Peritoneal Dialysis–Associated Peritonitis

Cheuk-Chun Szeto and Philip Kam-Tao Li

Abstract
Peritonitis is a common and severe complication in peritoneal dialysis (PD). Detailed recommendations on the
prevention and treatment of PD-associated peritonitis have been published by the International Society for
Peritoneal Dialysis (ISPD), but there is a substantial variation in clinical practice among dialysis units. Prophylactic
antibiotics administered before PD catheter insertion, colonoscopy, or invasive gynecologic procedures, daily Department of
topical application of antibiotic cream or ointment to the catheter exit site, and prompt treatment of exit site or Medicine and
catheter infection are key measures to prevent PD-associated peritonitis. When a patient on PD presents with Therapeutics, Carol
and Richard Yu
clinical features compatible with PD-associated peritonitis, empirical antibiotic therapy, with coverage of both
Peritoneal Dialysis
Gram-positive and Gram-negative organisms (including Pseudomonas species), should be started once the Research Centre,
appropriate microbiologic specimens have been obtained. Intraperitoneal is the preferred route of administra- Prince of Wales
tion. Antifungal prophylaxis, preferably oral nystatin, should be added to prevent secondary fungal peritonitis. Hospital, The Chinese
Once the PD effluent Gram stain or culture and sensitivity results are available, antibiotic therapy can be University of Hong
Kong, Shatin, Hong
adjusted accordingly. A detailed description on the dosage of individual antibiotic can be found in the latest Kong SAR, China
recommendations by the ISPD. The duration of antibiotics is usually 2–3 weeks, depending on the specific
organisms identified. Catheter removal and temporary hemodialysis support is recommended for refractory, Correspondence:
relapsing, or fungal peritonitis. In some patients, a new PD catheter could be inserted after complete resolution Prof. Philip Kam-Tao
of the peritonitis. PD catheter removal should also be considered for refractory exit site or tunnel infections. Li, Department of
After the improvement in clinical practice, there is a worldwide trend of reduction in PD-associated peritonitis Medicine and
Therapeutics, Prince of
rate, supporting the use of PD as a first-line dialysis modality. Wales Hospital, 32
CJASN 14: 1100–1105, 2019. doi: https://doi.org/10.2215/CJN.14631218 Ngan Shing Street,
Shatin, New
Territories, Hong
Kong, China. Email:
Introduction rate at least on a yearly basis (6). The rate should be [email protected]
Peritonitis is a common and serious complication of reported as the number of episode per patient-year
peritoneal dialysis (PD). PD-associated peritonitis is the but not the number of patient-months per episode (6).
direct or major contributing cause of death in .15% of In addition to the overall peritonitis rate, the perito-
patients on PD (1,2). Moreover, a single episode of severe nitis rates of specific organisms, percentage of peri-
peritonitis or multiple peritonitis episodes frequently tonitis-free patients per year, and the spectrum of
leads to diminished peritoneal ultrafiltration capacity antibiotic resistance should be monitored (6). During
and is the most common cause of conversion to long- the calculation of peritonitis rate, relapsing episodes
term hemodialysis (3). should be counted only once, and all episodes that
Over the past 30 years, recommendations on the develop after PD training has commenced (not com-
treatment and prevention of PD-associated peritonitis pleted) should be counted (6). Although the recom-
were published and revised regularly under the aus- mendations state that the overall peritonitis rate
pices of the International Society for Peritoneal Dialysis should be below 0.5 episodes per patient-year, there
(ISPD). In the 2010 version, two sets of recommendations is a wide variation in the peritonitis rates reported by
were issued: one on the treatment of PD-associated different countries, as well as by different centers within
peritonitis and catheter-related infections (4), and an- the same country (8). A recent study shows highly
other on their prevention (5). In the latest 2016 version, variable rates of adopting the ISPD recommendations
however, both the treatment and prevention of PD- across different centers, and such variations probably
associated peritonitis were combined into one set of account for the difference in infection risk between PD
recommendations (6), and a separate set of recommen- centers (9).
dations on catheter-related infections was published in
2017 (7). Because their focuses are different, their specific Prevention of PD-Associated Peritonitis
recommendations are not entirely identical. In this re- PD Equipment and Training. At least four random-
view, we focus on the prevention and treatment of ized, controlled trials support the use of prophylactic
PD-associated peritonitis. antibiotics before PD catheter insertion (6,10). Intrave-
nous vancomycin, cefazolin, gentamicin, and cefurox-
Reporting of Peritonitis Rate ime have been tested (10). The optimal choice of
The ISPD recommendations emphasize that every PD antibiotic, however, is not well defined, and should
program should monitor the PD-associated peritonitis be determined by the local spectrum of antibiotic

1100 Copyright © 2019 by the American Society of Nephrology www.cjasn.org Vol 14 July, 2019
CJASN 14: 1100–1105, July, 2019 PD-Associated Peritonitis, Szeto and Li 1101

resistance. Besides prophylactic antibiotics, other aspects of rate of peritonitis (24,25). Intranasal mupirocin is effective for
catheter insertion practice, including the method of catheter reducing S. aureus exit site infection, but not peritonitis (26).
