Unusual and complicated peritonitis: Your questions answered

Effective treatment of infections is a growing challenge owing to antimicrobial resistance. Peritoneal dialysis (PD) patients experience more frequent hospitalisations than the general population and have greater exposure to antibiotics, making them particularly vulnerable to this threat. Over the last decade, we have noted a surge in cases of complicated peritoneal dialysis-associated peritonitis (PD peritonitis) caused by antimicrobial-resistant organisms, including extended-spectrum beta-lactamase (ESBL), AmpC beta-lactamase-producing Enterobacterales, Pseudomonas aeruginosa and fungi. Practitioners must be alert to these organisms, seek early recognition of these resistance patterns and make timely adjustments in order to avoid delay in treatment that may increase risk of PD catheter removal and technique failure. We present a case of successful treatment of ESBL peritonitis, highlight its challenges, while providing guidance on management of other unusual and complicated PD peritonitis.

The efficacy of fluconazole for anti-fungal prophylaxis in peritoneal dialysis patients: A systematic review and meta-analysis

INTRODUCTION AND OBJECTIVES

The efficacy of fluconazole as a prophylactic strategy in patients with chronic kidney disease (CKD) on peritoneal dialysis (PD) with prior antibiotic exposure is controversial in the current literature. This study aimed to compare a strategy of fluconazole prophylaxis versus no-prophylaxis for patients in PD on antibiotics for previous episodes of peritonitis.

MATERIALS AND METHODS

We performed a systematic review and meta-analysis of observational studies and randomized controlled trials (RCTs) comparing fluconazole prophylaxis with no prophylaxis for PD-related peritonitis. The search was conducted on PubMed, EMBASE, and Cochrane Central in January 23, 2023. The outcome of interest was the occurrence of fungal peritonitis (FP).

RESULTS

We included six studies (1 RCT, 5 observational) with 4515 occurrences of peritonitis, of which 1098 (24.8%) received fluconazole prophylaxis in variable doses, whereas 3417 (75.6%) did not receive prophylaxis during peritonitis episodes. Overall, fluconazole prophylaxis was associated with a lower incidence of FP (OR 0.22; 95% CI 0.12-0.41; p<0.001; I2=0%). Subgroup analysis of studies that administered daily doses of fluconazole also demonstrated a reduced incidence of FP in patients who received antifungal prophylaxis (OR 0.31; CI 0.14-0.69; p=0.004; I2=0%).

CONCLUSIONS

In this meta-analysis of 4515 episodes of PD-related peritonitis, prophylaxis with fluconazole significantly reduced episodes of FP as compared with no antifungal prophylaxis.

ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment

Peritoneal dialysis (PD)-associated peritonitis is a serious complication of PD and prevention and treatment of such is important in reducing patient morbidity and mortality. The ISPD 2022 updated recommendations have revised and clarified definitions for refractory peritonitis, relapsing peritonitis, peritonitis-associated catheter removal, PD-associated haemodialysis transfer, peritonitis-associated death and peritonitis-associated hospitalisation. New peritonitis categories and outcomes including pre-PD peritonitis, enteric peritonitis, catheter-related peritonitis and medical cure are defined. The new targets recommended for overall peritonitis rate should be no more than 0.40 episodes per year at risk and the percentage of patients free of peritonitis per unit time should be targeted at >80% per year. Revised recommendations regarding management of contamination of PD systems, antibiotic prophylaxis for invasive procedures and PD training and reassessment are included. New recommendations regarding management of modifiable peritonitis risk factors like domestic pets, hypokalaemia and histamine-2 receptor antagonists are highlighted. Updated recommendations regarding empirical antibiotic selection and dosage of antibiotics and also treatment of peritonitis due to specific microorganisms are made with new recommendation regarding adjunctive oral N-acetylcysteine therapy for mitigating aminoglycoside ototoxicity. Areas for future research in prevention and treatment of PD-related peritonitis are suggested.

