CAPD peritonitis. Incidence, pathogens, diagnosis, and management

Peritoneal dialysis in Herzegovina, Federation of Bosnia and Herzegovina: 18 years of experience from our center

INTRODUCTION

Due to treatment of end-stage-renal-disease (ESRD), continuous peritoneal dialysis (CAPD) is used in 11% of cases and is associated with several PD-associated infections.

METHODS

Clinical data on 71 patients with CAPD were evaluated in addition to exit site infections and episodes of acute peritonitis (AP).

RESULTS

There were 39 men and 32 women. Average age was 61 years when we began CAPD and average time spent on CAPD program was 3.35 years. Illness that dominantly caused ESRD was diabetes (23 patients). Exit site infection was mostly caused by S epidermidis-MRSE and AP was most commonly caused by Staphylococcus sp. group. Most common cause of death was cardiovascular disease. At the end of this study, 9 patients were alive and still on CAPD, 10 were transplanted, 15 switched to HD and 36 died.

CONCLUSION

Optimal prevention measures and treatment of infectious complications in CAPD is necessary for better treatment possibilities.

Peritoneal dialysis in Dalmatian County, Croatia: 21 years of a single-center experience

INTRODUCTION

With end-stage renal disease becoming more prevalent, the importance of continuous ambulatory peritoneal dialysis (CAPD) is expected to rise even more. However, CAPD is associated with several infections with peritonitis being of the biggest importance.

METHODS

We collected data regarding acute peritonitis episodes (APEs), date of birth and CAPD start, BMI, diabetes mellitus (DM) prevalence, year of renal disease discovery, and details about renal replacement therapies. Primary outcomes included death, transplantation, and a switch to hemodialysis (HD).

RESULTS

Hundred and twenty-nine men and 123 women were analyzed. 63 patients had DM. The median age at the start of CAPD was 56. The median length of CAPD treatment was 24 months. In the end, 147 patients were still alive of which 97 were transplanted, 33 were on CAPD, and 26 were switched to HD. A total of 327 APE were observed.

CONCLUSION

Although the incidence is decreasing, efforts are required to enhance the prevention and treatment of APE.

Mycobacterium abscessus Associated Peritonitis with CAPD Successfully Treated Using a Linezolid and Tedizolid Containing Regimen Suggested Immunomodulatory Effects

Patient: Female, 38-year-old

Final Diagnosis: Peritonitis

Symptoms: Abdominal and/or epigastric pain

Medication:—

Clinical Procedure: —

Specialty: Infectious Diseases

Diagnostic Value of Effluent Endotoxin Level in Gram-Negative Peritonitis in Capd Patients

Objective

To evaluate the diagnostic usefulness of effluent endotoxin by Limulus amoebocyte lysate (LAL) assay in gram-negative peritonitis patients on continuous ambulatory peritoneal dialysis (CAPD) therapy.

Design

Prospective study with patients serving as their own controls. Standard microbiologic work up and endotoxin analysis of effluents (night dwell) were done during the pre- and posttreatment phases.

Setting

Specimens from three teaching hospitals were processed and tested at a common center. Patients were left for treatment at their respective centers without intervention.

Patients

32 clinical peritonitis and 40 infection-free CAPD patients were studied.

Results

75% ( n = 24) of cultures were positive: 41.6% ( n = 10) gram-negative and 58.4% ( n = 14) gram-positive bacteria. Effluents of pre- and posttreated gram-negative cultures had endotoxin levels of 1.53 ± 0.169 and 0.214 ± 0.085 endotoxin units (EU)/mL, respectively ( p < 0.0001); pre- and posttreated gram-positive levels of 0.102 ± 0.06 and 0.122 ± 0.052 EU/mL, respectively ( p > 0.05); pre- and posttreated culture-negative peritonitis levels of 0.110 ± 0.025 and 0.087 ± 0.031 EU/mL, respectively ( p > 0.05); peritonitis-free effluents contained 0.117 ± 0.079 EU/mL. The diagnostic specificity and the sensitivity of LAL assay were 100% and 98.2% respectively.

Conclusion

Where initial microbiological work-up cannot demonstrate a pathogen, effluent endotoxin determined by quantitative LAL assay is a useful marker for diagnosis and management, within safe time limits, of gram-negative peritonitis in CAPD patients.

Comparison of Peritoneal Fluid Culture Results from Adults and Children Undergoing Capd

Background

Peritonitis is a common complication in patients with end-stage renal disease treated by continuous ambulatory peritoneal dialysis (CAPD). Empirical treatment is based on the organisms that are most frequently isolated and their susceptibilities.

Objective

To analyze and then compare peritoneal fluid culture results from adult and pediatric patients on CAPD, with respect to micro-organisms and antimicrobial susceptibilities.

Design

Three-year retrospective review of peritoneal fluid cultures from adults and children on CAPD.

