DISEASEOFTHE MONTH J Am Soc Nephrol 9: 1956-1964. 1998

Peritonitis as a Complication of Peritoneal Dialysis

BETH PIRAINO Renal Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.

Peritonitis continues to be a serious complication for patients cultures, that had initial effluent WBC count less than 100/pA. on peritoneal dialysis (PD). Peritonitis is one of the major In 40 episodes (67%) the inflammatory response was delayed, causes of hospitalization, accounting for 23% of admissions in in 16 episodes (27%) the effluent cell count eventually reached the CANUSA study (1). Peritonitis is the leading cause of 30 to 100 WBC/pi, and in four episodes (7%) the cell count technique failure and catheter loss (2,3). Patients with frequent never exceeded 30 WBC/pi. The Gram stain was positive in peritonitis are at increased risk of dying, independent of other 70% of these cases. The organism was more likely to be factors (4). Although the rates of peritonitis have decreased Staphylococcus aureus compared to episodes of peritonitis dramatically from the inception of CAPD, rates above 0.5 with a normal inflammatory response. Half of the patients with episodes per year still commonly occur. The success of this the impaired cell reaction to peritonitis had more than one such dialysis technique is closely tied to the ability of the dialysis episode, and in the absence of peritonitis had bower peritoneab team to reduce the risk of peritonitis, and when it occurs, macrophage cell count than a group of control patients. In view manage the patient appropriately. of this study, all patients on PD presenting with abdominal pain should be considered to have peritonitis until proven otherwise. Clinical Presentation The usual presentation of peritonitis is abdominal pain, Etiologies of Peritonitis cloudy effluent or, most often, both. The pain can range from The most common microorganisms responsible for perito- extremely severe to nonexistent. In the inexperienced patient, nitis are listed in Table 1 (6,7). Many studies on peritonitis will the absence of pain may lead him/her to ignore the cloudy list the different organisms as a percentage of the total. This effluent initially, leading to a delay in presentation and subse- makes it difficult to compare the results of one study to quent treatment. All patients must be instructed to call imme- another, if the overall rates are dissimilar. For example, in the diately if the effluent is even slightly cloudy. Peritonitis is two studies shown in the table, the percentages of peritonitis present if the white blood cell (WBC) count in the effluent is episodes due to Staphylococcus aureus are 23 and 12%, re- b00/p.b or greater, with at least 50% polymorphonuclear cells. spectively, yet the actual difference in rates is only 0.04 epi- If the specimen is collected from a short cycle, an aspirate from sodes per year. It is striking that the rates of coagulase-negative a drained abdomen, or obtained from a patient already on Staphylococcus are almost identical in the two studies. This antibiotics, the percentage of polymorphonuclear cells (i.e., remains the most frequent microorganism responsible for peri- more than 50%) is a more reliable marker for peritonitis than tonitis in many centers. the absolute number of WBC. The leading cause of peritonitis continues to be contamina- Occasionally, blood-tinged effluent will be confused with tion at the time of the PD exchange. Peritonitis due to skin cloudiness, but trained personnel can readily detect the differ- organisms such as coagulase-negative Staphylococcus, enee. Other causes of cloudy effluent include chylous ascites, Corynebacterium, Bacillus species, and Branhamella ca- which have a milky appearance, intra-abdominal malignancy, tarrhalis are generally believed to be due to contamination. diagnosed by cell cytology, and pancreatitis, which can be However, PD patients may also have on their (unwashed) differentiated by an effluent amylase level of >50 UIL. Also fingers Streptococcus viridans, Staphylococcus aureus, micro- included in the differential diagnosis is eosinophilie peritonitis, coccus, Proteus species, Kiebsiella pneumoniae, Enterobacter which is rarely associated with unusual fungi, but more often is species, Escherichia coli, and Acinetobacter species (8). If the idiopathic; recent reports suggest that treatment with steroids is patient is questioned closely about contamination, the source effective in reducing the cellularity. may become obvious. For example, a patient from our center In up to 6% of the episodes of peritonitis, the patient pre- had frequent bouts of peritonitis related to contamination; an sents with abdominal pain but has clear effluent (5). Koopmans episode due to Streptococcus viridans occurred after perfor- et a!. reported 60 such episodes of peritonitis, all with positive manee of an exchange while his granddaughter was in the room without a mask. A second episode of peritonitis followed an exchange in which the patient overheated his bag, which was Correspondence to Dr. Beth Piraino. Professor of Medicine. A9152 Scaife Hall, 3550 Terrace Street. Pittsburgh. PA 15261. then cooled by running under cold water. Miller and Findon performed an elegant study examining the level of bacterial 1046-6673/09010- 1956$03.O0/O Journal of the American Society of Nephrology contamination associated with touching the connector during Copyright U 1998 by the American Society of Nephrology an exchange (8). Touching the connection after hand washing I Am Soc Nephrol 9: 1956-1964. 1998 Peritonitis as a Complication of Peritoneal Dialysis 1957

