The microbial management of peritonitis in Type: Clinical Guideline

Peritoneal Dialysis patients. Register No: 16017

Status: Public
Developed in response to: CNST Best Practice
Best Practice Guidelines
UK Renal Association Guidelines
NICE Guidelines
International Society for Peritoneal Dialysis
Guidelines
Contributes to CQC Regulation: 9, 12

Consulted With Post/Committee/Group Date

Dr S Abeygunasekara Clinical Director for Medicine April 2016
Rebecca Culpin Matron Renal Unit April 2016
Professionally Approved By Consultant Microbiologist and April 2016
Dr Louise Teare Director of Infection Prevention and Control
Version Number 1.0
Issuing Directorate Acute Medicine
Ratified by: DRAG Chairmans Action
Ratified on: 24th May 2016
Trust Executive Board Date June 2016
Implementation Date 25th May 2016
Next Review Date April 2019
Author/Contact for information Jeanette Faux/Pamela Ayling

Policy to be followed by (target staff) Medical & Renal Nursing staff. Terling Ward
Nursing Staff.
Distribution Method Intranet & website
Related Trust Policies (to be read in Infection Control Policy (04072)
Conjunction with) MRSA Policy
Safe Handling & Disposal of Sharps Policy ( 10004)
Waste Management Policy (04088)
Antibiotic Policy (06045)
Confidentially & Data Protection Policy (07011)
Risk Management Strategy & Policy (04061)
Aseptic Technique & Aseptic Non Touch Technique
Policy (08038)
Administration of medicines to inpatients (08103)
Injectable medicines Policy (09060)
Document Review History
Version No Authored/Reviewed by Active Date
1.0 Jeanette Faux/Pamela Ayling 25th May 2016

1
Index

1. Purpose
2. Scope
3. Exclusions
4. Introduction
5. Standards
6. Clinical Presentation and diagnosis
7. Assessment and investigation
8. Treatment
9. Assessment of patients who fail to demonstrate clinical improvement (refractory
peritonitis)
10. Staffing & Training
11. Audit & Monitoring of Policy
12. Appendices
1. Patients presenting with suspected peritonitis
2. Specimen collection method for Peritoneal Dialysis Fluid
3. Method for Administering IP Vancomycin
4. Method for Administering IP Gentamicin

2
1.0 Purpose

1.1 The purpose of this guideline is to reduce the morbidity and mortality
associated with peritoneal dialysis (PD) peritonitis by effective management
of infections or suspected infections:

Reduction in the loss of PD access through infection

Preservation of the peritoneal membrane and duration of PD
Timely and appropriate sampling of PD fluid
Prompt diagnosis of infection and reduction in severity of infection
Timely initiation of appropriate antibiotic therapy
Timely removal of PD catheter where clinically indicated

2.0 Scope

2.1 Inclusions Adult patients on Peritoneal Dialysis.

2.2 Exclusions - Paediatric patients under 18 seek specialist advice.

3.0 Introduction

3.1 Peritonitis is one of the major risks in PD, causing significant morbidity and in
some cases mortality. It is a significant cause of change of treatment modality
from PD to haemodialysis.

3.2 Diagnosis is based on clinical features (abdominal pain, cloudy fluid and
fever) and confirmed by an effluent white cell count of > 100/L (after a dwell
time of at least 2 hours), with 50 % polymorphonuclear neutrophil cells.

4 Standards

4.1 UK Renal Association Standards (2010)

Peritonitis rates of less than 1 episode per 18 patient months. (NSF Part 1 2004)
A primary cure rate of 80%.
A culture negative rate of < 20%.

4.2 The ISPD guidelines (2010)

Peritonitis rate within the PD population should be no more than 1 episode in

every 18 patient months.
Culture negative peritonitis should not be greater than 20% of episodes (direct
injections of PD effluent into blood culture bottles).

5 Clinical Presentation and Diagnosis

5.1 Any patient presenting with signs and symptoms of peritonitis should be
referred as soon as possible to either a physician from the nephrology team
or a renal trained nurse. The patient should be initiated on treatment in
accordance with the protocol.

3
5.2 Patients with uncomplicated peritonitis may be managed as an outpatient.

5.3 Patients who are clinically unwell or have complicated peritonitis should be
admitted to Terling Ward and should be referred to a nephrology consultant.

5.4 A patient with uncomplicated peritonitis will normally present with at least 2 of
the following:
Cloudy effluent with duration of less than 12 hours
Mild abdominal discomfort
Mild pyrexia ( 38 C)
WCC in PD fluid of > 100/L (after a dwell time of at least 2 hours)

5.5 A patient with complicated peritonitis will normally present with one or more of
the following:
Cloudy effluent with duration of more than 12 hours
Moderate to severe abdominal pain
Rebound tenderness
Pyrexia 38 C
Confusion
Diarrhoea and vomiting

6.0 Assessment and Investigation

6.1 Routine observations:

Temperature
Lying and standing blood pressure
Weight
Abdominal assessment for signs of guarding / rebound tenderness. Exit site and
tunnel review
Visual inspection of the dialysis fluid (colour, opacity, turgidity, debris)

6.2 A specimen of fluid should be collected from the first cloudy bag (see Appendix 2
for sampling method).

7.0 Treatment

7.1 Initial empiric treatment: Day One

7.1.1 The patient should be started on the following intra-peritoneal (IP) antibiotic regime,
once a sample of PD fluid has been sent to microbiology (see sampling appendix).

