DaVita Medical Insights

Addressing Peritonitis to Improve the Peritoneal Dialysis Success Rate

Peritonitis (PTN) remains a significant cause for peritoneal dialysis (PD) technique failure in the United States and around the world. The causes of PTN demonstrate a pattern indicating touch contamination from organisms such as Methicillin-resistant Staphylococcus epidermidis, Staphylococcus epidermidis and Staphylococcus aureus, and PTN is most often treated with intraperitoneal (IP) antibiotics. Expediting treatment for PTN is highly important: Recently, Muthucumarana K et al found that each hour of delay in administering antibacterial therapy increased the risk of PD failure by 6.8 percent. Because IP antibiotic treatment is not available after hours at a dialysis center, it is important to have a protocol in place to help avoid delays in antibiotic initiation and, ultimately, lower the PD technique failure rate.

Cipro has been used by DaVita as a proactive approach to early treatment of apparent PTN to avoid delays in treatment (delays may negatively impact technique survival). However, with concern for the appropriate use of Cipro for after-hours treatment in an age of antibiotic stewardship, observed drug-related complications (albeit small) and the special infection applications of Cipro (i.e., for anthrax and resistant infections), DaVita advanced an alternate antibiotic approach for PTN in May 2017. This new approach involves an early bridge treatment of peritoneal infections with a cephalosporin prior to IP antibiotic administration, which is more in line with FDA alerts, and addresses the need for treatment within two hours of PTN symptoms.

This new therapy regimen (outlined below) was developed after discussions with a number of U.S. nephrologists and review of the antibiogram of organism sensitivities seen with DaVita peritoneal dialysis (PD) infections.

After-hours antibiotic utilization for early treatment of PD infection

DaVita’s new Suspected PTN Bridge Therapy Antibiotic Protocol is as follows:

  • Antibiotics. At-home after-hours PTN kits contain a full 72-hour supply of either a first- or third-generation cephalosporin:
    • Cephalexin: 500 mg by mouth every 12 hours (with initial suggested loading dose of 1,000 mg)
      OR
    • Cefdinir: 300 mg by mouth every 24 hours (with recommendation that dose is taken two hours before or two hours after antacids, phosphate binders or oral iron supplements)

Septra DS 160 mg/800 mg (by mouth every 12 hours) remains the alternative for patients with allergic contraindications. Cipro will not be offered as a formulary alternative for after-hours PTN kits.

  • Timing. If a patient is symptomatic with cloudy fluid after hours, oral antibiotic therapy should be initiated promptly with instruction from the physician or home nurse. Note that the use of antibiotics can lead to complications, so the decision to treat should be based on the likelihood of PTN.
  • Severity Assessment. When a patient presents with symptoms of PTN, a nurse assesses the severity of the episode. A severe episode can include significant pain, vomiting, a fever greater than 101 degrees F, hypotension (or symptoms related to hypotension), symptoms that have persisted for more than 24 hours and an inability to drain. A patient with these symptoms is encouraged to go to the local emergency room for assessment and treatment.
  • Patient Instructions. If a patient has PTN symptoms but not a severe episode, the patient is instructed to drain and keep the cloudy effluent bag or a sample in the refrigerator to slow bacterial multiplication and white cell death until he or she can bring in the sample. The patient takes the oral dose of antibiotics as prescribed.
  • Follow-up. The patient goes to a dialysis center the following day to receive IP antibiotic therapy, if prescribed. A nurse then calls the patient daily, until the patient is seen again in the facility, to evaluate the patient’s severity of symptoms, suitability to remain home or need for further instruction.

The most recent International Society for Peritoneal Dialysis (ISPD) Guidelines were published in June 2016 and continue to provide significant scientific guidance for teams in preventing, diagnosing and treating PTN. Updated from the 2010 version, the newest guidelines highlight:

  • The importance of PTN reporting
  • Strategies for preventing PTN
  • Modifying PTN risk factors
  • Culture techniques for programs with sterile PTN rates greater than 10 to 20 percent
  • Limiting aminoglycoside use after organism identification and alternate drug selection based on susceptibilities
  • The importance of IP antibiotic dosing whenever possible
  • Special consideration for antibiotic dosing in automated PD PTN patients

The ISPD Guidelines provide valuable information regarding how PD programs should be addressing the multiple aspects or PD infection prevention, diagnosis and treatment. Ideally, these recommendations should become a vital component to a PD unit’s policies and procedures and should be reviewed and discussed by the PD care team.

A Note on PTN Prevention: An increase in PTN events prior to PD training has occurred in some programs and raises concerns about a need to track surgeon performance and ensure appropriate pre-op antibiotic coverage. Vancomycin may be preferential to cephalosporins in certain hospital locations based on bacteria sensitivity patterns.

Martin Schreiber, MD

Martin Schreiber, MD

With nearly 40 years of experience in nephrology, Martin Schreiber, MD, serves as vice president of clinical affairs for DaVita Kidney Care's home dialysis. Before this role, he worked primarily with Cleveland Clinic and held a number of key positions there, including member of the Board of Governors, chairman of the Department of Nephrology and Hypertension and director of home dialysis.