A prospective randomized control study of oral nystatin prophylaxis for Candida peritonitis complicating continuous ambulatory peritoneal dialysis

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.

Peritoneal Dialysis in Critically Ill Patients: Time for a Critical Reevaluation?

Peritoneal dialysis (PD) as an AKI treatment in adults was widely accepted in critical care settings well into the 1980s. The advent of extracorporeal continuous KRT led to widespread decline in the use of PD for AKI across high-income countries. The lack of familiarity and comfort with the use of PD in critical care settings has also led to lack of use even among those receiving maintenance PD. Many critical care units reflexively convert patients receiving maintenance PD to alternative dialysis therapies at admission. Renewed interest in the use of PD for AKI therapy has emerged due to its increasing use in low- and middle-income countries. In high-income countries, the coronavirus disease 2019 (COVID-19) pandemic, saw PD for AKI used early on, where many critical care units were in crisis and relied on PD use when resources for other AKI therapy modalities were limited. In this review, we highlight advantages and disadvantages of PD in critical care settings and indications and contraindications for its use. We provide an overview of literature to support both PD treatment during AKI and its continuation as a maintenance therapy during critical illness. For AKI therapy, we further discuss establishment of PD access, PD prescription management, and complication monitoring and treatment. Finally, we discuss expansion in the use of PD for AKI therapy extending beyond its role during times of resource constraints.

Care of the hospitalised patient receiving peritoneal dialysis: Your questions answered

Peritoneal dialysis (PD) patients have higher hospitalisation rates than the general population. The hospitalisations are not always related to dialysis issues, and physicians with little or no experience with PD may be responsible for the care of these hospitalised patients. Furthermore, the hospital may not be familiar with or equipped to manage these patients. This review highlights barriers, knowledge gaps and management strategies to guide the care of hospitalised PD patients.

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.

Continuous Ambulatory Peritoneal Dialysis Peritonitis Guidelines - Consensus Statement of Peritoneal Dialysis Society of India - 2020

Continuous ambulatory peritoneal dialysis (CAPD) related peritonitis is a major cause of technique failure, morbidity, and mortality in patients on CAPD. Its prevention and management is key to success of CAPD program. Due to variability in practice, microbiological trends and sensitivity towards antibiotics, there is a need for customized guidelines for management of CAPD related peritonitis (CAPDRP) in India. With this need, Peritoneal Dialysis Society of India (PDSI) organized a structured meeting to discuss various aspects of management of CAPDRP and formulated a consensus agreement which will help in management of patients with CAPDRP.

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 children on peritoneal dialysis at a tertiary care Centre

BACKGROUND

Fungal peritonitis (FP) is an infrequent but serious complication in children undergoing peritoneal dialysis (PD). This study aimed to explore the risk factors, clinical manifestations, causative organisms, fungal susceptibility findings, and outcomes of FP in children from Saudi Arabia.

METHODS

In this case-control study, the medical records and laboratory results of paediatric patients aged 0-14 years who underwent PD were reviewed for FP episodes. All FP episodes were matched with PD-related bacterial peritonitis episodes (1:4 ratio).

RESULTS

A total of 194 episodes of PD-related peritonitis occurred between 2007 and 2017, among which 11 were FP episodes (5.6%), representing a rate of 0.03 episodes per patient-year. Of these 11 episodes, 9 were caused by Candida species (82%). Compared with the bacterial peritonitis group, the FP group had a higher proportion of patients with congenital/infantile nephrotic syndrome (p = 0.005) and those younger than 5 years of age (p = 0.001). We observed a higher rate of catheter removal in the FP group than in the bacterial peritonitis group (p <  0.001); however, 1 patient died despite catheter removal. Moreover, 75% of Candida species isolates were susceptible to fluconazole.

CONCLUSIONS

This study revealed that FP is associated with a significant risk of peritoneal membrane failure among children undergoing PD. Therefore, early diagnosis and prompt management are essential. We also found that congenital/infantile nephrotic syndrome and young age (5 years old or younger) were risk factors for FP in children undergoing PD.

Regional variation in the treatment and prevention of peritoneal dialysis-related infections in the Peritoneal Dialysis Outcomes and Practice Patterns Study

BACKGROUND

Peritoneal dialysis (PD)-related infections lead to significant morbidity. The International Society for Peritoneal Dialysis (ISPD) guidelines for the prevention and treatment of PD-related infections are based on variable evidence. We describe practice patterns across facilities participating in the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS).

