High C-reactive protein and number of previous episodes at diagnosis increase the risk of catheter removal in peritoneal dialysis-related peritonitis in children

BACKGROUND

A minority of patients with peritonitis require removal of peritoneal dialysis (PD) catheters. We examined risk factors at diagnosis that could predict the removal of PD catheter before obtaining the results of treatment success in children with peritonitis.

METHODS

We analyzed 156 peritonitis episodes in 57 pediatric PD patients.

RESULTS

The peritonitis rate was 0.68 peritonitis episode per patient year. Catheter removal was required in 22 of 156. C-reactive protein (CRP) ≥ ×10 of upper limit at diagnosis and increased previous episode number were found to be associated with catheter removal (OR [95% CI] 6.4 [2.3-18.1], p = 0.001 and 3.8 [1.4-10.6], p = 0.009).

CONCLUSION

These findings supported that CRP could be an early marker in predicting catheter removal even before obtaining the results of treatment success. Furthermore, it should be kept in mind that the risk of catheter removal is high in patients with high number of previous episodes especially of three or more.

Periton Diyalizi İle ilişkili Peritonitlerin İrdelenmesi

Objective: In this study, it was aimed to determine the causative microorganisms isolated in peritonitis attacks in peritoneal dialysis (PD) patients in our hospital and methicilline resistance rate in Staphlococci. Material and methods: 194 patients in the peritoneal dialysis unit of XXXXl Training and Research Hospital, Nephrology Clinic, between January 2009 and 2020, were evaluated retrospectively in terms of peritonitis development, causative microorganisms and methicillin resistance in Stapylococci, which is the most common causative agent. Results: Peritonitis attack developed in 149 out of a total of 194 patients. The causative agent has been isolated in 91 (61%) of the patients who developed peritonitis. When we look at the order of frequency among all microorganisms isolated, methicillin-susceptible Staphylococci (MHS) 59 (44.02%), methicillin-resistant Staphylococci (MRS) 28 (20.89%), Escherichia coli 12 (8.95%), Streptococcus spp 12 (8.95%), Enterobacter spp 7 (5.22%), Pseudomonas spp 4 (2.98%), diphtheroid bacilli 4 (2.98%), Klebsiella spp 2 (1.49%), Acinetobacter spp 1 (0.07%), a total of 129 bacteria, including five fungi were detected. Methicillin resistance rate was 32.18% among Staphylococci, which was found to be the most common causative agent. Conclusion: There is a need for studies with large patient groups to show the agents of peritonitis and the change in the resistance profile these microorganisms. Key words: Peritoneal Dialysis, Peritonitis, Methicillin Resistance

30 Years of Peritoneal Dialysis Development: The past and the Future

A review is given of 30 years of development in peritoneal dialysis (PD). After a short description of the first 20 years, the main emphasis is put on the last 10 years. Subjects discussed are the increasing use of PD in high-risk populations, peritonitis and other catheter-related problems, adequacy of dialysis and nutrition, patient outcomes in comparison with hemodialysis, and peritoneal membrane changes with time on PD. Topics that have emerged during the last decade and the challenges for the next decennium are discussed. The great importance of quality assurance in fast-growing PD populations and of prevention of long-term membrane alterations are emphasized.

Incidence and characteristics of methicillin-resistant coagulase-negative Staphylococcus aureus in peritoneal dialysis-associated peritonitis in a single center using molecular methods

PURPOSE

Peritonitis is a serious complication of peritoneal dialysis and coagulase-negative Staphylococcus (CNS) is the most frequent cause of peritoneal dialysis (PD)-infections in many centers. This study aimed to investigate the molecular epidemiology of CNS isolated from PD-peritonitis in a Brazilian single center, focusing on the genetic determinants conferring methicillin resistance.

METHODS

Bacterial strains were isolated from peritoneal fluid of patients presenting PD-peritonitis, identified by phenotypic and molecular methods, and those identified as CNS were submitted to mecA detection, SCCmec, pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST).

RESULTS

Over the 18-year period of this study (1995-2011), a total of 878 peritonitis episodes were diagnosed in this unit, 115 were caused by coagulase-negative staphylococci of which 72 by Staphylococcus epidermidis. mecA gene was detected in 55 CNS (47.8%), more frequently on the more recent years. SCCmec type III was the most frequent cassette, followed by SCCmec type IV and SCCmec type II. A diverstity of pulsotypes was observed among the S. epidermidis isolates, but five clusters (based on the 80% cutoff) were identified. Diversified sequence types (ST02, ST05, ST06, ST09, ST23, ST59 and ST371) were detected.

CONCLUSIONS

Detection of SCCmec type III among coagulase-negative Staphylococcus underscores the role of hospital environments as potential source of methicillin-resistant Staphylococcus causing peritonitis in PD patients.

The impact of the superficial cuff position on the exit site and tunnel infections in CAPD patients

BACKGROUND

Peritoneal dialysis (PD) related infections continue to be a major cause of morbidity and mortality in patients on PD. In the last ten years, in order to reduce cuff and exit-site infections, in continuous ambulatory peritoneal dialysis (CAPD) patients, we have positioned the superficial cuff subcutaneously 4 cm instead of 2 cm internal to the exit-site.

METHODS

We analysed the infective episodes occurred in 123 CAPD patients (88 men and 35 women, mean age 62.4 ± 16.8) treated for 3337 months between 1st January 2011 and 31th December 2018 at Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico.

RESULTS

31 of the 123 patients (25.2%) developed 52 episodes of exit site infection, with an incidence of 1 episode every 64.1 patient-months. The cumulative probability of remaining infection free was 80.7% at 12 months and 61.8% at 36 months. Gram-positive organism accounted for 78.7% of exit site infections. Forty-one episodes (87%) were successfully treated with medical therapy. Peritonitis incidence was 1 episode every 51.7 and 1 episode every 49.2 patient-months, in patients with or without a history of exit site infection respectively. The overall incidence of tunnel infection was 1 episode every 278.1 patient-months.

CONCLUSIONS

Positioning the superficial cuff subcutaneously at least 4 cm internal to the exit-site might prevent the bacterial cuff colonization and reduce ESIs, tunnel infections and peritonitis.

Nontuberculous mycobacteria infections of peritoneal dialysis patients: A multicenter study

OBJECTIVES

Nontuberculous mycobacteria (NTM) infections pose a diagnostic challenge in peritoneal dialysis (PD) patients. In this study, we sought to identify findings that are suggestive of NTM infection in PD adult patients.

METHODS

All patients with NTM exit-site infection (ESI) with/without tunnel infection and peritonitis identified during the last decade in eight medical centers in Israel were included. Clinical, microbiological, and outcome data were collected and analyzed.

RESULTS

Thirty patients were identified; 16 had ESI (53%) and 14 had peritonitis (47%). Median age was 65 years (interquartile range 52-76). Abdominal pain and cloudy PD fluid were reported in all patients with peritonitis, whereas exit-site discharge and granulation tissue were common in patients with ESI. Fourteen patients (47%) had negative cultures prior NTM diagnosis, and isolation of diphtheroids or Corynebacterium spp. was reported in 9 of 30 patients (30%). Antimicrobial treatment prior to diagnosis was documented in 13 of 30 patients (43%). Delayed diagnosis was frequent. Treatment regimens and duration of therapy varied widely. In 26 of 30 (87%) patients, catheter was removed and 19 of 30 patients (63%) required permanent transition to hemodialysis. Two patients with peritonitis (2 of 14, 14%) and seven with ESI (7 of 16, 44%) were eligible for continuation of PD.

CONCLUSIONS

Culture negative peritonitis, isolation of diphtheroids or Corynebacterium spp., previous exposure to antibiotics, and/or a refractory infection should all prompt consideration of PD-related NTM infection and timely workup. Catheter removal is recommended aside prolonged antimicrobial therapy. In select patients with ESI, continuation of PD may be feasible.

