Multiple-Dose-Kinetics of Ofloxacin after Intraperitoneal Application in CAPD Patients

Pharmacokinetics of ofloxacin in plasma and peritoneal fluid were studied in 11 patients on continuous ambulatory peritoneal dialysis (CAPD). Seven patients without peritonitis received 20 mg ofloxacin added to 2L dialysate i.p. every 6 h for one day only, while 4 patients with acute peritonitis were treated with this same dosage every 4 h for 3 days, then every 6 h for the next 7 days. Ofloxacin concentrations in plasma and dialysate were determined by HPLC.

After i.p. drug application there was a rapid elimination of ofloxacin from dialysate, this being significantly faster in patients with peritonitis as compared to those without. Likewise, the total amount lost from the first bag after a 3 h dwell was higher in the peritonitis group (84.7±1.5%; mean±SEM) than in the non-peritonitis group (75.6±2.1 %). Twenty-four h after start of ofloxacin treatment, the mean peritoneal fluid concentrations at the end of each exchange studied were all above 3 mg/L. In patients with peritonitis, plasma concentrations of ofloxacin rose to 0.94±0.05 mg/L after 24 h reaching a Cmax of 1.8±0.2 mg/L after a tmax of 84±23 h.lntraperitoneal administration of ofloxacin was well tolerated, and no local or systemic adverse events were observed. Peritonitis episodes that were caused by Staphylococcus epidermidis (3) and by E. coli (1) were cured in all patients.

CAPD Peritonitis and Fluoroquinolones: A Review

Fluoroquinolones are potentially useful agents in the treatment of CAPD peritonitis, due to their wide spectrum of antimicrobial activity, favourable pharmacokinetics, oral availability and their relatively low toxicity.

The microbiological, pharmacokinetic, and clinical aspects of these drugs in CAPD are reviewed.

Ciprofloxacin showed superior in-vitro activity in comparison with various beta lactam agents; gentamicin and vancomycin against staphylococci and particularly against Gram-negative bacteria. Its activity against streptococci is low. The in vitro activity of fiuoroquinolones is reduced in peritoneal dialysis fluid.

A limited rise in serum levels is observed with daily administration of fiuoroquinolones in CAPD patients during 5–15 days. Effective dialysate levels are reached in most patients after oral dosing, but these levels are highly variable and low levels are often observed during the first day, an d with short dwell times. Concurrent administration with phosphate binding antacids should be avoided.

Initial clinical experience shows that ciprofloxacin and ofloxacin may be effective agents to treat CAPD peritonitis via the oral route. They are usually well tolerated, although convulsions have been observed. The relative efficacy in comparison with “standard therapies” will have to be shown in comparative studies.

Single -Dose Pefloxacin Pharmacokinetics and Metabolism in Patients Undergoing Continuous Ambulatory Peritoneal Dialysis (CAPD)

Seven adult patients on continuous ambulatory peritoneal dialysis (CAPD) received one dose of pefloxacin, a novel quinolone antibiotic, orally and intravenously on two separate occasions to characterize the pharmacokinetics and metabolism of the drug. Concentrations of both pefloxacin and its active metabolite N-desmethylpefloxacin (norfloxacin) were measured in serum and dialysate by HPLC. Half-life, total body clearance and peritoneal clearance were determined. The overall elimination half-life was 19.9h. Relative to the IV dose the bioavailability following oral administration of pefloxacin was 76%. The mean serum and dialysate concentrations were similar up to 24 h after the oral or IV dose. After a 6 h dwell time the dialysate concentration of pefloxacin was 2.24 mg/L which is above the MICgo for most bacteria responsible for peritonitis in CAPD patients. The peritoneal clearance of pefloxacin averaged 2.5 mL/min. Serum concentrations of the metabolite norfloxacin were less than 0.5 mg/L during the 24 h study period.

We conclude that pefloxacin might be equally effective in the treatment of peritonitis of CAPD after oral or IV administration. Since the peritoneal clearance contributes insignificantly to the elimination of pefloxacin during CAPD, the proposed maintenance regimen of an oral or IV 400 mg dose/day seems to be a reasonable therapy for infections in CAPD patients.

Risk factors and outcome of contamination in patients on peritoneal dialysis--a single-center experience of 15 years

OBJECTIVE

Contamination is an important risk factor for peritoneal dialysis (PD)-related peritonitis. The present study outlines the clinical characteristics and outcomes of PD patients experiencing touch contamination.

METHODS

We reviewed the case records of PD patients from 1995 to 2010. Patients who experienced contamination of their PD system were identified and stratified into "dry" and "wet" contamination groups. Risk factors, microbiology, and clinical outcomes were compared.

RESULTS

Of 548 episodes of touch contamination, 246 involved dry contamination, and 302, wet contamination. After contamination, 17 episodes of peritonitis (3.1%) developed; all episodes occurred in the wet contamination group (p < 0.001). The incidence of peritonitis after wet contamination was 5.63%. Prophylactic antibiotics significantly reduced the risk of peritonitis (1 of 182 episodes, p < 0.001). Half the patients experiencing peritonitis had either culture-negative or staphylococcal episodes, and most of those episodes responded to intraperitoneal antibiotics. In 2 patients, peritonitis was attributable to Pseudomonas, and in 3, to Acinetobacter. In these latter patients, outcomes were less favorable, with catheter removal being required in 4 of the 5 episodes.

CONCLUSIONS

The overall rate of peritonitis was low after contamination. Wet contamination was associated with a much higher risk of peritonitis. Prophylactic antibiotics after wet contamination were effective in preventing peritonitis.

[Pharmacokinetics and dose adaptation of ofloxacine, pefloxacine and ciprofloxacine during haemodialysis and continuous ambulatory peritoneal dialysis]

Fluoroquinolones present various pharmacokinetic properties. That's the way we carried out a bibliographic summary about the pharmacokinetics of pefloxacin, ofloxacin and ciprofloxacin in patients hit by chronic renal failure, under haemodialysis or under continuous ambulatory peritoneal dialysis. Then, we will describe how to adapt drug dose according to the degree of renal insufficiency and the used molécule.

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.