placement (mini-laparotomy, laparoscopy, or peritoneo- Excessive amounts of topical mupirocin directly applied onto
scopy), site of skin incision (midline or lateral), catheter the polyurethane or silicone catheter surface can cause
design (e.g., extended, presternal, or upper abdominal catheter), catheter erosion (27). Patients must be educated about the
configuration (straight or swan-neck, single or double cuff), and proper method of application.
the direction of exit site do not significantly affect the peritonitis Topical gentamicin is a reasonable alternative to mupir-
rate (11,12). Nonetheless, a large, observational study suggests ocin for exit site care (28), but the evidence seems less
that the double-cuff catheter is associated with a reduction in robust. Gentamicin offers an advantage over mupirocin in
peritonitis caused by Staphylococcus aureus (13). centers with a high rate of exit site infection by Gram-negative
Disconnect PD systems with a “flush before fill” design organisms, but the possibility of gentamicin resistance, which
are consistently associated with a lower peritonitis rate than affects the choice of antibiotic for peritonitis treatment, is a
the traditional spike systems, and are the standard of contin- definite concern. Other alternative strategies, such as
uous ambulatory peritoneal dialysis (CAPD) practice nowa- topical antibacterial honey (29) or triple ointment (polymyxin,
days (11,14). There is no significant difference in peritonitis bacitracin, and neomycin) (30), have been tested, but none is
rate between various disconnect systems (Y-set, double- shown to be superior than topical mupirocin. In general,
bag, or luer lock) (11,14), or between CAPD and machine- regular systemic antibiotic prophylaxis is not advisable.
assisted automated PD (15,16). It is uncertain whether the Although intermittent oral rifampicin reduces the rate of
choice of dialysis solution (conventional glucose-based S. aureus peritonitis (31), rifampicin resistance, adverse
solutions or biocompatible solutions with neutral pH and effects, and drug interactions are all serious concerns.
low glucose-degradation product) leads to any differences Other Modifiable Risk Factors. Many other modifiable
in peritonitis occurrence (17). risk factors for PD peritonitis have been reported (8), but
Training and Nursing Practice. A good PD training pro- their absolute risk (e.g., cirrhosis, polycystic kidney disease,
gram would logically minimize the peritonitis rate. It is left ventricular assist device, neutropenia during chemo-
generally accepted that PD training should be conducted by therapy) are not well defined, and interventions to only very
nursing staff with the appropriate qualifications and expe- few have been proved to reduce peritonitis risk. Peritonitis often
rience, and the latest ISPD recommendations for teaching follows invasive endoscopic procedures (e.g., colonoscopy,
PD patients and their caregivers should be followed (18,19). hysteroscopy) in patients on PD (32). Prophylactic systematic
However, published data are limited, and the critical ele- antibiotic before colonoscopy or invasive gynecologic pro-
ments of a training program that determine the peritonitis cedures should be considered (6). Although the optimal
rate remain undefined. The ongoing Targeted Education antibiotic regimen is unknown, intravenous ampicillin
Approach to Improve Peritoneal Dialysis Outcomes Trial, with or without aminoglycoside or metronidazole is most
to be completed in 2023 (20), will help to clarify the benefit commonly used (10). The efficacy of prophylactic antibiotic
of comprehensive PD training programs. given intraperitoneally before other invasive procedures is
After PD training is completed, a home visit by PD nurse not proved. Prophylactic antibiotics should also be consid-
is valuable in detecting unforeseen practical problems with ered after wet contamination or other breaches in technique
home dialysis (6). However, the benefit of home visit on (5), but there is no widely accepted regimen (6). Although it
peritonitis risk has not been formally tested. In addition to is a common practice to change the extension tubings after
the initial training, retraining should be considered after touch contamination, published evidence is limited. Con-
peritonitis or catheter infection episodes; any change in stipation, enteritis, and hypokalemia are associated with
dexterity, vision, or mental acuity; change in supplier or an increased risk of peritonitis by enteric organisms (6,8),
connection system; prolonged hospitalization; or interruption and these conditions deserve treatment on their own right.
