Abstract
The Relevant Factors of Exit-Site Infection in Peritoneal Dialysis Patients
The present study is a retrospective observational investigation. The purpose of study was to review the causes of exit-site infection (ESI) and its prognostic factors in peritoneal dialysis (PD) patients. The study subjects were chronic PD patients in 1 PD unit of hospital-affiliated. The analyzed data included causes of ESI, pathogens, types of antibiotics, prognosis, and causes of PD catheter loss. The version of statistical analysis was SPSS® 12.0. The results were (1) showering and improper traction of the PD catheter were the major causes (75.6%) of ESI; (2) the most common pathogen of ESI was Staphylococcus aureus (49.5%); (3) most patients (80%) with PD catheter loss had more than 3 episodes of ESI; (4) cure rate of ESI was 97.6%; (5) more antibiotic use in patients with PD catheter loss than in those without PD catheter loss; (6) causes of PD catheter loss were refractory response to antibiotic treatment and peritonitis.
In conclusion, a majority of ESI episodes could be resolved by antibiotic treatment. The impact factors of ESI prognosis were pathogens, frequency of ESI, and types of antibiotics.
Changing Bacterial Spectrum in Peritoneal Dialysis-Related Peritonitis: A Fifteen-Year Observation
Objective: The incidence of peritoneal dialysis (PD)-related peritonitis decreased gradually after the introduction of the twin-bag system. However, peritonitis is still the leading reason for patients’ withdrawal. This study was undertaken to evaluate changes in the bacterial spectrum inducing PD-related peritonitis over a period of 15 years.
Methods: This study included all episodes of PD-related peritonitis that developed at Chi Mei Medical Center from January 1993 to December 2007. To evaluate the changes in the bacterial spectrum, we arbitrarily separated the 15 years into phases I (1993-1999) and II (2000-2007).
Results: Except for no growth or contamination accounting for 35%, bacterial infection accounted for 98% (n = 249) of culture-positive peritonitis. For all bacterial infections, the ratio of gram-negatives [G(–)] to grampositives [G(+)] was 60% but this ratio increased from 55% in phase I to 103% in phase II. Compared to phase I, the number of episodes of Staphylococcus aureus (SA) in phase II decreased to 47%, coagulase-negative staphylococcus (CoNS) increased to 215%, Streptococcus viridans (SV) increased to 242%, and no Staphylococcus epidermidis infection was found in phase II. In G(–)-related peritonitis, E. coli infection increased to 640% in phase II compared to phase I, Klebsiella pneumonia to 325%, and pseudomonas to 120%. Successful treatment rate of G(–) peritonitis was significantly lower than that of G(+), especially in phase II.
Conclusions: Compared to the pathogens before 2000, the percentage of G(–) infections increased gradually. The number of episodes of G(–) peritonitis was even higher than G(+) infections in the recent 7 years. In G(+) peritonitis, the incidence of SA infection decreased gradually, while SV and CoNS increased progressively. E. coli accounted for the majority of G(–) infections and it was also related to treatment failure.
Ciprofloxacin and Cefazolin as a Combination for Initial Empiric Therapy of Peritoneal Dialysis (PD)-Related Peritonitis: Nine Years’ Follow-Up
Objective: To describe the outcome of an empiric therapeutic regimen for peritonitis (P) affecting PD patients. This treatment consisted of oral ciprofloxacin (Cip) and cefazolin (Cef) given intraperitoneally (IP). This combination of drugs was applied to avoid the regular use of vancomycin and third-generation cephalosporins, such as ceftazidime, which is being related to the appearance of VRE and ESBL-producing Enterobacter.
Patients and Methods: 165 episodes of P affecting 94 CAPD and APD patients were evaluated between 03/2000 and 03/2009. All episodes were treated with Cip 500 mg p.o. b.i.d. and Cef 15 mg/kg IP, added once per day in a 6-hour dwell. Laboratory tests consisted of peritoneal fluid culture, cell count, and Gram staining. The episodes were considered completely cured when no signs and symptoms of P were manifested at least for 2 months after the end of therapy.
Results: Peritoneal fluid cultures were positive in 61.8% of episodes, with coagulase-negative staphylococcus (CoNS) being the most prevalent (41.1%) and Staphylococcus aureus presenting in 11.7% of positive cultures. Of the 165 episodes observed, 89% were considered completely cured. Among the failing episodes, 4 types of bacteria were resistant to therapy (2.4% of total), 2 Candida sp (1.2%), 6.6% responded to either Cip or Cef (5 P. aeruginosa, 1 Sphingomonas, 3 CoNS, 1 S. aureus, 1 Acinetobacter, 1 Enterobacter); however, complete cure was not attested, leading to catheter withdrawal. 23.6% of episodes were related to exit-site infection.
Conclusion: The present study showed that the empiric therapy with oral ciprofloxacin and IP cefazolin was safe and effective for P in PD patients. We suggest this regimen as an alternative to the use of vancomycin and ceftazidime in order to avoid possible induction of bacterial resistance observed with these antibiotics.
Risk Factors for Peritonitis in Peritoneal Dialysis (PD) Patients
Objective: To study the risk factors and causes of peritonitis (P), the Achilles’ heel of PD.
Methods: Data were collected from the records of patients (pts) who received PD therapy from 2006 to 2008 in the Dept. of Nephrol., Serdang Hosp.
Result: There were 99 pts on PD program (97.0% CAPD, 3.0% APD) with 44276 cumulative pt-days. All were Baxter® system except 1 on Fresenius® system. 43.4% males and 56.6% females; mean age 49.9 ± 14.9 years; 57.6% were diabetic; 58.6% did PD themselves, 17.1% partially assisted, and 30.3% totally assisted, majority (80.5%) of assistants were female. Total 8 cases of mortality and 26 cases of P were recorded with mortality rate of 6.59%/year and P rate of 56.0 pt-months. 38.5% of P were gram-positive, 23.1% were gram-negative, and 38.5% were culture-negative. Incidence of P was significantly higher in pts with history of exit-site infection (ESI; p < 0.001).
(ESI and Peritonitis
Mean serum potassium (taken before the P episode) in P group was significantly lower (3.31 ± 0.64 mmol/L) compared to P-free group (3.96 ± 0.71 mmol/L) (p = 0.020). Gram(–) P had insignificantly lower K level (3.14 ± 0.45 mmol/L) compared to gram(+) (3.43 ± 0.85 mmol/L) and culture(–) (3.30 ± 0.55 mmol/L) groups. There was no correlation between incidence of P and age, gender, diabetic status, assisted or self-PD, assistant gender, nasal MRSA carrier, transporter characteristic, Kt/V, nPCR, serum albumin, or hemoglobin level. Other risk factors identified were the initial 1st month training period (30.8%), recent change in social environmental factors (23.1%), pts’ selection problem (15.4%), unauthorized performer (15.4%), unhealthy exit site due to povidone allergy (7.7%), and unidentified (7.2%).
Conclusion: PD pts with history of ESI and hypokalemia were associated with a higher prevalence of P. ESI implies pt is predisposing to the infection. The possible causes need to be identified and they need retraining and closer monitoring. However, the link between hypokalemia and P needs further investigation. The translocation of gram-negative organism from intestinal mucosa into the peritoneal cavity was postulated. There was no correlation between hypokalemia and nutrition status. Imperfect technique especially during the initial training period remained a problem. Changing social and environmental factors need to be identified among CAPD pts to ensure perfect CAPD exchange technique is maintain at all times.
High Mortality and Technique Failure Rate in Peritoneal Dialysis (PD) Patients Presenting with Peritonitis and Septic Shock
Background: Peritonitis (P) is the most common complication and leading cause of technique failure for ESRD patients (pts) treated with PD. P with septic shock (SS) secondary to PD or other intra-abdominal infections may have a poor prognosis and the differential diagnosis is difficult. The aim of this study was to investigate the clinical characteristics of PD pts presenting with P and SS.
Methods: 365 pts receiving chronic PD for more than 3 months from 3 institutes were screened. 34 and 70 pts presenting with P with and without SS developing within 3 days after admission (groups A and B respectively) were included for study. Data regarding demographic features, etiology, pathogens, and pt and technique survival were collected for analysis.
