Peritonitis Prevention Strategies

Overview

Peritonitis is an inflammation of the abdomen's inner lining, also known as the peritoneum, and causes significant abdominal pain. The peritoneum covers internal organs such as the bowel, kidneys, and liver. It can also be used to filter blood for individuals with malfunctioning kidneys. This process is known as peritoneal dialysis, and if not correctly maintained carefully and safely maintained, infection such as peritonitis can occur.¹ Peritonitis is the second most common cause of death worldwide for patients who use peritoneal dialysis(PD). Thus, it can be life-threatening if peritonitis is not treated.⁷ This article will focus on strategies to prevent the occurrence of peritonitis.

What are the causes and symptoms of peritonitis?

The NHS has outlined symptoms of peritonitis as:¹

• Abdominal pains
• Having a high temperature
• Speedy heartbeat
• Urinating less than normal
• Lack of appetite
• Swollen stomach

Also, according to the NHS, there are several causes of peritonitis, such as:¹

• Bacteria
• Microorganisms in the bowel and  female reproductive organs
• A perforated ulcer
• A burst appendix
• Crohn’s disease: long-term gut inflammation
• Diverticulitis: irregular inflammation across the large intestine wall
• Pancreatitis: inflammation of the pancreas
• Surgery
• Abdominal injury
• Pelvic inflammatory disease
• Cirrhosis: scarring of the liver due to long-term liver damage

However, patients who undergo peritoneal dialysis (PD) are at high risk of having peritonitis.²

Peritoneal dialysis-associated peritonitis

Peritoneal dialysis (PD) is a type of dialysis in which blood is filtered through the peritoneum. PD varies from haemodialysis as haemodialysis uses an external machine to filter blood.³ In peritoneal dialysis,  tubing connections via a catheter are used to filter unwanted compounds and waste (toxins) present in the blood into an external dialysis collection bag. The skin needs to be punctured to insert the catheter. Unfortunately, if hygiene and safety are not maintained, the surrounding area becomes infected. Such an infection can migrate toward the peritoneum.. The risk factors for PD-associated peritonitis includes:⁴

• Touch contamination due to poor patient self-care
• PD procedure, including a connection error during catheter insertion
• Lack of initial training and periodic retraining on how to use PD and the self-care involved in maintaining PD

Peritonitis can occur in PD patients after having a colonoscopy or after invasive dental or gynaecological procedures due to bacterial migration towards the surrounding area of the peritoneum.² It causes significant pain for patients and may lead to discontinuation of the use of PD, an increase in treatment costs and hospital visits, as well as the use of haemodialysis.⁵ Moreover, if not treated immediately, it could lead to other health-related problems or even death.⁶ Thus, it takes a collaborative approach of key stakeholders, including clinicians, researchers and policymakers to implement ways to prevent peritonitis.

How to prevent peritonitis?

The International Society of Peritoneal Dialysis (ISPD) peritonitis guideline recommendations have been updated in 2022. They recommended that the yearly rate of peritonitis should be no more than 0.40 episodes per year at risk, and the percentage of peritonitis-free patients should be targeted at more than 80% per year.⁴ If you are experiencing the symptoms mentioned above, get medical help as this can prevent infection development or other health-related issues. Additionally, below are some recommendations from the ISPD on how to minimise the risk of developing PD-associated peritonitis:^4,7

• Administration of prophylactic antibiotics (antibiotics administered to prevent infection) before proper catheter placement to reduce the risk of exit-site infection where the catheter contacts the patient’s skin

• Continuous monitoring of the catheter exit site by:
  • Daily cleaning of the area of the catheter 
  • Daily applying antibiotic cream or ointment, and
  • Immediate treatment of any contamination of the exit site or the catheter tunnelling (tubing inserted into the body towards the peritoneum area. It takes away the toxins and waste products filtered by the peritoneum). Peritonitis prevention is crucial so that the viability of the peritoneal membrane can be preserved. This is especially important for patients who have high risk factors for infectious complications combined with limited access to facilities for hemodialysis in cases of technique failure of peritoneal dialysis (PD)
  • Ensure that trainers are equipped with the best education from a standardised curriculum, as well as their ability to teach a diverse range of patients (or caregivers if applicable)
  • Stress the importance of not taking shortcuts when using PD
  • Involve patients in being tested on their knowledge through practice
  • Ensure that patients with home PD are visited regularly by PD nurses to check that the PD technique is correctly done, as well as check for any signs of contamination or infection
  • Have regular reassessments and updates of PD technique, knowledge, practice and inspection
  • Provide refresher courses and/or retraining for trainers, patients, caregivers and any professionals who will work or be in contact with PD equipment

