Extended antibiotic therapy for the prevention of relapsing and recurrent peritonitis in peritoneal dialysis patients: a randomized controlled trial

Clinical practice guideline for the prevention and management of peritoneal dialysis associated infections in children: 2024 update

Infection-related complications remain the most significant cause for morbidity and technique failure in infants, children and adolescents who receive maintenance peritoneal dialysis (PD). The 2024 update of the Clinical Practice Guideline for the Prevention and Management of Peritoneal Dialysis Associated Infection in Children builds upon previous such guidelines published in 2000 and 2012 and provides comprehensive treatment guidance as recommended by an international group of pediatric PD experts based upon a review of published literature and pediatric PD registry data. The workgroup prioritized updating key clinical issues contained in the 2012 guidelines, in addition to addressing additional questions developed using the PICO format. A variety of new guideline statements, highlighted by those pertaining to antibiotic therapy of peritonitis as a result of the evolution of antibiotic susceptibilities, antibiotic stewardship and clinical registry data, as well as new clinical benchmarks, are included. Recommendations for future research designed to fill important knowledge gaps are also provided.

Rare Pathogens in Peritoneal Dialysis-Associated Peritonitis: A Comprehensive Case Study and Guideline Review

BACKGROUND Peritoneal dialysis (PD) serves as a critical renal replacement therapy for individuals with end-stage renal disease (ESRD), leveraging the peritoneum for fluid and substance exchange. Despite its effectiveness, PD is marred by complications such as peritonitis, which significantly impacts patient outcomes. The novelty of our report lies in the presentation of a rare case of PD-associated peritonitis caused by 2 unusual pathogens, emphasizing the importance of rigorous infection control measures. CASE REPORT We report on an 80-year-old African-American female patient with ESRD undergoing PD, who was admitted twice within 8 months for non-recurring episodes of peritonitis. These episodes were attributed to the rare pathogens Achromobacter denitrificans/xylosoxidans and Carbapenem-resistant Acinetobacter baumannii. Despite presenting with similar symptoms during each episode, such as abdominal pain and turbid dialysis effluent, the presence of these uncommon bacteria highlights the intricate challenges in managing infections associated with PD. The treatment strategy encompassed targeted antibiotic therapy, determined through susceptibility testing. Notably, the decision to remove the PD catheter followed extensive patient education, ensuring the patient comprehended the rationale behind this approach. This crucial step, along with the subsequent shift to hemodialysis, was pivotal in resolving the infection, illustrating the importance of patient involvement in the management of complex PD-related infections. CONCLUSIONS This case underscores the complexities of managing PD-associated peritonitis, particularly with uncommon and resistant bacteria. It emphasizes the importance of rigorous infection control measures, the need to consider atypical pathogens, and the critical role of patient involvement in treatment decisions. Our insights advocate for a more informed approach to handling such infections, aiming to reduce morbidity and improve patient outcomes. The examination of the literature on recurrent peritonitis and treatment strategies provides key perspectives for navigating these challenging cases effectively.

Persistent peritonitis in peritoneal dialysis: a comphrenesive review of recurrent, relapsing, refractory, and repeat peritonitis

Peritonitis is a major cause of morbidity and technique failure in patients receiving peritoneal dialysis. Complicated peritonitis that manifests as multiple or unresolving episodes is classified as refractory, recurrent, relapsing, or repeat peritonitis, and often possesses higher risk of technique failure and mortality as well as lower complete cure rates than primary or uncomplicated episodes. While these peritonitis subtypes affect a considerable portion of PD patients, details regarding their epidemiology, pathogenesis, diagnosis, clinical sequelae, and management have not yet been fully elucidated. Improved clinical awareness and understanding of complicated peritonitis subtypes is crucial to ensure optimal management for these patients; thus, we consolidate and report the pertinent findings of recent literature on these four entities.

Recurrent peritonitis relapse in a patient with atrial septal defect undergoing peritoneal dialysis: a case report

BACKGROUND

Peritonitis is the most common complication in patients undergoing peritoneal dialysis (PD). Most patients recover with appropriate antibiotic treatment; however, when peritonitis repeatedly relapses, the cause of recurrence must be explored. The relationship between atrial septal defect (ASD), infective endocarditis (IE), and peritonitis is rarely reported. Here, we present a case of recurrent peritonitis due to Staphylococcus aureus in a patient with ASD and IE undergoing PD.

CASE PRESENTATION

A 46-year-old woman with chronic renal failure secondary to chronic glomerulonephritis experienced three episodes of peritonitis within 80 days of starting PD. The patient had a history of untreated ASD without symptoms. After undergoing PD for approximately 35 days, the patient was admitted to our hospital on April 5, 2016, due to abdominal pain and fever for 1 week (maximum temperature of 38.5 °C) accompanied by chills and shivering. The PD effluent from the time of her admission was positive for S. aureus. Thereafter, peritonitis recurred each month. When the third episode of peritonitis occurred, transthoracic echocardiography was performed, and a vegetation measuring 9.5 × 6.4 mm attached to the surface of the right ventricle around the ventricular septal membrane was identified. Finally, the patient was diagnosed with IE. Then, ASD repair surgery was successfully performed after the infection was controlled. The patient was followed up for 5 years, with no further episodes of recurrence.

CONCLUSIONS

When a patient with ASD undergoing PD develops peritonitis, especially relapsing peritonitis, the possibility of IE is significantly increased. ASD repair surgery may be an important contributing factor to prevent peritonitis recurrence.

