Changes in Causative Organisms and Their Antimicrobial Susceptibilities in Capd Peritonitis: A Single Center's Experience over one Decade

Background

In recent years, the rate of peritonitis during continuous ambulatory peritoneal dialysis (CAPD) has been significantly reduced. However, peritonitis remains a major complication of CAPD, accounting for considerable mortality and hospitalization among CAPD patients.

Objective

To generate a “center tailored” treatment protocol for CAPD peritonitis by examining the changes of causative organisms and their susceptibilities to antimicrobial agents over the past 10 years.

Method

Retrospective review of the medical records of 1015 CAPD patients (1108 episodes of peritonitis) who were followed up from 1992 through 2001.

Results

The overall incidence of peritonitis was 0.40 episodes/patient-year. The annual rate of peritonitis and the incidence of peritonitis caused by a single gram-positive organism were significantly higher in 1992 and 1993 compared with those in the rest of the years ( p < 0.05). The incidence of peritonitis due to coagulase-negative staphylococcus (CoNS) decreased significantly over time, whereas there was no significant change in the incidence of Staphylococcus aureus (SA)-induced peritonitis. Among CoNS, resistance to methicillin increased from 18.4% in 1992 – 1993 to 41.7% in 2000 – 2001 ( p < 0.05). In contrast, the incidence of methicillin-resistant SA was not different according to the calendar year. Catheter removal rates were significantly higher in peritonitis due to a single gram-negative organism (16.6%) compared with gram-positive peritonitis (4.8%, p < 0.005). The mortality associated with peritonitis was also higher in gram-negative (3.7%) compared with gram-positive peritonitis (1.4%), but there was no statistical significance. Among single gram-positive organism-induced peritonitis, catheter removal rates were significantly higher in SA (9.3%) than those in CoNS (2.9%, p < 0.01) and other gram-positive organisms (2.9%, p < 0.05). In peritonitis caused by CoNS, the methicillin-resistant group showed significantly higher removal rates than the methicillin-susceptible group (8.2% vs 1.0%, p < 0.01).

Conclusion

The incidence of peritonitis for 2001 decreased to less than half that for 1992, due mainly to a significant decrease in CoNS-induced peritonitis, whereas the proportions of peritonitis due to a single gram-negative organism and methicillin-resistant CoNS increased. These findings suggest that it is necessary to prepare new center-based guidelines for the initial empirical treatment of CAPD peritonitis.

Catheter revision for the treatment of intractable exit site infection/tunnel infection in peritoneal dialysis patients: a single centre experience

AIM

Catheter-related infection is a major cause of catheter loss in peritoneal dialysis (PD). We evaluated the effect of catheter revision on the treatment of intractable exit site infection (ESI)/tunnel infection (TI) in PD patients who required catheter removal.

METHODS

We reviewed the medical records of 764 continuous ambulatory peritoneal dialysis (CAPD) patients from May 1995 to April 2011 at our hospital. One hundred and twenty six patients had more than one occurrence of ESI. Catheter revision was performed to treat intractable ESI/TI. Incidence of ESI, causative organisms and the outcomes of catheter revision were analyzed.

RESULTS

The total PD duration of all patients was 32,581 months. Three hundred and twelve ESI episodes occurred in 126 patients and the incidence of ESI was 1/104 patient-months (0.12/patient-year). The most common causative organism was methicillin-sensitive Staphylococcus aureus (MSSA) (98 episodes), followed by Pseudomonas aeruginosa (63 episodes) and methicillin-resistant S. aureus (MRSA) (28 episodes). Among these, catheter revision was required due to intractable ESI/TI in 36 patients. The most common causative organism was MSSA (14 episodes) followed by P. aeruginosa (10 episodes) and MRSA (six episodes) in catheter revision cases. The outcomes of catheter revision were as follows: ESI relapsed in 11 patients (30.6%) after catheter revision. Among them, five patients were treated with antibiotic treatment, two patients required secondary catheter revision, four patients required catheter removal due to ESI/TI accompanying peritonitis. The catheter survival rate after catheter revision was 89.7% in one year. There were no statistical differences in the rates of ESI relapse after catheter revision between ESI caused by P. aeruginosa (5/10, 50%) and ESI caused by S.aureus (6/21, 28.6%).

CONCLUSION

Catheter revision may be an alternative treatment option to treat intractable ESI/TI before catheter removal is considered in PD patients.

