Review

Peritoneal Dialysis–Associated Peritonitis: Suggestions

for Management and Mistakes to Avoid
Muthana Al Sahlawi, Joanne M. Bargman, and Jeffrey Perl

Peritonitis is a common complication of peritoneal dialysis that is associated with substantial morbidity Complete author and article
and mortality. Peritonitis increases treatment costs and hospitalization events and is the most common information provided before
reason for transfer to hemodialysis. Although there is much focus on preventing peritoneal references.
dialysis–associated peritonitis, equally as important is appropriate management to minimize the Kidney Med. 2(4):467-475.
morbidity of a peritonitis episode when it has occurred. Despite the presence of international guidelines Published online July 3,
on peritonitis treatment, the evidence base to support optimal peritonitis treatment practices is lacking, 2020.
leaving the practitioner to rely on clinical experience and extrapolate from across other infection doi: 10.1016/
treatment practices. This article reviews common mistakes and misconceptions that we have observed j.xkme.2020.04.010
in the management of peritonitis that may compromise treatment success. It also provides suggestions
on common controversial aspects of peritonitis management based on the best available literature.
Although the use of the word mistakes is somewhat controversial and subjective, we acknowledge that
evidence is lacking and have based many of our suggestions on clinical judgment, experience, and
available data.
© 2020 Published by Elsevier Inc. on behalf of the National Kidney Foundation, Inc. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

INTRODUCTION recommends that empirical treatment be started as soon as

Peritoneal dialysis (PD)-associated peritonitis is associated peritonitis is suspected.11
with substantial morbidity, contributing to death in up to The relationship between the timing of antibiotic
8.6% of patients.1 Peritonitis increases treatment costs and administration in peritonitis and PD-related outcomes was
hospitalization events and is a primary reason for transition studied by Muthucumarana et al12 in a prospective
to hemodialysis (HD).2-4 PD-related infection has been multicenter study of 116 patients with 159 episodes of
identified as a core outcome of critical importance in the peritonitis in Western Australia. The 3 main time mea-
multistakeholder SONG (Standardised Outcomes in surements were symptom-to-contact time (contact to
Nephrology) PD initiative.5 medical or nursing personnel), contact-to-treatment time,
Despite International Society for Peritoneal Dialysis and symptom-to-treatment time (the sum of both). The
(ISPD) guidelines on peritonitis treatment, variability ex- outcome for each peritonitis episode was resolution of
ists in the diagnosis and management of peritonitis among peritonitis at 30 days and PD failure, which was defined as
PD centers worldwide, with limited uptake of these rec- either catheter removal or death at 30 days. Thirty-eight
ommendations.6 Overall peritonitis treatment failure rates patients had PD failure at 30 days (28 catheter removals
are as high as 25%.7,8 Although many studies have focused and 10 deaths). Contact-to-treatment time was indepen-
on peritonitis prevention, more effort needs to be focused dently associated with PD failure, and risk for PD failure
on successful management. increased by 5.5% for each hour of delay of administration
By addressing mistakes and misconceptions in the of antibiotics.
management of peritonitis that can compromise treatment The ISPD recommends the intraperitoneal (IP) route in
success, we hope to improve peritonitis outcomes. It is the administration of antibiotics unless features of systemic
important to note that there are areas in peritonitis man- sepsis are present. The evidence supporting the superiority
agement in which evidence is weak or lacking, meaning of the IP route was based on only 1 study. In that study,
that we rely on clinical judgment and extrapolate from the Bennett-Jones et al13 reported 75 patients with peritonitis
infectious disease literature. The following are 10 sug- who were randomly assigned to receive either IP or
gestions and possible mistakes to avoid in the management intravenous (IV) vancomycin and tobramycin. An increase
of patients with peritonitis (Box 1). was observed in the primary treatment failure rate for IV
versus IP vancomycin and tobramycin (risk ratio, 3.52;
95% confidence interval, 1.26-9.81).13 The advantages of
1. WE WAIT TOO LONG TO GIVE ANTIBIOTICS the IP route are delivering a high concentration of anti-
AND FOCUS TOO MUCH ON THE ROUTE biotics to the peritoneum, avoidance of IV access, and the
Early initiation of antibiotic therapy leading to improved possibility of home antibiotic administration by trained
patient survival has been well studied in the infectious patients. However, antibiotic administration delays may be
disease literature.9,10 Because prompt initiation of anti- related to the IP route, particularly in emergency de-
biotic therapy for peritonitis also is critical, the ISPD partments and wards in which PD-trained staff are not

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 Al Sahlawi et al.