Results: Overall mean age was 47 ± 17 years, 59 (57%) pts were female, and culture-negative rate was (14%). In pts with P and SS, PD duration was longer (67 vs 24 months), CAPD was less preferred (21% vs 3%), and hospitalization duration was longer (28 vs 13 days) than those without SS. In group A there were 30 (88%) pts developing SS secondary to PD-related P and 3 (9%) due to bowel ischemia; the in-hospital mortality rate was 26% (6 PD-related P and 3 bowel ischemia), and 16 (47%) had transferred to hemodialysis. There were 9 (26%) pts continuing on PD therapy at discharge with a technique failure rate at discharge 74% in group A. The leading pathogens were Staphylococcus aureus (n = 6) and Escherichia coli (n = 6) in the group A and coagulase-negative staphylococcus (n = 14) in group B. Development of SS, longer PD and hospitalization duration, and P secondary to bowel ischemia were important characteristics associated with technique failure in PD pts with P necessary for admission.
Conclusions: This study demonstrated a poor outcome with high mortality and technique failure rate for the PD pts presenting with peritonitis and septic shock.
Rapidly Growing Mycobacterial (RGM) Infection in Peritoneal Dialysis (PD) Patients: A Single Center's Experience
Objectives: To review the clinical course of RGM infection in PD patients (pts) in a single center.
Methods: We retrospectively reviewed the clinical records of pts who developed RGM infection from 1/1/2008 to 31/12/2008.
Results: 14 episodes of RGM infection involving 10 pts were identified. Male-to-female: 5:5; mean age: 62.6 (39-78); 3 were diabetics; 4 received prolonged courses of antibiotics (>1 week) prior to onset of RGM infection; 3 had Kt/V 1.7. All episodes were treated with at least 2 antibiotics and all included amikacin. Eight pts presented with exit-site infection (ESI). Among them, 6 were due to Mycobacterium chelonae (MC), 2 to Mycobacterium for tuitum (MF). Mean treatment duration was 98.4 (21-199) days; 5 pts had Tenckhoff (TK) external cuff shaved, 3 pts (including 1 with external cuff shaved) required TK removal; 1 pt cured without the need of manipulations. All pts could continue PD except 1 due to intestinal obstruction unrelated to RGM infection; 2 pts had complicated courses with tunnel abscess; 2 pts developed mild ototoxicity due to amikacin; 3 developed relapses of disease with 2 peritonitis (P) and 1 ESI. No significant differences in risk factors (p = NS) and treatment duration (p = NS) noted between relapsers and non-relapsers; 6 episodes of P were noted in 4 pts with 2 pts having prior ESI, 4 episodes were due to MC, 2 due to MF. Mean treatment duration was 77.4 (18-214) days; 4 episodes required TK removal. For the 2 episodes without TK removal, 1 developed relapse of P later and the TK was then removed; the other pt died; 2 developed relapse of P and the clinical courses were complicated by persistent infection of TK wound in both pts and intraperitoneal collection in 1 pt. Both were permanently switched to hemodialysis; 1 pt could continue PD after a single episode of P. For the episodes that did not relapse, treatment duration was longer although it did not reach statistical significance. One pt developed mild ototoxicity related to amikacin.
Conclusions: RGM cause serious infection in PD pts, with frequent development of complications. Prolonged course of antibiotics is usually required for cure and prevention of relapse, but with frequent toxicity. Relapse is common and removal of TK catheter is frequently required especially those with P.
The Clinical Course of Peritonitis Due to Acinetobacter Species Complicating Peritoneal Dialysis
Background and Aims: Infection due to Acinetobacter species is becoming more common. It is one of the organisms causing continuous ambulatory peritoneal dialysis (CAPD) peritonitis (P). However, the clinical course of P due to Acinetobacter remained unclear.
Methods: All episodes of P due to Acinetobacter species complicating PD from 1/10/1999 to 30/9/2008 in 3 renal centers were studied. 64 P episodes in 60 patients were recorded in this period, of which 23 episodes were excluded due to mixed growth. The remaining 41 episodes in 40 patients were analyzed.
Results: Acinetobacter species were responsible for 2.11% of CAPD P in this study period. Mean age was 59.9 ± 12.8, 24 (60%) were male, 23 patients (57.5%) had diabetes mellitus (DM). The prevalence of diabetes was higher than the existing pool of CAPD patients (p = 0.00002). There were uses of antibiotic within 30 days prior onset of P due to Acinetobacter species in 17 episodes (45%) and hospitalization within 1 month in 11 episodes (26.8%). Seven cases failed antibiotic treatment, of which 3 patients died (mortality 7.3%) and 4 required Tenckhoff (TK) catheter removal. There were no associations between the response rates with history of P, hospitalization within 1 month, or the use of antibiotics within 30 days of onset of P. There were no differences in the response rates to antibiotic treatment in patients with DM and without DM. The TK catheter was reinserted successfully in majority of cases (6/7; 85.7%). None of these patients had relapse of P within 3 months.
Conclusions: Most patients had community-acquired Acinetobacter CAPD P and patients with diabetes were more susceptible. Recent history of P, hospitalization, and use of antibiotic were not risk factors. Patients who required TK catheter removal could resume PD after resting of peritoneal membrane.
Peritoneal Dialysis Program in Nepal: Incidence of Peritonitis and Its Predisposing Factors
Background: The options for renal replacement therapy are limited in Nepal. Most patients (pts) with end-stage renal disease receive hemodialysis (HD), largely located within the capital of the country. In 1998, continuous ambulatory peritoneal dialysis (CAPD) was initiated in Nepal without success. High rate of peritonitis was cited for failure. Hot tropical climate of Nepal along with poor sense of hygiene among pts is thought to be responsible for the high rate of peritonitis. A new chronic peritoneal dialysis (CPD) program was started in 2002 in our institute. We reviewed the incidence of peritonitis and factors predisposing to peritonitis.
Methods: 103 pts who were initiated on CPD since 2002 to 2008 were included in the study. Three CAPD nurses follow-up these pts and were responsible for the recording data along with resident doctors in dialysis unit. Peritonitis was diagnosed if pt reported cloudy effluent and/or pain in abdomen and had dialysate white cell count >100/mL of which 50% or more were polymorphonuclear leukocytes. All pts were on prophylactic mupirocin ointment. Pts complicated with peritonitis (n = 24) and pts without peritonitis (n = 79) were compared.
Results: Most pts were male (n = 78). Mean duration of dialysis was 16 month per pt. 32 episodes of peritonitis in 24 pts were recorded during this period. 18 episodes of peritonitis were culture positive (Staphylococcus aureus 7, Enterococcus species 2, Pseudomonas aeruginosa 2, other gram-negative organisms 6, fungal 1). Six pts in each group were shifted to HD therapy. Low level of education, more number of care provider, end stage related due to diabetes mellitus, and low serum albumin were predisposing factors for development of peritonitis.
Conclusion: Peritonitis is not a limiting factor for growth of CAPD in Nepal. Low serum albumin and diabetes patients are prone to CAPD-related peritonitis.
Microbiology Pattern of Peritoneal Dialysis (PD)-Related Peritonitis and Their Outcome: A Single Center's Experience
Objectives: To investigate the incidence, microbiology pattern, and outcome of PD patients (pts) who suffered from PD-related peritonitis (P) in a single center, retrospective, observational cohort study in North Taiwan.
Methods: All new pts who underwent PD in our medical center from January 1996 to December 2005 were enrolled and followed until December 2008. Episodes of P, time to first episode of P, causing pathogens, and treatment outcome were reviewed through medical records.
Results: 370 pts were included in this study. During the observation period, 153 pts (41.3%) experienced 284 episodes of P. The incidence of PD-related P was 1 in 58 pt-months (overall peritonitis rate 0.206 episodes/pt-year). Of them, 63 pts (41.2%) suffered from first P event within 1 year after the start of PD. The average time to first episode of P was 22.8 months (median 14.8 months). Among 284 episodes of P, 231 episodes (81.3%) were positive micro-organism while 53 episodes (18.7%) were culture-negative P. Within culture(+) P, 98 (42.4%) were gram(+) organism, 105 (45.5%) were gram(–) organism, 8 (3.5%) were fungal P, 4 (1.7%) were tuberculous P, and 16 (6.9%) showed polymicrobial organism. Coagulase-negative staphylococcus (10.8%), Streptococcus species (9.5%), and methicillin-sensitive Staphylococcus aureus (8.7%) were the most common gram(+) organisms. The most prevalent gram(–) organisms were Escherichia coli (28.6%), Klebsiella (8.2%), and Pseudomonas species (6%). As for PD outcome, 65 pts had Tenckhoff catheter (TC) removal during and after episodes of P and 16 pts died of P-related severe sepsis. Only 7 pts experienced successful TC reimplantation after recovery from P. Seven pts suffered from polymicrobial P finally found to have intra-abdominal pathology and all needed surgical intervention.
Conclusions: This study provided detailed information about the incidence, causing pathogens, and outcome of PD-related P in Taiwan. E. coli was the leading pathogen isolated from PD-related P in our cohort. Risk factors for P-related technique failure, including death, warranted further investigation.