A Quarter of a Century of Adult Peritoneal Dialysis-Related Peritonitis at an Australian Medical Center

Background

Peritonitis remains one of the major complications of peritoneal dialysis (PD) and results in reduced technique survival and increased patient morbidity and mortality.

Methods

We prospectively recorded comprehensive data on all episodes of PD peritonitis over a 25-year period, including organisms isolated and antibiotic sensitivities. Data on 1588 PD patient-years with 2073 episodes of peritonitis were analyzed; 2089 organisms were isolated in 608 patients. Peritoneal dialysis technique and patient survival were also recorded.

Results

There was a significant decline over the years in the incidence of peritonitis, from 6.5 to 0.35 episodes/patient-year, with the decline in the post twin-bag era from 2.3 to 0.47 ( p < 0.001) due primarily to a decrease in gram-positive organisms. The most common isolates (68.9%) were gram-positive organisms; gram-negative organisms comprised 26.8% and fungi 4.1%. Coagulase-negative staphylococci were the most common pathogen isolated (35.3%). Culture-negative peritonitis was seen in 13.4% of episodes.

Conclusion

This is the largest series of PD peritonitis reported, demonstrating a dramatic reduction over a 25-year period and also detailing the changing trends of organisms isolated in association with improved technique and patient survival. Although rates have improved, peritonitis remains a major complication and further research needs to be done to improve both PD technique and patient survival.

Predictors of Survival and Technique Success after Reinsertion of Peritoneal Dialysis Catheter following Severe Peritonitis

Background

Peritonitis remains the most important complication of peritoneal dialysis (PD). The success rate of restarting PD after severe peritonitis (peritonitis unresolved despite treatment with appropriate antibiotics for 3 days, or fungal or pseudomonas infections) is unclear. We wished to determine PD technique survival and overall mortality when PD is offered to these patients and to identify predictors of successful reinitiation.

Method

We conducted a retrospective single-center study of 556 patients undergoing PD between January 2000 and December 2001. We collected demographic information from the 106 patients who had their PD catheter removed for peritonitis, details about their dialysis history and peritonitis, and whether they successfully restarted PD and if not, the reason.

Results

We divided patients into groups as follows: group 1 ( n = 42) underwent catheter reinsertion, group 2 ( n = 16) had no medical contraindication to restarting PD but the patients elected to remain on hemodialysis, group 3 ( n = 35) were deemed medically unsuitable to return to PD, and group 4 ( n = 13) were those that died within 4 weeks of presenting with peritonitis. If there were no medical contraindications, Indo-Asians were more likely to retry PD. In group 1, after a mean follow-up of 20 ± 7.3 months, 23 of 42 patients restarted PD successfully. Technique survival for group 1 as a whole was 69% at 3 months and 55% at the end of follow-up. Patients of greater dialysis vintage were more likely to develop PD technique failure after restarting. Of those judged suitable for PD, there was no statistically significant difference in the mortality of patients who wished to either restart PD or remain on hemodialysis (group 1 vs group 2). Significant numbers of patients returned successfully to PD after pseudomonas and fungal peritonitis.

Conclusion

Restarting PD after severe peritonitis was possible and safe. Ethnicity was an important predictor for wanting to retry PD, but not for technique failure: given the choice, Indo-Asians preferred PD and had a higher failure rate after restarting, but this did not reach statistical significance. Only dialysis vintage predicted technique failure. We conclude that, after severe peritonitis, patients should be given the choice to return to PD but risk stratification based on dialysis vintage is important. Patient retraining and creating a backup arteriovenous fistula might minimize morbidity in these high-risk patients.

Ciprofloxacin and Cefazolin as a Combination for Empirical Initial Therapy of Peritoneal Dialysis-Related Peritonitis: Five-year Follow-up

The treatment of peritoneal dialysis (PD)-related peritonitis has been a matter of extensive investigation, frequently generating therapeutic trials. Several combinations of antibiotics have served as newer protocols and tended to be efficacious, comfortable, and cost-effective. According to the more recent recommendations from the International Society for Peritoneal Dialysis, the rationale for empirical initial therapy of clinically detected peritonitis in PD patients has been to follow the bacterial profile derived from cultured specimens of PD effluents.

The current study describes 5 year's experience with the use of a new antibiotic regimen for the treatment of peritonitis. We herein analyze the outcome of 95 episodes of peritonitis in 54 patients on either automated PD or continuous ambulatory PD at the dialysis unit of the Federal University of Rio de Janeiro. Peritoneal dialysis-related peritonitis was treated with the combination of oral ciprofloxacin and intraperitoneal cefazolin. The observed cure rate was 85.2% and the sensitivity test was observed to be positive for this combination of antibiotics in 88.9% of positive cultures. Of the 14 unsuccessful episodes, 7 were due to catheter colonization and the rest did not respond to the proposed therapy within 48 hours. These 7 cases were also related to peritoneal fluid cultures that were resistant to both ciprofloxacin and cefazolin.

From this study, we propose this combination of oral ciprofloxacin and intraperitoneal cefazolin as a first choice for empirical initial therapy of PD-related peritonitis, given its efficacy and low cost. However, in order to apply the most adequate cost-effective therapy, careful examination of the bacterial profile and sensitivities to antibiotics used in each unit is strongly recommended.

Peritonitis in Latin America

Peritoneal dialysis has a high acceptance rate in Latin America, thus the knowledge concerning complication patterns is of great relevance. This work reviews Latin American data on peritonitis, the most serious complication of peritoneal dialysis.

The incidence of peritonitis has been reduced over time, concomitantly with the incorporation of safer exchange systems and the use of prophylactic measurements. Today, rates lower than 1 episode per 24 patient-months are commonly reported. Furthermore, changes in causative organisms have been observed, with predominance of Staphylococcus aureus up through the mid-1990s, as well as increases in coagulase-negative staphylococcus and participation of gram negatives. However, the prevalence of S. aureus is still high, due possibly to climatic conditions and the elevated prevalence of carriers. Resolution rate varies from 55% to 78%, transfer to hemodialysis from 10.9% to 15.4%, and death in 3% to 9.9% of cases. Outcome is worse in S. aureus episodes compared to those with coagulase-negative staphylococcus, despite the higher percentage of oxacillin-resistant strains among the former. In general, despite socioeconomic or climatic conditions, our results are similar to those in developed countries, perhaps as a consequence of technological improvements and/or center expertise.

Patient and Technique Survival and Factors Affecting Mortality on Peritoneal Dialysis in Turkey: 12 Years’ Experience in a Single Center

Background

We investigated patient and technique survival and factors affecting mortality in Turkish peritoneal dialysis (PD) patients.

Patients and Methods

This was a retrospective study. 423 PD patients were included. The demographic, clinical, and biochemical data were collected from the medical records. Clinical outcomes were mortality and technique failure.

Results

Mean age at the start of PD was 46.0 ± 14.3 years and mean PD duration was 37.1 ± 28.3 (median: 30, range: 4 – 137) months. Diabetes mellitus was the most common cause of end-stage renal disease (35.2%), followed by hypertension (14.7%). There were 89 (21.0%) deaths. 25 (5.9%) patients received a kidney transplant, 74 (17.4%) patients were transferred to hemodialysis. Estimation of technique survival by Kaplan–Meier was 96.1%, 83.2%, 67.6%, 45.8%, and 33.6% at 1, 3, 5, 8, and 10 years. Technique failure was associated with peritonitis rate [relative risk (RR): 3.22, p < 0.001] and peritoneal Kt/V urea (RR: 0.38, p = 0.001) in the Cox proportional hazards model analysis. Estimation of patient survival by Kaplan–Meier was 96.9%, 83.8%, 68.8%, 50.2%, and 40.7% at 1, 3, 5, 8, and 10 years, respectively. In the Cox proportional hazards model analysis, age (RR: 1.01, p = 0.05), transfer to PD from hemodialysis (RR: 1.84, p = 0.03), comorbid cardiovascular disease (RR: 1.90, p = 0.004), serum creatinine level (RR: 0.75, p < 0.001), total Kt/V urea (RR: 0.34, p < 0.001), peritonitis rate (RR: 1.87, p < 0.001), and dialysate-to-plasma creatinine ratio (RR: 6.49, p = 0.04) predicted mortality.

