Peritoneal Dialysis International, Vol. 20, pp. 610-624
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Copyright © 2000 International Society for Peritoneal Dialysis
Consensus Guidelines for the Treatment of Peritonitis in
Pediatric Patients Receiving Peritoneal Dialysis
Bradley A. Warady, Franz
Schaefer,1 Maggie Holloway,2 Steven
Beth Piraino,4 Isidro
Divino,6 Masataka Honda,7
Salim Mujais,8 and Enrico
Verrina,9 for the International Society for
Peritoneal Dialysis (ISPD) Advisory Committee on
Peritonitis Management in Pediatric Patients
The Children's Mercy Hospital, Kansas City, Missouri, U.S.A.; University Children's
Heidelberg, Germany; U.C.L.A.
Hospital,2 Los Angeles, California; Stanford University
Medical Center,3 Stanford, California; University of
Pennsylvania, U.S.A.; Baxter Limited,
Japan,5 Tokyo, Japan; Baxter
SA,6 Brussels, Belgium;
Tokyo Metropolitan Children's
Hospital,7 Tokyo, Japan; Renal
Baxter Healthcare Corporation, Deerfield, Illinois, U.S.A.;
G. Gaslini Children's
Hospital,9 Genoa, Italy
Guideline 1: Diagnosis of Peritonitis
An empiric diagnosis of peritonitis should be
made if the peritoneal effluent is cloudy, the effluent
white blood cell (WBC) count is greater than
100/mm3, and at least 50% of the WBCs are
polymorphonuclear leukocytes. The diagnostic workup should be
performed using a standardized procedure (Table 1).
Although the diagnostic criteria for
peritonitis have not been validated in clinical studies, they
represent an international consensus among adult
and pediatric nephrologists (4-11). Abdominal pain
and fever are generally features that are too
nonspecific in children to predict peritonitis in the absence of
an elevated dialysate leukocyte count. If the effluent
is cloudy, the initial sample is optimal for
evaluation, irrespective of the length of the exchange dwell time.
In equivocal cases, or in patients on cycler
dialysis with short exchange dwell times and with
systemic or abdominal symptoms, and in whom the
effluent appears to be clear, a second exchange is
performed with a dwell time of at least 1 hour and the
appearance of the effluent is re-evaluated. It is
noteworthy that 6% of adults with culture-positive
peritonitis present with clear fluid and abdominal pain
(10). (Only two thirds of these patients subsequently
develop cloudy effluent.) Dialysate culture results
are typically not available before 24 hours and, albeit
confirming the diagnosis in retrospect, are not
helpful in initial clinical decision making. A negative
culture does not exclude bacterial peritonitis. In up
to 20% of pediatric peritonitis episodes, culture
results are negative (4,11-14).
Eosinophilic peritonitis (diagnosed when
eosinophils represent more than 10% of the total
dialysate polymorphonuclear leukocyte count) is commonly associated with the development
of cloudy effluent in an asymptomatic patient new
to dialysis. It is likely secondary to a local
allergic reaction to components of the dialysis fluid or
substances released from the dialysis equipment. It
is typically self-limited (4,10).
Guideline 2: Empiric Therapy of Peritonitis
In patients with cloudy effluent, without fever
and/or severe abdominal pain, and no risk factors for
severe infection (listed below), the combined intraperitoneal
administration of a first-generation cephalosporin
and ceftazidime is recommended (Figure 1). In
patients with fever and/or severe abdominal pain, a history
of methicillin-resistant Staphylococcus
aureus (MRSA) infection, a recent history or current evidence of
an exit-site/tunnel infection or nasal/exit-site colonization
with S. aureus, and in patients younger than
2 years, a glycopeptide (vancomycin or teicoplanin)
combined with ceftazidime should be administrated
intraperitoneally (Figure 1). Aminoglycosides should not
be used as initial treatment in children.
Children with end-stage renal failure may be
dependent upon a functional peritoneum for a
prolonged period of time (15,16). Moreover, children
are at a high cumulative risk of experiencing severe
adverse effects of various drugs, including
ototoxicity and nephrotoxicity (17-19). The latter is
particularly important in view of the considerable residual
renal function that commonly is preserved in children
with hypoplastic kidney disorders. Hence,
antibiotic therapy of peritonitis in children should aim to
provide the highest efficacy and lowest potential for
Antibiotic treatment should be initiated as soon
as the diagnosis of peritonitis is made. While it is
advisable to perform and review the results of a
dialysate cell count and Gram stain prior to the initiation
of treatment (and possibly obtain a blood culture
during infancy), treatment should be started
immediately upon recognition of effluent cloudiness if signs of
severe infection, such as pain and fever, are present.
