Pathophysiology and prevention of peritonitis in peritoneal dialysis
- John M Burkart, MD
John M Burkart, MD
- Section Editor — Dialysis
- Professor of Medicine/Nephrology
- Wake Forest University Medical Center
Peritonitis is one of the major complications of peritoneal dialysis and remains the primary reason why patients switch from peritoneal dialysis to hemodialysis . A review of the factors responsible for peritonitis in this setting and the modalities that can be used to reduce the frequency of this complication are presented in this topic review.
PATHOPHYSIOLOGY AND CAUSES
Peritonitis associated with peritoneal dialysis is most often due to contamination with pathogenic skin bacteria, with Staphylococcus epidermidis and Staphylococcus aureus accounting for the majority of cases. (See "Microbiology and therapy of peritonitis in continuous peritoneal dialysis".)
The intact peritoneum and the defense mechanisms of the mesothelium are probably the most important barriers to the development of peritonitis in peritoneal dialysis patients and play an important role in limiting the infection to the peritoneum, where peritonitis does develop. The incidence of systemic bacteremia in association with peritoneal dialysis peritonitis is extremely low (<1 percent), in contrast to the reported 30 percent with surgical peritonitis  and 39 to 76 percent of spontaneous peritonitis in cirrhotic patients with ascites [3,4].
A number of factors contribute to the development of peritonitis in patients on peritoneal dialysis, even when the patient is maximally skilled with the dialysis technique:
●The patient on continuous ambulatory peritoneal dialysis (CAPD) usually connects and disconnects from the transfer set many times a day and, therefore, must perform a large number of sterile exchanges per year; it would be naive to assume that bacterial contamination does not occur at times. In comparison, a patient on continuous cycling peritoneal dialysis (CCPD) or ambulatory peritoneal dialysis (APD) needs to connect or disconnect from the transfer set far fewer times, and, therefore, the peritonitis rate is generally lower than that in patients on CAPD. (See 'Different peritoneal dialysis systems' below.)
- Voinescu CG, Khanna R. Peritonitis in peritoneal dialysis. Int J Artif Organs 2002; 25:249.
- Lorber B, Swenson RM. The bacteriology of intra-abdominal infections. Surg Clin North Am 1975; 55:1349.
- Correia JP, Conn HO. Spontaneous bacterial peritonitis in cirrhosis: endemic or epidemic? Med Clin North Am 1975; 59:963.
- Weinstein MP, Iannini PB, Stratton CW, Eickhoff TC. Spontaneous bacterial peritonitis. A review of 28 cases with emphasis on improved survival and factors influencing prognosis. Am J Med 1978; 64:592.
- Williams JD. Biocompatibility in peritoneal dialysis: definitions and mechanisms. Perit Dial Int 1995; 15:S5.
- Brulez HF, Verbrugh HA. First-line defense mechanisms in the peritoneal cavity during peritoneal dialysis. Perit Dial Int 1995; 15:S24.
- Szeto CC, Chow KM, Wong TY, et al. Influence of climate on the incidence of peritoneal dialysis-related peritonitis. Perit Dial Int 2003; 23:580.
- Gupta B, Bernardini J, Piraino B. Peritonitis associated with exit site and tunnel infections. Am J Kidney Dis 1996; 28:415.
- van Diepen AT, Tomlinson GA, Jassal SV. The association between exit site infection and subsequent peritonitis among peritoneal dialysis patients. Clin J Am Soc Nephrol 2012; 7:1266.
- Szeto CC, Chow KM, Kwan BC, et al. Staphylococcus aureus peritonitis complicates peritoneal dialysis: review of 245 consecutive cases. Clin J Am Soc Nephrol 2007; 2:245.
- Blake PG. Getting excited about exit sites in peritoneal dialysis? Clin J Am Soc Nephrol 2012; 7:1206.
- Anwar H, Dasgupta MK, Costerton JW. Testing the susceptibility of bacteria in biofilms to antibacterial agents. Antimicrob Agents Chemother 1990; 34:2043.
- Dasgupta MK, Ulan RA, Bettcher KB, et al. Effects of exit site infection and peritonitis on the distribution of biofilm-encased adherent bactereial microcolonies (BABM) on Tenchkhoff (T) catheters in patients undergoing continuous ambulatory. In: Advances in Continuous Ambulatory Peritoneal Dialysis, Khanna R, Nolph KD, Prowand BF, et al (Eds), Univesrity of Toronto Press, Toronto 1986. p.102.
- Dasgupta MK, Bettcher KB, Ulan RA, et al. Relationship of adherent bacterial biofilms to peritonitis in chronic ambulatory peritoneal dialysis. Perit Dial Bull 1987; 7:168.
- Verger C, Chesneau AM, Thibault M, et al. Biofilm on the Tenckhoff catheter: A negligible source of contamination. Perit Dial Bull 1987; 7:178.
- Swartz R, Messana J, Holmes C, Williams J. Biofilm formation on peritoneal catheters does not require the presence of infection. ASAIO Trans 1991; 37:626.
- Dasgupta MK, Kowalewaska-Grochowska K, Costerton JW. Biofilm and peritonitis in peritoneal dialysis. Perit Dial Int 1993; 13 Suppl 2:S322.
