Applied Nephrology Master Series

Chapter 10 Peritoneal Dialysis-Associated Peritonitis

CHAPTER MISSION Recognise PD-associated peritonitis at the first clinically meaningful signal, obtain high-yield microbiology without delaying treatment, start appropriate empiric therapy quickly, use organism and response trajectory to guide treatment duration and catheter decisions, identify surgical and catheter-related sources early, and turn every episode into a prevention intervention.

Figure 10.1 — Routes to PD-associated peritonitis. Peritonitis is a final common inflammatory syndrome produced by several routes. The organism, timing, contamination history, exit-site/tunnel findings and abdominal phenotype help reconstruct the source.

MASTER PRINCIPLE Cloudy effluent is an emergency signal, not a final diagnosis. Treat suspected infectious peritonitis promptly after obtaining proper specimens, but keep asking a second question in parallel: “What source or organism would make antibiotics alone insufficient?”

0. One-page chapter map

Table 10.1 — The eight decisions that govern PD-peritonitis care.

Decision	Core question	Bedside output
1. Threat	Is the patient septic, haemodynamically unstable, or presenting with a surgical abdomen?	Hospital / sepsis / surgical pathway when needed.
2. Confirm	Does the presentation meet the ISPD diagnostic framework?	Named syndrome: peritonitis, mimic, or uncertain.
3. Sample	Was the effluent collected and cultured correctly before antibiotics?	High-yield microbiology + cell-count baseline.
4. Cover	What empiric regimen gives prompt local Gram-positive and Gram-negative coverage?	Documented first-dose time and delivery plan.
5. Identify	What organism and source explain the episode?	Organism-specific therapy + source hypothesis.
6. Track	Is pain, cloudiness and effluent WBC trajectory improving?	Continue, re-investigate, or declare treatment failure.
7. Catheter	Is the catheter a salvageable conduit or an infected biofilm reservoir?	Retain, remove, exchange, or reinsert deliberately.
8. Prevent	Why did this episode occur and what changes before the next exchange?	Root-cause action, retraining, prophylaxis and CQI.

Learning outcomes

Diagnose PD-associated peritonitis using the current ISPD two-of-three diagnostic framework and apply the APD-specific PMN caveat correctly.
Distinguish infectious peritonitis from hemoperitoneum, eosinophilic/chemical inflammation, chylous effluent and intra-abdominal surgical disease.
Obtain cell count, differential, Gram stain and culture using culture techniques that minimize culture-negative episodes.
Start centre-specific empiric therapy promptly after sampling, covering both Gram-positive and Gram-negative organisms without waiting for laboratory confirmation.
Use local resistance patterns, APD/CAPD schedule, residual kidney function and dwell exposure to judge whether antibiotic delivery is actually adequate.
Interpret the 48-hour, day-3 and day-5 response trajectory and apply the corrected 2024 refractory-peritonitis definition.
Match treatment duration and catheter strategy to common organisms, culture-negative disease, polymicrobial/enteric disease, fungi and mycobacteria.
Distinguish relapsing, recurrent and repeat peritonitis and know when simultaneous catheter removal/reinsertion may be considered.
Apply primary and secondary prevention including wet-contamination management, antifungal prophylaxis during antibiotic courses, procedure prophylaxis, training review and apparent-cause analysis.
Document medical cure and unit-level peritonitis outcomes consistently for quality improvement.

EVIDENCE POSTURE The current adult ISPD peritonitis guideline remains the 2022 update; the ISPD guideline repository still lists it as the active adult prevention/treatment standard in 2026. Two corrigenda (2023 and 2024) must be read with it, especially the corrected refractory-peritonitis leukocyte threshold. The 2023 catheter-related infection guideline and 2025 PD-training position paper refine source control and prevention. Local microbiology and antimicrobial stewardship govern the final regimen. [1–5]

1. Core concept: peritonitis is time-sensitive infection plus source control

PD-associated peritonitis is inflammation of the peritoneal cavity in a patient receiving peritoneal dialysis, most often caused by infection introduced through touch contamination, a catheter-related route, an enteric/intra-abdominal source or less commonly an environmental or procedural exposure. It matters because an episode can produce severe pain, hospitalisation, catheter removal, transition to haemodialysis, peritoneal membrane injury and death. The acute clinical task is therefore dual: suppress microbial growth quickly and identify whether there is a source that antibiotics cannot eradicate. [1,6]

The first therapeutic error is delay. In the prospective PROMPT study, longer contact-to-treatment time after presentation to a healthcare facility was independently associated with catheter removal or death; the signal is clinically important even though the observational design does not prove a precise causal dose-response. The practical rule is simpler: sample correctly, then treat promptly. [8]

Table 10.2 — Peritonitis is three problems at once.

Problem	What is happening	Clinical question
Inflammation	Mesothelial and leukocyte response produces pain, cloudy effluent and transport changes.	How sick is the patient and is the trajectory improving?
Microbial burden	Bacteria/fungi may be free in dialysate or embedded in biofilm.	What organism is present and is the antibiotic active at the site?
Source	Touch, catheter, bowel, procedure or environmental exposure may continue to seed the cavity.	Will antibiotics alone eradicate the cause?

BEDSIDE TRANSLATION The antibiotic name is only one part of treatment. Timing, route, dwell exposure, susceptibility, source control and follow-up determine whether the prescription becomes a cure.

2. Diagnosis: use the two-of-three rule

Figure 10.2 — Diagnostic triad. ISPD 2022 recommends diagnosis when at least two of three criteria are present: compatible symptoms/cloudy effluent; elevated effluent leukocytes with PMN predominance after an adequate dwell; and positive effluent culture. [1]

Table 10.3 — ISPD diagnostic criteria.

Criterion	Operational definition	Interpretation
Clinical	Abdominal pain and/or cloudy dialysis effluent.	Either may be absent early; cloudiness should trigger urgent evaluation.
Effluent inflammation	WBC >100/µL (>0.1 × 10⁹/L) after dwell ≥2 h, with >50% PMN.	Strongly supports infectious peritonitis in the correct context.
Microbiology	Positive dialysis-effluent culture.	Identifies cause and guides narrowing/source inference.

