Short course ciprofloxacin therapy for CAPD peritonitis

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.

Poor Response to Oral Ciprofloxacin in the Treatment of Peritonitis in Patients on Intermittent Peritoneal Dialysis

Objectives

To assess the clinical value of oral ciprofloxacin in the treatment of peritonitis in an intermittent peritoneal dialysis (IPD) population.

Design

Open nonrandomized prospective study.

Setting

Nephrology Peritoneal Dialysis Unit in a tertiary care, teaching hospital of the University of Toronto.

Patients

Subjects were participants of the IPD program with an acute episode of peritonitis defined as at least two of the following: 1. signs and symptoms of peritonitis, 2. cloudy peritoneal fluid with a white blood cell count of >100!IJl, 3. demonstration of bacteria in peritoneal effluent by gram stain or culture. Ten patients were enrolled in the study, but two were withdrawn because of side effects and growth of a resistant bacteria.

Interventions

Ciprofloxacin 750 mg po q12h for 2 doses, then 750 mg daily or 500 mg twice daily for 10 days.

Main Outcome Measures

Efficacy was determined by clinical and microbiological assessment. Cure was defined as resolution of signs and symptoms with eradication of the causative organism. Peritoneal effluent and blood samples were analyzed for ciprofloxacin concentration.

Results

Ciprofloxacin was effective in treating only one of ten episodes of peritonitis. Seven patients were defined as microbiological failures (persistence or relapse of organisms). The signs and symptoms of peritonitis improved in 2 patients, but the remaining 5 failed clinically. Only Gram-positive organisms were cultured.

Conclusions

Ciprofloxacin cannot be recommended for the treatment of intermittent peritoneal dialysis related Gram-positive bacterial peritonitis.

Ciprofloxacin. An updated review of its pharmacology, therapeutic efficacy and tolerability

Ciprofloxacin is a broad spectrum fluoroquinolone antibacterial agent. Since its introduction in the 1980s, most Gram-negative bacteria have remained highly susceptible to this agent in vitro; Gram-positive bacteria are generally susceptible or moderately susceptible. Ciprofloxacin attains therapeutic concentrations in most tissues and body fluids. The results of clinical trials with ciprofloxacin have confirmed its clinical efficacy and low potential for adverse effects. Ciprofloxacin is effective in the treatment of a wide variety of infections, particularly those caused by Gram-negative pathogens. These include complicated urinary tract infections, sexually transmitted diseases (gonorrhoea and chancroid), skin and bone infections, gastrointestinal infections caused by multiresistant organisms, lower respiratory tract infections (including those in patients with cystic fibrosis), febrile neutropenia (combined with an agent which possesses good activity against Gram-positive bacteria), intra-abdominal infections (combined with an antianaerobic agent) and malignant external otitis. Ciprofloxacin should not be considered a first-line empirical therapy for respiratory tract infections if penicillin-susceptible Streptococcus pneumoniae is the primary pathogen; however, it is an appropriate treatment option in patients with mixed infections (where S. pneumoniae may or may not be present) or in patients with predisposing factors for Gram-negative infections. Clinically important drug interactions involving ciprofloxacin are well documented and avoidable with conscientious prescribing. Recommended dosage adjustments in patients with impaired renal function vary between countries; major adjustments are not required until the estimated creatinine clearance is < 30 ml/min/1.73m2 (or when the serum creatinine level is > or = 2 mg/dl). Ciprofloxacin is one of the few broad spectrum antibacterials available in both intravenous and oral formulations. In this respect, it offers the potential for cost savings with sequential intravenous and oral therapy in appropriately selected patients and may allow early discharge from hospital in some instances. In conclusion, ciprofloxacin has retained its excellent activity against most Gram-negative bacteria, and fulfilled its potential as an important antibacterial drug in the treatment of a wide range of infections. Rational prescribing will help to ensure the continued clinical usefulness of this valuable antimicrobial drug.

Activity of quinolones against gram-positive cocci: clinical features

The potential role of the commercially available fluoroquinolones in the treatment of Gram-positive infections is discussed on the basis of data obtained from animal experiments and clinical trials. In respiratory tract infections, and particularly in community-acquired pneumonia, it is evident that the presently available quinolones cannot be prescribed empirically as first-line therapy because of their borderline activity against Streptococcus pneumoniae and anaerobes. Reports of pneumococcal seeding in other tissues during quinolone therapy render their administration a debatable issue. Experience in endocarditis is limited to the use of ciprofloxacin plus rifampicin in intravenous drug users with right-sided Staphylococcus aureus endocarditis. Patients with staphylococcal osteomyelitis are included among cases of other bone infections. In noncontrolled studies ciprofloxacin, ofloxacin and pefloxacin attained a staphylococcal eradication rate ranging from 70 to 100%, while the addition of rifampicin has been proven to reduce the emergence of resistant mutants during therapy. In soft tissue and skin structure infections that also involve Gram-negative bacteria, ciprofloxacin and ofloxacin eradicated 72.6 and 89% of staphylococci, respectively; however, the presence of diabetes or vascular disease compromised the success of treatment. In staphylococcal peritonitis complicating continuous ambulatory peritoneal dialysis, results with ciprofloxacin given intravenously or intraperitoneally were promising. In infections in neutropenic hosts, success of prophylaxis or therapy is still not clear, since colonisation and breakthrough bacteraemias with viridans streptococci and staphylococci have been reported. Furthermore, therapeutic results are compromised by the low response rate in Gram-positive infections. Despite the reported clinical efficacy of the newer fluoroquinolones, physicians should be alerted to the emergence of staphylococci resistant to fluoroquinolones, mainly methicillin-resistant variants.

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.

Infectious consequences of continuous ambulatory peritoneal dialysis

The peritoneal cavity of patients undergoing CAPD is critically immunocompromised and infectious peritonitis is the most important complication of the technique. Nevertheless, recent research into the epidemiology and pathogenesis of infections caused by the most important microorganisms has enabled significant reductions in peritonitis rates to be made. Peritonitis caused by Staphylococcus aureus and Pseudomonas aeruginosa can be prevented by eliminating their principal source, an infected Tenckhoff catheter wound. The source of infection for coagulase-negative staphylococci and other pseudomonads cannot be eliminated, but peritonitis caused by these organisms may be prevented by interrupting their routes of entry into the peritoneal cavity. The identification of host factors predictive of enhanced susceptibility to infectious peritonitis offers the further possibility of prevention by immunological approaches. Although the main difficulties surrounding the diagnosis of infective peritonitis have been clarified, approximately 20% of episodes remain culture-negative, with multifactorial aetiology. Initial (empirical) combination antibiotic therapy can be both appropriate and effective in approximately 85% of cases. Intraperitoneal monotherapy with fluoroquinolones has been equally successful, and these agents may prove effective by the oral route, offering considerable advantages in cost and convenience. Approximately 5% of episodes of bacterial peritonitis are unresponsive to antibiotic therapy. These cases may be conveniently managed by the technique of Tenckhoff catheter removal and replacement at a single operation.