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World J Nephrol. Aug 6, 2012; 1(4): 106-122
Published online Aug 6, 2012. doi: 10.5527/wjn.v1.i4.106
Peritoneal dialysis associated infections: An update on diagnosis and management
Jacob A Akoh
Jacob A Akoh, South West Transplant Centre, Plymouth Hospitals NHS Trust, Derriford Hospital, Plymouth PL6 8DH, United Kingdom
Author contributions: Akoh JA solely contributed to this paper.
Correspondence to: Jacob A Akoh, FRCSEd, FRCS (Gen), Consultant General and Transplant Surgeon, Level 04, South West Transplant Centre, Plymouth Hospitals NHS Trust, Derriford Hospital, Plymouth PL6 8DH, United Kingdom.
Telephone: +44-1752-439798 Fax: +44-1752-774651
Received: December 26, 2011
Revised: June 9, 2012
Accepted: June 20, 2012
Published online: August 6, 2012

Peritoneal dialysis (PD) is associated with a high risk of infection of the peritoneum, subcutaneous tunnel and catheter exit site. Although quality standards demand an infection rate < 0.67 episodes/patient/year on dialysis, the reported overall rate of PD associated infection is 0.24-1.66 episodes/patient/year. It is estimated that for every 0.5-per-year increase in peritonitis rate, the risk of death increases by 4% and 18% of the episodes resulted in removal of the PD catheter and 3.5% resulted in death. Improved diagnosis, increased awareness of causative agents in addition to other measures will facilitate prompt management of PD associated infection and salvage of PD modality. The aims of this review are to determine the magnitude of the infection problem, identify possible risk factors and provide an update on the diagnosis and management of PD associated infection. Gram-positive cocci such as Staphylococcus epidermidis, other coagulase negative staphylococcoci, and Staphylococcus aureus (S. aureus) are the most frequent aetiological agents of PD-associated peritonitis worldwide. Empiric antibiotic therapy must cover both gram-positive and gram-negative organisms. However, use of systemic vancomycin and ciprofloxacin administration for example, is a simple and efficient first-line protocol antibiotic therapy for PD peritonitis - success rate of 77%. However, for fungal PD peritonitis, it is now standard practice to remove PD catheters in addition to antifungal treatment for a minimum of 3 wk and subsequent transfer to hemodialysis. To prevent PD associated infections, prophylactic antibiotic administration before catheter placement, adequate patient training, exit-site care, and treatment for S. aureus nasal carriage should be employed. Mupirocin treatment can reduce the risk of exit site infection by 46% but it cannot decrease the risk of peritonitis due to all organisms.

Keywords: Exit site infection, Peritonitis, Tunnel infection, Polymicrobial infection, Catheter removal, Dialysis modality change, Fungal peritonitis, Sclerosing encapsulating peritonitis, Peritoneal dialysis