⚠ 已註記敗血症：勿為等待 IP 給藥而延遲抗生素。立即給予適當靜脈抗生素、抽血液培養並評估住院、器官支持與感染源控制；穩定後再由腎臟科／感染科規劃 IP 治療，避免 IV＋IP 重複造成過量。
⚠ Sepsis flagged: do not delay antibiotics while arranging IP therapy. Give appropriate IV antibiotics immediately, obtain blood cultures, and assess admission, organ support, and source control. Plan subsequent IP therapy with Nephrology/ID and avoid unintended duplicate IV+IP dosing.
1
診斷確認Confirm the diagnosis
3 項中 ≥2 項≥2 of 3給藥前以無菌技術取樣：細胞計數與分類、革蘭氏染色、培養（床邊接種需氧＋厭氧血液培養瓶）。一般診斷門檻使用留置 ≥2 小時的透析液。Before antibiotics, obtain an aseptic sample for cell count/differential, Gram stain, and culture (bedside inoculation into aerobic and anaerobic blood-culture bottles). The standard cell-count threshold applies after a dwell of ≥2 h.
- ?① 腹痛 和／或 透析液混濁① Abdominal pain and/or cloudy effluent
- ?② 透析液 WBC >100/µL（留置 ≥2h）且 PMN >50%；APD 快速循環時 PMN >50% 即為強烈證據② Effluent WBC >100/µL after ≥2 h with PMN >50%; in rapid-cycle APD, PMN >50% is strong evidence even with WBC <100/µL
- ?③ 透析液培養陽性③ Positive effluent culture
重要：混濁透析液應先視為腹膜炎並治療，直到確認或排除。APD 無日間留置者，可灌入慣用容量、留置至少 2 小時後採樣。腹痛局限、反彈痛或多重腸道菌時，應警覺外科腹症。並檢查出口與隧道。
Important: Cloudy effluent should be presumed to represent peritonitis and treated until confirmed or excluded. For APD without a daytime dwell, instill the usual fill volume and dwell for at least 2 h before sampling. Localized pain, rebound, or multiple enteric organisms should prompt evaluation for surgical pathology. Inspect the exit site and tunnel.
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經驗性抗生素（立即開始）Empiric antibiotics (start promptly)
同時覆蓋 G(+)/G(−)cover G(+) and G(−)取得適當檢體後立即治療，勿等待培養。無敗血症時首選 IP；間歇給藥原則上放入每日一次的長留置袋（通常 ≥6 小時）。Start immediately after obtaining appropriate specimens; do not wait for cultures. IP is preferred without sepsis. Intermittent doses are generally placed in one long dwell each day, usually ≥6 h.
小兒 2024：可使用 IP cefepime 單方；或 cefazolin／vancomycin ＋ ceftazidime（優先於 aminoglycoside）。若中心 MRSA 比例高（例如 >10%）或病人有 MRSA 感染／移生史，應納入 vancomycin。敗血症先使用 IV。
Pediatric 2024: use IP cefepime monotherapy, or cefazolin/vancomycin plus ceftazidime (preferred over an aminoglycoside). Include vancomycin when local MRSA prevalence is high (e.g. >10%) or with prior MRSA infection/colonization. Use IV therapy first in sepsis.
成人 2022：依在地菌譜選第一代 cephalosporin 或 vancomycin 覆蓋 G(+)，並以第三代 cephalosporin 或 aminoglycoside 覆蓋 G(−)；cefepime 單方亦有證據支持。
Adult 2022: choose a first-generation cephalosporin or vancomycin for G(+) coverage and a third-generation cephalosporin or aminoglycoside for G(−) coverage according to local susceptibility; cefepime monotherapy is also supported.
革蘭氏陽性覆蓋Gram-positive coverage
MRSA／高抗藥風險選項MRSA/high-resistance option
Vancomycin
—
對 methicillin 敏感菌選項Methicillin-susceptible option
Cefazolin
—
革蘭氏陰性覆蓋Gram-negative coverage
首要 cephalosporin 選項Primary cephalosporin option
Ceftazidime
—
替代（避免延長療程）Alternative (avoid prolonged use)
Gentamicin
—
依在地菌譜與過敏史調整。顯著殘餘腎功能可能需要較高或較頻繁劑量，但本工具不自動加量；請依院內 protocol、TDM 與感染科／藥師建議。β-lactam 過敏不可一概等同使用 aztreonam，須先釐清過敏型態及目標菌。
Adapt to local susceptibility and allergy history. Significant residual kidney function may require a higher or more frequent dose, but this tool does not automatically increase doses. Follow local protocols, TDM, and ID/pharmacy advice. Do not automatically substitute aztreonam for every reported beta-lactam allergy; clarify the reaction and target organisms.
