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Blanchard F, Henry B, Vijayaratnam S, Canouï E, Moura A, Thouvenot P, Bracq-Dieye H, Tessaud-Rita N, Valès G, Diakité A, Leclercq A, Lecuit M, Charlier C. Listeria monocytogenes-associated spontaneous bacterial peritonitis in France: a nationwide observational study of 208 cases. THE LANCET. INFECTIOUS DISEASES 2024; 24:783-792. [PMID: 38608698 DOI: 10.1016/s1473-3099(24)00151-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 02/22/2024] [Accepted: 02/26/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND Listeriosis is a foodborne infection caused by Listeria monocytogenes. Three main forms of listeriosis are well characterised, but little is known about L monocytogenes-associated spontaneous bacterial peritonitis. We used data from the French national surveillance of listeriosis to perform a nationwide retrospective study. METHODS All patients with L monocytogenes isolated by culture from a peritoneal fluid sample in France between April 1, 1993, and Dec 31, 2022, were included. Individuals for whom bacterial peritonitis was not confirmed and those who also had another type of invasive listeriosis were excluded. A standardised checklist was used to collect demographic, clinical, and biological data as well as antibiotic treatment and follow-up data. The primary outcome was to determine the characteristics of L monocytogenes-associated spontaneous bacterial peritonitis. We did descriptive analyses and assessed risk factors for 1-month mortality using an exploratory multivariable Cox model analysis. FINDINGS Among the 8768 L monocytogenes cases reported, 208 (2%) were patients with L monocytogenes-associated spontaneous bacterial peritonitis. Mean age was 65 years (SD 13), 50 (24%) of 208 patients were female, and 158 (76%) were male (no data on race or ethnicity were available). 200 (98%) of 205 patients with L monocytogenes-associated spontaneous bacterial peritonitis with available data had immunosuppressive comorbidities, including cirrhosis (148 [74%] of 201 with available data), ongoing alcoholism (58 [62%] of 94), and ongoing neoplasia (60 [31%] of 195). Causes of ascites included cirrhosis (146 [70%] of 208), ongoing neoplasia (26 [13%]), end-stage heart failure (13 [6%]), and peritoneal dialysis (11 [5%]). Among those with available data, presentation was pauci-symptomatic and non-specific; only 67 (50%) of 135 patients presented with fever, 49 (37%) of 132 with abdominal pain, and 27 (21%) of 129 with diarrhoea. 61 (29%) of 208 patients were dead at 1 month, 92 (44%) were dead at 3 months, and 109 (52%) were dead at 6 months after diagnosis. Ongoing neoplasia (hazard ratio 2·42 [95% CI 1·05-5·56]; p=0·039), septic shock (8·03 [2·66-24·02]; p=0·0021), and high blood leukocyte count (1·05 [1·00-1·09]; p=0·045) were independently associated with 1-month mortality. INTERPRETATION Despite the non-specific and mild presentation of L monocytogenes-associated spontaneous bacterial peritonitis, the outcome is poor and similar to that of neurolisteriosis, and so identification of L monocytogenes in ascitic fluid samples requires urgent parenteral amoxicillin-based treatment to avoid a fatal outcome. FUNDING Institut Pasteur, Inserm, and French Public Health Agency. TRANSLATION For the French translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Florian Blanchard
- Listeria National Reference Center and WHO Collaborating Center, Institut Pasteur, Paris, France; Antibiotic stewardship team, Department of Infectious Diseases and Tropical Medicine, Cochin Port-Royal University Hospital, APHP, Paris, France; Department of Anesthesiology and Critical Care Sorbonne University, GRC 29, AP-HP, DMU DREAM, Pitié-Salpêtrière Hospital, Paris, France
| | - Benoît Henry
- Listeria National Reference Center and WHO Collaborating Center, Institut Pasteur, Paris, France; Division of Infectious Diseases and Tropical Medicine, Bicêtre University Hospital, APHP, Le Kremlin-Bicêtre, France
| | - Sofieya Vijayaratnam
- Listeria National Reference Center and WHO Collaborating Center, Institut Pasteur, Paris, France
| | - Etienne Canouï
- Antibiotic stewardship team, Department of Infectious Diseases and Tropical Medicine, Cochin Port-Royal University Hospital, APHP, Paris, France
| | - Alexandra Moura
- Listeria National Reference Center and WHO Collaborating Center, Institut Pasteur, Paris, France; Biology of Infection Unit, Institut Pasteur, Université Paris Cité, Inserm U1117, Paris, France
| | - Pierre Thouvenot
- Listeria National Reference Center and WHO Collaborating Center, Institut Pasteur, Paris, France
| | - Hélène Bracq-Dieye
- Listeria National Reference Center and WHO Collaborating Center, Institut Pasteur, Paris, France
| | - Nathalie Tessaud-Rita
- Listeria National Reference Center and WHO Collaborating Center, Institut Pasteur, Paris, France
| | - Guillaume Valès
- Listeria National Reference Center and WHO Collaborating Center, Institut Pasteur, Paris, France
| | - Andrée Diakité
- Listeria National Reference Center and WHO Collaborating Center, Institut Pasteur, Paris, France
| | - Alexandre Leclercq
- Listeria National Reference Center and WHO Collaborating Center, Institut Pasteur, Paris, France
| | - Marc Lecuit
- Listeria National Reference Center and WHO Collaborating Center, Institut Pasteur, Paris, France; Biology of Infection Unit, Institut Pasteur, Université Paris Cité, Inserm U1117, Paris, France; Université Paris Cité, Paris, France; Department of Infectious Diseases and Tropical Medicine, Necker-Enfants Malades University Hospital, APHP, Institut Imagine, Paris, France.
