Empiric Antibiotic Therapy for Peritoneal Dialysis-Related Peritonitis

Initial Empiric Regimen

• The International Society of Peritoneal Dialysis recommends avoiding aminoglycosides as first-line therapy for peritoneal dialysis-related peritonitis due to their nephrotoxic effects and lack of anaerobic coverage, which can lead to decreased residual kidney function and increased mortality 1

Critical Pitfalls to Avoid

• The American Society of Nephrology advises against using cefazolin as empiric gram-positive coverage in centers with high rates of coagulase-negative staphylococcal resistance, as treatment failure rates will be unacceptably high, although the exact resistance threshold is not specified 1

Reassessment and De-escalation

• The World Society of Emergency Surgery recommends reassessing patients with peritoneal dialysis-related peritonitis at 48-72 hours, when culture results become available, to determine the need for de-escalation of antibiotic therapy, with a strength of evidence rated as moderate 2
• The International Society of Peritoneal Dialysis suggests that if gram-positive organisms are confirmed, gram-negative coverage should be discontinued, and if gram-negative organisms are identified, therapy should be narrowed based on susceptibilities, with a strength of evidence rated as low 2, 1
• For treatment failure at 72 hours, the World Society of Emergency Surgery recommends considering catheter removal, imaging for undrained collections, or resistant organisms, including fungi, with a strength of evidence rated as low 2