• Maintain an ideal dialysis environment, thus, the area should be clean, dry and well-lit
• Medical supplies should also be stored in a cool, clean, and dry place
• Precautions should be taken if patients have domestic pets, to create some distance while undergoing home PD, however, this can be quite difficult due to the bond between owner and pet. However, it has been suggested that:
  • Close contact, such as a bite or scratch, should be avoided. It has been shown that domestic pets have unusual organisms that, if contracted by a PD patient, can lead to the development of peritonitis
  • Pets could also bite and/or scratch the tubing. The damage can lead to the leaking of dialysis fluid if unnoticed. But also, the unknown opening could lead to contamination of the catheter tubing, leading to infection if not changed immediately. Thus, the medical supplies must be stored in a safe place

• Lastly, it is important to maintain clean personal hygiene including:
  • Constant hand washing
  • Using an aseptic procedure when connecting dialysis bags
  • Wear a mouth/nose mask during fluid exchanges
  • Inspect the collection bag for signs of contamination, such as cloudiness, before you use it

More recommendations can be found in this study.⁷ Most importantly, medical help should be sought if unsure about how to maintain PD and also if there is any contamination of the dialysis fluid or catheter in the dialysis collection bag. In addition, it has been suggested in this study that there needs to be further research and awareness on the importance of peritonitis prevention and treatment.⁴ This is because implementing the recommendations can reduce the risk of peritonitis, which in turn reduces associated pain, numerous hospital visits, as well as treatment costs.⁷  

Summary

The peritoneum is essential in protecting gastrointestinal organs, including the stomach, liver, and kidneys. It is also vital to filter toxins and waste from blood via the use of peritoneal dialysis (PD). However, infection of the peritoneum, also known as peritonitis, can lead to a significant decline in the peritoneum’s function, leading to other health problems, but it can also be life-threatening. Peritonitis can be prevented by ensuring patients and medical professionals are trained and retrained regularly on the importance of having a clean environment when using PD, as well as hygiene practices before, during and after the use of PD. This can reduce treatment costs and hospital visits, and patients are less likely to transition to the use of haemodialysis.

FAQs

What is the diagnosis of PD-associated peritonitis?

According to the ISPD, at least two of the following three factors are required to diagnose an individual with peritonitis:⁴

1. PD fluid white blood cell count of more than 100 cells/μL with at least 50% neutrophils (a type of white blood cell that is essential in the immune system by helping the body to fight infection), known as polymorphonuclear leukocytes
2. Abdominal pain and/or cloudy peritoneal effluent in the PD collection bag, and
3. A positive culture of organisms identified in PD effluent that are associated with peritonitis

What are the risk factors of peritonitis?

The following are risk factors linked to peritonitis, especially for end-stage kidney disease patients:²

• Hypokalaemia: low potassium in the blood
• Constipation
• Immunocompromised status: weakened immune system, so most likely to have peritonitis
• Gastroenterological ulcers, which include stomach ulcers
• Hypoalbuminemia: decreased levels of albumin in blood. Albumin is essential for maintaining fluid distribution in the body
• Depression
• Loss of motivation
• Chronic inflammatory state
• Malnutrition

What are the treatment options for peritonitis?

Peritonitis is normally treated via the use of antibiotics, but depending on the cause, surgery might be required. For instance, if a burst appendix is the cause of peritonitis, it will need to be surgically removed. It might be difficult to eat and digest food while undergoing treatment, however, there is the option to have a feeding tube connected to the stomach either through the nose or by keyhole surgery. Alternatively, liquid nutrients can be administered via the veins.¹