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Peritoneal infections
1Renal Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. piraino@msx.dept-med.pitt.edu
Abstract:
Peritoneal dialysis related infections include infection of the catheter exit site, subcutaneous pathway, or effluent. Exit-site infections, predominately owing to Staphylococcus aureus, are defined as purulent drainage at the exit site, although erythema may be a less serious type of exit-site infection. Tunnel infections are underdiagnosed clinically, and sonography of the tunnel is useful to delineate the extent of the infection and to evaluate response to antibiotic therapy. S aureus infections occur more frequently in S aureus carriers and immunosuppressed patients and can be reduced by mupirocin prophylaxis either intranasally or at the exit site. Patients with peritonitis present with cloudy effluent and usually pain, although 6% of patients may initially have pain without cloudy effluent. A white blood cell count of 100 or greater per microL, 50% of which are polymorphonuclear cells, has long been the hallmark of peritonitis. Empiric therapy is controversial, with some recommending cefazolin and others vancomycin (with cefatazidime for Gram-negative coverage). The choice should depend on the center's antibiotic sensitivity profile; those centers with a high rate of Enterococcus- or methicillin resistant organisms should use vancomcycin. Peritonitis episodes occurring in association with a tunnel infection with the same organism seldom resolve with antibiotics and require catheter removal. Other indications for catheter removal are refractory peritonitis, relapsing peritonitis, tunnel infection with inner-cuff involvement that does not respond to antibiotic therapy (based on ultrasound criteria), fungal peritonitis, and enteric peritonitis owing to intra abdominal pathology. Centers can reduce dialysis related infections to very low levels by proper catheter selection and insertion, careful selection and training of patients, avoidance of spiking techniques, and use of antibiotic prophylaxis against S. aureus. Further research is required to identify methods to reduce the risk of enteric peritonitis.
Insights
Peritoneal dialysis infections, including exit-site and peritonitis, can be reduced with proper techniques and Staphylococcus aureus prophylaxis. Early diagnosis and appropriate antibiotic therapy are crucial for effective management.
Area of Science:
- Nephrology
- Infectious Diseases
- Medical Imaging
Background:
- Peritoneal dialysis (PD) is a vital renal replacement therapy.
- PD-related infections, including exit-site, tunnel, and peritonitis, are significant complications.
- Staphylococcus aureus is a common pathogen in PD infections.
Purpose of the Study:
- To review the diagnosis, management, and prevention of PD-related infections.
- To highlight the role of sonography in diagnosing tunnel infections.
- To discuss strategies for reducing infection rates in PD patients.
Main Methods:
- Literature review of PD-related infections.
- Discussion of diagnostic criteria for peritonitis and exit-site infections.
- Overview of treatment options and preventative measures.
Main Results:
- Exit-site infections often caused by Staphylococcus aureus; mupirocin prophylaxis can reduce incidence.
- Tunnel infections require sonographic evaluation and may necessitate catheter removal.
- Peritonitis diagnosis relies on cloudy effluent and elevated white blood cell counts; antibiotic choice depends on local resistance patterns.
- Catheter removal is indicated for refractory, relapsing, or complicated infections.
Conclusions:
- Comprehensive strategies, including proper catheter care, patient training, and antibiotic prophylaxis, can minimize PD-related infections.
- Sonography aids in assessing tunnel infections and treatment response.
- Further research is needed to address enteric peritonitis prevention.