1. ΕΙΔΙΚΗ ΑΝΤΙΜΕΤΩΠΙΣΗ ΠΕΡΙΤΟΝΙΤΙΔΑΣ ΚΛΙΝΙΚΕΣ ΟΔΗΓΙΕΣ ISPD
ΠΗΝΕΛΟΠΗ ΧΡ. ΚΟΥΚΗ
«ΙΠΠΟΚΡΑΤΕΙΟ» Γ.Ν.Α

2. REFRACTORY(ANΘΕΚΤΙΚΗ) PERITONITIS
Failure of the effluent to clear after 5 days of appropriate antibiotics
RECURRENT (YΠΟΣΤΡΟΦΟΣ) PERITONITIS
Αn episode that occurs within 4 weeks of completion of therapy of a prior episode but with a different organism

3. RELAPSING (ΥΠΟΤΡΟΠΙΑΖΟΥΣΑ) PERITONITIS
An episode that occurs within 4 weeks of completion of therapy of a prior episode with the same organism or 1 sterile episode
REPEATED (ΕΠΑΝΑΛΑΜΒΑΝΟΜΕΝΗ) PERITONITIS
An episode that occurs more than 4 weeks after
completion of therapy of a prior episode with the
same organism

4. Relapsed Recurrent Non-rec, rel Outcome N= 356 epis N=165 epis
Hospitalization
No (%)
248 (70)
115 (70)
1473 (73)
Duration (d)
Catheter removal
108 (30)
61 (37)
54 (22)
Relapsing and Recurrent Peritoneal Dialysis –Associated Peritonitis : A Multicenter Registry Study. Burke M et al. Am J Kidney Dis. 2011;58(3):

5. Relapsed
Recurrent
Non-rec, rel
Outcome
N= 356 epis
N=165 epis
N=2021 epis
Temporary hemodialysis
No (%)
21 (6)
11 (7)
80 (4)
Duration (d) 78 99
66.5
Permanent hemodialysis
88 (25)
52 (32)
379 (20)
Death (Death of a patient with active peritonitis , or admitted with peritonitis , or within 2 weeks of a peritonitis episode)
7 (2.0)
2 (1.2)
7 (2.8)

6. Time since previous peritonitis episode (months)
120-
100-
80-
60-
40-
20- 0-
Non-Repeat
120-
100-
80-
60-
40-
20- 0-
Frequency
Repeat
Histogram shows timing of occurrence
of repeated versus non repeated
peritonitis after a prior episode of peritonitis
in Australian peritoneal dialysis patients in
Time since previous peritonitis episode (months)

7. Non-repeated peritonitis
Outcome
N = 245 episodes
N = 824 episodes
Relapse
83 (34)
77 (9)
Hospitalization
Events (%)
149 (61)
585 (71)
Catheter removal
48 (20)
166 (20)
Permanent hemodialysis
38 (16)
143 (17)
Death
3 (1.2)
23 (2.8)
Repeated peritoneal dalysis associated peritonitis A multicenter registry study. Thirugnanasambathan T et al.Am J Kidkey Dis xx(x)xxx

8. ROC curve of dialysate white counts
1.00-
.75-
.50-
.25-
0.00-
Sensitivity and specificity of dialysate white cell
counts at various time points of the peritonitis to predict treatment
failure, assessed by receiver-operating characteristic
(ROC) curve analysis.
> 1090/mm3
True-positive proportion (Sensitivity)
White count on day 5
White count on day 3
White count on day 1
False-positive proportion (1-Specificity)
Predictive value of dialysate cell counts in peritonitis complicating peritoneal dialysis. Kai Ming Chow..Clin J Am Soc Nephrol2006;1:

9. Gram- Positive Organisms, Including Coagulase-
Negative Staphylococcus, on Culture
Due primarily to touch contamination
Leads sometimes to relapsing peritonitis due to biofilm involve –replacing the cathe
ter under antibiotic coverage as a single procedure once the effluent clears
Continue gram-positive coverage based on sensitivities
Stop gram-negative coverage
If Methicillin resistance : Definition based on MIC levels and the presence of mec A gene
Defined as the presence of the mecA gene and indicates that the organism is considered resistant to all beta lactam related antibiotics, including penicillins, cephalosporins, and carbapenems.
Assess clinical improvement, repeat dialysis effluent cell
count and culture at days 3-5