METHODS

PDOPPS, a prospective cohort study, enrolled nationally representative samples of PD patients in Australia/New Zealand (ANZ), Canada, Thailand, Japan, the UK and the USA. Data on PD-related infection prevention and treatment practices across facilities were obtained from a survey of medical directors'.

RESULTS

A total of 170 centers, caring for >11 000 patients, were included. The proportion of facilities reporting antibiotic administration at the time of PD catheter insertion was lowest in the USA (63%) and highest in Canada and the UK (100%). Exit-site antimicrobial prophylaxis was variably used across countries, with Japan (4%) and Thailand (28%) having the lowest proportions. Exit-site mupirocin was the predominant exit-site prophylactic strategy in ANZ (56%), Canada (50%) and the UK (47%), while exit-site aminoglycosides were more common in the USA (72%). Empiric Gram-positive peritonitis treatment with vancomycin was most common in the UK (88%) and USA (83%) compared with 10-45% elsewhere. Empiric Gram-negative peritonitis treatment with aminoglycoside therapy was highest in ANZ (72%) and the UK (77%) compared with 10-45% elsewhere.

CONCLUSIONS

Variation in PD-related infection prevention and treatment strategies exist across countries with limited uptake of ISPD guideline recommendations. Further work will aim to understand the impact these differences have on the wide variation in infection risk between facilities and other clinically relevant PD outcomes.

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.

Risk Factors for Poor Outcome of Fungal Peritonitis in Chinese Patients on Continuous Ambulatory Peritoneal Dialysis

Objective

Fungal peritonitis is rare among end-stage renal disease patients treated with continuous ambulatory peritoneal dialysis (CAPD), but when it occurs, it is associated with a high risk of mortality and peritoneal membrane failure. In the present study, we identified risk factors for poor outcome and examined the effect of treatment profile on outcome in fungal peritonitis.

Patients and Methods

We identified cases of fungal peritonitis in CAPD patients in a regional dialysis center and analyzed the possible risk factors for poor outcome in fungal peritonitis. To estimate the amount of dextrose presented to the peritoneum, we scored the dextrose content of the peritoneal dialysis fluid used by the patient at the time of admission to hospital (1 point to each bag of 1.5% fluid, 2 points to each bag of 2.3% or 2.5% fluid, and 3 points to each bag of 4.25% fluid daily).

Results

Among 471 episodes of CAPD-related peritonitis in 7.8 years, we identified 22 episodes of fungal peritonitis (4.7%). The ratio of men to women in the fungal peritonitis group was 1.4:1. Seventeen patients (77.3%) practiced dialysis without a helper. Within the 3 months preceding the fungal peritonitis, 12 patients (55%) had had bacterial peritonitis. Among the cases of fungal peritonitis, we identified 9 cases of Candida parapsilosis and 13 cases of non C. parapsilosis. All of the patients received fluconazole, and 7 patients (31.8%) also received flucytosine. The Tenckhoff catheter was removed in 17 patients (77.3%). Eight patients (36.4%) either died or lost peritoneal function. The risk of mortality was increased if the fungal organism was C. parapsilosis [odds ratio (OR): 4.25; 95% confidence interval (CI): 1.8 to 10.0; p = 0.002], if a helper was involved (OR: 11.3; 95% CI: 1.1 to 114; p = 0.024), or if CAPD duration was more than 26 months (OR: 2.2; 95% CI: 1.3 to 3.5; p = 0.034). Addition of flucytosine to fluconazole did not significantly improve the mortality rate in either the C. parapsilosis or non C. parapsilosis group. Multivariate analysis showed that C. parapsilosis was an independent factor associated with mortality ( p = 0.013). A dextrose score greater than 5 was associated with a trend toward increased risk of peritoneal failure (OR: 3.4; 95% CI: 1.6 to 7.1; p = 0.021).

Conclusion

C. parapsilosis is an independent risk factor for mortality in fungal peritonitis.

Prevention and Treatment of Peritoneal Dialysis-Associated Peritonitis in Pediatric Patients

Peritoneal dialysis (PD) is the preferred dialysis modality in children and adolescents aged less than 15 years. Peritoneal dialysis-associated peritonitis remains a major cause of morbidity and reason for dropout from the PD program, although the incidence of peritonitis seems to have decreased during the past few years. Improved patient care, more frequent use of automated peritoneal dialysis (APD), use of PD catheters with downward facing exit sites, and Staphylococcus aureus prophylaxis account for this decline in infectious complications. With respect to the isolated micro-organism in PD-associated peritonitis, a predominance of gram-positive germs is found in children. Recent registry data suggest a decrease in coagulase-negative staphylococci, with a relative increase in gram-negative peritonitis episodes. The empiric antibiotic treatment regimen using a first-generation cephalosporin or a glycopeptide in combination with a third-generation cephalosporin in a risk-stratified manner was suggested in the pediatric peritonitis treatment guidelines. This regimen is currently being evaluated in the International Pediatric Peritonitis Registry.

