin. However, a
recent study showed that rifampicin dialysis fluid levels
are low due to its high molecular weight, high proteinbinding capacity, and lipid solubility. Therefore, for treatment of tuberculous peritonitis, rifampicin may need to
be given via the IP route. Treatment with pyrazinamide
and ofloxacin is stopped after 3 months; rifampicin and
isoniazid are continued for a total of 12 18 months.
Pyridoxine (50 100 mg/day) should be given to avoid
isoniazid-induced neurotoxicity. The optimal duration of
treatment for multidrug-resistant tuberculous peritonitis remains unknown. The treatment protocol for nontuberculous mycobacterial peritonitis is not well
established and requires individualized protocols based
on susceptibility testing.
Removal of the catheter is still a contentious issue.
While many people would remove the PD catheter in a
patient with tuberculous peritonitis and consider reinsertion after 6 weeks of antituberculous treatment, there
are some case series of successful treatment without
catheter removal. Long-term continuation of CAPD is
possible, especially if the diagnosis is made early and
appropriate therapy promptly initiated.
Data on peritonitis caused by nontuberculous mycobacteria remain limited. Most nontuberculous mycobacteria have growth characteristics similar to normal
skin bacteria and are only recognized by acid-fast
staining. Although the case remains controversial, it has
been postulated that extensive use of topical gentamicin ointment for exit-site infection might predispose
patients to atypical mycobacterial infection of the exit
site (192).

Mycobacterial peritonitis can be caused by Mycobacterium tuberculosis or non-tuberculosis mycobacteria,

such as M. fortuitum, M. avium, M. abscessus, and
M. chelonae. The incidence of tuberculous peritonitis is
higher in Asia than elsewhere. It is important to differentiate patients with miliary tuberculosis, whose peritonitis is part of the disseminated disease, from those
with isolated tuberculous peritonitis without extraperitoneal infection. While the classic symptoms of
fever, abdominal pain, and cloudy effluent may occur
with mycobacterial peritonitis, the diagnosis should be
considered in any patient with prolonged failure to
thrive, prolonged symptoms despite antibiotic therapy,
and relapsing peritonitis with negative bacterial
cultures.
The cell count cannot be used to differentiate mycobacterial peritonitis from other forms although chronic
tuberculous peritonitis is frequently associated with lymphocytosis. Most cases of acute mycobacterial peritonitis have a predominance of polymorphonuclear WBC,
similar to bacterial peritonitis. Smears of the peritoneal
effluent should be examined with ZiehlNeelsen stain
but smear negative disease is common. The sensitivity
of the smear examination by the ZiehlNeelsen technique can be enhanced by centrifuging 100 150 mL of
the dialysate sample, digestion with a mixture of 2%
N-acetyl-L-cysteine (NALC)2% NaOH, and smear preparation from the pellet. Alternatively, mycobacterial DNA
PCR can be performed on peritoneal dialysate for improved sensitivity, although false positives are not uncommon (191). A specific diagnosis can be made by
culturing the sediment, after centrifugation of a large
volume of effluent (50 100 mL), using a combination
of solid medium (such as LwensteinJensen agar) with
fluid media (Septi-Chek, BACTEC, etc.). The time of
detection for growth of mycobacteria is decreased considerably in fluid medium. The recovery rate of nontuberculous mycobacteria may increase when lower incubation
temperatures are applied and growth-promoting supple-
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LENGTH OF THERAPY FOR PERITONITIS
The Committee feels that the minimum therapy for

peritonitis is 2 weeks; although 3 weeks is recommended for more severe infections (Opinion).
CATHETER REMOVAL AND REINSERTION FOR PERITONEAL

