PERITONITISYousaf khan Lecturer Renal Dialysis IPMS- KMU

PERITONITISInfection, or rarely some other type of inflammation, of the

peritoneum.

Peritoneum is a membrane that covers the surface of both the organs that

lie in the abdominal cavity and the inner surface of the abdominal

cavity itself

PATHOGENESISPotential Routes of infection:Intraluminal: Improper technique in making or breaking a transfer set to bag or

catheter to transfer set connection. This allows bacteria to gain access to peritoneal catheter via the

catheter lumen.Periluminal: Bacteria present on skin surface can enter the peritoneal cavity via

the peritoneal catheter tract.Transmural: Bacteria of intestinal origin can enter the peritoneal cavity by

migrating through bowel wall.Hematogenous: Less commonly, bacteria that have seeded the peritoneum from a

distant site by way of the blood stream.Transvaginal: Possibility of ascending infection reaching the peritoneum from the

vagina

Bacteria Laden Plaque: Several months, the intraperitoneal (IP) portion of almost

permanent peritoneal catheters becomes covered with a bacteria laden slime or plaques.

Unknown whether such plaque has an important role in the pathogenesis of peritonitis.

Role of host defenses: Peritoneal leukocytes are critical in combating bacteria that have

entered peritoneal space by any of the routes.

A number of factors are now known to alter their efficacy in phagocytizing and killing invading bacteria.

Dialysis solution PH and osmolality Peritoneal dialysis solution calcium levels Peritoneal fluid immunoglobulin G (IgG) levels Human immunodeficiency virus (HIV) infection

Dialysis solution Ph and osmolality: Ph dialysis solution 5- 5.5 and osmolality of most ranges from 1.3 – 1.8

times that of normal plasma depending glucose conc. Used. These unphysiologic conditions greatly inhibit the ability of peritoneal

leukocytes to phagocytose and kill bacteria.

Peritoneal dialysis solution calcium levels: Antimicrobial action of peritoneal macrophages are enhanced by both

calcium and cholecalciferol. Increased risk of S.epidermidis peritonitis – low calcium dialysis solution.

Peritoneal fluid Immunoglobulin G (IgG) levels: Patient with abnormally low levels may be prone to having more

frequent episode of peritonitis.

Human Immunodeficiency virus (HIV) infection: Incidence of peritonitis does not appear to be higher in HIV infected

patient

ETIOLOGY Culture techniques, organism can isolated from peritoneal fluid in over

90% of cases in which symptoms and signs of peritonitis and elevate peritoneal fluid neutrophil count are present.

The responsible pathogen is almost always bacterium usually of gram positive verity.

Frequency of organisms isolated in patients with peritonitis

Organism Frequency (%)Bacteria 80 -90 Staphylococcus epidermidis 30 – 45 S. aureus 10 - 20 Streptococcus sp. 5 – 10 Klebsiella and enterobacter 5 Pseudomonas 3 – 8 Others < 5 Mycobacterium tuberculosis < 1 Candida and other fungi < 1 – 10 Culture negative 5 -20

RISK FACTORS FOR DEVELOPMENT OF PERITONITIS: Number of connection and disconnection made each

day b/w catheter or its attached line. Poor hand washing Patient ability to carry out connection using sterile non

touch technique. Exit site infection particularly tunnel infections. In hospital, exchanges being carried out by poorly

trained personnel. Poor eyesight unless special connection devices are

used. Patients disconnecting themselves from APD machine

at night ( toilet, care for children etc) Diarrhea, particularly if associated with poor hand

washing.

DIAGNOSIS1: Diagnostic criteria for peritonitis:a. Symptoms and signs of peritoneal inflammationb. Cloudy peritoneal fluid with elevated peritoneal fluid cell

count(more than 100/ mcl) due predominantly to neutrophils

c. Demonstration of bacteria in the peritoneal effluent by gram stain or culture.

A. Symptoms and signs of peritonitis:Percentage

SymptomsAbdominal pain 95Nausea and vomiting 30Feverish sensation 30chills 20Constipation or diarrhea 15SignsCloudy peritoneal fluid 99Abdominal tenderness 80Rebound tenderness 10 -50Increased temperature 33Blood leukocytosis 25

B. Peritoneal Fluid

1:Cloudiness of the fluid: Peritoneal fluid generally cloudy ( cell count 50 -100/ mcl ). Sudden onset of cloudy fluid with appropriate abdominal

symptoms ( initiation of antimicrobial therapy ). Peritoneal fluid cloudiness may be due to other factors

(fibrin, blood etc) or increase WBC count. Prolonged dwell period appear ( in APD day time )

2: Importance of performing a differential count of peritoneal fluid cells: In Peritonitis usually increase in the absolute number and

percentage of peritoneal fluid neutrophils. High peritoneal fluid cell count due to increase number of

monocyte or eosinophil's.

