Guideline for the diagnosis and treatment of PD peritonitis and exit site infections in adults

Transcription

1 Full title of guideline Author Division & Speciality Scope (Target audience, state if Trust wide) Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis) Guideline for the diagnosis and treatment of PD peritonitis and exit site infections in adults Dr G McHaffie (Renal consultant) DIRC, renal Nursing staff and doctors on the renal wards and dialysis unit. Renal unit network. All adult peritoneal dialysis patients with clinically suspected peritonitis or exit site infection. All peritoneal dialysis patients with clinically suspected peritonitis or exit site infection. Review date September 2020 Changes from previous version Summary of evidence base this guideline has been created from Pre-op antibiotic changed from flucloxacillin to teicoplanin Contamination treatment updated to include gentamicin to cover for gram negative pathogens Culture negative peritonitis updated- if remains culture negative at 72 hours discontinue gentamicin, if gram negative pathogen unlikely Biopatch changed to zonis patch due to observation of allergic reactions. Advise that antibiotics should continue for 1 week after a PD tube is removed for infection. July Abelcet changed to ambisome, clarified treatment would be ambisome or Anidulafungin for fungal infection Change from clarithromycin to doxycycline for exit site infection and penicillin allergic. Change teicoplanin peritontitis treatment regimen to intermittent IP dosing. Initial IV dose not required. These guidelines were developed in conjunction with medical and nursing staff within the renal unit, Dr Shing Soo (Consultant Microbiologist), Ian Hogg (Renal Pharmacist) and Sister W. Spooner (Peritoneal Dialysis Sister). See Appendix (page 18) for reference list This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. Nottingham Renal Peritonitis and Exit site infection guidelines Page 1 of 18

2 Introduction... 3 Prophylactic antibiotics prior to PD tube Insertion Prophylactic Antibiotics following Accidental Touch Contamination... 4 Prophylactic antibiotics prior to invasive procedures... 4 Exit Site Infections... 5 Definition... 5 Prophylaxis... 5 Treatment... 5 Figure 1:- Management of Exit Site Infections... 6 PD Peritonitis... 7 Diagnosis of PD Peritonitis... 7 Causes of cloudy dialysate... 7 Blood-stained PD Fluid... 7 Management of PD peritonitis... 8 Management of peritonitis patients treated by APD Figure 2:- Gram Positive Organism on Culture Figure 3:- Gram Negative Organism on Culture Figure 4:- Culture Negative peritonitis Figure 5:- Yeast (or other fungus) on culture Figure 6:- Overview of peritonitis protocol Appendix: Evidence base, audit, education Nottingham Renal Peritonitis and Exit site infection guidelines Page 2 of 18

3 INTRODUCTION Peritoneal Dialysis (PD) is the use of the peritoneal membrane for dialysis. Bags of dialysis fluid are put into the peritoneal cavity via a peritoneal dialysis catheter. The dialysis solution contains dextrose that pulls wastes and extra fluid into the abdominal cavity. The process of draining and filling is called an exchange and takes about 30 to 40 minutes. The period the dialysis solution is in the abdomen is called the dwell time. A typical schedule calls for four exchanges a day, each with a dwell time of 4 to 6 hours. Different types of PD have different schedules of daily exchanges. CAPD APD Continuous Ambulatory Peritoneal Dialysis standard regime - the patient has dialysis fluid in the peritoneal cavity at all times. The fluid is changed by manual connection up to four times each day Automated Peritoneal Dialysis a machine is used to perform dialysis exchanges whilst the patient sleeps at night. They may then use additional bags during the day. Nottingham Renal Peritonitis and Exit site infection guidelines Page 3 of 18

4 PROPHYLACTIC ANTIBIOTICS PRIOR TO PD TUBE INSERTION. IV Teicoplanin 800mg dose This has been chosen because it can be administered as a single push IV injection rather than an infusion. It can be given on the ward before the procedure or in theatre. PROPHYLACTIC ANTIBIOTICS FOLLOWING ACCIDENTAL TOUCH CONTAMINATION Following a break in sterile technique antibiotics will be given and the patient s catheter extension set changed. IP vancomycin 500mg AND IP 0.6mg/kg gentamicin PROPHYLACTIC ANTIBIOTICS PRIOR TO INVASIVE PROCEDURES Patients undergoing colonoscopy should receive the following antibiotics prior to the procedure. Co-amoxiclav 625 mg single dose PO Gentamicin 0.6mg/kg single dose IP Patients undergoing any invasive procedure involving the abdomen or pelvis e.g. colonoscopy, renal transplantation or endometrial biopsy should have their abdomen emptied of fluid. Nottingham Renal Peritonitis and Exit site infection guidelines Page 4 of 18