The absolute effluent WBC count depends on dwell duration. In APD patients with rapid cycles, a PMN proportion above 50% is strong evidence even when the absolute WBC is below 100/µL. If an APD patient has no daytime effluent available, the guideline describes instilling 1 L of dialysis solution, dwelling for 2 hours and then draining for inspection and testing. [1]

CLOUDY-BAG RULE A PD patient presenting with cloudy effluent should be presumed to have peritonitis and treated as such until the diagnosis is confirmed or excluded. Do not wait for fever, severe tenderness or a positive culture. [1]

3. Cloudy effluent: infectious until proven otherwise, but not always infection

Table 10.4 — Rapid differential for cloudy or abnormal effluent.

Pattern	Clues	What separates it from routine bacterial peritonitis
Bacterial peritonitis	Pain, cloudiness, PMN-predominant leukocytosis.	Usually meets ≥2 diagnostic criteria; culture may be positive or negative.
Hemoperitoneum	Pink/red effluent; RBC predominance.	Blood rather than neutrophilic inflammation; investigate gynaecologic, traumatic or intra-abdominal cause.
Eosinophilic reaction	Often early after catheter exposure/air/drug; eosinophil predominance.	May be noninfectious; infection still needs exclusion.
Chemical / icodextrin-associated inflammation	Temporal relation to solution/exposure; variable cell differential.	Review solution lot/exposure and culture; do not assume sterility.
Chylous effluent	Milky appearance; triglyceride-rich.	Not equivalent to neutrophilic cloudy dialysate.
Enteric inflammatory process	Severe/localised pain, ileus, systemic toxicity; may be polymicrobial or culture-negative.	Imaging/surgical assessment may be more important than effluent appearance.
Pancreatitis / intra-abdominal inflammation	Pain pattern and systemic biochemical clues.	Contiguous sterile inflammation may mimic peritonitis.

DO NOT MISCLASSIFY Culture-negative effluent does not automatically mean “culture-negative infectious peritonitis.” Enteric inflammation, chemical/eosinophilic reactions and other mimics must stay in the differential when the clinical course is atypical.

4. Pathogenesis: use the organism to reconstruct the source

Figure 10.4 — Organism-to-source map. Microbiology provides mechanistic clues. Coagulase-negative staphylococci commonly imply touch contamination; S. aureus and Pseudomonas should raise concern for catheter-related infection; mixed enteric organisms demand intra-abdominal thinking; fungi often follow antibiotic exposure. [1,2,6]

Table 10.5 — Source phenotypes worth recognising.

Source phenotype	Typical clues	Immediate implication
Touch contamination	Technique lapse; CoNS; no tunnel abnormality.	Review exchange technique; retraining may prevent recurrence.
Catheter-related	Exit-site/tunnel inflammation with same organism or temporal association.	Source-control threshold is lower; cross-reference Chapter 11.
Enteric / surgical	Severe or focal abdominal findings, ileus, polymicrobial growth, Gram-positive + Gram-negative mix.	Imaging and surgical assessment; broaden antimicrobial coverage appropriately.
Wet contamination	Open-system breach, infused fluid after contamination, proximal tubing leak.	Contact PD team urgently; prophylactic antibiotic pathway if no peritonitis yet.
Procedural	Recent colonoscopy or invasive gynaecological procedure.	Assess prophylaxis history and possible enteric flora.
Pet/environmental	Animal contact with equipment or tubing; unusual organism.	Environmental history and prevention redesign.
Post-antibiotic fungal	Recent antibiotic course.	Immediate catheter removal if fungus identified; prevention should include antifungal prophylaxis during antibiotic courses.

5. The first 30 minutes: threat assessment before routine treatment

Figure 10.3 — The first 30 minutes. The acute workflow is threat assessment, correct sampling, source assessment, prompt empiric coverage and a documented follow-up plan.

Table 10.6 — Features that should lower the threshold for hospitalisation or urgent escalation.

Finding	Why it matters
Haemodynamic instability / sepsis	Requires resuscitation and systemic sepsis management in parallel with PD-specific treatment.
Guarding, rebound, severe focal tenderness or rigid abdomen	Raises concern for bowel pathology or another surgical source.
Persistent vomiting, ileus or inability to perform PD safely at home	Outpatient IP therapy may be unreliable.
Fungal, polymicrobial enteric, difficult non-fermenter or NTM suspicion	Source control and complex antimicrobial management are more likely.
Uncontrolled pain or rapidly worsening clinical status	Clinical deterioration overrides routine outpatient algorithms.
Limited social support / inability to administer IP antibiotics	Logistics can make an otherwise stable episode unsafe at home.

Peripheral blood cultures are usually unnecessary in uncomplicated PD peritonitis but should be obtained when the patient is clinically septic, immunosuppressed or bacteraemia/another systemic focus is suspected. Bacteraemia during PD peritonitis should prompt consideration of another intra-abdominal or systemic source. Routine abdominal radiography is not required merely because peritonitis is suspected; imaging should answer a specific clinical question. [1]

6. Effluent sampling: culture quality is part of treatment

Table 10.7 — What to send whenever peritonitis is suspected.

Specimen/test	Purpose	Common failure
Effluent WBC count	Quantifies inflammatory burden and establishes response baseline.	Sampling after a very short dwell can understate WBC.
Differential	PMN predominance supports acute infectious inflammation.	Ignoring differential in APD rapid-cycle patients.
Gram stain	Low sensitivity but can guide urgency and fungal/Gram pattern clues.	Using a negative result to exclude infection.
Effluent culture	Identifies organism and susceptibility.	Wrong container, delayed transport, low inoculum.
Special cultures when indicated	Mycobacteria, fungi, Nocardia, fastidious bacteria.	Waiting too long in persistent culture-negative disease.

ISPD recommends that effluent be sent for cell count with differential, Gram stain and culture whenever peritonitis is suspected. Direct inoculation into blood-culture bottles at the bedside is standard practice in many units. Where resources permit, concentration/centrifugation of effluent and prompt laboratory transport improve organism recovery and help centres meet the culture-negative target. [1]

Table 10.8 — When culture-negative rates are telling you about the system.

Signal	Interpretation	Unit action
Culture-negative >15% of peritonitis episodes	Above ISPD target.	Audit collection, inoculation, transport, laboratory methods and recent pre-culture antibiotic exposure.
Sudden cluster of culture-negative episodes	Potential process/environmental issue.	Epidemiologic investigation; inspect solution, equipment and sampling chain.
Culture negative after 3 days + poor response	Possible unusual organism or wrong diagnosis.	Repeat WBC/differential and request targeted special cultures; reassess source.

QUALITY RULE A culture-negative rate is partly a microbiology outcome and partly a unit-process outcome. Treat persistent culture negativity as a diagnostic signal and a quality signal.