- Finkelstein ES, Jekel J, Troidle L, et al. Patterns of infection in patients maintained on long-term peritoneal dialysis therapy with multiple episodes of peritonitis. Am J Kidney Dis 2002; 39:1278.
- Reid G, Khoury AE, Preston CA, Costerton JW. Influence of dextrose dialysis solutions on adhesion of Staphylococcus aureus and Pseudomonas aeruginosa to three catheter surfaces. Am J Nephrol 1994; 14:37.
- Boudville N, Kemp A, Clayton P, et al. Recent peritonitis associates with mortality among patients treated with peritoneal dialysis. J Am Soc Nephrol 2012; 23:1398.
- Piraino B, Bailie GR, Bernardini J, et al. Peritoneal dialysis-related infections recommendations: 2005 update. Perit Dial Int 2005; 25:107.
- Mactier R. Peritonitis is still the achilles' heel of peritoneal dialysis. Perit Dial Int 2009; 29:262.
- Hall G, Bogan A, Dreis S, et al. New directions in peritoneal dialysis patient training. Nephrol Nurs J 2004; 31:149.
- Chow KM, Szeto CC, Law MC, et al. Influence of peritoneal dialysis training nurses' experience on peritonitis rates. Clin J Am Soc Nephrol 2007; 2:647.
- Buoncristiani U, Cozzari M, Quintaliani G, et al. Abatement of exogenous peritonitis risk using the Perugia CAPD system. Dial Transplant 1983; 12:14.
- Burkart JM, Hylander B, Durnell-Figel T, Roberts D. Comparison of peritonitis rates during long-term use of standard spike versus Ultraset in continuous ambulatory peritoneal dialysis (CAPD). Perit Dial Int 1990; 10:41.
- Maiorca R, Cantaluppi A, Cancarini GC, et al. Prospective controlled trial of a Y-connector and disinfectant to prevent peritonitis in continuous ambulatory peritoneal dialysis. Lancet 1983; 2:642.
- Scalamogna A, De Vecchi A, Castelnovo C, et al. Long-term incidence of peritonitis in CAPD patients treated by the Y set technique: experience in a single center. Nephron 1990; 55:24.
- Port FK, Held PJ, Nolph KD, et al. Risk of peritonitis and technique failure by CAPD connection technique: a national study. Kidney Int 1992; 42:967.
- Peritonitis in continuous ambulatory peritoneal dialysis (CAPD): a multi-centre randomized clinical trial comparing the Y connector disinfectant system to standard systems. Canadian CAPD Clinical Trials Group. Perit Dial Int 1989; 9:159.
- Daly CD, Campbell MK, MacLeod AM, et al. Do the Y-set and double-bag systems reduce the incidence of CAPD peritonitis? A systematic review of randomized controlled trials. Nephrol Dial Transplant 2001; 16:341.
- Strippoli GF, Tong A, Johnson D, et al. Catheter-related interventions to prevent peritonitis in peritoneal dialysis: a systematic review of randomized, controlled trials. J Am Soc Nephrol 2004; 15:2735.
- Li PK, Szeto CC, Law MC, et al. Comparison of double-bag and Y-set disconnect systems in continuous ambulatory peritoneal dialysis: a randomized prospective multicenter study. Am J Kidney Dis 1999; 33:535.
- Harris DC, Yuill EJ, Byth K, et al. Twin- versus single-bag disconnect systems: infection rates and cost of continuous ambulatory peritoneal dialysis. J Am Soc Nephrol 1996; 7:2392.
- Kiernan L, Kliger A, Gorban-Brennan N, et al. Comparison of continuous ambulatory peritoneal dialysis-related infections with different "Y-tubing" exchange systems. J Am Soc Nephrol 1995; 5:1835.
- Balteau PR, Peluso FP, Coles GA, et al. Design and testing of the Baxter Integrated Disconnect Systems (IDS). Perit Dial Int 1991; 11:131.
- Monteón F, Correa-Rotter R, Paniagua R, et al. Prevention of peritonitis with disconnect systems in CAPD: a randomized controlled trial. The Mexican Nephrology Collaborative Study Group. Kidney Int 1998; 54:2123.
- Kavanagh D, Prescott GJ, Mactier RA. Peritoneal dialysis-associated peritonitis in Scotland (1999-2002). Nephrol Dial Transplant 2004; 19:2584.
- Honkanen E, Kala AR, Gronhagen-Riska C. Divergent etiologies of CAPD peritonitis in integrated double bag and traditional systems?. In: Advances in Continuous Ambulatory Peritoneal Dialysis, 7th ed., Khanna R, Nolph KD, Prowant BF, et al (Eds), University of Toronto Press, Toronto 1991. p.129.
- Wong HS, Ong LM, Lim TO, et al. A randomized, multicenter, open-label trial to determine peritonitis rate, product defect, and technique survival between ANDY-Disc and UltraBag in patients on CAPD. Am J Kidney Dis 2006; 48:464.
- Dombros N, Dratwa M, Feriani M, et al. European best practice guidelines for peritoneal dialysis. 2 The initiation of dialysis. Nephrol Dial Transplant 2005; 20 Suppl 9:ix3.