5 EXIT SITE INFECTIONS Definition An exit site infection is defined by the presence of purulent drainage with or without erythema of the skin at the catheter-epidermal interface. Positive culture from the exit site in the absence of inflammation does not indicate infection. Prophylaxis All pre-operative patients for PD tube insertion, exchange or repositioning should have MRSA screening. They should receive empirical decolonisation with an Octenisan body wash and nasal 2% mupirocin ointment (Bactoban) as part of their pre-operative care. A Biopatch dressing should be used around exit site for the first six weeks following PD tube insertion. This should be changed every week and should be covered with a clear dressing. Mupirocin 2% nasal ointment, used both nasally and topically at the exit site, has been shown to reduce the rate of peritonitis related to both exit site and tunnel infections. Our policy now is to apply topical mupirocin 2% nasal ointment to the exit site daily as part of routine exit site care (after week 6). Gentamicin 0.3% eyedrops (2-3 drops once per day) can be used to prevent the recurrence of a Pseudomonas exit site infection. Treatment See Figure 1 below Nottingham Renal Peritonitis and Exit site infection guidelines Page 5 of 18

6 Figure 1:- Management of Exit Site Infections Clinical Diagnosis Send Exit Site swab for culture Commence Empirical Therapy Flucloxacillin PO 500mg qds If penicillin allergic: Doxycycline oral 200mg oral first dose 100mg PO od thereafter If known MRSA patient: Doxycycline if MRSA is sensitive 200mg oral first dose 100mg PO od thereafter Vancomycin 30mg/kg IP single dose if MRSA resistant to doxycycline or no sensitivities Gram Positive Organism If necessary adjust therapy according to sensitivities Gram Negative Organism Ciprofloxacin 500mg bd PO or adjust according to sensitivities If no improvement add Rifampicin 300mg bd PO If Pseudomonas consider adding Gentamicin 0.3% drops bd topically or Ceftazidime 1g daily IP Continue treatment for 2 weeks and then re-evaluate Resolution Stop therapy Improvement Re-swab Further 2 weeks therapy No Improvement Consider catheter removal NB Ciprofloxacin should be taken 2 hours before phosphate binders (calcichew, calcium acetate, sevelamer, lanthanum) or iron medications If 3 rd recurrent exit site infection with same organism consider elective tube change Nottingham Renal Peritonitis and Exit site infection guidelines Page 6 of 18

7 PD PERITONITIS Peritonitis is a serious complication of peritoneal dialysis. It is potentially life threatening. Additionally repeated episodes of peritonitis are implicated in early failure of the peritoneal membrane and subsequent failure of peritoneal dialysis. A number of regimes have been utilised in the past. Unfortunately, no single regimen has been shown to be the most efficacious in clinical trials. The guidelines below are based around a review of peritonitis management along with local microbiological advice. These guidelines provide a framework around which an individual patient's management can be based, but must be interpreted in light of the clinical condition of each patient. Diagnosis of PD Peritonitis 2 of the following 3 features:- 1. Symptoms and signs of peritonitis Abdominal pain Nausea and vomiting, constipation or diarrhoea Fever 2. Cloudy PD fluid with PD White cell count >100/mm 3 (>50% polymorphonuclear neutrophils) (PD fluid is clear and colourless before draining in. On draining out, PD fluid should be clear but may be yellow in colour. Cloudy fluid looks like pineapple juice and it is difficult to read text through the bag. If in doubt ask an experienced doctor or nurse.) 3. Micro-organisms in the peritoneal fluid confirmed by culture Causes of cloudy dialysate Infective peritonitis - bacterial, fungal, TB, other Culture Negative peritonitis Secondary to other intra-abdominal pathology - diverticulitis, appendicitis, perforated bowel, abscess, transcolonic migration of catheter Eosinophilic peritonitis - Asymptomatic cloudy dialysate fluid with >15% eosinophils on differential cell count Blood-stained PD Fluid Common and harmless in females during menstruation. It can also happen if the small blood vessels in the peritoneum break e.g. lifting something heavy, playing sport. It usually clears quickly in a few exchanges but patients should be seen if the fluid is very bloody or not clearing or they are unwell in any way. Initial investigations should include exclusion of peritonitis, abdominal film and consideration of surgical review. Nottingham Renal Peritonitis and Exit site infection guidelines Page 7 of 18