Peritoneal Dialysis Guidelines 2019 Part 1 (Position paper of the Japanese Society for Dialysis Therapy)

Approximately 10 years have passed since the Peritoneal Dialysis Guidelines were formulated in 2009. Much evidence has been reported during the succeeding years, which were not taken into consideration in the previous guidelines, e.g., the next peritoneal dialysis PD trial of encapsulating peritoneal sclerosis (EPS) in Japan, the significance of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), the effects of icodextrin solution, new developments in peritoneal pathology, and a new international recommendation on a proposal for exit-site management. It is essential to incorporate these new developments into the new clinical practice guidelines. Meanwhile, the process of creating such guidelines has changed dramatically worldwide and differs from the process of creating what were “clinical practice guides.” For this revision, we not only conducted systematic reviews using global standard methods but also decided to adopt a two-part structure to create a reference tool, which could be used widely by the society’s members attending a variety of patients. Through a working group consensus, it was decided that Part 1 would present conventional descriptions and Part 2 would pose clinical questions (CQs) in a systematic review format. Thus, Part 1 vastly covers PD that would satisfy the requirements of the members of the Japanese Society for Dialysis Therapy (JSDT). This article is the duplicated publication from the Japanese version of the guidelines and has been reproduced with permission from the JSDT.

Fungal Peritonitis in Peritoneal Dialysis Patients

Peritonitis is one of the most frequent complications of peritoneal dialysis (PD) and 1% – 15% of episodes are caused by fungal infections. The mortality rate of fungal peritonitis (FP) varies from 5% to 53%; failure to resume PD occurs in up to 40% of patients. The majority of these FP episodes are caused by Candida species. Candida albicans has historically been reported to be a more common cause than non-albicans Candida species, but in recent reports a shift has been observed and non-albicans Candida may now be more common. Unusual, often “nonpathogenic,” fungi are being increasingly reported as etiologic agents in FP. Clinical features of FP are not different from those of bacterial peritonitis. Phenotypic identification of fungi in clinical microbiology laboratories is often difficult and delayed. New molecular diagnostic techniques ( e.g., polymerase chain reaction) are being developed and evaluated, and may improve diagnosis and so facilitate early treatment of infected patients. Abdominal pain, abdominal pain with fever, and catheter left in situ are risk factors for mortality and technique failure in FP. In programs with high baseline rates of FP, nystatin prophylaxis may be beneficial. Each program must examine its own history of FP to decide whether prophylaxis would be beneficial. Catheter removal is indicated immediately after fungi are identified by Gram stain or culture in all patients with FP. Prolonged treatment with antifungal agents to determine response and attempt clearance is not encouraged. Antifungals should be continued for 10 days to 2 weeks after catheter removal. Attempts at reinsertion should be made only after waiting for 4 – 6 weeks.

Nystatin Prophylaxis: Its Inability to Prevent Fungal Peritonitis in Patients on Continuous Ambulatory Peritoneal Dialysis

Objective

To evaluate the potential effectiveness of nystatin as prophylaxis for fungal peritonitis (FP) in patients on continuous ambulatory peritoneal dialysis (CAPD).

Design

This historically controlled study was designed to investigate the effectiveness of nystatin in the prevention of FP. For this purpose we compared the incidence of FP among 240 (new and prevalent) CAPD patients between January 1996 and November 1996 (period A) with its incidence in 240 new and prevalent CAPD patients in our program between January 1997 and November 1997 (period B) when nystatin prophylaxis was used. There were 2400 patient-months in each period. Nystatin (500000 IU four times per day), was given orally at the beginning of other antibiotic therapy (usually for peritonitis) and continued for 5 days after the end of the antibiotic therapy.

Results

During period A, 133 peritonitis episodes were recorded, and during period B, 99 episodes were recorded. Six episodes of FP were identified in over 2400 patient months of period A, and 12 in over 2400 patient-months of period B. This difference was not statistically significant. Three episodes of antibiotic-related FP were seen in period A, and four in period B. The remaining episodes arose de novo, that is, unrelated to the use of antibiotics. We observed no side effects for nystatin.