Results

We isolated 481 organisms from 378 peritoneal fluid specimens, collected from 135 patients (45 children, 90 adults). There were 191 episodes of peritonitis in children (mean 4.2 ± 3.5, range 1 – 15) compared to 187 in adults (2.1 ± 1.9, range 1 – 10) ( p < 0.001). Two or more episodes occurred in 30 of 45 children (67%) compared to 33 of 90 adults (37%) ( p < 0.001). The number of different organisms/patient as well as the total number of isolates/patient were significantly greater in children (respectively, 2.8 ± 2.3, range 1 – 12; and 5.3 ± 5.2, range 1 – 27) than in adults (2.0 ± 1.3, range 1 – 6; and 2.7 ± 2.4, range 1 – 10) ( p < 0.005). After Staphylococcus epidermidis, S. aureus was the most frequently isolated organism, occurring in 18% of episodes in adults and 12% of episodes in children ( p < 0.01). Twenty-two of 33 fungal isolates (67%) in children were Candida parapsilosis compared to 3 of 24 (12%) in adults ( p < 0.001). Subanalysis of multiple episodes revealed that Pseudomonas and Candida occurred significantly more often in children ( p < 0.01), whereas S. aureus occurred more often in adults ( p < 0.001). In polymicrobial episodes S. epidermidis occurred more often in adults ( p < 0.05). Significant differences in susceptibilities to ampicillin, ceftriaxone, chloramphenicol, and gentamicin were found between children and adults ( p < 0.05 – 0.001).

Conclusions

CAPD-associated peritonitis occurs significantly more often in children than adults. Significant differences in microbial etiology and susceptibilities were found between pediatric and adult patients. Each dialysis unit should periodically analyze peritoneal fluid culture results from its CAPD patients. These data can then be used for optimization of empirical antimicrobial therapy of peritonitis.

Peritoneal Dialysis-Related Peritonitis Caused by Microbacterium paraoxydans

A 54-year-old woman receiving continuous ambulatory peritoneal dialysis was admitted, complaining of diffuse abdominal pain. Peritoneal fluid cell analysis showed that the white blood cell count was 2,990 cells/mm³, with a neutrophil count of 2,510 cells/mm³. The patient was treated empirically with intraperitoneal cefazolin and ceftazidime. After 6 days, Microbacterium species grew on a peritoneal dialysate culture that had been collected on the day of admission. We analyzed the 16S rRNA gene nucleotide sequence and identified the organism as Microbacterium paraoxydans. Based on the results of the antibiotic susceptibility test, the patient was treated with intraperitoneal vancomycin and oral clarithromycin. She recovered uneventfully without interruption of peritoneal dialysis. This is a unique case of peritoneal dialysis-related peritonitis due to M. paraoxydans.

Peritonitis in a continuous ambulatory peritoneal dialysis patient by two different species of enterococci: A rare finding

Peritonitis in a continuous ambulatory peritoneal dialysis patient by two different species of enterococci is a rare condition. We report a case of peritonitis from which vancomycin sensitive Enterococcus faecalis and vancomycin resistant Enterococcusc faecium were isolated. It also emphasizes the effectiveness of linezolid for the treatment of vancomycin resistant enterococcal infection.

Serratia marcescens Peritonitis in a Diabetic Patient Receiving Continuous Ambulatory Peritoneal Dialysis

We report a case of Serratia marcescens peritonitis in a 45-year-old man with insulin-dependent diabetes mellitus undergoing continuous ambulatory peritoneal dialysis (CAPD). The patient presented with abdominal pain and cloudy dialysate. Empiric antibiotic therapy was initiated intraperitoneally with cefazolin and ceftazidime for 5 days. Cultures of the dialysate revealed S. marcescens, and the treatment was subsequently changed to gentamicin and ceftazidime. Oral ciprofloxacin was also added. The patient's abdominal pain and the dialysate white blood cell (WBC) count, however, did not improve. The indwelling CAPD catheter was therefore removed. This is an unusual case report in the Korean literature of S. marcescens peritonitis in a patient receiving CAPD.

Mycobacterium porcinum peritonitis in a patient on continuous ambulatory peritoneal dialysis

Mycobacterium porcinum has been reported to cause a variety of illnesses including wound infections, respiratory tract infections, osteomyelitis and catheter-related bacteremias. We report the first case of M. porcinum peritonitis in a patient on continuous ambulatory peritoneal dialysis (CAPD). A 67-year-old woman on CAPD presented with three weeks of constitutional symptoms and abdominal pain. Peritoneal fluid cultures on day three grew acid-fast rods. Nocardiosis was suspected and the patient was empirically treated with amikacin and trimethoprim-sulfamethoxazole. The dialysis catheter was removed. Two weeks later final culture results revealed M. porcinum. Ciprofloxacin and trimethoprim-sulfamethoxazole were initiated with good clinical response.

Erysipelothrix rhusiopathiae peritonitis in a patient undergoing continuous ambulatory peritoneal dialysis

Erysipelothrix rhusiopathiae is known as a pathogen of occupational diseases or a zoonosis. We report a case of E. rhusiopathiae peritonitis in a 50-yr-old male undergoing continuous ambulatory peritoneal dialysis (CAPD). He was suffered from mild abdominal pain with a distinctive erysipeloid skin lesion. E. rhusiopathiae was considered to be introduced through a lacerated wound on his hand when he was exposed to contaminated materials. He was treated successfully with a first generation cephalosporin. To our knowledge, CAPD peritonitis due to E. rhusiopathiae is very rare, and this is a report of the first case in Asia.

S-thanatin enhances the efficacy of tigecycline in an experimental rat model of polymicrobial peritonitis

We investigated the efficacy of the peptide s-thanatin alone and in combination with tigecycline in an animal model of sepsis induced by cecal ligation and puncture. Adult male Wistar rats were randomized to receive intravenously isotonic sodium chloride solution, 5mg/kg s-thanatin, 2mg/kg tigecycline, 5mg/kg s-thanatin combined with 2mg/kg tigecycline. The experiment was also performed with administration of the drugs 360 min after the surgical procedure to better investigate the clinical situation where there is an interval between the onset of sepsis and the initiation of therapy. Lethality, bacterial growth in blood, peritoneum, spleen and liver, and NO indices were evaluated. All compounds reduced the lethality when compared to control. In all experiments, the compounds reduced significantly bacterial growth and lethality compared with saline treatment. Treatment with s-thanatin resulted in significant decrease in plasma NO levels compared to tigecycline and control group. The combination between s-thanatin and tigecycline proved to be the most effective treatment in reducing all variables measured. S-thanatin may have potential therapeutic usefulness alone and when associated to tigecycline in polymicrobial peritonitis.

Automated peritoneal dialysis-associated peritonitis due to Haemophilus influenzae showing the BLNAR phenotype

A rare case of peritonitis due to beta-lactamase-negative, ampicillin-resistant Haemophilus influenzae is described in an 18-year-old male undergoing automated peritoneal dialysis. The infection was probably of respiratory origin. Two strains of H. influenzae cultured from peritoneal fluid and a nasal swab were indistinguishable by molecular methods. The patient was successfully treated with oral ciprofloxacin. The authors suggest that this species should be taken into account as the etiologic agent of peritoneal dialysis-associated peritonitis. Targeted antimicrobial therapy should be based on local antibiotic resistance patterns.

Receptor-interacting protein-2 deficiency delays macrophage migration and increases intracellular infection during peritoneal dialysis-associated peritonitis

BACKGROUND

Early upregulation of receptor-interacting protein-2 (RIP2) expression during peritoneal dialysis (PD)-associated peritonitis correlates with a favorable clinical outcome, while failure to upregulate RIP2 correlates with a protracted course. We noticed that patients who do not upregulate RIP2 during PD-associated peritonitis have more peritoneal macrophages during the early phase of infection.

METHODS

To study the mechanism behind this observation, we examined the role of RIP2 in the immune response to bacterial challenge in a mouse model of acute peritonitis. We injected RIP2(+/+) and RIP2(-/-) mice intraperitoneally with a Staphylococcus epidermidis cell free-preparation, and peritoneal cells were isolated 3, 6 and 24 h after challenge.

RESULTS

Surprisingly, RIP2(-/-) mice had a comparable influx of inflammatory leukocytes, but had a significantly higher number of peritoneal macrophages at 3 h, indicating delayed emigration of these cells. No significant differences were seen at later times suggesting that migration was delayed but not inhibited. In addition, RIP2(-/-) macrophages were more permissive to intracellular infection by Staphylococcus aureus, indicating that, in the absence of RIP2, resident peritoneal macrophages could become reservoirs of bacteria.

CONCLUSION

These findings provide a mechanism for the observation that upregulation of RIP2 expression is required for rapid resolution of peritonitis, by decreasing intracellular infection and by regulating the migration of antigen-presenting cells in the early stages of an inflammatory response.

Extended spectrum β-lactamase–producing Klebsiella pneumoniae chronic ambulatory peritoneal dialysis peritonitis treated successfully with polymyxin B

Peritonitis is not an infrequent complication of inpatients with chronic ambulatory peritoneal dialysis (CAPD). CAPD peritonitis may be related to the catheter or secondary to perforation of an intra-abdominal viscus. The most common organisms usually associated with CAPD peritonitis are Staphylococcus aureus and Staphylococcus epidermidis (coagulase-negative staphylococci). Rarely, aerobic gram-negative bacilli have been the causative agents of CAPD peritonitis. The treatment of CAPD peritonitis usually requires removal of the peritoneal catheter and treatment with parenteral antibiotics active against the causative pathogen. We report a case of CAPD-associated peritonitis caused by an extended spectrum beta-lactamase-producing strain of Klebsiella pneumoniae. The case presented had this strain of multidrug-resistant K. pneumoniae present in blood cultures and the peritoneal fluid. Extended spectrum beta-lactamase-producing bacteria, for example, K. pneumoniae, are multidrug-resistant and sensitive to few antibiotics. This isolate was intermediately sensitive to amikacin and meropenem, but the patient did not clinically improve on these 2 antibiotics. Polymyxin B therapy was initiated after lack of clinical improvement after dialysis catheter removal and 1 week of meropenem and amikacin therapy. The patient responded rapidly to therapy with polymyxin B. Polymyxin B has a unique mechanism of action on bacterial cells and is highly active against all multidrug-resistant gram-negative organisms except Proteus species and Serratia marcescens. No toxicity was observed during therapy. Polymyxin B is being used increasingly as a therapeutic alternative to multidrug-resistant gram-negative organisms.

Aspergillus fumigatus peritonitis in ambulatory peritoneal dialysis: A case report and notes on the therapeutic approach (Case Report)

Aspergillus peritonitis is a rare disease in continuous peritoneal dialysis. It is a severe form of peritonitis, which is frequently lethal. We report a case of Aspergillus fumigatus peritonitis in a female patient on automated peritoneal dialysis (APD), who was successfully treated with intravenous amphotericin B and the removal of the peritoneal catheter. As delayed treatment has an increased mortality rate, it is mandatory to remove the catheter and to start intravenous treatment with amphotericin B empirically.