Table 1. Fungal Peritonitis Without and With Prophylaxis While

Box 1. Summary of Suggestions for Management and
Receiving Antibiotics
Mistakes to Avoid
Incidence of
1. We wait too long to give antibiotics and focus too much on Fungal Peritonitis,
the route episodes/y Prophylaxis Reference
2. We do not consider antifungal prophylaxis 0.29 vs 0.02 Nystatin 3×/d Zaruba et al. Am J Kidney
3. We might be collecting and interpreting the PD effluent Dis. 1991;17:43-46
cell count incorrectly 0.17 vs 0 Nystatin or Robitaille P. Perit Dial Int.
4. We do not dose and choose antibiotics correctly ketoconazole 1995;15:77-79
5. We remove the PD catheter too quickly or not quickly 0.08 vs 0.01 Fluconazole Wadhwa et al. Adv Perit
enough QOD Dial. 1996;12:189-191
6. Not all abdominal pain and cloudy effluent is peritonitis 0.02 vs 0.01 Nystatin 4×/d Lo et al. Am J Kidney Dis.
7. We do not consider return to PD after catheter removal 1996;28:549-552
8. We do not perform quality improvement and talk to our 0.02 vs 0.02 Nystatin 4×/d Thodis et al. Perit Dial Int.
microbiology laboratory 1998;18:583-589
9. We do not consider simultaneous PD catheter removal 0.01 vs 0.01 Nystatin 4×/d Williams P, et al. Perit Dial
and reinsertion Int. 2000;20:352-353
10. Not all peritonitis is PD peritonitis Abbreviation: QOD, every other day.

Abbreviation: PD, peritoneal dialysis. individual countries and centers because the utility of this
approach might be lower in centers with low rates of
fungal peritonitis. The preferred agent in our opinion is
readily available to attend to the patients quickly. In such nystatin, given the low cost and safety profile with a dose
case, using the IV route for faster administration should be of 500,000 units orally 4 times per day for the entire
considered. However, the efficacy of different IV antibi- duration of antibiotic therapy plus 1 week. In centers and
otics in PD peritonitis needs further evaluation and study. countries in which nystatin is not available, fluconazole
Although some centers provide patients with IP antibiotics can be used at a dose of 200 mg every 48 hours. Systemic
to keep at home for prompt administration when the side effects, drug interactions, and the development of
symptoms are recognized by the patient, the benefit of this resistant strains are major concerns that need to be
approach should be weighed against the possibility of considered when prescribing fluconazole.
increasing the risk for culture-negative peritonitis by
inadvertently initiating antibiotic therapy before PD 3. WE MIGHT BE COLLECTING AND
effluent culture. This can be obviated by having the patient INTERPRETING THE PD EFFLUENT CELL
collect and refrigerate the effluent sample before antibiotic COUNT INCORRECTLY
initiation.
Peritonitis is defined by the presence of at least 2 of the
following: (1) clinical features consistent with peritonitis
2. WE DO NOT CONSIDER ANTIFUNGAL (eg, abdominal pain and/or cloudy dialysis effluent); (2)
PROPHYLAXIS dialysis effluent white blood cell (WBC) count > 100 cells/
Prior antibiotic therapy for peritonitis (or any other indi- μL or >0.1 ×109 cells/L, with >50% polymorphonuclear
cation) is a known risk factor for fungal peritonitis. This is leukocytes (PMNs); and (3) positive effluent culture.
possibly the result of the disruption of normal bowel flora It is important to note that the WBC count in the
by the antibiotics, which promote enteric fungal over- effluent is dependent on the dwell time and an appropriate
growth.14-17 The ISPD recommends antifungal prophylaxis dwell time is at least 2 hours. The short dwell in automated
to prevent fungal peritonitis when PD patients receive PD (APD) patients with rapid cycles may not be enough
antibiotics (evidence level 1B).11 This is particularly time to mount a cell count. In this case, the percentage of
important in immunocompromised patients and those PMNs can be more reliable because a proportion > 50% of
receiving broad-spectrum antibiotics for longer duration PMNs is strong evidence of peritonitis, even if the absolute
because these are additional risk factors for fungal perito- WBC count is <100/μL.11 Tuberculous peritonitis usually
nitis. Table 1 summarizes the studies of the effectiveness of also presents with a higher effluent neutrophil count,
fungal prophylaxes on incidence of fungal peritonitis. although cases with effluent lymphocyte predominance
In the Peritoneal Dialysis Outcomes and Practice Pat- have been reported.18,19
terns Study (PDOPPS), substantial variation was observed In the absence of clinical features suggestive of perito-
in the use of antifungal prophylaxis during antibiotic nitis (abdominal pain and/or cloudy dialysate), routine
therapy among participating centers. In Australia and New effluent culture is discouraged, resulting in unnecessary
Zealand, for instance, 89% of the centers used antifungal treatment if positive in the face of a normal effluent cell
prophylaxis compared with 54% in the United States and count. If PD effluent cultures are persistently positive with
only 8% in Japan.6 Of note, consideration for fungal a normal effluent cell count, it is important to consider
prophylaxis practice needs to be taken in the context of bacteremia with secondary peritoneal seeding, possible

