Despite advanced connectology of peritoneal dialysis (PD) equipment and improved patient education, peritonitis continues to be a problem for many patients on PD and is associated with increased hospitalization rates and modality failure. In addition, it may lead to decreased residual renal function, membrane failure with loss of ultrafiltration, anemia, increased albumin loss, and increased risk of death (Piraino, 1998). Exit site infections (ESIs) and/or tunnel infections often precede an episode of peritonitis and are significant as they may lead to peritonitis and PD catheter removal (Piraino, 1996).  Most episodes of peritonitis and ESIs can resolve with prompt identification, appropriate initial empiric therapy with modification per culture results, and patient education regarding technique and prevention. 

To ensure best practice in the treatment of peritonitis and ESIs, a case management tool was developed and implemented in our clinic through collaboration with the multidisciplinary team. It consists of a care pathway and a protocol to guide the clinician through the entire treatment process. Based on established treatment guidelines, published nursing data and past clinical experience, it is reactive in the medical treatment of peritonitis and ESIs as well as proactive in the prevention of complications and future episodes of peritonitis and ESIs (Keane, et al., 2000; Prowant, 1996). The peritonitis care pathway and protocol are evaluated and updated as necessary for process and patient outcomes. Through utilization of the care pathway and protocol, episodes of peritonitis and ESIs in our clinic were found to resolve more successfully with fewer hospitalizations and complications.

Patient Profile
KB is a 46-year-old, white female with end stage renal disease (ESRD) secondary to polycystic kidney disease. She is married with 2 children, employed part time, and enjoys many social activities.  KB started hemodialysis in October 2001 and transferred to  PD within 2 months for the flexibility and independence that it would provide her.

KB has since been on continuous cycling peritoneal dialysis (CCPD). She dialyzes at night and has a day dwell of 1 liter due to vaginal prolapse. Surgical repair of the prolapse is planned but has not yet been scheduled. KB is non-anuric with greater than 100cc urine per day. Kt/V is monitored quarterly and urine volume checked monthly. Labs were drawn on/03, 1 month prior to KB’s first episode of peritonitis (see Table1). 

On 4/02/03, KB presented with her first episode of peritonitis. KB reported a break in technique that occurred several days prior to symptoms of peritonitis. KB had been on vacation and had not taken enough supplies to use when the technique break occurred, nor had she notified the nursing staff. KB was treated with antibiotics and the peritonitis resolved successfully.

Six weeks later, KB complained of pain and tenderness at the exit site. The exit site was examined and noted to have peri-catheter erythema and purulent drainage. A culture of the exit site was obtained and KB was started on oral antibiotic therapy.

1. The current episode of peritonitis and exit site infection will resolve with proper therapy.
2. KB will demonstrate an understanding of preventing peritonitis and exit site infection. 
3. Residual renal function will be maintained.
4. KB will maintain her active lifestyle.
   

Case Report
On/03, KB presented with abdominal pain and cloudy fluid. Peritonitis was identified and medical treatment was promptly initiated following the peritonitis care pathway and protocol. Peritoneal effluent was obtained for culture and the peritoneal cavity was lavaged with dialysate.  Initial empiric antibiotics were initiated with intraperitoneal (IP) cefazolin and IP ceftazidime for both gram positive and gram negative coverage. Upon identification of the organism as staphylococcus aureus, antibiotic therapy was modified. The ceftazidime was discontinued and IP cefazolin continued for a total of 21days. Rifampin would have been added if peritonitis was slow to improve, however, this was not necessary. Antibiotic selection and the dosage administered were determined by KB’s weight, residual renal function, past medical history, allergies and patient assessment. Vancomycin was not administered for initial empiric therapy due to increased incidence of vancomycin resistant organisms and no known patient history of MRSA. Aminoglycosides were not administered since they may cause nephrotoxicity and potential decrease in residual renal function. KB’s Epogen dose was increased as epoetin response may be altered by infection and inflammation. To ensure peritoneal membrane function and adequacy, a Kt/V was rescheduled for 4-8 weeks following peritonitis.

Patient teaching included IP medication administration, selection of dextrose concentration for potential fluid retention, IP heparin for fibrin, increasing protein intake due to increased albumin loss, and prophylactic use of mupirocin to the exit site to reduce staphylococcus aureus ESIs and peritonitis. KB was evaluated on PD technique and re-educated on travel and contamination procedures.

Six weeks later, KB presented with symptoms of an ESI.  Utilization of the ESI care pathway and protocol directed the PD nurse (who was new in her position) through the entire treatment process. The following actions were taken which led to successful treatment of KB’s ESI. Upon identification of the ESI, a culture of the exit site was obtained.  KB was also assessed for a tunnel infection and peritonitis, which were both negative. Keflex was started as initial empiric therapy but was promptly discontinued when pseudomonas aeruginosa was identified on culture. A combination therapy of oral ciprofloxacin and IP ceftazidime was selected due to the difficulty in resolving most pseudomonas ESIs. Although pseudomonas aeruginosa is sensitive to aminoglycosides, these drugs were avoided to preserve KB’s residual renal function. KB also received oral anti-fungal prophylaxis during the treatment course to prevent secondary fungal infections. Patient instruction was provided on when to take the ciprofloxin for optimum absorption. Ciprofloxacin absorption is significantly reduced when administered within 2 hours of taking iron, calcium, antacids and milk.

KB was re-educated on exit site care, swimming, showering, and prevention of ESIs and peritonitis. During her initial PD training, KB had been instructed not to swim or bathe in lakes, public pools, or hot tubs due to possible exposure to pseudomonas and other water-borne organisms. This was reinforced after KB reported using a hot tub while on vacation several weeks earlier. She received antibiotic therapy for 21 days and the pseudomonas ESI resolved successfully without complications or relapse. Labs and Kt/V were drawn on/03, 8 weeks following peritonitis (see Table 1).  KB has since had surgical intervention to correct the vaginal prolapse and continues on CCPD.

Summary
The outcomes and objectives for KB were met by following a case management tool specific to peritonitis and exit site infection. Utilization of the care pathway and protocol ensured best practice in the nursing care provided and the medical treatment administered. Both the peritonitis and the ESI resolved successfully without complications, loss of residual renal function, hospitalization or relapse. KB received retraining on technique and prevention and has had no further episodes of peritonitis or ESI. She continues to do well on PD and maintains her active lifestyle.

References

Keane, W., Bailie, G., Boeschoten, E., Gokal, R., Golper, T., Holmes, C., et al. (2000). Adult peritoneal dialysis-related peritonitis treatment recommendations: 2000 update. Peritoneal Dialysis International, 20, 396-411.

Piraino, B. (1998). Prevention of peritonitis, Peritoneal Dialysis International, 18, 244-246.

Piraino, B. (1996). Peritoneal catheter exit-site and tunnel infections. Advances in Renal Replacement Therapy, 3, 222-227.

Prowant B.F. (1996). Nursing interventions related to peritoneal catheter exit-site infections. Advances in Renal Replacement Therapy, 3, 228-231.