7.1.2 Dwell time: the bag containing antibiotic should dwell for a minimum of 6 hours.

Antibiotic Patient weight (kg) Dose of antibiotic

50kg 1 gram
Vancomycin* 50-70 kg 1.5 grams
70 kg 2 grams
Gentamicin 80 mg

*Vancomycin sensitive patients should have Linezolid 600mg bd (orally

4
7.2 Day Two

7.2.1 Gentamicin should be continued daily until culture results are available.

Dose of Gentamicin Patient weight (kg)

20 mg 70 kg
30 mg 70 kg

7.2.2 No further Vancomycin should be given until levels are obtained.

7.2.3 Treatment modification following Gram stain, culture and sensitivities

7.3 Day Three

7.3.1 Levels should be taken for Vancomycin and Gentamicin.

7.3.2 Therapeutic Targets for antibiotic levels:

Gentamicin 2 micrograms/ml
Vancomycin 15 micrograms/ml 20 micrograms/ml

Note that IP levels of Vancomycin after the initial dose will always be lower than
serum levels therefore serum levels need to be maintained higher than would
otherwise be indicated.

7.3.3 Further levels should then be taken every third to fifth day (ideally a trough level) for
the duration of treatment.

7.3.4 Once culture and sensitivities are known, antibiotic therapy should be adjusted as
appropriate.

7.3.5 The table below should be used as a guide only; involvement and advice from the
microbiologist will be required in some circumstances.

Gram-positive Coagulase Continue IP Vancomycin (dose according

Cocci negative to levels) for 1 week. Change to oral
Staphylococcus antibiotics (according to sensitivities) after 1 week
(CNS) responding.

Total duration of therapy:14 days

Staphylococcus Continue IP Vancomycin (dose according to
aureus levels) for 3 weeks

MSSA / MRSA If poor clinical response to Vancomycin at one

week, add oral Rifampicin (300mg bd)

Total duration of therapy:21 days

Enterococcus Continue IP Vancomycin
Stop IP Gentamicin

Total duration of therapy: 14 days

Discuss therapy options with microbiologist

5
 VRE Continue antibiotics according to
sensitivities

Total Duration of therapy: 14 days

Gram-negative Single Continue IP Gentamicin according to
rods Gram-negative Levels. Adjust according to sensitivities
organism (NOT
Pseudomonas) Total Duration of therapy: 14 days
Pseudomonas Continue daily IP Gentamicin.
Add further antibiotic according to sensitivities.

Consider catheter removal if no improvement

in 1-2 weeks.

Total duration of therapy: 21 days

Fungal Immediate catheter removal.

IV anti-fungal treatment following catheter

removal.
Culture Continue IP Vancomycin and Gentamicin
negative according to levels. If clinical improvement by
day 4, stop Gentamicin and continue 14 days of
IP Vancomycin according to levels.

If poor response at day 3-4, reculture fluid.

Total duration of therapy : 14 days

8 Assessment of Patients Who Fail to Demonstrate Clinical Improvement

(Refractory Peritonitis)

8.1 Patients should feel symptomatically better within 3-4 days of starting treatment: If
not, re-culture fluid and liaise with Nephrologist and microbiologist.

8.2 Consider catheter removal or replacement if:

Patient remains symptomatically unwell

There is evidence of increasing sepsis
The PD fluid fails to clear in 3-4 days
The PD fluid becomes increasingly turbid
The PD catheter is blocked with thick fluid
There is relapsing peritonitis (i.e. an episode within 4 weeks of completing
therapy with the same organism)
There is failure to an early response in a pseudomonas infection
There are two organisms indicating possible bowel pathology (consider
laparotomy)

8.3 Once catheter is removed, time required before reinsertion of the PD catheter will
be dependent on the clinical situation / organism identified. In some situations the
PD catheter may be exchanged and the patient can continue on PD with reduced fill
volumes. Patients may however need to transfer to haemodialysis depending on the

6
 degree of their residual renal function. If patients are holding off dialysis they will
need regular monitoring of biochemistry and fluid status.

8.4 Of note, if either MSSA or MRSA is isolated, the patient will need to be started on
the staphylococcal decontamination regime in accordance with the protocol.