Conclusion

In CAPD patients the use of nystatin, a nonabsorbable antifungal agent, as prophylaxis in every instance of peritonitis or other indications for antibiotics, did not lower the incidence of fungal peritonitis.

Prevention of Fungal Peritonitis with Nystatin Prophylaxis in Patients Receiving CAPD

Objective

Fungal peritonitis (FP) is a serious complication of continuous ambulatory peritoneal dialysis (CAPD), being associated with significant morbidity and mortality. The role of nystatin prophylaxis during antibiotic therapy in the prevention of FP remains controversial, especially in programs with a modest or low baseline FP rate. The aim of the present study was to evaluate the effect of nystatin prophylaxis on the occurrence of FP in programs with a relatively modest baseline FP rate.

Patients and Methods

Incident and prevalent patients receiving CAPD between April 1995 and April 2005 at our center were included and divided into 2 groups. The control group included 320 patients (total follow-up 8875 patient-months) being treated without nystatin before October 1999; the nystatin group included 481 patients (total follow-up 13725 patient-months) being treated after October 1999. Nystatin tablets (500000 units, 4 times per day) were given orally during whatever use of antibiotics to cover the whole course of antibiotic therapy. Occurrence of FP and antibiotic-related FP (AR-FP) in patients with and without nystatin prophylaxis was compared.

Results

The two groups were of similar age but the nystatin group had a significantly higher percentage of diabetics. In addition, the nystatin group had a higher proportion of patients using disconnecting twin-bag exchange systems and had a significantly lower peritonitis rate compared with the control. There were 13 and 14 episodes of FP in the nystatin and control groups respectively. The fungal peritonitis rate of the nystatin group was slightly lower than that of the control group (0.011 vs 0.019 per patient-year) but it did not reach statistical significance. There was, however, a significant decrease in the incidence and proportion of AR-FP in the nystatin group compared with the control group, which persisted even after adjustment for the peritonitis rate. Kaplan–Meier analysis further demonstrated significantly better AR-FP-free survival in the nystatin group compared with the control group. No significant side effects were observed for nystatin. Subgroup analyses in patients of the 2 different connecting systems revealed a similar but nonsignificant trend toward reduction of AR-FP in patients given nystatin prophylaxis.

Conclusion

Oral nystatin prophylaxis might prevent the occurrence of AR-FP in CAPD patients, resulting in a trend toward reduction in the incidence of FP even in programs with a modest baseline FP rate. A large scale, prospective, randomized controlled trial is needed to further examine this issue.

Percutaneous Endoscopic Gastrostomy in Children on Peritoneal Dialysis

Objective

Insertion of percutaneous endoscopic gastrostomies (PEG) in patients on chronic peritoneal dialysis (PD) has been reported to be contraindicated due to an increased risk of morbidity and mortality. However, no systematic survey on this topic has yet been published.

Design

Retrospective multicenter study.

Setting

23 pediatric dialysis units associated with the working group Arbeitsgemeinschaft für Pädiatrische Nephrologie (APN).

Data Source

A structured questionnaire on clinical details of PD patients who had undergone PEG insertion or open gastrostomy (OG) since 1994 was distributed to all pediatric dialysis units of the APN.

Results

27 PD patients (20 males) from 12 centers in whom PEG insertion was performed after Tenckhoff catheter introduction were evaluated. Age at intervention ranged from 0.25 to 10.9 years (median 1.3 years). Most patients were malnourished, with standard deviation score (SDS) for body weight between –4.2 and –0.6 (median -2.2). Major complications were early peritonitis <7 days after PEG in 10/27 (37%) patients, episodes of fungal peritonitis in 7/27 (26%) patients, 4 cessations of PD and change to hemodialysis, and 2 associated deaths. However, in 14 patients, no such problems were encountered and, in 4 patients, early peritonitis effectively treated with intraperitoneal antibiotics was the only major complication. Thus, in 18/27 (67%) patients, PD was successfully reinitiated shortly after PEG insertion. Among all participating centers, only two OG procedures were reported during the study period, illustrating a clear preference for the PEG over the OG procedure among members of the APN.

