Gastroscopy-associated peritonitis in PD: Toward targeted rather than universal prophylaxis

Dear Editor,

We read with great interest the study by Chandler et al., which provides important binational evidence that peritoneal dialysis (PD)-associated peritonitis after gastroscopy may occur at a rate comparable to that after colonoscopy. ¹ This finding is clinically relevant because current ISPD guidance recommends prophylactic antibiotics before colonoscopy but not routinely before gastroscopy alone. ²

However, before extending colonoscopy-style prophylaxis to all gastroscopy procedures in PD patients, a risk-stratified approach may be more appropriate. The study could not capture antibiotic exposure, acid-suppressing therapy, endoscopic indications, or detailed endoscopic findings. ¹ These factors are central because gastroscopy for gastrointestinal bleeding, mucosal injury, or urgent clinical deterioration may carry different biological risk from elective diagnostic gastroscopy.

Emergency gastroscopy was associated with higher peritonitis risk. ¹ Future studies should separate elective diagnostic procedures from emergency or therapeutic procedures, especially those involving bleeding, biopsy, dilation, or haemostatic intervention. Prior evidence also suggests that gastroscopy-related peritonitis may be influenced by patient-level and medication-related factors, including acid-suppressing therapy. ³

The microbiological findings are informative. Enteric organisms and coagulase-negative staphylococci were common, while polymicrobial infection strongly predicted subsequent modality change. ¹ These data support prophylactic strategies tailored not only to procedure type but also to microbiological risk and local practice variation. ⁴

Thus, Chandler et al. highlight an important gap in PD infection prevention. The next step may not be universal prophylaxis for gastroscopy, but targeted prophylaxis for high-risk PD patients and high-risk gastroscopy contexts.