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Tuesday, September 18, 2007

Infective Complications In Peritoneal Dialysis

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Infective Complications In Peritoneal Dialysis Slideshow Transcript


Slide 2: Contents • Peritonitis • Exit site and tunnel infections • Prophylaxis • Catheter placement and removal

Slide 3: Peritonitis- Consequences • Leads to technique failure, hospitalisation and death. • Association between peritonitis and death well documented (for every 0.5/yr increase in peritonitis rate, risk of death increase by 10%) • Most common cause of conversion to HD (Burkart et al PDI 1996)

Slide 4: Peritonitis-Clinical Presentation • Abd. Pain, fever, cloudy effluent • Dialysate effluent: wbc >100/mm3, >50% PMN • Consider even if PD fluid clear (small %) • Abd. Pain less with CoNS, more with Staph aureus, strept, G-ve rods

Slide 5: Peritonitis • Common, past decade ~ 1 per 24 pt-treatment- months • Disconnect system reduce incidence • Organisms: G +ve • With disconnect, reduced G+ve, relatively increased G-ve • No single regimen most efficacious

Slide 6: Peritonitis • Ultra twin bag significantly lower peritonitis rate (1 in 33.9 pt-month) than Y set (1 in 11.7 pt- month) Kiernan et al JASN 1995 • Mixed results in regards to APD vs CAPD • European APD Outcome Study: CAPD 1 in 22.5 pt-month, APD 1 in 29.1 pt-month

Slide 7: Differential Diagnosis of Cloudy Effluent • Infectious peritonitis (culture positive or sterile) • Chemical peritonitis • Eosinophilia • Hemoperitoneum • Dry abdomen specimen (APD) • Malignancy, chylous (rare)

Slide 8: Eosinophilic Peritonitis • > 10% cells eosinophils • Must be treated as bacterial peritonitis until proven otherwise • Fungal, viral, parasitic, icodextrin, chemical (IP Vancomycin), idiopathic/culture negative

Slide 9: Icodextrin Peritonitis • Immediately or after several months of exposure • Mild abd pain, no systemic sx, cloudy effluent, sterile culture, predominance of monocytes/macrophages • Mechanism unclear, ? Peptidoglycan contamination

Slide 10: APD- Diagnosis • Occ. initial drain cloudy, but mononuclear cells, no abd. pain, fluid rapidly clears on initiation of APD • Use % of PMN rather than absolute no. of cells to diagnose • No daytime dwell: 1L 1-2 hour dwell • Equivocal cases, sx with clear effluent: 2nd exchange with at least 2 hours dwell

Slide 11: Peritonitis • Enquire break in technique, recent ESI, last episode of peritonitis, constipation or diarrhoea • Examine : abdomen for tenderness, exit site and tunnel inspection (any discharge cultured) • Find root cause • If necessary, retraining

Slide 12: Specimen Processing • Standard culture technique: directly inject effluent into blood culture bottles (culture negative 20%) • Culturing the sediment after centrifuging 50ml of effluent in standard blood culture and solid culture medium < 5% culture negative • Antibiotic removal technique • >75%, culture positive within 72 hours

Slide 13: EMPIRIC THERAPY • Covers both G+ve and G-ve (not based on Gram stain , except if yeast seen) • Likelihood same with most recent infection • Frequent peritonitis: relapse • Exit site infection • Prompt home antimicrobial for pts residing far away from hospital

Slide 14: Empiric Therapy • G+ve: cloxacillin, 1st generation cephalosporin, Vancomycin • G-ve: ceftazidime, aminoglycoside, cefepime, carbrpenem (oral quinolones can be used if local sensitivities support such use)

Slide 15: Empiric Therapy • Aminoglycoside: no evidence short courses harm RRF, repeated/prolonged not advisable (opinion), once daily as effective as continuous • Monotherapy: imipenem/cilastatin as effective as cefazolin + ceftazidime (PDI 2004), cefepime as good as Vanco + netilmicin (AJKD 2001)

Slide 16: Duration of Therapy • No good trials to define the length • Minimum 2 weeks, more severe 3 weeks (opinion)

Slide 17: Treatment strategies for Enterococcus/Streptococcus • Severe pain • Ampicillin preferred (evidence), consider aminoglycosides for synergy. • Ampicillin resistant: Vancomyin • VRE: ampicillin if susceptible, otherwise linezolid, quinupristin/dalfopristin

Slide 18: Staphylococcus aureus • Severe • Often due to catheter infection, then unlikely to resolve without catheter removal (evidence) • If poor response/MRSA, can add rifampicin 600mg /day for 1 week. • Vancomycin resistance reported: linezolid, daptomycin, quinupristin/dalfopristin • 21 days

Slide 19: Coagualase-negative Staphylococcus • Mild, responds to treatment • Sometimes relapsing due to biofilm, catheter replacement advised (evidence)

Slide 20: Pseudomonas Aeruginosa • Severe, 2 drugs (evidence), 21 days • Ceftazidime, piperazillin (IV 4g bd), cefepime. • Combination: aminoglycoside or quinolones • Often associated with catheter infection, then needs to be removed • Avoid P. aeruginosa peritonitis by replacing catheter for recurrent, relapsing or refractory ESI with P. aeruginosa.

