Antibiotic availability for outpatient treatment of acute peritonitis in chronic peritoneal dialysis patients: A case series

Best practice guidelines recommend intraperitoneal as the preferred route of antibiotics for the treatment of ABP. Unless features of sepsis or intractable pain are present, ABP should be treated on an outpatient basis. Once a sample of dialysis effluent has been collected in the peritoneal dialysis clinic (PDC) or the emergency room (ER) and sent for analysis, intraperitoneal antibiotics should be administered without delay, with daily antibiotic therapy to continue for 14–21 days, depending upon the organism cultured.

Unfortunately, there are barriers to expeditious diagnosis and treatment of ABP. Diagnosis may be delayed and/or inaccurate if patients do not realize that they have acquired ABP or if they live far from their PDC or an ER. We are particularly interested in barriers to prompt and continuous outpatient treatment of ABP, once PD fluid analysis and clinical evaluation have suggested the diagnosis of ABP. In our local health care system, we have observed a number of episodes of suboptimal outpatient intraperitoneal antibiotic treatment, after patients have presented with cloudy PD fluid and abdominal pain to a PDC or ER. However, it is unclear how common these episodes are and what clinical factors predispose to them. Clinical relevance is high, in that delayed, discontinuous, or inappropriate intraperitoneal antibiotic therapy predisposes to prolonged pain, increased risk of bacteremia, sepsis, death, prolonged peritoneal inflammation, scarring of the peritoneal membrane, PD modality failure, and excessive medical costs.

To determine the frequency of chronic PD patients not receiving appropriate outpatient intraperitoneal antibiotics for ABP promptly and consistently, as well as to assess the risk factors for these inconsistencies, we reviewed all cases of ABP from a single PDC over a 17-month period. We tested the null hypothesis that all chronic PD patients with ABP received appropriate outpatient intraperitoneal antibiotics promptly upon presentation to the PDC or ER with subsequent continuous (ie daily) therapy on an outpatient basis, without gaps in therapy for the entire prescribed length of therapy. To our knowledge, this type of analysis has not been performed previously.