Treatment of peritonitis in patients undergoing continuous ambulatory peritoneal dialysis

The epidemiology, etiology, pathogenesis, diagnosis, and pharmacotherapy of peritonitis in patients with end-stage renal disease treated with continuous ambulatory peritoneal dialysis (CAPD) are reviewed. CAPD-associated peritonitis is a localized infection of the peritoneal cavity. Approximately 70% of the cases are caused by a single gram-positive microorganism indigenous to the patient's skin or upper respiratory tract that infects the peritoneal cavity. Gram-negative microorganisms cause 25% of the cases; fungi, anaerobes, and mycobacteria cause approximately 5%. Clinical manifestations include a cloudy, turbid peritoneal dialysate effluent and abdominal pain or tenderness. Diagnosis is confirmed by the detection and isolation of microorganisms in the peritoneal dialysate effluent. Of patients with CAPD-associated peritonitis, 70-80% can be successfully treated on an outpatient basis with intraperitoneal (i.p.) instillation of antimicrobials. Vancomycin, cephalosporins, and aminoglycosides are the agents most commonly used to treat CAPD-associated peritonitis. Most recently, alternative dosing regimens using intermittent i.p. administration of vancomycin have been used. In certain types of CAPD-associated peritonitis (those caused by Pseudomonas aeruginosa or fungi), removal of the peritoneal catheter may be required to achieve a cure. Approximately two thirds of the patients transferring to another form of dialysis from CAPD do so because of peritonitis. Currently available data indicate that the most effective therapy for CAPD-associated peritonitis is i.p. administration of antimicrobial agents with activity against the suspected microorganism.