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early peritonitis, or colonization/infection of the PD patients receiving APD will likely have greater antibiotic
catheter. Only if persistently positive, we would recom- clearance and require more frequent dosing.23,24 The
mend treatment even in the absence of peritoneal effluent relationship between peritonitis relapse rates and vanco-
leukocytosis. mycin trough levels was investigated In a retrospective
analysis of 31 episodes of Gram-positive peritonitis by
Mulhern et al.25 Patients who had a cumulative 4-week
4. WE DO NOT DOSE AND CHOOSE trough serum vancomycin level < 12 mg/L or an initial
ANTIBIOTICS CORRECTLY 7-day trough serum level < 9 mg/L had significantly
Dual antibiotic regimens are recommended for empiric higher risks for peritonitis relapse.25 In another study by
peritonitis treatment and include vancomycin or a first- Dahlan et al26 of 35 episodes of coagulase-negative Staph-
generation cephalosporin to cover Gram-positive ylococcus species peritonitis, the mean trough vancomycin
organisms and a third-generation cephalosporin or an ami- concentration was lower in patients who experienced
noglycoside to cover Gram-negative organisms (including relapse compared with those who did not (13.3 vs
antipseudomonal activity). Given that vancomycin, most 18.2 mg/L).
cephalosporins, and aminoglycoside are excreted by the Another controversial area is whether dosing of IP an-
kidneys, patients with significant residual kidney function tibiotics in every exchange is more efficacious than inter-
will have more clearance of the antibiotics and therefore mittent (in 1 daily exchange) dosing. Some studies have
lower concentrations in the blood and peritoneum. shown that intermittent dosing of IP vancomycin and
The importance of dosing the antibiotics on the basis of gentamicin is as effective as continuous dosing in CAPD
the degree of residual kidney function was supported by an patients.22,27,28 Although in our center we use intermittent
observational study of 181 patients with 339 episodes of dosing of IP ceftazidime, 2 pharmacokinetic studies
Gram-positive, Gram-negative, and culture-negative peri- demonstrated that a once-daily IP administration of cef-
tonitis. Episodes were categorized according to patients’ tazidime at a dose of 15 to 20 mg/kg can result in sub-
urinary creatinine clearances (0, 0-5, and >5 mL/min). In therapeutic blood levels. To achieve a therapeutic level of
patients with greater residual kidney function, the risk for ceftazidime, a recommended loading dose of 3 g with
treatment failure, relapse, and recurrent peritonitis for maintenance dosing of 1 to 2 g every 24 hours is sug-
Gram-positive or culture-negative peritonitis was signifi- gested. It is important to note that in both studies, there
cantly higher compared with anuric patients.20 were no data for residual kidney function.29,30
Another important antibiotic-dosing consideration is Extended-spectrum β-lactamase organisms are an
PD modality (APD vs continuous ambulatory PD [CAPD]). emerging concern in Gram-negative PD peritonitis and
Although APD is the most common PD modality across carry higher treatment failure and mortality rates.31,32
many high-income countries, pharmacokinetic and dosing Although these organisms might be sensitive to cephalo-
data for IP antibiotics and in particular cephalosporins sporin and aminoglycosides at the outset, they often
remain limited because most studies have been conducted become resistant to those antibiotics but remain sensitive
in CAPD patients. Extrapolation of antibiotic pharmacoki- to carbapenems in most cases. There are few data for the
netic data from CAPD to APD may be misleading due to efficacy of IP carbapenems in peritonitis patients. Few case
greater peritoneal antibiotic clearance in APD compared reports have suggested that meropenem is effective and
with CAPD, possibly resulting in subtherapeutic antibiotic safe when given IP.33,34
levels. In some circumstances, switching APD patients to When treating Pseudomonas peritonitis, double antibiotic
CAPD may ensure adequate levels of antibiotics.21 In coverage for this organism should be considered. Pseudo-
addition, if antibiotics need to be given continuously, APD monas species are usually difficult to treat and are associated
will need to be switched to CAPD. In our center, we switch with higher rates of concomitant exit-site and tunnel
APD patients with ampicillin-sensitive Enterococcus perito- infection, hospitalization, catheter removal, and technique
nitis to CAPD to facilitate ampicillin dosing, which must be failure.4,35,36 To improve the outcomes of such infection,
dosed continuously. the 2016 update of the ISPD guidelines for management of
Given that maintaining a therapeutic antibiotic con- PD-related infections recommends using dual antibiotic
centration is an important factor in the treatment of therapy with different mechanisms of action and to which
peritonitis, antibiotics such as vancomycin, if given during the organism is sensitive. This includes either gentamicin
peritonitis treatment, should be measured and kept or oral ciprofloxacin with ceftazidime or cefepime for 3
at >15 μg/mL. An accepted dosing interval to achieve such weeks.11 In a large observational study from the Australia
level is every 4 to 5 days. Although some centers may give and New Zealand Dialysis and Transplant Registry (ANZ-
vancomycin on a daily basis using lower doses, this DATA), episodes caused by Pseudomonas species that were
approach might be impractical and less cost-effective. A treated with dual antipseudomonal agents were signifi-
randomized controlled trial in children demonstrated that cantly less likely to be complicated by the need for per-
intermittent dosing of vancomycin is as efficacious as manent HD transfer than those that did not receive such
continuous dosing.22 However, it is important to note that treatment (10% vs 38%, respectively; P = 0.03). No sig-
patients with substantial residual kidney function or nificant difference was observed with respect to relapse,