Table 1. Common microorganisms causing peritonitis’ 10% of dialysis patients without nasal carriage ( 1 3). From the hands, the Staphylococcus aureus is quickly transmitted to the . . Holley Van Biesen Microorganism et a/. (6) et ci/. (7) catheter exit site and/or to the connection port at the time of an exchange. This risk factor is important to recognize, because Coagulase-negative Staphylococcus 0. 17 0.18 the risk of Staphylococcus aureus peritonitis can be consider- Staphylococcus aureus 0.13 0.09 ably reduced by prophybaxis for Staphylococcus aureus ear- Streptococcus 0.04 0.06 riage (14,15) (Figure 1). Several different approaches have Other Gram-positive <0.01 0.02 been identified (15-18). Either at the time the catheter is placed 0#{149}16b Gram-negative 0.09 or, ideally, before placement, the nose should be cultured, and, Polymierobial 0.01 if positive, the patient should be treated with intranasal mupi- Fungal <0.01 rocin. Once training begins, mupirocin can be used at the exit Culture-negative 0. 1 1 0.20 site as part of routine care, or the intranasal course can be Total rate 0.56c 0.73’ repeated monthly. Patients who have three negative nose cub- a Rates provided as episodes per year at risk. tures are at very low risk for infection and do not require b Pseudomonas accounted for 0.06. prophylaxis, unless immunosuppressed (12,19). C Rates do not add to total due to rounding. Peritonitis due to Gram-negative bacilli may be the result of contamination, catheter infection, or may come from the bowel. Treatment of constipation with enemas, diarrhea, and using ehlorhexidine followed by thorough drying reduced the gastric acid inhibitors may predispose to enterie peritonitis numbers of bacteria reaching the peritoneal cavity to <5. In (20-22). Although frank bowel perforation is distinctly un- contrast, absence of hand washing resulted in considerably common (23), Harwell et al. reported that enterie peritonitis higher numbers of organisms on the connection, and wet hands was associ?ed with underlying intra-abdominal pathology resulted in the transport of up to 4500 organisms. Proper such as eholeeystitis, isehemic colitis, and appendicitis in one- training of the patient in aseptic technique is obviously critical in reducing peritonitis from contamination. third of patients (24). Because few of these episodes resolved Fifteen to 20% of peritonitis episodes are due to catheter with antibiotic therapy alone (Figure 2), early recognition infections, with Staphylococcus aureus and Pseudomonas followed by laparotomy is critical to decrease the risk of death. aeruginosa accounting for the great majority (9). Patients at latrogenie peritonitis could be classified under bacteremia, greatest risk for Staphylococcus aureus catheter-related peri- enteric, or gynecologie categories, but is listed separately to tonitis are those who are Staphylococcus aureus carriers emphasize this unusual but important (potentially preventable) (10,1 1). Approximately one-half of PD patients are Staphylo- cause of peritonitis. It is well recognized that peritonitis may coccus aureus nasal carriers ( 1 1, 12). Staphylococcus aureus in follow cobonoseopy with polypeetomy, endoscopy with sele- the nose is transmitted to the hands; Boelaert et al. found that rotherapy, and dental procedures (24-26). Vaginal leak of 75% of dialysis patients with Staphylococcus aureus in their dialysate, the use of intrauterine devices, endometrial biopsy, nares had Staphylococcus aureus on their hands, in contrast to and hysteroseopy with polypeetomy have all been associated