✚
CAPD／APD 加藥計算機CAPD/APD bag-additive calculator
依 ISPD 表格換算based on ISPD tables選藥物、給藥方式、模式與留置類型。計算只作數學換算；相容性、穩定性、過敏、藥敏與 TDM 仍需另行核對。Choose the drug, strategy, modality, and dwell type. This is a mathematical conversion only; compatibility, stability, allergy, susceptibility, and TDM still require independent verification.
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48–72 小時再評估Reassess at 48–72 hours
臨床反應、WBC 趨勢、培養response, WBC trajectory, culture- ✓規律觀察透析液是否轉清，重新檢查導管出口與隧道。Inspect effluent clearing regularly and re-examine the catheter exit site and tunnel.
- ✓48 小時仍無改善：重抽細胞計數／分類與培養，重新評估外科腹症、黴菌、分枝桿菌及其他特殊病原。No improvement by 48 h: repeat cell count/differential and cultures; reassess for surgical pathology, fungi, mycobacteria, and other unusual organisms.
- ✓培養與藥敏完成後選擇最窄、有效的藥物，停用不需要的廣效或耳／腎毒性藥物。Once culture and susceptibility data are available, use the narrowest effective therapy and stop unnecessary broad-spectrum or oto/nephrotoxic agents.
難治性腹膜炎：適當抗生素治療 5 天後透析液仍未轉清，原則上應移除導管。但第 5 天不是機械式硬門檻：若病況穩定且透析液 WBC 持續明顯下降、趨近正常，可依病原毒力與臨床情況短暫延長觀察；若病況惡化則應更早拔管。
Refractory peritonitis: failure of the effluent to clear after 5 days of appropriate antibiotics generally warrants catheter removal. Day 5 is not a mechanical rule: if the patient is stable and effluent WBC is clearly falling toward normal, brief additional observation may be reasonable according to organism virulence and the clinical course; remove earlier if the patient deteriorates.
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培養導向治療Culture-directed therapy
依上方族群顯示population-specific下列為建議的總療程，不是自透析液轉清日起重新計算。應依臨床反應、藥敏、導管感染與感染源控制個別化。Durations below refer to the recommended total course, not a new count beginning when the effluent clears. Individualize according to response, susceptibility, catheter infection, and source control.
G(+)凝固酶陰性葡萄球菌Coagulase-negative staphylococci 14d
- 依藥敏使用 IP cefazolin 或 vancomycin，共 2 週。檢討換液技術與觸染。Use IP cefazolin or vancomycin according to susceptibility for 2 weeks. Review exchange technique and touch contamination.
- 復發／重複發作應考慮生物膜及導管更換策略。Relapsing or repeat episodes should prompt consideration of biofilm and catheter-exchange strategies.
G(+)金黃色葡萄球菌／MRSAS. aureus / MRSA 21d14d
- MSSA：IP cefazolin；MRSA：IP vancomycin，依藥敏與 TDM 調整。MSSA: IP cefazolin. MRSA: IP vancomycin, adjusted to susceptibility and TDM.
- 成人總療程 3 週。可考慮口服 rifampicin 5–7 天作輔助，但注意交互作用且不可單用。AdultTotal course 3 weeks. Adjunctive oral rifampicin for 5–7 days may be considered; check interactions and never use it alone.
- 小兒總療程 2 週；僅在初期反應不佳時考慮加口服 rifampicin。PediatricTotal course 2 weeks; consider oral rifampicin only for a poor initial response.
- 同菌出口／隧道感染時屬導管相關感染，應積極評估拔管。A concurrent exit-site/tunnel infection with the same organism is catheter-related and warrants aggressive catheter-removal assessment.
G(+)鏈球菌Streptococcus 14d
- 依藥敏使用窄效藥物 2 週；小兒可用 IP cefazolin，若不敏感則依藥敏改 cefepime 或 vancomycin。Use the narrowest susceptible agent for 2 weeks; in children, IP cefazolin is preferred when susceptible, otherwise use cefepime or vancomycin according to susceptibility.
G(+)腸球菌Enterococcus 21d14–21d
- Ampicillin-sensitive：優先考慮口服 amoxicillin；ampicillin-resistant、vancomycin-sensitive：IP vancomycin。Ampicillin-susceptible: consider oral amoxicillin; ampicillin-resistant but vancomycin-susceptible: IP vancomycin.