10. (symptoms resolve; bags clear): -Continue antibiotics;
Clinical improvement
(symptoms resolve; bags clear):
-Continue antibiotics;
-Reevaluate for exit-site or occult tunnel infection, intra –abdominal abscess, catheter colonization
Duration of therapy : 14 days
Peritonitis with exit-site or tunnel infection: Consider catheter removal. Duration of therapy :14-21 days

11. No clinical improvement (symptoms persist; effluent remains cloudy):
-Reculture and evaluate
No clinical improvement by 5 days on appropriate
antibiotics: Remove catheter

12. Enterococcus/ Streptococcus on Culture
-Touch contamination-
Intra abdominal pathology- Exit site and tunnel infection- Dental hygiene
Discontinue starting antibiotics
Start continuous ampicillin 125mg/L each bag;consider adding aminoglycoside once daily IP as 20mg/L for Enterococcus
The manifacturer’s precaution label states that these antibiotics should not be mixed together in the same solution container
If ampicillin resistant, start vancomycin;
If vancomycin – resistant enterococcus, consider quinupristin/dalfopristin, daptomycin or linezolid ( Bone marrow suppresion after days)
Assess clinical improvement, repeat dialysis effluent cell
count and culture at days 3-5

13. (symptoms resolve; bags clear): -Continue antibiotics;
Clinical improvement
(symptoms resolve; bags clear):
-Continue antibiotics;
-Reevaluate for exit-site or occult tunnel infection, intra –abdominal abscess, catheter colonization
Duration of therapy :
14 days (Streptococcus)
21 days (Enterococcus)
Peritonitis with exit-site or tunnel infection: Consider catheter removal. Duration of therapy :21 days

14. No clinical improvement (symptoms persist; effluent remains cloudy):
-Reculture and evaluate
No clinical improvement by 5 days on appropriate
antibiotics: Remove catheter

15. Streptococcal peritonitis Non-Streptococcal peritonitis N=287 episodes
Treatment characteristics and clinical outcomes of PD
associated peritonitis due to streptococci or other organisms in Australia
Outcome
Streptococcal peritonitis
Non-Streptococcal peritonitis
N=287 episodes
N=3307 episodes
Hospitalization
Number (%)
212 (74)
2292(69)
Catheter removal
29(10)
746(23)
Permanent hemodialysis
25(9)
610(18)
Death
4(1)
78(2)
Streptococcal peritonitis in Australian peritoneal dialysis patients: predictors, treatment and outcomes in 287 cases. Stace O’Shea et al. BMJ Nephrology 2009, 10;19

16. Pure enterococcal peritonitis Polymicrobial enterococcal peritonitis
Treatment characteristics and clinical outcomes of PD
associated peritonitis due to pure enterococcal, polymicrobial entedrococcal and non-enterococcal in Australia
Outcome
Pure enterococcal peritonitis
Polymicrobial enterococcal peritonitis
Non-enterococcal peritonitis
N=64episodes
N=52episodes
N=3478episodes
Hospitalization
Number(%)
48(75)
43(83)
2413(69)
Catheter removal
16(25)
27(52)
732(21)
Permanent hemodialysis
11(17)
26(50)
598(17)
Death
1(1.6)
3(5.8)
78(2.2)
Enterococcal peritonitis in Australian peritoneal dialysis patients: predictors, treatment and outcomes in 116 cases. Edey M et al. NDT :

17. Staphylococcus aureus on Culture
Touch contamination-Exit-site or tunnel infection
Continue gram-positive based on sensitivities
Stop gram-negative coverage, assess exit site again
If methicillin resistant, adjust coverage to vancomycin (1gr IP every 5 days) or teicoplanin
If vancomycin – resistant S aureus, consider quinupristin/dalfopristin, daptomycin or linezolid ( Bone marrow suppresion after days)
Teicoplanin can be used in a dose of 15mg/kg once daily
Add Rifampin 600mg/day orally for 5-7 days( 450 mg/day if BW < 50kg)
Assess clinical improvement, repeat dialysis effluent cell
count and culture at days 3-5

