PERITONITIS COMPLICATING PERITONEAL DIALYSIS
Continuous ambulatory peritoneal dialysis (CAPD) creates another mechanism for the development of peritonitis. The incidence of peritonitis is 1.3 to 1.4 episodes per CAPD patient per year. The most common route of access by organisms into the peritoneal cavity is via the dialysis catheter, followed by hematogenous seeding and transmural penetration through the intestinal wall.
FloraA single pathogen is isolated in CAPD peritonitis in most cases. Gram-positive cocci account for 60% to 70% of cases, with coagulase-negative staphylococci being the most common, followed by S. aureus and Streptococcus species. Gram-negative bacilli account for 20% to 30% of cases, with Enterobacteriaceae implicated in the majority of cases. Fungal infections have become increasingly important, with Candida species accounting for 80% to 90% of fungal cases, although molds such as Aspergillus, Mucor, and Rhizopus species have been reported-Mycobacterial infections make up less than 3% of cases of CAPD peritonitis.
DiagnosisAny two of the following criteria are required to establish the diagnosis of CAPD peritonitis: (1) symptoms of peritoneal inflammation, (2) cloudy dialysate fluid (leukocyte count of >100 cells/mm3 with >50% neutrophils), and (3) a positive fluid Gram stain or bacterial culture.
TreatmentEmpiric therapy should cover both gram-positive and gram-negative organisms until culture results are available. Third-generation cephalosporins and vancomycin are generally recommended. The use of intraperitoneal antibiotics has allowed most patients to be treated on an ambulatory basis. The duration of therapy is usually 10 to 14 days.*94/348/5*
