Dialysis-Related Spontaneous Bacterial Peritonitis

1. See Also
   1. Peritoneal Dialysis
2. Incidence
   1. Once in 15 patient-months of Peritoneal Dialysis
3. Causes
   1. Complication of Peritoneal Dialysis
   2. Common
      1. Staphylococcus epidermidis (most common)
      2. Staphylococcus aureus
      3. Gram-negative bowel flora
   3. Other
      1. Pseudomonas aeruginosa
      2. Candida
      3. Tuberculosis
      4. Anaerobes
4. Risk Factors
   1. Immunocompromised state
   2. Frequent daily dialysate exchanges
   3. Biofilm formation
   4. Hot and humid weather
5. Symptoms
   1. Abdominal Pain
   2. Fever
   3. Vomiting
6. Signs
   1. Acute Abdomen with peritoneal signs may be present
7. Labs
   1. Complete Blood Count
   2. Blood Cultures
   3. Dialysate culture
      1. Cultures typically grow Gram Positive skin flora as well as Gram Negative Bacteria
      2. Other infections include candida, Tb or Anaerobes
   4. Dilaysate exam and Gram Stain
      1. Cloudy dialysate
      2. Dialysate exam with >100 white cells and >50% PMNs
8. Management
   1. Start with repeated multiple rapid dialysate fluid exchanges
   2. Use Heparin 500 units/Liter dialysate with intraperitoneal antibiotic
   3. Continue antibiotics for 7 to 14 days
   4. First-line Intraperitoneal antibiotic
      1. Cephalothin 200-500 mg/L of dialysate intraperitoneal or
      2. Gentamicin 8 mg/L of dialysate intraperitoneal followed by 4 mg/L subsequent intraperitoneal infusions
         1. Pretreat with Gentamicin IM or IV
   5. MRSA suspected: Vancomycin IV and intraperitoneal (VRE risk)
      1. Vancomycin 15-25 mg/kg/L of dialysate intraperitoneal
      2. Pre-administer Vancomycin 1 gram IV load
   6. Gram-Negative Bacteria suspected: Ceftazidime AND Aztreonam
      1. Ceftazidime 1 gram IV or intraperitoneal AND
      2. Aztreonam 3 grams IV or intraperitoneal
   7. Failure to improve
      1. Consider peritoneal catheter removal (consult with patient's nephrologist first)
      2. Consider adding Fluconazole if fungal infection suspected
9. References
   1. Campana (2014) Crit Dec Emerg Med 28(4): 2-8
   2. Glauser (2013) Crit Dec Emerg Med 27(10): 2-12