- Burkart JM, Jordan JR, Durnell TA, Case LD. Comparison of exit-site infections in disconnect versus nondisconnect systems for peritoneal dialysis. Perit Dial Int 1992; 12:317.
- Holley JL, Bernardini J, Piraino B. Continuous cycling peritoneal dialysis is associated with lower rates of catheter infections than continuous ambulatory peritoneal dialysis. Am J Kidney Dis 1990; 16:133.
- Korbet SM, Vonesh EF, Firanek CA. Peritonitis in an urban peritoneal dialysis program: an analysis of infecting pathogens. Am J Kidney Dis 1995; 26:47.
- Rodríguez-Carmona A, Pérez Fontán M, García Falcón T, et al. A comparative analysis on the incidence of peritonitis and exit-site infection in CAPD and automated peritoneal dialysis. Perit Dial Int 1999; 19:253.
- Locatelli AJ, Marcos GM, Gómez MG, et al. Comparing peritonitis in continuous ambulatory peritoneal dialysis patients versus automated peritoneal dialysis patients. Adv Perit Dial 1999; 15:193.
- Huang JW, Hung KY, Yen CJ, et al. Comparison of infectious complications in peritoneal dialysis patients using either a twin-bag system or automated peritoneal dialysis. Nephrol Dial Transplant 2001; 16:604.
- Oo TN, Roberts TL, Collins AJ. A comparison of peritonitis rates from the United States Renal Data System database: CAPD versus continuous cycling peritoneal dialysis patients. Am J Kidney Dis 2005; 45:372.
- Bender FH, Bernardini J, Piraino B. Prevention of infectious complications in peritoneal dialysis: best demonstrated practices. Kidney Int Suppl 2006; :S44.
- Bieber SD, Burkart J, Golper TA, et al. Comparative outcomes between continuous ambulatory and automated peritoneal dialysis: a narrative review. Am J Kidney Dis 2014; 63:1027.
- Johnson DW, Brown FG, Clarke M, et al. Effects of biocompatible versus standard fluid on peritoneal dialysis outcomes. J Am Soc Nephrol 2012; 23:1097.
- Montenegro J, Saracho R, Gallardo I, et al. Use of pure bicarbonate-buffered peritoneal dialysis fluid reduces the incidence of CAPD peritonitis. Nephrol Dial Transplant 2007; 22:1703.
- Furkert J, Zeier M, Schwenger V. Effects of peritoneal dialysis solutions low in GDPs on peritonitis and exit-site infection rates. Perit Dial Int 2008; 28:637.
- Lee HY, Choi HY, Park HC, et al. Changing prescribing practice in CAPD patients in Korea: increased utilization of low GDP solutions improves patient outcome. Nephrol Dial Transplant 2006; 21:2893.
- Srivastava S, Hildebrand S, Fan SL. Long-term follow-up of patients randomized to biocompatible or conventional peritoneal dialysis solutions show no difference in peritonitis or technique survival. Kidney Int 2011; 80:986.
- Szeto CC, Chow KM, Lam CW, et al. Clinical biocompatibility of a neutral peritoneal dialysis solution with minimal glucose-degradation products--a 1-year randomized control trial. Nephrol Dial Transplant 2007; 22:552.
- WHITE A, SMITH J. NASAL RESERVOIR AS THE SOURCE OF EXTRANASAL STAPHYLOCOCCI. Antimicrob Agents Chemother (Bethesda) 1963; 161:679.
- Luzar MA, Coles GA, Faller B, et al. Staphylococcus aureus nasal carriage and infection in patients on continuous ambulatory peritoneal dialysis. N Engl J Med 1990; 322:505.
- Nouwen J, Schouten J, Schneebergen P, et al. Staphylococcus aureus carriage patterns and the risk of infections associated with continuous peritoneal dialysis. J Clin Microbiol 2006; 44:2233.
- Tzamaloukas AH, Obermiller LE, Gibel LJ, et al. Peritonitis associated with intra-abdominal pathology in continuous ambulatory peritoneal dialysis patients. Perit Dial Int 1993; 13 Suppl 2:S335.
- Piraino B. Prevention of peritonitis. Perit Dial Int 1998; 18:244.
- Singharetnam W, Holley JL. Acute treatment of constipation may lead to transmural migration of bacteria resulting in gram-negative, polymicrobial, or fungal peritonitis. Perit Dial Int 1996; 16:423.
- Bakir N, Surachno S, Sluiter WJ, Struijk DG. Peritonitis in peritoneal dialysis patients after renal transplantation. Nephrol Dial Transplant 1998; 13:3178.
- PATHOPHYSIOLOGY AND CAUSES
- Sources of contamination
- Exit-site infection
- Proper training
- Prophylactic antibiotic administration for procedures
- Y and double-bag systems
- Different peritoneal dialysis systems
- Different peritoneal dialysis solutions
- Staphylococcus aureus nasal carriage
- Treatment of catheter infections
- Secondary bacterial peritonitis
- Fungal peritonitis
- Catheter removal after renal transplantation
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS