ࡱ>  Bbjbj[[ 699{8&I"!"!n"n"n""""8"#"K$\)"~)~)~)O1N45|ʽ̽̽̽̽̽̽$en" 6=0O1 6 6"!"!~)~)=== 6f"!~)n"~)ʽ= 6ʽ==^"^6~) "@s7Zh0K³ty86n"6 6 6= 6 6 6 6 6 ;t 6 6 6K 6 6 6 6 6 6 6 6 6 6 6 6 6 : The Royal Wolverhampton Hospitals NHS Trust PERITONITIS PROTOCOL Reviewed Nov 2016 Contents  TOC \o "1-3" \h \z \u  HYPERLINK \l "_Toc346784413" 1 Definitions  PAGEREF _Toc346784413 \h 3  HYPERLINK \l "_Toc346784414" 2 Management outline of PD patient with Abdominal pain with or without cloudy fluid.  PAGEREF _Toc346784414 \h 4  HYPERLINK \l "_Toc346784415" 3 Immediate action  PAGEREF _Toc346784415 \h 5  HYPERLINK \l "_Toc346784416" 3.1 Samples to be taken and sent to microbiology:  PAGEREF _Toc346784416 \h 5  HYPERLINK \l "_Toc346784417" 3.1.1 20ml dialysate into a sterile universal container for URGENT WCC and gram stain  PAGEREF _Toc346784417 \h 5  HYPERLINK \l "_Toc346784418" 3.1.2 10 ml dialysate into each blood culture bottle for bacterial culture  PAGEREF _Toc346784418 \h 5  HYPERLINK \l "_Toc346784419" 3.2 Observations to be recorded:  PAGEREF _Toc346784419 \h 5  HYPERLINK \l "_Toc346784420" 3.3 Previous peritonitis  PAGEREF _Toc346784420 \h 5  HYPERLINK \l "_Toc346784421" 3.4 Start antibiotic treatment immediately (page 7 or8)  PAGEREF _Toc346784421 \h 5  HYPERLINK \l "_Toc346784422" 3.5 Caveats  PAGEREF _Toc346784422 \h 5  HYPERLINK \l "_Toc346784423" 4 In-patient or out-patient  PAGEREF _Toc346784423 \h 6  HYPERLINK \l "_Toc346784424" 4.1 Systemically well  PAGEREF _Toc346784424 \h 6  HYPERLINK \l "_Toc346784425" 4.2 Systemically unwell  PAGEREF _Toc346784425 \h 6  HYPERLINK \l "_Toc346784426" 5 The initial empirical treatment as an out-patient  PAGEREF _Toc346784426 \h 7  HYPERLINK \l "_Toc346784427" 5.1 Intra-peritoneal Vancomycin  PAGEREF _Toc346784427 \h 7  HYPERLINK \l "_Toc346784428" 5.2 Oral Ciprofloxacin 500 mg bd for 5 days.  PAGEREF _Toc346784428 \h 7  HYPERLINK \l "_Toc346784429" 5.3 Immediate handover for Follow-up  PAGEREF _Toc346784429 \h 7  HYPERLINK \l "_Toc346784430" 5.4 Review on day 3  PAGEREF _Toc346784430 \h 7  HYPERLINK \l "_Toc346784431" 6 Start of Empirical Treatment as In-Patient  PAGEREF _Toc346784431 \h 8  HYPERLINK \l "_Toc346784432" 6.1 Intra-peritoneal Vancomycin as a stat dose  PAGEREF _Toc346784432 \h 8  HYPERLINK \l "_Toc346784433" 6.2 2nd dose Vancomycin  PAGEREF _Toc346784433 \h 8  HYPERLINK \l "_Toc346784434" 6.3 Intra-peritoneal Gentamicin  PAGEREF _Toc346784434 \h 8  HYPERLINK \l "_Toc346784435" 6.4 Immediate handover for Follow-up  PAGEREF _Toc346784435 \h 8  HYPERLINK \l "_Toc346784436" 7 DAY 3: (In-patient and Out-patient)  PAGEREF _Toc346784436 \h 9  HYPERLINK \l "_Toc346784437" 7.1 Assess antibiotic choice(s)  PAGEREF _Toc346784437 \h 9  HYPERLINK \l "_Toc346784438" 7.2 Assess and monitor progress  PAGEREF _Toc346784438 \h 9  HYPERLINK \l "_Toc346784439" 7.3 Vancomycin dosing  PAGEREF _Toc346784439 \h 9  HYPERLINK \l "_Toc346784440" 7.4 Gentamicin dosing  PAGEREF _Toc346784440 \h 9  HYPERLINK \l "_Toc346784441" 8 DAY 5 (In-patient and Out-patient)  PAGEREF _Toc346784441 \h 11  HYPERLINK \l "_Toc346784442" 9 Indications of PD catheter removal due to infection:  PAGEREF _Toc346784442 \h 12  Definitions Any one of the following is an acceptable definition of PD peritonitis Cloudy dialysate +/- abdominal pain +/- fever An elevated peritoneal fluid WCC>100/mm, of which at least 50% polymorphs 50% polymorphs even if total WCC <100 indicate PD peritonitis in patients on Automated PD Management outline of PD patient with Abdominal pain with or without cloudy fluid.  