Peritonitis Protocol - April 2016

The microbial management of peritonitis in Type: Clinical Guideline Register No: 16017 Peritoneal Dialysis patients. Status: Public Developed in response to: CNST Best Practice Best Practice Guidelines UK Renal Association Guidelines NICE Guidelines International Society for Peritoneal Dialysis Guidelines Contributes to CQC Regulation: 9, 12 Consulted With Dr S Abeygunasekara Rebecca Culpin Professionally Approved By Dr Louise Teare Version Number Issuing Directorate Ratified by: Ratified on: Trust Executive Board Date Implementation Date Next Review Date Author/Contact for information

Post/Committee/Group Clinical Director for Medicine Matron – Renal Unit Consultant Microbiologist and Director of Infection Prevention and Control 1.0 Acute Medicine DRAG Chairmans Action 24th May 2016 June 2016 25th May 2016 April 2019 Jeanette Faux/Pamela Ayling

Policy to be followed by (target staff) Distribution Method Related Trust Policies (to be read in Conjunction with)

Date April 2016 April 2016 April 2016

Medical & Renal Nursing staff. Terling Ward Nursing Staff. Intranet & website Infection Control Policy (04072) MRSA Policy Safe Handling & Disposal of Sharps Policy ( 10004) Waste Management Policy (04088) Antibiotic Policy (06045) Confidentially & Data Protection Policy (07011) Risk Management Strategy & Policy (04061) Aseptic Technique & Aseptic Non Touch Technique Policy (08038) Administration of medicines to inpatients (08103) Injectable medicines Policy (09060)

Document Review History Version No Authored/Reviewed by 1.0 Jeanette Faux/Pamela Ayling

Active Date 25th May 2016














Clinical Presentation and diagnosis


Assessment and investigation




Assessment of patients who fail to demonstrate clinical improvement (refractory peritonitis)

10. Staffing & Training 11. Audit & Monitoring of Policy 12. Appendices 1. Patients presenting with suspected peritonitis 2. Specimen collection method for Peritoneal Dialysis Fluid 3. Method for Administering IP Vancomycin 4. Method for Administering IP Gentamicin





The purpose of this guideline is to reduce the morbidity and mortality associated with peritoneal dialysis (PD) peritonitis by effective management of infections or suspected infections: • • • • • •

Reduction in the loss of PD access through infection Preservation of the peritoneal membrane and duration of PD Timely and appropriate sampling of PD fluid Prompt diagnosis of infection and reduction in severity of infection Timely initiation of appropriate antibiotic therapy Timely removal of PD catheter where clinically indicated




Inclusions – Adult patients on Peritoneal Dialysis.


Exclusions - Paediatric patients under 18 – seek specialist advice.




Peritonitis is one of the major risks in PD, causing significant morbidity and in some cases mortality. It is a significant cause of change of treatment modality from PD to haemodialysis.


Diagnosis is based on clinical features (abdominal pain, cloudy fluid and fever) and confirmed by an effluent white cell count of > 100/µL (after a dwell time of at least 2 hours), with ≥ 50 % polymorphonuclear neutrophil cells.

4 4.1

Standards UK Renal Association Standards (2010) • Peritonitis rates of less than 1 episode per 18 patient months. (NSF Part 1 2004) • A primary cure rate of ≥ 80%. • A culture negative rate of < 20%.


The ISPD guidelines (2010) • •

Peritonitis rate within the PD population should be no more than 1 episode in every 18 patient months. Culture negative peritonitis should not be greater than 20% of episodes (direct injections of PD effluent into blood culture bottles).


Clinical Presentation and Diagnosis


Any patient presenting with signs and symptoms of peritonitis should be referred as soon as possible to either a physician from the nephrology team or a renal trained nurse. The patient should be initiated on treatment in accordance with the protocol. 3


Patients with uncomplicated peritonitis may be managed as an outpatient.


Patients who are clinically unwell or have complicated peritonitis should be admitted to Terling Ward and should be referred to a nephrology consultant.


A patient with uncomplicated peritonitis will normally present with at least 2 of the following: • Cloudy effluent with duration of less than 12 hours • Mild abdominal discomfort • Mild pyrexia (≤ 38° C) • WCC in PD fluid of > 100/µL (after a dwell time of at least 2 hours)


A patient with complicated peritonitis will normally present with one or more of the following: • Cloudy effluent with duration of more than 12 hours • Moderate to severe abdominal pain • Rebound tenderness • Pyrexia ≥ 38° C • Confusion • Diarrhoea and vomiting


Assessment and Investigation


Routine observations: • Temperature • Lying and standing blood pressure • Weight • Abdominal assessment for signs of guarding / rebound tenderness. Exit site and tunnel review • Visual inspection of the dialysis fluid (colour, opacity, turgidity, debris)


A specimen of fluid should be collected from the first cloudy bag (see Appendix 2 for sampling method).