Conclusions

Even though we cannot conclude with certainty that survival rates in Turkish patients are better than those in the United States and Europe, our results seem to suggest this and warrant further studies adjusted for more extensive demographic features and comorbidities. The factors affecting mortality in Turkish PD patients are similar to other populations.

Antibiotic Prophylaxis in an Animal Model of Chronic Peritoneal Exposure

Objectives

Acute infection in an animal model of chronic peritoneal dialysis (PD) induces structural changes in the peritoneum and alters functional characteristics of transport. These changes may compromise observations of the chronic effects of dialysis solutions. To test the hypothesis that antibiotics would prevent acute infection without affecting transport and structural properties, we characterized the frequency of infection in our rat model of PD and examined whether the inclusion of antibiotics in the dialysis solution altered the transport and structural properties of the peritoneum.

Design

Female Sprague–Dawley rats were aseptically injected daily under gas anesthesia with 30 – 40 mL of a sterile solution for 2 months via a peritoneal catheter tunneled to a subcutaneous port. Solutions used were Krebs–Ringer bicarbonate (KRB) alone, KRB with antibiotics (cefazolin 200 mg/L and gentamicin 2 mg/L), KRB with 4% glucose, and KRB with both glucose and antibiotics. After 2 months, osmotic filtration and solute transport were assessed in each animal and peritoneal fluid was collected for bacterial culture. Angiogenesis was evaluated by quantitative image analysis of tissue sections stained with CD31. Tissue content of collagen, hyaluronic acid, and sulfated glycosaminoglycan was determined.

Results

Technique survival (successful PD for 2 months) and infection rate were comparable among all treated groups. There were no differences between the groups in transport properties. Structural changes were comparable between groups, with or without antibiotics.

Conclusions

Addition of antibiotics to the dialysis solution did not affect the transport characteristics of the peritoneum or the pathologic reaction of the tissue to the PD solution.

IncreasingStaphylococcusSpecies Resistance in Peritoneal Dialysis-Related Peritonitis Over a 10-Year Period in a Single Taiwanese Center

Background

Peritonitis is a major complication of peritoneal dialysis (PD). Staphylococcus species are gram-positive bacteria that are most commonly associated with peritoneal peritonitis. The increasing antimicrobial resistance rate is a severe burden when considering the initial choice of antibiotics. This investigation examined the trends of staphylococcal infection as well as the resistance rate and clinical outcomes from 2006 to 2015 in southern Taiwan.

Methods

We retrospectively investigated all PD-related peritonitis episodes in southern Taiwan between January 2006 and December 2015 and evaluated the clinical characteristics of peritonitis, microbiological prevalence and resistance of Staphylococcus species, and outcomes in patients.

Results

Among 244 episodes of peritonitis, Staphylococcus species accounted for approximately 65% of the gram-positive bacteria that caused the infection. The methicillin resistance rate among Staphylococcus species substantially increased to 64% by 2015 in both Staphylococcus aureus and coagulase-negative staphylococci in southern Taiwan. Notably, patients with methicillin-resistant staphylococcal infection exhibited a significantly higher hospitalization rate than those with methicillin-sensitive staphylococcal infection. However, the catheter removal rate and transfer to hemodialysis exhibited no differences between the 2 groups.

Conclusion

Peritonitis is the most serious complication in patients on PD, and microbiological trends have changed over the past 10 years at a single center in southern Taiwan. The number of methicillin-resistant Staphylococcus species has substantially increased. Empirical initial antibiotic therapy should be adapted on the basis of the growing microbiological resistance.

Characterization of Escherichia coli obtained from patients undergoing peritoneal dialysis and diagnosed with peritonitis in a Brazilian centre

Purpose. This study aimed to characterize 27 Escherichia coli isolates obtained from peritoneal dialysis (PD)-related peritonitis that occurred at the University Hospital of Botucatu Medical School, Brazil, between 1997 and 2015.Methodology. These isolates were characterized regarding the occurrence of 22 virulence factor-encoding genes, antimicrobial resistance and biofilm production. We then evaluated whether these factors influenced the clinical outcome.Results. Over an 18-year period, 726 episodes of PD-related peritonitis were diagnosed, with 27 of them (3.7 %) being due to E. coli. The majority of the isolates were classified in phylogroups B1 (33.3 %), B2 (30.0 %) or F (18.0 %). fimH (100.0 %), ompT (66.7 %) and irp2 (51.9 %) were the most prevalent genes, while papA, papC, iha, sat, irp2, iucD, ireA, ibe10, ompT and kpsMTII were significantly more prevalent among isolates belonging to phylogroups B2 and F (P<0.05). Non-susceptibility to quinolones was detected in six isolates, which harboured chromosomal and/or plasmid-mediated quinolone resistance determinants, while two CTX-M extended-spectrum β-lactamase-producing E. coli were identified. Virulence factor-encoding genes (alone or in combination) and antimicrobial resistance were not associated with non-resolution outcomes. However, there was a trend for the ability to produce biofilm to be associated with treatment failure, although this association was not statistically significant.Conclusion. The E. coli isolates were heterogeneous in terms of the features investigated, and were susceptible to most of the antimicrobial drugs tested, despite the unsuccessful treatment observed in more than 50.0 % of the patients. Studies including more cases could help to clarify if biofilm production can influence the outcome in patients with PD-related peritonitis.

Microbiology, clinical spectrum and outcome of peritonitis in patients undergoing peritoneal dialysis in India: Results from a multicentric, observational study

BACKGROUND

Peritoneal dialysis (PD)-related peritonitis is a major risk factor for drop out of patients on continuous ambulatory PD (CAPD) and automated PD (APD). Factors affecting PD-related peritonitis and centre-specific microbiological data are lacking in India. A multicentric prospective observational study was designed to overcome the gaps in the existing data regarding causative organism and outcome.

METHODOLOGY

The present study was a prospective, uncontrolled, open-label; observational study conducted in 21 centres representing all the four geographical regions (North, South, East and West) of India between April 2010 and December 2011.

RESULTS

A total of 244 patients on chronic PD with peritonitis were enrolled in the study (CAPD and APD), who met the inclusion criteria, from 21 centres covering the different geographical areas of India. Amongst the 85 samples that were culture positive, 38 (44.7%) were in the monsoon season followed by 23 (27.1%) in the post-monsoon, 18 (21.2%) during winter and 11 (12.9%) during summer. Maximum culture positivity (72.7%) was observed with automated culture technique. Microorganisms could be isolated in only 85 cases (35.3%) while the remaining samples were culture negative (156/241, 64.7% of samples). Organisms isolated were Gram-negative in 47.8%, Gram-positive in 36.7%, fungal in 13.3% and Mycobacterium tuberculosis in 2.2%.

CONCLUSION

This large multicentre study of peritonitis offers insights into the aetiology and outcomes of infectious complications of chronic PD in India that are germane to clinical decision-making.