7. Empiric therapy: cover first, then narrow

Table 10.9 — ISPD empiric-therapy architecture.

Requirement	Guideline principle	Bedside implementation
Timing	Start as soon as possible after appropriate specimens are obtained.	Document presentation time, sample time and first-antibiotic time.
Spectrum	Cover both Gram-positive and Gram-negative organisms.	Use centre antibiogram and previous patient isolates.
Gram-positive	First-generation cephalosporin or vancomycin.	Vancomycin use depends on local methicillin resistance and patient factors.
Gram-negative	Third-generation cephalosporin or aminoglycoside.	Consider ESBL/AmpC epidemiology and prior resistant organisms.
Alternative	Cefepime monotherapy may be acceptable.	Use only where local susceptibility and programme protocol support it.
Route	IP or systemic may be used initially; IP delivers high local exposure when feasible.	Do not delay urgent treatment simply because IP logistics are unavailable.

Empiric choice should be centre-specific. The largest practical error is a regimen that fails to cover one side of the microbiologic spectrum or is administered so late that a theoretically “correct” prescription becomes ineffective. PDOPPS data support the principle that complete empiric coverage is associated with better cure. [1,6]

Table 10.10 — Route and delivery questions before you say “the patient is on antibiotics.”

Question	Why it changes treatment
Was the antibiotic actually instilled into a dwell long enough for intermittent IP delivery?	ISPD intermittent IP regimens generally assume one exchange daily with a dwell of at least 6 h.
Is the patient on APD?	Rapid cycling can shorten antibiotic dwell exposure; regimen may need adaptation.
Does substantial residual kidney function increase drug clearance?	Underdosing can occur for renally eliminated antibiotics; follow centre/pharmacy protocol.
Is the patient septic or unable to perform PD?	Systemic therapy may be necessary initially; IP can be incorporated when feasible.
Are concentrations/levels needed?	Vancomycin/aminoglycoside monitoring is drug- and protocol-specific; do not extrapolate HD targets blindly.

THRESHOLD DISCIPLINE This chapter teaches the regimen architecture and guideline durations. Exact drug doses must follow the current ISPD dosing table, local pharmacy protocol, PD modality, dwell schedule, residual kidney function, susceptibility and formulation stability. Do not copy an isolated dose into a different APD/CAPD context.

8. Adjunctive care during the acute episode

Table 10.11 — Useful adjuncts and what they do not replace.

Adjunct	Use	Boundary
Analgesia	Controls pain and enables exchanges.	Does not substitute for source assessment.
IP heparin for fibrin	ISPD notes 500 units/L may help prevent catheter occlusion while effluent is cloudy.	Treats fibrin, not infection.
Reduced fill volume when pain is severe	May improve tolerance temporarily.	Antibiotic mass/concentration must remain appropriate.
One or two rapid initial exchanges	Sometimes used for pain relief before IP antibiotics.	Extensive rapid lavage has not improved cure/relapse in randomized trials.
Antifungal prophylaxis	Co-prescribe during any antibiotic course in PD patients.	Choose nystatin/fluconazole according to availability, interactions and local policy.
N-acetylcysteine with aminoglycoside exposure	2022 guideline introduced an ototoxicity-mitigation recommendation in selected contexts.	Does not eliminate need to minimize prolonged/repeated aminoglycoside exposure.

9. Follow the response: 48 hours, day 3, day 5

Figure 10.5 — Response trajectory. Most responsive episodes improve clinically within ~48–72 hours. The day-5 rule is a safety reference, not permission to ignore earlier deterioration or a clearly improving delayed-response trajectory. [1]

Table 10.12 — Response checkpoints.

Time	What should be happening	If not
First 24–48 h	Pain and systemic features begin improving; effluent starts clearing.	Confirm antibiotic delivery, susceptibility, source and need for admission/imaging.
~48 h with poor response	Clinical improvement absent.	Repeat effluent WBC and culture; re-examine exit site/tunnel; reconsider organism/resistance/surgical source.
Day 3	WBC trajectory should be clearly downward in most successful episodes.	High persistent WBC is prognostic, not an automatic catheter-removal threshold; intensify reassessment.
Day 5	If effluent remains cloudy or WBC >0.1 ×10⁹/L after appropriate therapy, episode meets refractory definition.	Catheter removal recommended, unless a credible decreasing trajectory toward normal supports short expectant observation in a stable patient.
Any time	Clinical deterioration, sepsis, new surgical signs.	Escalate immediately; do not wait for day 5.

CORRIGENDUM ALERT The 2024 corrigendum corrected the refractory-peritonitis leukocyte definition to persistent effluent leukocytes >0.1 × 10⁹/L after 5 days of appropriate antibiotics, not >100 × 10⁹/L. Use the corrected definition. [2]

10. Organism-specific treatment: duration reflects biology, not convenience

Flowchart 10.3 — Organism → duration → catheter decision. The table below compresses major ISPD 2022 duration recommendations. Susceptibility and source control always modify the pathway.

Table 10.13 — High-yield ISPD organism-specific treatment durations.

Organism / category	Guideline direction	Catheter/source emphasis
Coagulase-negative Staphylococcus	IP cephalosporin or vancomycin by susceptibility for 2 weeks.	Review technique; consider biofilm/catheter removal in repeat or refractory disease.
Staphylococcus aureus	Effective antibiotics for 3 weeks.	Inspect exit site/tunnel carefully; catheter-related disease has lower salvage probability.
Streptococci	Appropriate antibiotics for 2 weeks.	Usually favorable; viridans group may relapse and can suggest oral source.
Corynebacterium	Effective antibiotics for 2 weeks; vancomycin for beta-lactam-resistant strains.	Early removal if poor response or catheter infection; repeat episodes may reflect biofilm.
Enterococcus	3 weeks: amoxicillin if ampicillin-susceptible or IP vancomycin; VRE requires active alternative.	Polymicrobial enterococcal disease should trigger enteric-source concern.
Pseudomonas	Two active antibiotics with different mechanisms for 3 weeks.	Remove catheter with concomitant exit-site/tunnel infection or poor response by day 5.
Enteric Gram-negative bacilli	Effective antibiotics for at least 3 weeks.	ESBL/AmpC/resistance and bowel source may drive regimen and removal threshold.
Culture-negative, improving	Continue effective initial therapy; 2 weeks is sufficient.	No growth by day 3 + poor response -> special cultures / alternative diagnosis.
Fungal	Immediate catheter removal + appropriate antifungal for at least 2 weeks after removal.	Catheter salvage is not recommended.
Mycobacterium tuberculosis	Antituberculous therapy is primary treatment.	Routine removal is not automatically required if diagnosis established and patient responding.
Non-tuberculous mycobacteria	Effective multidrug therapy + catheter removal.	Request acid-fast studies in persistent culture-negative disease when clinically plausible.

