Today's approaches to prevent peritonitis.

Peritonitis continues to be a significant problem in patients on peritoneal dialysis. There is a striking variability of peritonitis rates from one center to another. These results suggest that all centers can strive for the low levels of peritonitis that are seen at some centers of excellence (0.3 episodes per year at risk or lower). Routine monitoring of PD related infections as organism specific rates (rather than proportions) is critical to achieving lower rates. Training and retraining of PD patients may be key to lowering peritonitis rates, particularly from organisms that commonly come from contamination such as coagulase-negative staphylococcus (CNS). Rates of CNS peritonitis may be used as a hallmark of adequate patient training, with a goal of a CNS peritonitis rate of 0.03 episodes per year at risk or less. New technology in connectology would be helpful to lower peritonitis related to contamination. Protocols to prevent peritonitis related to exit site infection include exit site mupirocin or exit site gentamicin as part of routine care. A randomized control trial (RCT) comparing exit site medi-honey to intranasal mupirocin is nearing completion and may prove to be an attractive alternative. Enteric peritonitis may be due to a bowel source; there are limited data on approaches to prevention. Procedures such as colonoscopy are clearly a risk for peritonitis and prophylaxis is recommended. Bowel approaches such as the prescription of a probiotic should be tested in a multicenter RCT to see if such approaches may lower enteric peritonitis. Hypokalemia is a known risk factor for peritonitis from Enterobacteriacea and should be prevented/treated. More research is needed to test various approaches to reduce peritonitis. Until more RCTs have been done, best demonstrated practices (as outlined in the recent ISPD position paper) should be utilized to lower peritonitis rates.