Simultaneous Esophageal and Peritoneal Tuberculosis (TB) Complicating Continuous Ambulatory Peritoneal Dialysis (CAPD) Patient
Patients with end-stage renal failure are highly susceptible to TB, which is predominantly extrapulmonary in nature. Peritoneal TB is the most prevalent extrapulmonary TB in patients on CAPD but esophageal TB is extremely rare in the general population and even in patients with CRF. Presented here is a case of a patient receiving CAPD who complained of nausea, dysphagia, and turbid peritoneal dialysate and was diagnosed as concurrent esophageal and peritoneal TB.
Case: A 54-year-old woman with CRF secondary to type 2 diabetes mellitus who had started CAPD 2.5 years ago visited renal clinic with nausea, dysphagia, and turbid dialysate. The initial dialysate cell count was 460/μL with neutrophil predominance. The peritoneal fluid was sent for culture and broad-spectrum antibiotic therapy with vancomycin and ceftazidime was started. Two days later, she revisited and presented with persistent nausea, abdominal pain, and mild fever (37.5°C). An upper GI endoscopy revealed a 2.5-cm solitary mass-like lesion with central ulcer at 17 cm from incisor. Esophageal malignancy was suspected at first, but biopsy found only chronic inflammatory cells. While dialysate bacterial cultures remained sterile, her general condition became worse and blood pressure was going down with spiking fever (38.5°C). The peritoneal catheter was removed and high fever disappeared. However, mild abdominal pain and low-grade fever were not completely gone away. A computed tomography (CT) scan of the abdomen showed an enhanced thickened peritoneum along the greater omentum and multiple enlarged retroperitoneal lymph nodes. On the next day, US-guided diagnostic paracentesis and second upper GI endoscopic biopsy were performed, and anti-TB medication consisting of isoniazid, rifampicin, ethambutol, and pyrazinamide was started. On the second endoscopic findings, a central hollow in mass was deep but esophagogram found no perforation and no evidence of tracheoesophageal fistula. Peritoneal fluid for acid-fast bacilli smear was negative but ascites adenosine deaminase activity showed 97 U/L (normal range 4–21 U/L) and the second endoscopic esophageal biopsy revealed chronic granulomatous inflammation consistent with TB. Seven weeks later, Mycobacterium tuberculosis was cultured from ascitic fluid and was found to be sensitive to isoniazid, rifampicin, ethambutol, pyrazinamide, and streptomycin on susceptibility test. She looked better and mild fever completely disappeared after 7 days of anti-TB medication. A follow-up upper GI endoscopy after 6 months confirmed complete healing of the previous esophageal tuberculous lesion.
Prophylaxis for Peritoneal Exit-Site Infections (ESI) with Mupirocin Reduces Peritonitis Due to Staphylococcus aureus Only
Background and Aims: Infection is the Achilles’ heel in the management of peritoneal dialysis (PD). Local application of mupirocin has been suggested to prevent ESI and decrease peritonitis (P) rates. However, uniform agreement has not been reported in the literature. We proposed to evaluate the impact of prophylactic mupirocin application on P rate, mupirocin resistance, and infection due to opportunistic organisms
Methods: Mupirocin was not used at Tenckhoff catheter exit sites prior to June 2004. From June 2004, all patients (pts), prevalent and incident, were advised to apply 2% mupirocin daily to the exit site. Prevalent pts on PD were 60 and 89 in June 2004 and June 2009 respectively. Routine screening for staphylococcal carrier state was not performed. Exit site swabs were performed annually and when ESI is suspected. The infection related data for following 5 years until April 2009 were compared with similar data (historical control) for 1 year preceding June 2004. These rates were reported as episode/pt-months.
Results: The rates of ESI fell dramatically since the introduction of prophylactic mupirocin and virtually disappeared to date (1 episode/20.5 vs 1 episode /543 pt-mths in 2004 and 2008 respectively). However, a similar trend is not reflected in the rates of P over time (1 in 33.98 pt-mths in 2003–2004 vs 1 in 21.80 pt-mths in 2007–08). Gram-positive organisms, except Staphylococcus aureus, are still the major source of P, followed by gram-negative bacteria. P due to S. aureus, other gram(+) organisms, Pseudomonas, and other gram(–) bacteria were 15%, 24%, 8%, and 46% in 2004–2005 and 0%, 58%, 4%, and 20% in 2007–08 respectively. Mupirocin resistance or increased incidence of Pseudomonas infection was not reported so far.
Conclusions: ESI have markedly reduced with prophylactic mupirocin application locally. However, a similar trend was not seen in rates of P except those due to S. aureus. Limitations of our study are small numbers of subjects. Randomized controlled trails with greater number of subjects may be required to resolve this issue. Acknowledgement: We thank the nursing staff and the Renal Physicians involved in the management of these pts and Professor Robert Fassett for his comments on this abstract.
Memory Disturbance Causing Peritonitis: A Case Report
Peritonitis (P) is a major cause for treatment failure and mortality in patients on peritoneal dialysis (PD). Breach of aseptic techniques while performing PD exchanges often is the culprit for contamination leading to P. We report a unique case of P due to memory disturbances and dyspraxia secondary to an acute parieto-occipital cerebrovascular accident (CVA).
Case Report: A 61-year-old Chinese lady with a medical history of hypertension and hyperlipidemia had been doing well on continuous ambulatory PD for the past 1 year. Two weeks prior to hospitalization, she was found to have left the peritoneal catheter exposed without capping after her exchanges on 2 separate occasions. She was hospitalized this time for complaints of generalized abdominal pain and cloudy dialysate. Moreover, she gave a history that lately she “has not been able to remember the various steps involved in performing her PD exchanges.” There was no history of recent head injury, weakness or numbness, or giddiness. Neither was there any ingestion of new medications. Physical examination revealed a “reserved” lady (usually she was chatty) with a normal blood pressure. Neurologically, she had mild dysphasia and dyspraxia and had difficulty performing 2 steps commands. There was mild homonymus visual field defects detected and there was a loss of short-term memory on testing. No other cranial nerves abnormalities nor any sensory/motor deficit in all 4 limbs was detected clinically. All reflexes were normal. Abdominal examination showed mild generalized tenderness but no guarding or rebound tenderness. The PD dialysate was noted to be cloudy. Brain CT revealed acute infarction in the left occipital and posterior parietal cortex. The dialysate cell count was elevated and the fluid culture showed coagulase-negative Staphylococcus aureus. She was diagnosed to have acute parieto-occipital CVA with amnesia resulting in her inability to recall the various aseptic steps required in performing PD exchanges. Aspirin was started and she was referred to neurologist for further management. The P was adequately treated with intraperitoneal vancomycin. In view of her inability to perform PD due to recent CVA, a domestic helper was employed to take over the role of PD exchanges thereafter. Since that event, she has been doing well on PD with no further P to date.
Repeated Peritonitis in Continuous Ambulatory Peritoneal Dialysis (CAPD) Leads to Emergence of More Drug-Resistant Organisms
Objectives: Repeated episodes (epi) of peritonitis (P) in patients (pts) on CAPD is a pitfall that often leads to discontinuation of this modality. This study evaluated the pattern of organisms’ drug sensitivity in pts suffering from repeated P.
Method: Pts with 2 or more P epi in 1 pt-year were selected. In these subjects PD effluent was collected and sent to laboratory for Gram stain and cytology. Culture was done by direct inoculation of PD fluid simultaneously in plate media (blood agar and MacConkey's agar) and broth media (trypticase soy broth). Antibiogram of available antibiotics was used. The drug sensitivity pattern of the organisms causing first infection was compared to that of reinfection episodes.
Results: 15 pts were identified with history of frequent infections. These pts had 51 epi of P (3.4 epi/pt-year). Isolated more frequent organisms in first epi were Staphylococcus aureus (33%), Pseudomonas spp (20%), S. epidermidis (13%), E. coli (13%), and rest are others. Organisms of reinfections were S. aureus (25%), S. epidermidis (22%), E. coli (22%), and Pseudomonas spp (19%). The frequencies of causative organisms in reinfections were similar to those of 1st epi. Drugs tested for sensitivity were ampicillin, cloxacillin, cephalosporin, vancomycin, rifampicin, ciprofloxacin, gentamicin, amikacin, ceftriaxone, ceftazidime, imipenem, and aztreonam. When drug sensitivity of organisms in 1st epi of infections was compared to sensitivity of reinfections, it was found that the sensitivity patterns were significantly altered. Average sensitivity to above-mentioned drugs (applicable ones) of S. aureus in 1st epi of P was 56% & resistance 44% (p = NS) but in reinfections it was only 30% vs 70% (p < 0.002). Similarly, for S. epidermidis it was 35% vs 65% (p = NS) & in reinfections 32% vs 68% (p < 0.008); E. coli was 50% vs 50% (p = NS) & in reinfections 35% vs 65% (p < 0.04); Pseudomonas spp was 72% vs 28% (p < 0.05) & in reinfection 50% vs 50% (p = NS). It is found that sensitivity to drugs was significantly decreased in repeated P.