Risk Factors for Developing Peritonitis Caused by Micro-Organisms of Enteral Origin in Peritoneal Dialysis Patients

Objective

To investigate the risk factors associated with the development of peritonitis caused by enteral bacteria in peritoneal dialysis patients, including the prescription of gastric acid inhibitors as a potential risk factor.

Design

Retrospective single-center study.

Setting

Tertiary university hospital.

Patients an d Main Outcome Measures

Fifty-five patients who entered into our continuous ambulatory peritoneal dialysis (CAPD) program during the last 6 years were included. Multiple logistic regression analysis was used to establish the best determinants over the development of at least one episode of enteric peritonitis. The predictive variables included in the model were: age, gender, diabetic versus nondiabetic, polycystic versus nonpolycystic kidney diseases, history of constipation, presence or absence of moderate/severe malnutrition, peritoneal transport characteristics, peritoneal protein losses, rate of exit-site infections, rate of total peritonitis, intestinal abnormalities, and treatment with inhibitors of gastric acid secretion.

Results

The total number of peritonitis episodes during the studied period was 88, which clustered in 34 of 55 patients. Fourteen (16%) were caused by enteric microorganisms in 10 patients: Escherichia coli (6), Klebsiella sp (2), Enterobacter sp (1), and Enterococcus sp (5). Nine of 10 patients who developed enteric peritonitis were on gastric acid inhibitors (3 patients on omeprazole and 6 patients on H2-antagonists), while 15 of 45 patients who did not develop enteric peritonitis were on gastric acid inhibitors (all of them on H2-blockers). There were temporal relationships between the start of gastric acid inhibitors and the development of enteric peritonitis in 6 of 9 patients who were on this medication. Four of 10 patients who developed enteric peritonitis had diverticulosis. Ten of 45 patients who did not develop enteric peritonitis had been diagnosed with diverticulosis of the colon or sigmoid prior to entry to CAPD. The unique patient who was not on gastric acid inhibitors and developed enteric peritonitis, had been diagnosed with chronic atrophic gastritis with achlorhydria. By multiple logistic regression analysis, the treatment with gastric acid inhibitors was the only independent variable that entered into the best predictive equation over the development of enteric peritonitis (Iog likelihood ratio = -26.077, odds ratio = 18; 95% CI odds ratio: 2 - 155).

Conclusion

Gastric acid inhibitors may increase the risk for developing enteric peritonitis in peritoneal dialysis patients.

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.

A Retrospective Study of Seven Cases of Candida Parapsilosis Peritonitis in CAPD Patients: The Therapeutic Implications

Background

Candida peritonitis accounts for the majority of fungal peritonitis in continuous ambulatory peritoneal dialysis (CAPD), but the Candida species were not routinely subtyped in previous studies. The clinical course and the outcome of Candida parapsilosis peritonitis remain unclear.

Objective

To study the clinical course and outcome of C. parapsilosis peritonitis in CAPD patients.

Setting

Peritoneal dialysis unit in a regional hospital.

Patients and Design

A retrospective study on seven cases of C. parapsilosis peritonitis occurring in a single center over 3 years.

Results

The 7 patients included 4 males and 3 females. Their mean age was 62 ± 11.5 years. Two (29%) were diabetic. Three (43%) had a history of preceding peritonitis and 5 (71%) had received broad spectrum antibiotic within the previous 1 month. All presented with cloudy dialysate, abdominal pain, and fever. The mean dialysate white cell count was 300 ± 168/mm3 with a predominance of neutrophils (81.4% ± 13.1%). The mean time from onset of symptoms to diagnosis was 5.7 ± 3.1 days. All had been treated with immediate catheter removal within 24 hours of diagnosis and antifungal therapy, including oral fluconazole, intravenous (IV) amphotericin, or their sequential combination. Environmental samplings were negative for C. parapsilosis. The overall complication rate was exceptionally high (71%), with three (43%) complicated by abscess formation requiring surgical drainage, one peritoneal adhesion (14%), and one mortality (14%). In the end, only two (29%) could resume CAPD.