U no prophylaxis o prophylaxis . Reference 15: daily exit site S aureus peritonitis, episodes/y mupirocin

0 Reference 16: rifampin 600 mg qd

for 5 days every 12 weeks

0 Reference 17: intranasal mupirocin bid for 5 days every month in nasal carriers

. Reference 18: intranasal mupirocin tid for 7 days for each positive nose culture

RefiS Refl6 Ref 17 Ref 18 *p < 0.001, no prophylaxis versus prophylaxis

Figure 1. Protocols to prevent Staphylococcus aureus peritonitis. 1958 Journal of the American Society of Nephrology J Am Soc Nephrol 9: 1956-1964. 1998

% of episodes

resolved recurred catheter lost died

I peritonitis with intra-abdominal disease 0 all other episodes

From reference 24 Figure 2. Outcome of peritonitis related to intra-abdominal catastrophe.

with peritonitis (26-28). Antibiotic prophylaxis prior to any peritonitis, and catheter infection history. The exit site and procedure associated with the risk of peritonitis is warranted. tunnel should be closely examined for evidence of infection. In addition, the patient’s abdomen should be drained, and the Risk Factors for Peritonitis effluent sent for cell count with differential, Gram stain, and Modifiable risk factors for peritonitis are listed in Table 2. In culture. The cell count with differential will confirm the pres- addition, certain patient populations are at higher risk for ence of peritonitis. Centrifuging 10 ml of effluent results in a coagubase-negative peritonitis, including African-American positive Gram stain of the infected sediment in 93% of epi- and native American patients (3,29,30). This risk can be mm- sodes (3 1 ). The culture should be obtained by placing 5 ml in imized by using a disconnect system. Also at increased risk for each of two tryptie soy broth blood culture bottles (aerobic and peritonitis are immunosuppressed patients ( 19). Andrews et al. anaerobic); Lye et al. found that the rate of culture-negative reported that those receiving immunosuppressive therapy in the peritonitis was reduced from 42 to 25% by this technique (32). past I 2 months or with a disease predisposing to infection, In addition to inadequate culture techniques, culture-negative such as HIV, had a peritonitis rate of 1.8 episodes per patient peritonitis may also be due to the presence of antibiotics, so the year compared with a rate of 0.68 episodes per patient year in patient should be questioned closely about recent antibiotic use other patients (19). The risk of Staphylococcus aureus and (33). In one-third of culture-negative peritonitis episodes, re- fungal peritonitis was especially high. culturing will result in identification of an organism (34). A decision must be made about whether to hospitalize the Evaluation patient. This will depend on the severity of the peritonitis, and Upon presentation, a rapid assessment of the patient should the need for intravenous analgesia and fluids. Because the include questions on breaks in technique, recent procedures disconnect systems have primarily diminished peritonitis due that may have led to peritonitis, change in bowel habits, prior to less virulent organisms such as coagulase-negative Staphy- lococcus, as opposed to Gram-negative and Staphylococcus aureus, a high proportion of the patients will require admission Table 2. Factors associated with decreased risk of peritonitis (23).