In such cases, dialysate samples should be collected
for subsequent cytological analysis, Gram stain, and
culture prior to initiating treatment. The initial
antibiotic regimen should be selected according to
symptom severity, peritonitis history, and the patient's risk
The combined administration of a
glycopeptide (e.g., vancomycin or teicoplanin) and a
third-generation cephalosporin (e.g., ceftazidime) has been
found to be superior to other antibiotic combinations by
meta analysis in adults, and the excellent efficacy
and safety profile of this regimen has been
demonstrated in children (20-22). Intermittent peritoneal
treatment with a glycopeptide (e.g., 2 loading doses of
vancomycin or teicoplanin 5 - 7 days apart) is equally
effective as and more convenient and economical
than continuous treatment (20). Intermittent therapy
with ceftazidime (e.g., antibiotic added to a single
exchange daily) may also be as effective as continuous
therapy in children, in a manner similar to other
cephalosporins in adults (23-25). On the other hand, the
possible spread of vancomycin-resistant enterococci and
the potential emergence of glycopeptide-resistant
staphylococci, in general, mandate the restricted use of
glycopeptides in all end-stage renal failure
patients (26-30). Therefore, the use of a
glycopeptide/ceftazidime combination is recommended only
for children at risk for a severe clinical course and/or an
infection with a methicillin-resistant causative
organism, whereas a first-generation cephalosporin
(e.g., cefazolin or cephalothin) instead of a
glycopeptide should be prescribed in asymptomatic patients
with cloudy effluent and without such risk
factors. Aminoglycosides should not be a part of empiric
peritonitis therapy in children due to their oto- and
Guideline 3: Modification of APD Regimen for Treatment of Peritonitis
In patients who receive nocturnal automated
peritoneal dialysis (APD) with short dwell times for
routine therapy, the initial (24 - 48 hours) treatment
of peritonitis should include a prolongation of the
dialysate dwell time to 3 - 6 hours, until there is
clearing of the peritoneal effluent. This does not apply
to asymptomatic patients in whom the routine
prescription can be continued, or to patients with
ultrafiltration needs requiring more-frequent
exchanges. Patients receiving continuous ambulatory
peritoneal dialysis (CAPD) do not require any change in
their exchange frequency.
Many children who receive APD
characteristically receive dialysis exchanges with short
(£ 2 hours) dwell times in order to enhance solute and fluid
removal. However, the cellular components of local
host defense mechanisms are depleted by frequent
exchanges, and the cytotoxicity of fresh
conventional dialysis solutions compromises the function of
peritoneal macrophages (31,32). Accordingly,
prolongation of the dwell time allows for at least
partial normalization of the peritoneal "milieu," which
hopefully enhances bacterial killing. (This may,
however, be preceded by several rapid flushes of dialysis
solution at diagnosis to help reduce abdominal pain.)
The patient can be disconnected from the cycler
during the prolonged dialysate dwell times, if
symptoms permit. When the effluent demonstrates
clearing, which typically occurs within the initial 48 hours
of treatment, the patient may return to a more
standard APD regimen. However, the daytime dwell
that contains antibiotics should be a full exchange
(approximately 1100 mL/m2 body surface area) as
long as antibiotic treatment is continued. If, on the
other hand, the peritoneal volume is slightly
(e.g., < 25%) decreased during the initial 24 - 48 hours of
therapy because of abdominal pain (Guideline 11), the
concentration of antibiotics must be increased to
ensure the infusion of the same mass of antibiotics
that would be provided in a full dwell volume (Table 2).
