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278 Fig 16.3 (continued) A M Neu et al 16 Infectious Complications of Peritoneal Dialysis in Children Fig 16.3 (continued) 279 280 Fig 16.3 (continued) A M Neu et al 16 Infectious Complications of Peritoneal Dialysis in Children a utomated peritoneal dialysis (APD) with a daytime exchange, respectively [9] For children on APD without a daytime dwell, the fill volume should be allowed to dwell for at least 1–2 h prior to specimen collection [9] In specimens collected in this manner, peritonitis should be diagnosed if the percentage of PMNs exceeds 50%, even if the total WBC does not exceed 100/mm3 [9] Among the clinical peritonitis episodes reported to the IPPR, a WBC of less than 100/m3 was present in 2.8% and the percentage of PMNs lower than 50% in 8.5% of episodes [31] Although the sensitivity of gram stain of the dialysis effluent is low, the presence of organisms, particularly budding yeast, may guide empiric therapy [9] Whereas bacterial or fungal growth in a culture obtained from effluent typically confirms the diagnosis of peritonitis, a negative culture does not rule out infectious peritonitis It has been suggested that the center-specific culture-negative rate should not exceed 20% and, ideally, should be lower than 10% However, and as mentioned previously, data from the IPPR and SCOPE reveal that this goal is not routinely achieved at pediatric centers [8, 9, 12, 99] Efforts to optimize culture yields include prompt delivery of the specimen to the laboratory, ideally within 6 h of collection, with refrigeration (4 °C) of samples that are not immediately delivered to a lab [99, 100] Centrifugation of at least 50 mL of effluent, with resuspension of the sediment for inoculation onto solid-culture media and into blood culture media, is recommended [101, 102] Alternatively, 20–30 mL of effluent may be injected directly into 3–4 blood culture bottles [99] In the majority of cases, cultures will be positive within 72 h If cultures remain negative after 3–5 days, repeat cell count, differential, culture, as well as fungal and mycobacterial culture should be obtained from dialysis effluent, with an additional subculture on media with aerobic, anaerobic, and microaerophilic incubation conditions to identify fastidious bacteria and yeasts [9, 21] 281 Empiric Therapy To optimize treatment outcomes, empiric antibiotics should be delivered in suspected cases of peritonitis as soon as a dialysis effluent sample for cell count, differential, gram stain, and culture is obtained Intraperitoneal instillation, if possible, is the preferred method of antibiotic delivery, and antibiotics may be given continuously, as recommended for beta-lactam antibiotics, or intermittently [9, 103] Continuous dosing typically begins with a higher antibiotic concentration (loading dose) delivered with an extended- dwell cycle, followed by a lower maintenance dose [9] Current guidelines suggest that intermittent dosing with glycopeptide antibiotics (vancomycin or teicoplanin) may be considered, but the dose in this case should be provided using an extended dwell (6–8 h), and antibiotic blood levels should be monitored, particularly in non- anuric patients for whom the frequency of dosing may need to be increased [9, 99] The dosing recommendations for the various antibiotics and antifungals used to treat children with peritonitis are shown in Table 16.2 [9] Antibiotics selected for empiric treatment should cover both gram-positive and gram- negative organisms [9, 21] Given the significant variability in both causative organisms and antibiotic susceptibility seen around the globe, center-specific antibiotic susceptibility patterns should influence empiric antibiotic selection [8, 9, 21] Current pediatric guidelines recommend either monotherapy with cefepime for empiric coverage or a first-generation cephalosporin or a glycopeptide in combination with ceftazidime or an aminoglycoside, if cefepime is not available [9] The empiric use of a glycopeptide, either in addition to cefepime or as a substitute for a first-generation cephalosporin, is recommended if the center-specific resistance rate of MRSA exceeds 10% or the patient has a history of MRSA [9] A M Neu et al 282 Table 16.2 Dosing recommendations for the treatment of peritonitis Continuous therapya Loading dose Maintenance dose Intermittent therapy Aminoglycosidesb Gentamicin 8 mg/L 4 mg/L Netilmicin 8 mg/L 4 mg/L Tobramycin 8 mg/L 4 mg/L Amikacin Cephalosporins Cefazolin Cefepime Cefotaxime Ceftazidime Glycopeptidesc Vancomycin 25 mg/L 12 mg/L Anuric: 0.6 mg/kg Non-anuric: 0.75 mg/kg Anuric: 0.6 mg/kg Non-anuric: 0.75 mg/kg Anuric: 0.6 mg/kg Non-anuric: 0.75 mg/kg mg/kg 500 mg/L 500 mg/L 500 mg/L 500 mg/L 125 mg/L 125 mg/L 250 mg/L 125 mg/L 20 mg/kg 15 mg/kg 30 mg/kg 20 mg/kg 1000 mg/L 25 mg/L Teicoplanin 400 mg/L 20 mg/L 30 mg/kg; repeat dosing 15 mg/kg q 3–5 days 15 mg/kg q 5–7 days – 125 mg/L – 50 mg/L 25 mg/L – 1000 mg/L 300 mg/L 250 mg/L 250 mg/L 150 mg/L 50 mg/L – – – Penicillinsb Ampicillin Quinolones Ciprofloxacin Others Aztreonam Clindamycin Imipenem/ cilastatin Linezolid (oral) Metronidazole (oral) Rifampin (oral) Antifungals Fluconazole Caspofungin
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