Conclusion: It may be concluded that frequent P epi could result in emergence of more resistant organisms with decreasing drug sensitivity. Vigilant infection control procedures are needed to reduce P epi to minimum and thereby preserve a wider choice of sensitive drug regimen.
Comparing Outcome of Caregiver-Dependent Patients and Overall Patients on Continuous Ambulatory Peritoneal Dialysis (CAPD) Covered by PD-First Policy in Thailand
Background: In 2002 Thai government launched a healthcare scheme in Thailand started to include 48 million people who are not government related and not private employee. This scheme is called “universal coverage (UC)” healthcare. Thai government has officially announced a PD-first policy for ESRD people in October 2007 and set it effective since 1 January 2008. At present over 3000 new PD patients (pts) have received the treatment. Data from 23 CAPD hospitals called “Phase I CAPD hospitals,” which had experience with PD before the policy, were studied.
Objectives: To compare outcomes of CAPD pts covered by PD-first policy between caregiver-dependent pts and overall pts.
Methods: A descriptive study with analytical part included all pts who started on PD between 1 Jan 2008 and 31 Dec 2008 at 23 Phase I CAPD hospitals. The caregiver cases were included in 3 CAPD dialysis centers (Nakonping Hosp, Chiangmai Univ Hosp, Nopparatrajathanee Hosp). The outcomes peritonitis (P) rate (episodes/pt-year), exit-site infection rate (ESI; episodes/pt-year), and mortality rate were compared between caregiver and overall cases. Comparisons of % between groups by chi-square test (χ2). Statistical analysis was performed using SPSS® software.
Results: 105 pts were enrolled from 3 dialysis centers. 45 pts were caregiver dependent; in this group the pts were older, the P rate was 0.33 episode/pt-year, the ESI rate was 0.48 episode/pt-year, and the mortality rate was 20%/year. To compared outcomes of PD pts between caregiver and overall pts in CAPD covered by PD-first policy project in Thailand in these centers, there was significant difference between caregiver-dependent and overall pts in P rate +(0.33 and 0.22, p < 0.05) and ESI rate (0.44 and 0.18, p < 0.05) but the mortality rate was similar.
Conclusions: In this study, we found that there is higher P rate and ESI rate in caregiver-dependent pts. Multiple factors may be considered, including old age, poor self-care, inactive life, and needs to be clarified. At present, retraining and more frequent home visits may be valuable in caregiver-dependent PD pts.
Outcome of Continuous Ambulatory Peritoneal Dialysis (CAPD) Patients with Initial Catheter-Related and Mechanical Complications in India
Background and Objectives: There is paucity of data on effect of initial catheter-related (CRC) and mechanical complications (MC) on outcome of CAPD patients (pts) from India, where initiation of renal replacement therapy is usually very late. Therefore we undertook this study to analyze the incidence and effect of MC on outcome of CAPD.
Method: In this prospective observational study, 567 ESRD pts who opted for CAPD from Jan 2002 to Oct 2006 were included. All pts had double-cuffed straight Tenckhoff catheter inserted by surgical technique. PD was started after break-in period of 12 ± 2 days. Incidence of MC and outcome of CAPD after this complication were analyzed.
Results: Of the 567 (mean age 49.8 ± 15 years, male 425) pts, 298 were diabetics and 269 nondiabetics. CRC and MC were noted in 176/567 (30%) pts (diabetic 97/298 vs nondiabetic 79/269 pts, p = 0.55). Of the 176 pts, exit-site bleeding was seen in 37 (21%), bleeding from incision site 22 (12.5%), malposition and poor outflow 72 (41%), different hernias 18 (10%), pleuroperitoneal communication 6 (3%), scrotal swelling 2 (1.3%), bowel injury in 2 (1.3%), intestinal obstruction 8 (5%), wound dehiscence 8 (4%). Significantly higher proportion of pts 120/176 (68%) with these complications developed peritonitis compared to 180/391 (46%; p = 0.001) pts who did not develop these complications. It was also observed that multiple episodes of peritonitis (≥2 episodes) were also higher in pts with these complications 56/120 (46.6%) compared to pts who did not have any these complications 20/180 (11.1%; p = 0.001). The overall mean peritonitis rate in pts having these complications was significantly higher (1.66 ± 2.11 vs 0.49 ± 1.04, p < 0.001) than pts without complications. Catheter removal for resolution of these complications was required in 65/176 (36.9%) pts. Of them, 25/65 (38.4%) could not resume PD, while 40/65 (61.6%) successfully resumed PD. Mean technique survival was 47.9 pt-months (95%CI 42.5–53.3 months) in pts with these complications compared to 62.4 pts-months (95%CI 58.0–66.8) without these complications (p = 0.001).
Conclusion: Peritonitis is common in pts with initial CRC and MC. Initial CRC and MC may result in catheter removal and technique failure in such pts.
Model of Nursing Care for Peritoneal Dialysis (PD)-Related Peritonitis in CAPD Patients Covered by PD-First Policy Project in Thailand
Background: In 2002 the Thai government launched a healthcare scheme in Thailand started to include 48 million people who are not government related and not private employee. This scheme is called “universal coverage (UC)” healthcare. Thai government has officially announced a “peritoneal dialysis first” (PD-first) policy for ESRD people in October 2007 and set it effective since 1 January 2008. At present over 3000 new PD patients have received the treatment. Data from 23 CAPD hospitals called “Phase I CAPD hospitals,” which have had experience with PD before the policy, were studied.
Objectives: To demonstrate a model of nursing care for PD-related peritonitis.
Methods: A descriptive study was performed to demonstrate a model of nursing care for PD-related peritonitis in CAPD patients covered by PD-first policy project in Thailand.
Results: We developed a flowchart of nursing care for peritonitis in our center as follows: (1) the diagnostic criteria of PD related peritonitis using “Thai CPG on CAPD patient care 2005, the Nephrol. Society of Thailand”; (2) specimen collection protocol: peritoneal fluid cell count and bacteriologic study; (3) empiric antibiotics protocol: cefazolin 1 g/2 L plus ceftazidime 1 g/2 L, IP, intermittent dosing method; (4) technique review and retraining; (5) home visit in recurrent or relapsed PD-related peritonitis.
Conclusions: Due to rapid growth of CAPD patients, our center set up PD-related peritonitis care to help primary physicians and nurses care for the patients. The major problem in our center is a low rate of home visits. The cost-effectiveness of this model should be evaluated.
Nursing Care for Peritonitis Prevention in CAPD Patients Covered by PD-First Policy Project in Thailand
Background: In 2002 the Thai government launched a healthcare scheme in Thailand started to include 48 million people who are not government related and not private employee. This scheme is called “universal coverage (UC)” healthcare. Thai government has officially announced a “peritoneal dialysis first” (PD-first) policy for ESRD people in October 2007 and set it effective since 1 January 2008. At present over 3000 new PD patients have received the treatment. Data from 23 CAPD hospitals called “Phase I CAPD hospitals,” which had experience with PD before the policy, were studied.
Objectives: To study nursing care for peritonitis prevention in CAPD patients.
Methods: A descriptive study to survey by interviewing expert CAPD nurses about nursing care for peritonitis prevention in CAPD patients covered by PD-first policy project in Thailand. An open question was used: “How does PD nurse play roles in peritonitis prevention?” The statistical analysis used frequency and percentage.
Results: The study recruited 23 expert CAPD nurses from Phase I CAPD hospitals. The opinions for peritonitis prevention are shown in the following table.
Conclusions: In this study we found that expert CAPD nurses preferred a good quality training program as a key step on peritonitis prevention.
Analysis of Peritonitis in Peritoneal Dialysis Patients with Diabetic Nephropathy
Objectives: To explore the relativity of peritonitis in peritoneal dialysis (PD) patients with diabetic nephropathy.
Methods: 62 PD patients were enrolled into this study. The patients were divided into 2 groups depending on the primary disease: diabetic nephropathy (n = 22; 8 females, 14 males; average age 44.6 ± 18.5 years) and nondiabetic nephropathy (n = 40; 14 females, 26 males; average age 41.8 ± 20.1 years). The incidence rates of peritonitis, mortality, and termination rate in these 2 groups were analyzed by use of SPSS® 13.0 statistical software.