10.1 Coagulase-negative staphylococci: technique plus biofilm

Coagulase-negative staphylococci are commonly linked to touch contamination. Two weeks of susceptibility-guided therapy is generally sufficient when antibiotic exposure is adequate. A repeat episode—especially after an apparently successful course—should shift the mental model from “another touch event” toward catheter biofilm. Retraining is a treatment intervention, not a punishment. [1]

10.2 Staphylococcus aureus: search for the catheter source

S. aureus peritonitis carries a higher risk of catheter loss and relapse than low-virulence skin flora. The guideline recommends 3 weeks of effective therapy. Simultaneous exit-site or tunnel infection changes the source-control threshold and should be managed with the 2023 catheter-infection guidance. [1,3]

10.3 Pseudomonas: dual therapy and early source control

Pseudomonas behaves as a biofilm-forming difficult pathogen. ISPD suggests two active agents with different mechanisms for 3 weeks. Concomitant exit-site/tunnel infection warrants catheter removal, and lack of clinical response after 5 days should trigger early removal rather than escalation to three anti-pseudomonal drugs. [1]

10.4 Polymicrobial and enteric disease: antibiotics may not be the definitive treatment

Multiple enteric organisms, severe abdominal findings or a mixed Gram-positive/Gram-negative pattern should trigger urgent consideration of bowel pathology. Broad antimicrobial coverage, abdominal imaging and surgical consultation may dominate the case. By contrast, polymicrobial episodes containing only Gram-positive organisms can behave more like touch-contamination peritonitis and may respond to medical therapy. [1]

10.5 Fungal peritonitis: the catheter is the reservoir

Fungal peritonitis is the clearest example of source-control biology. ISPD recommends immediate catheter removal when fungi are identified and continuation of appropriate antifungal therapy for at least 2 weeks after removal. Delayed salvage attempts expose the patient to persistent biofilm infection and high mortality. [1]

11. Culture-negative peritonitis: a diagnosis that should trigger two audits

Flowchart 10.2 — Culture-negative peritonitis. A responding culture-negative episode can be treated as infectious peritonitis, but a nonresponding episode requires both a diagnostic audit and a culture-process audit.

Table 10.14 — Culture-negative peritonitis: two parallel questions.

Question	Why it matters	Action
Is this truly infectious peritonitis?	Chemical, eosinophilic, enteric and other inflammatory mimics can meet part of the phenotype.	Reassess differential if course is atypical.
Did the laboratory have a fair chance to identify the organism?	Recent antibiotics, poor inoculation, delayed transport and inadequate culture methods increase false-negative results.	Audit collection and repeat/special cultures when needed.

For episodes with no growth after 3 days, ISPD advises repeat effluent WBC/differential and special culture requests when unusual organisms are plausible. If the patient improves promptly, the initial regimen can be continued, with a 2-week treatment duration. [1,11]

12. Catheter decisions: source control is part of antimicrobial therapy

Figure 10.6 — Catheter decision logic. Catheter removal is required or strongly considered when biofilm or uncontrolled infection makes continued salvage biologically unsafe.

Table 10.15 — Catheter removal / exchange decision matrix.

Situation	Guideline direction	Reason
Fungal peritonitis	Immediate removal.	High biofilm burden and mortality with retention.
Refractory peritonitis	Remove catheter; short expectant observation only in stable patient with clearly improving WBC trajectory.	Persistent inflammatory burden harms peritoneum and patient.
Clinical deterioration before day 5	Remove/escalate earlier as indicated.	Calendar threshold must not delay source control.
Pseudomonas + exit-site/tunnel infection	Remove catheter.	Concordant catheter source is difficult to eradicate.
Pseudomonas not responding after 5 days effective therapy	Early removal favored.	A third antibiotic is not a substitute for source control.
NTM peritonitis	Antibiotics + catheter removal.	Difficult biofilm-forming infection.
Relapsing/recurrent/repeat episodes	Timely removal should be considered.	Biofilm or unresolved source may be driving recurrence.
Selected relapse/repeat after control	Simultaneous removal/reinsertion may be considered when culture negative, WBC <100/µL and no exit-site/tunnel infection.	Allows continued PD while removing colonized catheter.

13. Refractory, relapsing, recurrent and repeat are not synonyms

Table 10.16 — ISPD outcome-specific definitions.

Term	Definition	Clinical meaning
Medical cure	Complete resolution with none of: relapse/recurrent peritonitis, catheter removal, HD transfer ≥30 d or death.	Patient-important success, not merely temporary clearing.
Refractory	Persistently cloudy bags or effluent leukocytes >0.1 ×10⁹/L after 5 days of appropriate therapy.	Treatment/source-control failure unless trajectory strongly supports delayed response.
Relapsing	Within 4 weeks after therapy, same organism or specific organism/culture-negative pair.	Think persistence/biofilm.
Recurrent	Within 4 weeks after therapy, different organism.	New episode but often marks vulnerable technique/host/unit.
Repeat	>4 weeks after therapy, same organism.	Think recurrent exposure or persistent catheter biofilm.
Peritonitis-associated catheter removal	Catheter removed as part of treatment of active episode.	Outcome to report.
Peritonitis-associated HD transfer	Any transfer to HD as part of episode.	Capture even if temporary.
Peritonitis-associated death	Death attributable/associated according to guideline definition.	Unit quality outcome.

LANGUAGE MATTERS “Relapse” means same-organism persistence within 4 weeks; “recurrent” means a different organism within 4 weeks; “repeat” means the same organism after more than 4 weeks. These labels drive different causal thinking.

14. Prevention begins before the first episode

Table 10.17 — Primary prevention bundle.