Cathelicidin Peptide Sheep Myeloid Antimicrobial Peptide-29 Prevents Endotoxin-induced Mortality in Rat Models of Septic Shock

The present study was designed to investigate the antiendotoxin activity and therapeutic efficacy of sheep myeloid antimicrobial peptide (SMAP)-29, a cathelicidin-derived peptide. The in vitro ability of SMAP-29 to bind LPS from Escherichia coli 0111:B4 was determined using a sensitive limulus chromogenic assay. Two rat models of septic shock were performed: (1) rats were injected intraperitoneally with 1 mg E. coli 0111:B4 LPS and (2) intraabdominal sepsis was induced via cecal ligation and single puncture. All animals were randomized to receive parenterally isotonic sodium chloride solution, 1 mg/kg SMAP-29, 1 mg/kg polymyxin B or 20 mg/kg imipenem. The main outcome measures were: abdominal exudate and plasma bacterial growth, plasma endotoxin and tumor necrosis factor-alpha concentrations, and lethality. The in vitro study showed that SMAP-29 completely inhibited the LPS procoagulant activity at approximately 10 microM peptide concentration. The in vivo experiments showed that all compounds reduced the lethality when compared with control animals. SMAP-29 achieved a substantial decrease in endotoxin and tumor necrosis factor-alpha plasma concentrations when compared with imipenem and saline treatment and exhibited a slightly lower antimicrobial activity than imipenem. No statistically significant differences were noted between SMAP-29 and polymyxin B. SMAP-29, because of its double antiendotoxin and antimicrobial activities, could be an interesting compound for septic shock treatment.

Antiendotoxin activity of protegrin analog IB-367 alone or in combination with piperacillin in different animal models of septic shock

The therapeutic efficacy of protegrin peptide IB-367 was investigated in three rat models of septic shock: (i) rats injected intraperitoneally with 1mg Escherichia coli 0111:B4 lipopolysaccharide, (ii) rats given an intraperitoneal injection of 2 X 10(10) CFU of E. coli ATCC 25922, and (iii) rats in which intra-abdominal sepsis was induced via cecal ligation and puncture. All animals were randomized to receive parenterally isotonic sodium chloride solution, 1mg/kg of IB-367, 60mg/kg piperacillin and 1mg/kg of IB-367 plus 60mg/kg piperacillin. The peptide demonstrated lower level of antimicrobial activity than piperacillin, nevertheless it exhibited the dual properties of antimicrobial and antiendotoxin agent. Finally IB-367 and piperacillin association showed to be the most effective therapeutic approach.

Cationic peptides combined with betalactams reduce mortality from peritonitis in experimental rat model

The efficacy of cationic peptides combined with betalactams was investigated in a peritonitis rat model. Intraabdominal sepsis was induced in adult Wistar rats via cecal ligation and single puncture. The study included eight drug-treated groups: each of them received intravenous polymyxin-E (1 mg/kg), buforin II (1 mg/kg), imipenem (20 mg/kg), amoxicillin-clavulanate (50 mg/kg), polymyxin-E (1 mg/kg) plus imipenem (20 mg/kg), or amoxicillin-clavulanate (50 mg/kg), and buforin II (1 mg/kg) plus imipenem (20 mg/kg), or amoxicillin-clavulanate (50 mg/kg). The study included an untreated control group that received intravenous isotonic sodium chloride solution. All compounds significantly reduced the lethality and the number of bacteria in abdominal fluid compared with saline treatment. Among compounds, imipenem showed the highest antimicrobial activity, while buforin II produced the highest reduction in plasma endotoxin and TNF-alpha levels. Overall, buforin II and imipenem association were the most effective therapeutic approach. Data presented here suggest the potential advantages of combining antimicrobial agents and compounds able to neutralize the biological effect of the endotoxin.

Evaluation of an antimicrobial-impregnated continuous ambulatory peritoneal dialysis catheter for infection control in rats

Infection is the most serious complication arising in long-term continuous ambulatory peritoneal dialysis (CAPD), specifically peritonitis and exit-site infection. The initial weeks after implantation is the crucial period during which bacterial colonization of the catheter results in maximal morbidity, with Staphylococcus aureus being the most virulent organism. We developed an antimicrobial-impregnated CAPD catheter by impregnating the cuff and tubing with chlorhexidine, silver sulfadiazine, and triclosan in a polymer matrix. The antimicrobial spectrum and duration were shown by measuring zones of inhibition to various bacteria and fungi over the course of 5 to 10 days. Activity also was assessed subsequent to soaking in trypticase soy broth containing 20% bovine serum over the course of 1, 3, and 7 days. Significant antimicrobial activity was shown against all organisms tested for, with particular efficacy against gram-positive bacteria. Catheters were implanted in rats followed by inoculation of the exit site with S aureus. Seven days postimplantation, 0% of the impregnated catheters were colonized intraperitoneally compared with 100% of the control catheters. Similarly, 12.5% of the impregnated catheters were colonized at the exit site, whereas 100% of the controls were colonized. Histologic analysis showed that this combination and concentration of antimicrobials did not retard healing or cause increased inflammation compared with control catheters after 3, 10, and 24 days postimplantation in noninoculated rats.

Infections associated with uremia and dialysis

Patients with chronic renal failure are predisposed to infections. Infections in end-stage renal disease patients are caused by immunosuppressive effects of uremia. Patients with renal failure on dialysis have impaired host defenses and may develop infections related to vascular access. This article reviews the infectious complications related to chronic renal failure in dialysis.