- VRE：依藥敏使用 IP daptomycin 或口服／IV linezolid，照會感染科。VRE: use IP daptomycin or oral/IV linezolid according to susceptibility and consult ID.
- 不要使用 IP ampicillin 治療腸球菌腹膜炎，也不建議以 aminoglycoside 作協同治療。Do not use IP ampicillin for enterococcal peritonitis; aminoglycoside synergy is not recommended.
- 成人總療程 3 週。AdultTotal course 3 weeks.
- 小兒總療程 2–3 週。PediatricTotal course 2–3 weeks.
G(−)腸桿菌目／其他常見 G(−)Enterobacterales / common G(−) ≥21d14d
- 成人依藥敏治療至少 3 週；ESBL／AmpC／CRE 依機轉選藥並考慮感染科。AdultTreat according to susceptibility for at least 3 weeks; select therapy according to ESBL/AmpC/CRE mechanisms and consider ID input.
- 小兒一般敏感菌以 IP cefazolin 或 ceftazidime 治療 2 週；ESBL 可用 meropenem 或 ciprofloxacin，AmpC 高風險菌優先 cefepime（敏感時），CRE 照會感染科。PediatricFor usual susceptible organisms, use IP cefazolin or ceftazidime for 2 weeks. For ESBL use meropenem or ciprofloxacin; for high-risk AmpC organisms use cefepime when susceptible; consult ID for CRE.
G(−)綠膿桿菌Pseudomonas aeruginosa 21d
- 成人使用兩種不同機轉且均敏感的抗生素，共 3 週。AdultUse two susceptible agents with different mechanisms for 3 weeks.
- 小兒依藥敏使用單一有效藥物 3 週；優先 IP ceftazidime 或 cefepime，必要時 meropenem 或 ciprofloxacin。不常規持續雙藥。PediatricUse one active susceptible agent for 3 weeks, preferably IP ceftazidime or cefepime; use meropenem or ciprofloxacin when needed. Routine prolonged dual therapy is not recommended.
- 合併同菌出口／隧道感染，或有效治療 5 天仍無反應，應移除導管。Remove the catheter for a concurrent exit-site/tunnel infection with the same organism or failure to respond after 5 days of effective therapy.
G(−)Stenotrophomonas maltophiliaStenotrophomonas maltophilia ≥21d · 2 drugs
- 成人TMP-SMX 為主要藥物之一，使用兩種不同類別的敏感藥至少 3 週。AdultTMP-SMX is a key option; use two susceptible agents from different classes for at least 3 weeks.
- 小兒口服 TMP-SMX 加另一種有效藥物（如 levofloxacin、minocycline／tigecycline 或 cefiderocol），共 3 週。PediatricUse oral TMP-SMX plus another active agent such as levofloxacin, minocycline/tigecycline, or cefiderocol for 3 weeks.
⚑多重腸道菌／厭氧菌Multiple enteric organisms / anaerobes 個別化individualize
- 警覺腸穿孔、缺血、闌尾炎或其他腹內感染源；加入厭氧覆蓋並擴大 G(−) 覆蓋。Suspect perforation, ischemia, appendicitis, or another intra-abdominal source; add anaerobic and broader G(−) coverage.
- 立即腹部影像與外科照會。導管處置取決於感染源控制與臨床反應。Obtain urgent abdominal imaging and surgical consultation. Catheter management depends on source control and clinical response.
陰性Neg培養陰性腹膜炎Culture-negative peritonitis 14d
- 符合診斷且反應良好：總療程 2 週。When diagnostic criteria are met and the response is prompt, use a total 2-week course.
- 小兒72 小時仍培養陰性且症狀改善時，改為 cefazolin 單方；停用 vancomycin 與 aminoglycoside 等不必要藥物。PediatricIf cultures remain sterile at 72 h and symptoms improve, switch to cefazolin monotherapy and discontinue unnecessary vancomycin or aminoglycoside therapy.
- 72 小時未改善：重採檢體並加做黴菌、分枝桿菌、Nocardia 及其他特殊培養；第 5 天仍無改善則依難治性腹膜炎處置。No improvement by 72 h: re-sample and request fungal, mycobacterial, Nocardia, and other special cultures; manage as refractory peritonitis if there is still no improvement by day 5.
⚠黴菌性腹膜炎Fungal peritonitis 立即拔管remove promptly
透析液見黴菌元素或培養陽性，即儘速移除導管，不要等待完整菌種鑑定。When fungal elements are seen or culture is positive, remove the catheter promptly; do not wait for complete species identification.
