Long-Term Prophylactic Intraperitoneal Antibiotics in Outpatient Peritoneal Dialysis Patients: A Case Series

Introduction: Bacterial peritonitis is a potentially fatal complication for peritoneal dialysis patients. Despite following ISPD guidelines, patients in remote areas are at higher risk of developing peritonitis due to decreased direct access to experienced nursing staff. Those patients in remote areas also are less likely to relocate closer to a hemodialysis center if perionteal dialysis cannot be continued. One approach to prevent peritonitis in these patients with frequent peritonitis is to use prophylactic intraperitoneal antibiotics. However, extended use antibiotic prophylaxis to prevent bacterial peritonitis in peritoneal dialysis patients is not well characterized in the literature. The risk of developing multi-drug resistant organisms limits its widespread use. Case Description: In this case series, we investigated the safety and efficacy of prophylactic intraperitoneal antibiotics in 3 peritoneal patients with a history of relapsing Staphylococcal peritonitis infections unwilling to transition to hemodialysis. Discussion: Each patient had an exit site infection causing multiple relapsing peritonitis infections whereby each patient refused PD catheter removal during a peritonitis exacerbation, limiting the nephrologist to antibiotic therapy. As a last resort, all three patients received intraperitoneal and an oral antibiotic to double-cover the identifed pathogen. In all three cases, no opportunistic infections were reported in the observation period despite absence of fungal peritonitis prophylaxis. Patients did not report any side-effects after starting prophylactic antibiotics. Dialysis adequacy did not appear to be affected by prophylactic antibiotics in the observation period. Two of the cases passed away due to failure to thrive or to complications after foot amputation. No cloudy effluent or signs of peritonitis was observed near time of death. After this relatively successful case series of prophylactic antibiotics in this small subset of peritoneal dialysis patients, randomized prospective studies should be conducted to assess the feasibility of this novel approach to sustain peritoneal dialysis longevity. Patient Demographics / Infection Information - Patient PD Duration Exit Site Organism / Treatment Peritonitis History / Treatment Prophylaxis Regimen Caucasian male (1938-2020), BMI 30 Dec 2017-Jan 2020 Jan 2018 (MSSA) - IP cefazolin 2g daily x2 weeksMar 2018 (MSSA) - PO cephalexin 500 mg BID x10 days Aug 2018 - MSSA - IP vancomcyin 2g q4days x3 weeksSept 2018 - MSSA - IP vancomycin 2g q3days x3 weeksNov 2018 - MSSA - IP cefazolin 2g daily x3 weeksMay 2019 - MSSA - IP cefazolin 2g daily x3 weeks then IP cefazolin 2g daily + PO rifampin 600 mg daily x2 weeks IP cefazolin 1g Mon/Wed/Fri (July 2019-Jan 2020) Caucasian male (1942-2021), BMI 26 Feb 2018-Apr 2021 Mar 2019 (MRSA) - PO SMP/TMX DS daily x10 days Sept 2018 - MRSA - IP vancomycin 2g q4days x3 weeksNov 2018 - MRSA - IP vancomycin 2g q4days x3 weeksJan 2019 - MRSA - IP vancomycin 2g q4days + PO rifampin 600 mg daily x3 weeks IP vancomycin 2g every Friday (Feb 2019-Apr 2021) Caucasian male (1947-present), BMI 31 Nov 2019-present July 2020 (coagulase-negative Staphylococcus) - PO cephalexin 500 mg BID x7 days Apr 2020 - coagulase negative Staph* - IP vancomycin 2g q4days x2 weeksOct 2020 - coagulase negative Staph* - IP vancomycin 2g q4days x2 weeksNov 2020 - coagulase negative Staph* - IP vancomycin 2g q4days + rifampin 600 mg daily x4 weeksDec 2020 - coagulase negative Staph* - IP vancomycin 2g q4days + clindamycin 300 mg daily x4 weeks IP vancomycin 2g weekly (Dec 2020 - present)

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