Conclusions

The outcome of this study group appeared worse than those previously described in the literature, and the optimal treatment for this group of patients remains unclear.

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.

Infection Prophylaxis in Peritoneal Dialysis Patients: Results from an Australia/New Zealand Survey

Background

Clinical practice guidelines aim to reduce the rates of peritoneal dialysis (PD)-related infections, a common complication of PD in end-stage kidney disease patients. We describe the clinical practices used by Australian and New Zealand nephrologists to prevent PD-related infections in PD patients.

Methods

A survey of PD practices in relation to the use of antibiotic and antifungal prophylaxis in PD patients was conducted of practicing nephrologists identified via the Australia and New Zealand Society of Nephrology (ANZSN) membership in 2013.

Results

Of 333 nephrologists approached, 133 (39.9%) participated. Overall, 127 (95.5%) nephrologists prescribed antibiotics at the time of Tenckhoff catheter insertion, 85 (63.9%) routinely screened for nasal S. aureus carriage, with 76 (88.4%) reporting they treated S. aureus carriers with mupirocin ointment. Following Tenckhoff catheter insertion, 79 (59.4%) prescribed mupirocin ointment at the exit site or intranasally, and 93 (69.9%) nephrologists routinely prescribed a course of oral antifungal agent whenever their PD patients were given a course of antibiotics.

Conclusions

Although the majority of nephrologists prescribe antibiotics at the time of Tenckhoff catheter insertion, less than 70% routinely prescribe mupirocin ointment and/or prophylactic antifungal therapy. This variation in practice in Australia and New Zealand may contribute to the disparity in PD-related infection rates that is seen between units.

Peritoneal Dialysis Access Associated Infections

Infection is a significant driver of morbidity and mortality in patients with end-stage renal disease undergoing maintenance dialysis. In the United States, septicemia and other infections account for 8% deaths in patients undergoing dialysis. In patients undergoing peritoneal dialysis (PD), PD-related peritonitis remains the most frequent treatment-related infection and is the greatest contributor to infection-related morbidity, including risk for hospitalization, and temporary or permanent transfer to hemodialysis. In the 4 decades since the introduction of ambulatory PD in clinical practice, a large number of treatment innovations have been shown to be effective in reducing the risk for exit site infection and PD-related peritonitis. Notwithstanding the evidence for efficacy of these innovations and the numerous adverse health consequences with PD-related peritonitis, the uptake of these interventions in clinical practice around the world remains inconsistent. This article reviews current knowledge with regards to prevention of PD-associated infections, and the diagnosis and management of exit site infections and 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.

Fungal peritonitis in the Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) Collaborative

BACKGROUND

Fungal peritonitis is a serious complication among peritoneal dialysis (PD) patients. The Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) Collaborative is a North American multicenter quality improvement initiative with the primary aim to reduce catheter-related infections in children on chronic dialysis.

OBJECTIVE

To describe the epidemiology of fungal peritonitis and outcomes of affected patients among pediatric subjects receiving chronic PD and enrolled in SCOPE.

METHODS

Data pertaining to PD characteristics, peritonitis episodes and patient outcome were collected between October 2011 and September 2015 from 30 pediatric dialysis centers participating in the SCOPE collaborative. Peritonitis-related data were stratified by etiology, fungal versus bacterial/culture-negative peritonitis. Differences among groups were assessed by Chi-square analysis.

RESULTS

Of 994 patients enrolled in the registry, there were 511 peritonitis episodes of which 41 (8.0%) were fungal. Thirty-six individual patients with 39 unique catheters accounted for the fungal peritonitis episodes. Twenty-three (59%) of the episodes occurred in patients aged < 2 years (p = 0.03). Fungal peritonitis was the initial episode of peritonitis in 48.8% of affected patients, and only 17.1% of these patients had had a previous peritonitis episode within 30 days of the fungal infection. Insertion of the PD catheter at < 2 years of age was associated with an adjusted odds ratio of 2.8 (95% confidence interval 1.24, 6.31) for development of fungal peritonitis compared to older children (p = 0.01). Fungal peritonitis was associated with an increased rate of hospitalization (80.5 vs. 63.4%; p = 0.03), increased length of hospitalization (median of 8 vs. 5 days; p < 0.001) and increased rates of catheter removal (84.6 vs 26.9%; p = 0.001) and technique failure (68.3 vs. 8%; p = 0.001) compared to other causes of peritonitis.