Epidemiology and Clinical Characteristics of Acinetobacter Peritoneal Dialysis-Related Peritonitis in Hong Kong-With a Perspective on Multi-Drug and Carbapenem Resistance

♦ BACKGROUND: Acinetobacter spp. is an important cause of peritoneal dialysis (PD)-related peritonitis, but studies on Acinetobacter peritonitis have been scarce. In view of the rising concern of carbapenem-resistant Acinetobacter (CRA) and multidrug-resistant Acinetobacter (MDRA) infections, we conducted this study on the incidence of Acinetobacter peritonitis and the impact of CRA and MDRA on its outcome. ♦ METHODS: We retrospectively evaluated the clinical characteristics, prevalence, antibiotic sensitivity patterns, outcomes, and factors associated with treatment failure over the past 16 years in our patients with Acinetobacter PD-related peritonitis. ♦ RESULTS: Out of 2,389 episodes of peritonitis, there were 66 episodes (3%) of Acinetobacter peritonitis occurring in 59 patients. Twelve episodes were caused by MDRA (18%), of which 5 were CRA (8%). There was a progressive increase in the incidence of MDRA and CRA infections over the study period. Most isolates were sensitive to sulbactam combinations (ampicillin-sulbactam [95.4%] and cefoperazone-sulbactam [93.9%]), aminoglycosides (amikacin [92.4%], tobramycin [90.9%], and gentamicin [89.4%]), and carbapenems (imipenem [92.2%]). There was 1 case of relapse. Fifteen episodes resulted in catheter removal (23%), and 7 patients died (11%). Hypoalbuminemia (odds ratio [OR] = 0.85, p = 0.006) and carbapenem resistance (OR = 18.2, p = 0.049) were significantly associated with higher rates of treatment failure. ♦ CONCLUSION: Both carbapenem resistance and hypoalbuminemia were significantly associated with treatment failure. Up to 80% of peritonitis episodes by CRA resulted in catheter loss or mortality. Sulbactam combinations and/or aminoglycosides remained effective for the majority of Acinetobacter isolates. There seemed to be an increasing relative incidence of MDRA and CRA infections over the past 16 years.

Risk Factors for and Outcomes of Catheter-Associated Peritonitis in Children: The SCOPE Collaborative

BACKGROUND AND OBJECTIVES

The Standardizing Care to Improve Outcomes in Pediatric ESRD Collaborative is a quality improvement initiative that aims to reduce peritoneal dialysis-associated infections in pediatric patients on chronic peritoneal dialysis. Our objectives were to determine whether provider compliance with peritoneal dialysis catheter care bundles was associated with lower risk for infection at the individual patient level and describe the epidemiology, risk factors, and outcomes for peritonitis in the Standardizing Care to Improve Outcomes in Pediatric ESRD Collaborative.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We collected peritoneal dialysis characteristics, causative organisms, compliance with care bundles, and outcomes in children with peritonitis between October of 2011 and September of 2014. Chi-squared tests, t tests, and generalized linear mixed models were used to assess risk factors for peritonitis.

RESULTS

Of 734 children enrolled (54% boys; median age =9 years old; interquartile range, 1-15) from 29 centers, 391 peritonitis episodes occurred among 245 individuals over 10,130 catheter-months. The aggregate annualized peritonitis rate was 0.46 episodes per patient-year. Rates were highest among children ≤2 years old (0.62 episodes per patient-year). Gram-positive peritonitis predominated (37.8%) followed by culture-negative (24.7%), gram-negative (19.5%), and polymicrobial (10.3%) infections; fungal only peritonitis accounted for 7.7% of episodes. Compliance with the follow-up bundle was associated with a lower rate of peritonitis (rate ratio, 0.49; 95% confidence interval, 0.30 to 0.80) in the multivariable model. Upward orientation of the catheter exit site (rate ratio, 4.2; 95% confidence interval, 1.49 to 11.89) and touch contamination (rate ratio, 2.22; 95% confidence interval, 1.44 to 3.34) were also associated with a higher risk of peritonitis. Infection outcomes included resolution with antimicrobial treatment alone in 76.6%, permanent catheter removal in 12.2%, and catheter removal with return to peritoneal dialysis in 6% of episodes.

CONCLUSIONS

Lower compliance with standardized practices for follow-up peritoneal dialysis catheter care in the Standardizing Care to Improve Outcomes in Pediatric ESRD Collaborative was associated with higher risk of peritonitis. Quality improvement and prevention strategies have the potential to reduce peritoneal dialysis-associated peritonitis.

Technique failure in Korean incident peritoneal dialysis patients: a national population-based study

Background

Technique failure is an important issue for peritoneal dialysis (PD) patients. In this study, we aimed to analyze technique failure rate in detail and to determine the predictors for technique failure in Korea.

Methods

We identified all patients who had started dialysis between January 1, 2005, and December 31, 2008, in Korea, using the Korean Health Insurance Review and Assessment Service database. A total of 7,614 PD patients were included, and the median follow-up was 24.9 months.

Results

The crude incidence rates of technique failure in PD patients were 54.1 per 1,000 patient-years. The cumulative 1-, 2-, and 3-year technique failure rates of PD patients were 4.9%, 10.3%, and 15.6%, respectively. However, those technique failure rates by Kaplan–Meier analysis were overestimated compared with the values by competing risks analysis, and the differences increased with the follow-up period. In multivariate analyses, diabetes mellitus and Medical Aid as a crude reflection of low socioeconomic status were independent risk factors in both the Cox proportional hazard model and Fine and Gray subdistribution model. In addition, cancer was independently associated with a lower risk of technique failure in the Fine and Gray model.

Conclusion

Technique failure was a major concern in patients initiating PD in Korea, especially in diabetic patients and Medical Aid beneficiaries. The results of our study offer a basis for risk stratification for technique failure.

Age-Related Differences of Organism-Specific Peritonitis Rates: A Single-Center Experience

Peritonitis remains an important cause of morbidity and mortality in peritoneal dialysis (PD) patients, but its incidence and the distribution of causative organisms vary widely between institutions and age groups. This study was performed to investigate the recent status and risk factors of PD-related peritonitis and to clarify differences between age groups. We retrospectively reviewed the medical records of 119 PD patients treated at our department between January 2002 and January 2013. We calculated both overall and organism-specific peritonitis rates and also analyzed risk factors. Sixty-three episodes of peritonitis occurred during 261.5 patient-years for an incident rate of 0.24 episodes/patient-year. Multivariate analysis showed that older age (≥65 years) and hypoalbuminemia (<3.0 g/dL) were associated with an increased risk of peritonitis (P = 0.035 and P = 0.029, respectively). In elderly patients (≥65 years old), the rate of peritonitis due to Gram-positive and Gram-negative bacteria was 0.17 and 0.08 episodes/patient-year, respectively, and Gram-positive peritonitis was markedly more frequent than in younger patients (<65 years old). In particular, there was a high frequency of Staphylococcus aureus peritonitis in elderly patients (0.09 episodes/patient-year) and it had a poor outcome. At our department, the risk of peritonitis was increased in older patients and patients with hypoalbuminemia. The distribution of causative organisms was markedly different between age groups and analysis of organism-specific peritonitis rates helped to identify current problems with our PD program.

[Peritonitis in pediatric patients receiving peritoneal dialysis]

BACKGROUND

Peritonitis on catheter of dialysis represents the most frequent complication of the peritoneal dialysis (PD) in the pediatric population. It remains a significant cause of morbidity and mortality. In this study, we investigated the risk factors for peritonitis in children.

METHODS

In this study, we retrospectively collected the records of 85 patients who were treated with PD within the past ten years in the service of pediatrics of the University Hospital Charles-Nicolle of Tunis.

RESULTS

Peritonitis rate was 0.75 episode per patient-year. Notably, peritonitis caused by Gram-positive organisms were more common. Analysis of infection risk revealed three significant independent factors: the poor weight (P=0.0045), the non-automated PD (P=0.02) and the short delay from catheter insertion to starting PD (P=0.02). The early onset peritonitis was significantly associated with frequent peritonitis episodes (P=0.0008). The mean duration between the first and second episode of peritonitis was significantly shorter than between PD commencement and the first episode of peritonitis. We revealed a significant association between Gram-negative peritonitis and the presence of ureterostomy (0.018) and between Gram-positive peritonitis and the presence of exit-site and tunnel infections (0.02). Transition to permanent hemodialysis was needed in many children but no death occurred in patients with peritonitis.

CONCLUSION

Considering the important incidence of peritonitis in our patients, it is imperative to establish a targeted primary prevention. Nutritional care must be provided to children to avoid poor weight. The automated dialysis has to be the modality of choice.