Results: The incidence rate of peritonitis was 77.2%, mortality was 18.2%, termination rate was 27.2% in the diabetic nephropathy group and 32.5%, 7.5%, and 10.0%, respectively, in the nondiabetic nephropathy group. There was significant statistical difference between these 2 groups (p < 0.05).
Conclusion: PD patients with diabetic nephropathy are prone to have the complication of peritonitis, especially fungal peritonitis, which made the patients withdraw from PD. So it is important to take strict aseptic technique, control blood sugar strictly, and give anti-infection treatment in time. We also should emphasize the importance of anti-infection to patients and their relations who take PD at home.
Effect of Hypokalemia on Peritonitis in Continuous Ambulatory Peritoneal Dialysis (CAPD) Patients
Objective: We retrospectively analyzed our CAPD patients (pts) who had complicated peritonitis (P) in latest 2 years to investigate the effect of hypokalemia on P in CAPD pts.
Methods: The influence of hypokalemia on the clinical features of P was assessed. From Sept 2006 to Aug 2008, 40 unselected pts undergoing CAPD treatment and followed up in our hospital were recruited for the study. Hypokalemia was defined as a serum potassium level <3.5 mmol/L. The impact of hypokalemia on several clinical parameters, including nutrition status, dialysis adequacy, occurrence of P, and the etiologic pathogens was analyzed. The peritoneal equilibration test (PET) was used to assess the status of peritoneal ultrafiltration.
Results: During the study period, the overall P rate was 20.6 pt-month/episode. The prevalence of P was significantly higher in pts with hypokalemia (8.9%) compared to those without hypokalemia (2.8%, p < 0.01). Hypokalemia was also associated with lower serum albumin (p < 0.01), serum phosphate (p < 0.01), total serum cholesterol (p = 0.049), and normalized protein nitrogen appearance (p < 0.01). There was no correlation between the serum K level and daily PD exchange volume, total Kt/V, urine volume, or daily ultrafiltration volume. Data of PET were not significantly different between pts with or without hypokalemia. When the etiologic organisms of P were grouped according to their usual site of colonization, Enterobacteriaceae appeared to be much more prevalent than epidermal micro-organisms (53.1% vs 18.8%, p = 0.004) in the hypokalemia group. However, it was not the case in pts with normal serum K.
Conclusion: CAPD pts with hypokalemia are associated with a higher prevalence of P and poor nutritional status. Enterobacteriaceae are the predominant organisms causing P in the group with hypokalemia. This unique and novel finding implies the translocation of these organisms from intestinal mucosa into the peritoneal cavity. A pathogenic mechanism linking malnutrition and hypokalemia is also proposed.
A Case of Peritonitis Caused by Serratia Liquefaciens
Objective: Peritonitis (P) is a common complication of peritoneal dialysis (PD). The etiology of P is various but Serratia liquefaciens is rare. This study is to keep vigilance over P caused by S. liquefaciens and improve the level of diagnosis and treatment of S. liquefaciens P.
Methods: A patient (pt) came to our hospital for treatment with a chief complaint of hyperglycemia for 20 years, renal failure for 2 years, PD for more than 1 year, and nausea and vomiting for 10 days. PE: temperature 38°C, BP 146/86 mmHg, R 22/min, clear consciousness, and bad spirit. Heart and lung showed normal. Abdomen was soft; tenderness was obvious in the mid and lower abdomen, no rebound tenderness. Edema of both lower extremities was obvious. Peritoneal dialysate was not clear. Routine test showed yellow turbid solution, nucleated cells 750 × 106/L, RBC 10 × 106/L, multinuclear cells 96%. Smears examination showed no bacteria and fungi. We treated him with amoxicillin sulbactam (sig: 1.5 g IV q12 hours) and added cefazolin and amikacin in the PD solutions. The 2nd day, the pt's temperature was above 39°C. On the 3rd day after admission, the bacterial culture of peritoneal dialysate showed positive with S. liquefaciens. According to the drug sensitivity test, we used cravit (sig: 0.5 IV q.d.) and added ceftriaxone sodium (sig: 0.25 q.i.d.) and amikacin (sig: 0.05 q.i.d.) in the PD solutions. After 2 to 3 days’ subsequent treatment, clinical symptoms disappeared and temp turned normal.
Results: S. liquefaciens showed high resistance to penicillin or other common antibiotics and was sensitive to the 3rd-generation cephalosporin. After anti-infection treatment, the bacterial culture of peritoneal dialysate showed negative. The pt recovered and was discharged.
Conclusion: The symptom of P caused by S. liquefaciens was not typical. Bacteria culture for many times can give the etiology evidence and help us make the right diagnosis and treat the pts with the rational antibiotics. The risk factors such as age, diabetes, uremia, and PD were related to this opportunistic pathogen infection.
Analysis Factors Associated with Continuous Ambulatory Peritoneal Dialysis Peritonitis
Objective: To investigate the relevant factors and preventive measures of peritonitis in patients receiving continuous ambulatory peritoneal dialysis (CAPD).
Methods: 118 chronic renal failure patients treated with CAPD were included in this study. Patients were divided into different groups according to their primary disease types, education level, SGA score, and dialytic time. We analyzed the incidence of peritonitis in each group.
Results: Patient's peritonitis incidence of low educational grade was significantly higher than that of highly educated: 1/50 vs 1/111 patient-months (p < 0.05). The peritonitis incidence of malnutrition group was significantly higher than well-nourished: 1/48 vs 1/143 patient-months (p < 0.001). Compared with patients dialyzed over 12 months, patients dialyzed less than 12 months had a higher incidence of peritonitis: 1/77 vs 1/56 patient-months (p < 0.05). There were no significant differences between diabetics and nondiabetics patients (p > 0.05).
Conclusion: Our results suggested that education status, nutritional status, and dialytic time are considered factors of CAPD-related peritonitis. Thus, preventing and controlling the relevant factors of peritonitis may decrease the peritonitis incidence and improve the quality of life in CAPD patients.
Initial Therapy for Peritonitis in Peritoneal Dialysis (PD) Patients
Objective: According to the 2005 updated recommendations of the International Society for Peritoneal Dialysis (ISPD), initial antibiotics for PD-related peritonitis (P) must cover both gram-positive and gram-negative organisms. The choice of initial antibiotics should be tailor made and center specific. In our retrospective study, we attempted to evaluate the efficacy of combinations of ceftazidime with vancomycin or cefazolin.
Methods: From January 2006 to January 2009, we treated 138 PD-related P episodes in 96 patients. Diagnosis of P was established if they had symptoms of P and the effluent cell count exceeded 100 white blood cells (WBC)/mL. 38 P episodes were treated with intraperitoneal (IP) cefazolin 1 g plus ceftazidime 1 g daily as initial empirical antibiotic therapy, while 100 episodes with IP vancomycin 1 g on day 1, 0.5 g on day 2 and day 3 plus ceftazidime 1 g daily. Initial therapy lasted for 3 days and was considered primary effective if effluent cell count <100 WBC/mL on day 4.
Results: There were no significant differences between the 2 groups in gender, age, prevalence of diabetes mellitus, dialysis duration, and the cause of the P. The efficacy of the cefazolin/ceftazidime combination was 86.8% and in the vancomycin/ceftazidime combination, 87.0%. There were no statistically significant differences between the 2 combinations of antibiotics (p > 0.05). The results of culture of 2 groups were similar (p > 0.05). No case of vancomycin-resistant bacteria was noted but, in the primary inefficacy cases, withdrawal rates of cefazolin/ceftazidime group and vancomycin/ceftazidime group were 90% and 31% respectively.
Conclusion: As initial treatment for PD-related P, IP cefazolin + ceftazidime and vancomycin + ceftazidime had similar primary efficacy in Peking University Third Hospital. As far as the outcome was concerned, vancomycin plus ceftazidime seems to be more suitable for general use.
Risk Factors of Peritonitis in Continuous Ambulatory Peritoneal Dialysis Patients
Objective: Peritonitis is the most common complication and the leading cause of technique failure among end-stage renal disease (ESRD) patients treated with continuous ambulatory peritoneal dialysis (CAPD). This study was done to investigate the possible risk factors associated with CAPD-related peritonitis.
Methods: All patients who had experienced peritonitis from 1 January 2005 to 30 November 2007 were enrolled. Medical records of these patients were retrospectively reviewed and possible risk factors inducing infection were categorized as following: ignorance of aseptic technique, exit-site infection, diarrhea, unclean exchange place or poor economic status, mistake, immuno-dysfunction, and by accident.