9 Staffing & Training:

9.1 This policy applies to all registered nurses in contact with renal patients on
either Terling Ward or in the Renal Unit. Training is carried out by competent
trained staff on either Terling Ward or the Renal Unit. Training will be
recorded in the Competency Portfolio which is kept in the Managers office

10 Audit & Monitoring of Policy

10.1 Where there has been non-compliance which has resulted in patient harm,
the risk event must be recorded on a Datix.

10.2 There will be an on-going audit process to investigate the safety of and
compliance with the policy. This will be completed by the author and senior
members of the Renal Home Therapies staff.

10.3 Findings will be presented at departmental audit meetings. All staff will be
responsible for implementing any required actions

11. Breaches of Policy

11.1 Any harm or near miss will be considered a breach of policy and must be
recorded on a Datix risk event form.

11.2 Risk event forms will be reviewed at the monthly renal clinical governance
meetings by the renal team as part of the process.

11.3 Suggestions for improvement will be proposed at the Renal Clinical

Governance Meetings and the Author of these guidelines will lead
implementations and lessons learnt.

7
Appendix 1

PATIENTS PRESENTING WITH SUSPECTED PERITONITIS

Date:

Name:

DOB:

Hospital No:

Presenting Symptoms:

BP: Temp: Pulse: RR: Sats:

GCS: Weight: NEWS Score:

Bloods sent: RDU FBC CRP Clotting Screen Blood Cultures (if pyrexial)

Visual inspection of dialysis fluid (colour, opacity, turgidity, debris):

Send 10mls of PD fluid in each blood culture bottle to Microbiology and mark for
culture and gram stain with 20mls of PD fluid in a white sterile universal container
white cell count and differential. Mark as urgent. (See Appendix 2 for sampling
collection method)

Length of dwell: (time fluid has been in peritoneum): hrs (must be > 2hrs)

Page 1 of 2

8
Appendix 1/Page 2

Name of Consultant/Registrar reported to:

Date: Time:

Patient reviewed Dr name/time/plan:

Commenced on IP Antibiotics as per Day 1 of peritonitis protocol Yes:

If not reasons:

Patient shown how to administer IP Gentamicin as per day 2 of protocol if

necessary:

Yes: If not, give reasons:

Blood test for Vancomycin and Gentamicin levels arranged for day 3 of protocol.

Date:
Time:

Advice given on who/when to contact if symptoms worsen:

Documented on eMed:
Message left for PD office Ext: 6563:
Contact details of patient double checked:
Recommended that patient does not be alone whilst unwell:
Note: If patient has abdominal pain but a clear effluent, peritonitis should still be
considered.

9
Appendix 2

Specimen Collection Method for Peritoneal Dialysis Fluid

Optimal time of specimen collection is before antimicrobial therapy where possible.
Effluent should be drained from first cloudy bag after a dwell time of at least 2 hours.

Method of Collection

1 Wipe the medication/sample port on the dialysis drainage bag with 2%

chlorhexidine.
2 Aseptically transfer 5 10 mls of dialysis fluid into blood culture bottles using
the butterfly collecting set provided with the blood culture bottles. Inoculate the
blue (aerobic) bottle first and then the purple (anaerobic) bottle so that any
oxygen trapped in the tubing will not be transferred to the anaerobic bottle.
3 Aseptically transfer 20ml of fluid into a sterile plain universal container for Total
White Cell count.

10
Appendix 3

Method for Administering Intra-peritoneal (IP) Vancomycin

Ensure procedure is carried out in accordance with the Aseptic Non Touch Technique
(ANTT) protocol

Equipment Required

20ml syringe
Green Needles x2
Alcohol Wipe x2
Vancomycin
Water for injection (20mls)

1 Wash hands in accordance with MEHT hand washing policy and use alcohol rub

2 Attach needle to 20ml syringe

3 Draw up 20 mls of water for injection

4 Insert needle into bottle of Vancomycin powder and infuse gradually, shake until
powder has dissolved

5 Draw up Vancomycin into syringe according to prescribed dose

6 Change to a clean needle

7 Disinfect your hands with alcohol rub

8 Wipe the medication port of the peritoneal dialysis bag with 2% chlorhexidine.

9 Inject the antibiotic into the bag after the flush step of the exchange

10 Dispose of SHARPS safely

PD fluid with antibiotics should be left to dwell for a minimum of 6 hours.

11
Appendix 4

Method for Administering Intra-Peritoneal Gentamicin

Ensure procedure is carried out in accordance with the Aseptic Non Touch Technique
(ANTT) protocol

Equipment Required

5ml syringe
Blunt fill Needle with filter x 1
Green Needle x1
Alcohol Wipe x2
Gentamicin

1 Wash hands in accordance with MEHT hand washing policy and use alcohol rub

2 Attach filter needle to 5ml syringe

3 Draw up Gentamicin into syringe according to prescribed dose

4 Change to a clean needle

5 Disinfect your hands with alcohol rub

6 Wipe the medication port of the peritoneal dialysis bag with 2% chlorhexidine.

7 Inject the antibiotic into the bag after the flush step of the exchange

8 Dispose of SHARPS safely

PD fluid with antibiotics should be left to dwell for a minimum of 6 hours.

12