8 Management of PD peritonitis Peritonitis is life-threatening condition. In the presence of cloudy fluid and/or abdominal pain and/or fever prompt initiation of antibiotic therapy is needed. 1. Measure and record pulse, BP (lying and standing), respiratory rate and temperature. 2. Drain bag and collect the following samples 3 x 20ml samples of PD fluid in universal containers for WCC, gram stain and culture SEND TO MICROBIOLOGY 10 mls of PD fluid injected (using sterile technique) (QMC campus) into a pair of blood culture bottles. 5 ml sample into a EDTA (purple topped) tube SEND TO for DIFFERENTIAL WCC HAEMATOLOGY (City Campus) Samples should be sent to the laboratory immediately. 3. Patient should have a full medical review. Examine abdomen to exclude surgical abdomen (see point 18). Examine exit site; swab if there appears to be exit site infection. Examine tunnel for evidence of tunnel infection. 4. An AXR is not routinely required but if there is concern about obstruction or perforation then this can be requested. Air can get into the abdomen during a PD exchange and a small amount of gas under the diaphragm is often present. This is not diagnostic of perforation however if there are additional concerns then the case should be discussed with the surgical team as detailed below. 5. Check with patient regarding allergies. Record this. 6. Ensure pain relief given. 7. Ask about recent episodes of peritonitis and exit site infections. Check recent microbiology results on Notis or emed. Record any positive or negatives findings (e.g. no recent samples, or recent culture negative samples) in the clerking. Treatment may need modification discuss with SpR / consultant.] 8. Record the insertion date of the current tube and the number of previous infections with this tube. Nottingham Renal Peritonitis and Exit site infection guidelines Page 8 of 18

9 9. Commence empirical antibiotics: - THIS IS DAY 1 IP Vancomycin 30mg/kg IP single dose dwell 6 hours IP Gentamicin 0.6mg/kg IP once per day dwell 6 hours IP Heparin 1000 units in each exchange 4 days (continue until bags clear and no fibrin clots present) If recent PSEUDOMONAS infection (in the previous 3 months) add : IV Ceftazidme 1 g every 24 hours. Can also be administered IP but discuss with renal pharmacist to ensure compatibility with other antibiotics. IP Vancomycin and Gentamicin can be administered in the same PD exchange. Measure serum vancomycin and gentamicin levels as detailed in flow charts below. Teicoplanin can be used in those that have a history of vancomycin allergy BUT there are reports of cross sensitivity between vancomycin and teicoplanin. Those with a severe allergy to vancomycin should be discussed with microbiology. A history of red man syndrome (an infusion related reaction which occurs on rapid infusion, typically consisting of severe hypotension, wheezing, dyspnoea, urticaria, pruritus and/or flushing of the upper body) is not a contraindication to using teicoplanin. IP Teicoplanin dose: 15mg/kg IP single dose. Dwell 6 hours. Repeat every 5 days. 10. Patients should have a PD tube set change. 11. The majority of patients with peritonitis will be managed in the community and can be discharged after the samples have been taken and IP antibiotics have been administered. If they go home they should be supplied with bags injected with heparin sufficient for 24 hours dialysis. Patients who are treated in the community should be told to contact the unit if they become more unwell. The PD Registrar and Nurses MUST be made aware of all patients with a diagnosis or suspected diagnosis of PD peritonitis, especially those who are discharged to the community. Out of hours, messages can be left in the communication book on Bramley Ward and on the answer-phone Reasons for admission include patients with severe peritonitis who are systemically unwell (e.g. diarrhoea or vomiting, pyrexia >38 O C, hypotension), those requiring surgical intervention and those with severe pain unlikely to respond to oral analgesics. Patients should be discussed/ reviewed by medical staff. Nottingham Renal Peritonitis and Exit site infection guidelines Page 9 of 18

