Nephrology

341 Management Of Peritonitis In Children On Peritoneal Dialysis

  • Step 1: Within 2hrs of Presentation of Suspected Peritonitis

    Presentation Action

    Peritonitis is suspected if the patient has ANY of the following Signs or Symptoms:

      • +/- Cloudy effluent fluid with WCC > 100*
      • +/- Abdominal pain
      • +/- Vomiting or nausea
      • +/- Fever

    SAVE FIRST CLOUDY BAG

    Parents are instructed to bring the cloudy bag in with them to ED

    * WCC >50% polymorphs if cell count available

    On consultation with nephrologist: UNLESS THE CHILD’S CLINICAL PRESENTATION REQUIRES URGENT ACTION ensure the effluent has been dwelling for 2 hours before collecting sample.

    Step 2: Initial Empiric Treatment of Peritonitis - Immediately post PD specimen

    Presentation Action

    An empiric diagnosis of peritonitis should be made if:

    • Peritoneal effluent is cloudy and
    • PD Effluent with WCC>100 of which at least 50% are polymorphnuclear neutrophils
    • Symptomatic with WCC >50

    Empiric maintenance dosing:

    • Should be administered while awaiting final cultures
    • Recommended that 2-3 in/out flushes of 1.5% balance fluid be performed prior to with added loading dose of Intra Peritoneal Antibiotics (IPAB)  loading dose dwell. See Protocol  3.3.3 In/Out flushes
    • x1 Manual exchange with IPAB loading dose:
    • Continuous APD cycling with IPAB dosing should be ordered in consultation with Nephrologist (+/- heparin 500u/L) and should be charted on the PD prescription sheet and the medication chart MR690/A.
    • Consider IV antibiotic cover if child is septic, in consultation with the Consultant Nephrologist
    • Intra peritoneal administration of a third generation cephalosporin usually Vancomycin 25mg/L + Ceftazidime 125mg/L is recommended until culture results finalised.

    Antifungal cover is compulsory to prevent fungal peritonitis

    Antifungal prophylaxis is used whilst undergoing antibiotic treatment:  Nilstat 1-2mls  orally QID

    Step 3: At 48hours Targeted Treatment

    Check vancomycin level at 48 hours
    Culture results at 48 hours to determine targeted treatment

    Presentation Action

    Culture negative

    Consider ceasing IP antibiotics in consultation with Consultant Nephrologist and depending on initial presentation

    Culture positive

    Modify IP antibiotic cover depending on sensitivities, in consultation with Consultant Nephrologist.

    Contamination Episode

    A contamination is any breach of the Tenckhoff or PD set-up at any time.

    Examples:

    • Accidental removal of betadine cap
    • Disconnection of Tenckhoff extension from catheter.
    • Any break/split or leak in the lines or sets


    An Extension change is required and  must be attended to by the PD coordinator or an accredited PD nurse

    See protocol: 3.5 Extension Catheter Change


    * KEY:

    • PD - Peritoneal Dialysis
    • IPAB - Intra-Peritoneal Antibiotics
    • APD - Automated Peritoneal Dialysis
    • Loading Dose - initial-once only dose added to any strength balance fluid. The order for loading dose is to be written on CAPD section of the peritoneal dialysis daily record and on the once only section of medication chart. Fill patient to usual volume, dwell 4-6hrs then drain.
    • Maintenance Dose - dose added to each bag used in APD, continue APD as normal. The order for maintenance dose is to be written in the APD section of the peritoneal dialysis daily record and in the regular medication section of the medication chart. Perform usual dialysis program or extend cycling up to 24hours in severe cases.