Global Evolution of Microbiological Patterns and Pharmacological Guidance in the Management of Peritoneal Dialysis-Associated Peritonitis: An Evolution of Epidemiology and Clinical Practice

Peritoneal dialysis (PD)-associated peritonitis remains a major cause of treatment failure, hospitalisation, catheter loss and transition to haemodialysis despite reductions in incidence over the decades. This narrative review examines the global evolution of microbiological epidemiology and pharmacological management of PD-associated peritonitis, looking at global trends in microbiological epidemiology and exploring how treatment recommendations have evolved in response to changing pathogen distribution, antibiotic resistance patterns and associated clinical outcomes. Although Gram-positive organisms remain the predominant pathogens in most PD programmes, recent evidence demonstrates marked geographical and centre-level heterogeneity with rising clinical importance of Gram-negative, polymicrobial, fungal and culture-negative infections in certain regions. Antibiotic resistance has emerged as an additional challenge, including methicillin-resistant staphylococci, vancomycin-resistant enterococci, extended-spectrum β-lactamase-producing Enterobacterales and multidrug-resistant non-fermenting Gram-negative organisms. These changes challenge conventional empirical regimens and emphasise the importance of programme-specific microbiological surveillance. In parallel, pharmacological management has evolved considerably from relatively standardised empirical antibiotic combinations towards an individualised approach incorporating intraperitoneal administration, local susceptibility profiles, organism-directed therapy, pharmacokinetic optimisation, therapeutic drug monitoring and antifungal prophylaxis. However, substantial evidence gaps remain, particularly regarding antibiotic resistance patterns globally, optimal dosing in automated PD, intraperitoneal stability and clinical efficacy of newer antimicrobial agents.