Slide 21: Stenotrophomonas • Only sensitive to a few antimicrobials • Usually not as severe as pseudomonas, not associated with ESI • 2 drugs, 3-4 weeks • Other single G-ve: may be touch contamination, ESI or transmural migration. Treat based on sensitivities.

Slide 22: Polymicrobial Peritonitis • Multiple G+ve: more common, usually responds to antibiotic (evidence) • Multiple enteric organisms: increased risk of death , surgical evaluation should be obtained (evidence). Catheter may need to be removed. • Ceftazidime or aminoglycoside + ampicillin/cloxacillin+ metronidazole (21 days)

Slide 23: Culture Negative or Not Performed • Should be < 20% • Use of antibiotics before presentation • No growth by 3 days, repeat cell count/diff. If not improving, consider infrequent pathogens. • If improve, continue initial therapy 2 weeks (aminoglycoside may be discontinued) • Not improved by 5 days: consider remove catheter

Slide 24: Fungal Peritonitis • Catheter removal indicated immediately (evidence) • Mortality 15% if catheter removed within 1 week, 50% if left in place (overall 25 %) • Flucytosine, fluconazole or itraconazole • No RCT comparing ampho B with imidazole/triazole, retrospective data as efficacious • IP ampho B causes chemical peritonitis and pain, IV ampho B poor peritoneal administration • Voriconazole for filamentous fungi • 4-6 weeks, 2 weeks if catheter removed

Slide 25: Tuberculous Peritonitis • Rare (higher in Asia), TB or non-TB mycobacteria • Not responding to a/b either culture negative or proven bacterial peritonitis • Effluent cell count (most PMN predominance)/AFB smear rarely helpful • TB culture: 6 weeks • Earlier diagnosis: biopsy, PCR

Slide 26: TB Peritonitis • Few data exist for optimal choice and duration of chemotherapy, based on experience of treatment of extra-pulmonary TB in ESRF • 4 drugs (Isoniazid, rifampicin, pyrazinamide, ofloxacin), pyridoxine 50-100mg/day • IP Rifampicin? (low levels in dialysis fluid) • Streptomycin: ototoxic • Ethambutol: optic neuritis • Catheter removal? (reinsert 6 weeks)

Slide 27: Treatment in APD • Little known about dosing in APD • Intermittent dosing , must dwell at least 6 hours to allow adequate absorption (rapid exchanges in APD inadequate time to achieve IP levels) • extensive evidence for efficacy of intermittent dosing of aminoglycoside and vancomycin in CAPD (Vanco in APD RCT in children)

Slide 28: APD • Vancomycin: 50% absorption without peritonitis, 90% with. Re-entry during subsequent exchanges. Redosing once trough< 15mcg/ml (IP level < serum) • Cephalosporin: few data, night IP levels < MIC if daytime exchange only. Adding to each exchange (opinion). • Option oral antibiotics: lack pharmacokinetics study

Slide 29: APD • Convert to CAPD (not always practical) • Increase dwell time on cycler (has not been well studied) • Conclusion: needs further research

Slide 30: Relapsing Peritonitis • Another episode of peritonitis caused by same species within 4 weeks of antibiotic completion • Staph.: 4 weeks • Biofilm (CoNS): catheter replacement • Search for tunnel infection in staph. • Search for intra-abd. abscess in enterococcus/ G-ve • Pseudomonas: catheter removal

Slide 31: Refractory Peritonitis • Failure to respond to appropriate antibiotic within 5 days • Catheter removal to protect peritoneal membrane for future use (evidence) • Prevent morbidity and mortality (risk of death highest with G-ve bacilli and fungus)

Slide 32: Adjunctive Therapy in Peritonitis • 2 or 3 rapid exchanges only symptomatic benefit • Heparin 500-1000U/L until effluent clears (extremely cloudy/ hemoperitoneum to prevent occlusion of catheter by fibrin) • Thrombolytic therapy occ useful in recurrent peritonitis (IP streptokinase: pain, fever and peritonitis like syndrome)