Conclusion

PEG insertion following PD initiation carries a high risk for fungal peritonitis and potential PD failure; however, complication rates in this largest reported series were lower than previously described. Antibiotic and anti-fungal prophylaxis, withholding PD for 2 – 3 days, and gastrostomy placement by an experienced endoscopy team are suggested precautions for lowering the risk of associated complications. When gastrostomy placement does not occur prior to or at the time of initiating PD, the risks and benefits of percutaneous versus open placement must be carefully weighed.

Prevention of peritonitis in peritoneal dialysis

Reducing the frequency of peritonitis for patients undergoing peritoneal dialysis (PD) continues to be a challenge. This review focuses on recent updates in catheter care and other patient factors that influence infection rates. An experienced nursing staff plays an important role in teaching proper PD technique to new patients, but nursing staff must be cognizant of each patient's unique educational needs. Over time, many patients become less adherent to proper dialysis technique, such as washing hands or wearing a mask. This behavior is associated with higher risk of peritonitis and is modifiable with re-training. Prophylactic antibiotics before PD catheter placement can decrease the infection risk immediately after catheter placement. In addition, some studies suggest that prophylaxis against fungal superinfection after antibiotic exposure is effective in reducing fungal peritonitis, although larger randomized studies are needed before this practice can be recommended for all patients. Over time, exit site and nasal colonization with pathogenic organisms can lead to exit-site infections and peritonitis. For patients with Staphylococcus aureus colonization, exit-site prophylaxis with either mupirocin or gentamicin cream reduces clinical infection with this organism. Although there are limited data for support, antibiotic prophylaxis before gastrointestinal, gynecologic, or dental procedures may also help reduce the risk of peritonitis.

Prevention of peritoneal dialysis-related infections

Despite substantial advances in peritoneal dialysis (PD) as a renal replacement modality, PD-related infection remains an important cause of morbidity, technique failure, and mortality. This review describes the microbiology and outcomes of PD peritonitis and catheter infection, followed by a discussion of several strategies that may reduce the risk of PD-related infections. Strategies that are reviewed include use of antibiotics at the time of PD catheter insertion, selection of PD catheter design and insertion technique, patient training, PD connectology, exit site prophylaxis, periprocedural prophylaxis, fungal prophylaxis, and choice of PD solutions.

Does antifungal prophylaxis with daily oral fluconazole reduce the risk of fungal peritonitis in peritoneal dialysis patients? The Pan Thames Renal Audit

BACKGROUND AND OBJECTIVES

Fungal peritonitis increases the risk of transfer to haemodialysis and mortality.

METHODS

We audited the effect of co-prescription of daily oral fluconazole with antibiotics in the Pan Thames centres on fungal peritonitis.

RESULTS

We found 49 (1.5%) fungal peritonitis cases in 3,322 episodes of peritonitis. Two centres co-prescribed prophylactic fluconazole with antibiotics, with a fungal peritonitis rate of 0.0032/patient year, compared to 0.0099 from centres not using prophylaxis. However, centres using fungal prophylaxis had lower peritonitis rates of 0.036, compared to 0.05 for the other centres. Correcting for background peritonitis rates, there was no significant difference in the incidence of fungal peritonitis.

CONCLUSIONS

In centres with a low incidence of fungal peritonitis, additional co-prescription of fluconazole with antibiotics appeared to reduce the risk of fungal peritonitis. However, variation in practice between centres is the main determinant of the observed incidence of fungal peritonitis rather than the use of antifungal prophylaxis.

