Insights on peritoneal dialysis-related infections.

Peritonitis remains a serious complication of peritoneal dialysis and can lead to death of the patient. Most peritonitis is due to either contamination with the peritoneal dialysis exchange or exit site infection and can be prevented by protocols for appropriate training and exit site care. The micro-organism infecting the peritoneum is an important clue to the etiology: coagulase-negative Staphylococcus is generally due to touch contamination while Pseudomonas aeruginosa and Staphylococcus aureus are most often due to catheter infections. The etiology of other Gram-negative peritonitis is uncertain but appears to relate to bowel problems especially constipation, hypokalemia, perhaps leading to dysmotility, as well as touch contamination at the time of the exchange. The approach to treating peritonitis is always to rapidly resolve the infection, even if this entails removing the peritoneal catheter. Refractory peritonitis is generally defined as peritonitis treated with an appropriate antibiotic for fi ve days without evidence of resolution. The antibiotic to treat peritonitis should be chosen based on the past history of the organisms and sensitivities of the program, should cover Gram-negative and Gram-positive organisms, and tailored once the cause is identified. Relapsing peritonitis requires catheter exchange. Each program should have continuous quality improvement that tracks each episode, performing root cause analysis, examining organisms, rates of organisms, and outcome. In this way, each program can develop initiatives to lower peritonitis rates. Such protocols might include the use of routine exit site antibiotic cream as part of daily care, re-training of patients, prevention of constipation, and removal of infected catheters. With an aggressive approach peritonitis rates can be lowered to very low rates.