Staphylococcal peritonitis in continuous ambulatory peritoneal dialysis: colonization with identical strains at exit site, nose, and hands

To evaluate the relationship of nasal or skin Staphylococcus carrier status with identical strains and the development of staphylococcal peritonitis, 59 consecutive peritonitis episodes in patients using a twin-bag system for continuous ambulatory peritoneal dialysis from a single dialysis center were prospectively studied. Dialysate samples and exit-site, nose, and nail swabs from patients and their dialysis partners were obtained on the same day for culture. When bacteria belonging to the same species of the Staphylococcus genus were isolated from dialysate and at least one extraperitoneal anatomic site, pulsed-field gel electrophoresis typing was performed. The bacterial strains isolated from catheter exit site, nose, or nails of each patient and his or her dialysis partner were classified as identical or different. Twenty-seven of the 59 peritonitis episodes (46%) were caused by staphylococci. Nineteen of these 27 patients carried the same Staphylococcus species causing the peritonitis episode at the exit site, nose, or nails, but only 17 patients (63%) carried an identical strain. Four of 5 dialysis partners carried the same Staphylococcus species causing the peritonitis episode at nose or nails, but the strain was identical for only 3 dialysis partners (60%). Four patients and 1 dialysis partner carried unrelated strains of the Staphylococcus species causing the peritonitis episode. The most frequently colonized site with strains identical to that causing the peritonitis episode was the catheter exit site, followed by nose and nails. This finding may be clinically relevant because eradication of Staphylococcus aureus colonizing the catheter exit site may be more important and have a greater likelihood of success than maneuvers directed to more distant locations.

Protection from lethal gram-positive infection by macrophage scavenger receptor-dependent phagocytosis

Infections with gram-positive bacteria are a major cause of morbidity and mortality in humans. Opsonin-dependent phagocytosis plays a major role in protection against and recovery from gram-positive infections. Inborn and acquired defects in opsonin generation and/or recognition by phagocytes are associated with an increased susceptibility to bacterial infections. In contrast, the physiological significance of opsonin-independent phagocytosis is unknown. Type I and II class A scavenger receptors (SR-AI/II) recognize a variety of polyanions including bacterial cell wall products such as lipopolysaccharide (LPS) and lipoteichoic acid (LTA), suggesting a role for SR-AI/II in innate immunity to bacterial infections. Here, we show that SR-AI/II-deficient mice (MSR-A(-/-)) are more susceptible to intraperitoneal infection with a prototypic gram-positive pathogen, Staphylococcus aureus, than MSR-A(+/+) control mice. MSR-A(-/-) mice display an impaired ability to clear bacteria from the site of infection despite normal killing of S. aureus by neutrophils and die as a result of disseminated infection. Opsonin-independent phagocytosis of gram-positive bacteria by MSR-A(-/-) macrophages is significantly decreased although their phagocytic machinery is intact. Peritoneal macrophages from control mice phagocytose a variety of gram-positive bacteria in an SR-AI/II-dependent manner. Our findings demonstrate that SR-AI/II mediate opsonin-independent phagocytosis of gram-positive bacteria, and provide the first evidence that opsonin-independent phagocytosis plays a critical role in host defense against bacterial infections in vivo.

Peritonitis caused by Haemophilus parainfluenzae in a patient undergoing continuous ambulatory peritoneal dialysis

We report a case of peritonitis in a patient undergoing continuous ambulatory peritoneal dialysis. Haemophilus parainfluenzae biotype III was recovered in pure culture from dialysis fluid.

Efficacy of locally delivered polyclonal immunoglobulin against Pseudomonas aeruginosa peritonitis in a murine model

Infectious peritonitis results from bacterial contamination of the abdominal cavity. Conventional antibiotic treatment is complicated both by the emergence of antibiotic-resistant bacteria and by increased patient populations intrinsically at risk for nosocomial infections. To complement antibiotic therapies, the efficacy of direct, locally applied pooled human immunoglobulin G (IgG) was assessed in a murine model (strains CF-1, CD-1, and CFW) of peritonitis caused by intraperitoneal inoculations of 10(6) or 10(7) CFU of Pseudomonas aeruginosa (strains IFO-3455, M-2, and MSRI-7072). Various doses of IgG (0.005 to 10 mg/mouse) administered intraperitoneally simultaneously with local bacterial challenge significantly increased survival in a dose-dependent manner. Local intraperitoneal application of 10 mg of IgG increased animal survival independent of either the P. aeruginosa or the murine strains used. A local dose of 10 mg of IgG administered up to 6 h prophylactically or at the time of bacterial challenge resulted in 100% survival. Therapeutic 10-mg IgG treatment given up to 12 h postinfection also significantly increased survival. Human IgG administered to the mouse peritoneal cavity was rapidly detected systemically in serum. Additionally, administered IgG in peritoneal lavage fluid samples actively opsonized and decreased the bacterial burden via phagocytosis at 2 and 4 h post-bacterial challenge. Tissue microbial quantification studies showed that 1.0 mg of locally applied IgG significantly reduced the bacterial burden in the liver, peritoneal cavity, and blood and correlated with reduced levels of interleukin-6 in serum.