Guideline 4: Modification of Therapy for Gram-Positive Peritonitis
If a gram-positive organism is cultured, the
empiric use of ceftazidime should be discontinued. A
first-generation cephalosporin should be continued for
non methicillin-resistant staphylococci;
vancomycin, clindamycin, or teicoplanin for
methicillin-resistant staphylococci; and ampicillin for enterococci and
streptococci (Figure 2). Treatment duration should
be 2 weeks for all organisms except
S. aureus, which should be treated for 3 weeks.
Gram-positive organisms are the cause of
peritonitis in more than 50% of pediatric cases
(7,9,11-14, 33,34). Peritonitis secondary to
coagulase-negative staphylococci is typically the result of touch
contamination, while infections secondary to
S. aureus are commonly associated with a catheter
tunnel/exit-site infection with/without
S. aureus nasal carriage.
In patients whose peritoneal culture is positive
for methillicin-sensitive S. aureus or
coagulase-negative staphylococci, who are clinically improved, and
whose empiric therapy included the use of a
first-generation cephalosporin, the cephalosporin should be
continued to complete therapy. In patients who
received a glycopeptide as part of empiric therapy,
substitution of this antibiotic with a first-generation
cephalosporin should be considered. In some cases,
the coagulase-negative staphylococci susceptibility
profile will suggest "resistance" to the
first-generation cephalosporin when the organism is actually
susceptible in vivo because of the high intraperitoneal
drug levels that are obtained. Rifampin may also be
added to the cephalosporin if the clinical response is
less than optimal.
In the setting of methicillin-resistant
S. aureus or coagulase-negative staphylococci, the use of
clindamycin, vancomycin, or teicoplanin with/without
the addition of rifampin is recommended. The choice
of antibiotics should take into consideration the
clinical symptoms of the patient and the concerns in
relation to emerging resistance to glycopeptides.
If the culture is positive for enterococcus, the
first-generation cephalosporin or glycopeptide and
ceftazidime should be discontinued and replaced
with ampicillin. On occasion, a second antibiotic, such
as an aminoglycoside, may be added based on
sensitivity results and patient response. Vancomycin or
clindamycin should be used in the setting of
Guideline 5: Modification of Therapy for Gram-Negative Peritonitis
If a single ceftazidime-sensitive gram-negative
organism (e.g., Escherichia coli,
Klebsiella, or Proteus species) is cultured, the empiric use of
ceftazidime should be continued and the first-generation
cephalosporin or glycopeptide should be discontinued. If
the single organism is a pseudomonad (e.g.,
Pseudomonas aeruginosa), ceftazidime should be continued
and a second antibiotic with activity against the
isolated organism should be added. If anaerobic bacteria
or multiple gram-negative organisms are isolated,
intra-abdominal pathology should be considered and treatment should include the use of
metronidazole (Figure 3). Treatment duration should be 2 weeks
for a single gram-negative organism other than
Treatment duration should be 3 weeks for
Pseudomonas/Stenotrophomonas species, multiple organisms,
Gram-negative peritonitis is particularly
troublesome because it is frequently unresponsive to
antibiotic therapy alone, and because it can have
long-term adverse consequences on peritoneal membrane
function and lead to inability to conduct peritoneal
dialysis (PD). Studies in children have
demonstrated chronic alterations of peritoneal membrane
transport capacity following the development of
peritonitis (35-37). There is evidence that the changes are
most dramatic in children with a history of
gram-negative peritonitis, a complication that may lead to
peritoneal membrane failure. In many situations, the
unsuccessful treatment of gram-negative
peritonitis results in the need for catheter removal
A third-generation cephalosporin such
as ceftazidime is generally recommended for
treatment of peritonitis secondary to a gram-negative
organism (other than
Pseudomonas/Stenotrophomonas species or anaerobes) in contrast to an
aminoglycoside because of the risks of ototoxicity and
the loss of residual renal function associated with
the latter antibiotic (18,19). On occasion, however,
the use of a first-generation cephalosporin, which is
less expensive than ceftazidime, may suffice for
treatment of E. coli peritonitis based on antibiotic
susceptibility testing. Whereas most clinical
experience with ceftazidime treatment has been with
continuous therapy (e.g., presence of antibiotic in each
bag of dialysate), a single pediatric study evaluated
the use of intermittent ceftazidime therapy
(e.g., antibiotic administered during 1 cycle/day) (20). The
intermittent therapy was less successful than continuous treatment according to clinical
judgment, but not when rated by a standardized disease
Infections secondary to
Pseudomonas/Stenotrophomonas species are difficult to treat because of
the organisms' capacity to generate a biofilm that
decreases the likelihood of successful treatment
without catheter removal. While combination therapy
with ceftazidime and an additional agent
(e.g., piperacillin, ciprofloxacin,
aminoglycoside, aztreonam) to which the organism is susceptible
is indicated, the use of ciprofloxacin should be
restricted to patients older than 12 years, unless the
antibiotic susceptibility pattern, severity of illness, or
mitigating circumstances suggest otherwise. The use of
intermittent intraperitoneal dosing of
aminoglycosides and cephalosporins with CAPD, and intermittent
intravenous dosing of tobramycin and cefazolin
with APD, has been demonstrated to be efficacious
in adults, but not yet in children (23-25,38).
