Peritonitis refers to the inflammation of the peritoneum, the thin layer of tissue lining the inside of the abdominal wall and covering the abdominal organs. It can be infectious or non-infectious in origin and represents a medical emergency that requires prompt recognition and treatment. Among patients on peritoneal dialysis (PD), peritonitis is a frequent and serious complication that may lead to treatment failure and increased morbidity.

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Peritonitis

 📌 Introduction 




 🔍 Types of Peritonitis

1. Primary Peritonitis (Spontaneous Bacterial Peritonitis - SBP)

  • Occurs without any apparent source of infection within the abdomen.

  • Common in patients with cirrhosis and ascites.

  • Frequently caused by E. coli, Klebsiella, or Streptococcus species.

2. Secondary Peritonitis

  • Caused by perforation of abdominal organs due to conditions like:

    • Appendicitis

    • Peptic ulcer rupture

    • Diverticulitis

    • Bowel ischemia

  • It involves a polymicrobial infection, including anaerobes.

3. PD-Associated Peritonitis

  • Occurs in patients undergoing continuous ambulatory peritoneal dialysis (CAPD) or automated peritoneal dialysis (APD).

  • Typically results from contamination during dialysis exchanges or catheter-related infections.

🧫 Causes and Risk Factors

  • Touch contamination during dialysate exchange

  • Catheter site infections

  • Contaminated dialysate or improper storage

  • Poor hygiene or lack of training

  • Bowel perforation (secondary peritonitis)

  • Hematogenous spread of infection from other body sites

🧬 Common Pathogens

  • Staphylococcus epidermidis (most common in PD)

  • Staphylococcus aureus

  • Pseudomonas aeruginosa

  • Escherichia coli

  • Candida species (fungal peritonitis, rare but severe)

🩺 Clinical Manifestations

Patients may present with a range of symptoms including:

  • Cloudy peritoneal effluent (hallmark sign in PD)

  • Abdominal pain or tenderness

  • Fever, chills

  • Nausea, vomiting

  • Fatigue, malaise

  • Signs of systemic infection (in severe cases)

  • Redness or pus around the catheter exit site (in PD patients)

🧪 Diagnosis

Accurate and prompt diagnosis is crucial. It involves:

  • Peritoneal fluid analysis:

    • WBC count > 100 cells/µL with >50% neutrophils

    • Gram stain and culture

  • Blood tests: Elevated WBC count, C-reactive protein (CRP), procalcitonin

  • Imaging (CT or ultrasound): Helps identify bowel perforation or abscesses in secondary peritonitis

💊 Management

Initial Treatment (Empirical):

  • Intraperitoneal antibiotics for PD-associated peritonitis:

    • Vancomycin (or cefazolin) + ceftazidime or cefepime

  • For secondary peritonitis: broad-spectrum IV antibiotics

    • Coverage for gram-positive, gram-negative, and anaerobes

Tailored Therapy:

  • Adjust antibiotics based on culture and sensitivity results.

  • Duration: Usually 10–14 days for bacterial peritonitis, longer for fungal.

Additional Measures:

  • Catheter removal may be required if:

    • The infection is fungal

    • No response to antibiotics

    • Recurrent episodes

  • In secondary peritonitis, surgical intervention may be needed.

🛡️ Prevention (for PD Patients)

  • Strict aseptic technique

  • Routine use of exit-site prophylaxis (e.g., mupirocin ointment)

  • Proper hand hygiene

  • Use of "flush-before-fill" systems

  • Regular training and retraining of patients and caregivers

  • Prompt treatment of any catheter site infection

⚠️ Complications

If left untreated or if treatment fails, peritonitis can lead to:

  • Sepsis

  • Intestinal ileus

  • Peritoneal membrane damage

  • Ultrafiltration failure

  • Encapsulating Peritoneal Sclerosis (EPS) – a rare but severe complication

  • Death in severe or neglected cases

🧾 Conclusion

Peritonitis is a critical condition requiring early recognition and prompt intervention. In peritoneal dialysis patients, it not only impacts health outcomes but can also compromise the effectiveness of dialysis therapy. Prevention strategies, including patient education and proper catheter care, are essential to reduce the incidence and severity of peritonitis. With timely treatment, most cases can be successfully managed without long-term complications.

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