Intermittent versus continuous intraperitoneal glycopeptide/ceftazidime treatment in children with peritoneal dialysis-associated peritonitis. The Mid-European Pediatric Peritoneal Dialysis Study Group (MEPPS)

Intermittent intraperitoneal antibiotic administration appears as a practical and economical therapeutic concept in continuous peritoneal dialysis (CPD)-related peritonitis, but the equivalence of this principle with standard continuous treatment awaits confirmation by prospective, randomized clinical trials. This study evaluates the efficacy, safety, and clinical acceptance of an initial combination treatment including a glycopeptide (vancomycin or teicoplanin) and ceftazidime, each applied either intermittently or continuously, in a cohort of pediatric patients with CPD-related peritonitis. Patients randomized for continuous treatment received an intraperitoneal loading dose of glycopeptide and ceftazidime followed by maintenance doses added to each dialysate bag. In the intermittent treatment groups, the glycopeptide was administered in two loading doses 7 d apart, and ceftazidime during one dialysis cycle per day. Initial treatment response was evaluated after 60 h by the change in a Disease Severity Score and by the clinical decision to continue initial treatment. Of 152 patients observed for a total of 234 patient years, 90 patients developed 195 episodes of peritonitis (including 27 relapses within 4 wk after end of treatment). Dialysate cultures were positive in 83% of the episodes. In gram-positive peritonitis (79% of culture-positive cases), the primary success (overall 95%) and relapse rates (21%) were not different between continuous and intermittent, or between vancomycin and teicoplanin treatment. Oversensitivity reactions occurred in three and ototoxicity in one vancomycin-treated patient, whereas no such side effects were observed with teicoplanin. Residual renal function declined during peritonitis episodes regardless of treatment modality. In gram-negative peritonitis (18% of cases), intermittent ceftazidime treatment was less successful than continuous treatment according to clinical judgment (3 of 11 versus 10 of 14, P < 0.05), but not when rated by Disease Severity Score (8 of 11 versus 12 of 14). In conclusion, intermittent and continuous intraperitoneal treatment of CPD-related peritonitis with glycopeptides and ceftazidime is equally efficacious and safe when measured by objective clinical criteria. This contrasts with a strong tendency of clinicians to move from intermittent to continuous treatment in severe peritonitis.

Prevention of peritonitis with disconnect systems in CAPD: a randomized controlled trial. The Mexican Nephrology Collaborative Study Group

BACKGROUND

Recently, disconnect systems for CAPD that are associated with a reduced frequency of peritonitis have been introduced. Our objective was to compare the incidence of peritonitis using three current CAPD systems in a high-risk population with low educational and socioeconomic levels, and high prevalence of malnutrition.

METHODS

In a prospective controlled trial, 147 patients commencing CAPD were randomly assigned to one of three groups: 29 to the conventional, 57 to the Y-set, and 61 to the twin bag systems. The number of peritonitis episodes was registered, and patients were followed up for an average of 11.3 months.

RESULTS

The average peritonitis-free interval for the conventional group was 6.1 months, for the Y system was 12.0 months, and for the twin bag was 24.8 months (P < 0.001). By multivariate analysis, the only factor associated with peritonitis was the CAPD system. Peritonitis-related hospitalization was 5.3 +/- 2.0, 2.7 +/- 1.0, and 1.5 +/- 0.9 days/patient/year in the conventional, Y system, and twin bag groups, respectively. The cost per bag was similar for the conventional and Y system, but higher for the twin bag. However, the total costs of treatment (pesos/patient/year) were lower for twin bag (62,159 for the conventional, 70,275 for the Y system, and 54,387 for the twin bag), due to the lower peritonitis incidence and associated hospitalizations.

CONCLUSIONS

Y system and twin bag use was associated with a reduction of 50 and 75% peritonitis incidence, respectively, in patients on CAPD. The cost of the twin bag was actually lower, because of savings from a decreased usage of antibiotics and fewer hospitalizations.

Osmotic agents and buffers in peritoneal dialysis solution: monocyte cytokine release and in vitro cytotoxicity

Peritonitis remains a major problem in peritoneal dialysis. The incidence of peritonitis may be reduced by the use of more "biocompatible" peritoneal dialysis solutions that do not impair local host defense mechanisms, such as occurs with conventional lactate-buffered glucose solutions. In the present study, we investigated the use of bicarbonate and lactate as buffer systems and glucose, amino acids, and glucose polymer as osmotic agents on specific cellular functions of isolated fresh blood monocytes in vitro. The bicarbonate-buffered solutions had a physiologic pH (7.0 to 7.6). Lactate-buffered solutions were tested with a pH between 5.5 and 7.3. RPMI 1640 (Roswell Park Memorial Institute, supplied by Biochrom, Berlin, Germany) and phosphate-buffered saline were used as control mediums. The test solutions were incubated with 200,000 monocytes/mL for 45 minutes followed by a 1:1 mix with RPMI 1640 (with supplements) during a 24- or 4-hour tetrazolium bromide test (MTT test) recovery period. Constitutive and lipopolysaccharide (LPS)-stimulated release of interleukin-1beta (IL-1beta) and IL-6 in the supernatants as parameters of cellular host defense and lactate dehydrogenase concentrations and MTT-formazan production as parameters for cell cytotoxicity were measured. Significantly higher IL-6 and IL-1beta release was found in the bicarbonate-buffered solutions, both under basal conditions and after LPS stimulation, compared with the lactate-buffered solutions (LPS stimulation: 1% amino acids/34 mmol/L bicarbonate, IL-1beta: 1,166 +/- 192 pg/mL; 1.5% glucose/34 mmol/L bicarbonate, IL-1beta: 752 +/- 107 pg/mL; 1.5% glucose/35 mmol/L lactate/pH 5.5, IL-1beta: 174 +/- 51 pg/mL). Some of these differences could even be detected in spent dialysate after a 6-hour dwell in continuous ambulatory peritoneal dialysis patients (n = 10). A lower degree of cellular cytotoxicity (lactate dehydrogenase activity) and better-preserved metabolic activity (MTT test) also were found for the bicarbonate-buffered solutions. Amino acids (1%) proved to be comparable to glucose (1.5%) as an osmotic agent at a neutral pH with regard to LPS-stimulated cytokine release and cytotoxicity. The incubation with a glucose polymer solution (7.5% glucose polymer in phosphate-buffered saline, pH 7.3) resulted in a significantly lowered cytokine release (LPS stimulation: IL-1beta, 69 +/- 19 pg/mL) compared with the other solutions with neutral pH (P < 0.01). These results suggest that bicarbonate as a buffer provided better biocompatibility with regard to mononuclear cytokine release and viability compared with lactate. Amino acids and glucose were equivalent to these parameters at a physiologic pH. The glucose polymer solution, however, was associated with a marked depression of cytokine release.