of PD because of other reasons (6). Early studies suggest Secondary Prevention. Most fungal peritonitis episodes
that a continuous quality improvement (CQI) program in are preceded by the use of systemic antibiotics (6,33). Ran-
the PD center may help to reduce peritonitis rates (6,21). domized, controlled trials and a systematic review show that
Nationwide CQI programs have been found to sustainably the use of either oral nystatin or fluconazole during antibiotic
reduce peritonitis rates (22). A detailed description on the therapy reduces the risk of secondary fungal (especially
organization of CQI programs is beyond the scope of this Candida) peritonitis (6,10). In countries where nystatin is
review. Nonetheless, a multidisciplinary team that runs available, it should be the preferred choice because it has
CQI programs should meet and review performance metrics no systematic effect or drug interactions. Antifungal pro-
regularly (6). phylaxis may also reduce the risk of fungal peritonitis when a
Exit Site and Catheter Infections. Exit site and catheter patient on PD receives systemic antibiotics for nonperitonitis
tunnel infections are an important risk factor of PD- infections (10), but this practice does not seem to be widely
associated peritonitis (23). Their early detection and prompt adopted.
antibiotic treatment are logical steps to minimize the risk of After each episode of peritonitis, a root cause analysis
subsequent peritonitis (6). The proper care of catheter exit site should be performed to determine the etiology and possible
plays a pivotal role in prevention. Daily topical application of interventions to prevent further episodes (6). For example,
antibiotic cream or ointment to the catheter exit site is exchange technique should be reviewed after peritonitis
recommended (6), and mupirocin cream or ointment should episodes caused by touch contamination, and replacement
be the agent of choice (24). Daily application of mupirocin of PD catheter should be considered after relapsing or repeat
cream or ointment to the skin around the exit site reduces the peritonitis episodes (6). The key measures for the prevention
rate of S. aureus exit site infection and probably decreases the of PD-associated peritonitis are summarized in Table 1.
1102 CJASN

intraperitoneal antibiotics, however, the systemic route

Table 1. Key measures for the prevention of PD-associated should be used as a temporary measure so as to ensure a
peritonitis
prompt treatment (35). Vancomycin, aminoglycosides, and
Prevention Measures cephalosporin can be mixed in the same dialysis solution
bag (36). However, vancomycin and ceftazidime are in-
Primary preventiona compatible if combined in the same syringe for injection (6).
Systemic prophylactic antibiotics before PD catheter insertion The recommended dosages of antibiotics are summarized in
Disconnect systems with a “flush before fill” design for CAPD
PD training by nursing staff with the appropriate the latest ISPD recommendations (6), but many of them are
qualifications and experience on the basis of clinical experience rather than pharmacoki-
Daily topical application of antibiotic cream or ointment to the netic studies. The dosage of many antibiotics needs to be
catheter exit site adjusted for patients with substantial residual kidney func-
Prompt treatment of exit site or catheter tunnel infection
Antibiotic prophylaxis before colonoscopy or invasive
tion (4,6). A fixed generic dosage for all patients may explain
gynecologic procedures the observation that residual kidney function is associated
Secondary prevention with treatment failure (37).
Antifungal prophylaxis during antibiotic therapy Intraperitoneal antibiotics can be given as continuous
Determine the cause and possible interventions (in each exchange) or intermittent dosing (6). Intermittent
dosing is often possible because many antibiotics have
PD, peritoneal dialysis; CAPD, continuous ambulatory perito-
neal dialysis. substantial systemic absorption during peritonitis, which
a
The strength of recommendation and the quality of the sup- permit reentry into the peritoneal cavity in subsequent PD
porting evidence can be found in the latest International Society cycles. When given intermittently, the antibiotic-containing
for Peritoneal Dialysis (ISPD) treatment recommendations (6). PD solution should dwell for at least 6 hours to allow
adequate absorption. For b-lactams, both continuous and
intermittent intraperitoneal dosing are reasonable op-
tions, but continuous dosing has a theoretical advantage
Management of PD-Associated Peritonitis because the bactericidal activity is time-dependent (i.e.,
Diagnosis. The diagnosis of PD-associated peritonitis the reduction in bacterial density is proportional to the
requires any two of the following features: (1) clinical features time above minimal inhibitory concentration), and should
consistent with peritonitis, i.e., abdominal pain or cloudy be the preferred regimen (6). However, intermittent dosing is
dialysis effluent; (2) dialysis effluent white cell count .100/ml often effective and may be the only feasible regimen when the
(after a dwell time of at least 2 hours), with .50% neutrophils; patient requires helpers or health care visitors to administer
and (3) positive dialysis effluent culture (6). However, prompt the antibiotics, or in patients on automated PD who could not
clinical diagnosis and early initiation of antibiotic therapy are be converted to CAPD temporarily (6).