18. (symptoms resolve; bags clear): -Continue antibiotics;
Clinical improvement
(symptoms resolve; bags clear):
-Continue antibiotics;
-Reevaluate for exit-site or occult tunnel infection, intra –abdominal abscess, catheter colonization
Peritonitis with exit-site or tunnel infection may prove to be refractory and catheter removal should be considered
Allow a minimum rest period of 3 weeks before reinitiating PD
Duration of therapy :
At least 21 days

19. No clinical improvement (symptoms persist; effluent remains cloudy):
-Reculture and evaluate
No clinical improvement by 5 days on appropriate
antibiotics: Remove catheter

20. Non S aureus peritonitis N=503 episodes N=3091episodes Relapse
Treatment characteristics and clinical outcomes of PD
associated peritonitis due to to Staphylococcus aureus or other organisms in Austalia
Outcome
S aureus peritonitis
Non S aureus peritonitis
N=503 episodes
N=3091episodes
Relapse
Number(%)
100(20)
402(13)
Hospitalization
338(67)
2166(70)
Catheter removal
116(23)
659(21)
Permanent hemodialysis
93(18)
542(18)
Death
11(2.2)
71(3.3)
Staphylococcus aureus peritonitis in Australian peritoneal dialysis patients: predictors, treatment and outcomes in 503 cases. Govindarajulu S et al.Per Dial Inter. 30;

21. Permanent hemodialysis 66(17) 27(25) Death 6(2) 5(5)
Treatment characteristics and clinical outcomes of PD
associated peritonitis due to to MSSA and MRSA in Australia
Outcome
MSSA peritonitis
MRSA peritonitis
N=394 episodes
N=109episodes
Relapse
Number(%)
79(20)
21(19)
Repeat
Number(%0
122(31)
26(24)
Hospitalization
256(65)
82(75)
Catheter removal
82(21)
34(31)
Permanent hemodialysis
66(17)
27(25)
Death
6(2)
5(5)

22. Culture negative on Days I and 2
Clinical features of peritonitis (abdominal pain or cloudy
dialysate), dialysate leukocytosis ( white blood cell count
>100/μL with >50% neutrophils) and negative dialysate
culture result for any organism ( including fungi and my
cobacteria)
( Program with >20% culture negative peritonitis- reviewed and improved)
Continue initial therapy
Day 3 : culture still negative
Clinical assessment
Repeat PD fluid white cell count and differential

23. Patient improvement clinically
Infection resolving
Patient improvement clinically
Continue initial therapy for
14 days

24. Infection not resolving
Special culture technique for unusual causes ( e.g viral, mycoplasma, mycobacteria, legionella, fungi)
Still culture negative
Now culture positive
Clinical improvement: Continue antibiotic therapy
Duration of therapy:14 days
No clinical improvement after 5 days:
Remove catheter
Adjust therapy according to sensitivity patterns.
Duration of therapy based on organism identified
Continue antibiotics for at least 14 days after catheter removal

25. Culture-negative peritonitis Culture-positive peritonitis
Treatment characteristics and clinical outcomes of culture-negative and culture positive PD associated peritonitis in Australia
Outcome
Culture-negative peritonitis
Culture-positive peritonitis
N=425 episodes
N=3159episodes
Relapse
Number(%)
62(14)
440(14)
Hospitalization
262(60)
2242(71)
Catheter removal
54(12)
721(23)
Permanent hemodialysis
43(12)
592(19)
Death
4(1.0)
78(2.5)
Culture negative peritonitis in peritoneal dialysis patients in Australia; predictors, treatment and outcomes in 425 cases. Gahim M et al. Am J Kidney Dis 2010:

26. Pseudomonas Species on Culture
Without catheter infection (exit-site/tunnel)
Give 2 different antibiotics acting in different ways that organism is sensitive to e.g oral quinolone, ceftazidime. cefepime, tobramycin, piperacillin
Assess clinical improvement, repeat dialysis effluent cell
count and culture at days 3-5