10 13. Exit site infection should be treated appropriately (page 5) and oral antibiotics may be needed for a defined exit site infection. 14. Adequate documentation is important especially if therapy is initiated out of hours. Details of the date of onset of peritonitis and the antibiotics prescribed should be entered. Culture results and length of antibiotic course should be entered subsequently. 15. Patients on the ACTIVE Transplant list should be suspended from the list for the duration of their antibiotic course and the peritonitis should have resolved fully before they are reinstated. 16. Further antibiotic therapy should be reviewed once culture results and sensitivities are available. The guidelines for therapy detailed below are suggestions only and close liaison with microbiology is important. In particular patients who are not responding to antibiotic therapy should be reviewed surgically with a view to laparotomy and tube removal. 17. Surgical Review Close liaison with the surgical team is important. The surgical team should review all patients who are ill enough to be admitted with peritonitis. Referral should be made to the Transplant Surgeon on-call for that week for review on the next morning ward round. If the patient has a surgical abdomen, the Transplant Surgeon on call should be informed urgently, who may then request referral to the general surgical team (discuss with renal registrar on-call out of hours). Patients with relapsing peritonitis or frequent episodes of peritonitis (especially with the same organism) are likely to need surgical intervention either in the form of acute removal of their PD catheter or an elective tube change (removal and re-insertion). Patients with resistant or relapsing exit-site infections may benefit from an elective tube change. Patients with fungal peritonitis require catheter removal except in exceptional circumstances. Pseudomonas infections have a high morbidity and mortality and all patients should be admitted and reviewed by the surgical team within 24 hours. In general these patients need early catheter removal if not improving after hours treatment. An elective tube exchange should be considered for patients with a successfully treated pseudomonas or staph aureus peritonitis. This should be done near the end of the antibiotic course ie between week PD Tube removal for infection. The duration of antibiotic therapy following catheter removal and timing or resumption of peritoneal dialysis (PD) may be modified depending on clinical course. Typically antibiotics should be continued for 1 week after PD tube removal. The choice of antibiotic would be dependent on culture and sensitivity results. Fungal peritonitis will require therapy for days after tube removal. Nottingham Renal Peritonitis and Exit site infection guidelines Page 10 of 18

11 Management of peritonitis patients treated by APD Diagnosis Previously concern was raised that the short dwells used in APD may lead to low cell counts and misleading culture results resulting in late treatment of peritonitis. The experience from paediatric practice does not support this and cloudy PD fluid remains the diagnostic hallmark. If the initial drain bag is turbid then this should be sent to microbiology. In equivocal cases (i.e. patients with abdominal pain and/or systemic symptoms but clear PD fluid) a further sample of fluid should be obtained from a dwell of at least 1-hour. Management The above management regime is applicable to APD with minor modification. The six-hour antibiotic dwell is done in the day bag. The patient can have APD exchanges overnight as usual. Use of heparin on the machine is possible, if indicated, at 1000 units per litre in the first bag to a maximum of 5000 units per APD session. If in doubt, discuss this with the PD nurses and Registrar. Modification of PD Peritonitis treatment once culture and sensitivity results are known: Figure 2. Gram Positive organism on culture. page 12 Figure 3. Gram Negative organism on culture. page 13 Figure 4. Culture negative peritonitis. page 14 Figure 5. Yeast on culture (Fungal Peritonitis) page 15 Nottingham Renal Peritonitis and Exit site infection guidelines Page 11 of 18

12 Figure 2:- Gram Positive Organism on Culture DAY 1 Empirical treatment usually with Vancomycin 30mg/kg IP single dose and Gentamicin 0.6mg/kg IP od Stop loop diuretic Gram Positive Organism on culture (Result available at hours) Stop Gentamicin Staph epidermidis and other Gram positives Staph. Aureus MSSA MRSA Add Flucloxacillin 1g qds po and/or Rifampicin 300mg bd po Add Rifampicin 300mg bd po Day 5 Vancomycin level. If <15 re-dose with 15mg/kg IP on day 6 and 11 If >15 re-dose with 15mg/kg on day 8 Day 5 Vancomycin level. If <15 re-dose with 15mg/kg IP on day 6, 11, 16 and 21 If >15 re-dose with 15mg/kg on day 8 and day 15 In total: 14 days In total: 21 days treatment Consider elective tube exchange Nottingham Renal Peritonitis and Exit site infection guidelines Page 12 of 18