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catheter removal, and death rates.36 If oral ciprofloxacin is 6. NOT ALL ABDOMINAL PAIN OR CLOUDY
given, it should be separated from oral iron and phosphate EFFLUENT IS PERITONITIS
binders to maximize absorption or in many cases, the latter Although abdominal pain is a common presenting symp-
medications can be temporarily withheld while on anti- tom of peritonitis, other causes should not be overlooked.
biotic treatment. These include but are not limited to ischemic colitis,
pancreatitis, pyelonephritis, ruptured ovarian or kidney
5. WE REMOVE THE PD CATHETER TOO cyst, transplant kidney rejection, Clostridium difficile infec-
QUICKLY OR NOT QUICKLY ENOUGH tion, and strangulated/incarcerated hernia. Another
The indications for PD catheter removal are refractory component of peritonitis definition is cloudy effluent,
peritonitis, relapsing peritonitis, refractory exit-site and which can also be nonspecific for peritonitis because it can
tunnel infection, and fungal peritonitis. Catheter removal be the result of various noninfectious causes such as
should also be considered in the case of repeat peritonitis, eosinophilic peritonitis, hemoperitoneum, malignancy,
mycobacterial peritonitis, and multiple enteric organisms.11 chylous effluent, and sampling fluid from a dry abdomen
Fungal peritonitis carries high rates of hospitalization, or from a dwell with an extended time.39
technique failure, and death.14,37,38 Immediate catheter Analysis of the effluent cells can provide clues toward
removal is recommended by the ISPD when fungi are the cause. Eosinophilic peritonitis for instance presents
identified in PD effluent in the face of effluent leukocy- with cloudy effluent with an elevated eosinophilic count
tosis, no matter the clinical status of the patient.11 (typically 10%-30%). This typically occurs within the
Observational studies have demonstrated that prompt first weeks of PD initiation and can be the result of an
catheter removal in fungal peritonitis improves outcomes allergic reaction to the PD solutions, plasticizers, tubing,
and reduces mortality. In a large single-center study by air, vancomycin, streptokinase, or the PD catheter it-
Chang et al,38 the effect of immediate catheter removal on self.40-45 Effluent eosinophilia can be associated with
mortality in PD patients was investigated in 94 episodes of concomitant elevation of peripheral-blood eosino-
fungal peritonitis in 92 patients. The mortality rate of philia.46-48 Eosinophilic peritonitis usually resolves
fungal peritonitis in this study was 28.7%, with a 21-day spontaneously, although it can take several months. Use
median duration between the diagnosis of fungal perito- of antihistamines or low-dose corticosteroid therapy may
nitis and death. The PD catheter was removed within 24 be helpful.40,42,49-51
hours in 39 patients and between 2 and 9 days after the Cytology and possibly flow cytometry should be or-
diagnosis in 42 patients. Delayed catheter removal (after dered in cases of recurrent sterile cloudy effluent to rule
24 hours from the diagnosis of fungal peritonitis) was an out malignant cells in the dialysate. Although rare, cases of
independent predictor for fungal peritonitis–related mor- lymphoma and peritoneal metastasis presenting with
tality (31.7% vs 12.8%).38 cloudy effluent and malignant cells in the cytologic anal-
The ISPD recommends removing the PD catheter in ysis of the effluent have been reported.52-55 In cases of
case of refractory peritonitis, which is defined as failure milky white effluent, checking triglyceride levels can be
of the PD effluent to clear after 5 days of appropriate helpful because chylous effluent is typically noncellular
antibiotic treatment. This approach of using a 5-day and rich in triglycerides (higher dialysate levels compared
cutoff may lead to unnecessary or premature catheter with serum). It may wax and wane relating to dietary fat
removal given the lack of evidence on its effect on long- intake. Lymphatic obstruction secondary to lymphoma is
term outcomes compared with a longer wait. Although another cause of chylous effluent.56 Acute pancreatitis,57
infectious disease consultants often advocate for early and certain calcium channel blockers,58 superior vena cava
more aggressive catheter removal as “source control,” in syndrome,59 and trauma to the lymphatics following PD
our opinion, the decreasing trajectory of the effluent catheter insertion are additional causes.60
WBC count should allow for more than 5 days of treat-
ment before the catheter is removed, particularly in the 7. WE DO NOT CONSIDER RETURN TO PD
face of less virulent organisms such as coagulase-negative AFTER CATHETER REMOVAL
staphylococci. This may even be applied in the case of Following severe peritonitis that necessitates PD catheter
peritonitis caused by Pseudomonas species. There is a removal and regardless of the responsible organism,
misperception that the catheter should be removed early approximately 30% to 50% of patients could potentially
in the course of the infection. However, a trial of therapy return to PD.61-64 The ISPD suggests that it is appropriate
should be allowed because a significant proportion of to consider return to PD following catheter removal for
these infections can be successfully treated with antibi- refractory, relapsing, or fungal peritonitis. Using ANZ-
otics. The exception to this approach would be if there DATA, Cho et al65 demonstrated that return to PD
was a concomitant pseudomonal or Staphylococcus aureus following temporary HD was not associated with inferior
exit-site or tunnel infection, in which case it is assumed clinical outcomes compared with patients who either
that the catheter itself is infected or colonized with the never required HD or stayed permanently on HD after
organism and should be removed. peritonitis. In an observational study from Hong Kong,