27. (symptoms resolve; bags clear): -Continue antibiotics;
Clinical improvement
(symptoms resolve; bags clear):
-Continue antibiotics;
Duration of therapy :
At least 21 days

28. No clinical improvement (symptoms persist; effluent remains cloudy):
-Reculture and evaluate
No clinical improvement by 5 days on appropriate
antibiotics: Remove catheter
Continue oral and/or systemic antibiotics for at least 14 days

29. Pseudomonas Species on Culture
With catheter infection (exit-site/tunnel)
current or prior to peritonitis
Remove catheter
Continue oral and/or systemic antibiotics for at least 14 days

30. Pseudomonas peritonitis Non-Pseudomonas peritonitis N=191episodes
Prompt catheter removal and use of two anti-pseudomonal antibiotics are associated with better outcomes
Outcome
Pseudomonas peritonitis
Non-Pseudomonas peritonitis
N=191episodes
N=3403episodes
Relapse
Number(%)
17(9)
485(14)
Hospitalization
150(79)
2354(69)
Catheter removal
84(44)
691(20)
Permanent hemodialysis
66(35)
569(17)
Death
6(3)
76(2)
Pseudomonas Peritonitis is Australia: predictors, treatment and outcomes in 191 cases.Siva B et al. Clin J Am Soc Nephrol 2009;4:

31. Single Gram-Negative Organism on Culture
Touch contamination-Exit site infection-Transmural migration from
constipation, diverticulitis or colitis
Stenotrophomonas
(Prior therapy with carbapenemes, fluoroquinolones, and 3 and 4 generation cephalosporins)
Other –E.coli, Proteus, Klebsiella etc
Adjust antibiotics to sensitivity pattern. Cefalosporin ( ceftazidime or cefepime) may be indicated-Fluoroquinolone
Treat with 2 drugs with differing mechanisms based on sensitivity pattern ( oral trimethoprim/ sulfamethoxazol is preferred)
(IP ticarcillin/clavulanate, per os minocycline)
Assess clinical improvement, repeat dialysis effluent cell
count and culture at days 3-5

32. Other –E.coli, Proteus, Klebsiella etc Stenotrophomonas
Clinical improvement
(symptoms resolve; bags clear):
-Continue antibiotics;
-Duration of therapy:
14-21 days
Clinical improvement
(symptoms resolve; bags clear):
-Continue antibiotics;
-Duration of therapy:
21-28 days
No clinical improvement by 5 days on appropriate antibiotics
(symptoms persist; effluent remains cloudy) : Remove catheter

33. Amphotericin B and flucytosine
Fungal peritonitis
Immediately after fungi are identified by microscopy or culture :Remove catheter
Strongly suspected after recent antibiotic treatment for bacterial peritonitis
Amphotericin B and flucytosine
Intraperitoneal use of amphotericin causes chemical peritonitis
Trough serum flucytosine concentrations < 100μg/mL to avoid bone marrow toxicity
Fluconazole
Voriconazole ( 200mg IV twice daily for 5 weeks after catheter removal)
Posaconazole ( 400mg twice daily for six months)
Caspofungin
Used successfully as monotherpy or in combination with amphotericin B

34. Non-fungal peritonitis N=162episodes N=3432episodes Hospitalization
The risks of repeat fungal peritonitis and death were lowest with catheter removal combined with antifungal therapy when compared to either intervention alone
Treatment characteristics and clinical outcomes of PD-
associated peritonitis due to fungi or other organism in Australia
Outcome
Fungal peritonitis
Non-fungal peritonitis
N=162episodes
N=3432episodes
Hospitalization
Number(%)
159(98)
2345(68)
Catheter removal
142(88)
633(18)
Permanent hemodialysis
120(74)
515(15)
Death
14(9)
68(2)
Predictors and outcomes of fungal peritonitis in peritoneal dialysis patients. Miles R et al. Kidney Int :

35. Effect of timing of catheter removal on subsequent clinical outcomes in 142 patients with fungal peritonitis requiring catheter removal
Characteristic
≤ 5days
> 5days
N=64episodes
N=78episodes
Permanent hemodialysis
Number(%)
67(86)
53(83)
Death
6(8)
4(6)