13 Figure 3:- Gram Negative Organism on Culture DAY 1 Empirical treatment usually with Vancomycin 30mg/kg IP single dose and Gentamicin 0.6mg/kg IP od Stop loop diuretic Stop Loop diuretic Gram Negative Organism on culture Result available at hours No further Vancomycin Pseudomonas (or Stenotrophomonas) Single Gram Negative Organism e.g. E. Coli Mixed organisms and/or anaerobes ADMIT Urgent Surgical review Gentamicin for 14 days Monitor levels every 5 days Alternative antibiotic if sensitivities allow ADMIT Urgent Surgical review?bowel perforation Use 2 antipseudomonal antibiotics e.g.: Gentamicin 0.6 mg/kg/day IP Ceftazidime 1g daily IV / IP (or ciprofloxacin 500mg bd po) Treat for 21 days (Stenotrophomonas discuss treatment with microbiologist) If poor response in hours remove catheter and continue 2 antibiotics IV for at least 5-7 days Consider antibiotics for at least 21 days as guided by microbiology Check serum Gentamicin levels every 5 days Target level 2-4 mg/l Level <2mg/l increase by 0.2mg/kg Level 2-4mg/l no change Level 4-6mg/l reduce by 0.2mg/kg Level >7mg/l miss a day and reduce Nottingham Renal Peritonitis and Exit site infection guidelines Page 13 of 18

14 Figure 4:- Culture Negative peritonitis DAY 1 Empirical treatment usually with Vancomycin 30mg/kg IP single dose and Gentamicin 0.6 mg/kg IP od Stop loop diuretic Gentamicin 0.6mg/kg IP od No clinical improvement at 72 hours Clinical improvement at 72 hours White cell differential?eosinophilic. Re-culture, including AAFB staining. Seek microbiology advice re: culture methods and therapy CONSIDER TUBE REMOVAL STOP Gentamicin (as long as no Gm ve risk factors identified eg diarrhoea) Continue Vancomycin Day 5 Vancomycin level if <15 re-dose with 15mg/kg IP on day 6 and 11 if >15 re-dose with 15mg/kg on day 8 Nottingham Renal Peritonitis and Exit site infection guidelines Page 14 of 18

15 Figure 5:- Yeast (or other fungus) on culture DAY 1 Empirical treatment usually with Vancomycin 30mg/kg IP single dose and Gentamicin 0.6mg/kg IP od Stop loop diuretic Yeast (or other fungus) on culture Result available at hours Fungal Peritonitis is an emergency Admit and remove catheter within 24 hours Unless joint medical and surgical consultant decision to treat with anti-fungals (exceptional circumstances only) Decisions on antifungal treatment should involve discussion with microbiology consultant Antifungal therapy dosing: Ambisome (liposomal amphotericin B) 3mg/kg IV OD Need test dose (see below) Can be increased to 5mg/kg OD if very unwell or poor response Test dose: 1mg over 10minutes then stop the infusion. Observe patient for 30minutes and if there are no signs of hypersensitivity administer the rest of the dose, refer to online IV administration guide for duration of infusion. OR Anidulafungin 1st dose 200mg IV single dose, then Maintenance dose 100mg IV OD Treatment to be reviewed when identification of fungus established (usually within 48-72hrs) Treatment should be continued for days post catheter removal to reduce peritoneal scarring/adhesions Nottingham Renal Peritonitis and Exit site infection guidelines Page 15 of 18

