Researchers give strategies for management of peritoneal dialysis-associated peritonitis
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Researchers have identified common mistakes clinicians make in the management of patients who develop peritonitis while receiving peritoneal dialysis treatments and suggest ways to improve care.
According to Muthana Al Sahlawi, MD, of the University of Toronto, and colleagues, PD-associated peritonitis not only leads to morbidity and mortality, but also increases treatment costs and hospitalizations. In addition, it is the primary reason that patients transition from PD to hemodialysis.
“Despite International Society for Peritoneal Dialysis (ISPD) guidelines on peritonitis treatment, variability exists in the diagnosis and management of peritonitis among PD centers worldwide, with limited uptake of these recommendations,” they wrote. “Overall peritonitis treatment failure rates are as high as 25%. Although many studies have focused on peritonitis prevention, more effort needs to be focused on successful management.”
Below, Healio Nephrology provides a condensed version of the identified mistakes along with the proposed strategies for better management that were addressed in the article.
Mistake: Starting antibiotics too late
Al Sahlawi and colleagues cited a study that found the risk for PD failure increased by 5.5% for each hour delay in the administration of antibiotics.
“Early initiation of antibiotic therapy leading to improved patient survival has been well studied in the infectious disease literature,” the researchers wrote. “Since prompt initiation of antibiotic therapy for peritonitis is critical as well, the ISPD recommends that empirical treatment be started as soon as peritonitis is suspected.”
They added that while utilizing the intraperitoneal route for antibiotic administration has several advantages (including delivering a high concentration of the antibiotics to the peritoneum, avoidance of IV access and the possibility of home antibiotic administration by trained patients), this route may lead to antibiotic delays, most notability in EDs when PD-trained staff is not available.
“In such case, using the IV route for faster administration should be considered,” the researchers suggested.
Mistake: Inappropriate timing of catheter removal
According to Al Sahlawi and colleagues, the PD catheter should be removed in the cases of refractory peritonitis, relapsing peritonitis, refractory exit site and tunnel infection, and fungal peritonitis; removal should also be considered for repeat peritonitis, mycobacterial peritonitis and multiple enteric organisms.
In the case of fungal peritonitis, the researchers emphasized the importance of prompt catheter removal, citing a study that found delayed catheter removal (defined as after 24 hours from diagnosis) was an independent predictor for fungal peritonitis-related mortality.
“Immediate catheter removal is recommended by the ISPD when fungi are identified in PD effluent in the face of effluent leukocytosis, no matter the clinical status of the patient,” they wrote.
However, when treating a patient with refractory peritonitis, the researchers caution against strictly following the ISPD’s recommendation for removal if the PD effluent does not clear after 5 days of antibiotic treatment.
“This approach of using a 5-day cut-off may lead to unnecessary or premature catheter removal given the lack of evidence on its effect on the long-term outcomes compared to a longer wait,” they contended.
Instead, they suggest allowing for more than 5 days of treatment before removing the catheter, especially for “less virulent organisms such as coagulase-negative Staphylococcus.”
Mistake: Overlooking causes, symptoms
Although abdominal pain and cloudy effluent occur commonly with peritonitis, Al Sahlawi and colleagues recommend careful consideration of whether either of these is indicative of the condition.
“[Cloudy effluent] can be non-specific for peritonitis, as it can be the result of various non-infectious causes such as eosinophilic peritonitis, hemoperitoneum, malignancy, chylous effluent, and sampling fluid from a dry abdomen or from a dwell with an extended period of time,” they wrote. “The analysis of the effluent cells can provide clues toward the cause.”
They stress that other etiologies, such as ischemic colitis, pancreatitis, pyelonephritis, ruptured ovarian or kidney cyst, transplant kidney rejection, clostridium difficile infection and strangulated/incarcerated hernia, should not be overlooked.
Mistake: Assuming each case of peritonitis is PD-related
“Peritonitis that results from non-PD related complications (eg, ruptured appendix, ischemic bowel, cholecystitis) is well reported, but still uncommon,” the researchers wrote. “Differentiating this from peritonitis that is PD related can be very challenging as both can have similar presentation.”
They argued that while CT scans are routinely utilized to assess patients presenting with features of PD-related peritonitis, “the role of imaging in establishing the diagnosis of PD peritonitis is limited.”
They suggest performing a CT scan in cases that include patients with polymicrobial enteric organisms, hypotensive or hemodynamically unstable patients, patients with accompanying bacteremia or in patients with other gastrointestinal symptoms.
Imaging findings should always be analyzed in conjunction with a detailed patient history and physical exam to determine the correct clinical cause of peritonitis, they wrote.
According to Al Sahlawi and colleagues, it remains uncertain how to treat peritonitis effectively in many cases.
“However, utilizing the best available evidence can improve PD practice and patients’ outcomes,” they suggested. “Where evidence is lacking, clinical judgement should ensue with the ultimate goal of reducing the morbidity associated with PD peritonitis while maximizing treatment success.”
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