key to successful treatment. Therefore, patients presenting Unlike b-lactams, intraperitoneal vancomycin is more
with cloudy effluent should be presumed to have perito- commonly administered intermittently every 4–5 days. The
nitis and treated as such until the diagnosis is confirmed or serum vancomycin level should be kept .15 mg/ml to
excluded (6). Whenever peritonitis is suspected, PD efflu- maintain efficacy (38). Intraperitoneal aminoglycoside is
ent should be tested for cell count, differential, Gram stain, also preferably administered as daily intermittent dosing
and bacterial culture (6). Blood culture bottle kits are the (6). Short-term aminoglycoside therapy does not accelerate
preferred technique for bacterial culture (6). If immediate the loss of residual kidney function (39), but prolonged or
delivery of the inoculated culture bottles to the laboratory repeated exposure is associated with vestibular toxicity
is not possible, they should be incubated at 37°C. Other (40) and should be avoided.
effluent concentration techniques may further increase Patients on automated PD who develop peritonitis may
the yield, but are cumbersome to use. There is insufficient switch temporarily to CAPD, so as to facilitate intraperi-
evidence for other novel laboratory techniques (e.g., re- toneal antibiotics therapy, but conversion is not always
agent strip or molecular-based tests) (6). feasible for pragmatic reasons (6). For patients who remain
Empirical Antibiotic Therapy. Once the appropriate on automated PD, the intermittent intraperitoneal dosing
microbiologic specimens have been obtained, empirical should be given in the day dwell (6). Unfortunately, there
antibiotic therapy should be started (6). No single antibiotic is a substantial knowledge gap regarding the antibiotic
regimen has been proved to be superior than the others, dosing for the treatment of peritonitis in automated PD.
and the choice should be center-specific (34). The basic prin- Because extrapolation of pharmacokinetic data from CAPD
ciple is to provide adequate coverage of both Gram- to automated PD may result in significant underdosing in
positive and Gram-negative organisms, including Pseudomonas patients on automated PD (6), a higher daily dose is often
species. The current recommendations are vancomycin or required.
first-generation cephalosporin for Gram-positive organism Adjunctive Measures. Most patients with PD-associated
coverage, and third-generation cephalosporin or aminogly- peritonitis could be managed as outpatients. The decision of
coside for Gram-negative organism coverage (6). The choice hospital admission depends on the clinical severity, hemo-
of vancomycin versus first-generation cephalosporin should dynamic status, and often practical considerations of treatment.
depend on the prevalence of methicillin-resistant organisms Antifungal prophylaxis, preferably oral nystatin, should
in each center. be given along with antibiotic therapy (6). Intraperitoneal
Intraperitoneal administration of antibiotics is the pre- heparin is usually added when the PD effluent is cloudy,
ferred route unless there are features of systemic sepsis so as to prevent catheter occlusion by fibrin. In addition,
(6). When there is a foreseeable delay in administering careful blood glucose monitoring is advisable in patients
CJASN 14: 1100–1105, July, 2019 PD-Associated Peritonitis, Szeto and Li 1103

Subsequent Management. Once the PD effluent Gram

Table 2. Indications for catheter removal stain or culture results are known, antibiotic therapy
should be adjusted (6). In general, if Gram-positive organ-
Indications for Catheter Removal
isms are identified, antibiotic coverage for Gram-negative
Refractory peritonitisa bacteria (i.e., aminoglycoside or third-generation cephalo-
Relapsing and recurrent peritonitis sporin) could be stopped, and vice versa once sensitivities
Refractory exit site and tunnel infection are available. PD effluent leukocyte counts and bacterial
Fungal and non-tuberculous mycobacterial peritonitis
Catheter removal may also be considered for culture should be performed again 2–3 days after antibiotic
Repeat peritonitis therapy, especially when there is no clinical improvement.
Peritonitis caused by Mycobacterium tuberculosis PD effluent leukocyte count .1090/ml on day 3 may
Multiple enteric organisms predict treatment failure (41).
a
The current ISPD recommendations provide a detailed
Adapted from reference 6, with permission. description on the treatment of peritonitis episodes caused
by specific organisms (6). In essence, if the clinical response
is satisfactory, peritonitis caused by coagulase-negative
with diabetes because glucose absorption from the PD staphylococci, streptococci, or culture-negative episodes
solution may be increased during peritonitis. Peritoneal should be treated for 2 weeks (6). For culture-negative
protein loss is also increased during peritonitis and episodes, it remains controversial whether the antibiotic for
malnutrition may develop quickly. Gram-negative coverage should be discontinued. The

Figure 1. | Algorithm for the management of peritoneal dialysis-related peritonitis. aClinical evaluation includes routine history, physical
examination, examination of exit site and catheter tunnel, collection of PDE for cell count, differential count, Gram stain, and bacterial culture.
b
The choice of empirical antibiotics coverage should be on the basis of patient history and center sensitivity patterns. cIn centers with a high
prevalence of Gram-negative peritonitis, empirical Gram-negative coverage may be continued for culture negative peritonitis episodes. dNeed
to screen for S. aureus carrier. eNeed to use vancomycin or other appropriate agents if enterococci identified. fGive two effective antibiotics
according to sensitivity; also apply to Stenotrophomonas and other Pseudomonas-like species. gConsider surgical problem; in addition to Gram-
negative coverage, consider metronidazole and vancomycin. hEspecially for peritonitis episodes caused by S. aureus or Pseudomonas species.