CONCLUSION

Fungal infections were responsible for 8.0% of peritonitis episodes in the SCOPE collaborative, with the majority of fungal peritonitis episodes occurring in children aged < 2 years. Although no risk factors for infection other than young age were identified, fungal peritonitis was associated with an increased risk of hospitalization, longer hospital stay and an increased frequency of technique failure.

Untargeted antifungal therapy in adult patients with complicated intra-abdominal infection: a systematic review

BACKGROUND

Systematic reviews comparing untargeted antifungal treatment with placebo or no treatment in critically ill patients have provided conflicting results. We aimed to assess patient-important benefits and harms of untargeted antifungal therapy vs. placebo or no treatment in adult patients with complicated intra-abdominal infection.

METHODS

We conducted a systematic review with meta-analysis and trial sequential analysis of randomised clinical trials assessing untargeted antifungal therapy compared to placebo or no treatment in adults with complicated intra-abdominal infection. We used the Cochrane and GRADE methodologies and exclusively assessed patient-important outcomes. Two independent authors screened trials for eligibility, extracted data and assessed risk of bias. We performed conventional meta-analyses, including sensitivity and subgroup analyses, and trial sequential analysis to assess the risk of random errors and to estimate trial sequential analysis adjusted confidence intervals.

RESULTS

We included six trials (1,067 patients) in the review, and four trials reported data on the predefined outcome measures and were included in the meta-analysis. Three of the four trials had high risk of bias. We observed no statistically significant difference in mortality (relative risk 0.58, 95% confidence interval 0.24-1.39) or in any of the other patient-important outcomes between untargeted antifungal treatment and placebo or no treatment (low/very low quality of evidence). Trial sequential analysis demonstrated lack of data and high risk of random errors.

CONCLUSIONS

The quantity and quality of evidence supporting untargeted antifungal treatment in adult patients with complicated intra-abdominal infection are low to very low with no firm evidence for benefit or harm.

Oral Yeast Colonization and Fungal Infections in Peritoneal Dialysis Patients: A Pilot Study

Peritonitis and exit-site infections are important complications in peritoneal dialysis (PD) patients that are occasionally caused by opportunistic fungi inhabiting distant body sites. In this study, the oral yeast colonization of PD patients and the antifungal susceptibility profile of the isolated yeasts were accessed and correlated with fungal infection episodes in the following 4 years. Saliva yeast colonization was accessed in 21 PD patients and 27 healthy controls by growth in CHROMagar-Candida® and 18S rRNA/ITS sequencing. PD patients presented a lower oral yeast prevalence when compared to controls, namely, Candida albicans. Other species were also isolated, Candida glabrata and Candida carpophila. The antifungal susceptibility profiles of these isolates revealed resistance to itraconazole, variable susceptibility to caspofungin, and higher MIC values of posaconazole compared to previous reports. The 4-year longitudinal evaluation of these patients revealed Candida parapsilosis and Candida zeylanoides as PD-related exit-site infectious agents, but no correlation was found with oral yeast colonization. This pilot study suggests that oral yeast colonization may represent a limited risk for fungal infection development in PD patients. Oral yeast isolates presented a variable antifungal susceptibility profile, which may suggest resistance to some second-line drugs, highlighting the importance of antifungal susceptibility assessment in the clinical practice.

Antimicrobial agents for preventing peritonitis in peritoneal dialysis patients

BACKGROUND

Peritoneal dialysis (PD) is an important therapy for patients with end-stage kidney disease and is used in more than 200,000 such patients globally. However, its value is often limited by the development of infections such as peritonitis and exit-site and tunnel infections. Multiple strategies have been developed to reduce the risk of peritonitis including antibiotics, topical disinfectants to the exit site and antifungal agents. However, the effectiveness of these strategies has been variable and are based on a small number of randomised controlled trials (RCTs). The optimal preventive strategies to reduce the occurrence of peritonitis remain unclear.This is an update of a Cochrane review first published in 2004.

OBJECTIVES

To evaluate the benefits and harms of antimicrobial strategies used to prevent peritonitis in PD patients.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant's Specialised Register to 4 October 2016 through contact with the Information Specialist using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE, and EMBASE; handsearching conference proceedings; and searching the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

RCTs or quasi-RCTs in patients receiving chronic PD, which evaluated any antimicrobial agents used systemically or locally to prevent peritonitis or exit-site/tunnel infection were included.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed risk of bias and extracted data. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratio (RR) with 95% confidence intervals (CI).