Prophylactic antibiotics at time of catheter placement Initial Treatment 2-cuffed catheter (versus one-cuff catheter) Often, the clinician does not know the causative organism Downward pointing tunnel when antibiotic therapy is ordered. Therefore, the initial ther- Twin bag connection system apy should be active against the most commonly offending Treatment of Staphylococcus aureus carriage organisms, including Staphylococcus (both coagulase-negative J Am Soc Nephrol 9: 1956-1964. 1998 Peritonitis as a Complication of Peritoneal Dialysis 1959

and -positive), Streptococcus, and Gram-negative bacilli. In the been effectively treated, based on sensitivities (7). These au- absence of clinical data suggestive of bowel perforation, an- thors propose an alternative approach, shown in Table 4, which aerobic coverage is generally not given initially. Coverage for would provide I 00% coverage of Gram-positive organisms and fungus should be implemented immediately only if the Gram 87.5% coverage of Gram-negative organisms. stain is positive for yeast. Within 2 to 3 d, the organism is usually identified and The Ad Hoc treatment guidelines of 1996 recommended sensitivities are available. Subsequent therapy is chosen to using a first-generation cephalosporin, in combination with provide narrow coverage with the least toxicity. Dosing sched-

gentamicin for the initial therapy (35) (Table 3). This change ules for some commonly used antibiotics are given in Table 5. from the prior recommendation for vancomyein in conjunction Guidelines by organism are provided below. If the culture is with Gram-negative coverage was due to the increasing mci- negative, generally the aminoglycoside is stopped and a single denee of vaneomycin-resistant enterocoecus and the fear that drug such as a first-generation cephabosporin or vaneomycin is this resistance will be transferred to staphylococci, leaving us continued alone. with no drugs to treat these infections. Indeed, peritonitis due to vancomycin-resistant Staphylococcus has been reported Coagulase-Negative Staphylococcus Peritonitis (36). These patients often do not require hospitalization, because Lai et al. reported on the results of once daily intraperitoneal the pain is less severe than that due to other organisms (23). cefazolin and gentamicin, with subsequent modification of Cefazolin or cephalothin should be changed to vaneomyein if therapy as needed, for treatment of peritonitis (37). It is im- the organism is methicillin-resistant (38). Although vaneomy- portant to note that episodes of peritonitis related to catheter cm is often given weekly, this may lead to underdosing in infection were excluded from this study. All I 9 episodes of many patients, especially those with residual renal function. Gram-positive peritonitis resolved. Three episodes of Staphv- Low trough levels in the dialysate increases the risk of relaps- lococcus epidermidis were resistant in vitro to both gentamicin ing peritonitis (40). We prefer the use of 30 mg/kg vaneomycin and cephabosporin, yet responded in vivo to these antibiotics, intraperitoneally (maximum of 2 g) in the initial exchange, presumably due to the high local concentration in one ex- which is allowed to dwell for a minimum of 6 h, with one-half change each day. These data, therefore, support the Ad Hoe of this dose repeated in 4 to 5 d. Before the second dose, a Committee’ s recommendations. blood level is measured, which in outpatients is not back before Unfortunately, data from other dialysis programs suggest redosing, but the value guides the timing of the third dose,

that use of a first-generation cephabosporin for initial therapy usually about 5 d later. These three doses then provide antibi- may result in a considerable number of untreated or made- otie coverage for a minimum of 2 wk. quately treated patients. Vas et al. reported that cefazolin (1.5 g intraperitoneally once daily for 3 wk) resulted in resolution of Staphylococcus Aureus Peritonitis only 45% of episodes of peritonitis due to methicillin-resistant Patients with Staphylococcus aureus peritonitis often have coagulase-negative Staphylococci (38). This was in contrast to severe abdominal pain and generally require hospitalization. If a 73% response during the historical period for which vanco- Staphylococcus aureus exit site or tunnel infection is present, mycin (2 g intraperitonealby once weekly for three doses) was the catheter should be removed without delay (9). If there is no used. The proportion of Staphylococci with methicillin resis- clinically obvious tunnel infection, an ultrasound of the tunnel tance is reported to range from 33 to 67% (7,39). We have to confirm the absence of involvement is helpful, as catheter

found an increase in methicillin-resistant eoagulase-negative infections may be occult (41 ). Peritonitis associated with a Staphylococci in our program, as shown in Figure 3. Using the catheter infection will prove to be either refractory or relapsing Ad Hoc 1996 recommendations for initial therapy, Van Biesen (9,42). The course can be deceptive because the episode may noted that only 76.5% patients with Gram-positive infections appear to resolve with clearing of the effluent, yet the effluent and 8 1% of patients with Gram-negative infections would have culture remains positive with recrudescence of full-blown peri-