Initial empiric treatment: Day One

7.1.1 The patient should be started on the following intra-peritoneal (IP) antibiotic regime, once a sample of PD fluid has been sent to microbiology (see sampling appendix). 7.1.2 Dwell time: the bag containing antibiotic should dwell for a minimum of 6 hours. Antibiotic Vancomycin* Gentamicin

Patient weight (kg) ≤ 50kg 50-70 kg ≥ 70 kg

Dose of antibiotic 1 gram 1.5 grams 2 grams 80 mg

*Vancomycin sensitive patients should have Linezolid 600mg bd (orally



Day Two

7.2.1 Gentamicin should be continued daily until culture results are available. Dose of Gentamicin 20 mg 30 mg

Patient weight (kg) ≤70 kg ≥70 kg

7.2.2 No further Vancomycin should be given until levels are obtained. 7.2.3 Treatment modification following Gram stain, culture and sensitivities 7.3

Day Three

7.3.1 Levels should be taken for Vancomycin and Gentamicin. 7.3.2 Therapeutic Targets for antibiotic levels: Gentamicin ≤ 2 micrograms/ml Vancomycin 15 micrograms/ml – 20 micrograms/ml Note that IP levels of Vancomycin after the initial dose will always be lower than serum levels therefore serum levels need to be maintained higher than would otherwise be indicated. 7.3.3 Further levels should then be taken every third to fifth day (ideally a trough level) for the duration of treatment. 7.3.4 Once culture and sensitivities are known, antibiotic therapy should be adjusted as appropriate. 7.3.5 The table below should be used as a guide only; involvement and advice from the microbiologist will be required in some circumstances. Gram-positive Cocci

Coagulase negative Staphylococcus (CNS)

Continue IP Vancomycin (dose according to levels) for 1 week. Change to oral antibiotics (according to sensitivities) after 1 week responding.

Staphylococcus aureus

Total duration of therapy:14 days Continue IP Vancomycin (dose according to levels) for 3 weeks



If poor clinical response to Vancomycin at one week, add oral Rifampicin (300mg bd) Total duration of therapy:21 days Continue IP Vancomycin Stop IP Gentamicin Total duration of therapy: 14 days Discuss therapy options with microbiologist 5


Gram-negative rods

Single Gram-negative organism (NOT Pseudomonas) Pseudomonas

Continue antibiotics according to sensitivities Total Duration of therapy: 14 days Continue IP Gentamicin according to Levels. Adjust according to sensitivities Total Duration of therapy: 14 days Continue daily IP Gentamicin. Add further antibiotic according to sensitivities. Consider catheter removal if no improvement in 1-2 weeks.


Culture negative

Total duration of therapy: 21 days Immediate catheter removal. IV anti-fungal treatment following catheter removal. Continue IP Vancomycin and Gentamicin according to levels. If clinical improvement by day 4, stop Gentamicin and continue 14 days of IP Vancomycin according to levels. If poor response at day 3-4, reculture fluid. Total duration of therapy : 14 days


Assessment of Patients Who Fail to Demonstrate Clinical Improvement (Refractory Peritonitis)


Patients should feel symptomatically better within 3-4 days of starting treatment: If not, re-culture fluid and liaise with Nephrologist and microbiologist.


Consider catheter removal or replacement if: • • • • • • • •


Patient remains symptomatically unwell There is evidence of increasing sepsis The PD fluid fails to clear in 3-4 days The PD fluid becomes increasingly turbid The PD catheter is blocked with thick fluid There is relapsing peritonitis (i.e. an episode within 4 weeks of completing therapy with the same organism) There is failure to an early response in a pseudomonas infection There are two organisms indicating possible bowel pathology (consider laparotomy)

Once catheter is removed, time required before reinsertion of the PD catheter will be dependent on the clinical situation / organism identified. In some situations the PD catheter may be exchanged and the patient can continue on PD with reduced fill volumes. Patients may however need to transfer to haemodialysis depending on the 6

degree of their residual renal function. If patients are holding off dialysis they will need regular monitoring of biochemistry and fluid status. 8.4

Of note, if either MSSA or MRSA is isolated, the patient will need to be started on the staphylococcal decontamination regime in accordance with the protocol.


Staffing & Training:


This policy applies to all registered nurses in contact with renal patients on either Terling Ward or in the Renal Unit. Training is carried out by competent trained staff on either Terling Ward or the Renal Unit. Training will be recorded in the Competency Portfolio which is kept in the Managers’ office


Audit & Monitoring of Policy

10.1 Where there has been non-compliance which has resulted in patient harm, the risk event must be recorded on a Datix. 10.2 There will be an on-going audit process to investigate the safety of and compliance with the policy. This will be completed by the author and senior members of the Renal Home Therapies staff. 10.3 Findings will be presented at departmental audit meetings. All staff will be responsible for implementing any required actions 11.