MAIN RESULTS

Thirty-nine studies, randomising 4435 patients, were included. Twenty additional studies have been included in this update. The risk of bias domains were often unclear or high; risk of bias was judged to be low in 19 (49%) studies for random sequence generation, 12 (31%) studies for allocation concealment, 22 (56%) studies for incomplete outcome reporting, and in 12 (31%) studies for selective outcome reporting. Blinding of participants and personnel was considered to be at low risk of bias in 8 (21%) and 10 studies (26%) for blinding of outcome assessors. It should be noted that blinding of participants and personnel was not possible in many of the studies because of the nature of the intervention or control treatment.The use of oral or topical antibiotic compared with placebo/no treatment, had uncertain effects on the risk of exit-site/tunnel infection (3 studies, 191 patients, low quality evidence: RR 0.45, 95% CI 0.19 to 1.04) and the risk of peritonitis (5 studies, 395 patients, low quality evidence: RR 0.82, 95% CI 0.57 to 1.19).The use of nasal antibiotic compared with placebo/no treatment had uncertain effects on the risk of exit-site/tunnel infection (3 studies, 338 patients, low quality evidence: RR 1.34, 95% CI 0.62 to 2.87) and the risk of peritonitis (3 studies, 338 patients, low quality evidence: RR 0.94, 95% CI 0.67 to 1.31).Pre/perioperative intravenous vancomycin compared with no treatment may reduce the risk of early peritonitis (1 study, 177 patients, low quality evidence: RR 0.08, 95% CI 0.01 to 0.61) but has an uncertain effect on the risk of exit-site/tunnel infection (1 study, 177 patients, low quality evidence: RR 0.36, 95% CI 0.10 to 1.32).The use of topical disinfectant compared with standard care or other active treatment (antibiotic or other disinfectant) had uncertain effects on the risk of exit-site/tunnel infection (8 studies, 973 patients, low quality evidence, RR 1.00, 95% CI 0.75 to 1.33) and the risk of peritonitis (6 studies, 853 patients, low quality evidence: RR 0.83, 95% CI 0.65 to 1.06).Antifungal prophylaxis with oral nystatin/fluconazole compared with placebo/no treatment may reduce the risk of fungal peritonitis occurring after a patient has had an antibiotic course (2 studies, 817 patients, low quality evidence: RR 0.28, 95% CI 0.12 to 0.63).No intervention reduced the risk of catheter removal or replacement. Most of the available studies were small and of suboptimal quality. Only six studies enrolled 200 or more patients.

AUTHORS' CONCLUSIONS

In this update, we identified limited data from RCTs and quasi-RCTs which evaluated strategies to prevent peritonitis and exit-site/tunnel infections. This review demonstrates that pre/peri-operative intravenous vancomycin may reduce the risk of early peritonitis and that antifungal prophylaxis with oral nystatin or fluconazole reduces the risk of fungal peritonitis following an antibiotic course. However, no other antimicrobial interventions have proven efficacy. In particular, the use of nasal antibiotic to eradicate Staphylococcus aureus, had an uncertain effect on the risk of peritonitis and raises questions about the usefulness of this approach. Given the large number of patients on PD and the importance of peritonitis, the lack of adequately powered and high quality RCTs to inform decision making about strategies to prevent peritonitis is striking.

The Current State of Peritoneal Dialysis

Technical innovations in peritoneal dialysis (PD), now used widely for the long-term treatment of ESRD, have significantly reduced therapy-related complications, allowing patients to be maintained on PD for longer periods. Indeed, the survival rate for patients treated with PD is now equivalent to that with in-center hemodialysis. In parallel, changes in public policy have spurred an unprecedented expansion in the use of PD in many parts of the world. Meanwhile, our improved understanding of the molecular mechanisms involved in solute and water transport across the peritoneum and of the pathobiology of structural and functional changes in the peritoneum with long-term PD has provided new targets for improving efficiency and for intervention. As with hemodialysis, almost half of all deaths on PD occur because of cardiovascular events, and there is great interest in identifying modality-specific factors contributing to these events. Notably, tremendous progress has been made in developing interventions that substantially reduce the risk of PD-related peritonitis. Yet the gains have been unequal among individual centers, primarily because of unequal clinical application of knowledge gained from research. The work to date has further highlighted the areas in need of innovation as we continue to strive to improve the health and outcomes of patients treated with PD.

