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Ginjal > PD peritonitis > Flashcards

PD peritonitis Flashcards

1
Q

How to diagnose PD peritonitis?

A

**2/3 **
a. clinical features
b. dialysis effluent:
>50% polymorphonucleus cells
>100/uL WBC
>0.1 x 10*9/L WBC (after 2hrs dwell)
c. +ve effluent culture

ISPD guideline 2022

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2
Q

What is
culture -ve peritonitis?

A

Full diagnosis criteria (1/2) however no organism identified.

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3
Q

Causes of culture -ve peritonitis

Mx & Treatment duration

A
  1. recent abx exposure
  2. inadequate sample
  3. slow growing atypical organism (fungal/TB)
    *4. eusinophilic peritonitis
  4. chemical peritonitis (icodextrin) *

mx:
1. if NG after3/7, then repeat cell count + special culture
2. cont initial tx - duration: 2/52

infectious, non infectious

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4
Q

what is the peritonitis rate recommended?

A

should be** no more than 0.40 episode per year at risk**

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5
Q

diagnosis of fungal PD peritonitis

A
  1. PD effluent culture
  2. PD effluent galactomannan
  3. Serum Galactomannan
    - 65.2% sensitivity
    - 85% specificity
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6
Q

Antibiotics for PD peritonitis

A
  1. Emperic abx **(IP) **:
    Gram pos coverage: 1st gen cephalosporin / vancomycin
    Gram neg: 3rd gen **cephalosporin / aminoglycoside
    Cefepime: monotherapy **

Aminoglycoside
- cant be use os monotherapy
- +post abx effect (exhibit [ ] dependent activity even below MIC
- suggest for intermittent daily dosing IP
- SE: irrevesible ototoxicity
- RF: elderly / episodes of peritonitis / cumulative dose of amikacin / vancomycin
- prevention: oral NAC 600mg bd, avoid prolonged / repeated use

  1. culture guided therapy
  2. Adjunct therapy
    - heparin 500u/L IP - prevent fibrin clog
    - pain mx: analgesic / rapid cycler (augmented peritoneal lavage)
    - IP urokinase + rifampicin (following CONS inf) : prevent biofim formation esp in refractory (not proven)

ISPD guideline: PD peritonitis 2022

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7
Q

Mx of PD peritonitis as in-pt

A
  1. hemodynamic instability /shock
  2. persistent severe symptoms
  3. fluid overloaded
  4. poor social support
  5. inability to provide IP abx as outpt
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8
Q

Complication of PD peritonitis

A

1. Fluid overload
- increase inflammation > vasodilatation > increase effective peritoneal surface area > increase transfer rate > faster absorption of glucose > early osmotic equilibration > transient loss of UF capacity
- —high transporter
- use icodextrin

**2. increase protein loss

  1. intraabdominal abscesses / systemic seeding **
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9
Q

Refractory PD peritonitis

A

Failure of PD effluent to clear after 5 days of appropiate abx

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10
Q

indication for catheter removal

A
  1. refractory PD peritonitis
  2. systemic / clinical deterioration
  3. fungal / TB
  4. Peritonitis + exit site/ tunnel
  5. Intrabd collection / perforated bowel
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11
Q

Pattern of treatment outcome

A

1. Early responses
2. delayed response: gradual decline of effluent WBC but still above 100/uL on D5 *
3. treatment failure: not cure by abx, change modality to HD temporarily of permanent / peritonitis related death*
**4.medical cure: **complete resolution with NONE of the cx (relapse / recurrent / removal / death / transfer to HD > 30 days

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12
Q

PD catheter insertion - related peritonitis

A

episode of peritonitis that occur within 30days of insertion

aim: **< 5% of insertion **

IPSD PD peritonitis 2022

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13
Q

Reporting, monitoring and measuring

A

monitor:
1. PD related peritonitis rate (after PD commencement)
2. antimicrobial susceptibility of organism
3. culture negative peritonitis
4. peritonitis outcome
5. mean time to 1st peritonitis episode
6. % of pt with peritonitis free (aim: >80% / year)

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14
Q

Peritonitis rate reporting

A

number of episodes per patient-year

Aim: < 0.4 episodes per pt-year

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15
Q

**Culture negative **peritonitis rate reporting

A

reported as
**% of all peritonitis episodes per unit time **

Aim: < 15% of all peritonitis episode

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16
Q

Specific definition following peritonitis

A
  1. Refractory
  2. recurrent: different organism, within 4/52 of abx completion
  3. relapsing: same organism, with 4/52 of completion abx
  4. repeat: same organism, > 4/52 of abx completion
17
Q

PD contamination

A
  1. DRY contamination
    - contamination outside a closed PD system
  2. WET contamination
    - contamination with an open system, either dialysate is infused after contamination / cath set left open for extended period
    - + prophylatic abx
    - change sterile transfer set
    - PD effluent send for cell count + culture
18
Q

How to reduce the peritonitis rate in your center?

A
  1. systemic prophylatic abx per cath insertion: IV cefazolin / cefuroxime / genta / vanco
  2. exit side care: topical abx, proper PD cath immobilization , avoid mechanical stress
  3. proper training and re-training (both staff and pt)
  4. pre-procedures prophylactic abx
  5. no domestic pet / prevent zoonotic infection
  6. avoid HYPOkalemia / constipation- bacterial translocation
  7. Avoid H2 rec antagonist - suppress gastric acidity
  8. Avoid constipation
  9. anti-fungal prophylaxis
    - oral nystatin 500k u qid
    - oral fluconazole 200mg eod
    (during abx therapy)
  10. revisit on environmental RF: PD fluid / hospital air / water contamination
  11. *choose pt wisely

ISPD guideline PD peritonitis 2022

19
Q

Balance solution
Icodextrin

A

Balance solution :
more biocomplatible

Icodextrin
7.5% glucose polymer

20
Q

Fungal peritonitis

A
  1. identification of organism
  2. removal of cath
  3. antifungal 2 weeks post removal
  4. reinsertion after 4 week min
21
Q

chemical peritonitis

A
  1. symptoms
  2. cell counts > 100-3500 white cells per uL (predominant mononuclear)
  3. sterile culture

causes:
icodextrin

mx:
stop icodextrin
re-challenge 2-4 weeks
stop if recur

Ginjal (14 decks)

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