3: obtaining the specimen:a. CAPD patients: After disconnecting the drain bag full of peritoneal effluent, the

bag is inverted several times to mix its contents. 7ml aspirated from the port of drain bag and transferred to a

tube containing ethylenediamine tetraacetic acid (EDTA).

b. APD patients: In CCPD: obtained easily from the day time dwell by first draining

the abdomen and taking the sample from drainage bag. In APD: who go (dry) during the day – some residual fluid present

in the abdomen – sample can be obtain directly PD catheter.

c. Storage time: morphologic identification of the various cell type – difficult – stored 3 -5 hours prior to injection into the EDTA tube.

CULTURE OF PERITONEAL FLUID1: Technique: the incidence of positive peritoneal fluid culture in patients suspected of having peritonitis depend upon culture technique.a. Storage: infected fluid kept at room temperature or

refrigerated for a period often grows pathogenic organisms on subsequent culture.

b. Sample volume: at least 50 ml because larger volumes increase the yield of positive culture results.

c. Sample preparation

2: Yield of positive cultures: 70 -90 % of dialysate sample obtained from patients with clinically peritonitis yield positive culture for micro organism within 24 -48 hours. a more prolonged incubation period may be needed for

more fastidious organism.

3: Gram stain:

PREVENTION: Prevention is also achieved by Careful selection of patients Patient education and training. Avoiding constipation Adequate nurse training with special emphasis on

hand washing b/w patients Isolating patients who are carriers of antibiotic

resistant bacteria such as MRSA or VRE Ensuring that exchanges are only done by trained

personnel when patients are admitted for intercurrent illness or surgery.

TREATMENT OF PERITONITIS (PRINCIPLE) Recommendation made here are based on current guidelines

from the International society of peritoneal dialysis Treatment with antibiotic should be commenced at once in

all patients with a cloudy bag and in those with positive microscopy – culture result should not be awaited.

Most units treat peritonitis with intraperitoneal antibiotics. The advantage are

a. High antibiotic concentration in peritoneumb. No intravenous access neededc. Patients can administer antibiotics themselves, minimizing

need for hospitalization.o Intraperitoneal antibiotics are systemically absorbed and

blood levels of potentially toxic antibiotics such as vancomycin and aminoglycosides need to be monitered.

Numerous different antibiotic regimens have been developed in different hospitals. There is no evidence that one is any better than another as long as the following rules are followed…

a. Initial antibiotics with broad gram positive and gram negative cover

b. Peritoneal concentration of antibiotic high enough to eradicate infection

c. Follow up of culture results and appropriate adjustments made to antibiotics

d. Allowance for renal excretion of antibiotic if there is residual renal function.

e. Measurement of vancomycin and aminoglycoside blood levels to avoid underdosing if patients have residual renal function and over dosing with the potential side effect of nephrotoxicity and ototoxicity.

f. Sufficient duration of treatment to avoid recurrence of infection

TREATMENT OF PERITONITIS: INITIAL TREATMENT Initial treatment on diagnosis or suspicion of peritonitis Day 1: send PD fluid for micro and culture; swab exit site if

inflamed Treatment: cefazolin 1.5G, Gentamicin 1.5 mg/kg IP (if

urine output > 500 ml/24 hr) or 0.6 mg/kg IP (if urine output < 500 ml/24 hr)

Allow exchange with antibiotics to dwell for 6 hours patient to take home two bags of CAPD fluid 1.36% containing (Gentamicin 0.6 mg/kg + cefazolin1.5 G)

One to be self administered each day for next two days as part of normal CAPD regime and allowed to dwell for a minimum of 6 hours.

TREATMENT OF PERITONITIS: INITIAL TREATMENT If patient on APD, antibiotic should be added to 1.5 or

2 lit bag which is drained in after completing overnight APD; fluid should be left in all day until next APD session or for a minimum of 6 hours if patient normally does a day time exchange.

Arrange for patient to return on day 4 Day 4: Patient returns to PD unit change treatment according

to PD fluid culture result and response to treatment.

THANK YOU FOR YOUR ATTENTION