Intervention	Current evidence/guidance	Practice translation
Antibiotic prophylaxis before catheter insertion	ISPD 1A recommendation.	Choose agent according to local resistance and access protocol.
High-quality training and competency assessment	ISPD guidance; PDOPPS links training practices with peritonitis risk.	Individualized teaching, return-demonstration, reassessment after events.
Exit-site/tunnel prevention and prompt treatment	2023 ISPD catheter guideline.	Cross-reference Chapter 11; catheter infection is a peritonitis risk.
Connection-system integrity	Wet contamination carries peritonitis risk.	Immediate PD-team contact after breach; do not improvise at home.
Procedure prophylaxis	ISPD suggests prophylaxis for colonoscopy and invasive gynaecological procedures; drain abdomen before procedure.	Create a pre-procedure PD checklist.
Pet/environmental precautions	Guideline recognizes pet-associated risk.	Keep animals away from equipment/exchanges; investigate unusual organisms.
Medication/host review	Hypokalaemia and H2-receptor antagonist use are modifiable associations highlighted by ISPD.	Correct clinically relevant hypokalaemia; review unnecessary H2RA exposure rather than automatic PPI substitution.
Unit surveillance	Track overall/organism-specific rates and susceptibilities.	Local antibiogram should change empiric therapy when microbiology changes.

15. Wet contamination: prevention before peritonitis develops

Table 10.18 — Dry versus wet contamination.

Contamination type	Operational idea	Action direction
Dry contamination	Contamination outside a closed system; clamp remained closed and no contaminated fluid entered.	Contact PD team; prophylactic antibiotics not routinely indicated solely for dry contamination.
Wet contamination	Open system with possibility that contaminated fluid entered; proximal leak/breach, open catheter set or touch during active connection.	Immediate PD-team advice; ISPD suggests prophylactic antibiotics.
Uncertain clamp status	Cannot confirm whether system was open.	Treat as wet contamination until proven otherwise in local protocol.

PREVENTION RULE A patient should never be left to decide alone whether a contamination event “counts.” Every breach gets immediate unit contact and a named dry-vs-wet decision.

16. Antifungal prophylaxis: make it automatic when antibiotics are prescribed

ISPD recommends antifungal prophylaxis whenever a PD patient receives an antibiotic course, regardless of the indication. Randomized trials of nystatin or fluconazole and a Cochrane synthesis support reduced subsequent fungal peritonitis. The guideline cites oral nystatin 500,000 units four times daily or fluconazole 200 mg every 48 hours as studied prophylaxis regimens, but local availability, interactions, QT/hepatic considerations, resistance ecology and pharmacy policy must guide the chosen regimen. [1,14,15]

Table 10.19 — Antifungal prophylaxis safety check.

Question	Why
Is nystatin available?	Avoids systemic azole interactions where available.
If fluconazole is used, what interacts?	Warfarin, calcineurin inhibitors, some statins and other drugs may require review.
Is prophylaxis prescribed for non-peritonitis antibiotic courses too?	ISPD recommendation applies regardless of antibiotic indication.
Is the stop date linked to the antibacterial course?	Prevents unplanned prolonged antifungal exposure.

17. Every episode gets an apparent-cause analysis

Table 10.20 — Root-cause review after peritonitis.

Domain	Questions	Corrective action examples
Technique	Any touch contamination, rushing, visual/hand limitation, skipped steps?	Observed exchange + targeted retraining.
Connection/equipment	Bag, tubing, transfer set or cycler breach?	Replace component, clarify wet-contamination plan, manufacturer review if cluster.
Exit site/tunnel	Recent drainage, pain, cuff/tunnel abnormality?	Treat catheter infection; cross-reference Chapter 11.
Bowel	Constipation, diarrhoea, GI procedure, diverticular disease symptoms?	Bowel regimen, procedure prophylaxis, surgical/GI assessment where indicated.
Medication	Recent antibiotic course without antifungal prophylaxis? Hypokalaemia? H2RA?	Correct medication/process gap.
Environment/pets	Animals near exchange area? water/air/environment cluster?	Environmental redesign; unit investigation for unusual clusters.
Microbiology process	High culture-negative rate or delayed transport?	Laboratory/process intervention.
Patient capability	Vision, dexterity, cognition, caregiver support changed?	Retraining, assisted PD or modality redesign rather than blame.

18. Major clinical algorithms

Flowchart 10.1 — Suspected PD-associated peritonitis. The algorithm begins with threat recognition, then sampling, source assessment and prompt empiric therapy. Unstable or surgical phenotypes bypass routine outpatient logic.

Flowchart 10.2 — Culture-negative peritonitis. A responding episode can complete a 2-week course; a nonresponding episode triggers repeat cell count, special cultures and reconsideration of source or diagnosis.

Flowchart 10.3 — Organism to duration and catheter strategy. Treatment duration reflects pathogen biology. Source-control decisions are not delayed merely to “finish the antibiotics.”

19. Retention tables: pattern recognition

Table 10.21 — If you see this, think this first.

Finding	First hypothesis	Immediate action
Cloudy bag + mild diffuse pain	PD peritonitis.	Send effluent and start empiric therapy promptly.
Cloudy bag + rigid/focal abdomen	Enteric/surgical source until excluded.	Hospital assessment, imaging/surgery as indicated.
Pain on APD with WBC 80/µL but 85% PMN	Peritonitis still likely despite low absolute WBC.	Use PMN proportion and dwell context; treat after sampling.
No growth day 3 + improving WBC	Culture-negative bacterial episode likely.	Continue effective initial therapy; complete 2 weeks.
No growth day 3 + WBC rising	Unusual organism, wrong regimen, wrong source or noninfectious mimic.	Repeat studies; special cultures; source re-evaluation.
Same CoNS 6 weeks later	Repeat peritonitis.	Think biofilm/re-exposure; consider catheter strategy.
Same S. aureus 2 weeks after therapy	Relapsing peritonitis.	Think persistent catheter/source; timely removal consideration.
Pseudomonas + tunnel drainage	Catheter-related difficult infection.	Dual active therapy + catheter removal.
Yeast on culture	Fungal peritonitis.	Immediate catheter removal + antifungal.
Recent systemic antibiotics without prophylaxis + fungal peritonitis	Preventable secondary risk.	Treat episode and fix antifungal-prophylaxis process.

Table 10.22 — What not to confuse.

Do not confuse	With	Correction
Cloudy effluent	Automatic culture-positive bacterial infection	Use diagnostic triad and differential.
Culture negative	No infection	Could reflect prior antibiotics or poor culture method.
Day-5 WBC >100/µL	Automatic removal regardless of trajectory	Refractory definition matters, but stable delayed responders with falling WBC may be observed briefly.
Relapse	Recurrent	Relapse = same organism/sterile pairing within 4 weeks; recurrent = different organism within 4 weeks.
Antibiotics completed	Medical cure	Medical cure excludes relapse/recurrent, catheter removal, HD transfer ≥30 d and death.
More antibiotics	Better source control	Fungal/NTM/refractory/biofilm disease may require removal.
Exit site looks normal	No catheter source	Tunnel infection or intraluminal biofilm can still exist.
IP route	Guaranteed adequate exposure	Dwell time, APD cycle, drug clearance and preparation matter.