Finally, the intraperitoneal combination of
an aminoglycoside and piperacillin may be incompatible and mandates the provision of piperacillin
by the intravenous route when prescribed in this
Guideline 6: Modification of Therapy for Culture-Negative Peritonitis
If the initial cultures remain sterile at
72 hours and signs and symptoms of peritonitis are
improved, the combined empiric antibiotic therapy
prescribed to cover the gram-positive and gram-negative
spectra should be continued for 2 weeks.
In the absence of outcome data concerning
the early termination of antibiotic therapy with
sterile peritonitis, it appears safe to apply full
antibiotic coverage for a complete treatment course
to decrease the risk of recurrent infection. In
centers where culture-negative peritonitis represents
more than 20% of peritonitis episodes, applied
sampling and culture techniques (Table 1) should be
reviewed with the dialysis staff and the
Guideline 7: Modification of Therapy for Fungal Peritonitis
If fungi are identified by Gram stain or
culture, treatment should be initiated with either
intravenous amphotericin B or a combination of an
imidazole/triazole (e.g., intraperitoneal or oral
fluconazole) and flucytosine. In each case, it is recommended
that treatment should be associated with early
catheter removal. In patients in whom the catheter is not
removed initially, immediate catheter removal
should take place if improvement does not occur
within 3 days of treatment initiation. Treatment
duration following catheter removal for all patients
should be 2 weeks or longer following complete
resolution of the clinical symptoms of infection. Treatment
duration without catheter removal should be
4 - 6 weeks.
Fungal peritonitis is an infrequent but
potentially serious complication of PD. In pediatrics, this
infection represents less than 2% of all peritonitis
episodes (4,12-14,39,40). Historically, the development of
fungal peritonitis has resulted in the frequent
conversion of patients to hemodialysis. A recent study
of 51 pediatric patients suggests that successful
therapy can frequently result in preservation of the
peritoneal membrane and continued PD (40).
Several factors appear to predispose patients to
the development of fungal peritonitis, the most
common of which is the prior use of antibiotics to treat
bacterial peritonitis or a catheter-related infection.
However, Warady et al. found that, in nearly 50%
of children who developed fungal peritonitis, there
was no history of a prior peritoneal infection. Despite
a previous suggestion to the contrary, it is also
likely that the presence of a gastrostomy does not
predispose to the development of fungal peritonitis
(40-42). The role of antifungal prophylaxis
(e.g., nystatin, fluconazole) in the setting of antibiotic therapy
remains controversial, but is generally advocated (Guideline 11) (43-45).
Whereas amphotericin B has generally been
recommended as treatment for fungal peritonitis in
patients receiving PD, data collected in children
and adults provide evidence that the peritoneal
penetration of amphotericin B with systemic
administration is poor. In addition, the intraperitoneal
administration of amphotericin B is characteristically
irritating to the peritoneum and may result in severe
abdominal pain. On the other hand, fluconazole is
characterized by excellent bioavailability and
peritoneal penetration, and is currently the drug of choice
for most Candida species other than
C. krusei and some isolates of
C. glabrata (46-53). Since oral
absorption is essentially complete, the recommended dose
of fluconazole is the same for oral, intraperitoneal,
and intravenous administration. Ideally, fungal
susceptibilities should be obtained to help direct therapy.
The reliability of susceptibility results has recently
improved following the development of standardized techniques for yeast, but not molds (54,55).
The recommendation that the duration of
antifungal treatment following catheter removal be
2 weeks or longer following complete resolution of the
clinical symptoms of infection (or 4 - 6 weeks without
catheter removal) takes into consideration the
inability to create an evidence-based recommendation
because of the lack of pediatric or adult data in the
literature, and the treatment goal of long-term peritoneal
membrane function in children (5).