CNSS, coagulase negative staphylococcal species; IP, intraperitoneal; PDE, peritoneal dialysis effluent.
1104 CJASN

current recommendations state that if aminoglycoside is are not available for many new antibiotics, the chemical
used as the empirical Gram-negative coverage, it should stability of many antibiotics in modern PD solutions is
be stopped to minimize the risk of ototoxicity from re- unknown, and the effective means to prevent relapsing or
peated exposure (6), although a small study has suggested recurrent peritonitis episodes are wanting. On the basis of
that N-acetylcysteine may prevent aminoglycoside-related the current recommendations (6), the overall management
ototoxicity (42). algorithm of PD-associated peritonitis is summarized in
For the treatment of peritonitis episodes caused by S. aureus, Figure 1. With the connectology system improvement,
enterococci, Corynebacterium species, Gram-negative bacilli better hygiene, and implementation of global PD perito-
(Pseudomonas or non-Pseudomonas species), and polymi- nitis guidelines for enhancing prevention and manage-
crobial peritonitis, effective antibiotics should be continued ment, we do observe a worldwide reduction of peritonitis
for 3 weeks. Because enterococci have intrinsic resistance to in PD (8,49), supporting the use of PD as a first-line dialysis
cephalosporin, and ampicillin is rapidly inactivated when modality (50).
given intraperitoneally (43), enterococcal peritonitis should
be treated with intraperitoneal vancomycin unless there is Acknowledgments
vancomycin resistance (6). Unlike other bacterial causes, This work was supported in part by the Chinese University of
Pseudomonas peritonitis should be treated with two effec- Hong Kong research accounts 6901031 and 6900570.
tive antibiotics with different mechanisms of action (e.g.,
gentamicin or oral ciprofloxacin with ceftazidime or cefe- Disclosures
pime) (6,44,45). If multiple enteric organisms are identified Dr. Szeto reports grants and personal fees from Baxter Healthcare,
from PD effluent and when there is no prompt clinical during the conduct of the study. Dr. Li has nothing to disclose.
response to empirical antibiotics, surgical evaluation should
be obtained immediately, and metronidazole should be
References
used with vancomycin and either an aminoglycoside or 1. Szeto CC, Wong TY, Chow KM, Leung CB, Li PK: Are peritoneal
ceftazidime (6). In contrast, if multiple Gram-positive organ- dialysis patients with and without residual renal function
isms are identified from the PD effluent, antibiotic treatment equivalent for survival study? Insight from a retrospective review
alone is usually effective (46). Standard antituberculous of the cause of death. Nephrol Dial Transplant 18: 977–982, 2003
2. Boudville N, Kemp A, Clayton P, Lim W, Badve SV, Hawley
chemotherapy is highly effective for peritonitis caused by CM, McDonald SP, Wiggins KJ, Bannister KM, Brown FG,
Mycobacterium tuberculosis. The treatment regimen for non- Johnson DW: Recent peritonitis associates with mortality
tuberculous mycobacterial peritonitis is not well defined, but among patients treated with peritoneal dialysis. J Am Soc
catheter removal is usually needed. Nephrol 23: 1398–1405, 2012
Severe Episodes. The indications of PD catheter removal 3. Htay H, Cho Y, Pascoe EM, Darssan D, Nadeau-Fredette AC,
Hawley C, Clayton PA, Borlace M, Badve SV, Sud K, Boudville N,
are summarized in Table 2. Specifically, refractory peritonitis McDonald SP, Johnson DW: Multicenter registry analysis of
episode is now defined as failure of the effluent to clear after center characteristics associated with technique failure in
5 days of appropriate antibiotics (6), whereas relapsing patients on incident peritoneal dialysis. Clin J Am Soc Nephrol
peritonitis refers to the episode that occur within 4 weeks 12: 1090–1099, 2017
4. Li PK, Szeto CC, Piraino B, Bernardini J, Figueiredo AE, Gupta A,
of completion of therapy of a prior episode with the same
Johnson DW, Kuijper EJ, Lye WC, Salzer W, Schaefer F, Struijk DG;
organism or being culture negative (6). Recurrent perito- International Society for Peritoneal Dialysis: Peritoneal dialysis-
nitis refers to an episode that occurs within 4 weeks of related infections recommendations: 2010 update. Perit Dial Int
completion of therapy of a prior episode but with a different 30: 393–423, 2010
organism (6), whereas repeat peritonitis refers to an episode 5. Piraino B, Bernardini J, Brown E, Figueiredo A, Johnson DW, Lye
WC, Price V, Ramalakshmi S, Szeto CC: ISPD position statement
that occurs .4 weeks after completion of therapy of a prior on reducing the risks of peritoneal dialysis-related infections.