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Table 2. Root Cause Analysis by Causative Organism

Organism Possible Cause Action
Coagulase-negative Breaks in sterile technique Patient retraining; exit-site care; transfer set exchange; consider
staphylococcal species and during connection; exit-site biofilm infection in relapse or repeat peritonitis
Staphylococcus aureus infection
Streptococcus Dental procedures; GI flora Review protocols for dental and endoscopic procedures
translocation prophylaxis; examination for and treatment of dental and
periodontal disease
Enteric organisms (Gram- Intra-abdominal pathology; Avoid constipation; antibiotic prophylaxis for endoscopic
negative rods and severe constipation/GI procedures; if multiple organisms, consider CT
anaerobes) procedures
Fungus Prior antibiotic therapy/ Consider antifungal prophylaxis for antibiotic courses
immunocompromised state
Pseudomonas aeruginosa Exit-site and tunnel infection Review protocols for exit-site and catheter care
Pasteurella species Domestic pets, mainly cats Patient education on avoiding the pets during exchanges and
exit-site care; hand hygiene
Culture negative Prior antibiotic therapy; Review culturing methods and specimen handling; ask about
suboptimal culturing antibiotic exposure; if unresolving, consider unusual organisms
techniques (ie, TB)
Abbreviations: CT, computed tomography; GI, gastrointestinal; TB, tuberculous.

