Treatment of Secondary Peritonitis in Peritoneal Dialysis

Diagnostic Confirmation

A neutrophil count in peritoneal fluid >250/mm³ confirms the diagnosis of peritonitis, regardless of culture results, as recommended by the International Society of Peritoneal Dialysis 1
Inoculating at least 10 mL of peritoneal fluid into blood culture bottles (aerobic and anaerobic) at the patient's bedside before starting antibiotics increases the sensitivity of the culture to >90%, according to the International Society of Peritoneal Dialysis 1
Simultaneous blood cultures should be obtained before starting antibiotics, as suggested by the International Society of Peritoneal Dialysis 1

The American Society of Nephrology recommends that empirical treatment should not be delayed waiting for culture results - the neutrophil count is sufficient to initiate empirical therapy 1
The European Renal Association recommends a combination of a glycopeptide (vancomycin) and ceftazidime as the first-line empirical treatment, with a resolution rate of 86% 1

The International Society of Peritoneal Dialysis recommends performing a control paracentesis to evaluate the efficacy of treatment at 48 hours 1
Therapeutic success is defined as a decrease in the neutrophil count to <25% of the pre-treatment value with clinical improvement, as defined by the International Society of Peritoneal Dialysis 1, 2
Treatment failure is defined as the absence of a marked decrease or an increase in the neutrophil count compared to diagnosis, according to the International Society of Peritoneal Dialysis 2

If there is no adequate response at 48 hours, suspect resistant bacteria and modify antibiotics according to in vitro sensitivity or empirically escalate to broader-spectrum agents, as recommended by the European Renal Association 1, 3
Rule out secondary peritonitis (intestinal perforation) by performing an urgent abdominal CT scan and considering early surgery, as suggested by the American Society of Nephrology 2, 4

The International Society of Peritoneal Dialysis recommends a minimum of 5 days of treatment, which is as effective as 10 days, according to the European Renal Association 5
Antibiotics should be continued for 2 days after the disappearance of signs and symptoms, although in complicated infections, longer treatment may be required, as recommended by the American Society of Nephrology 6

The American Society of Nephrology advises against using quinolones if the patient is already receiving them as prophylaxis, in areas with high quinolone resistance, or in nosocomial peritonitis, due to the risk of resistance 2, 5
The European Renal Association recommends against prolonging treatment for more than 10 days without justification, as it increases the risk of colonization by resistant strains 6

The American Society of Nephrology recommends vancomycin administration based on pharmacokinetic characteristics that permit dosing after each dialysis session, with validated dosing schedules to ensure therapeutic concentrations 7, 8
The Infectious Diseases Society of America suggests ceftazidime as an appropriate agent for dialysis patients due to favorable pharmacokinetics 7, 8

The European Renal Association advises against using aminoglycosides as first-line therapy due to nephrotoxic effects, lack of anaerobic coverage, and risk of irreversible ototoxicity in dialysis patients 7