A 55 year old male with ESRD on peritoneal dialysis (PD) presents with fever and abdominal pain, reporting cloudy-appearing effluent today from his PD port. You are concerned, appropriately, that the patient has peritonitis.
Since the patient has a port leading directly to his peritoneum, could you just twist open the port, take a sample of fluid, and replace the cap?
Answer: NO. The standard of care (at Sinai) in this situation is to replace the PD port with a new, sterile cap every time it is accessed. Even if you do the procedure in full sterile garb, your decision could lead to a costly/complicated catheter replacement. Call renal and they will bring down a new, sterile cap.
Recently released recommendations from the International Society for Peritoneal Dialysis contain several important points for the EP:
- Peritoneal dialysis patients presenting with cloudy effluent should be presumed to have peritonitis. Peritonitis should always be included in the differential diagnosis of the PD patient with abdominal pain, even if the effluent is clear, as a small percentage of patients present in this fashion.
- An effluent cell count with WBC > 100/mL (after a dwell time of at least 2 hours), with at least 50% PMN’s, indicates the presence of inflammation, with peritonitis being the most likely cause.
- Patients with cloudy effluent may benefit from the addition of heparin (500 units/L) to the dialysate to prevent occlusion of the catheter by fibrin.
- For patients on automated PD (APD) who present during their nighttime treatment, the dwell time is much shorter than with continuous ambulatory PD (CAPD); in this case, the clinician should use the percentage of PMNs rather than the absolute number of white cells to diagnose peritonitis. The normal peritoneum has very few PMNs; therefore, a proportion > 50% is strong evidence of peritonitis, even if the absolute WBC does not reach 100/mL.
- Even though the Gram stain is often negative in the presence of peritonitis, it should be performed as it may indicate the presence of yeast, thus allowing for prompt initiation of antifungal therapy and permitting timely arrangement of catheter removal.
- Intraperitoneal administration of antibiotics is superior to IV dosing.
- Treatment is with a 1st-generation cephalosporin (e.g. cefazolin or cephalothin), and a second drug for broader gram-negative coverage. Vancomycin may be considered if the patient has a history of MRSA colonization/infection, is seriously ill, or if there is a local increased rate of methicillin resistance. Gram-negative coverage is provided with an aminoglycoside, ceftazidime, cefepime, or carbapenem. Quinolones should be used for empiric coverage of gram-negative organisms only if local sensitivities support such use.
Reference: Perit Dial Int 2010; 30:393–423.
Thanks to Nick Genes for the case.