Results: A total of 73 episodes of peritonitis were recorded in 81 CAPD patients during the study period in our hospital. Among the 73 episodes of peritonitis, 41 (56.2%) were induced by ignorance of aseptic technique, 13 (17.8%) were due to diarrhea, 6 (8.2%) were considered caused by unclean exchange place or poor economic status, 5 (6.9%) were caused by accident, 4(5.5%) were considered associated with immuno-dysfunction, 3 (4.1%) were by mistake, and 1 (1.4%) was considered due to exit-site infection. Ignorance of aseptic technique was the most common risk factor associated with peritonitis.
Conclusion: Ignorance of aseptic technique was the leading factor associated with CAPD-related peritonitis in our center, suggesting that patient training with emphasis on aseptic technique might be essential for prevention of peritonitis.
Management of Catheter Infections in Peritoneal Dialysis (PD) Patients Using Ultrasonography (US) and Exit-Site Score
Objective: Catheter infections, a term which includes both exit-site (ES) and tunnel infections, can result in PD-related infections, leading to catheter loss. Recently, there was a report about using an exit-site score (ESS) in children to diagnosis ES infection, it may be more convenient and practical than the microbiology. For a long time, the diagnosis of tunnel infections in CAPD lacked a useful method; some authors try to use US. This study used both methods to evaluate its effects in diagnosis and treatment of catheter infections.
Methods: We studied CAPD patients (pts) (n = 80) in our peritoneal center using the cross-section study. The catheter ES was judged by an ESS (0-10) considering the presence of an erythema (0 = none; 1 = <0.5 cm; 2 = >0.5 cm), a crust (0 = none; 1 = <0.5 cm; 2 = >0.5 cm), tenderness (0 = none; 1 = moderate; 2 = severe), swelling (0 = none; 1 = moderate; 2 = severe), and discharge (0 = none; 1 = clear; 2 = purulent). Infection should be assumed with ESS of ≥4. A score of <4 may or may not represent infection. We chose ESS of ≥2 as study group and score of 0–1 as control group. US examination of the subcutaneous catheter tunnel was performed using the scanner with a 7.5 MHz linear transducer. A positive US was defined as an area of hypoechogenicity (indicative of fluid collection) in width along any portion of the catheter tract. For the positive pt in US examination, we applied mupirocin to the ES as part of routine daily care. Meanwhile, these pts were treated with ofloxacin (200 mg/d, by mouth) over a period of approximately 2 weeks. Then we repeated the US examination in these pts for evaluating change in hypoechogenicity.
Results: (1) In 80 pts, 3 had a score of >4 (3%), 21 had score of >2 (26%); mean value was 2.7 ± 0.6; 40 pts had a score 0 (50%). (2) After the treatment, the score of the pts was improved: from 2.7 ± 0.6 to 2.2 ± 0.5 (p < 0.05). (3) From the result of US examination, hypoechogenicity in width along the catheter tract in some pts in studied group was improved.
Conclusion: For pts with a score >2 and with abnormal finding in US examination, it is effective to apply mupirocin to the ES and with ofloxacin by mouth in improving the status of the exit of the catheter and tunnel infection We need further study to elucidate if such treatment can lower the incidence of the peritonitis in CAPD and how to treat the refractory pt with the proper course of the treatment.
A Ten-Year Review of Adult Peritoneal Dialysis-Related Peritonitis in a Chinese Medical Center
Objective: Peritonitis is one of the major complications of peritoneal dialysis (PD), and continues to be a major cause of technique failure and patient morbidity and mortality. The peritonitis rate, the organisms isolated, and antibiotic sensitivities vary around the world, but detailed descriptive studies focusing on PD-related peritonitis in Chinese patients are relatively unexplored. This study is to review the etiology and antibiotic sensitivities of PD-related peritonitis in China.
Methods: 187 cases of PD-related peritonitis were enrolled into this study. We retrospectively analyzed data on all episodes of PD-related peritonitis over the past decade in Chinese medical center, including organism isolated and antibiotic sensitivities.
Results: 79 cases were culture positive, accounting for 42.2%. The most common isolated organisms were gram-positive organisms (65.5%); gram-negative organisms comprised 18.2% and fungi 16.3%. Staphylococcus epidermidis, S. aureus, S. haemolyticus, and Corynebacteria sp were the most common kinds of gram-positive organisms, all of which were sensitive to vancomycin and 81.5% were sensitive to ampicillin/sulbactam. Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa were the most common kinds of gram-negative organisms which showed high sensitivity to ceftazidime (91.1%) and amikacin (88.1%). Fungal peritonitis represents a clinical challenge and administration of antifungal agents was often ineffective.
Conclusion: Most peritonitis caused by gram-positive organisms. Vancomycin, ampicillin/sulbactam, ceftazidime, and amikacin should be recommended for empiric therapy for adult PD-related peritonitis in China.
Mupirocin for Preventing Exit-Site Infection and Peritonitis in Patients Undergoing Peritoneal Dialysis (PD): Was it Still Effective?
Objectives: Recently, there were increasing concerns about the emergence of mupirocin resistance and the enhancing infections caused by other organisms for the inhibition to Staphylococcus aureus. We conducted this systemic analysis on whether the application of mupirocin was still effective on prevention of exit-site infection (ESI) and peritonitis (P) in patients (pts) undergoing PD.
Methods: Recruited studies met the following criteria: they were randomized controlled trials (RCT) or historical cohort studies; subjects consisted of adults (age ≥18 years) undergoing PD; mupirocin treatment was administered to the therapy group and placebo or no treatment was administered to control group. The primary extracted data was the difference in the episodes of ESI and P caused by S. aureus or other organisms among therapy and control groups.
Results: 14 studies described in 13 articles and a total of 1233 pts versus 1217 controls were included in the analysis. Of the 13 articles, 6 were newly published articles that had not been analyzed previously, 3 were RCT. Application of mupirocin decreased the risk by 72% [95% confidence interval (CI),0.60–0.81] in ESI and by 70% (95% CI, 0.52–0.81) in P caused by S. aureus among all pts undergoing PD. Treatment of mupirocin reduced the risks of ESI and P caused by S. aureus and other organisms by 57% (95% CI, 0.46–0.66) and 41% (95% CI, 0.24–0.54) respectively. Based on the 6 newly published articles, the reduced risk rate for mupirocin therapy was 80% (95% CI, 0.39–0.93, p = 0.004) in ESI and 91% (95% CI, 0.72–0.97, p < 0.0001) in P caused by S. aureus; 70% (95% CI, 0.47–0.82, p < 0.0001) in ESI and 42% (95% CI, 0.25–0.55, p < 0.0001) in P caused by S. aureus or other organisms among mupirocin-treated and -untreated subjects. Based on the 3 RCT, ESI and P caused by S. aureus were found to be reduced by 73% (95% CI, 0.63–0.80, p < 0.0001) and 40% (95% CI, 0.17–0.56, p = 0.002) respectively. Interestingly, although mupirocin treatment can reduce the risk rate of ESI by 46% (95% CI, 0.35–0.55, p < 0.00001), it cannot decrease the risk rate of P caused by S. aureus and other organisms (p = 0.56).
Conclusions: Mupirocin prophylaxis was still effective in preventing ESI and P caused by S. aureus and other organisms in PD pts.
Efficacy of Secondary Training in Prevention of Peritonitis in Continuous Ambulatory Peritoneal Dialysis (CAPD) Patients
Objective: Peritonitis is one of the most common complications of peritoneal dialysis (PD). This study aimed to analyze the duration and reasons of the first time peritonitis after implanting the tube for PD and evaluate the efficacy of secondary training on prevention of peritonitis in CAPD patients.
Methods: 150 patients in our center before 2003 were enrolled in the study as without the secondary training group (control group). 80 patients in our center after 2003 were chosen as the secondary training group. Secondary training was performed 12 months after tube implantation and before the time of first peritonitis happened. The incidence rate of peritonitis, the duration and reasons of the first time peritonitis after tube implantation were analyzed and compared between the 2 groups.
Results: Peritonitis occurred in 56 of 150 CAPD patients without secondary training and in 41 of 80 CAPD patients with secondary training. The duration of the first-time peritonitis after implanting a tube was longer in patients with secondary training than without secondary training (26.05 ± 10.34 vs 18.25 ± 6.34 months, p < 0.05). The incidence rate of peritonitis was lower in secondary training group than without secondary training (50.8 vs 48.8 patient-months, p < 0.05). The correlation of peritonitis with manipulation was reduced from 52.6% to 22.6%. There were no differences in bacterial strains distribution between the patient with and without secondary training. Staphylococcal infections were 57.14% in patients without secondary training and 56.74% in patients with secondary training (p > 0.05).