100 patients with 108 episodes of peritonitis that required prevent further episodes. Such interventions may include
catheter removal and temporary HD between 1995 and patient retraining, applying new protocols for exit-site care,
2000 were analyzed. All patients had an attempted prophylaxis for dental or endoscopic procedures, and
Tenckhoff catheter reinsertion at least 4 weeks after the management protocols for dry and wet contamination. It is
initial catheter was removed; 51 of 100 patients had suc- important to note as well that the responsible organism for
cessful catheter reinsertion with resumption of PD, peritonitis can often provide a clue to the cause (Table 2).
whereas for the remaining 49, catheter reinsertion was For instance, coagulase-negative staphylococci are often
attempted but failed, mainly because of significant peri- related to contamination during connection and hence
toneal sclerosis and bowel adhesions. The group with reviewing patient technique and retraining are critical.
failed catheter reinsertion had a higher proportion of Reducing rates of culture-negative peritonitis is another
fungal peritonitis compared with patients with successful important role of a continuous quality improvement team.
PD catheter reinsertion (16% vs 4%) and were of longer A rate < 10% is ideal and can be achieved in experienced
dialysis vintage (41 ± 29 vs 29.7 ± 17 months).63 centers.11 The main 2 modifiable causes of culture-
Taken together, it is important to consider the overall negative peritonitis are antibiotic administration before
clinical picture of the patient before peritonitis before effluent culture and suboptimal culture techniques and
making a decision to return to PD and to allow for shared specimen handling. In a retrospective study, 212 consec-
decision making after explaining the risks and benefits of utive episodes of culture-negative peritonitis in 149 pa-
PD return. In our centers, we always discuss with patients tients in Hong Kong during a 6-year period were analyzed.
that in some cases of fungal or severe peritonitis, the extent Approximately 26.4% had a history of antibiotic therapy
of the adhesions may not make it possible to return to PD. within 30 days before the onset of peritonitis, and in 109
There is no evidence on the optimal time between episodes of peritonitis for which effluent culture was ob-
catheter removal for peritonitis and reinsertion of a new tained by a trained renal nurse, 11.6% had negative culture
one. A few observational studies suggest a minimum of 2 results compared with 56.5% when performed by nurses
to 3 weeks.63,64 Surgical advanced laparoscopic reinsertion in general medical wards.69 In a single-center experience
is preferred over approaches that do not allow for direct aiming to reduce rates of culture-negative peritonitis,
visualization and lysis of potential adhesions. Kocyigit et al70 demonstrated a significant reduction (from
40.5% to 18.8%) over 7 years following improvement in
culturing techniques. Of note, culture-negative rates might
8. WE DO NOT PERFORM QUALITY be higher when patients with suspected peritonitis go to
IMPROVEMENT AND TALK TO OUR emergency departments, given the variability in culturing
MICROBIOLOGY LABORATORY technique compared with PD units. However, it is not
Each PD center should have a continuous quality improve- always possible to have patients come to the PD unit
ment program in place to reduce peritonitis rates.11 The because many home dialysis units do not have weekend
impact of such programs on the reduction of peritonitis is call facilities. To improve the culture yield, the ISPD sug-
well demonstrated.66-68 The continuous quality improve- gests the following: sending the specimens to the labora-
ment team should investigate and identify the root cause of tory within 6 hours of sampling, direct bedside
every single peritonitis episode to plan interventions to inoculation of 5 to 10 mL of effluent into 2 rapid (aerobic