Fungal peritonitis in peritoneal dialysis patients: successful prophylaxis with fluconazole, as demonstrated by prospective randomized control trial

OBJECTIVES

To determine whether oral administration of the antifungal fluconazole during the entire period of treatment of bacterial peritonitis (BP), exit-site infection (ESI), or tunnel infection (TI) prevents later appearance of fungal peritonitis (called secondary) in patients with chronic kidney disease stage 5 in a peritoneal dialysis (PD) program. ♢

PATIENTS AND METHODS

All patients treated in the PD program in RTS Ltda Sucursal Caldas, during the period 1 June 2004 to 30 October 2007 were screened. Patients that had infectious bacterial complications (BP, ESI, TI) were included in a prospective randomized trial to receive or not receive oral fluconazole (200 mg every 48 hours) throughout the time period required by the administration of therapeutic antibiotics via any route. It was evaluated whether the fungal peritonitis complication appeared within 30 - 150 days following the end of antibacterial treatment. Based on local results, the sample size necessary to obtain statistically significant results was determined to be 434 episodes of peritonitis. ♢

RESULTS

The 434 episodes of peritonitis presented between the previously specified dates and during this same period there were 174 ESI or TI, of which only 52 received oral antibiotic treatment. Information in relation to consumption of antibiotics for purposes other than BP, ESI, and TI was not reliable and thus this variable was excluded. Among the episodes of peritonitis, 402 (92.6%) were of bacterial origin and 32 (7.3%) were mycotic, mainly Candida species [30 (93.75%)]. Of the fungal peritonitis, 14 (43.73%) were primary (without prior use of antibiotics) and 18 (56.25%) were secondary. In the group of patients that received prophylaxis with fluconazole (210 for BP and 26 for ESI or TI), only 3 occurrences of fungal peritonitis were observed within 30 - 150 days of its administration, which is opposite to the group without prophylaxis (210 for BP and 26 for ESI or TI), in which 15 occurrences of fungal peritonitis were detected. Statistical analysis of the group of patients with BP found comparisons of the proportions of those receiving fluconazole (0.92%) or not (6.45%) presented a highly significant difference in favor of prophylaxis (p = 0.0051, Z = 2.8021). Given that only 1 patient in each group with ESI or TI, with or without prophylaxis, presented the complication fungal peritonitis, it was concluded that this result was not statistically significant. During laparoscopic surgery attempting reintroduction of the peritoneal catheter, it was found that 11 patients had severe adhesions or peritoneal fibrosis leading to obliteration of the peritoneal cavity. In 19 patients, reintroduction of the catheter was possible and the patients returned to PD without consequence. ♢

CONCLUSION

In patients with bacterial peritonitis, administration of prophylactic oral fluconazole throughout the time they received antibiotics significantly prevented the appearance of secondary fungal peritonitis.

Dialysis-associated peritonitis in children

Peritonitis remains a frequent complication of peritoneal dialysis in children and is the most common reason for technique failure. The microbiology is characterized by a predominance of Gram-positive organisms, with fungi responsible for less than 5% of episodes. Data collected by the International Pediatric Peritonitis Registry have revealed a worldwide variation in the bacterial etiology of peritonitis, as well as in the rate of culture-negative peritonitis. Risk factors for infection include young age, the absence of prophylactic antibiotics at catheter placement, spiking of dialysis bags, and the presence of a catheter exit-site or tunnel infection. Clinical symptoms at presentation are somewhat organism specific and can be objectively assessed with a Disease Severity Score. Whereas recommendations for empiric antibiotic therapy in children have been published by the International Society of Peritoneal Dialysis, epidemiologic data and antibiotic susceptibility data suggest that it may be desirable to take the patient- and center-specific history of microorganisms and their sensitivity patterns into account when prescribing initial therapy. The vast majority of patients are treated successfully and continue peritoneal dialysis, with the poorest outcome noted in patients with peritonitis secondary to Gram-negative organisms or fungi and in those with a relapsing infection.

Update on Fungal Peritonitis and its Treatment

Fungal peritonitis (FP) is a rare but potentially fatal complication of chronic peritoneal dialysis (PD), associated with high morbidity and mortality ranging between 20% and 30%. If not leading to death, the inflammatory process usually causes irreversible damage to the peritoneal membrane with subsequent dropout from PD therapy. Fungal peritonitis accounts for 3% – 6% of all peritonitis episodes; however, in some areas, the numbers can be much higher. The most common cause of the disease is Candida, predominately C. albicans, C. parapsilosis, and—more recently— C. glabrata; other yeasts and filamentous fungi such as Aspergillus, Paecilomyces, Penicillium, and Zygomycetes are found, but much less frequently. The main factors associated with the development of FP include previous antibiotic therapy, particularly for bacterial peritonitis, when two important operative mechanisms coincide: fungal overgrowth in the gastrointestinal tract and declining peritoneal defense because of peritonitis.