Stability of Tigecycline in Different Types of Peritoneal Dialysis Solutions

♦

INTRODUCTION

Intraperitoneal tigecycline is a potential option for the treatment of peritoneal dialysis (PD)-associated peritonitis caused by microorganisms resistant to commonly used antibiotics. However, the stability of tigecycline must be assessed in the PD solution before evaluating its safety and therapeutic efficacy in PD-associated peritonitis. The objective of this study was to investigate the stability of tigecycline in 3 types of PD solutions at different temperatures for various time points. ♦

METHODS

A total of 27 PD bags (9 PD bags for each type of PD solution; 1.5% glucose, 7.5% icodextrin, and 1.5% glucose pH neutral) containing 2 μg/mL of tigecycline were prepared and stored at either 4, 25, or 37°C. An aliquot was withdrawn immediately before (0 hour) and after pre-defined time points. Each sample was analyzed in duplicate for the concentration of tigecycline using a stability-indicating high-performance liquid chromatography (HPLC) technique. Samples were also assessed for pH, color changes, and evidence of precipitation immediately after preparation and on each day of analysis. ♦

RESULTS

Tigecycline in all 3 types of PD solutions retained more than 90% of its initial concentration for at least 216, 72, and 8 hours at 4, 25, and 37°C, respectively. There was no evidence of precipitation at any time under the tested storage conditions. The pH and color of tigecycline admixed PD solutions stored at 4, 25, and 37°C remained essentially unchanged for 336, 96, and 48 hours respectively. ♦

CONCLUSION

The results obtained from the study provide a platform for future clinical studies aiming to determine the safety and therapeutic efficacy of intraperitoneally administered tigecycline for the treatment of PD-associated peritonitis.

Microbiological Surveillance of Peritoneal Dialysis Associated Peritonitis: Antimicrobial Susceptibility Profiles of a Referral Center in GERMANY over 32 Years

Objectives

Peritonitis is one of the most important causes of treatment failure in peritoneal dialysis (PD) patients. This study describes changes in characteristics of causative organisms in PD-related peritonitis and antimicrobial susceptibility.

Methods

In this single center study we analyzed retrospective 487 susceptibility profiles of the peritoneal fluid cultures of 351 adult patients with peritonitis from 1979 to 2014 (divided into three time periods, P1-P3).

Results

Staphylococcus aureus decreased from P1 compared to P2 and P3 (P<0.05 and P<0.01, respectively). Methicillin-resistant S. aureus (MRSA) occurred only in P3. Methicillin-resistant Staphylococcus epidermidis (MRSE) increased in P3 over P1 and P2 (P <0.0001, respectively). In P2 and P3, vancomycin resistant enterococci were detected. The percentage of gram-negative organisms remained unchanged. Third generation cephalosporin resistant gram-negative rods (3GCR-GN) were found exclusively in P3. Cefazolin-susceptible gram-positive organisms decreased over the three decades (93% in P1, 75% in P2 and 58% in P3, P<0.01, P<0.05 and P<0.0001, respectively). Vancomycin susceptibility decreased and gentamicin susceptibility in gram-negatives was 94% in P1, 82% in P2 and 90% in P3. Ceftazidim susceptibility was 84% in P2 and 93% in P3.

Conclusions

Peritonitis caused by MSSA decreased, but peritonitis caused by MRSE increased. MRSA peritonitis is still rare. Peritonitis caused by 3GCR-GN is increasing. An initial antibiotic treatment protocol should be adopted for PD patients to provide continuous surveillance.

Effects of a Statewide Protocol for the Management of Peritoneal Dialysis-Related Peritonitis on Microbial Profiles and Antimicrobial Susceptibilities: A Retrospective Five-Year Review

♦

BACKGROUND

Peritonitis is a major complication of peritoneal dialysis (PD) and is associated with significant morbidity and mortality. Early empirical antibiotic therapy is recommended, with the choice of agents guided by local resistance patterns. As routine use of specific antimicrobial agents can drive resistance, regular assessment of causative organisms and their susceptibility to empirical therapy is essential. ♦

METHODS

We conducted a retrospective review of all PD peritonitis cases and positive PD fluid cultures obtained over a 5-year period in Western Australia following the introduction of a statewide protocol for the initial management of PD peritonitis with intraperitoneal vancomycin and gentamicin. ♦

RESULTS

The incidence of PD peritonitis decreased from 1 in 16 patient months (0.75/year at risk) to 1 in 29 patient months (0.41/year at risk) over the 5 years. There were 1,319 culture-positive samples and 1,069 unique isolates identified. Gram-positive bacteria accounted for 69.9% of positive cultures, with vancomycin resistance averaging 2% over the study period. Gram-negative bacteria accounted for 25.4% of positive cultures, with gentamicin resistance identified in an average of 8% of organisms. No increase in antimicrobial resistance to vancomycin or gentamicin occurred over the 5 years and there was no change in the proportion of gram-positive (69.9%), gram-negative (25.4%) or fungal (4.4%) organisms causing PD peritonitis. ♦

CONCLUSIONS

Over time, the peritonitis rates have dramatically improved although the profile of causative organisms remains similar. Empirical treatment of PD peritonitis with intraperitoneal vancomycin and gentamicin remains efficacious, with high levels of susceptibility and no evidence that the introduction of this statewide empirical PD peritonitis treatment protocol is driving resistance to these agents.

The changing trends of peritoneal dialysis related peritonitis and novel risk factors

AIM

Continuous ambulatory peritoneal dialysis (PD) has become a treatment modality for end stage renal disease with a peak of its use in 1990 s. The aim of this study was to examine the peritonitis rates, causative organisms and the risk factors of peritonitis in a large group of patients in our center.

METHODS

The study was conducted in the Nephrology Department of a University Hospital in Turkey. Patients in the PD programme between January 2000 and January 2006 were included. Cohort-specific and subject specific peritonitis incidence, and peritonitis-free survival were calculated. Causative organisms and risk factors were evaluated.

RESULTS

Totally 620 episodes of peritonitis occurred in 440 patients over the six years period. Peritonitis rates showed a decreasing trend through the years (0.79 episodes/patient-year 2000-2003 and 0.46 episodes/patient-year 2003-2006). Cohort-specific peritonitis incidence was 0.62 episodes/patient-years and median subject-specific peritonitis incidence was 0.44 episodes/patient-years. The median peritonitis-free survival was 15.25 months (%95 CI, 9.45-21.06 months). The proportion of gram-negative organisms has increased from 9.8% to 17.3%. There was a significant difference in the percentage of culture negative peritonitis between the first three and the last three years (53.1% vs. 43.2%, respectively). Peritonitis incidence was higher in patients who had been transferred from HD, who had catheter related infection and who had HCV infection without cirrhosis.

CONCLUSIONS

Our study showed significant trends in the peritonitis rates, causative organisms and antibiotic resistance. Prior HD therapy, catheter related infections and HCV infection were found to be risk factors for peritonitis.

Efficacy of antibiotic therapy for peritoneal dialysis-associated peritonitis: a proportional meta-analysis

Background

The choice of antimicrobials for initial treatment of peritoneal dialysis (PD)-related peritonitis is crucial for a favorable outcome. There is no consensus about the best therapy; few prospective controlled studies have been published, and the only published systematic reviews did not report superiority of any class of antimicrobials. The objective of this review was to analyze the results of PD peritonitis treatment in adult patients by employing a new methodology, the proportional meta-analysis.

Methods

A review of the literature was conducted. There was no language restriction. Studies were obtained from MEDLINE, EMBASE, and LILACS. The inclusion criteria were: (a) case series and RCTs with the number of reported patients in each study greater than five, (b) use of any antibiotic therapy for initial treatment (e.g., cefazolin plus gentamicin or vancomycin plus gentamicin), for Gram-positive (e.g., vancomycin or a first generation cephalosporin), or for Gram-negative rods (e.g., gentamicin, ceftazidime, and fluoroquinolone), (c) patients with PD-related peritonitis, and (d) studies specifying the rates of resolution. A proportional meta-analysis was performed on outcomes using a random-effects model, and the pooled resolution rates were calculated.

