The use of intracatheter instillation of streptokinase in the treatment of recurrent bacterial peritonitis in continuous ambulatory peritoneal dialysis

Initial Treatment of Dialysis Associated Peritonitis: A Controlled Trial of Vancomycin versus Cefazolin

Objective

To determine if intraperitoneal administration of vancomycin (a slowly absorbed antibiotic) im proves the management of dialysis-associated peritonitis over that obtained by using cefazolin, an equally potent, rapidly absorbed antibiotic.

Setting

A university operated teaching hospital, with patient treatment initiated at home.

Patients

One hundred thirty-one patients trained to perform peritoneal dialysis (CAPD and CCPD) and followed at the University of Iowa Hospitals and Clinics Home Dialysis Treatment Center.

Design

Patients were prospectively allocated into groups adding either vancomycin 25 mgm/L, orcefazolin 50 mgm/L to their dialysate when signs or symptoms of peritonitis developed. Treatment results were analysed using chi-square testing.

Findings

Compared to cefazolin, initial peritonitis therapy with vancomycin improved the peritonitis resolution rate [67% vs 81 %; p=0.008], reduced the incidence of hospital admissions [68% vs 48%; p=0.001], and decreased the risk of superinfection [4% vs 0%; p=0.039].

Conclusion

Vancomycin appeared to be superior to cefazolin in the treatment of peritoneal dialysis associated peritonitis.

Campylobacter Jejuni Peritonitis During Chronic Ambulatory Peritoneal Dialysis (CAPD)

A patient treated with chronic ambulatory peritoneal dialysis developed recurrent peritonitis. During a fourth episode, Campylobacter jejuni was cultured from the dialysate. She responded well to streptokinase and imipenem.

Streptokinase Therapy for Occluded Tenckhoff Catheters in Children on CAPO

Streptokinase was infused through the partially thrombosed Tenckhoff catheters of four children on continuous ambulatory peritoneal dialysis (CAPD). Radiographic contrast studies performed before and after the infusions demonstrated dramatic dissolution of the fibrin thrombi associated with restoration of normal catheter function. The catheters subsequently functioned for an average of 12.5 months. No allergic or hemorrhagic complications were noted in association with the infusions. Coagulation studies revealed no evidence for systemic streptokinase absorption. We suggest that streptokinase, when given in the manner described, is a safe and effective treatment of thrombosed Tenckhoff catheters in children.

Successful use of recombinant tissue plasminogen activator in a patient with relapsing peritonitis

Intraperitoneal (IP) administration of either streptokinase (SK) or urokinase (UK) has assumed an adjunctive role to antibiotic therapy in selected patients with relapsing peritonitis. In these circumstances, bacteria may be protected from antibiotics through sequestration in either fibrinous structures or biofilms within the lumen of the peritoneal dialysis (PD) catheter or the peritoneal cavity. In some cases, it appears that disruption of these sheltered microenvironments by thrombolytic agents facilitated eradication of the offending organism and obviated the need for catheter removal, replacement, or interim hemodialysis. Although IP SK has been generally well tolerated as additive therapy in relapsing peritonitis, sporadic reports of significant complications, such as abdominal pain, fever, and severe hypotension, have precluded its more widespread acceptance. The only other thrombolytic agent used in this setting, UK, is presently unavailable because of a manufacturing shortfall. Therefore, adjunctive thrombolytic therapy for relapsing peritonitis is currently restricted. To circumvent these limitations, we devised an IP tissue plasminogen activator (tPA) protocol to eliminate recurring infection in a patient undergoing chronic ambulatory PD. After a third episode of peritonitis caused by Enterobacter cloacae, treated twice previously with an adequate antibiotic regimen, we instilled 6 mL of tPA (1 mg/mL) into the PD catheter for a 2-hour dwell time. The treatment was well tolerated and, in conjunction with a third course of antibiotic therapy, has produced an infection-free interval of 8 months.

Intraperitoneal thrombolytic therapy for peritoneal dialysis-associated peritonitis

OBJECTIVE

To review the literature pertaining to the use of adjunctive thrombolytic therapy for the treatment of peritoneal dialysis-associated peritonitis (PDAP).

DATA SOURCES

A MEDLINE search was conducted (January 1966-December 1997) to find articles using the terms peritonitis, peritoneal dialysis, and each thrombolytic drug. References from these articles were then reviewed to identify further sources.

DATA EXTRACTION

Representative case reports and clinical trials are summarized in this report. Information regarding thrombolytic dosing, administration techniques, and reported efficacy rates are included from both case reports and clinical trials.

DISCUSSION

Thrombolytic agents administered intraperitoneally appear to facilitate antibiotic penetration into the biofilm formed by certain bacteria. Numerous case reports of intraperitoneal thrombolytic adjunctive therapy for recurrent or persistent PDAP have indicated that these agents may have a role in the treatment of selected patients. Urokinase and streptokinase are the only thrombolytics that have been studied. They appear to have similar efficacy, but the adverse drug event rate with streptokinase is unacceptably high. The efficacy of therapy with urokinase is probably inferior to removal of the peritoneal dialysis catheter, but, if successful, allows for the continuation of peritoneal dialysis therapy.

CONCLUSIONS

In conjunction with appropriate antibiotic therapy, intraperitoneal instillation of urokinase should be reserved for patients who develop two or more episodes of recurrent or persistent PDAP in the absence of poor compliance and in whom dialysis catheter removal should be avoided (i.e., they cannot tolerate hemodialysis).

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.