The inclusion of the recommendation for
catheter removal following the diagnosis of fungal
peritonitis is due to the propensity of fungi to colonize the
PD catheter and prevent eradication of the infection
despite drug therapy (Guideline 12). The optimal
timing of catheter removal, in terms of number of
days post treatment initiation, has not been determined.
Guideline 8: Evaluation of Primary Treatment Response
The response to the initial antibiotic
treatment should be evaluated daily after treatment
initiation. Treatment can be considered successful if an
improvement in clinical status (e.g., cessation of
abdominal pain and fever, reduction of effluent cloudiness)
has been achieved by 72 hours of therapy. A reduction
of the dialysate WBC count by more than 50% is
additional evidence of successful therapy.
The early assessment of treatment efficacy
characteristically consists of an evaluation of the
patient's symptoms and the appearance of the peritoneal
effluent. Improvement in patient symptoms
(e.g., decrease of pain and fever) and clearing of
effluent cloudiness at 72 hours is, in most cases, evidence
of successful therapy.
In some cases, the use of objective,
standardized response criteria can be helpful to avoid
unnecessary premature changes of treatment and delayed
recognition of an insufficient treatment response. This
approach was applied in a pediatric prospective
trial, with excellent agreement between an initial
response rating and the final outcome (20). A decrease in
the effluent WBC count 3 days after initiation of
treatment was a helpful diagnostic indicator of
treatment response. A relative shift from polymorphonuclear to
mononuclear cells should also start at this time,
but occurs with much greater temporal variability
than the absolute decrease in the number of WBCs.
Incomplete eradication of micro-organisms from
the peritoneal cavity after 3 days of antibiotic
therapy should not be considered treatment failure. In a
prospective evaluation, Schaefer et al. found
persistent bacterial growth in 20% of peritonitis episodes
60 hours after treatment initiation (20). After 7 days of
continued therapy, the eradication rate was 95%;
eradication by treatment days 3 or 7 did not predict the risk
for peritonitis relapse.
Guideline 9: Approach to Patients Who Fail to Demonstrate Clinical Improvement
If no clinical improvement occurs within
72 hours of treatment initiation, potential sources of
persistent infection should be evaluated. Treatment
modifications may include an alteration of antibiotic
therapy and/or catheter removal.
Most pediatric patients demonstrate prompt
clinical improvement soon after the initiation of
successful treatment for peritonitis. In one pediatric
study, Schaefer et al. found that 74% of all peritonitis
episodes were free of any associated clinical
symptoms after 60 hours of antibiotic treatment (20).
Accordingly, it is reasonable to pursue further
investigation if a patient has not demonstrated any
improvement after 3 days of therapy. In all cases, the
re-evaluation should include a repeat assessment of the
peritoneal effluent cell count, Gram stain, and effluent
culture. In some cases (e.g., tuberculosis,
capnocytophagia), special culture techniques may be necessary.
In the setting of coagulase-negative
staphylococci and S. epidermidis treatment-resistant infections,
a brief (48- to 72-hour) trial with the addition of
oral rifampin therapy should be considered. If the
patients are receiving a first-generation cephalosporin and
the organism is methicillin-resistant, the
cephalosporin should be discontinued and therapy with a
glycopeptide (e.g., vancomycin or teicoplanin) or
clindamycin should be instituted. Continued treatment
failure, especially with S. aureus, may be the result of a
concomitant catheter tunnel infection and should
result in catheter removal (Guideline 12) (56). Detection
of a tunnel infection can be made by a combination
of clinical evaluation and ultrasound assessment in
the majority of cases (57). Infections secondary
to Pseudomonas sp that are resistant to
combination therapy should also result in catheter removal
and subsequent intravenous antibiotic therapy. In patients
with treatment-resistant peritonitis secondary
to anaerobic bacteria or multiple gram-negative
organisms, the possibility of intraperitoneal
pathology (e.g., ruptured appendix) should be considered,
the catheter removed, and intravenous therapy
prescribed (58). In the rare case of tuberculous peritonitis in
children, exploratory laparotomy or laparoscopy with
biopsy of the peritoneum in addition to cultures
may be necessary for diagnosis (4,5,10,59). Therapy
consists of a combination of isoniazid, rifampin,
Finally, although not recommended, some
pediatric patients may be prescribed antifungal
therapy without catheter removal for treatment of fungal
peritonitis. In these patients, failure to demonstrate
clinical improvement within 72 hours should result
in catheter removal and intravenous/oral
antifungal therapy for a minimum of 2 or more weeks
following the resolution of clinical symptoms.