Results

A total of 64 studies (32 for initial treatment and negative culture, 28 reporting treatment for Gram-positive rods and 24 reporting treatment for Gram-negative rods) and 21 RCTs met all inclusion criteria (14 for initial treatment and negative culture, 8 reporting treatment for Gram-positive rods and 8 reporting treatment for Gram-negative rods). The pooled resolution rate of ceftazidime plus glycopeptide as initial treatment (pooled proportion = 86% [95% CI 0.82–0.89]) was significantly higher than first generation cephalosporin plus aminoglycosides (pooled proportion = 66% [95% CI 0.57–0.75]) and significantly higher than glycopeptides plus aminoglycosides (pooled proportion = 75% [95% CI 0.69–0.80]. Other comparisons of regimens used for either initial treatment, treatment for Gram-positive rods or Gram-negative rods did not show statistically significant differences.

Conclusion

We showed that the association of a glycopeptide plus ceftazidime is superior to other regimens for initial treatment of PD peritonitis. This result should be carefully analyzed and does not exclude the necessity of monitoring the local microbiologic profile in each dialysis center to choice the initial therapeutic protocol.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2334-14-445) contains supplementary material, which is available to authorized users.

Predictors for and impact of high peritonitis rate in Taiwanese continuous ambulatory peritoneal dialysis patients

AIM

The influence of high peritonitis rate (HPR) on clinical outcomes of continuous ambulatory peritoneal dialysis (CAPD) patients has been far less studied in the Chinese population than in those of the USA, Australia and Europe. Furthermore, concerning the peritonitis risk, most studies primarily examined the risk of developing the first peritonitis episode, rather than a HPR.

METHODS

A single-center, retrospective, observational study was carried out over 10 years in Taiwan. A total of 124 patients with at least one peritonitis episode were the study subjects. The Cox proportional hazard model was used to assess the impact of HPR on clinical outcomes. Multivariate logistic regression was conducted to determine the independent factors associated with a HPR.

RESULTS

In the multivariate Cox regression model, HPR was still a significant predictor for technique failure, patient mortality and dropout from peritoneal dialysis (PD). Factors independently associated with a HPR were peritonitis occurrence during the first year after the start of CAPD and the first peritonitis infected with streptococcus species.

CONCLUSION

Peritonitis during the first year after PD commencement and the first peritonitis infected by streptococcus species were significantly associated with an increased risk of a HPR. Our data also indicate that HPR was correlated with technique failure, patient mortality and dropout from PD, thus highlighting the need and role of future studies to reduce this complication.

Implementation of a continuous quality improvement program reduces the occurrence of peritonitis in PD

OBJECTIVE

To investigate the causes of peritonitis in patients with peritoneal dialysis (PD) using continuous quality improvement (CQI) to develop effective interventions and reduce the occurrence of peritonitis.

METHODS

A quality control team consisting of 10 members, including the department head, four nephrologists and four nurses, all specialized in PD care, and the head nurse, was established at the Peritoneal Dialysis Center of the Third Xiangya Hospital of Central South University. All patients with peritonitis occurring between 1 July 2010 and 31 December 2011 (pre-CQI period) were analyzed and compared with data obtained between January 2012 (implementation of CQI) and March 2013 to investigate possible causes of peritonitis and to develop corresponding interventions. Fishbone analysis, including laboratory parameters, was carried out monthly.

RESULTS

Gastrointestinal tract dysfunction, nonstandard procedures and malnutrition were found to be the top three risk factors for peritonitis. Gastrointestinal tract dysfunction was the likely cause of peritonitis in 42.8% of the subjects before CQI and 36.0% after CQI (p<0.05). Nonstandard procedures were the cause of peritonitis in 33.3% of the subjects before CQI and 24.0% after CQI (p<0.05). The overall incidence of peritonitis reduced from once every 40.1 patient months before the CQI to once every 70.8 patient months after CQI (p<0.05). The incidence of Gram-positive bacteria peritonitis reduced from once every 96.9 patients per month before CQI to once every 209.1 patient months after CQI (p<0.05), whereas the incidence of Gram-negative bacteria peritonitis reduced from once every 234.2 patient months before CQI to once every 292.8 patient months after CQI.

CONCLUSION

CQI can effectively reduce the occurrence of PD-related peritonitis.

Peritoneal dialysis-related peritonitis due to coagulase-negative Staphylococcus: a review of 115 cases in a Brazilian center

BACKGROUND AND OBJECTIVES

Coagulase-negative Staphylococcus (CNS) is the most frequent cause of peritoneal dialysis (PD)-related peritonitis in many centers. This study aimed to describe clinical and microbiologic characteristics of 115 CNS episodes and to determine factors influencing the outcome.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This study reviewed the records of 115 CNS peritonitis episodes that occurred in 74 patients between 1994 and 2011 at a single university center. Peritonitis incidences were calculated for three consecutive 6-year periods (P1, 1994-1999; P2, 2000-2005; P3, 2006-2011) and annually. The production of biofilms, enzymes, and toxins was evaluated. Oxacillin resistance was evaluated based on its minimum inhibitory concentration and the presence of the mecA gene.

RESULTS

The overall incidence of CNS peritonitis was 0.15 episodes per patient per year and did not vary over time (0.12, 0.14, and 0.16 for P1, P2, and P3, respectively; P=0.21). The oxacillin resistance rate was 69.6%. Toxin and enzyme production was infrequent and 36.5% of CNS strains presented the gene encoding biofilm production. The presence of icaAD genes associated with biofilm production was predictive of relapses or repeat episodes (odds ratio [OR], 2.82; 95% confidence interval [95% CI], 1.11 to 7.19; P=0.03). Overall, 70 episodes (60.9%) resolved; oxacillin susceptibility (OR, 4.41; 95% CI, 1.48 to 13.17; P=0.01) and vancomycin use as the first treatment (OR, 22.27; 95% CI, 6.16 to 80.53; P<0.001) were the only independent predictors of resolution.

CONCLUSIONS

Oxacillin resistance and vancomycin use as the first treatment strongly influence the resolution rate in CNS peritonitis, which reinforces the validity of the International Society for Peritoneal Dialysis guidelines on monitoring bacterial resistance to define protocols for initial treatment. These results also suggest that the presence of biofilm is a potential cause of repeat peritonitis episodes.

The negative impact of early peritonitis on continuous ambulatory peritoneal dialysis patients

BACKGROUND

Peritonitis rate has been reported to be associated with technique failure and overall mortality in previous literatures. However, information on the impact of the timing of the first peritonitis episode on continuous ambulatory peritoneal dialysis (CAPD) patients is sparse. The aim of this research is to study the influence of time to first peritonitis on clinical outcomes, including technique failure, patient mortality and dropout from peritoneal dialysis (PD).

METHODS

A retrospective observational cohort study was conducted over 10 years at a single PD unit in Taiwan. A total of 124 patients on CAPD with at least one peritonitis episode comprised the study subjects, which were dichotomized by the median of time to first peritonitis into either early peritonitis patients or late peritonitis patients. Cox proportional hazard model was used to analyze the correlation of the timing of first peritonitis with clinical outcomes.

RESULTS

Early peritonitis patients were older, more diabetic and had lower serum levels of creatinine than the late peritonitis patients. Early peritonitis patients were associated with worse technique survival, patient survival and stay on PD than late peritonitis patients, as indicated by Kaplan-Meier analysis (log-rank test, p = 0.04, p < 0.001, p < 0.001, respectively). In the multivariate Cox regression model, early peritonitis was still a significant predictor for technique failure (hazard ratio (HR), 0.54; 95% confidence interval (CI), 0.30 - 0.98), patient mortality (HR, 0.34; 95% CI, 0.13 - 0.92) and dropout from PD (HR, 0.50; 95% CI, 0.30 - 0.82). In continuous analyses, a 1-month increase in the time to the first peritonitis episode was associated with a 2% decreased risk of technique failure (HR, 0.98; 95% CI, 0.97 - 0.99), a 3% decreased risk of patient mortality (HR, 0.97; 95% CI, 0.95 - 0.99), and a 2% decreased risk of dropout from PD (HR, 98%; 95% CI, 0.97 - 0.99). Peritonitis rate was inversely correlated with time to first peritonitis according to the Spearman analysis (r = -0.64, p < 0.001).