Oral yeast colonization in peritoneal dialysis and hemodialysis patients and renal transplant recipients

OBJECTIVE

We aimed to investigate the frequency of oral yeast colonization (OYC) and the risk factors for patients who received continuous ambulatory peritoneal dialysis (CAPD) or hemodialysis (HD) or were renal transplant recipients (RTRs). The patients admitted to the Nephrology Clinic at Ataturk University Medical School from January through April 2013 were included in the study. A questionnaire about risk factors was filled out, and swab cultures were taken from the tongue surface of each participant. OYC was detected in 32.1% of the RTRs, 40% of the HD patients, 20.9% of the CAPD patients, and 18% of the healthy control (HC) group. Of the 42 yeast strains isolated from the renal replacement therapy groups, 26 strains (61.9%) were Candida albicans, nine (21.4%) were Candida glabrata, two (4.7%) were Candida krusei, two (4.7%) were Candida kefyr, one (2.38%) was Candida parapsilosis, and two (4.7%) were Geotrichum candidum. Risk factors for OYC in the RTRs group included antibiotic use and the presence of dental prostheses; however, in patients with chronic renal failure undergoing CAPD, only the presence of dental prostheses was found to be a statistically significant risk factor. Although OYC was mostly detected in patients with chronic kidney disease (undergoing HD, a variety of isolated yeast strains in the RTRs was noted. The rates of OYC and isolated Candida species in CAPD were similar to those of the HC group.

Fungal peritonitis in continuous ambulatory peritoneal dialysis: The impact of antifungal prophylaxis on patient and technique outcomes

Fungal peritonitis (FP) is a rare, but serious complication of peritoneal dialysis. We analyzed the incidence of FP, associated risk factors and outcome of patients with FP and evaluated the role of prophylactic antifungal agent in reducing its incidence. We studied all patients with FP from January 2005 to January 2012. Study period was divided into two parts, period I (January 2005 to January 2010), when prophylactic antifungal was not used and period II (January 2010 to January 2012), when prophylactic antifungal (fluconazole) was used. A total of 142 episodes of peritonitis were documented during this period of which 20 (14%) were FP. During the study period I, 18 of 102 episodes of peritonitis (17.6%) and in the study period II (with antifungal prophylaxis), only 2 of 40 episodes of peritonitis (5%) were due to fungal infection (P = 0.04). Nine out of 20 patients (45%) had prior exposure to antibiotics. Fungal isolates were Candida albicans in 65%, non-albicans Candida in 25%, Rhizopus species in 5% and Alternaria in 5% of the patients. While 12 out of 20 patients (60%) recovered completely and were re-initiated on continuous ambulatory peritoneal dialysis (CAPD), 4 of them expired (20%) and 4 others (20%) were shifted to hemodialysis. Use of prophylactic antifungal agent significantly reduced the incidence of FP (P = 0.04). We conclude that - fluconazole when used as a prophylactic agent in the setting of bacterial peritonitis significantly reduces the incidence of subsequent FP in CAPD patients.

Peritoneal dialysis-related peritonitis: towards improving evidence, practices, and outcomes

Peritonitis is a common serious complication of peritoneal dialysis that results in considerable morbidity, mortality, and health care costs. It also significantly limits the use of this important dialysis modality. Despite its importance as a patient safety issue, peritonitis practices and outcomes vary markedly and unacceptably among different centers, regions, and countries. This article reviews peritonitis risk factors, diagnosis, treatment, and prevention, particularly focusing on potential drivers of variable practices and outcomes, controversial or unresolved areas, and promising avenues warranting further research. Potential strategies for augmenting the existing limited evidence base and reducing the gap between evidence-based best practice and actual practice also are discussed.

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.

Non-candidal fungal peritonitis in Far North Queensland: a case series

BACKGROUND

Fungal peritonitis is a recognized complication in patients with end-stage renal failure treated with peritoneal dialysis (PD). Most infections are attributable to Candida species. In approximately one third of cases, the causative fungus is a non-Candida species. Recent reports in the literature show a rising incidence of non-candidal fungal peritonitis (NCFP). We report a case series of NCFP, together with two hitherto unreported species of fungi causing peritonitis, from a tropical geographic area (Far North Queensland).