episode with the same organism (6). Perit Dial Int 31: 614–630, 2011
After catheter removal for fungal or refractory peritoni- 6. Li PK, Szeto CC, Piraino B, de Arteaga J, Fan S, Figueiredo AE, Fish
tis, effective antibiotics should be continued for another DN, Goffin E, Kim YL, Salzer W, Struijk DG, Teitelbaum I, Johnson
DW: ISPD peritonitis recommendations: 2016 update on pre-
2 weeks (6,47). Insertion of a new PD catheter and return to
vention and treatment. Perit Dial Int 36: 481–508, 2016
PD is sometimes possible (47,48), but should be performed 7. Szeto CC, Li PK, Johnson DW, Bernardini J, Dong J, Figueiredo AE,
at least 2 weeks after catheter removal and complete resolu- Ito Y, Kazancioglu R, Moraes T, Van Esch S, Brown EA: ISPD
tion of peritoneal symptoms (6). PD catheter should also be catheter-related infection recommendations: 2017 update. Perit
removed for refractory exit site or tunnel infections (6). If there Dial Int 37: 141–154, 2017
8. Cho Y, Johnson DW: Peritoneal dialysis-related peritonitis: To-
is no concomitant peritonitis (or after PD effluent has cleared wards improving evidence, practices, and outcomes. Am J Kidney
up from the concomitant episode), a new PD catheter could be Dis 64: 278–289, 2014
inserted simultaneously and PD could be continued (7). 9. Boudville N, Johnson DW, Zhao J, Bieber BA, Pisoni RL, Piraino B,
Bernardini J, Nessim SJ, Ito Y, Woodrow G, Brown F, Collins J,
Kanjanabuch T, Szeto CC, Perl J: Regional variation in the treat-
ment and prevention of peritoneal dialysis-related infections in
Conclusions the Peritoneal Dialysis Outcomes and Practice Patterns Study
Although comprehensive recommendations on PD-associated [published online ahead of print July 23, 2018]. Nephrol Dial
peritonitis are available (6), there are important gaps of Transplant doi: 10.1093/ndt/gfy204
knowledge that deserve further studies. Notably, the 10. Strippoli GF, Tong A, Johnson D, Schena FP, Craig JC: Antimi-
correction of many modifiable risk factors for PD-associated crobial agents to prevent peritonitis in peritoneal dialysis: A
systematic review of randomized controlled trials. Am J Kidney
peritonitis does not appear to reduce the risk, the optimal Dis 44: 591–603, 2004
treatment regimen for patients on machine-assisted auto- 11. Strippoli GF, Tong A, Johnson D, Schena FP, Craig JC: Catheter-
mated PD is poorly defined, important pharmacokinetic data related interventions to prevent peritonitis in peritoneal dialysis:
CJASN 14: 1100–1105, July, 2019 PD-Associated Peritonitis, Szeto and Li 1105

A systematic review of randomized, controlled trials. J Am Soc exit site versus cyclic oral rifampin. Am J Kidney Dis 27: 695–700,
Nephrol 15: 2735–2746, 2004 1996
12. Hagen SM, Lafranca JA, IJzermans JN, Dor FJ: A systematic review 32. Yip T, Tse KC, Lam MF, Cheng SW, Lui SL, Tang S, Ng M, Chan TM,
and meta-analysis of the influence of peritoneal dialysis catheter Lai KN, Lo WK. Risks and outcomes of peritonitis after flexible
type on complication rate and catheter survival. Kidney Int 85: colonoscopy in CAPD patients. Perit Dial Intern 27: 560–564,
920–932, 2014 2007
13. Nessim SJ, Bargman JM, Jassal SV: Relationship between double- 33. Prasad KN, Prasad N, Gupta A, Sharma RK, Verma AK, Ayyagari A:
cuff versus single-cuff peritoneal dialysis catheters and risk of Fungal peritonitis in patients on continuous ambulatory peritoneal
peritonitis. Nephrol Dial Transplant 25: 2310–2314, 2010 dialysis: A single centre Indian experience. J Infect 48: 96–101, 2004
14. Daly C, Cody JD, Khan I, Rabindranath KS, Vale L, Wallace SA: 34. Ballinger AE, Palmer SC, Wiggins KJ, Craig JC, Johnson DW, Cross
Double bag or Y-set versus standard transfer systems for contin- NB, Strippoli GF: Treatment for peritoneal dialysis-associated
uous ambulatory peritoneal dialysis in end-stage kidney disease. peritonitis. Cochrane Database Syst Rev 26: CD005284, 2014
Cochrane Database Syst Rev 8: CD003078, 2014 35. Muthucumarana K, Howson P, Crawford D, Burrows S,
15. Rüger W, van Ittersum FJ, Comazzetto LF, Hoeks SE, ter Wee PM: Swaminathan R, Irish A: The relationship between presentation
Similar peritonitis outcome in CAPD and APD patients with di- and the time of initial administration of antibiotics with outcomes
alysis modality continuation during peritonitis. Perit Dial Int 31: of peritonitis in peritoneal dialysis patients: The PROMPT study.