36. Refractory peritonitis ( Simultaneous catheter removal not possible)
Indications for Catheter Removal for Peritoneal Dialysis-Related Infections
Refractory peritonitis ( Simultaneous catheter removal not possible)
Relapsing peritonitis ( Catheter removal as a single procedure
can be done if the effluent can first be cleared. The procedure should be
done under antibiotic coverage)
Refractory exit-site and tunnel infection (Timely
replacement of the catheter can prevent peritonitis –Permitting simultaneous
replacement)
Fungal peritonitis ( Simultaneous catheter removal not possible
2-3 weeks or later)
Catheter removal may also be considered for
Repeat peritonitis
Mycobacterial peritonitis
Multiple enteric organisms

37. ISPD Definitions of Recurrent, Relapsing and Repeated Peritonitis
Time elapsed since completing antibiotics for prior peritonitis episode
Same
Organism
Different
≤ 4w
Relapse
Recurrence
> 4w
Repeated
Non-Repeated

38. Antibiotics
Duration of Therapy
Peritonitis with CI -CR
Catheter removal
Gram (+) organisms
Continue gram-positive coverage based on sensitivities
14 days
14-21 days
Steptococccus-Enterococccus
Ampicillin
Aminoglycoside-Enteroc.
If ampicillin resistant enterococcus, start vancomycin;
If vancomycin – resistant enterococcus, consider quinupristin/dalfopristin, daptomycin or linezolid
14 days (Streptoc)
21 days (Enteroc)
21 days
Staphylococcus aureus
Continue gram-positive based on sensitivities
If methicillin resistant, adjust coverage to vancomycin (1gr IP every 5 days) or teicoplanin
Add Rifampin
Peritonitis with exit-site or tunnel infection may prove to be refractory and catheter removal should be considered
Allow a minimum rest period of 3 weeks before reinitiating PD
Pseudomonas species
Give 2 different antibiotics acting in different ways that organism is sensitive to e.g oral quinolone, ceftazidime. cefepime, tobramycin, piperacillin
No catheter infection
With catheter infection (exit-site/tunnel)
current or prior to peritonitis
Remove catheter
E.coli, Proteus, Klebsiella
Cefalosporin ( ceftazidime or cefipime) may be indicated-Fluoroquinolone
Stenotrophomonas
Treat with 2 drugs with differing mechanisms based on sensitivity pattern ( oral trimethoprim/ sulfamethoxazol is preferred
21-28 days
Fungal
Amphotericin B and flucytosine
Fluconazole
Voriconazole
Caspofungin
Immediately after fungi are identified by microscopy or culture :Remove catheter

39. Relapsing and Recurrent Peritoneal Dialysis –Associated Peritonitis : A Multicenter Registry Study. Burke M et al. Am J Kidney Dis. 2011;58(3):
Repeated peritoneal dialysis associated peritonitis A multicenter registry study. Thirugnanasambathan T et al.Am J Kidkey Dis xx(x)xxx
Streptococcal peritonitis in Australian peritoneal dialysis patients: predictors, treatment and outcomes in 287 cases. Stace O’Shea et al. BMJ Nephrology 2009, 10;19
Enterococcal peritonitis in Australian peritoneal dialysis patients: predictors, treatment and outcomes in 116 cases. Edey M et al. NDT :
Predictive value of dialysate cell counts in peritonitis complicating peritoneal dialysis. Kai Ming Chow Clin J Am Soc Nephrol 20061:
Staphylococcus aureus peritonitis in Australian peritoneal dialysis patients: predictors, treatment and outcomes in 503 cases. Govindarajulu S et al. Per Dial Inter. 30;
Culture negative peritonitis in peritoneal dialysis patients in Australia; predictors, treatment and outcomes in 425 cases. Gahim M et al. Am J Kidney Dis 2010:
Pseudomonas Peritonitis is Australia: predictors, treatment and outcomes in 191 cases. Siva B et al. Clin J Am Sox Nephrol 2009;4:
Predictors and outcomes of fungal peritonitis in peritoneal dialysis patients. Miles R et al. Kidney Int :