METHODS

This series of 10 cases of NCFP was identified from the PD peritonitis database in Far North Queensland between 1998 and 2010. All 10 patients were from the Aboriginal and Torres Strait Islander ethnic group, 8 of whom lived in remote locations. All but 1 patient had type 2 diabetes mellitus. Of the 10 cases, 7 occurred while the patients received continuous ambulatory PD. Only 1 patient avoided catheter removal, and 5 patients were permanently transferred to hemodialysis. No patient died as a result of the fungal infection. All 10 fungi represented different species. Most (6 of 10) were saprophytic; only 2 were normal skin flora. Two of the causative species (Chaetomium and Beauveria) have rarely been associated with any form of human infection. In 7 patients, the infection occurred during the wet season (November - April). All cases met clinical criteria for peritonitis.

DISCUSSION AND CONCLUSIONS

The NCFP cases described in this series involved a variety of previously known fungal species and also two new species that have not been reported to cause disease in humans. Indigenous patients from Far North Queensland are particularly predisposed to infection with these exotic fungi as a result of environmental and social factors. Further understanding is desirable to help devise preventive strategies to avoid the consequences of catheter failure.

Long-term peritoneal dialysis experience: quality control supports the use of fluconazole to prevent fungal peritonitis

BACKGROUND

Fungal peritonitis (FP) is rare, but it is associated with high morbidity and mortality.

PATIENTS AND METHODS

A prospective study was conducted based on the peritonitis episodes registry to evaluate FP rate, possible risk factors, and outcomes. The impact of prophylactic intervention with oral fluconazole was evaluated.

RESULTS

Over 24 years of experience, 417 patients underwent peritoneal dialysis (PD), followed for 956 patient-years. By the end of the study, the peritonitis rate reached 0.47 episodes per patient-year of treatment (ep/pt-y). FP was detected in 24 patients. The global rate of FP was 0.03 ep/pt-y (4.8%). Candida species accounted for 92% of the FP. Risk factors identified: recent use of antibiotics in 63% (13 episodes of bacterial peritonitis and 2 exit-site infections (ESI)) and immunosuppressive therapy in 8%. While rare, the FP proportion was still observed to increase from the beginning of the program, reaching 7.8% (0.05 ep/pt-y). A strategy of antifungal prophylaxis with oral fluconazole during peritonitis or ESI antibiotic therapy was adopted, which allowed thereafter a 4.0% falling FP proportion (by study end, rate of 0.01 ep/pt-y). Catheter removal occurred in all patients. The mortality rate was 12.5%. Reinsertion of dialysis catheter was attempted in 4 patients and PD was successfully resumed in 3 patients.

CONCLUSIONS

FP was associated with high mortality and required early removal of the catheter in all patients. Recent use of antibiotics was a predisposing factor to PF. The quality control process determined a prophylactic strategy and reduction of PF after introduction of oral fluconazole was implemented.

Effects of climatic region on peritonitis risk, microbiology, treatment, and outcomes: a multicenter registry study

BACKGROUND

The impact of climatic variations on peritoneal dialysis (PD)-related peritonitis has not been studied in detail. The aim of the current study was to determine whether various climatic zones influenced the probability of occurrence or the clinical outcomes of peritonitis.

METHODS

Using ANZDATA registry data, the study included all Australian patients receiving PD between 1 October 2003 and 31 December 2008. Climatic regions were defined according to the Köppen classification.

RESULTS

The overall peritonitis rate was 0.59 episodes per patient-year. Most of the patients lived in Temperate regions (65%), with others residing in Subtropical (26%), Tropical (6%), and Other climatic regions (Desert, 0.6%; Grassland, 2.3%). Compared with patients in Temperate regions, those in Tropical regions demonstrated significantly higher overall peritonitis rates and a shorter time to a first peritonitis episode [adjusted hazard ratio: 1.15; 95% confidence interval (CI): 1.01 to 1.31]. Culture-negative peritonitis was significantly less likely in Tropical regions [adjusted odds ratio (OR): 0.42; 95% CI: 0.25 to 0.73]; its occurrence in Subtropical and Other regions was comparable to that in Temperate regions. Fungal peritonitis was independently associated with Tropical regions (OR: 2.18; 95% CI: 1.22 to 3.90) and Other regions (OR: 3.46; 95% CI: 1.73 to 6.91), where rates of antifungal prophylaxis were also lower. Outcomes after first peritonitis episodes were comparable in all groups.

CONCLUSIONS

Tropical regions were associated with a higher overall peritonitis rate (including fungal peritonitis) and a shorter time to a first peritonitis episode. Augmented peritonitis prophylactic measures such as antifungal therapy and exit-site care should be considered in PD patients residing in Tropical climates.

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.