Overview of ISPD 2022 guideline recommendations for peritonitis prevention and treatment.

Abstract

This article is a summary of the new ISPD recommendations for peritonitis prevention and treatment. The latter recommendations bring definition clarifications, and new targets with respect to the rates of peritonitis. It also brings new recommendations on the prevention and the management of peritonitis with new guidelines regarding empirical use of antibiotics, dosage, and treatment of peritonitis due to specific microorganisms. In case of doubt or need of precisions, the original article (https://doi.org/10.1177/08968608221080586) and the exhaustive list of references that it contains should be consulted.

INTRODUCTION

Peritoneal dialysis (PD)-associated peritonitis is the most common PD-related infection and can be associated with PD discontinuation, transfer to hemodialysis and death. Recent guidelines from the International Society for Peritoneal Dialysis (ISPD) have been published in 2022, with respect to peritonitis prevention and treatment.

This article is an overview of the latter guidelines from ISPD (1).

DEFINITION AND MEASUREMENT OF PERITONITIS

Definition of peritonitis is heterogeneous in literature. Efforts for standardization are of certain importance. Similarly, definition of outcomes measures need standardization.

According to ISPD guidelines, peritonitis should be diagnosed when at least two of the following criteria are present: (1) Consistent clinical features (cloudy effluent, abdominal pain etc.), (2) Effluent white cells count: > 100/µl and > 50% of neutrophils and (3) Positive dialysis effluent culture. Figure1 summarizes definition and classification of cause-specific PD-associated peritonitis.

Peritonitis can be defined according to its etiology (cause-specific peritonitis,Figure 1)

Figure 1.Example caption for this image

- Culture-negative peritonitis:defined by the presence of criteria (1) and (2) in the absence of a positive effluent culture. All cases of culture-negative peritonitis should be counted in the peritonitis statistics. The latter can be either infectious or non-infectious.

- Catheter-related peritonitis:defined by the presence of peritonitis occurring concomitantly or up to 3 months after the onset of either exit-site infection and/or tunnel infection and with the same organism.

-Enteric peritonitis:defined as a peritonitis occurring from an intestinal source. It can be either infectious (in less than 20%, effluent culture may be positive to both gram positive and gram-negative bacteria) or non-infectious (secondary to contiguous inflammatory reaction through peritoneal membrane and therefore culture-negative). The latter should be counted as enteric peritonitis rather than culture-negative peritonitis.

- Culture-positive peritonitis

Peritonitis can be defined according to the timeline of occurrence (time-specific peritonitis,Figure 1)

- Pre-PD peritonitis:Under recognized. Defined as a peritonitis occurring after PD catheter insertion but before initiation of the technique. Weekly flushing of the catheter should not be considered as PD initiation.

- PD catheter insertion-related peritonitis:defined as a peritonitis occurring within 30 days of PD catheter insertion.

- PD-related peritonitis:starting from PD initiation. According to the ISPD Guidelines on Creating and Maintaining Optimal PD Access in the Adult Patient.

Peritonitis can be defined according to its outcomes (outcome-specific definitions of peritonitis)

The ISPD recommends frequent monitoring (as a part of a continuous quality improvement (CQI) program) of peritonitis rate and outcomes, using the following definitions to describe outcomes following peritonitis.

At least on a yearly basis:

- Rate of peritonitis: number of episodes per patient-year.

o Overall peritonitis rate: should not exceed 0.4 episodes per patient-year (year at risk).

o Culture-negative peritonitis: should be reported as a percentage of all peritonitis episodes per unit time and should be less than 15% of all peritonitis episodes.

On a monthly basis, or at least quarterly, for local reports to inform local practices:

- PD catheter insertion-related peritonitis: should be <5% of catheter insertion.

- Mean time to first peritonitis episode: where time counts from the first day of PD initiation.

- Percentage of patients free of peritonitis per unit time: target >80% per year.

- Pre-PD peritonitis: reported as episodes per year

- Other: medical cure, recurrent peritonitis, relapsing peritonitis, peritonitis-associated catheter removal, peritonitis-associated transfer to hemodialysis and peritonitis - associated hospitalization or death (occurring within 30 days of peritonitis onset).

Figure 2summarizes the outcome-specific definitions following peritonitis.

Figure 2.Outcome specific definition following peritonitis, according to ISPD guideline recommendations

PREVENTION OF PERITONITIS

Table Isummarizes ISPD recommendations with respect to the prevention of peritonitis.

Catheter placement:

systemic prophylactic antibiotics should be administered immediately prior to catheter placement. The choice of antibiotic should be determined after considering the local spectrum of antibiotic resistance. There is no data regarding the effectiveness of routine screening and eradication of S. aureus nasal carriage before catheter insertion.

Table I.Prevention of peritonitis according to the ISPD peritonitis guideline recommendations

Prevention of peritonitis
Catheter placement: Prophylactic antibiotics prior to catheter placement No data regarding the effectiveness of screening and eradication of S. aureus nasal carriage before catheter insertion.
Exit site care: Topical application of antibiotic Proper PD catheter immobilization Prompt treatment of exit-site or catheter tunnel infection
Contamination of PD system: Prophylactic antibiotic Change of a sterile transfer set PD effluent culture Close monitoring
Invasive gastrointestinal and gynecological procedures: Prophylactic antibiotics prior to colonoscopy and invasive gynecological procedure. The abdomen should preferably be empty before the procedure.
Training program:  reassessment of PD exchange technique and knowledge, and direct inspection of practice of PD technique. Consider : Home visit by PD nurses, retraining (e.g. following prolonged hospitalization, peritonitis and/or catheter infection, change in dexterity, vision or mental acuity, etc.)
Domestic pet and zoonotic infection: Avoid pet in the same room where PD exchanges are taking place and equipment are stored.
Other modifiable risk factors: Treatment of hypokalemia (higher risk of enteric peritonitis) Avoiding or limiting the use of histamine-2 receptors inhibitors. Constipation prevention (regular lactulose use is associated with a lower rate of peritonitis).
Secondary prevention: Anti-fungal prophylaxis (either oral nystatin or fluconazole) is recommended after an antibiotic course (regardless of the indication), in order to prevent fungal peritonitis. Oral Nystatin (500,000 U qid during ATB course)

Exit-site care:

topical antibiotic cream on the PD catheter exit site is recommended. Also, proper PD catheter immobilization may be useful, and

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