20. Clinical pearls

1. Peritonitis diagnosis is clinical + cellular + microbiologic; culture is not required if the other two criteria are met.

2. In APD, PMN percentage can be more informative than absolute WBC when dwell times are short.

3. Obtaining the specimen first is important; waiting for the result before starting therapy is not.

4. If the patient is unstable, systemic sepsis care and surgical evaluation proceed in parallel with PD-specific treatment.

5. Culture-negative peritonitis that is not improving by day 3 is a diagnostic problem, not a reason to blindly continue the same plan.

6. Fungal peritonitis is a source-control emergency: remove the catheter immediately.

7. Pseudomonas plus tunnel/exit infection is a catheter-removal phenotype.

8. Repeated prolonged antibiotic courses can select fungus and resistance without curing catheter biofilm.

9. Every antibiotic course in a PD patient should automatically trigger an antifungal-prophylaxis decision.

10. Every peritonitis episode should end with a prevention action, even when the immediate cure is uncomplicated.

21. Common pitfalls — and the correction

Table 10.23 — High-frequency errors in PD-peritonitis care.

Pitfall	Why it fails	Correction
Waiting for lab confirmation before antibiotics	Delays treatment in a time-sensitive infection.	Sample promptly, then cover empirically.
No differential count	Misses APD/atypical diagnostic signal.	Always request WBC + differential.
Culture in a sterile pot only	Lower organism recovery.	Use validated blood-culture bottle / concentration method.
Empiric regimen covers only Gram-positive organisms	Misses severe Gram-negative disease.	Cover both sides according to local antibiogram.
Copying CAPD dosing into rapid APD	May underexpose the organism.	Check dwell and modality-specific protocol.
Calling day-5 cloudiness “refractory” without checking trend	May remove a catheter in a delayed responder.	Use symptoms + WBC trajectory, while respecting safety threshold.
Trying a third drug for Pseudomonas instead of removing source	Biofilm persists.	Use two active agents + timely source control.
Treating fungus with catheter retention	High failure/mortality risk.	Immediate removal.
No antifungal prophylaxis with antibiotics	Increases secondary fungal risk.	Hardwire prophylaxis into antibiotic order set.
No post-episode technique review	Misses preventable recurrence.	Apparent-cause analysis + retraining when indicated.

22. Mini-cases: decisions, not trivia

Case 1 — Short-dwell APD

A patient on nocturnal APD presents at noon with diffuse abdominal pain. A freshly instilled 2-hour dwell returns slightly cloudy; WBC is 82/µL with 88% PMN.

BEST NEXT STEP The low absolute WBC does not exclude peritonitis. The dwell is adequate and PMN predominance is strong evidence. Obtain culture and start prompt empiric Gram-positive/Gram-negative coverage.

Case 2 — Culture negative but improving

Day 3: cultures remain negative. Pain has nearly resolved, effluent is clearer and WBC has fallen markedly.

BEST NEXT STEP This is a responding culture-negative episode, commonly due to Gram-positive organisms or culture-process limitations. Continue effective initial therapy and complete the guideline 2-week course; review culture technique if the unit rate is high.

Case 3 — Day-5 delayed responder

On day 5 the patient is clinically well. Effluent is still faintly cloudy and WBC is 180/µL, down from 4,500/µL on day 1.

BEST NEXT STEP The episode technically meets the refractory threshold, but the patient has a clear downward trajectory. ISPD allows short expectant observation beyond day 5 in a stable patient when WBC is decreasing toward normal. Continue close review; deterioration changes the decision immediately.

Case 4 — Pseudomonas plus tunnel pain

Pseudomonas grows from effluent. The exit site is erythematous and there is tenderness along the tunnel.

BEST NEXT STEP This is a high-probability catheter-related difficult infection. Use two active anti-pseudomonal agents and remove the catheter rather than attempting prolonged salvage.

Case 5 — Same organism after 2 weeks

Two weeks after completing treatment for S. aureus peritonitis, the patient develops another episode with the same organism.

BEST NEXT STEP This is relapsing peritonitis. Search for catheter/tunnel source and biofilm; timely catheter removal should be considered rather than repeating the same course indefinitely.

Case 6 — Yeast after antibiotics

A patient completed antibiotics for pneumonia without antifungal prophylaxis. Two weeks later, peritonitis culture grows Candida.

BEST NEXT STEP Remove the PD catheter immediately and treat with an appropriate antifungal for at least 2 weeks after removal. The event also exposes a prevention-system failure: antifungal prophylaxis should accompany future antibiotic courses.

23. Active recall

MUST MEMORIZE

Table 10.24 — Core facts.

Prompt	Answer
ISPD diagnosis?	At least 2 of 3: compatible symptoms/cloudy effluent; WBC >100/µL after ≥2 h with >50% PMN; positive culture.
APD caveat?	>50% PMN strongly supports diagnosis even if absolute WBC <100/µL with short dwells.
Overall unit peritonitis target?	≤0.40 episodes per patient-year at risk.
Culture-negative target?	<15% of all peritonitis episodes.
Patients free of peritonitis target?	>80% per year.
Refractory definition?	Persistently cloudy bags or effluent leukocytes >0.1 ×10⁹/L after 5 days of appropriate antibiotics.
CoNS duration?	2 weeks.
S. aureus duration?	3 weeks.
Streptococcal duration?	2 weeks.
Enterococcus duration?	3 weeks.
Pseudomonas?	Two active agents, 3 weeks; catheter source-control logic.
Fungal?	Immediate catheter removal + antifungal ≥2 weeks after removal.
Culture-negative responding?	2 weeks.
Antibiotic course in any PD patient?	Co-prescribe antifungal prophylaxis.

MUST REASON

Why a rapid-cycle APD effluent WBC of 80/µL with 90% PMN can still represent peritonitis.
Why a culture-negative episode can be either an infection-management problem or a laboratory-process problem.
Why clinical deterioration should trigger catheter/source-control escalation before day 5.
Why a day-5 WBC of 180/µL can justify different decisions depending on its trajectory and the patient’s clinical state.
Why Pseudomonas tunnel infection and fungal peritonitis are biologically different from uncomplicated CoNS peritonitis.
Why a “successful” antibiotic course is not medical cure if the episode relapses or forces prolonged HD transfer.
How the same organism occurring at 2 weeks versus 8 weeks changes the label and the source hypothesis.