Guideline 10: Approach to the Patient with Relapsing Peritonitis
Relapsing peritonitis is defined as a recurrence
of peritonitis with the same organism as in the
immediately preceding episode, according to antibiotic
susceptibilities, within 4 weeks of completion of
antibiotic treatment. Since the causative organism is not
known at the time of onset of symptoms, empiric
treatment should be reinitiated according to Guideline 2.
After bacteriologic confirmation of a relapse,
treatment should be organism specific (see treatment
recommendations below) and (except for
Pseudomonas/Stenotrophomonas species) treatment duration
should be 3 weeks (Table 3).
Relapsing peritonitis is most frequently seen
when S. aureus or coagulase-negative staphylococci are
the causative organisms (60). Because of its
important therapeutic implications, the diagnosis of a
relapse should not rely solely on the genus/species, but
also on the antibiotic susceptibilities of the cultured
organism. In sophisticated laboratory settings,
strain identity can be confirmed by DNA genotype
staphylococci are believed to survive antibiotic therapy in
fibrinous adhesions and biofilm matrix on the catheter
surface. Catheter decontamination by local
installation of fibrinolytic agents and high-dose antibiotics
has been shown to improve final cure rates in adults
and children (60-62).
In relapsing peritonitis caused by
S. aureus, an occult (e.g., subclinical) tunnel infection or
intra-abdominal abscess should be sought. Also,
screening for nasal S. aureus carriership should be
performed in the child and his/her caregivers.
Patients with relapsing gram-negative
peritonitis should be evaluated for an intra-abdominal
abscess, and may require surgical exploration and
catheter removal. In the case of pseudomonas or
stenotrophomonas infections, the catheter should be
removed and intravenous antibiotics prescribed for a
minimum of 2 - 3 weeks prior to consideration of
Finally, if a second relapse occurs secondary to
any organism and no other pathology is identified,
the catheter should be removed.
Guideline 11: Adjunctive Therapy for Peritonitis
In patients who are being treated for
peritonitis, adjunctive therapy should be considered on an
individual basis and may include the following:
- Decreased peritoneal fill volume in patients with significant abdominal discomfort;
- Oral antifungal prophylaxis during the course of antibiotics;
- Low-dose intraperitoneal heparin as long as peritoneal effluent is cloudy; and
- Intravenous immune globulin (IVIG) in patients with hypogammaglobulinemia.
Significant abdominal pain is frequently noted
in children who develop peritonitis. Early in the
course of treatment, the pain may be worsened by the
presence of the routine exchange volume. Accordingly,
the peritoneal volume can be slightly (e.g., < 25%)
decreased during the initial 24 - 48 hours of
therapy until clinical symptoms improve. If this occurs,
the concentration of antibiotics must be increased
during this period of time to ensure the infusion of
an appropriate mass of antibiotics (Table 2). The
exchange volume should subsequently be increased
to the normal prescription to prevent a prolonged
period of underdialysis.
The association between antibiotic therapy
and fungal peritonitis has prompted several trials of
antifungal prophylaxis during antibiotic treatment
in patients receiving PD (40,43-45). Studies in
adults have been inconclusive with respect to the benefits
of oral nystatin. In a pediatric study, oral
nystatin (10 000 U/kg/day) or oral ketoconazole was
associated with a significant decrease in the risk of fungal
peritonitis in patients receiving antibiotics (43).
When used, the antifungal agent should likely be
continued for several days following completion of the
antibiotic therapy to allow for repopulation of the
gastrointestinal tract with the normal bacterial
flora. Empirically, the provision of
Lactobacillus might also be considered for this purpose.
Although the efficacy of intraperitoneal
heparin has not been formally proven, its inhibitory effect
on fibrin clot formation is believed to contribute to
catheter patency in cases of severe peritonitis with
massive protein exudation (63). Heparin also has bacteriostatic and anti-inflammatory properties.