CONCLUSIONS

Time to first peritonitis is significantly correlated with clinical outcomes of peritonitis patients with early peritonitis patients having poor prognosis. Patients with shorter time to first peritonitis were prone to having a higher peritonitis rate.

Viridans streptococci in peritoneal dialysis peritonitis: clinical courses and long-term outcomes

BACKGROUND

The clinical courses and long-term outcomes of viridans streptococcus (VS) peritoneal dialysis (PD) peritonitis remain unclear.

METHODS

We conducted a retrospective analysis of all PD patients in a single center with gram-positive cocci (GPC) peritonitis between 2005 and 2011, and divided them into 3 groups: VS, other streptococci and other GPC (apart from VS). Clinical characteristics and outcomes of the VS group were compared with the other streptococci and other GPC groups, with prognostic factors determined.

RESULTS

A total of 140 patients with 168 episodes of GPC peritonitis (44% of all peritonitis) were identified over 7 years. Among these, 18 patients (13%) developed VS peritonitis, while 14 patients (10%) developed other streptococcal peritonitis. Patients with VS peritonitis had a high cure rate by antibiotic alone (94%), despite a high polymicrobial yield frequency (28%). We found that VS peritonitis carried a lower risk of Tenckhoff catheter removal and relapsing episodes than other GPC peritonitis (6% vs 11%), and a lower mortality than other streptococci peritonitis (0% vs 7%). However, after the index peritonitis episodes, VS, other streptococci, and other GPC group had a significantly increased peritonitis incidence compared with the period before the index peritonitis (all p < 0.01). Patients with VS peritonitis had a significantly higher incidence of refractory peritonitis compared with other streptococci or other GPC peritonitis in the long term (both p < 0.01).

CONCLUSIONS

VS poses a higher risk of subsequent refractory peritonitis after the index episode as compared with other streptococcal or GPC peritonitis. It might be prudent to monitor the technique of these patients with VS peritonitis closely to avoid further peritonitis episodes.

Hand hygiene in peritoneal dialysis patients: a comparison of two techniques

INTRODUCTION AND OBJECTIVES

Hand hygiene is essential for preventing peritoneal dialysis (PD)-related infections. The present study compared the effectiveness of two hygiene techniques in reducing the number of colony-forming units (CFUs) on the hands of patients undergoing PD.

METHODS

In this controlled clinical trial, 22 participants enrolled in the same PD program underwent a two-hand evaluation for microbiologic flora. Participants participated in two treatments: a) simple hand hygiene plus antiseptic hand hygiene, in which the patients washed their hands with water and glycerin soap for 1 minute and then rubbed and dried their hands with 70% ethyl alcohol gel; and b) antiseptic hand hygiene, in which the patients rubbed their hands with 70% ethyl alcohol gel until fully dry. To sample distal finger surfaces, we asked the participants to touch sheep blood agar plates directly.

RESULTS

The CFU count for both hands was significantly higher in the regular hygiene group than in the gel-only group [69.0 (16.0 - 101.0) CFU vs 9.0 (2.2 - 55.5) CFU, p < 0.010]. Growth of coagulase-negative Staphylococcus colonies was significantly higher in right-hand cultures from the regular hygiene group than in those from the gel-only group [69.5 (26.25 - 101.0) CFU vs 9.5 (1.0 - 41.7) CFU; p < 0.050].

CONCLUSIONS

Among patients undergoing PD, using 70% ethyl alcohol gel to cleanse the hands may be more effective than following the regular hygiene recommendations in reducing bacterial populations.

The impact of diabetes mellitus on peritoneal dialysis: the Turkey Multicenter Clinic Study

PURPOSE

It is well established that diabetic peritoneal dialysis (PD) patients have a higher mortality rate than the other PD population. This study was designed to determine the overall predictors of survival and compared mortality and morbidity between diabetic and non-diabetic Turkish PD patients.

METHODS

We conducted a multicenter retrospective study with 915 PD patients [217 had diabetes mellitus (DM)]. Serum albumin, PTH, HbA1c, co-morbid diseases, dialysis adequacy (Kt/V), and peritoneal transport characteristics as well as peritonitis episodes and ultrafiltration failure during the follow-up period were recorded.

RESULTS

DM patients were older and had more co-morbidities than non-DM patients. Peritonitis rates were higher in DM patients (one episode per 35.9 patient months) compared to non-DM patients (one episode per 41.5 patient months) (p < 0.001). On Kaplan-Meier analysis, patient survival was significantly lower in DM patients with the 2-, 3- and 5-year patient survival rates of 90.8%, 87.8% and 78.2% in non-diabetics and 80.9%, 70.4% and 61.2% in diabetics, respectively. On Cox regression analysis, DM (HR 1.5, p = 0.022), age (HR 1.03, p < 0.001), baseline serum albumin (HR 0.39, p < 0.001), heart failure (HR 0.038, p = 0.038), peripheral artery disease (HR 1.83, p = 0.025) and amputation (HR 4.1, p = 0.009) at baseline were significant predictors of overall mortality.

CONCLUSIONS

Patient survival is lower in diabetic compared to non-diabetic patients on PD. Peritonitis rates were also higher in diabetic PD patients. DM, older age, albumin level and cardiovascular co-morbidities are predictors of mortality.

Extended Spectrum β-lactamase–producing &lt;italic&gt;E. coli&lt;/italic&gt;-related Nosocomial Peritonitis Treated Successfully with Meropenem in a Patient on Peritoneal Dialysis

Peritonitis is a common and potentially serious infection in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). The most common organisms usually associated with CAPD peritonitis are <italic>Staphylococcus aureus</italic> and <italic>Staphylococcus epidermidis</italic>. Rarely, aerobic gram negative bacilli have been the causative agents of CAPD peritonitis. The treatment of CAPD peritonitis requires removal of the peritoneal catheter and treatment with parenteral antibiotics active against the causative pathogen. While hospitalized for CAPD peritonitis, a 55-year-old man on CAPD had nosocomial peritonitis secondary to infection by ESBL–producing <italic>E. coli</italic>, that was sensitive to imipenem and meropenem. He was treated successfully with a 4-week course of intraperitoneal meropenem therapy without subsequent relapse, loss of peritoneal catheter, ultrafiltration failure, or dialysis inadequacy.

Peritonitis in recent years: clinical findings and predictors of treatment response of 170 episodes at a single Brazilian center

PURPOSE

Peritonitis continues to be a major cause of dropout in peritoneal dialysis (PD) patients. Changes in the prevalence of peritonitis etiologies and an increase in the frequency of methicillin-resistant coagulase-negative staphylococci (CoNS) and Gram-negative species resistant to commonly used antibiotics have been reported. As a consequence, the current clinical presentation and patient outcome may differ from classical descriptions. The objectives of this study were to describe the clinical and microbiological characteristics of PD-related peritonitis episodes that occurred over a period of 6 years at a single Brazilian dialysis center and to identify predictors of outcome.

METHODS

A total of 170 peritonitis episodes that occurred in 92 PD patients between January 2004 and December 2009 were reviewed. Multivariate analysis was used to identify demographic, clinical, and microbiological factors predicting endpoints (resolution and peritonitis-related death). Patients' characteristics and peritonitis incidence, etiology and outcomes were compared with a series of 232 episodes that occurred in the first 6 years (1995-2000) of the PD program at the same center.

