Peritoneal dialysis (PD) is a form of kidney replacement therapy that uses the lining of the abdomen, the peritoneum, to filter the blood. A significant complication for PD patients is peritonitis, an infection of the peritoneal cavity, which often requires treatment with intra-peritoneal antibiotics. The procedure for adding antibiotics is straightforward but requires meticulous attention to detail and a strict adherence to sterile protocols to avoid introducing further contamination.
The Importance of Aseptic Technique
Maintaining aseptic, or sterile, technique is the single most important aspect of adding medication to a PD bag. Peritonitis is most often caused by contamination entering the peritoneal cavity, frequently from small, inadvertent breaks in sterile procedure during exchanges. Introducing bacteria can worsen the infection and potentially lead to serious outcomes, including hospitalization, catheter removal, and transfer to hemodialysis.
Step-by-Step Guide to Adding Antibiotics
Following a precise, controlled procedure is essential for safe antibiotic administration.
Preparation
- Prepare the workspace: Choose a clean, dry, well-lit, and uncluttered surface. Clean the surface with an alcohol wipe and allow it to dry.
- Gather supplies: Collect all necessary equipment, including the correct PD solution bag, prescribed medication, sterile syringes, needles, alcohol or chlorhexidine swabs, and a sharps container.
- Perform hand hygiene: Wash your hands thoroughly with soap and water and dry them completely. Some protocols may also require sterile gloves and a face mask.
- Inspect the PD bag: Check the dialysate bag for clarity, leaks, the correct solution type, and an expiration date that has not passed. Do not use a bag that shows any signs of compromise.
- Prepare the medication: Depending on the antibiotic, you may need to reconstitute it from powder by adding a sterile diluent, such as sterile water for injection, following specific instructions. Clean the rubber top of the medication vial with an alcohol wipe and allow it to dry.
Medication Withdrawal and Injection
- Withdraw the dose: Using the correct size syringe and needle, withdraw the precise amount of medication prescribed by your doctor.
- Clean the injection port: Use a new alcohol or chlorhexidine swab to clean the injection port on the PD solution bag. Allow it to air-dry completely.
- Inject the medication: Inject the medication through the center of the port, ensuring the needle does not touch any other surface. Do not pierce the side of the port. If you accidentally stick the bag, discard it and start with a new one.
- Remove the needle: Carefully remove the needle from the port and immediately dispose of it in a sharps container.
Post-Injection Steps
- Mix the solution: Gently agitate or shake the PD bag to ensure the antibiotic is evenly distributed throughout the dialysate.
- Label the bag: Add a label to the bag indicating the medication, dose, and time of injection.
- Initiate the exchange: Once properly prepared, proceed with the PD exchange as usual, following your prescribed protocol.
Comparison of Intra-Peritoneal Dosing Methods
There are two primary methods for delivering intra-peritoneal antibiotics for peritonitis, depending on your PD regimen and the specific antibiotic being used:
| Feature | Intermittent Dosing | Continuous Dosing |
|---|---|---|
| Mechanism | Antibiotic is added to a single exchange per day, which then dwells for a minimum of 6 hours. | Antibiotic is added to all exchanges performed throughout the day. |
| Application | Commonly used for certain antibiotics like vancomycin, particularly in Automated Peritoneal Dialysis (APD) where it's added to the last fill bag. | Often used for patients on Continuous Ambulatory Peritoneal Dialysis (CAPD) and for some medications to maintain a constant level. |
| Advantages | Simpler for patients, as it minimizes the number of injections required daily. | Maintains consistent antibiotic levels in the peritoneal cavity and blood. |
| Disadvantages | Antibiotic concentration may fluctuate between exchanges. | Requires adding medication to multiple bags daily, increasing the risk of contamination with more frequent procedures. |
| Considerations | Not all antibiotics are suitable for intermittent dosing due to their stability or required concentration. | Must confirm compatibility of any combined antibiotics for stability throughout the treatment duration. |
Continuous vs. Intermittent Dosing
The choice between continuous and intermittent dosing for antibiotics in PD fluid is determined by the specific medication, the patient's PD schedule (CAPD vs. APD), and clinical guidelines. For instance, intermittent dosing is often preferred for vancomycin, with the antibiotic added to one exchange that is allowed to dwell for at least 6 hours. In contrast, some guidelines recommend continuous dosing for other antibiotics to maintain steady drug levels throughout all exchanges. Patients using an automated cycler for APD will often add their antibiotic dose to the final fill bag of the night, which provides a long dwell time. It is critical to follow the exact dosing and schedule prescribed by your healthcare provider.
Specific Antibiotic Considerations
Several antibiotics are commonly used for IP administration to treat peritonitis, with the choice often depending on the suspected or confirmed type of bacteria. Empiric therapy typically includes a combination of antibiotics to cover both Gram-positive and Gram-negative bacteria until specific culture results are available. Some common examples include:
- Vancomycin: Used for Gram-positive coverage, including methicillin-resistant Staphylococcus aureus (MRSA).
- Gentamicin or Cephalosporins (e.g., Cefepime, Ceftazidime): Used for Gram-negative coverage.
Crucially, not all antibiotics are compatible when mixed together in the same dialysate bag. It is essential to confirm the stability and compatibility of the prescribed antibiotic cocktail with your pharmacy or PD team before mixing.
Conclusion
Adding antibiotics to peritoneal dialysis fluid is a necessary procedure for treating peritonitis in PD patients. The process, while seemingly simple, requires a disciplined, aseptic technique to prevent further infection and ensure the treatment's success. By meticulously preparing the workspace, withdrawing the correct dose, injecting it safely into the dialysate bag, and following the prescribed dwell time, patients and caregivers can confidently perform this critical step. Always follow the specific instructions from your PD nurse and doctor, and consult them with any questions or concerns. For further official guidance, resources like the International Society for Peritoneal Dialysis (ISPD) provide invaluable information.
