›Cefazolin
›Loading dose 500 mg/L
›Maintenance dose 125 mg/L in each exchange bag
›Ceftazidime or cefepime
›Loading dose 500 mg/L
›Maintenance dose 125 mg/L in each exchange bag
›Vancomycin
›Loading dose 30 mg/kg IP
›Maintenance dose 1.5 mg/L in each exchange bag
›Intermittent dosing, drug in one exchange per day
›Required dwell time
›At least 6 hours dwell for adequate absorption
›Automated PD cycler patients often need to switch to a manual daytime exchange to achieve this dwell
›Cefazolin
›15 to 20 mg/kg IP once daily
›Round to a practical dose, exact mg/kg precision not required in adults
›Maximum single dose per institutional protocol
›Ceftazidime
›1000 to 1500 mg IP once daily
›Cefepime
›1000 mg IP once daily
›Gentamicin
›0.6 mg/kg IP once daily
›Intermittent dosing preferred over continuous dosing for aminoglycosides
›Cumulative course limited to reduce ototoxicity and vestibulotoxicity risk
›Vancomycin
›Loading dose 30 mg/kg IP in a long dwell
›Redose 15 mg/kg IP when the level falls below 15 mcg/mL, typically every 5 to 7 days
›Deceleration and safety brakes
›Vancomycin
›Do not redose on a fixed schedule, level-guided redosing only
›Trough target 15 to 20 mcg/mL before the next dose
›Gentamicin
›Limit total course length, prolonged or repeated aminoglycoside courses raise residual renal function loss risk
›Audiometry if the course extends beyond several days or is repeated within months
›Residual renal function preservation
›Avoid unnecessary nephrotoxin duplication
›Reassess dosing interval as residual urine output changes
Exit-site and tunnel infection management
›Exit-site infection without peritonitis
›Empiric oral or topical therapy pending culture
›Gram-positive coverage first line
›Add Pseudomonas coverage if prior Pseudomonas exit-site infection or high local risk
›Duration typically 2 to 3 weeks, longer if the response is slow
›Concurrent exit-site or tunnel infection with peritonitis
›Same organism at both sites
›Antibiotics alone frequently fail
›Early catheter removal planning, especially for Pseudomonas or Staphylococcus aureus
›Refractory tunnel infection despite appropriate antibiotics
›Catheter removal indicated
Refractory and relapsing peritonitis, catheter removal criteria
›Definitions
›Refractory peritonitis
›Failure of effluent to clear by day 5 of appropriate antibiotic therapy
›Relapsing peritonitis
›Recurrence with the same organism within 4 weeks of completing therapy for a prior episode
›Recurrent peritonitis
›Recurrence with a different organism within 4 weeks of completing therapy
›Repeat peritonitis
›Recurrence with the same organism after 4 weeks
›Catheter removal indications
›Refractory peritonitis, no improvement by day 5
›Relapsing peritonitis
›Refractory or relapsing exit-site and tunnel infection
›Fecal peritonitis or other surgical secondary peritonitis
›Fungal peritonitis, remove immediately
›Mycobacterial peritonitis
›After catheter removal
›Continue systemic antibiotics for the planned course
›Transition to hemodialysis
›New PD catheter reinsertion generally delayed at least 2 to 3 weeks after infection clears, longer after fungal peritonitis
›Recognition
›Candida species most common
›Often follows a prolonged or repeated bacterial antibiotic course
›Management
›Catheter removal immediately upon suspicion or diagnosis
›Do not wait for antifungal susceptibility results
›Delayed removal is associated with markedly higher mortality
›Antifungal therapy
›Fluconazole 200 mg IV or PO daily, renal dose adjustment per residual clearance
›First line for azole-susceptible Candida species
›Caspofungin 70 mg IV loading dose then 50 mg IV daily
›Alternative for azole-resistant or critically ill patients
›Continue for at least 2 weeks after catheter removal
›Prevention
›Antifungal prophylaxis during antibiotic courses for bacterial peritonitis
›Nystatin oral suspension 500,000 units PO 4 times daily during antibiotic treatment
›Fluconazole 200 mg PO every other day as an alternative prophylaxis option