16 Relapsing Peritonitis Definition Another episode of peritonitis caused by the same genus/species that caused the immediately preceding episode, occurring within 4 weeks of completion of the antibiotic course. Management Empirical antibiotic therapy should be initiated and later modified following culture results and after discussion with microbiology. Catheter removal is likely to be needed if the peritonitis does not settle quickly. If Staph Epidermidis is the relapsing organism then complete 21 days of vancomycin. If 3 episodes of peritonitis with same organism, then elective tube change should be planned (unless the clinical condition necessitates immediate tube removal) discuss with surgeons. The following specific points should be borne in mind: 1. Staphylococci Consider occult tunnel infection/ cuff colonisation. If Staph. aureus use combination of IP vancomycin and oral rifampicin (or flucloxacillin, if MSSA). Prolonged treatment (4 weeks) may be required. Consider IP urokinase 12,500 units prior to antibiotics to disrupt the biofilm. May need admission and surgical review with a view to catheter removal or exchange. If second relapse require catheter removal and replacement. 2. Gram negative Organisms Careful evaluation for intra-abdominal abscess. Catheter removal and surgical exploration should be strongly considered in these patients. 3. Pseudomonas Species If the first episode of pseudomonas peritonitis was treated with 2 anti-pseudomonal agents for 21 days then catheter removal is indicated on relapse. Nottingham Renal Peritonitis and Exit site infection guidelines Page 16 of 18

17 Figure 6:- Overview of peritonitis protocol Clinical diagnosis of PD peritonitis, no exit site, no tunnel infection Empirical treatment DAY 1 IP Vancomycin 30mg/kg single dose IP Gentamicin 0.6mg/kg once per day IP Heparin 1000 units in each exchange Vancomycin and Gentamicin levels day 5 Gram positives inc. Enterococcus, Staph Stop Gentamicin Day 5 Vancomycin level. If <15 re-dose with 15mg/kg IP on day 6 and 11 If >15 re-dose with 15mg/kg IP on day 8 Gram negatives (except pseudomonas) 14 days IP Gentamicin Use alternative antibiotic if sensitivities allow No further Vancomycin If Staph aureus: Consider Rifampicin and/or Flucloxacillin Continue Vancomycin to complete 21 days therapy If recurrent Staph epidermidis: Continue Vancomycin to complete 21 days therapy Pseudomonas, yeast, mixed gram negative and culture negative all special cases, see detailed protocols Nottingham Renal Peritonitis and Exit site infection guidelines Page 17 of 18

18 APPENDIX: EVIDENCE BASE, AUDIT, EDUCATION 1) These guidelines have been derived from the following evidence base:- a. Adult Peritoneal Dialysis-Related Peritonitis Treatment Recommendations: 2000 Update. Keane et al. Peritoneal Dialysis International 2000(20): Evidence level iv b. Peritoneal Dialysis-Related Infections Recommendations: Update 2005 Piraino et al Peritoneal Dialysis International 2005(25): Evidence level iv c. ISPD Peritonitis Recommendations: 2016 Update on Prevention and Treatment Philip Kam-Tao Li1 Peritoneal Dialysis International 2016(36): Evidence level iv d. ISPD Catheter-Related Infection Recommendations Update Szeto et al Peritoneal Dialysis International 2017 (37): Evidence level iv e. Renal Association Standards Document Third Edition 2006 Evidence level iv f. Kent, J.R., and Almond, M.K. Peritoneal Dialysis International 2000 (20): Evidence level iv g. Thodis E. et al. Advances in Peritoneal Dialysis 2000 (16): Evidence level iii h. Bernardini et al. Am J Kidney Disease 1996; 27 (5) Evidence level ib i. Gentamicin dosing and monitoring schedule taken from Charing Cross Hospital Peritonitis Treatment protocol with kind permission of Dr Edwina Brown, Consultant Nephrologist, Charing Cross Hospital, London. j. Baker RJ, Senior H, Clemenger M, Brown EA.Am J Kidney Dis Mar;41(3):670-5.Empirical aminoglycosides for peritonitis do not affect residual renal function k. Bernardini et al. AJKD 1996; 27: ) l. local microbiological advice Evidence level v 2) The guidelines will be subject to annual audit by the peritoneal dialysis nurses with respect to: - a. Peritonitis rates b. Initial cure rates for PD peritonitis c. Level of culture-negative peritonitis 3) The guidelines will be printed in the renal junior doctors handbook and distributed to all junior doctors working in the unit. 4) Junior doctors will be trained in management of PD peritonitis at the time of their induction into the renal unit. Nottingham Renal Peritonitis and Exit site infection guidelines Page 18 of 18