The recommended dose of heparin is 500 - 1000 U/L
dialysate until the effluent clears.
Finally, the presence of low serum levels of IgG
has repeatedly been demonstrated in patients
receiving PD during infancy (64,65). While there are no data
to support the routine use of prophylactic
immunoglobulin in this population, the provision of IVIG
should be considered in the infant with
documented hypogammaglobulinemia and peritonitis/sepsis.
Guideline 12: Indications for Catheter Removal and Replacement
Peritoneal dialysis catheter removal should
occur as part of the recommended treatment course in
situations in which failure to do so is unlikely to result
in successful peritonitis therapy. The timing of
catheter replacement should be 2 - 3 weeks following
catheter removal in most cases.
Catheter removal should be considered an
important component of peritonitis therapy. This
approach to therapy is often necessary in patients with
treatment-resistant peritonitis because of concerns
for long-term damage to the peritoneal membrane (16,35). In most cases, patients treated in this
manner receive hemodialysis for a variable period of
time and are then able to return to PD. In pediatric
patients, catheter removal and subsequent
replacement should be strongly considered in certain
situations as shown in Table 4.
There are no data in the pediatric or adult
literature that permit an evidence-based
recommendation with respect to the length of antibiotic treatment
following catheter removal. The recommendation of
2 - 3 weeks takes into consideration the absence of
data and the treatment goal of long-term peritoneal
membrane function in children. In all cases,
recommendations concerning the duration of antibiotic
therapy and the timing of catheter replacement may
require modification based upon the patient's
Guideline 13: Prophylactic Antibiotic Therapy
Prophylactic antibiotic therapy for
S. aureus nasal carriage is recommended to decrease the risk
of S. aureus catheter exit-site/tunnel infections.
Prophylactic antibiotic therapy should be given at the
time of catheter placement in the form of a single dose of a
first-generation cephalosporin. Antibiotic
prophylaxis should also be considered following accidental
intraluminal contamination, prior to dental
procedures, and prior to procedures involving the
gastrointestinal or urinary tract. Prophylactic systemic
long-term antibiotic treatment is not indicated.
nasal carriage is associated with a high incidence of PD catheter-related
infections with this organism. Intrafamilial
transmission of the organism is common. Intermittent
(i.e., 3 - 4 days/month) intranasal treatment of nasal
carriers with mupirocin eliminated carriage and
markedly reduced infections with
S. aureus in adult CAPD patients (66). Similar results were obtained with
cyclic local mupirocin ointment applied to the exit site
of S. aureus nasal carriers. More recently, Piraino
et al. recommended that a small amount of mupirocin
ointment be applied daily to the exit site, using a
cotton swab, for all PD patients, eliminating the need
for nasal cultures (67). Pediatric data on the impact
of treating S. aureus nasal carriers (patients and
care providers) is currently limited, making it
reasonable to extrapolate the adult experience to
children (68-70). Whereas the daily use of mupirocin in
all patients has the potential for generating
antibiotic resistance, this has not been a significant problem
as of this time.
The recommendation concerning
perioperative and post contamination prophylaxis takes into
account the current state of knowledge of
intra-abdominal surgery, where antibiotic administration
immediately prior to and within the first 6 hours
after conducting abdominal surgery appears to be
effective in preventing infection. A single pediatric
experience on the topic revealed that patients who received preoperative antibiotic therapy prior to
PD catheter placement had a significantly
decreased incidence of postoperative peritonitis when
compared to untreated patients (71). The most appropriate
prophylactic agent is a first-generation
cephalosporin (e.g., cefazolin or cephalothin), unless the patient
is known to be colonized with a
methillicin-resistant organism. A glycopeptide should not be the
initial agent routinely chosen because of the emerging
bacterial resistance to glycopeptides.
There are no data demonstrating the benefits
of antibiotic prophylaxis following a break in
dialysis technique. However, the use of a first-generation
cephalosporin for 1 - 3 days in this setting is
typically recommended by adult and pediatric
nephrologists. A glycopeptide should be used only in
the setting of a patient previously known to be
colonized with a methicillin-resistant organism.
Prophylactic antibiotic therapy is also
recommended in the setting of dental procedures
because of the risk of bacteremia and subsequent
peritonitis (72,73). Amoxicillin is the preferred agent in a
dose comparable to what is recommended by the
American Heart Association for subacute bacterial
endocarditis prophylaxis (Table 5) (74).