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and anaerobic) blood-culture bottle kits, and centrifuga- The effectiveness of the 1-step strategy is well demon-
tion of 50 mL of PD fluid at 3,000g for 15 minutes and strated in select cases of Gram-positive relapsing peritonitis
resuspending the sediment in 3 to 5 mL of buffer for and refractory exit-site and tunnel infections, whereas it
culturing.11 It is important to ensure that the PD care team remains unclear for enteric, Pseudomonas, and fungal-related
and microbiology laboratory are aware of these steps when peritonitis.77 As a result, in our center, simultaneous PD
processing PD effluent samples. catheter removal and reinsertion for relapsing peritonitis is
considered for only select organisms and we extend anti-
biotic therapy over the course of the procedure and in the
9. WE DO NOT CONSIDER SIMULTANEOUS PD
week following the new PD catheter placement.
CATHETER REMOVAL AND REINSERTION
When catheter removal and subsequent reinsertion is
indicated, the standard procedure consists of 2 stages: 10. NOT ALL PERITONITIS IS PD PERITONITIS
removal of the PD catheter and subsequent reinsertion of a Peritonitis that results from non–PD-related complica-
new catheter after an interval of peritoneal rest and anti- tions (eg, ruptured appendix, ischemic bowel, and
biotics. This undefined period usually requires temporary cholecystitis) is well reported but still uncommon.
transfer to HD, often using a central venous catheter. The Differentiating this from peritonitis that is PD related can
advantages of simultaneous catheter replacement include be very challenging because both can have similar pre-
the following: decreasing unplanned transfer to HD, sentations. The ISPD recommends extending empirical
maintaining patient preference regarding dialysis modal- antibiotic coverage to include metronidazole plus van-
ity, and avoiding the complications that might result from comycin in combination with ceftazidime or an amino-
temporary HD transfer, such as central venous catheter glycoside when a surgical cause of peritonitis is
infections and rapid decline in residual kidney function. suspected. Another alternative is monotherapy with a
The feasibility of a 1-step strategy of simultaneously carbapenem or piperacillin/tazobactam.11 Although
removing and reinserting the PD catheter in select cases of some PD centers and emergency departments perform
peritonitis was investigated in different studies with computed tomography routinely in patients presenting
acceptable outcomes.71-74 Although not appropriate for with features of PD-related peritonitis, the role of imag-
refractory peritonitis, simultaneous removal and reinser- ing in establishing the diagnosis of PD peritonitis is
tion may be considered for relapsing peritonitis in which limited. However, computed tomography in some select
the PD effluent cell count and culture have normalized cases of peritonitis can be of value in detecting loculated
after an appropriate duration of treatment. Crabtree and fluid collections or abscess, thickening of the small-bowel
Siddiqi75 analyzed the clinical outcomes of 55 cases that wall or adhesions, and exclusion of other causes of intra-
had laparoscopic simultaneous catheter replacement at 1 abdominal sepsis.78,79 We suggest that computed to-
center. Of those, 28 had relapsing peritonitis and 12 had mography be performed in the following cases: patients
refractory tunnel infections without peritonitis. The caus- with polymicrobial enteric organisms, especially those
ative organisms in the peritonitis cases were coagulase- who fail to respond to appropriate treatment clinically or
negative staphylococci in 26 cases, S aureus in 1 patient, biochemically; hypotensive or hemodynamically unstable
and Streptococcus viridans in 1 patient. For the tunnel in- patients; patients with accompanying bacteremia; or pa-
fections, the majority were secondary to Pseudomonas aerugi- tients with other gastrointestinal symptoms (such as se-
nosa. All patients were kept on antibiotic therapy until the vere nausea and vomiting) or more localized abdominal
procedure was performed and continued for 2 to 4 weeks pain that may suggest another pathology or abnormal
after the procedure. In all cases of peritonitis and tunnel blood test results (elevated lipase, bilirubin, or trans-
infections, PD was resumed at the day of surgery using a aminase enzyme levels). Of note, mild elevation in serum
day-dry, supine, low-volume APD protocol. At 8 weeks lactate level in patients with peritonitis may not neces-
follow-up, all patients were able to continue PD with no sarily indicate tissue hypoperfusion or bowel ischemia
subsequent relapse of peritonitis, pericatheter or incisional because it can be the result of delayed metabolism of the
leaks, or exit-site or wound infections.75 lactate buffer used in the PD solutions.80
In a recent French experience by Viron et al,76 11 pa- If imaging of the abdomen in these cases is performed,
tients who had simultaneous removal and insertion of the air under the diaphragm may be a finding. However, the
PD catheter were analyzed. The causative organisms in clinical significance of this sign can be variable. The cause
those patients were Gram-positive in 5 patients, Gram- of pneumoperitoneum in PD patients is mostly related to
negative in 4 patients (1 of which was Pseudomonas), and the PD catheter because it can provide an access for free air
yeast in 2 patients who refused to convert to HD. Eight to enter the peritoneum cavity. The incidence of this
(73%) patients were able to continue PD without transfer finding in PD patients has decreased from as high as
to HD and of those, 7 were still on PD at 1 year with no 34% in older studies to as low as 4% in a more recent
relapse of peritonitis. Of the 2 fungal peritonitis cases, one study.81-84 This decrease in incidence is likely related to
was able to continue PD for 15.9 months, while the other the advances in PD connectology that limit the introduc-
could not resume dialysis.76 tion of intraperitoneal air during an exchange and