SHAPE \* MERGEFORMAT    Immediate action Samples to be taken and sent to microbiology: 20ml dialysate into a sterile universal container for URGENT WCC and gram stain Same day results: 8am-8pm during week day and 9am-5 pm on weekends. If the patient is systemically very unwell please discuss with on-call microbiology consultant for urgent microscopy. Any contact with the peritoneal catheter and dialysate fluid should be performed using an aseptic technique by appropriately trained staff, according to PD unit exchange protocol. Determine from the patient whether the dialysis system is made by Baxter or Fresenius. Use  HYPERLINK "http://intranet.xrwh.nhs.uk/pdf/departments/renal/CAPD_Procedure_baxter_system_with_connection_shield.pdf" Procedure for Continuous Ambulatory Peritoneal Dialysis (CAPD) exchange Baxter system with connection shield or  HYPERLINK "http://intranet.xrwh.nhs.uk/pdf/departments/renal/CAPD_procedure_fresenius_stay_safe.pdf" Procedure for Continuous Ambulatory Peritoneal Dialysis (CAPD) exchange Fresenius Stay-Safe accordingly. 10 ml dialysate into each blood culture bottle for bacterial culture The needle is to be changed in between bottles to avoid cross contamination. Observations to be recorded: Temperature, Pulse and Blood pressure. Examine exit site: if there is any sign of infection swab the site and send to microbiology. Examine the tunnel site for signs of infection. If exit site infection present additional oral or i.v. antibiotics may be necessary. Previous peritonitis Ask the patient about any recent episodes of peritonitis. Check the computer system for any previous positive microbiology results. Empirical treatment may need to be altered if any recent positive results are obtained discuss with renal consultant or microbiologist Start antibiotic treatment immediately (page 7 or8) The delay to antibiotic administration must be < 1 hour from admission. Use  HYPERLINK "http://intranet.xrwh.nhs.uk/pdf/departments/renal/CAPD_adding_medication_to_peritoneal_dialysis_bags.pdf" Adding Medication to Peritoneal Dialysis Bags protocol. Caveats If diagnosis is unclear, e.g. slightly hazy dialysate, send a sample to microbiology for urgent WCC and wait for confirmation of diagnosis prior to treatment. In-patient or out-patient The decision as to whether to treat as an in-patient or out-patient depends upon whether the patient is systemically well or not. Systemically well The patient is not unwell in any other way and you have no concerns Manage as outpatient. Systemically unwell Admit Take bloods: FBC, U&E, Calcium, LFT, CRP, Amylase. Consider possibility of other intra-abdominal pathology and obtain a surgical opinion if necessary. The initial empirical treatment as an out-patient Use both vancomycin and ciprofloxacin Intra-peritoneal Vancomycin If weight >50 kg: 2g Vancomycin If weight <50 kg: 1g Vancomycin Vancomycin should be administered in the normal treatment volume for that patient, e.g. 1.0l or 2.5l PD fluid and left to dwell for 6 hours. Oral Ciprofloxacin 500 mg bd for 5 days. Immediate handover for Follow-up Following treatment please notify the PD unit of patient admission/discharge to ensure follow-up and subsequent treatment. This requires phoning 01902 695011 and speaking to the staff or by leaving a message on the answer-phone. Review on day 3 Assess response and repeat peritoneal white cell count if there are any concerns. Adjust antibiotic therapy in accordance with results of culture of initial PD fluid sample Start of Empirical Treatment as In-Patient Use both vancomycin and gentamicin Intra-peritoneal Vancomycin as a stat dose If weight >50kg: 2g Vancomycin If weight <50kg: 1g Vancomycin Vancomycin should be administered in the normal treatment volume for that patient, e.g. 1.0l or 2.5l PD fluid, and left to dwell for 6 hours. 