INFECTION
The Committee recommends removing the catheter for

relapsing peritonitis, refractory peritonitis, fungal
peritonitis, and refractory catheter infections. The
focus should always be on preservation of the peritoneum rather than on saving the peritoneal catheter
(Opinion) (3,3437,134,193195).
It is the impression of the Committee that catheter
removal is not done often enough in managing peritoneal infections. Indications for catheter removal for infections are shown in Table 7. Timely replacement of the
catheter for refractory exit-site infections can prevent
peritonitis, a far better approach than waiting until the
patient has the more serious infection. This approach has
the added advantage of permitting simultaneous replacement, thus avoiding prolonged periods on hemodialysis. Some patients, especially those using a cycler,
can avoid hemodialysis altogether by dialyzing only in
the supine position for several days to avoid leaks and
hernias, with subsequent addition of the daytime
exchange.
Catheter replacement as a single procedure can also
be done for relapsing peritonitis if the effluent can first
be cleared. This procedure should be done under antibiotic coverage.
For refractory peritonitis and fungal peritonitis, simultaneous catheter replacement is not possible. The
optimal time period between catheter removal for infection and reinsertion of a new catheter is not known.
Empirically, a minimum period of 2 3 weeks between
catheter removal and reinsertion of a new catheter is
recommended, although some would recommend later
reinsertion in cases of fungal peritonitis.
After severe episodes of peritonitis, some patients are
able to return to PD. In other patients, adhesions may
prevent reinsertion of the catheter, or continuation on
PD is not possible due to permanent membrane failure.
In a recent review of 189 peritonitis episodes, Troidle
et al. (195) found that only 47% of the patients underwent a successful catheter reinsertion and, of those, only
34% remained on PD 1 year later. Unfortunately, it is difficult to predict who will have many adhesions and who
will not. Reinsertion of a new catheter should preferably
be done by laparoscopic approach or minilaparotomy so
that any adhesion can be directly visualized by the
surgeon.
PREVENTION OF FURTHER PERITONITIS
The frequency of relapsing peritonitis also must be

examined. For each peritonitis episode, a root-cause
analysis should be done to determine the etiology and,
whenever possible, an intervention directed against any
reversible risk factor should be made to prevent another
episode. For example, single gram-positive infections
have been associated predominantly with touch contamination or catheter infections; S. aureus infections have
been associated with touch contamination or catheter
infections; single-organism gram-negative infections
have been associated with touch contamination, exitsite infections, or transmural migration (constipation or
colitis). Prior antibiotic use by the patient may also be
associated with culture-negative peritonitis. Identification of etiology may involve a review of the patients
technique. If necessary, retraining should be performed
and this should be done only by an experienced PD nurse.
FUTURE RESEARCH
Pharmacokinetic data of many new antibiotics, administered either systemically or IP, are urgently needed.
Further clinical trials in PD patients are required,
particularly double-blinded randomized trials assessing
different treatment strategies and powered to detect
meaningful differences using appropriate numbers of
patients, and with sufficient follow-up. Such studies
require large enough patient numbers to evaluate

415
In clinical practice, the length of treatment is determined mainly by the clinical response. After initiation
of antibiotic treatment, clinical improvement should be
present during the first 72 hours. Patients having cloudy
effluent on appropriate antibiotics after 5 days have refractory peritonitis and should have their catheter
removed.
In patients with CoNS peritonitis and in patients with
culture-negative peritonitis, antibiotic treatment should
be continued for at least 7 days after the effluent clears,
and for no less than 14 days total. This means that 14 days
is usually adequate for treatment of peritonitis in uncomplicated episodes due to CoNS. In patients who respond slowly to the initial antibiotic therapy (especially
episodes caused by S. aureus, gram-negative peritonitis, or enterococcal peritonitis), a 3-week treatment is
recommended (whether the catheter is removed or not).
LI et al.
JULY 2010 VOL. 30, NO. 4
416
TABLE 8
Recommendations for Research in Peritoneal
Dialysis (PD)-Related Infections
Manuscripts should include the following information
Description of population
Connection methodology (spike, Luer lock, etc.)
Type of PD (CAPD with number of exchanges, CCPD, APD with
dry day)
Exit-site infection, tunnel infection, and peritonitis
definitions
Use of standard definitions for repeat, recurrent, relapsed,
refractory, and cured peritonitis
Use of a standard definition for peritonitis-associated death
Exit-site care protocol
Staphylococcus aureus prevention protocol, if there is one
Training protocol
Proportion of patients requiring a helper
Proportion of patients who are carriers for all studies of
Staphylococcus aureus
Peritonitis rates: overall and for individual organisms
Power calculations for determining the number of patients
required for evaluation of an outcome
Detailed antimicrobial regimen description to include
agents, doses, frequency of administration, duration, route,
concomitant serum and dialysate levels (specify peak,
trough, mean, other)
CAPD = continuous ambulatory PD; CCPD = continuous cycling
PD; APD = automated PD.
overall rate but also as individual rates rather than percentages of infections due to specific organisms. Terminology for relapsing and refractory peritonitis as well as
primary cure should be kept constant. Multicenter
studies will probably be needed to enable recruitment
of the number of patients required to answer most of
these questions.
DISCLOSURES
Philip Kam-Tao Li has participated in clinical trials with
Baxter. Cheuk-Chun Szeto declares no conflict of interest. Judith Bernardini is a consultant with Baxter Healthcare. Ana Figueiredo has received speakers honoraria
from Baxter and travel sponsorship from Baxter and Fresenius. David Johnson has received speakers honoraria
from Baxter and Fresenius and has participated in clinical trials with Baxter, Fresenius, and Gambro. He has
been a consultant to Baxter and Gambro and has received
travel sponsorships from Baxter and Fresenius. He is also
the recipient of a Baxter Extramural Research Grant. Dirk
Struijk has received lecturing honoraria from Baxter and
has participated in clinical trials with Baxter.