- 抗黴菌藥依菌種與藥敏選擇；fluconazole 僅適用於敏感菌，且口服途徑通常優於 IP。非敏感 Candida 或絲狀真菌需其他 azole／echinocandin 等並照會感染科。Choose antifungal therapy by species and susceptibility. Fluconazole is only for susceptible organisms and the oral route is usually preferred over IP. Non-susceptible Candida or filamentous fungi require other azoles/echinocandins and ID consultation.
- 拔管後持續抗黴菌至少 2 週，部分病例需更久。Continue antifungal therapy for at least 2 weeks after catheter removal; some cases require longer treatment.
少見Rare分枝桿菌Mycobacteria 感染科處置ID-directed
- 結核分枝桿菌：以抗結核多藥治療為主，並非一律拔管。M. tuberculosis: primary treatment is multidrug antituberculous therapy; routine catheter removal is not mandatory.
- 非結核分枝桿菌：通常需有效多藥治療加導管移除。Nontuberculous mycobacteria: generally require effective multidrug therapy plus catheter removal.
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導管處置與名詞定義Catheter management and definitions
依臨床與 WBC 趨勢clinical course and WBC trajectory導管移除／更換的主要情境Major indications for removal or exchange
- !難治性腹膜炎：適當抗生素第 5 天仍未轉清；若 WBC 明顯下降且病況穩定，可個別化短暫觀察。Refractory peritonitis: effluent has not cleared by day 5; brief individualized observation is reasonable when WBC is clearly falling and the patient is stable.
- !黴菌性腹膜炎：發現黴菌元素即儘速移除。Fungal peritonitis: remove promptly once fungal elements are identified.
- !同菌出口／隧道感染合併腹膜炎，尤其 S. aureus 或 Pseudomonas。Exit-site/tunnel infection with peritonitis caused by the same organism, especially S. aureus or Pseudomonas.
- !復發、再現或重複腹膜炎：及時考慮拔除或同次拔除重置。Relapsing, recurrent, or repeat peritonitis: consider timely removal or simultaneous removal and reinsertion.
- !非結核分枝桿菌、未控制的腹內感染源及其他無法清除的生物膜感染。Nontuberculous mycobacteria, uncontrolled intra-abdominal sources, and other non-eradicable biofilm infections.
同次拔除重置：可在臨床感染已消退、透析液培養陰性、WBC <100/µL 且無出口／隧道感染時考慮；不適用於活動性難治、黴菌性腹膜炎或明顯腹腔沾黏。若同菌導管感染合併腹膜炎而需分期重置，通常至少待拔管後 2 週且腹膜炎完全消退。其他情況的最佳間隔尚無定論。
Simultaneous removal and reinsertion: may be considered after clinical resolution, negative effluent culture, WBC <100/µL, and absence of exit-site/tunnel infection. It should not be used for active refractory or fungal peritonitis or major adhesions. When catheter infection with the same organism accompanies peritonitis and staged reinsertion is required, generally wait at least 2 weeks after removal and complete resolution. The optimal interval in other situations is uncertain.
名詞定義Definitions
輔助處置Adjuncts
- ✓抗黴菌預防：PD 病人接受任何全身性或 IP 抗生素療程時，依院內 protocol 合併口服 nystatin 或 fluconazole；小兒僅使用至抗生素療程結束，不額外延長。Antifungal prophylaxis: co-prescribe oral nystatin or fluconazole according to local protocol whenever a PD patient receives systemic or IP antibiotics. In children, continue only for the duration of antibiotic therapy and not longer.
- ✓透析液有纖維蛋白絲：可加 IP heparin 500 U/L，並評估出血風險與院內作法。For fibrin strands in the effluent, consider IP heparin 500 U/L, taking bleeding risk and local practice into account.
Rx
IP 抗生素劑量參考表IP antibiotic dosing reference
ISPD 2022 / 2024下表列出常用藥物。間歇治療通常為每日一次長留置；APD 不可直接照搬 CAPD 劑量。顯著 RRF 可能需要約 25% 增量或更頻繁給藥，但須依藥物、TDM 與院內 protocol 決定。Common agents are shown below. Intermittent therapy is generally given once daily in a long dwell. CAPD dosing should not be extrapolated automatically to APD. Significant RRF may require about a 25% increase or more frequent dosing, depending on the drug, TDM, and local protocol.