2nd dose Vancomycin Administered between days 3 5 depending upon Vancomycin levels Intra-peritoneal Gentamicin Gentamicin dose: 4mg/l into each bag exchange. Gentamicin level monitoring & further dosing: see page 9 Immediate handover for Follow-up Following treatment please notify the PD unit of patient admission/discharge to ensure follow-up and subsequent treatment. This requires phoning 01902 695011 and speaking to the staff or by leaving a message on the answer-phone. DAY 3: (In-patient and Out-patient) Assess antibiotic choice(s) If the Gram stain and culture results are available, change treatment accordingly (See Table 1). This may be altered on day 2 if culture results are known by day 2. If culture negative from day 1 repeat PD effluent cultures. If patient improving continue current management If patient not improving discuss change of antibiotics with microbiology Assess and monitor progress Repeat PD effluent WCC on Day 3 Dialysate WBC > or = 1090/mm3 on day 3 is an independent prognostic marker for treatment failure. Clin J Am Soc Nephrol 2006; 1:768-73 At least alternate day dialysate WCC. Vancomycin dosing Perform level on day 3 The therapeutic plasma concentration of Vancomycin is 15-20 mg/l. International Society for Peritoneal Dialysis 2010 Am J Kidney Dis 1995; 25:611-15 The dose should be administered if the Vancomycin concentration <20 mg/l. Repeat levels should be taken every 3 5 days Gentamicin dosing In the management of CAPD peritonitis monitoring of gentamicin levels is used for the detection of toxicity rather than proof of efficacy. A trough concentration of < 2mg/l is recommended A random level should be taken on day 3 after an exchange; the next exchange should then be commenced with gentamicin added to the exchange. When results available: < 2mg/l Continue current regime >2mg/l A dose reduction or dose omission may be necessary to avoid toxicity. Monitor levels every 3 days to avoid toxicity; if concerns about toxicity levels may need to be done more frequently. Table  SEQ Table \* ARABIC 1. Initial Microbiology results and suggested treatment GRAM STAINCULTURE RESULTANTIBIOTIC ADVICE Gram positive cocciCoagulase negative staphylococcusStop gentamicin or ciprofloxacin. Continue vancomycin.Staph aureusMSSAStop gentamicin or ciprofloxacin. Continue vancomycin. Add flucloxacillin 1g qds po.MRSAStop gentamicin or ciprofloxacin. Continue vancomycin. Add rifampicin (if sensitive organism) 300 mg po bd.Gram negative bacilliPseudomonas ** Pseudomonas peritonitis associated with high rates of catheter removal and permanent haemodialysis transfer use of 2 antibiotics associated with better outcome.No further vancomycin. Use 2 antibiotics: Ciprofloxacin 500 mg bd orally and gentamicin 4mg/l IP in each exchange bag. If resistant organism discuss with microbiology for alternative agents. Single other gram negative eg. E.coliNo further vancomycin. Single antibiotic either ciprofloxacin 500 mg bd po or gentamicin 4 mg/l IP into each exchange bag. Stenotrophomomas maltophiliaStop empirical treatment Discuss with microbiology for alternative agent.Yeast or other fungusYeast or other fungusThis is an emergency and the patient needs to be admitted for urgent