39–47, 2011 Kidney Int Rep 1: 65–72, 2016
16. Lan PG, Johnson DW, McDonald SP, Boudville N, Borlace M, 36. de Vin F, Rutherford P, Faict D: Intraperitoneal administration of
Badve SV, Sud K, Clayton PA: The association between peritoneal drugs in peritoneal dialysis patients: A review of compatibility
dialysis modality and peritonitis. Clin J Am Soc Nephrol 9: and guidance for clinical use. Perit Dial Int 29: 5–15, 2009
1091–1097, 2014 37. Whitty R, Bargman JM, Kiss A, Dresser L, Lui P: Residual kidney
17. Htay H, Johnson DW, Wiggins KJ, Badve SV, Craig JC, Strippoli GF, function and peritoneal dialysis-associated peritonitis treatment
Cho Y: Biocompatible dialysis fluids for peritoneal dialysis. outcomes. Clin J Am Soc Nephrol 12: 2016–2022, 2017
Cochrane Database Syst Rev 10: CD007554, 2018 38. Blunden M, Zeitlin D, Ashman N, Fan SL: Single UK centre ex-
18. Figueiredo AE, Bernardini J, Bowes E, Hiramatsu M, Price V, Su C, perience on the treatment of PD peritonitis--antibiotic levels and
Walker R, Brunier G: A syllabus for teaching peritoneal dialysis to outcomes. Nephrol Dial Transplant 22: 1714–1719, 2007
patients and caregivers. Perit Dial Int 36: 592–605, 2016 39. Szeto CC, Kwan BC, Chow KM, Chung S, Yu V, Cheng PM, Leung
19. Zhang L, Hawley CM, Johnson DW: Focus on peritoneal dialysis CB, Law MC, Li PK: Predictors of residual renal function
training: Working to decrease peritonitis rates. Nephrol Dial decline in patients undergoing continuous ambulatory
Transplant 31: 214–222, 2016 peritoneal dialysis. Perit Dial Int 35: 180–188, 2015
20. Boudville NC, Chow JS, Cho Y: Targeted Education ApproaCH to 40. Tokgoz B, Somdas MA, Ucar C, Kocyigit I, Unal A, Sipahioglu MH,
Improve Peritoneal Dialysis Outcomes Trial (TEACH-PD), 2019. Oymak O, Utas C: Correlation between hearing loss and peri-
Available at https://clinicaltrials.gov/ct2/show/NCT03816111. tonitis frequency and administration of ototoxic intraperitoneal
Accessed February 14, 2019 antibiotics in patients with CAPD. Ren Fail 32: 179–184, 2010
21. Wang J, Zhang H, Liu J, Zhang K, Yi B, Liu Y, Liu J, Zhang X, Ji Y: 41. Chow KM, Szeto CC, Cheung KK, Leung CB, Wong SS, Law MC,
Implementation of a continuous quality improvement program Ho YW, Li PK: Predictive value of dialysate cell counts in peri-
reduces the occurrence of peritonitis in PD. Ren Fail 36: tonitis complicating peritoneal dialysis. Clin J Am Soc Nephrol 1:
1029–1032, 2014 768–773, 2006
22. Nataatmadja M, Cho Y, Johnson DW: Continuous quality im- 42. Tokgoz B, Ucar C, Kocyigit I, Somdas M, Unal A, Vural A, Sipahioglu
provement initiatives to sustainably reduce peritoneal dialysis- M, Oymak O, Utas C: Protective effect of N-acetylcysteine from
related infections in Australia and New Zealand. Perit Dial Int 36: drug-induced ototoxicity in uraemic patients with CAPD peritonitis.
