Initial management of peritoneal catheter exit-site and tunnel infections

* Refer to UpToDate content on clinical manifestations and diagnosis of peritonitis in peritoneal dialysis and microbiology and therapy of peritonitis in peritoneal dialysis for details.

¶ For patients with a tunnel infection who do not have a concomitant exit-site infection or drainage from the exit site after milking the catheter tract, obtaining an exit-site culture swab to direct antibiotic therapy is impossible. For such patients, ultrasound imaging may identify peri-catheter fluid collections amenable to drainage (ie, larger than 1 to 2 cm), in which case we refer to surgery or to interventional nephrology/radiology so that fluid can be drained and sent for culture and Gram stain.

Δ Refer to UpToDate content on peritoneal catheter exit-site and tunnel infections in peritoneal dialysis in adults for details.

◊ An initial ultrasound provides imaging to compare with repeat imaging in patients who have a tunnel infection that may prove refractory to antibiotic therapy. In patients with refractory infection, ultrasound findings such as a new fluid collection, or a fluid collection not substantially improved from baseline, are an indication for catheter removal or a catheter salvage procedure. Less commonly, some centers use initial ultrasound imaging to identify extensive fluid collections that may be treated with an early catheter salvage procedure. However, a trial of antimicrobial therapy is usually pursued before performing a catheter intervention.

§ If the patient cannot take ciprofloxacin, we use intraperitoneal ceftazidime.

¥ Fungal infections warrant removal of the catheter. However, it is important to ascertain that a fungus identified in the culture is not a contaminant by repeating a culture and demonstrating the absence of other organisms.

‡ For the minority of patients who receive initial empiric treatment with broad-spectrum intraperitoneal antibiotics, culture results usually can be used to switch antimicrobial therapy to an oral and more narrow regimen.