Conclusions: 1.5 years after implanting tube, the CAPD patients began to neglect aseptic technique. Secondary training is helpful for these patients before 1.5 years after implanting tube to reduce the occurrence of peritonitis that was correlated with manipulation.
Analysis of Inducing Factors and Intervention Measures of Peritoneal Dialysis (PD)-Related Peritonitis
Objective: Peritonitis (P) is a common complication of PD. This study investigated inducing factors of PD-related P and explored the approach to reduce the incidence of P and improve the quality of life of patients (pts).
Methods: 20 cases of pts with P from our PD center from 2006 to 2008 were enrolled into this study (9 men, 11 women; mean age 49.2 years; average time on PD 27.6 (3-66) months). Pts who had return visit every 1 or 2 months were regarded as regular return visit pts, while the others were considered irregular return visit pts. Data including pts’ age, gender, education level, economic status, psychological status, family supervision and support, indwelling dialysis catheter time, intuitive reasons for P, were collected by methods of out-pt questionnaire survey, telephone follow-up survey, face-to-face questionnaire, and so on. These data were analyzed using the statistical software SPSS® 13.0.
Results: P incidence in the pts whose indwelling PD catheter time was >6 months (14 cases) was significantly higher than in pts whose PD duration was <6 months (6 cases) (p < 0.05). The infection rate was 17.1% in the pts at their own expense and 13.0% in pts with medical insurance. The infection rate in the regular return visit pts and irregular return visit pts was 41.8% and 2.4% respectively (p < 0.05). For the pts with poor support, the infection rate was 34.7%, which was higher than in pts with good support (3.9%, p < 0.05). Malnutrition and decrease of defense and immunity capacity caused by depression, anxiety, and other adverse mental status were the inducing factors of P. In the long-term PD pts, the incidence rate of P had no significant correlation with age, sex, or education level of the pts (p > 0.05). The direct inducing factors of P were various: 14 cases of pts with violation of operation rules (including 4 cases of pts with repeated use of double-connecting tube; 3 cases of pts reusing disposable iodine cap; 5 cases of pts receiving treatment without required hand-washing, protective mouth-muffle, and environmental disinfection; 2 cases of pts receiving PD with damaged PD fluid bag; 4 cases were induced by other complications and 2 cases were caused by unexplained factors.
Conclusion: The inertia, simplified and violated operation caused by the prolongation of PD duration is a major inducing factor of P, and poor economic conditions directly lead pts to violate the operation rules. Irregular return visit and lack of family support of pts are also related to a high incidence of P. We should give training and retraining to PD pts, particularly in the aspects of water and salt intake and the sterile concept. Make individual treatment for PD pts in accordance with pt's economic situation. Mobilize the support and enthusiasm of family so that pts would have good attitude to the disease development and the negative impact of P is reduced. In addition, PD pts are a special group who need more attention from the community and government.
Effects of Strong Acid Aqueous Infusion into Abdominal Cavity on Peritoneum and Peritonitis
Objective: Strong acid aqueous (SAA) has been reported to have a quick and strong bactericidal function. We hypothesized that SAA infusion during peritoneal dialysis (PD) is effective in treating PD-related peritonitis. This study was designed to determine the effects of SAA infusion on the peritoneum and PD-related peritonitis in a rabbit model.
Methods: New Zealand white rabbits were used in phase-I study to evaluate the effects of SAA infusion to peritoneum. Rabbits were divided into 3 groups: saline infusion (n = 8), single SAA infusion (n = 8), and multiple SAA infusion (n = 8). In phase-II study, 36 rabbits with PD-related peritonitis were divided into 3 groups: group A: rabbits were treated with saline infusion into abdominal cavity; group B: rabbits were treated with saline and garamycin infusion; group C: rabbits were administrated with SAA infusion. Rabbits were closely monitored for their behavioral change. Blood, ascites, and peritoneum tissue samples were collected.
Results: Rabbits in phase I study demonstrated normal behavior and body weight. The biochemical parameters of blood samples were physiological without significant changes. Histological evaluation of peritoneum samples revealed normal structures without significant changes among these groups. In phase II study, blood from rabbits treated with saline infusion revealed increased WBCs and ascites showed increased WBCs and protein levels. In contrast, WBCs and protein levels were decreased significantly in groups B and C. Peritoneum samples collected from group C rabbits demonstrated minimal histological changes compared with groups A and B.
Conclusion: These results suggest that SAA infusion into the abdominal cavity is safe and effective to treat PD-related peritonitis.
Prediction of Risk Factors Relating to the Infective Peritonitis in Peritoneal Dialysis Patients
Objective: To evaluate the risk factors correlated to the infective peritonitis in continuous ambulatory peritoneal dialysis (CAPD) patients.
Methods: 78 CAPD patients in our peritoneal dialysis center from February 2002 to February 2009 enrolled in the study. Morbidity of infective peritonitis was analyzed in relation to the educational level of CAPD patients, home environment, nutrition status (hemoglobin and serum albumin), primary diseases, and dialysis dose.
Results: Mean age of the 78 patients (43 males, 35 females) suffering CAPD was 50.5 ± 10.3 years. 60 suffered infective peritonitis in the first 2 years. Incidence of infective peritonitis in the poorly educated patients (below senior high school level) was significantly higher than in the well-educated patients (above senior high school level): 87.8% vs 68.9% (p < 0.01). The incidence of infective peritonitis in the patients in favorable home environment (a special room was used for peritoneal dialysis) was lower than in the patients in adverse home environment: 64% vs 100% (p < 0.01). Malnourished (Hb < 90 g/L and/or serum albumin <30 g/L) patients were expected to suffer infective peritonitis more often than well nourished patients (p < 0.01). Patients with diabetic nephropathy were expected to suffer infective peritonitis more often than patients without diabetic nephropathy (p < 0.01). Adequacy of peritoneal dialysis was expected to decrease the incidence of infective peritonitis.
Conclusion: Poor education as well as adverse home environment, malnutrition, dialysis inadequacy, and diabetes are the risk factors of infective peritonitis in CAPD patients.
Conversion from Vancomycin to Linezolid in the Treatment of Peritoneal Dialysis (PD)-Related Peritonitis
Background: Peritonitis (P) remains a major complication in patients (pts) undergoing PD. With the emergence and prevalence of methicillin resistant gram-positive organisms mainly including MRSA and MRSE in the world, the treatment of PD-related P really becomes a clinical concern. Although vancomycin remains the drug of choice for the treatment of MRSA infections, its clinical efficacy decreased significantly with the MRSA vancomycin MIC creep, which may require administration of newer agents such as linezolid, quinupristin/dalfopristin, or daptomycin. This study was made to compare the clinical efficacy and safety of vancomycin and linezolid on PD-related P caused by methicillin-resistant gram-positive organisms.
Methods: 13 PD-related P pts infected with gram-positive organisms which were sensitive only to vancomycin, linezolid, and teicoplanin were prospectively included and randomized into 2 groups: group A (n = 6) received intraperitoneal vancomycin with loading dose 1 g and maintenance dose 30 mg/kg per 7 days; group B (n = 7) received intraperitoneal linezolid with loading dose 600 mg and maintenance dose 4 mg/kg q.i.d. Clinical and bacteriological responses were assessed after a minimum of 5 days and following completion of therapy.
Results: Resolution of P was achieved in 3/6 pts treated with vancomycin (50%) and in 7/7 pts treated with linezolid (100%, p < 0.001). One pt in vancomycin group was found gross hematuria and oliguria (16.6%). No adverse events were observed in linezolid group (p < 0.001). The cost of antibiotics was statistically higher in the linezolid group (p < 0.001).
Conclusions: Linezolid was more effective and safe than vancomycin in the treatment of P caused by methicillin-resistant gram-positive organisms in the PD pts enrolled in this study. However, the cost of the linezolid treatment regimen was more expensive than vancomycin.
Relapse of Peritonitis in Peritoneal Dialysis Patients Were Effectively Stopped by Catheter Exchange—Experience from Six Cases of Relapsing Peritonitis
Objective: Relapsing peritonitis in peritoneal dialysis (PD) patients is not uncommon. Characteristics of 6 cases of relapsing peritonitis and effective treatment were reported.
Methods: Relapsing peritonitis was diagnosed as an episode that occurs within 4 weeks of completion of therapy of a prior episode with the same organism or 1 sterile episode. By medical chart review, 6 cases of relapsing peritonitis were found in our PD center from November of 2005 to October 2008. Demographic, clinical features, treatment modalities, and outcome were summarized and reported.
