Standard Operating Procedure for the Outpatient Management of Peritoneal Dialysis-associated Peritonitis
The decision to treat as an outpatient and the responsibilities of the team
- The initial diagnosis of PD peritonitis will be made in the hospital, with the treating team expected to initiate therapy according to the protocol for treatment and monitoring of PD peritonitis (available on Edren) and to inform the community dialysis team (CDT) as soon as possible.
- The decision to treat a patient with PD peritonitis as an outpatient is at the discretion of the treating team, based on the patient’s clinical condition, frailty, social factors and practicalities of providing outpatient antibiotics.
- Once a diagnosis of PD peritonitis is made, and a decision made they are for outpatient management, CDT and the patient’s named PD consultant are responsible for the ongoing monitoring and decisions about antibiotic dosing and duration.
- Patients should be told to attend the community dialysis unit for relevant samples to be taken and for antibiotic doses Monday to Friday, and attend ward 206R if it is the weekend.
- If patients need to attend at the weekend, CDT will inform ward 206R, add the details to the ward diary and inform the weekend renal registrar (who will review any antibiotic trough result and prescribe a further vancomcyin dose if indicated and advise on timing of next trough check).
Monitoring and Administration of Antibiotics
- Patients need to be given vancomycin as per levels and ceftazidime daily intra-peritoneally (IP) which means they must attend hospital for samples to be taken and antibiotic doses given.
- It is not the role of CDT to go to patients’ homes to take samples and administer antibiotics if the patients are able to travel to the hospital.
- Vancomycin requires monitoring, and dosing according to levels, which will determine how often the patient needs to attend for samples and doses.
- Ceftazidime must be administered daily.
- Both vancomycin and ceftazidime need to be continued until the organism is known, then antibiotics should be rationalised according to protocol, and one or other stopped if possible. If culture negative then both ceftazidime and vancomycin need to continue for 2 weeks.
- Ceftazidime and Vancomycin can be given in the same bag and are compatible with standard dextrose bags and icodextrin. See Edren for information on alternative antibiotics.
- Ceftazidime is stable in dextrose bags for 4 days and Icodextrin (extraneal) for 2 days at room temperature (see Edren for stability of alternative antibiotics).
- Patients can be taught to self administer ceftazidime to PD bags at the discretion of the CDT. (In this situation it is recommended that the patient is provided with the 1g and 500mg vials of ceftazidime to make 1.5g rather than the 2g vial which would require them to discard 500mg before injecting the bag).
- Patients should be told to contact CDT Mon-Fri 8-530pm or Ward 206R out of hours if they are becoming more unwell at any point, despite antibiotic therapy. In this situation they should be advised to attend hospital for clinical review and possible admission, ideally direct to the renal unit.
- The timing of visits is determined by how often vancomycin levels/doses are needed, whether the patient is clinically improving and what antibiotics they continue when culture results available.
Recording of Peritonitis Episode and Antibiotic Dosing
- Each new peritonitis episode should be recorded on vital data under the peritonitis tab. To add a new episode click the blue + symbol at the bottom left of the page.
- This screen is used for audit purposes and updated by the community dialysis team but anyone with access to vital data is encouraged to enter details in this screen if a patient presents with peritonitis.
- Antibiotics should be prescribed on vital data. For vancomycin this should be prescribed as the dose calculated based on the patient’s weight (30mg/kg max 3g) and frequency as “other” with a note added to dose when level <20. Ceftazidime should be prescribed as 1.5g daily.
- The date vancomycin doses are given should be recorded under the peritonitis tab on vital data.
- The community dialysis team will keep a paper kardex to record antibiotic doses given. This will be left in the diary in the community dialysis office if the patient is attending at the weekend.
Typical Schedule of Visits to CDT (ward if weekend) for Samples and Antibiotics
Day 0
Assessment:
- Initial presentation and peritonitis confirmed
Antibiotics:
- First vancomycin IP 30mg/kg (max 3g) and ceftazidime 1.5g doses
- Patient given a 2l bag pre-injected with ceftazidime 1.5g for day 1
Day 1
Assessment:
- No visit required
Antibiotics:
- Patient self-administers bag pre-injected with ceftazidime
Day 2
Assessment:
- Patient told to attend CDT (or ward 206R if the weekend)
- Repeat PD WCC and culture sent
- Serum vancomycin level sent and patient waits until result back
Antibiotics:
- If vancomycin level <20 further vancomycin dose to be given with ceftazidime in a 2 litre bag to dwell for at least 6 hours.
- Patient should be given a further 2 litre bag pre-injected with 1.5g ceftazidime to self administer at home on day 3
- If clinically improving, patient can go home and told when to return
Day 3
Assessment:
- Patient not normally required to attend but if vancomycin level day 2 was >20 a further vancomycin trough check is needed to assess if further dose indicated.
- If day 2 PD WCC is not falling or patient still symptomatic, consider sending repeat sample for PD WCC and culture
- CDT to review PD culture results and rationalise antibiotics as needed
Antibiotics:
- Patient self-administers ceftazidime if at home (if it is to continue)
- (Further vancomycin dose if level was checked and is <20)
Day 4
Assessment:
- Patient attends CDT who will review the need for further vancomycin trough check depending upon last check date and result; this depends whether they are continuing vancomycin and how quickly the level fell <20.
- Send sample for further PD WCC and culture
Antibiotics:
- Ongoing antibiotics depends upon organism cultured.
- If Ceftazidime only to continue, patient to attend every 2 days to be given a dose and provided with a pre-injected bag for the next day
- If Vancomycin only to continue, patient to attend for levels and dose as decided by CDT, based upon how quickly the previous trough level has fallen <20 as outlined in Protocol for management of PD Peritonitis
Day 5
Assessment:
- If PD WCC has not fallen on samples sent day 2 and 4, further sample should be sent and if still not falling, consider PD catheter removal
Antibiotics:
- As for Day 4
Ongoing management
Beyond day 5, if the PD WCC has fallen and the patient has clinically improved, they should complete the course of antibiotics as per protocol.