Treatment and outcomes of peritonitis due to Rothia species in patients on peritoneal dialysis: A systematic review and multicentre registry analysis

Peritoneal dialysis (PD)-associated peritonitis remains a severe complication of PD. Although peritonitis due to Rothia spp. is rare, the treatment recommendations and outcomes are uncertain. Our study aims to review (1) published literature on peritonitis caused by Rothia spp. and (2) reported cases of peritonitis due to Rothia spp. in patients on PD in Australia and New Zealand. A literature search of PubMed, Scopus, Embase and Google Scholar for articles published between January 1949 and February 2022 was conducted. To be eligible, articles had to describe antibiotic therapy and treatment outcomes in all PD patients for peritonitis caused by Rothia or Stomatococcus spp. Data from the Australia and New Zealand Dialysis and Transplant (ANZDATA) registry of PD patients who developed peritonitis due to Rothia spp. between July 2011 and May 2020 were also reviewed. A total of 12 articles and 28 episodes were identified from the literature search and ANZDATA registry analysis, respectively. Over 60% of the peritonitis cases due to Rothia spp. were from the Rothia mucilaginosa species (8/12 and 17/28, respectively), while Rothia dentocariosa was the second most commonly identified species in both the literature search and the ANZDATA registry analysis (4/12 and 5/28, respectively). A majority 8 (66.7%) of the articles in the literature search employed a combination antibiotic regimen, while the remaining 4 (33.3%) used a single antibiotic regimen. In contrast, most of the episodes, 22 (78.6%) described in the ANZDATA registry analysis, employed a single antibiotic regimen, and only 6 (21.4%) episodes were treated with a combination antibiotic regimen. The duration of antibiotic therapy ranged from 2 to 3 weeks in the literature search, and 1 to 3 weeks in the ANZDATA registry. While no deaths within 30 days of developing peritonitis were reported, catheter removal was reported in three (25%) and two (7.1%) episodes in both the literature search and the ANZDATA registry analysis, respectively, of which the majority occurred in patients treated for ≤2 weeks. PD-associated peritonitis due to Rothia spp. is uncommon and associated with relatively good outcomes. Antibiotic treatment for 3 weeks is associated with better outcomes.

Excessive risk and poor outcome of hospital-acquired peritoneal dialysis-related peritonitis

Background

Peritoneal dialysis (PD) is a home-based renal replacement therapy. Since hospital staff are not often familiar with PD and its complications, PD patients may have an excess risk of developing PD-related peritonitis during hospital admission for unrelated reasons, and the outcome may be affected.

Methods

We reviewed 371 episodes of hospital-acquired PD-peritonitis in our center from 2000 to 2019. Their clinical characteristics and outcome were compared to 825 episodes that required hospital admission, and 1964 episodes that were treated as out-patient.

Result

Hospitalized PD patients had a significantly higher risk of developing peritonitis than out-patient ones (incident rate ratio 4.41, 95% confidence interval [CI] 3.95–4.91). Hospital-acquired peritonitis episodes were more commonly culture negative. Bacterial isolates from the hospital acquired episodes were more likely resistant to ceftazidime (p < 0.0001) than the other groups. The primary response rate, complete cure rate, and overall mortality of the hospital-acquired episode were 66.6%, 62.0%, and 23.2% respectively, all worse than episodes that developed outside the hospital (p < 0.0001 for all).

Conclusion

PD patients admitted to the hospital had a 4-fold increase in the risk of developing peritonitis. Hospital-acquired peritonitis episodes were more likely culture negative, be resistant to antibiotics. They also had a lower primary response rate, lower complete cure rate, and a higher mortality than episodes that developed outside hospital.

Pharmacokinetics and Pharmacodynamics of Fungal Defensin NZX Against Staphylococcus aureus-Induced Mouse Peritonitis Model

Staphylococcus aureus (S. aureus) is one of the most common pathogenic bacteria responsible for causing a life-threatening peritonitis disease. NZX, as a variant of fungal defensin plectasin, displayed potent antibacterial activity against S. aureus. In this study, the antibacterial and resistance characteristics, pharmacokinetics, and pharmacodynamics of NZX against the S. aureus E48 and S. aureus E48-induced mouse peritonitis model were studied, respectively. NZX exhibited a more rapid killing activity to S. aureus (minimal inhibitory concentration, 1 μg/ml) compared with linezolid, ampicillin and daptomycin, and serial passaging of S. aureus E48 for 30 days at 1/2 × MIC, NZX had a lower risk of resistance compared with ampicillin and daptomycin. Also, it displayed a high biocompatibility and tolerance to physiological salt, serum environment, and phagolysosome proteinase environment, except for acid environment in phagolysosome. The murine serum protein-binding rate of NZX was 89.25% measured by ultrafiltration method. Based on the free NZX concentration in serum after tail vein administration, the main pharmacokinetic parameters for T_1/2, C_max, V_d, MRT, and AUC ranged from 0.32 to 0.45 h, 2.85 to 20.55 μg/ml, 1469.10 to 2073.90 ml/kg, 0.32 to 0.56 h, and 1.11 to 8.89 μg.h/ml, respectively. Additionally, the in vivo pharmacodynamics against S. aureus demonstrated that NZX administrated two times by tail vein at 20 mg/kg could rescue all infected mice in the lethal mouse peritonitis model. And NZX treatment (20 mg/kg) significantly reduced CFU counts in the liver, lung, and spleen, especially for intracellular bacteria in the peritoneal fluid, which were similar or superior to those of daptomycin. In vivo efficacies of NZX against total bacteria and intracellular bacteria were significantly correlated with three PK/PD indices of ƒAUC/MIC, ƒC_max/MIC, and ƒT% > MIC analyzed by a sigmoid maximum-effect model. These results showed that NZX may be a potential candidate for treating peritonitis disease caused by intracellular S. aureus.

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.