Results: There were 3 males and 3 females; average age was 60.5 ± 12.8 years. Three patients were diabetic. Median dialysis vintage when they first experienced peritonitis was 17.5 (1-88) months. There were 20 episodes of peritonitis in the 6 cases (at least 2 episodes in each case). Effluent fluid bacterial culture showed Staphylococcus epidermidis infection in 3 cases and S. aureus infection in 2 cases. Empiric antibiotics were used in the first few days of infection and then changed to sensitive antibiotics according to bacterial culture result. Symptoms were slight and easily relieved after antibiotics treatment. The DSS were 1 at 5 patients and 0 point at 1 patient. All became 0 point within 3 days of antibiotic treatment. But episodes relapsed after antibiotics were stopped; the median interval between episodes was 2.4 (1-4) weeks. Catheter removal and replacing a new one at the same time (5 of 6) or 2 weeks later (1 of 6), all 6 patients have not had relapsing peritonitis until now for at least 8 months.
Conclusion: On the basis of effective antibiotic treatment, catheter replacement was an effective way to eradicate relapsing peritonitis in PD patients.
Clinical Features of Peritoneal Dialysis (PD) Patients with Multiple Episodes of Peritonitis
Objective: Repetitive peritonitis (P) is one of the major causes of technical failure of PD therapy. We analyzed the clinical data of PD patients (pts) with P to describe the clinical features of pts experiencing multiple episodes (epi) of P.
Methods: The data from pts undergoing multiple epi of P were compared with those of pts with single epi (including pathogenic microbiology, protocol of treatment, effects of treatment, and outcomes).
Results: From January 2000 to December 2007, 100 epi of P in 66 pts were recorded. 25 pts experienced multiple P (≥2 times; 5 males and 20 females, 67 ± 11 years old). There was no difference in demographic data between the 2 groups. The duration of PD therapy of pts with multiple P was 48 ± 35 months, longer than that of pts with single epi of P (24 ± 22 months, p = 0.002). The 25 pts with multiple epi of infections experienced 59 epi, up to 5 epi/pt, average 2.5 ± 0.8 epi/pt. The interval time between each epi was 327 ± 400 days. Among these pts, dialysate cultures were positive in 34 cases. By repetitive abdomen lavage and antibiotic therapy, 54 epi of abdomen infection were cured. Four cases removed catheter and turned to hemodialysis; their pathogen tests were Mycobacteria, Candida parapsilosis, Staphylococcus aureus, and culture negative, respectively. One pt died due to abdomen infection and the pathogen was Candida albicans. In 41 pts with single epi of P, dialysate culture was positive in 22 cases; 36 epi of infection were cured; 4 pts removed catheter and turned to hemodialysis, their pathogen tests were Escherichia coli, Acinetobacter baumannii, Pseudomonas pickettii, and culture negative, respectively. One pt died due to multiple organ failure; the pathogen was Staphylococcus epidermidis. The time required for relieving infection in pts with multiple P was 7 ± 5 days, which was not significantly different from pts with single abdomen infection (6 ± 4 days, p = 0.23).
Conclusion: Pts with long-term CAPD have higher risk of multiple epi of P. By proper therapy, most cases of infection can be cured.
Effect of Curcumin on Downregulation of Toll-Like Receptor 2 and 6 Expression in Rat Peritonitis Induced by Staphylococcus Epidermidis
Objective: Staphylococcus epidermidis is commonly responsible for peritonitis in patients undergoing continuous peritoneal dialysis. Toll-like receptor 2 (TLR2) and TLR6 play important roles in early and innate immune responses to various microbial agents. Our aim is to investigate the effect of curcumin on expressions of TLR2 and TLR6 in rat peritonitis induced by S. epidermidis.
Methods: S. epidermidis was intraperitoneally injected into rats to develop acute peritonitis treated with (experimental group) or without (control group) curcumin at various time points (3, 6, 12, 24, and 48 hours) after the S. epidermidis administration. Expressions of TLR2 and TLR6 protein were analyzed by immunohistochemistry and Western blot. Expressions of TLR2 and TLR6 mRNA were examined by RT-PCR.
Results: Western blot, immunohistochemistry, RT-PCR all revealed that the expressions of TLR2 and TLR6 increased in a time-dependent manner during 3 to 24 hours after infection by S. epidermidis. The expression of TLR2 and TLR6 in curcumin-treated group was significantly lower compared with that in the control group.
Conclusion: These findings suggest that TLR2 and TLR6 may play important roles in early immune response in S. epidermidis-induced peritonitis in rats and curcumin may be a protective agent in this process.
Organisms of Peritoneal Dialysis (PD)-Related Peritonitis—Experience from the Largest Asian PD Center
Objective: To characterize the spectrum of organisms causing PD-related peritonitis (P) and provide a better guide for treatment.
Methods: We retrospectively examined microbiologic findings in patients (pts) with P that were seen in our PD center in the past 3 years (2006-2008). During that time span, the number of center pts increased from 233 to 566.
Results: 220 episodes of P occurred among our pts within the time span (49, 76, and 95 episodes each year, respectively). The rate of P increased from 1/66.9 pt-months in 2006 to 1/58.8 pt-months in 2008. 20% of cases had negative microbiologic test results. Of the remaining 176 positive results, the 10 organisms most frequently cultured were coagulase-negative staphylococcus (CoNS, 23.8%), Escherichia coli (17.6%), Streptococcus (15.3%), Staphylococcus aureus (10.8%), Klebsiella pneumoniae (6.8%), gram-negative bacilli (9%), fungus (5.1%), Enterococcus (3.4%), Micrococcus Cohn (2.8%), and others (5.1%). A rise in the rate of E. coli-positive cultures from 4 (9.1%) to 17 (22.4%) was seen; the organism became the most commonly cultured organism in 2008. 50.8% of the CoNS organisms cultured were methicillin-resistant (MRSCon). During 2006 to 2008, the rates of MRSC on among CoNS were 63.6%, 73.7%, and 43.8%, respectively. 21.1% (4 in 19) of S. aureus isolates were methicillin-resistant (MRSA); most (3 in 4) were identified in 2008. Rates of extended-spectrum β–lactamase (ESBL)-positive E. coli and K. pneumoniae were 35.5% (11 in 31) and 41.7% (5 in 12) respectively. ESBL-positive E. coli also showed an increasing trend over the 3 years: 0 in 2006, 4 in 2007 (30%), and 7 in 2008 (41.2%). In addition, a high-level aminoglycoside-resistant (HLAR) Enterococcus was identified in 2008.
Conclusions: The organism composition of PD-related P is changing. Over the past 3 years, CoNS, E. coli, and Streptococcus were the most commonly cultured organisms in our center. Rates of antibiotic-resistant organisms associated with PD-related P are also increasing, which may contribute to the increased overall rate of P.
Bacteriological Investigation into Continuous Ambulatory Peritoneal Dialysis (CAPD)-Related Peritonitis
Objective: To investigate the pathogenic bacteria epidemiology and bacterial resistance to antibiotics in CAPD-related peritonitis.
Methods: The clinical manifestations, pathogenic bacteria, bacterial drug resistance, and prognosis in 53 patients with CAPD-related peritonitis were analyzed retrospectively.
Results: The number of positive bacterial cultures was 31 (58.5%) of the 53 patients with peritonitis. Among the 31 patients, 16 (51.6%) with gram-positive cocci, 10 (32.3%) with gram-negative cocci, 2 (6.5%) with gram-positive bacilli, 3 (9.7%) with fungi were obtained. The coagulase-negative staphylococci in gram-positive cocci were the main pathogen, followed by Streptococcus, Staphylococcus aureus, and enterococci. Gramnegative bacilli mainly consisted of Acinetobacter, E. coli, Pseudomonas, and Enterobacter cloacae. All gram-positive cocci were sensitive to vancomycin, the majority (70.6%) sensitive to levofloxacin. Gram-negative bacilli had the lowest resistance against piperacillin–tazobactam, amikacin, imipenem, and no one strain of gram-negative bacilli had drug-resistant. The drug resistance rate of gram-negative bacilli to gentamicin was 22.2%, while resistance rate to ceftazidime was 12.5%. All patients with fungal peritonitis dropped out of peritoneal dialysis, a patient with bacterial peritonitis died of septic shock, and the others were cured. The total CAPD withdrawal rate in peritonitis was 7.5% (4/53).
Conclusion: Gram-positive bacteria remain the major pathogen but the percentages of gram-negative bacteria have increased. Levofloxacin combined amikacin are the most suitable experience-based drug for peritonitis.