Table 3. Ad Hoc 1996 guidelines for initial therapy (35)

UrOut Treatment Protocol Urine Output <500 mb/d

In the first exchange cefazolin or eephalothin 500 mg/L, or 15 mg/kg 25% increase gentamicin 0.6 mg/kg I .5 mg/kg Subsequent therapy cefazolin or cephalothin 125 mg/L. each exchange, or 500 mg/L, 25% increase one exehange/d gentamicin 0.6 mg/kg, one exehange/d 0.6 mg&ga

‘I Increase dosing frequency based on serum and/or dialysate levels. 1960 Journal of the American Society of Nephrology J Am Soc Nephrol 9: 1956-1964. 1998

Coagulase negative staphylococcus peritonitis, episodes I year 0.5

0.4

0.3

0.2

0.1

0 ‘80-’Sl ‘82-’83 ‘84-’85 ‘86-’87 ‘88-’89 ‘90-’91 ‘92-’93 ‘94-’95 year

Figure 3. Rates of coagulase-negative Staphylococcus peritonitis over time.

Table 4. Empiric treatment of peritonitis, Van Biesen Table 5. Intraperitoneal antibiotic dosages for adults (35) approach (7)a Drug Intraperitoneal Dose Initial therapy Ampicillin 1 25 mgIL continuously vancomyein 15 mg/kg single dose IP Ampieillin/sulbaetam I g/L load, then 100 mg/L gentamicin 1 .5 mg/kg for urine output >500 mb/d, continuously 0.5 mg/kg for urine output <500 Cefazolin and cephalothin 500 mg/L load, then I 25 mgfL ml/d continuously After 24 hours Ceftazidime 1000 mg/exchange, once daily outpatient ciprofloxacin 500 mg twice a day Gentamicin and tobramycin 0.6 mg/kg, once daily inpatient eeftazidime 250 mg IP/exehange, and Impipenem/cilistat 500 mg/L load. then 200 mg/L ciprofloxacin 50 mg/exchange continuously

IP, intraperitoneally. Vaneomycin 15 to 30 mg/kg every 5 to 7 d

tonitis once the antibiotics are stopped (42). If the exit site and result in death. Therefore, treatment must be implemented tunnel are normal, then the presumption is that the episode is rapidly. Ampicillin appears to be more effective than vaneo- due to touch contamination (usually in a patient who is a mycin (43). Staph’locoecus aureus nasal carrier), and antibiotic treatment Enterococeal peritonitis is severe, responds slowly to anti- is often successful. The aminoglycoside is discontinued. If the bioties, and carries an increased risk of death (23,43). In the organism is methieiblin-sensitive, then methicilbin or a cepha- Network 9 Peritonitis Study. peritonitis due to enterococcus losporin may be used, and if methicillin-resistant, vaneomycin resulted in death in 7.4% of the episodes (23). Peritonitis due or clindamycin is prescribed. Rifampin, 600 mg/d, may be to enterococeus, compared with Streptococcus viridans perito- added. nitis, occurs in older patients and is likely spread from the bowel. The incidence has not fallen with the use of disconnect Streptococcus Peritonitis systems. Fortunately, vancomycin-resistant enterococeal