Multicenter study of effects of pediatric peritoneal dialysis practices on bacterial peritonitis

Bacterial peritonitis is a major cause of morbidity in pediatric peritoneal dialysis (PD) patients and can lead to catheter removal, hospitalizations, peritoneal membrane dysfunction, and sepsis. The goal of this prospective study was to determine whether the incidence of peritonitis had improved over time and what practice patterns influenced peritonitis. Two cohorts of PD patients within the End-stage Renal Disease (ESRD) Networks 9/10 and who were <21 years old were prospectively followed for 1 year in 1991 and 2002 and included 70 and 82 patients, respectively. A questionnaire was completed for each patient outlining demographic, clinical, and dialysis characteristics. A second questionnaire was completed for each peritonitis episode. The 2002 cohort was younger, included more nonwhites, and had fewer peritonitis episodes. A shift in practice patterns was evident, with more of the 2002 cohort receiving prophylactic antibiotics and omentectomy at catheter insertion and using cycler machines with a parent operator. Peritonitis-free interval was 10.8 months in 1991 and 17.3 months in 2002. The only variable statistically related to the lower rate of peritonitis in 2002 was fewer prior peritonitis events. The results show an improvement in peritonitis-free interval in studied patients on PD, which appears to be related to numerous changes in practice patterns.

Prevention of peritonitis in children receiving peritoneal dialysis

Peritonitis and catheter-related (exit-site/tunnel) infections are major causes of morbidity in children receiving peritoneal dialysis (PD). Our objective was to evaluate the impact of a combination of prophylactic measures on the rate of peritonitis and catheter-related infections subsequent to their implementation in 2001. This is a single center review of incident patients who received automated peritoneal dialysis (APD) from 1997 to 2004. The causal microorganisms, annualized peritonitis and catheter-related infections rates and the time to infection were reviewed using pooled data from 1997 to 2000 and from 2001 to 2004. Fifty-four patients received PD over 1099 patient months (pm). Twenty-eight peritonitis episodes occurred in 15 patients over 599 pm from 1997 to 2000 (annualized rate (AR): 0.56 infections/patient year). Eight episodes of peritonitis occurred in five patients over 500 pm from 2001 to 2004 (AR: 0.19 infections/patient year) (P = 0.01). Prior to 2001, the median time from dialysis initiation to the first peritonitis episode was 500 days (95% CI, 400-660 days), compared to 1137 days (95% CI, 1050 to +Infinity) from 2001 to 2004 (P = 0.008). The rate of catheter-related infections and time to initial infection during the two periods was not different. We conclude that measures to decrease the frequency of peritonitis can be successfully applied to children and should be incorporated as part of standard care.

The comparison in terms of early complications of a new technique and percutaneous method for the placement of CAPD catheters

BACKGROUND

Starting continuous ambulatory peritoneal dialysis (CAPD) immediately after insertion of a peritoneal dialysis catheter is essential in end-stage renal disease (ESRD). In relation to the insertion methods, various mechanical and infectious complications may arise. In this study, we aimed to compare early complications of the laparoscopic tunneling method of CAPD placement that we developed recently in order to minimize the complications, with those of the conventional percutaneous method.

SUBJECTS AND METHOD

Included in this study were 12 consecutive patients with ESRD to whom we introduced catheters for CAPD by way of laparoscopic tunneling between April 2003 and July 2003 and followed up for at least 6 months, and 30 patients to whom the catheters were placed percutaneously in the same time period with the same follow-up time. The complications seen during the first 6 months after catheter placement with these two different methods were compared.

RESULTS

In all of the subjects, dialysis was started soon after catheter placement. No peroperative morbidity was seen in any of the patients. While with laparoscopic tunneling method no mechanical problem was seen, the percutaneous method resulted in early leakage in 10%, pericatheter bleeding in 3.3%, and hernia in 3.3% of the patients. As infectious complications, peritonitis occurred as one episode/36 patient-months in laparoscopic tunneling and one episode/22.5 patient-months in percutaneous method; catheter insertion site infection was seen in none in the laparoscopic method, while one episode/90patient-months was seen with the percutaneous method. Tunnel infection did not arise in any of the subjects.

CONCLUSION

The authors of this study think that the peritoneal tunneling method for introducing CAPD, which has been recently developed and began to be routinely used by them, is rather safe in terms of early complications.

Lysostaphin-coated catheters eradicate Staphylococccus aureus challenge and block surface colonization

Lysostaphin is an endopeptidase that kills Staphylococcus aureus, a predominant organism in catheter-related infections. Lysostaphin-coated catheters prevented catheter colonization by several strains of S. aureus, and activity was maintained for at least 4 days. Prophylactic use of lysostaphin in catheters may help prevent the occurrence of catheter-related staphylococcal infections.