Consideration should also be given to the provision of
prophylactic therapy for children on PD having
gastrointestinal (e.g., gastrostomy tube placement) or
genitourinary surgery because of the likely increased risk of
peritonitis. Ampicillin plus ceftazidime are recommended.
Guideline 14: Diagnosis of Catheter Exit-Site Infection
The diagnosis of a catheter exit-site
infection should be made in the presence of a purulent
discharge from the sinus tract, or marked
pericatheter swelling, redness, and/or tenderness, with or
without a pathogenic organism cultured from the exit
site. Infectious symptoms should be rated according to
an objective scoring system (Table 6).
As the subjective judgment of an exit-site
status may differ widely, it is imperative that objective
criteria be used to diagnosis an exit-site infection.
Work by Twardowski has also led to a better
classification of exit-site morphology and a more uniform
approach to the diagnosis of infection (75).
Staphylococcus aureus accounts for the majority of infections,
followed by enterococci, Pseudomonas,
E. coli, Klebsiella, and other gram-negative
species. Staphylococcus epidermidis is frequently
cultured, but is usually not causative of an exit-site
infection. Whereas a positive culture is not required for
the diagnosis of an exit-site infection, positive
cultures in exit sites that are not inflamed indicate
colonization, not infection.
Guideline 15: Treatment of Catheter Exit-Site Infection
Antibiotic treatment of a catheter exit-site
infection should be started after culture results have
been obtained, unless signs of severe infection are
present. The antibiotic should be chosen according to the
susceptibilities of the cultured organism. Treatment
duration should be 2 - 4 weeks.
In view of the risks of increasing antibiotic
resistance in children with end-stage renal disease,
strict criteria should be applied to antibiotic prescribing
(e.g., vancomycin or teicoplanin) should be avoided for the routine
treatment of exit-site infections secondary to
Staphylococcus species because of concerns of
emerging bacterial resistance. Instead, a
first-generation cephalosporin or a penicillinase-resistant
penicillin with/without the addition of rifampin is
preferred. Gram-negative infections should be treated with
oral ciprofloxacin in children older than 12 years, or
with intraperitoneal ceftazidime. In patients in whom
the exit-site culture is negative, the choice of
antibiotics should be governed by Gram-stain results, if
available. In the absence of a positive culture or
Gram stain, or prior to obtaining the results in a
patient with a severe infection, empiric therapy with
either a first-generation cephalosporin or oral
ciprofloxacin should be initiated. Close monitoring of this
patient group is essential, with modification of the
antibiotic regimen contingent upon early response
to therapy. Screening for S. aureus nasal carriage
may be helpful in this situation to detect a possible
Adjunctive therapy should include the use of
daily or twice daily dressing changes as long as
significant discharge from the sinus tract is present
(75). Nonalcoholic disinfectants (e.g., octenidine)
should be used if available. Povidone iodine solutions
and hydrogen peroxide irritate the skin and may
impair local host defenses, and therefore should not be
routinely applied. Large crusts should be removed
with nonionic nontoxic surfactants such as 20% poloxamer 188
(76-78). The exit site should be kept dry between the dressing changes; this can
be achieved with a nonocclusive sterile dressing.
Exuberant granulomatous tissue ("proud flesh")
should be cautiously removed by cauterization with
silver nitrate. The catheter should be immobilized and
protected from trauma.
Treatment should continue for 2 - 4 weeks
and for at least 7 days following complete clinical
resolution of the infection. Failure to achieve resolution
of the infection in this period of time, or the
development of a catheter tunnel infection and
peritonitis secondary to the same organism, is an indication for
catheter removal (Guideline 12). Shaving of the
external cuff as an alternative to catheter removal
for treatment of a persistent exit-site infection has
occasionally been recommended, but with little
pediatric experience (79).
The authors thank Douglas Blowey, M.D., for his input
concerning a portion of the antibiotic dosing recommendations.
Correspondence to: B.A. Warady, Section of
Pediatric Nephrology, Children's Mercy Hospital, 2401 Gillham
Road, Kansas City, Missouri 64108 U.S.A.
Received 14 September 2000; accepted 26 October 2000.
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