USE AS REFERENCE

Exact IP and systemic antibiotic doses by agent, CAPD/APD schedule and residual kidney function.
Local antibiogram thresholds for empirical vancomycin or resistant Gram-negative coverage.
Drug compatibility/stability in specific PD solutions and bags.
Antifungal selection in Candida versus mould peritonitis.
NTM/TB multidrug regimens and duration.
Procedure-specific prophylaxis protocols and local surgical pathways.

24. Flashcards: spaced repetition

1. Q: Cloudy effluent: first assumption? A: Peritonitis until confirmed or excluded.

2. Q: Three diagnostic criteria? A: Symptoms/cloudy effluent; inflammatory effluent WBC/PMN; positive effluent culture.

3. Q: What makes APD diagnosis tricky? A: Short dwells can keep absolute WBC low; PMN proportion is key.

4. Q: First microbiology bundle? A: Effluent WBC/differential, Gram stain and culture.

5. Q: Empiric spectrum? A: Gram-positive + Gram-negative.

6. Q: Empiric Gram-positive choices? A: First-generation cephalosporin or vancomycin.

7. Q: Empiric Gram-negative choices? A: Third-generation cephalosporin or aminoglycoside; cefepime monotherapy may be acceptable.

8. Q: Why prompt antibiotics? A: Delay after healthcare presentation is associated with catheter loss/death.

9. Q: Day-5 threshold? A: Cloudy effluent or leukocytes >0.1×10⁹/L despite appropriate therapy = refractory definition.

10. Q: Same organism within 4 weeks? A: Relapsing.

11. Q: Different organism within 4 weeks? A: Recurrent.

12. Q: Same organism after >4 weeks? A: Repeat.

13. Q: Fungal catheter management? A: Immediate removal.

14. Q: Pseudomonas with tunnel infection? A: Remove catheter.

15. Q: Culture-negative + improving? A: Continue effective initial therapy for 2 weeks.

16. Q: No growth after 3 days + poor response? A: Repeat WBC, special cultures and rethink diagnosis/source.

17. Q: Antifungal prophylaxis timing? A: Whenever a PD patient receives any antibiotic course.

18. Q: Best prevention response after an episode? A: Apparent-cause analysis + targeted intervention/retraining.

25. Rapid differential / troubleshooting

Table 10.25 — Peritonitis troubleshooting from problem to action.

Problem	Differential	First actions
Cloudy effluent, minimal pain	Early bacterial peritonitis; chemical/eosinophilic; chylous effluent.	Cell count/differential + culture; inspect effluent appearance; treat as peritonitis until excluded.
Severe pain but low WBC	Very early infection; short APD dwell; bowel pathology; pancreatitis.	Repeat adequate dwell sample; assess PMN; examine abdomen; image if surgical concern.
No clinical response by 48 h	Wrong drug, resistant organism, catheter source, enteric disease, fungal/NTM, wrong diagnosis.	Repeat WBC/culture; review susceptibility/delivery; inspect catheter/tunnel; image/escalate as indicated.
Effluent remains cloudy day 5	Refractory episode or delayed responder.	Assess trend; remove catheter unless stable with clearly decreasing WBC toward normal.
Recurrent CoNS episodes	Repeated touch contamination or catheter biofilm.	Observed technique + retraining; consider catheter exchange/removal.
Polymicrobial Gram+ and Gram−	Enteric source.	Broad coverage, imaging, surgical assessment.
Culture-negative cluster in unit	Sampling/laboratory/environmental problem.	CQI investigation, culture-process audit, environmental review.
Fungal after recent antibiotics	Secondary fungal peritonitis.	Immediate catheter removal + antifungal; fix prophylaxis process.

26. Final revision sheet

CORE CONCEPT PD-associated peritonitis is a time-sensitive inflammatory syndrome in which success depends on five linked tasks: diagnose, culture, cover, identify source, and verify response. Catheter removal is a source-control tool, not a defeat.

Table 10.26 — One-minute revision.

Domain	Must remember
Diagnosis	≥2 of 3 criteria; PMN >50% is crucial in rapid-cycle APD.
Sampling	WBC/differential + Gram stain + culture before antibiotics.
Empiric therapy	Prompt, centre-specific, Gram+ and Gram− coverage.
Response	Clinical improvement should begin by 48–72 h; follow WBC trajectory.
Refractory	Day-5 cloudy/WBC >0.1×10⁹/L despite appropriate therapy; remove unless stable delayed responder with falling WBC.
Durations	CoNS 2 wk; S. aureus 3 wk; strep 2 wk; Coryne 2 wk; Enterococcus 3 wk; Pseudomonas dual therapy 3 wk; culture-negative responding 2 wk.
Catheter	Fungus remove now; NTM remove; Pseudomonas + catheter infection remove; relapse/repeat/recurrent consider timely removal.
Prevention	Insertion prophylaxis, training, exit-site care, wet-contamination plan, procedure prophylaxis, antifungal with every antibiotic course.
Quality	Unit target ≤0.40 episodes/patient-year; culture-negative <15%; >80% patients peritonitis-free/year.
After cure	Apparent-cause analysis and prevention intervention.

TEN TAKE-HOME RULES 1) Cloudy effluent is peritonitis until proven otherwise. 2) Diagnose using two of three ISPD criteria. 3) In APD, trust the PMN proportion when the dwell is short. 4) Sample first, then treat promptly. 5) Cover Gram-positive and Gram-negative organisms empirically. 6) Reassess at 48 h, day 3 and day 5 using the WBC trajectory. 7) Fungus and NTM require catheter source control; Pseudomonas often does. 8) Relapse/recurrent/repeat are different entities. 9) Give antifungal prophylaxis with every antibiotic course. 10) Every episode ends with apparent-cause analysis and prevention redesign.

Table 10.27 — One-minute bedside synthesis.