catheter removal. Stop gentamicin / ciprofloxacin and vancomycin. Commence i.v. antifungal treatment after discussion with microbiology.Multiple organismsMultiple gram positive organismsNo further gentamicin or ciprofloxacin. Continue vancomycin. Addition of other antibiotic may be necessary depending on the organisms identified and their sensitivities. Multiple enteric organismsRisk of underlying intra-abdominal pathology. Surgical review. May need broad spectrum iv antibiotics. Discuss with microbiology. DAY 5 (In-patient and Out-patient) Table  SEQ Table \* ARABIC 2. Treatment Guidance according to microbiology FINAL CULTURE RESULTANTIBIOTIC ADVICEOTHER INFORMATIONCoagulase negative staphylococcusContinue IP vancomycin for a total of 14 days. Monitor vancomycin levels.If associated tunnel or exit site infection may have to treat for 21 days and consider catheter removal.Staph aureusMSSAContinue IP vancomycin and oral flucloxacillin to complete 14 21 days treatment If failure to respond after 5 days on appropriate antibiotics or associated with exit site infection with the same organism consider catheter removal.MRSAContinue IP vancomycin and oral rifampicin to complete 14 21 days treatmentPseudomonas Continue antibiotics for a minimum of 14 days. Ciprofloxacin 500 mg bd po and gentamicin 4mg/l IP into each exchange bag. Monitor gentamicin regularly to avoid toxicity. If gentamicin toxicity contact microbiology for alternative agents. Pseudomonas peritonitis is generally severe and often associated with catheter infection; in such cases catheter removal is required. Continue antibiotics for a minimum of 14 days. Longer may sometimes be required. Single other gram negative eg. E.coliSingle antibiotic either ciprofloxacin 500 mg bd po or gentamicin 4 mg/l IP into each exchange bag. If gentamicin used monitor levels to avoid toxicity.Complete 14 days of treatment. If failure to respond after 5 days on appropriate antibiotics consider catheter removal. Stenotrophomomas maltophiliaDiscuss with microbiology. Prolonged therapy for 3 - 4 weeks may be indicated.Yeast or other fungusThis is an emergency and removal of catheter should have occurred. Continue anti-fungal treatment for at least 14 days after catheter removal. Discuss treatment options with microbiology.Fungal peritonitis is serious leading to death in approximately 25 % or more of episodes. If part of a polymicrobial culture may be associated with underlying bowel perforation.Multiple gram positive organismsContinue vancomycin and other additional antibiotics as per sensitivities for a total of 14 days. The source is most likely contamination or catheter infection; the patients technique should be reviewed and the exit site carefully examined. Generally resolves without catheter removal unless the catheter is the source of infection.Multiple enteric organismsDuration and choice of antibiotics should be discussed with microbiology.The catheter may need to be removed, particularly if laparotomy indicates an intra-abdominal focus.Culture negativeIf improving continue empirical antibiotics for 14 days.If no clinical improvement after 4 days consider other infective and non-infective causes and discuss with microbiology. Indications of PD catheter removal due to infection: Refractory peritonitis Relapsing peritonitis Refractory exit site and tunnel infection Fungal peritonitis May also be considered for Repeat peritonitis Mycobacterial peritonitis Multiple enteric organisms. 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