Long-term clinical experience with continuous ambulatory peritoneal dialysis: access-related problems

Patients with end-stage renal failure can be treated with peritoneal dialysis, which is based on the capacity of the peritoneum to exchange fluid and metabolic products. To achieve this, dialysis fluid has to be instilled in the abdominal cavity through a permanent percutaneous access device. Apart from the advantages of peritoneal dialysis, severe problems are related to the access device. In this study, catheter-related morbidity and mortality are described, as found in the patient population from the University Hospital, Nijmegen, The Netherlands. The overall rates of exit-site infections and peritonitis are respectively 0.80 and 1.36 infection episodes per patient-year. Furthermore, it appeared that exit-site infections and peritonitis are the main reasons for discontinuation of dialysis and removal of the catheter. A correlation between the occurrence of peritonitis and exit-site infections was found. Also, the efficacy of the antibiotic treatment necessary to control these infectious complications is described. It is concluded that the design and the materials used to manufacture the currently used access device are the main reason for the existing morbidity in peritoneal dialysis. Therefore, more efforts should be undertaken to improve the access device, in which the design and the material used are critically considered.

Principles of renal replacement therapy in children

Much has changed in pediatric renal replacement therapy during the past decade. Even the smallest critically ill patients can be temporarily supported, and chronic peritoneal and hemodialysis in young children has become routine. Although improved technical capabilities often may raise difficult ethical dilemmas, the health care team must know that such therapeutic modalities are available for the pediatric patient.

Bacterial peritonitis in continuous ambulatory peritoneal dialysis: effect on dialysis on host defense mechanisms

We have used an experimental model of continuous ambulatory peritoneal dialysis (CAPD) to investigate the effect of dialysis on host defense mechanisms in the peritoneal cavity. Laboratory rats undergoing regular dialysis were challenged with a single bolus of Staphylococcus epidermidis, Staphylococcus aureus, Candida albicans, and Pseudomonas aeruginosa. Intraperitoneal challenges with all four microbial strains underwent a rapid clearance during the first 4 hours, irrespective of whether the host was undergoing dialysis. Studies using S epidermidis showed that the rapid clearance was not mediated by the diaphragmatic stomata as might have been expected. Dialysis did, however, cause delays over the following 48 hours with all of the pathogens except C albicans. Bacterial clearance over a 10-day period was strain dependant, and microbial persistence was related to adhesion formation around the cannula. Again C albicans was an exception. Our conclusions are that dialysis does not affect the innate defense mechanisms involved in the early clearance of a bolus challenge to the peritoneal cavity but can cause delays in eradicating microorganisms that survive this phase. Because these experiments were carried out using a bolus inoculum, it may be necessary to reevaluate the effect of dialysis on host defenses in the peritoneal cavity under conditions in which the challenge more closely approximates a touch contamination event.

Acremonium kiliense peritonitis complicating continuous ambulatory peritoneal dialysis: report of two cases

Two cases of peritonitis caused by Acremonium kiliense in patients receiving a continuous ambulatory peritoneal dialysis treatment are reported. Diagnosis was established by direct examination and cultures of dialysis effluent, secretion of catheter-exit-site and from the tip of the catheter. Management of fungal peritonitis includes catheter removal, since in this infection the result of systemic antifungal therapy is inconsistent.

Trichosporon beigelii peritonitis associated with continuous ambulatory peritoneal dialysis

This paper reports a case of peritonitis caused by Trichosporon beigelii in a woman submitted to continuous ambulatory peritoneal dialysis. Diagnosis was established by direct examination and culture of dialysis effluent.

Paecilomyces variotii in peritoneal dialysate

Four cases of peritonitis caused by the filamentous fungus Paecilomyces variotii in patients on continuous ambulatory peritoneal dialysis are reported. Removal of the Tenckhoff catheter and antifungal chemotherapy led to resolution of symptoms in all cases. Possible contaminating events are discussed, and reported infections with P. variotii are reviewed.

Nocardia asteroides peritonitis during continuous ambulatory peritoneal dialysis

This paper reports a case of peritonitis by Nocardia asteroides during continuous ambulatory peritoneal dialysis in a man who had systemic lupus erythematous and chronic renal failure. Diagnosis was established by microscopic examination (Gram and Kinyoun) and culture of centrifuged dialysis fluid and the patient was treated with Trimethoprim-Sulfamethoxazole by intraperitoneal route.