Breaches of Policy

11.1 Any harm or near miss will be considered a breach of policy and must be recorded on a Datix risk event form. 11.2 Risk event forms will be reviewed at the monthly renal clinical governance meetings by the renal team as part of the process. 11.3 Suggestions for improvement will be proposed at the Renal Clinical Governance Meetings and the Author of these guidelines will lead implementations and lessons learnt.


Appendix 1 PATIENTS PRESENTING WITH SUSPECTED PERITONITIS Date: Name: DOB: Hospital No: Presenting Symptoms:





Bloods sent: RDU FBC




NEWS Score: CRP Clotting Screen

Blood Cultures (if pyrexial)

Visual inspection of dialysis fluid (colour, opacity, turgidity, debris): Send 10mls of PD fluid in each blood culture bottle to Microbiology and mark for culture and gram stain with 20mls of PD fluid in a white sterile universal container white cell count and differential. Mark as urgent. (See Appendix 2 for sampling collection method) Length of dwell: (time fluid has been in peritoneum):

 hrs (must be > 2hrs)

Page 1 of 2


Appendix 1/Page 2 Name of Consultant/Registrar reported to: Date:


Patient reviewed

Dr name/time/plan:

Commenced on IP Antibiotics as per Day 1 of peritonitis protocol If not reasons:


Patient shown how to administer IP Gentamicin as per day 2 of protocol if necessary: Yes:

If not, give reasons:

Blood test for Vancomycin and Gentamicin levels arranged for day 3 of protocol. Date: Time:

Advice given on who/when to contact if symptoms worsen: Documented on eMed: Message left for PD office Ext: 6563: Contact details of patient double checked: Recommended that patient does not be alone whilst unwell:

    

Note: If patient has abdominal pain but a clear effluent, peritonitis should still be considered.


Appendix 2 Specimen Collection Method for Peritoneal Dialysis Fluid Optimal time of specimen collection is before antimicrobial therapy where possible. Effluent should be drained from first cloudy bag after a dwell time of at least 2 hours.

Method of Collection 1 2


Wipe the medication/sample port on the dialysis drainage bag with 2% chlorhexidine. Aseptically transfer 5 – 10 mls of dialysis fluid into blood culture bottles using the butterfly collecting set provided with the blood culture bottles. Inoculate the blue (aerobic) bottle first and then the purple (anaerobic) bottle so that any oxygen trapped in the tubing will not be transferred to the anaerobic bottle. Aseptically transfer 20ml of fluid into a sterile plain universal container for Total White Cell count.


Appendix 3 Method for Administering Intra-peritoneal (IP) Vancomycin Ensure procedure is carried out in accordance with the Aseptic Non Touch Technique (ANTT) protocol Equipment Required • • • • •

20ml syringe Green Needles x2 Alcohol Wipe x2 Vancomycin Water for injection (20mls)


Wash hands in accordance with MEHT hand washing policy and use alcohol rub


Attach needle to 20ml syringe


Draw up 20 mls of water for injection


Insert needle into bottle of Vancomycin powder and infuse gradually, shake until powder has dissolved


Draw up Vancomycin into syringe according to prescribed dose


Change to a clean needle


Disinfect your hands with alcohol rub


Wipe the medication port of the peritoneal dialysis bag with 2% chlorhexidine.


Inject the antibiotic into the bag after the flush step of the exchange

10 Dispose of SHARPS safely PD fluid with antibiotics should be left to dwell for a minimum of 6 hours.


Appendix 4 Method for Administering Intra-Peritoneal Gentamicin Ensure procedure is carried out in accordance with the Aseptic Non Touch Technique (ANTT) protocol Equipment Required • • • • •

5ml syringe Blunt fill Needle with filter x 1 Green Needle x1 Alcohol Wipe x2 Gentamicin


Wash hands in accordance with MEHT hand washing policy and use alcohol rub


Attach filter needle to 5ml syringe


Draw up Gentamicin into syringe according to prescribed dose


Change to a clean needle


Disinfect your hands with alcohol rub


Wipe the medication port of the peritoneal dialysis bag with 2% chlorhexidine.


Inject the antibiotic into the bag after the flush step of the exchange


Dispose of SHARPS safely

PD fluid with antibiotics should be left to dwell for a minimum of 6 hours.



Peritonitis Protocol - April 2016

The microbial management of peritonitis in Type: Clinical Guideline Register No: 16017 Peritoneal Dialysis patients. Status: Public Developed in respo...

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