Slide 33: Exit Site and Tunnel Infections • Purulent discharge : ESI (positive culture with normal appearance is colonization) • Tunnel infection: tenderness/erythema or edema over subcut. pathways but can be occult (rarely occurs alone) • Staph aureus and P. aeruginosa ESI most often concomitant tunnel infection, frequently leads to peritonitis (evidence)

Slide 35: Ultrasound of Tunnel Infection

Slide 36: Treatment of ES and Tunnel Infection • Oral antibiotic = IP antibiotic (except MRSA) • Empiric therapy always covers Staph. Aureus • If previous Pseudomonas ESI, should cover it also • G+ve: cephalexin, amoxicillin, cloxacillin, clarithromycin (rifampicin combination if severe or slowly resolving) • Pseudomonas: difficult, prolonged therapy, oral quinolone 1st choice, slow resolution/recurrence, add IP Fortum (often needs 2 antimicrobial)

Slide 37: Treatment of ES and Tunnel Infection • Treatment until exit site appears normal • 2 weeks minimum (opinion) • ESI that progresses to / in conjunction with peritonitis usually require catheter removal • (Exception: CoNS, readily treated)

Slide 38: Prophylaxis of ESI • Staph aureus nasal carriage increases risk of ESI/tunnel infections, peritonitis and catheter loss • Intranasal mupirocin, exit site mupirocin and oral rifampicin effective in reducing ESI (Zimmerman et al 1991, Bernardini et al 1996) • Mupirocin negligible toxicity and less worried about resistance

Slide 39: Other promising options • Gentamicin cream was shown to be as good as mupirocin in reducing Staph ESI and P. aeruginosa ESI/peritonitis as well (Bernadini et al, 2005) • Ciprofloxacin otologic solution reduce ESI caused by SA and P. aeruginosa in a randomised trial

Slide 40: Prophylactic Antibiotics • Long term use of penicillin/cephalosporin has not been shown to decrease peritonitis • Chronic ESI(> 4 weeks): no data whether long term antibiotic is preferable to replacing catheter

Slide 41: Short Term Prophylaxis • Invasive procedures infrequently cause peritonitis (evidence) • Amoxicillin 2 g before dental procedure (opinion) • Colonoscopy with polypectomy: ampi + aminoglycoside (opinion) • Abdomen should be emptied of fluid prior to procedures involving abd/pelvis (opinion)

Slide 42: Prophylaxis After Technique Break • No data but most give 1-2 day course of antibiotics • 1st gen. cephalosporin adequate

Slide 43: Prevention of Fungal Peritonitis • Most fungal peritonitis preceded by courses of antibiotics (evidence) • Trials using Nystatin or fluconazole prophylaxis during antibiotic therapy to prevent fungal peritonitis: mixed results • Only programs with high baseline rates of fungal peritonitis showed benefit

Slide 44: Catheter Placement • No particular catheter shown to be better than standard silicon Tenckhoff for prevention of peritonitis (evidence) • Prophylactic antibiotics given at time of insertion reduces infection risk (evidence) • Recent trial ( AJKD 2000) found Vanco better but 2005 review recommend 1st or 2nd generation cephalosporin

Slide 45: Catheter Placement • Double cuff catheter better, less removal due to ESI (National CAPD Registry, PDI 88) • Downward directed tunnel may reduce peritonitis • Avoid trauma/haematoma • Suture increases infection • Treat nasal carriage of Staph aureus

Slide 46: Connection Methods • Abundant data shows spiking leads to peritonitis: double bag system, avoid spiking • “Flush before fill” reduces contamination and peritonitis (evidence)

Slide 47: Training Methods • Training and retraining reduces peritonitis (evidence) • Aseptic technique, hand washing, alcohol hand wash (opinion), response to contamination • PD nurses, best nurse to patient ratio (no studies) • Home visits if feasible

Slide 48: Prevention of Bowel Source of Infection • Association between severe constipation, enteritis and peritonitis due to enteric organisms (evidence) • Transmigration across bowel walls • hypomotility (hypoK), drugs contributing to constipation (iron, Ca, ) • Colitis & diarrhoea: transmural migration, touch contamination (hand washing)

Slide 49: Indications of Catheter Removal • Refractory peritonitis • Refractory catheter infection • Relapsing peritonitis • Fungal peritonitis • Consider if not responding in Mycobacterial peritonitis and multiple enteric organisms

Slide 50: Catheter Insertion after Removal • Optimal period unknown, minimum 2-3 weeks (opinion), 4 weeks (CPG) • Simultaneous catheter removal and replacement in refractory tunnel infections and relapsing peritonitis (Swartz et al, 1991) • Limited to those with wbc<100, not for pseudomonas/fungi/TB/intra-abd abscess


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