成人 · 間歇 IPAdult · intermittent IP
| 藥物Drug | 劑量Dose | 備註Notes |
|---|---|---|
| Vancomycin | CAPD: 15–30 mg/kg q5–7d APD: 15 mg/kg q4d | 依臨床與 TDM 調整；無一致最佳抽血時點Adjust to clinical response and TDM; no universally preferred sampling time |
| Cefazolin | 長留置 15 mg/kg daily 短留置 20 mg/kg dailyLong dwell 15 mg/kg daily Short dwell 20 mg/kg daily | RRF 可能需增量May need an increase with RRF |
| Ceftazidime | 長留置 1000–1500 mg daily 短留置 20 mg/kg dailyLong dwell 1000–1500 mg daily Short dwell 20 mg/kg daily | RRF 可能需增量May need an increase with RRF |
| Cefepime | 1000 mg daily | 可作經驗性單方；監測神經毒性May be used as empiric monotherapy; monitor neurotoxicity |
| Gentamicin / Tobramycin | 0.6 mg/kg daily | 僅間歇；避免延長使用及監測耳毒性Intermittent only; avoid prolonged use and monitor ototoxicity |
| Amikacin | 2 mg/kg daily | 僅間歇Intermittent only |
| Aztreonam | 2000 mg daily | 非所有 β-lactam 過敏均適用Not an automatic substitute for every beta-lactam allergy |
| Meropenem | APD 長留置 500 mg daily CAPD 短留置 1000 mg dailyAPD long dwell 500 mg daily CAPD short dwell 1000 mg daily | 依藥敏及感染科建議Use according to susceptibility and ID advice |
| Fluconazole | IP 150–200 mg q24–48h | 口服途徑優先；僅限敏感菌Oral route preferred; susceptible organisms only |
成人 · 連續 IP（首劑→維持）Adult · continuous IP (load→maintenance)
| 藥物Drug | 首劑Loading | 維持（每袋）Maintenance (each bag) |
|---|---|---|
| Vancomycin | 20–25 mg/kg | 25 mg/L |
| Cefazolin | 500 mg/L | 125 mg/L |
| Ceftazidime | 500 mg/L | 125 mg/L |
| Cefepime | 500 mg/L | 125 mg/L |
| Aztreonam | 500 mg/L | 250 mg/L |
| Meropenem | 未指定Not specified | 125 mg/L |
| Aminoglycosides | 不建議連續給藥Continuous dosing not advised | |
小兒 · IP 劑量（ISPD 2024）Pediatric · IP dosing (ISPD 2024)
| 藥物Drug | 間歇Intermittent | 連續 首劑→維持Continuous load→maintenance |
|---|---|---|
| Vancomycin | 30 mg/kg 負荷；之後 15 mg/kg q3–5d30 mg/kg load; then 15 mg/kg q3–5d | 500 → 25 mg/L |
| Cefazolin | 20 mg/kg daily | 500 → 125 mg/L |
| Cefepime | 15 mg/kg daily 每次上限 1000 mgmax 1000 mg/dose | 500 → 125 mg/L |
| Ceftazidime | 20 mg/kg daily | 500 → 125 mg/L |
| Gentamicin / Tobramycin | 0.6 mg/kg daily | 不建議／無建議值Not advised / N/A |
| Amikacin | 2 mg/kg daily | 不建議／無建議值Not advised / N/A |
| Meropenem | N/A | N/A → 125 mg/L |
小兒重點：連續療法的負荷袋須留置 6 小時，其後每袋使用維持濃度；間歇療法原則上每日一次放入長留置袋。顯著 RRF 可能需加速給藥。Vancomycin 可於血中濃度 <15 mg/L 時考慮再給藥，尤其無反應或疑毒性時應使用 TDM。Aminoglycoside 與 penicillin 不可同袋。
Pediatric points: For continuous therapy, the loading exchange should dwell for 6 h and all subsequent exchanges contain the maintenance concentration. Intermittent therapy is generally placed once daily in a long dwell. Significant RRF may require accelerated dosing. Vancomycin redosing may be considered when the serum concentration is <15 mg/L; use TDM especially with poor response or suspected toxicity. Do not mix aminoglycosides and penicillins in the same bag.
通則：APD 藥物清除與短留置可能造成不足量，不能把 CAPD 劑量直接照搬。Vancomycin 在 APD 至少留置 4 小時，6 小時較合理。每次加藥前確認特定藥物、透析液品牌、濃度、溫度與保存條件下的相容性／穩定性。
General: APD clearance and short dwells may cause underdosing; do not directly extrapolate CAPD dosing. For APD vancomycin, use at least a 4-h dwell, with 6 h generally more reasonable. Before every admixture, verify compatibility and stability for the specific drug, PD solution, concentration, temperature, and storage conditions.