significant differences in outcomes and such studies may

need to be multicenter in design. Outcomes to be examined should include not only resolution without catheter
removal but also duration of peritoneal inflammation,
relapse, and repeat peritonitis, as well as change in peritoneal solute transport. Investigations into the role of
biofilm in repeat episodes are also needed.
Many of the antibiotic stability data are old and need
to be repeated in new PD solutions (e.g., glucose polymer and amino acid solutions). Pharmacodynamic research has advanced the management of infectious
disease by characterizing complex antibioticpathogenhost interactions. Such investigations specific to
dialysis-related peritonitis, however, are scarce. Therapeutic decisions in the management of peritonitis are
guided largely by the standard MIC, even though it does
not account for unique factors such as high IP antibiotic concentration, commonly used antibiotic combinations, and altered antibiotic activity in the peritoneal
environment.
More information is needed on modifiable risk factors for peritonitis. The benefit of screening for S. aureus
carriage, either after an episode of staphylococcal peritonitis or routinely in a PD unit, needs to be clarified.
Conventional dialysis solutions inhibit peritoneal immune function, decreasing the ability of the patient to
fight infection. More studies are needed on the newer
dialysis solutions, which are more biocompatible and may
possibly impact on peritonitis risk.
The development of antibiotic resistance in PD patients requires further study. The impact on the development of resistant organisms through of the use of
vancomycin, fourth-generation cephalosporins, and
carbapenems as opposed to cephalosporins and fluoroquinolones to treat PD-related infections should be examined in a large multicenter trial.
It is probably a matter of time before PD infections
due to extended-spectrum beta-lactamase- and carbapenemase-producing gram-negative rods and multiresistant gram-positive bacteria will be diagnosed (97).
Treatment protocols should always include simple and
small-spectrum antibiotics but research is warranted on
the dosage and pharmacokinetics of new antibiotics and
antifungal agents so that we are better prepared when
multiresistance is observed.
As described in the previous recommendations, all
manuscripts relating to PD infections should be standardized to include sufficient data for interpretation and
reproducibility. Information that reviewers and editors
should look for is included in Table 8. Methods must include data on training methods and connection used to
perform PD. Results should be presented not only as an
PDI
PDI
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Peritoneal Dialysis International, Vol. 30, pp.

0896-8608/10 $3.00 + .00

PERITONEAL DIALYSIS-RELATED INFECTIONS

cluded sections on treatment as well as prevention of

Reporting of peritonitis rate

Correspondence to: P.K.T. Li, Department of Medicine and

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JULY 2010 VOL. 30, NO. 4

REPORTING OF PERITONITIS RATE

EXIT-SITE AND TUNNEL INFECTIONS

Purulent drainage from the exit site indicates the

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JULY 2010 VOL. 30, NO. 4

PD-RELATED INFECTIONS RECOMMENDATIONS

THERAPY FOR EXIT-SITE AND TUNNEL INFECTIONS

Oral Antibiotics Used in Exit-Site and Tunnel Infection

The most serious and common exit-site pathogens are

culosis is endemic. Rifampicin should never be given as

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JULY 2010 VOL. 30, NO. 4

INITIAL PRESENTATION AND MANAGEMENT OF

Culture-positive infectious peritonitis

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JULY 2010 VOL. 30, NO. 4

With this exception, empiric therapy should not be based

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trials comparing icodextrin- to glucose-based dialysis

PD-RELATED INFECTIONS RECOMMENDATIONS

JULY 2010 VOL. 30, NO. 4

Culture-negative peritonitis should not be greater

positive after the first 24 hours and, in over 75% of cases,

There is not enough evidence for recommending the

Empiric antibiotics must cover both gram-positive and

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In the ideal situation (e.g., in specialized academic

JULY 2010 VOL. 30, NO. 4

PD-RELATED INFECTIONS RECOMMENDATIONS

Start intraperitoneal antibiotics as soon as possible

Collect data to include

Determine and prescribe ongoing antibiotic treatment

continuous dosing of antibiotics are equally efficacious

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Immediately report cloudy effluent,

JULY 2010 VOL. 30, NO. 4

broad for routine application and should be considered

Vancomycin, aminoglycosides, and cephalosporins

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JULY 2010 VOL. 30, NO. 4

INTERMITTENT OR CONTINUOUS DOSING OF ANTIBIOTICS:

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