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enhanced patient education regarding proper technique. 10 years’ experience in a single center. Perit Dial Int.
Taken together, this radiologic finding is common in PD 2014;34(1):85-94.
patients in the absence of intra-abdominal pathology; 4. Mujais S. Microbiology and outcomes of peritonitis in North
America. Kidney Int Suppl. 2006;103:S55-S62.
however, it should not always be considered as an incidental 5. Manera KE, Johnson DW, Craig JC, et al. Patient and caregiver
benign finding. The right clinical context (ie, polymicrobial priorities for outcomes in peritoneal dialysis: multinational
enteric peritonitis), a detailed history and physical exami- nominal group technique study. Clin J Am Soc Nephrol.
nation, and adjunct additional supportive imaging findings 2019;14(1):74-83.
to suggest a surgical cause should be considered to differ- 6. Boudville N, Johnson DW, Zhao J, et al. Regional variation in the
entiate benign from more concerning causes. treatment and prevention of peritoneal dialysis-related in-
fections in the Peritoneal Dialysis Outcomes and Practice
Patterns Study. Nephrol Dial Transplant. 2019;34(12):2118-
CONCLUSIONS 2126.
7. Nochaiwong S, Ruengorn C, Koyratkoson K, et al. A clinical risk
Peritonitis carries substantial morbidity and mortality. The prediction tool for peritonitis-associated treatment failure in
evidence on how best to treat peritonitis is lacking. peritoneal dialysis patients. Sci Rep. 2018;8(1):14797.
However, using the best available evidence can improve 8. Ghali JR, Bannister KM, Brown FG, et al. Microbiology and
PD practice and patients’ outcomes. When evidence is outcomes of peritonitis in Australian peritoneal dialysis patients.
lacking, clinical judgment should ensue with the ultimate Perit Dial Int. 2011;31(6):651-662.
goal of reducing the morbidity associated with PD peri- 9. Liu VX, Fielding-Singh V, Greene JD, et al. The timing of early
tonitis while maximizing treatment success. antibiotics and hospital mortality in sepsis. Am J Respir Crit
Care Med. 2017;196(7):856-863.
10. Joo YM, Chae MK, Hwang SY, et al. Impact of timely antibiotic
ARTICLE INFORMATION administration on outcomes in patients with severe sepsis and
Authors’ Full Names and Academic Degrees: Muthana Al septic shock in the emergency department. Clin Exp Emerg
Sahlawi, MD, Joanne M. Bargman, MD, and Jeffrey Perl, MD, SM. Med. 2014;1(1):35-40.
Authors’ Affiliations: Division of Nephrology, St. Michael’s Hospital 11. Li PK, Szeto CC, Piraino B, et al. ISPD peritonitis recommen-
and the Keenan Research Center in the Li Ka Shing Knowledge dations: 2016 update on prevention and treatment. Perit Dial
Institute, St. Michael’s Hospital, University of Toronto, Toronto, Int. 2016;36(5):481-508.
Ontario, Canada (MAS, JP); Department of Internal Medicine, 12. Muthucumarana K, Howson P, Crawford D, Burrows S,
College of Medicine, King Faisal University, Al-Hasa, Saudi Arabia Swaminathan R, Irish A. The relationship between presentation
(MAS); and University of Toronto, University Health Network/ and the time of initial administration of antibiotics with out-
Toronto General Hospital, Toronto, Ontario, Canada (JMB). comes of peritonitis in peritoneal dialysis patients: the
Address for Correspondence: Dr Jeffrey Perl, Division of PROMPT Study. Kidney Int Rep. 2016;1(2):65-72.
Nephrology, St. Michael’s Hospital, 30 Bond St, 3-060 Shuter 13. Bennett-Jones D, Wass V, Mawson P, et al. A comparison of
Wing, Toronto, Ontario, Canada, M5B 1W8. E-mail: jeff.perl@ intraperitoneal and intravenous/oral antibiotics in CAPD peri-
utoronto.ca tonitis. Perit Dial Int. 1987;7(1):31-33.
14. Miles R, Hawley CM, McDonald SP, et al. Predictors and out-
Support: None.
comes of fungal peritonitis in peritoneal dialysis patients. Kid-
Financial Disclosure: Dr Perl has received speaking honoraria from ney Int. 2009;76(6):622-628.
Astra Zeneca, Baxter Healthcare, DaVita Healthcare Partners, 15. Restrepo C, Chacon J, Manjarres G. Fungal peritonitis in
Fresenius Medical Care, Dialysis Clinics Incorporated, Satellite
peritoneal dialysis patients: successful prophylaxis with flu-
Healthcare, and has served as a consultant for Baxter Healthcare,
conazole, as demonstrated by prospective randomized control
DaVita Healthcare Partners, Fresenius Medical Care, and LiberDi.
trial. Perit Dial Int. 2010;30(6):619-625.
Dr Bargman has received honoraria from Baxter Healthcare,
DaVita Healthcare Partners, Dialysis Clinics Incorporated and 16. Michel C, Courdavault L, al Khayat R, Viron B, Roux P,
Glaxo Smith Kline. Dr Al Sahlawi declared no relevant financial Mignon F. Fungal peritonitis in patients on peritoneal dialysis.
interests. Am J Nephrol. 1994;14(2):113-120.
17. Basturk T, Koc Y, Unsal A, et al. Fungal peritonitis in peritoneal
Peer Review: Received February 5, 2020, in response to an
dialysis: a 10 year retrospective analysis in a single center. Eur
invitation from the journal. Evaluated by 3 external peer reviewers,
Rev Med Pharmacol Sci. 2012;16(12):1696-1700.
with direct editorial input from the Editor-in-Chief. Accepted in
revised form April 24, 2020. 18. Khanna R, Fenton SS, Cattran DC, Thompson D, Deitel M,
Oreopoulos DG. Tuberculous peritonitis in patients undergoing
continuous ambulatory peritoneal dialysis (CAPD). Perit Dial
Int. 1980;1(3):10-12.
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