If you see…	Think…	Do now…
Cloudy effluent + pain	PD peritonitis	Effluent studies + prompt empiric therapy.
WBC <100/µL, PMN >50% on rapid APD	Peritonitis still likely	Use dwell context; culture and treat.
Rigid/focal abdomen	Enteric/surgical disease	Hospital + imaging/surgical review.
No growth day 3, improving	Culture-negative bacterial episode	Continue effective course; 2 weeks.
No growth day 3, worsening	Unusual organism / wrong source / mimic	Special cultures + diagnostic reset.
Same organism 2 weeks later	Relapse	Biofilm/source; catheter strategy.
Pseudomonas + tunnel infection	Catheter-related difficult infection	Dual therapy + remove catheter.
Fungus	Biofilm source-control emergency	Remove catheter immediately.
Any antibiotic course	Secondary fungal risk	Add antifungal prophylaxis.
Episode resolved	Prevention opportunity	Apparent-cause analysis + retraining/process fix.

FINAL MENTAL MODEL Threat -> diagnostic triad -> correct effluent sample -> prompt Gram+/Gram− coverage -> organism/source -> response trajectory -> catheter decision -> medical cure -> apparent-cause analysis.

Rapid oral viva

Give the ISPD diagnostic criteria and explain the APD short-dwell exception.
Walk through the first 30 minutes of a cloudy-bag presentation.
Differentiate refractory, relapsing, recurrent and repeat peritonitis.
Explain why culture-negative peritonitis can be a laboratory-quality problem.
Compare catheter strategy for CoNS, Pseudomonas, fungal and NTM peritonitis.
Explain why extensive lavage and indiscriminate prolonged antibiotics are not routine solutions.
Build a prevention plan after a touch-contamination CoNS episode and after fungal peritonitis following systemic antibiotics.

SAFETY BOUNDARY This chapter teaches clinical reasoning and guideline architecture. Exact antimicrobial dosing, compatibility, stability, therapeutic drug monitoring, allergy substitution, resistant-organism therapy, fungal species treatment and timing of catheter reinsertion require the current ISPD tables, local microbiology, renal pharmacy, infectious-disease and PD programme protocols. Surgical abdomen and sepsis pathways supersede routine outpatient PD logic.

27. Selected authoritative references

1. Li PKT, Chow KM, Cho Y, et al. ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment. Perit Dial Int. 2022;42(2):110–153. https://doi.org/10.1177/08968608221080586. PMID: 35264029.

2. Corrigendum to 2022 ISPD Peritonitis Guidelines: 2022 update on prevention and treatment. Perit Dial Int. 2024;44(3):223. https://doi.org/10.1177/08968608241251453. PMID: 38643390.

3. Chow KM, Li PKT, Cho Y, et al. ISPD Catheter-related Infection Recommendations: 2023 Update. Perit Dial Int. 2023;43(3):201–219. https://doi.org/10.1177/08968608231172740. PMID: 37232412.

4. Chow JSF, Brunier G, Figueiredo AE, et al. Teaching peritoneal dialysis: A position paper for the International Society for Peritoneal Dialysis. Perit Dial Int. 2025;45(6):327–343. https://doi.org/10.1177/08968608251375512. PMID: 40966019.

5. Hurst H, Figueiredo AE, Perez Moran D, et al. Peritoneal dialysis training and interventions: A narrative review. Perit Dial Int. 2026;46(1):6–15. https://doi.org/10.1177/08968608251328517. PMID: 40221963.

6. Perl J, Fuller DS, Bieber BA, et al. Peritoneal Dialysis-Related Infection Rates and Outcomes: Results From the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS). Am J Kidney Dis. 2020;76(1):42–53. https://doi.org/10.1053/j.ajkd.2019.09.016. PMID: 31932094.

7. Al Sahlawi M, Zhao J, McCullough K, et al. Variation in Peritoneal Dialysis-Related Peritonitis Outcomes in the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS). Am J Kidney Dis. 2022;79(1):45–55.e1. https://doi.org/10.1053/j.ajkd.2021.03.022. PMID: 34052357.

8. Muthucumarana K, Howson P, Crawford D, Burrows S, Swaminathan R, Irish A. The Relationship Between Presentation and the Time of Initial Administration of Antibiotics With Outcomes of Peritonitis in Peritoneal Dialysis Patients: The PROMPT Study. Kidney Int Rep. 2016;1(2):65–72. https://doi.org/10.1016/j.ekir.2016.05.003. PMID: 29142915.

9. Kitrungphaiboon T, Puapatanakul P, Chuengsaman P, et al. Intraperitoneal Cefepime Monotherapy Versus Combination Therapy of Cefazolin Plus Ceftazidime for Empirical Treatment of CAPD-Associated Peritonitis: A Multicenter, Open-Label, Noninferiority, Randomized, Controlled Trial. Am J Kidney Dis. 2019;74(5):601–609. https://doi.org/10.1053/j.ajkd.2019.05.011. PMID: 31331757.

10. Htay H, Cho Y, Pascoe EM, et al. Multicentre registry data analysis comparing outcomes of culture-negative peritonitis and different subtypes of culture-positive peritonitis in peritoneal dialysis patients. Perit Dial Int. 2020;40(1):47–56. PMID: 32063153.

11. Szeto CC, Wong TY, Chow KM, et al. The clinical course of culture-negative peritonitis complicating peritoneal dialysis. Am J Kidney Dis. 2003;42(3):567–574.

12. Htay H, Cho Y, Pascoe EM, et al. Outcomes of Corynebacterium Peritonitis: A Multicenter Registry Analysis. Perit Dial Int. 2017;37(6):619–626. https://doi.org/10.3747/pdi.2017.00028. PMID: 28698253.

13. Szeto CC, Chow KM, Kwan BCH, et al. Staphylococcus aureus peritonitis complicates peritoneal dialysis: review of 245 consecutive cases. Clin J Am Soc Nephrol. 2007;2(2):245–251.

14. Chang TI, Kim HW, Park JT, et al. Early catheter removal improves patient survival in peritoneal dialysis patients with fungal peritonitis: results of ninety-four episodes. Perit Dial Int. 2011;31(1):60–66.

15. Lo WK, Chan CY, Cheng SW, et al. A prospective randomized control study of oral nystatin prophylaxis for Candida peritonitis complicating continuous ambulatory peritoneal dialysis. Am J Kidney Dis. 1996;28(4):549–552.

16. Restrepo C, Chacon J, Manjarres G. Fungal peritonitis in peritoneal dialysis patients: successful prophylaxis with fluconazole, as demonstrated by prospective randomized control trial. Perit Dial Int. 2010;30(6):619–625.

17. Kraft L, Oppold J, Kitterer D, et al. Changing microbiology and outcomes of PD-associated peritonitis over four decades. Clin Kidney J. 2026;19(1):sfaf387. https://doi.org/10.1093/ckj/sfaf387. PMID: 41536568.