Iatrogenic harms and supportive care
›Fluid loading
›Standard sepsis crystalloid bolus dosing is dangerous if anuric or minimally producing urine
›A standard 30 mL/kg isotonic crystalloid bolus risks pulmonary edema in an anuric patient
›Individualize to smaller aliquots, for example 250 mL boluses with reassessment
›Peritoneal ultrafiltration is unreliable during acute peritonitis
›The inflamed membrane increases solute permeability but often reduces net ultrafiltration
›Do not rely on PD exchanges for volume removal during the acute episode
›Intubation and sedation
›Succinylcholine 1 to 1.5 mg/kg IV
›Avoid if hyperkalemia is suspected or dialysis has been missed
›Rocuronium 1 to 1.2 mg/kg IV preferred for RSI in this population
›Midazolam infusion
›Avoid prolonged infusion, the active metabolite accumulates in renal failure and prolongs sedation
›Propofol infusion or dexmedetomidine 0.2 to 0.7 mcg/kg/hour preferred with dose adjustment
›Oxygen and vasopressors
›Oxygen titrated to target, avoid unnecessary hyperoxia
›Norepinephrine 0.05 to 0.3 mcg/kg/minute IV infusion, first line for septic shock
›Titrate to mean arterial pressure at least 65 mmHg
›Central access preferred, a distinct line from the peritoneal catheter
›Avoid subclavian central lines, preserve future vascular access for possible hemodialysis
›Anticoagulation and analgesia
›Anticoagulation
›Unfractionated heparin preferred over low molecular weight heparin at low residual clearance
›Prophylactic unfractionated heparin 5000 units SC every 8 to 12 hours
›Enoxaparin requires dose reduction or avoidance at very low clearance
›Analgesia
›Avoid NSAIDs such as ibuprofen 400 to 600 mg PO every 6 to 8 hours, residual renal function preservation and bleeding risk
›Avoid morphine 2 to 4 mg IV every 3 to 4 hours, active metabolite accumulation causes prolonged sedation and respiratory depression
›Fentanyl 25 to 50 mcg IV every 1 to 2 hours as needed preferred, minimal renally cleared active metabolite
›Hydromorphone 0.2 to 0.4 mg IV every 2 to 3 hours as needed alternative, dose reduced for renal impairment
›Mechanical circulatory support and fibrinolysis
›Vascular access planning before any invasive line
›Avoid subclavian access, preserve forearm veins for future arteriovenous access
›Intraperitoneal fibrinolytic for catheter fibrin occlusion
›Adjunct for catheter dysfunction, not for treating the infection itself
›Bleeding risk consideration before use
›Glucose management
›Hyperglycemia from dialysate dextrose absorption
›Increased peritoneal permeability during peritonitis increases glucose absorption
›Monitor closely in diabetics
›Hypoglycemia risk
›Poor oral intake with continued home insulin dosing
›Check glucose in any lethargic or poorly feeding patient
›Monitoring and troubleshooting
›Effluent clarity checked with each exchange
›Document the trend daily
›Therapy not working
›Persistent turbidity or pain beyond 48 to 72 hours
›Repeat cell count and culture
›Reassess for a resistant organism, catheter biofilm, or secondary peritonitis
›Electrolyte and ECG surveillance
›Missed exchanges from illness can reduce dialysis clearance and raise potassium
›ECG changes of hyperkalemia, peaked T waves and widened QRS, warrant urgent potassium management
›Isolation and antimicrobial stewardship
›Contact precautions for known MRSA or resistant organism colonization
›De-escalate antibiotics once culture and sensitivity are available
›Guideline-based recommendations, cited without an invented numeric grade where the exact grade is uncertain
›ISPD 2022 guideline supports the two-of-three diagnostic criteria as the standard definition
›ISPD 2022 guideline supports intraperitoneal antibiotic administration over intravenous for peritonitis therapy
›ISPD 2022 guideline supports immediate catheter removal for fungal peritonitis
›ACEP evidence level mapping not directly available for ISPD-specific recommendations
›Do not apply ACEP Level A/B/C labels to ISPD statements