The source for peritonitis due to Streptococcus species (non- (VRE) peritonitis, with a reported mortality rate of 55%, is still enterococcus) may be the respiratory tract (either transient rare (44). VRE peritonitis is associated with prior use of both bacteremia or absence of a mask during an exchange), the skin cephalosporins and vaneomycin, as well as hospitalization. (touch contamination), or the bowel (43). Consistent with this, Treatment is problematic. Troidle et al. used ehloramphenieol, the incidence of Streptopcoccus viridans has decreased with mostly unsuccessfully (44). We have had one ease of VRE use of the disconnect systems. Streptococcus (especially group peritonitis at the University of Pittsburgh, in a patient with a A and group B) causes severe peritonitis and may quickly failed renal transplant given three weekly doses of vancomycin J Am Soc Nephrol 9: 1956-1964, 1998 Peritonitis as a Complication of Peritoneal Dialysis 1961 for culture-negative peritonitis; she did well with prompt cath- which requires surgical exploration. This is especially true if an eter removal and institution of quinupristin/dalfopristin, an anaerobe grows in culture. Metronidazole, 500 mg intrave- experimental drug. Stool carriage of VRE is still uncommon in nously every 8 h, should be added to the other antibiotics. PD patients, perhaps because PD is a home dialysis modality Intra-abdominal abscesses occur in < 1 % of peritonitis epi- (39). sodes. These are more common with Pseudotnonas aerugi- nosa, Candida albicans, and polymierobial peritonitis, and require drainage. Computed tomography scan of the abdomen Gram-Negative Peritonitis is useful to evaluate the patient. Once the organism is identified and sensitivities are known, the antibiotic therapy is adjusted to minimize use of amino- Fungal Peritonitis glycosides as much as possible, in view of the risk of vestibular Fungal peritonitis accounts for 3% of all episodes (47). toxicity. Alternatives to aminoglyeosides, such as ceftazidime Usually the patient has severe abdominal pain, and the effluent and quinolones, should be used whenever possible. An alter- WBC count is high. Gram stain is often helpful in establishing native approach has been to use a low dose of aminoglyeoside the diagnosis early. Candida is by far the most common in one exchange per day, which provides high local levels organism. Risk factors include frequent peritonitis. immuno- during the period of the dwell, yet very low systemic levels. suppression, and antibiotic therapy. At our institution, the Lai et al. treated 14 Gram-negative peritonitis episodes with catheter is removed as soon as the diagnosis is established. In gentamicin, 20 mg/L in one exchange per day intraperitoneally, an uncontrolled trial, Goldie et al. found that 15% of patients combined with 500 mgfL in the same exchange of cefazolin in whom the catheter was removed within 1 wk of diagnosis (37). For the eight non-Pseudornonas Gram-negative organ- died, in contrast to 50% when the catheter was left in place isms, only two infections due to Acinetobacter species required (47). Therapy with fluconazole (200 mg orally each day), alteration in therapy, and all resolved. Baibie et al. used 0.6 flucytosine (I g orally each day), and, if necessary, amphoter- mg/kg in one exchange of gentamicin (in combination with an iein, should be continued after catheter removal for at least an initial dose of vancomycin) with resolution of two-thirds of the additional 10 d. The catheter can be reinserted, but a waiting episodes of non-Pseudomonas Gram-negative peritonitis (45). period of 1 to 2 mo is advisable. Approximately 10% of The nonresponders included Acinetobacter and Alcaligenes patients will have peritoneal fibrosis making PD no longer an species. Acinetobacter peritonitis is difficult to treat, and two option. antibiotics should be used to treat this organism. Pseudomonas aeroginosa peritonitis is frequently associated Peritonitis due to Mycobacterium with a tunnel infection, which may be occult. Should the Tubereubous peritonitis occurs more frequently in Asia than effluent culture reveal a Pseudoinonas infection, the subeuta- in Western countries, but may become more common in view neous tunnel should be examined carefully, and if it appears of the current epidemic of myeobaeteria infections. As with normal, ultrasonography should be performed to further assess other microorganisms, the effluent WBC are predominately possible tunnel involvement. If the tunnel is involved, the polymorphonuelear cells. Because the effluent acid-fast bacil- catheter should be promptly removed, as resolution with anti- lus stain is generally negative and there is usually no tubercu- biotic therapy is highly unlikely (9). If there is no tunnel bus disease elsewhere, the diagnosis may be difficult (48). infection, Pseudomonas aeroginosa will usually resolve with Ultrafiltration failure may occur but is not inevitable. Therapy aminoglycoside therapy (generally given as 5 to 8 mg/L in each should consist of three drugs (isoniazid, rifampicin, and pyra- exchange) and the addition of a second agent active against zinamide) for 9 to 12 mo. Reportedly, the catheter does not Pseudomonas. Of note, in a recent article from Belgium, 7% of always require removal (48). patients with peritonitis died (3 of 42) from sepsis; two of these patients had Pseudornonas peritonitis (7). Refractory and Relapsing Peritonitis In view of the results of a recent article by Harwell et al. , in Refractory peritonitis is defined as an episode in which there every case of peritonitis due to enterie organisms, intra-abdom- is no improvement 5 d after appropriate antibiotic therapy is inal pathology underlying the infection should be considered initiated. There may be apparent resolution of the episode with (24). This can be evaluated with a computed tomography scan antibiotic therapy, but a cell count will often show persistence of the abdomen. Early surgical consultation should be consid- of an abnormal inflammatory response. Recurrent or relapsing ered, as prompt laparotomy may decrease the risk of death. peritonitis is defined as a second episode of peritonitis with the same organism as the first within 2 wk of stopping antibiotics. Polymicrobial Peritonitis and Intra-Abdominal Refractory and relapsing peritonitis may be due to a catheter Abscesses infection, which may not be clinically apparent. In every ease Approximately 6% of all episodes of peritonitis will have of relapsing and refractory peritonitis, the catheter subeutane- multiple organisms (46). If only Gram-positive organisms are ous tunnel should be examined clinically, and, if it appears present, the patient generally does well, with resolution of the normal, an ultrasonographie examination should be performed. infection with antibiotic therapy in the absence of catheter Recurrent peritonitis, in the absence of a tunnel infection, infection. However, if multiple enteric organisms grow from may be due to sequestration of bacteria (most often coagulase- the culture, intra-abdominal pathology must be considered, negative Staphylococcus) in the biofilm surrounding the intra- 1962 Journal of the American Society of Nephrology J Am Soc Nephrol 9: 1956-1964. 1998

abdominal portion of the catheter. Inadequate treatment of may be damaged. Alternative approaches are intranasal mupi- peritonitis predisposes to this complication. There are two rocin for Staphylococcus aureus nasal carriage. In the multi- options: fibrinobytic therapy or catheter replacement. Uroki- center European trial, this reduced Staphylococcus aureus nase, 5000 U in 5 ml of normal saline injected into the catheter catheter infections but not peritonitis (I 7). Perez-Fontan et al. with the abdomen drained and allowed to dwell for 2 h, is found a reduction in both Stapk’lococcus aureus catheter in- successful in 29 to 67% of patients with recurrent peritonitis fections and peritonitis with a course of intranasal mupirocin (49,50). This procedure has been primarily used on patients for each positive nose culture (18). Rifampin has also been with recurrent coagulase-negative Stapkvlococcus peritonitis, shown to reduce both Staphylococcus aureus catheter infee- and should be reserved for those recurrent episodes of perito- tions and peritonitis rates, but is associated with side effects in nitis for which tunnel infection has been excluded as a cause by 12% ofpatients (14-16). careful examination using ultrasonography. Alternatively, if Prophylaxis with nystatin, given to the patient taking anti- the peritoneal cell count can be suppressed to less than 100 biotics, successfully reduces the risk of andida peritonitis WBC/pi. then the catheter can be safely replaced at one (53). Additional studies will be needed to identify those pa- setting. allowing the avoidance of hemodialysis in many pa- tients who would benefit most from such prophylaxis. This tients (50,5 1 ). One of the most common problems in managing may prove to be patients at high risk for fungal peritonitis, peritonitis is delay in removing the catheter in episodes that are including those with frequent bacterial peritonitis. on pro- not responding or that are likely to result in relapsing perito- longed courses of antibiotics or with impaired immune sys- nitis. Table 6 lists examples in which catheter removal is often tems. necessary. Procedure-related causes of peritonitis may be decreased by asking the patient to inform the dialysis center before extensive Prevention of Peritonitis dental work, cobonoseopy, and endometrial biopsies. We be- Prevention of peritonitis is a key component of a successful lieve that antibiotic prophylaxis should be given for all such PD program, and is based on collaboration between patient, the procedures. In addition, the abdomen should be drained prior to nurses, and the physician. Decreasing risk from contamination pelvic and colonie procedures. Aggressive treatment of consti- is highly dependent on both patient selection and training pation may result in enterie peritonitis; therefore, every effort techniques. The nurses should reinforce the concepts of steril- should be made to prevent constipation in the PD patient. ity and compulsiveness in performing the exchange, even after In conclusion, peritonitis remains one of the most serious the initial training is completed. The best connection technol- problems facing the PD patient and PD health care worker. ogy, the twin bag system. should be chosen for continuous Reducing rates of peritonitis can be achieved by careful patient ambulatory PD patients, and for cycler patients who must do selection and training, use of the best connection technology, multiple spikes, use of the Compact Assist Device (Baxter and screening for and treating nasal carriage. Once peritonitis Healthcare Corp., Deerfield, IL) is helpful in reducing the risk occurs, the treatment should be prompt. There should be no of infection. Each program must monitor and periodically hesitation to remove the catheter if this appears to be appro- review cases of peritonitis to identify problem areas. Patients priate. with high peritonitis rates should be encouraged to transfer permanently to hemodialysis. The risk of Staphylococcus aureus peritonitis and catheter References infections can be reduced by monitoring and treating for nasal I . CANUSA Peritoneal Dialysis Study Group: Adequacy of dialy- carriage (Figure 1 ). We found that prophylaxis with mupirocin sis and nutrition in continuous peritoneal dialysis: Association at the exit site resulted in a reduction in Staphylococcus aureus with clinical outcomes. J Am Soc Nep/iro/ 7: 198-207. 1996 exit site infections and related peritonitis episodes (16). These 2. Woodrow G. Turney IH. Bownjohn AM: Technique failure in results have been recently confirmed by Thodis et a!. (52). This peritoneal dialysis and its impact on patient survival. Pent Dial protocol is well accepted by the patients, who use a Q-tip to mt 17: 360-364, 1997 place a thin smear of mupiroein around the catheter exit site 3. Golper TA, Brier ME, Bunke M: Risk factors for peritonitis in after bathing. One tube lasts for approximately 2 mo. This long-term peritoneal dialysis: The Network 9 peritonitis and method should not be used with polyurethane catheters, which catheter survival studies. Am J Kidney Dis 28: 428-436, 1996 4. Fried LF, Bernardini I, Johnston iR: Peritonitis influences mor- tality in peritoneab dialysis patients J Aii Soc Nephro/ 7: 2 176- Table 6. Episodes of peritonitis for which catheter removal 2182. 1996 is appropriate 5. Koopmans 1G. Boesehoten EW. Pannekeet MM: Impaired initial cell reaction in CAPD-related peritonitis. Pent Dial Jut 16[Suppl Peritonitis associated with same organism causing exit site” 1]: 5362-5367. 1996 or tunnel infection 6. Holley IL. Bernardini I, Piraino B: Infecting organisms in con- Fungal peritonitis tinuous ambulatory peritoneal dialysis patients on the Y-set. Relapsing or refractory peritonitis Am J Kidney Dis 23: 569-573. 1994 7. Van Biesen W, Vanholder R, Vogelaers D: The need for a Peritonitis associated with intra-abdominab pathology center-tailored treatment protocol for peritonitis. Peril Dial In!

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