New treatment options and protocols for peritoneal dialysis-related peritonitis

Peritonitis remains a major complication in patients undergoing peritoneal dialysis. The most recent ISPD guidelines for the empiric initial treatment of peritonitis recommend the use of antibiotics that provide coverage against Gram-positive organisms (vancomycin or cefazolin) and Gram-negative organisms (a third-generation cephalosporin or an aminoglycoside). However, there are some situations in which this regimen may not be desirable. Concerns of resistant organisms, changing microbiology, drug toxicity, or difficulties administering therapy may lead a provider to modify the initial regimen. Drug resistant Staphylococcus aureus strains and Enterococcus strains may require administration of newer agents such as linezolid, quinipristin/dalfopristin, or daptomycin. Many centers have reported that, over time, the microbiology at those institutions has been changing. Some centers have reported a significant decrease in gram positive organisms and increase in extended spectrum beta-lactamase (ESBL) organisms. It is important for each center to examine its microbiology to document such trends. Although the currently recommended therapies have low toxicities, it is possible that concerns for untoward side effects in an individual patient may dictate changing the regimen. Finally, there is evidence from many prospective studies that monotherapy with different agents (oral quinolones or cefepime) is efficacious; if ease of therapy is a consideration, these may also be appropriate agents.