Access Care Guide: Infectious Complications: Peritonitis Management

Infectious Complications: Peritonitis Management

Initial Empiric Management of Peritonitis

Introduction

The following steps including key assessments, key activities, patient education and outcomes evaluation are applicable to all peritonitis algorithms shown on subsequent pages.

ISPD guidelines suggest a peritonitis rate of minimum of 1 in 18 patient months. Rates of 1 in 41-52 months have been reported in some centers. The center’s overall peritonitis rate should be monitored at a minimum on an annual basis.27

Key Assessments

The clinical presentation of peritonitis may include any of the following: cloudy effluent, abdominal pain, fever and acutely declining peritoneal ultrafiltration.

Clinical Diagnosis:

  • The following three criteria alone or in combination may be indicative of the presence of peritonitis:6
    • Abdominal pain
    • Cloudy effluent with WBC >100/µL of which at least 50% are polymorphonuclear neutrophils (PMN)
    • If absolute cell count is less than 100/µL with a predominance of PMNs, the diagnosis of peritonitis is probable
    • Identification of organisms on Gram stain or culture

Differential Diagnosis of Cloudy Effluent:6, 28

  • Culture-positive infectious peritonitis
  • Infectious peritonitis with sterile cultures
    • Faulty culture techniques
    • Inadequate specimen
    • Inadequate culture conditions
    • Prior antibiotic usage
    • Slow-growing organisms
  • Noninfectious causes of cloudy effluent (see Appendix)
  • Specimen taken from “dry” abdomen

Key Activities

Initiate the following:

Performed by the patient or by the PD nurse in the dialysis unit:

  1. Perform physical exam including abdominal palpation, degree and location of pain, exit-site and tunnel assessment
  2. Disconnect drained bag and send sample to laboratory for cell count with differential, Gram stain and culture. Dwell time should be at least one to two hours.
    • Obtain specimen and inject 5-10 mLs into each blood culture bottle. Send 50 mL of peritoneal effluent to be centrifuged at 3000g for 15 min. followed by resuspension of the sediment for innoculation. For full detail on specimen handling (see Appendix)27
  3. In presence of cloudy effluent with pain and/or fever:
    • Initiate empiric antibiotic therapy within one hour while waiting for test results
  4. In presence of cloudy effluent, add heparin 500 U/L to new bag until effluent clears (usually 48 to 72 hours)27
  5. Initiate adequate pain management intervention. Peritonitis-related pain may require opiates for adequate control which should be prescribed in adequate amounts to control pain appropriately8
  6. Assess for need for hospitalization27
  • Discuss possibility of break in technique, compliance to hand washing, mask use
  • Inquire about recent procedures, constipation, diarrhea, and antibiotic use
  • Review peritonitis and exit-site infection history and treatment
  • Review use of exit-site prophylaxis

Patient Education

  • Immediately report cloudy effluent, abdominal pain and/or fever to PD unit6
  • Save drained cloudy dialysate and bring to clinic
  • Stress importance of obtaining specimen prior to beginning antibiotics

Patients previously educated on antibiotic administration should begin the following:

  • Add intraperitoneal antibiotics for duration of required therapy
  • Add heparin 500 U/L to each bag until clear6
  • Report persistent cloudiness to PD unit
  • Schedule retraining for technique issues

Outcomes Evaluation

Collect data to include:

  • Date of culture, organism identified, drug therapy used
  • Date infection resolved
  • Recurrent organisms, date of drug therapy
  • Documentation of contributing factors
    • Break-in technique, patient factors, exit-site infections, tunnel infections
  • Date of re-education/training

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