472–477, 2016 Nephrol Dial Transplant 26: 4073–4078, 2011
23. van Diepen AT, Tomlinson GA, Jassal SV: The association be- 43. Kussmann M, Schuster L, Zeitlinger M, Pichler P, Reznicek G,
tween exit site infection and subsequent peritonitis among perito- Wiesholzer M, Burgmann H, Poeppl W: The influence of different
neal dialysis patients. Clin J Am Soc Nephrol 7: 1266–1271, 2012 peritoneal dialysis fluids on the in vitro activity of ampicillin,
24. Xu G, Tu W, Xu C: Mupirocin for preventing exit-site infection and daptomycin, and linezolid against Enterococcus faecalis. Eur J
peritonitis in patients undergoing peritoneal dialysis. Nephrol Clin Microbiol Infect Dis 34: 2257–2263, 2015
44. Szeto CC, Chow KM, Leung CB, Wong TY, Wu AK, Wang AY, Lui
Dial Transplant 25: 587–592, 2010
SF, Li PK: Clinical course of peritonitis due to Pseudomonas
25. Wong C, Luk IW, Ip M, You JH: Prevention of gram-positive
species complicating peritoneal dialysis: A review of 104 cases.
infections in peritoneal dialysis patients in Hong Kong: A cost-
Kidney Int 59: 2309–2315, 2001
effectiveness analysis. Am J Infect Control 42: 412–416, 2014
45. Siva B, Hawley CM, McDonald SP, Brown FG, Rosman JB,
26. Piraino B: Mupirocin for preventing exit-site infection and peri-
Wiggins KJ, Bannister KM, Johnson DW: Pseudomonas peritonitis
tonitis in patients undergoing peritoneal dialysis. Was it effective?
in Australia: Predictors, treatment, and outcomes in 191 cases.
Nephrol Dial Transplant 25: 349–352, 2010
Clin J Am Soc Nephrol 4: 957–964, 2009
27. Gardezi AI, Schlageter KW, Foster DM, Astor BC, Chan MR,
46. Szeto CC, Chow KM, Wong TY, Leung CB, Li PK: Conservative
Waheed S: Erosion of the silicone peritoneal dialysis catheter with
management of polymicrobial peritonitis complicating perito-
the use of gentamicin cream at the exit site. Adv Perit Dial 32:
neal dialysis--a series of 140 consecutive cases. Am J Med 113:
15–18, 2016
728–733, 2002
28. Bernardini J, Bender F, Florio T, Sloand J, Palmmontalbano L, Fried
47. Szeto CC, Chow KM, Wong TY, Leung CB, Wang AY, Lui SF, Li PK:
L, Piraino B: Randomized, double-blind trial of antibiotic exit site
Feasibility of resuming peritoneal dialysis after severe peritonitis
cream for prevention of exit site infection in peritoneal dialysis and Tenckhoff catheter removal. J Am Soc Nephrol 13: 1040–
patients. J Am Soc Nephrol 16: 539–545, 2005 1045, 2002
29. Johnson DW, Badve SV, Pascoe EM, Beller E, Cass A, Clark C, de 48. Ram R, Swarnalatha G, Dakshinamurty KV: Reinitiation of peri-
Zoysa J, Isbel NM, McTaggart S, Morrish AT, Playford EG, Scaria A, toneal dialysis after catheter removal for refractory peritonitis.
Snelling P, Vergara LA, Hawley CM; HONEYPOT Study Collab- J Nephrol 27: 445–449, 2014
orative Group: Antibacterial honey for the prevention of 49. Li PK, Kwong VW: Current challenges and opportunities in PD.
peritoneal-dialysis-related infections (HONEYPOT): Semin Nephrol 37: 2–9, 2017
A randomised trial. Lancet Infect Dis 14: 23–30, 2014 50. Li PK, Chow KM, Van de Luijtgaarden MW, Johnson DW, Jager KJ,
30. McQuillan RF, Chiu E, Nessim S, Lok CE, Roscoe JM, Tam P, Jassal Mehrotra R, Naicker S, Pecoits-Filho R, Yu XQ, Lameire N:
SV: A randomized controlled trial comparing mupirocin and Changes in the worldwide epidemiology of peritoneal dialysis.
polysporin triple ointments in peritoneal dialysis patients: The Nat Rev Nephrol 13: 90–103, 2017
MP3 study. Clin J Am Soc Nephrol 7: 297–303, 2012
31. Bernardini J, Piraino B, Holley J, Johnston JR, Lutes R: A ran-
domized trial of Staphylococcus aureus prophylaxis in peritoneal Published online ahead of print. Publication date available at
dialysis patients: Mupirocin calcium ointment 2% applied to the www.cjasn.org.