RESULTS

The overall peritonitis rate was 0.65 episodes/patient-year. Gram-positive cocci were identified in 79 (46.5%) episodes, whereas Gram-negative bacilli were isolated from 48 (28.2%). CoNS were the main Gram-positive species identified in 48 episodes. Of these, 56.3% were resistant to methicillin. Among Gram-negative species, amikacin resistance was observed in 60% of non-fermentative Gram-negative bacilli (NFGNB) and in only 3.6% of Enterobacteriaceae. The overall resolution rate was 44.1%. Oxacillin resistance and NFGNB etiology were strong predictors of non-resolution, whereas older age was the only predictor of death. Antibiotic protocols did not influence outcome. Comparison with the results obtained for the 1990-1995 period showed a lower peritonitis rate, a strong decline in the proportion of Staphylococcus aureus episodes, a significant increase in the frequency of oxacillin-resistant CoNS and amikacin-resistant NFGNB, and a significantly lower resolution and higher death rate.

CONCLUSIONS

The current clinical characteristics and outcome suggest a greater severity of peritonitis episodes and higher risk of death, possibly due to bacterial resistance. Older age is a risk factor for death.

Peritonitis caused by Haemophilus parainfluenzae, Leifsonia aquatica, and Gordonia spp. in a patient undergoing continuous ambulatory peritoneal dialysis

BACKGROUND

Peritonitis has remained the most common serious complication of continuous ambulatory peritoneal dialysis (CAPD). In most cases, these infections are monomicrobial, and the pathogens involved most commonly are Staphylococci. Recently, polymicrobial infections with rare organisms have been reported more often.

CASE REPORT

We describe a patient who developed recurrent episodes of CAPD-associated peritonitis with a total of four pathogens: Methicillin-resistant S. aureus, Haemophilus parainfluenzae, Leifsonia aquatica, and Gordonia spp. The infection most likely was acquired when the patient used tap water for dialysis during a camping trip. All episodes were treated successfully with antibiotics. Finally, the device was removed, and later, a new catheter was implanted, which still is in use.

CONCLUSION

Peritoneal dialysis-associated peritonitis may be caused by rare organisms. Antibiotics may be able to treat disease temporarily, but removal of contaminated catheters usually is required.

Peritoneal adhesion: it can be life-threatening, and life-saving

Background

The inevitable post-inflammatory fibrosis and adhesion often compromises future treatment in peritoneal dialysis patients. Here, we describe a patient who experienced an unusual form of peritoneal adhesion that made her give up peritoneal dialysis. However, its unique pattern also saved her from infection caused by bowel perforation.

Case presentation

The female patient discontinued peritoneal dialysis due to gradual dialysis inadequacy. Two months after shifting to hemodialysis with generally improved sense of well-being and no sign of abdominal illness, she was admitted to remove the Tenckhoff catheter. The procedure was smooth, but fever and abdominal pain not at the site of operation developed the next day. Abdominal ultrasound showed the presence of ascites and aspiration revealed slimy, green-yellowish pus that gave a negative result on bacterial culture. Abdominal computed tomography (CT) with oral contrast medium was performed, but failed to demonstrate the suspected bowel perforation. The examination, however, did show accumulation of pus inside the abdomen but outside the peritoneal cavity. We drained the pus with two 14-F Pig-tail catheters and the total amount of drainage approached 4000 ml. The second CT was performed with double dose of the contrast medium and found a leak of the contrast from the jejunum. She then received laparotomy and had the perforation site closed.

Conclusions

In summary, this uremic patient suffered from pus accumulation inside her abdomen without obvious systemic toxic effect. The bowel perforation and pus formation might be caused by repeated peritonitis, but the peritoneal adhesion itself might also isolate her peritoneal cavity from the anticipated toxic injuries of bowel perforation.

Bacteria on catheters in patients undergoing peritoneal dialysis

BACKGROUND

Peritonitis is the leading cause of morbidity for peritoneal dialysis (PD) patients, and microbial biofilms have previously been identified on catheters from infected patients. However, few studies of catheters from patients without clinical signs of infection have been undertaken. The aim of the present study was to investigate the extent to which bacteria are present on catheters from PD patients with no symptoms of infection.

METHODS

Microbiologic culturing under aerobic and anaerobic conditions and confocal laser scanning microscopy were used to determine the distribution of bacteria on PD catheters from 15 patients without clinical signs of infection and on catheters from 2 infected patients. The 16S rRNA gene sequencing technique was used to identify cultured bacteria.

RESULTS

Bacteria were detected on 12 of the 15 catheters from patients without signs of infection and on the 2 catheters from infected patients. Single-species and mixed-microbial communities containing up to 5 species were present on both the inside and the outside along the whole length of the colonized catheters. The bacterial species most commonly found were the skin commensals Staphylococcus epidermidis and Propionibacterium acnes, followed by S. warneri and S. lugdunensis. The strains of these micro-organisms, particularly those of S. epidermidis, varied in phenotype with respect to their tolerance of the major classes of antibiotics.

CONCLUSIONS

Bacteria were common on catheters from patients without symptoms of infection. Up to 4 different bacterial species were found in close association and may represent a risk factor for the future development of peritonitis in patients hosting such micro-organisms.

Evaluation of DNA extraction methods and their clinical application for direct detection of causative bacteria in continuous ambulatory peritoneal dialysis culture fluids from patients with peritonitis by using broad-range PCR

Background

The aims of this study were to compare several DNA extraction methods and 16S rDNA primers and to evaluate the clinical utility of broad-range PCR in continuous ambulatory peritoneal dialysis (CAPD) culture fluids.

Methods

Six type strains were used as model organisms in dilutions from 10⁸ to 10⁰ colony-forming units (CFU)/mL for the evaluation of 5 DNA extraction methods and 5 PCR primer pairs. Broad-range PCR was applied to 100 CAPD culture fluids, and the results were compared with conventional culture results.

Results

There were some differences between the various DNA extraction methods and primer sets with regard to the detection limits. The InstaGene Matrix (Bio-Rad Laboratories, USA) and Exgene Clinic SV kits (GeneAll Biotechnology Co. Ltd, Korea) seem to have higher sensitivities than the others. The results of broad-range PCR were concordant with the results from culture in 97% of all cases (97/100). Two culture-positive cases that were broad-range PCR-negative were identified as Candida albicans, and 1 PCR-positive but culture-negative sample was identified as Bacillus circulans by sequencing. Two samples among 54 broad-range PCR-positive products could not be sequenced.

Conclusions

There were differences in the analytical sensitivity of various DNA extraction methods and primers for broad-range PCR. The broad-range PCR assay can be used to detect bacterial pathogens in CAPD culture fluid as a supplement to culture methods.

[Ecology and mechanisms of bacterial resistance to antibiotics in peritonitis]

Peritonitis remains a common complication of peritoneal dialysis. The aim of our study is to describe the mechanisms of antibiotic resistance in bacteria isolated during peritonitis in peritoneal dialysis, to determine whether antibiotic therapy proposed by the International Society for Peritoneal Dialysis (ISPD) is adapted to the mechanisms of resistance. All causative microorganisms of peritonitis, isolated in 106 dialysis patients and reported 170 episodes of peritonitis, during the study period (01/01/2005 to 31/12/2010) were reviewed. According to the usual classification, twelve groups of microorganism were created. An interpretive reading of antibiograms was performed in each group to identify resistance phenotypes. The species most frequently isolated are coagulase-negative staphylococci (n=73) of which 46 had PBP2a (penicillin-binding protein). Many Enterobacteriaceae were also isolated (n=45), they are susceptible to third generation cephalosporins with the exception of Enterobacteriaceae producing an extended spectrum β-lactamase (ESBL) or a cephalosporinase. Except for staphylococci, probabilistic antibiotic therapy recommended by the ISPD to treat peritonitis is effective. Indeed, many staphylococci producing a PBP2a, a first-generation cephalosporin cannot be administered in all cases. It is therefore necessary to identify patients with a strain of staphylococcus producing a PBP2a, it must be treated by vancomycin.