Intraperitoneal Antibiotic Dosing Strategy for Peritoneal Dialysis-Associated Peritonitis: A Quality Improvement Initiative

Background: The 2022 International Society of Peritoneal Dialysis guidelines for peritoneal dialysis-associated peritonitis do not describe a preference for a particular intraperitoneal antibiotic dosing strategy (intermittent dosing vs. continuous dosing) except for aminoglycosides where the guidelines recommend intermittent daily dosing. We aimed to assess the situation and identify potential barriers to improve patient outcomes. Methods: As a part of the quality improvement initiative, we conducted a retrospective study of adult patients admitted with peritoneal dialysis-associated peritonitis at NYC Health + Hospitals/Jacobi from 2022 to 2024. Results: There were 7 adult patients, all males with a mean age of 58.6 years (range: 37 to 73 years). Five patients presented with community-acquired peritonitis, whereas 2 patients developed peritonitis during hospital stay. The mean peritoneal dialysis effluent cell count was 7,303/uL (range: 293 to 20,190/uL). The average hospital length of stay was 21 days (range: 2 to 50 days). Five patients (71.43%) had missing antibiotic doses when the antibiotics were ordered with continuous dosing. One patient (14.29%) had his peritoneal dialysis catheter removed on hospital day 10 due to persistent abdominal pain. One patient (14.29%) had his peritoneal dialysis catheter removed on hospital day 8 due to refractory gastrointestinal bleed requiring subtotal colectomy. One patient (14.29%) expired. Conclusion: In this single-center experience, the continuous intraperitoneal antibiotic dosing strategy was associated with missing antibiotic doses. We identified a potential barrier with the continuous dosing strategy where peritoneal dialysis nurses were required to take dialysate bags to the pharmacy more than once a day to add antibiotics into dialysate bags. After the study, we have collaborated with the antibiotic stewardship team for the intermittent (with the longest dwell) intraperitoneal antibiotic dosing strategy for managing peritoneal dialysis-associated peritonitis.