The management of FP poses a difficult challenge. Prompt initiation of therapy is critical, but no typical clinical picture has emerged, and the infecting organism can be difficult to isolate. The approach to the disease has changed considerably in recent years, and the 2005 guidelines from the International Society for Peritoneal Dialysis list FP as a strong indication for immediate catheter removal with temporary hemodialysis. The conventional antifungal regimens include fluconazole, amphotericin B, and flucytosine alone or in combination, optimally based on fungal sensitivities. The newer agents such as caspofungin and voriconazole have the potential to alter treatment strategies for FP, but further studies are required to clarify the precise role of these agents in this group of patients.

Prevention of infectious complications in peritoneal dialysis: best demonstrated practices

Peritoneal dialysis (PD) related infections continue to be a serious complication for PD patients. Peritonitis can be associated with pain, hospitalization and catheter loss as well as a risk of death. Peritonitis risk is not evenly spread across the PD population or programs. Very low rates of peritonitis in a program are possible if close attention is paid to the causes of peritonitis and protocols implemented to reduce the risk of infection. Protocols to decrease infection risk in PD patients include proper catheter placement, exit-site care that includes Staphylococcus aureus prophylaxis, careful training of patients with periodic retraining, treatment of contamination, and prevention of procedure-related and fungal peritonitis. Extensive data have been published on the use of antibiotic prophylaxis to prevent exit site infections. There are fewer data on training methods of patients to prevent infection risk. Quality improvement programs with continuous monitoring of infections, both of the catheter exit site and peritonitis, are important to decrease the PD related infections in PD programs. Continuous review of every episode of infection to determine the root cause of the event should be routine in PD programs. Further research is needed examining approaches to decrease infection risk.

Management of peritonitis in children receiving chronic peritoneal dialysis

Bacterial peritonitis is a major threat to long-term peritoneal membrane function in pediatric patients receiving chronic peritoneal dialysis (CPD). This review summarizes the demographics, risk factors, and current recommendations regarding diagnostic procedures, management, and prevention of peritonitis in children. Albeit decreasing in incidence, bacterial peritonitis remains a major cause of technique failure in children with endstage renal disease receiving CPD. The use of standardized diagnostic procedures, efficacious antibacterial treatment, and objective response criteria are crucial in improving the outcome of this complication. Current guidelines recommend combining a first- and third-generation cephalosporin for empiric therapy in uncomplicated cases. The initial use of a glycopeptide/third-generation cephalosporin combination should be restricted to patients with risk factors for severe disease, as defined by clinical presentation, young age (<2 years), and recent infection with a methicillin resistant micro-organism. Several risk factors for primary or relapsing peritonitis have been identified, some of which are amenable to preventive measures. These relate to catheter design and implantation technique, connection methodology, early catheter removal in refractory or relapsing peritonitis, and eradication of Staphylococcus aureus from the catheter exit site and/or nasal reservoirs in patients and their caregivers.

Topical antifungal treatment cures exit-site fungal infection

Exit-site fungal infection, although rarely reported, may be a critical complication in patients on peritoneal dialysis. There is no optimal treatment of exit-site fungal infection. We report four cases of exit-site infection with Candida parapsilosis. Four-week treatment with topical sulconazole cream was administered. Fungal infection was cured in all patients but followed by exit-site bacterial infection in two patients. The topical application of sulconazole cream is recommended for exit-site fungal infection.