Clinical Pharmacy Care in Continuous Ambulatory Peritoneal Dialysis Patients

Continuous ambulatory peritoneal dialysis (CAPD) continues to grow as a treatment modality for end-stage renal disease (ESRD). The high cost of care, multiplicity of drugs used by each patient, high cost of individual drugs, and high incidence of complications, make this patient population a challenging area for clinical pharmacy input. This article discusses the mechanics of CAPD, together with patient selection criteria, monitoring of the dialysis prescription, and infectious complications. The potential for research involving clinical pharmacists is discussed. Apart from studies on the pharmacokinetic disposition of drugs administered to CAPD patients, there remains a relative lack of information on many aspects of drug therapy. Recommendations for areas of continued study include the optimization of antibiotic therapy for peritonitis and exit-site infections, use of the intraperitoneal route for systemic effects of drugs, quality-of-life investigations, and stability studies of drugs in dialysate.

Peritonitis rates in CAPD patients using the UVXD and O-set systems

We report experience with O-set and UVXD systems. Sixty-nine O-set patients (34 male; mean age +/- SD = 45.7 +/- 13.2 years) were compared with 54 UVXD patients (27 male; 56.8 +/- 16.8 years). Total (mean +/- SD) experience were 974 (14.1 +/- 10.8) months on O-set and 1010.9 (18.7 +/- 15.7) months on UVXD. Thirty-two O-set patients avoided peritonitis; 37 had 91 episodes. Seventeen UVXD patients avoided peritonitis; 37 had 137 episodes. Peritonitis occurred each 10.7 months (O-set) versus 7.4 months (UVXD), which was significantly different (p = 0.032, Z test; 95% confidence interval = -0.142 to +0.226). There were 18 relapses in 9 O-set patients, 34 in 12 UVXD. Gram-positive organisms caused 58.2% and 66%; gram-negative, 13.2% and 8.8%; and culture negative, 24.2% and 23.4% of peritonitis in O-set and UVXD, respectively. The time to first peritonitis was not different, 7.4 +/- 6.6 months O-set and 7.2 +/- 7.9 months (UVXD). There was no difference in the peritonitis-free period, 13.0 +/- 10.0 months (O-set) and 16.5 +/- 14.3 months (UVXD). There were 1.12 (O-set) and 16.1 (UVXD) cases per patient year, and 10.7 (O-set) and 7.43 (UVXD) patient months per episode. The peritonitis rate odds ratio was 1:1.85 (O-set:UVXD).

Continuous ambulatory peritoneal dialysis: a review of its mechanics, advantages, complications, and areas of controversy

OBJECTIVE

The primary objective of this article is to review the mechanics, advantages, complications, pharmacokinetics, and future trends of continuous ambulatory peritoneal dialysis (CAPD) as they pertain to pharmacotherapy.

DATA SOURCES

Pertinent articles were obtained from an English-language literature search using MEDLINE (1980-1991), Index Medicus (1987-1990), and bibliographic reviews of review articles. Indexing terms included peritoneal dialysis, pharmacokinetics, peritonitis, vancomycin, and fluoroquinolones.

DATA SYNTHESIS

All clinical studies comparing organism recovery methods and treatment of peritonitis have methodologic limitations (e.g., comparison of disparate patient groups, different definitions of peritonitis, lack of follow-up, lack of control for sterile cultures) that may affect the reported results.

CONCLUSIONS

CAPD is an alternative to hemodialysis for the treatment of endstage renal disease and has many complications, leading to significant morbidity. This indicates that CAPD is not appropriate for all patients. Using blood-culturing techniques to culture for dialysate is most productive, but also the most costly. There are few data to indicate exactly the drugs, doses, and durations of choice for peritonitis. Both intraperitoneal and oral administration appear to be appropriate.

Microbiological aspects of peritonitis associated with continuous ambulatory peritoneal dialysis

The process of continuous ambulatory peritoneal dialysis has provided a useful, relatively inexpensive, and safe alternative for patients with end-stage renal disease. Infectious peritonitis, however, has limited a more widespread acceptance of this technique. The definition of peritonitis in this patient population is not universally accepted and does not always include the laboratory support of a positive culture (or Gram stain). In part, the omission of clinical microbiological findings stems from the lack of sensitivity of earlier microbiological efforts. Peritonitis results from decreased host phagocytic efficiency with depressed phagocytosis and bactericidal capacity of peritoneal macrophages. During episodes of peritonitis, fluid movement is reversed, away from the lymphatics and peritoneal membrane and toward the cavity. As a result, bloodstream infections are rare. Most peritonitis episodes are caused by bacteria. Coagulase-negative staphylococci are the most frequently isolated organisms, usually originating from the skin flora, but a wide array of microbial species have been documented as agents of peritonitis. Clinical microbiology laboratories need to be cognizant of the diverse agents so that appropriate primary media can be used. The quantity of dialysate fluid that is prepared for culture is critical and should constitute at least 10 ml. The sensitivity of the cultural approach depends on the volume of dialysate, its pretreatment (lysis or centrifugation), the media used, and the mode of incubation. The low concentration of microorganisms in dialysate fluids accounts for negative Gram stain results. Prevention of infection in continuous ambulatory peritoneal dialysis patients is associated with the socioeconomic status of the patient, advances in equipment (catheter) technology, and, probably least important, the application of prophylactic antimicrobial agents.