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Does Intraperitoneal Vancomycin Cause Chemical Peritonitis?

Sir: The existence of chemical peritonitis resulting from intraperitoneal vancomycin remains controversial. Piraino and colleagues made the initial observation of chemical peritonitis after intraperitoneal administration of the drug (1). The controversy developed after two investigators could not produce sterile peritonitis by instillation of large doses of vancomycin into the peritoneum (2, 3). During the Tenth Annual Conference on Peritoneal Dialysis we reported our observations suggesting the existence of chemical peritonitis (4). The abstract presentation stimulated reports of similar experience by the viewers and a special forum was held to discuss vancomycin related complications. Intraperitoneal vancomycin, as suggested by The Ad Hoc Advisory Committee on Peritonitis Management (5), appears to be the preferred therapy of many practitioners for peritonitis and exit site infection. Thirty physicians and nurses verbally reported in excess of one hundred patients with a clinical syndrome of pain and cloudy peritoneal dialysate containing elevated numbers of segmented neutrophils. These episodes occurred three to six hours after intraperitoneal administration of vancomycin for a problem other than peritonitis. Dialysate cultures were invariably negative. Most of the patients were treated for exit site infections but there were a number related to other infections and prophylactic antibiotics. In at least one instance a patient told the nurse that he thought the vancomycin was giving him peritonitis, but was not believed. None of these cases were known to be due to Lilly&reg; (Eli Lilly and Company, Indianapolis, Indiana) vancomycin and most were seen when the unit or hospital switched from Lilly&reg; to another brand. The practitioners observed that the problem disappeared when switching either to intravenous administration or back to Lilly vancomycin. Dialysis units exclusively using Lilly vancomycin did not observe anything suggestive of chemical peritonitis (personal communication Margaret J. Small, Aukland, New Zealand). Symptoms suggestive of chemical peritonitis are not uniformly seen with administration of other brands of vancomycin. All the cases mentioned above were with doses of one to two grams with the exception of one case after intraperitoneal administration of 500 mg. There was only one case reported after use of maintenance doses (15-50 mg per liter of dialysate), and that was after three weeks of use. Even with intraperitoneal loading doses the syndrome was not universal. One careful observer noted two patients who did well with two or three doses and developed chemical peritonitis after switching to a new lot of vancomycin. This may explain why one of the reports failed to find chemical peritonitis after administration of large doses (3). Vancomycin is a biological product and there can be lotto-Iot variability in production. We conclude that intraperitoneal administration of high doses of vancomycin may cause chemical peritonitis. This problem rarely if ever occurs with Lilly vancomycin and appears to occur only with some lots of other brands. If unrecognized the chemi cal peritonitis may be assumed to be infectious and inappropriate treatment, even catheter removal, may ensue. We suggest that a registry of cases be initiated to determine the scope of the problem. Reports of positive or negative experiences would be welcome at our correspondence address. Further research into the mechanisms of the inflammation may benefit patients and help eliminate vancomycin induced chemical peritonitis.