Peritoneal dialysis. Prevention and control of infection

In spite of the reduction in peritonitis and catheter-related infection rates in patients undergoing peritoneal dialysis, these infections remain major sources of morbidity and transfer to haemodialysis. Touch contamination at the time of doing the exchanges is still a major cause of peritonitis and leads to Gram-positive organisms (coagulation-negative staphylococcus) being the most common pathogens. Newer exchange techniques have reduced this incidence but the more serious pathogens (Staphylococcal aureus, pseudomonas and fungi) remain a major problem. Treatment has to be immediate, and hence empirical, giving adequate cover for both Gram-positive and Gram-negative organisms. The use of vancomycin as an initial antibacterial has been discontinued because of the problem of vancomycin-resistant enterococcus. Recent guidelines advocate the use of a first generation cephalosporin combined with ceftazidime (if the urine output is >100 ml/day) or an aminoglycoside in anuric patients. Subsequent therapy changes are made upon bacterial isolation and sensitivities. Vancomycin is reserved for methicillin-resistant staphylococcus. Peritoneal catheter-related infections (exit site and tunnel) are predominantly caused by S. aureus and pseudomonal organisms and can be difficult to eradicate. Tunnel infections invariably involve the catheter dacron cuffs and therefore are more likely to lead to peritonitis; in this situation catheter removal is the treatment of choice. Treatment of exit-site infections is with oral antibacterials (penicillinase-resistant penicillins, cefalexin). Vancomycin is avoided if possible. The identification that nasal carriage of S. aureus predisposes to exit-site and tunnel infections has led to prophylactic regimens to combat this problem. Mupirocin applied at the exit site leads to a reduction in catheter-related infections and peritonitis.

Fungal peritonitis in children receiving peritoneal dialysis: a report of the NAPRTCS

BACKGROUND

The rarity of fungal peritonitis (FP) in children receiving chronic peritoneal dialysis (PD) has limited the amount of information available regarding the risk factors and management associated with this infection.

METHODS

We reviewed all cases of FP occurring in patients entered into the dialysis registry of the NAPRTCS between January 1992 and May 1996 in an attempt to identify risk factors for infection, treatment strategies, and patient outcome data. A total of 1592 patients who were less than 21 years of age were enrolled in the dialysis registry and received maintenance PD during the period of observation.

RESULTS

Of the total 1729 episodes of peritonitis in these patients occurring over 1732 patient-years of follow-up, FP accounted for 51 (2.9%) of the episodes. The patients on PD who developed FP were similar to those who did not develop FP with regard to race, gender, dialysis modality, and dialysis access characteristics. The overall peritonitis rate in patients who developed FP was 2.2 episodes per patient-year compared with 0.96 episodes per patient-year in the patients who did not develop this infection (P < 0.0001). In 25 (49%) cases, the FP was the patient's initial episode of peritonitis. Whereas recent antibiotic usage was present in 23 (56%) of 41 patients with FP, there was no statistically significant relationship (P = 0.26) noted between the presence of a gastrostomy and the development of FP. Candida species caused 33 of 42 (78.6%) FP episodes. Therapy consisted of PD catheter removal and Amphotericin B in the majority of patients. Six months after diagnosis, 27 patients remained on PD, twelve patients were receiving hemodialysis, and only three patients had died, in each case for reasons unrelated to their FP episode.

CONCLUSION

FP is an infrequent cause of peritonitis in children receiving chronic PD. The presence of a gastrostomy does not appear to predispose patients to the development of this infection, and successful therapy most often consists of a combination of antifungal medication and dialysis catheter removal. The outcome of FP in children appears to be more favorable than in the adult dialysis population.

The team approach to the management of children on chronic peritoneal dialysis

The diagnosis of chronic renal failure has a profound and lasting impact on a child and family, with the potential for impairment of the child's physical, mental, and social development. To achieve an ideal outcome, the peritoneal dialysis (PD) team must focus on preparing the child and family to perform home dialysis, prescribe the dialysis regimen most compatible with the patient's lifestyle and clearance requirements, ensure optimal nutrition, and facilitate psychosocial adaptation to PD. Close follow-up is essential for early detection, prevention, and treatment of potential complications of dialysis. A multidisciplinary team approach encompassing nursing, medicine, nutrition, and social work best suits the needs of the child and family.