| | - Caroline Charlier
- Listeria National Reference Center and WHO Collaborating Center, Institut Pasteur, Paris, France; Antibiotic stewardship team, Department of Infectious Diseases and Tropical Medicine, Cochin Port-Royal University Hospital, APHP, Paris, France; Biology of Infection Unit, Institut Pasteur, Université Paris Cité, Inserm U1117, Paris, France; Université Paris Cité, Paris, France.
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Phenotypic and Molecular Characterization of Nonfermenting Gram-Negative Bacilli Causing Peritonitis in Peritoneal Dialysis Patients. Pathogens 2022; 11:pathogens11020218. [PMID: 35215161 PMCID: PMC8879723 DOI: 10.3390/pathogens11020218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 02/03/2022] [Accepted: 02/04/2022] [Indexed: 11/23/2022] Open
Abstract
(1) Background: Peritonitis due to nonfermenting Gram-negative bacilli (NF-GNB) is a dramatic complication of peritoneal dialysis (PD) with bad outcomes. Previous studies of PD-related peritonitis due to Pseudomonas species have shown a low-resolution rate, without a high resistance rate to antipseudomonal antibiotics. This suggests that bacterial virulence factors can act and influence peritonitis evolution. This study aimed to describe the microbiological characteristics of NF-GNB causing PD-related peritonitis and analyze their influence on the outcome. (2) Methods: We analyze the 48 isolates from NF-GNB peritonitis, which were stored in our culture collection regarding bacterial resistance, biofilm, and other virulence factors’ production, and clonal profile. Additionally, we collected data on treatment and outcomes from patients’ clinical registers. (3) Results: The etiologies were species of Pseudomonas (50%), Acinetobacter (36%), and other NF-GNB (14%). There was a high (75%) proportion of biofilm producer lineages. The in vitro susceptibility rate of Pseudomonas spp. to amikacin, ciprofloxacin, and ceftazidime was significantly greater than that of Acinetobacter spp. and other species; however, there was a similar low-resolution rate (<45%) among the episodes attributable to them. Pseudomonas species have a polyclonal profile, while we found a clone of five multiresistant Acinetobacter baumannii over an 8-year interval (2000–2008), which suggest an origin from the healthcare environment. (4) Conclusions: We are not able to identify any predictor of outcome, but it is possible that biofilm and others virulence factors can act in concert and contribute to the bad outcome.
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Jeloka TK, Abraham G, Bhalla AK, Balasubramaniam J, Dutta A, Gokulnath, Gupta A, Jha V, Khanna U, Mahajan S, Nayak KS, Prasad KN, Prasad N, Rathi M, Raju S, Rohit A, Sahay M, Sampathkumar K, Sivakumar V, Varughese S. Continuous Ambulatory Peritoneal Dialysis Peritonitis Guidelines - Consensus Statement of Peritoneal Dialysis Society of India - 2020. Indian J Nephrol 2021; 31:425-434. [PMID: 34880551 PMCID: PMC8597799 DOI: 10.4103/ijn.ijn_73_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 05/08/2019] [Accepted: 06/30/2019] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Tarun K Jeloka
- Department of Nephrology, Aditya Birla Memorial Hospital, Pune, Maharashtra, India
| | - Georgi Abraham
- Department of Nephrology, Madras Medical Mission, Chennai, Tamil Nadu, India
| | - A K Bhalla
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, India
| | - J Balasubramaniam
- Department of Nephrology, Kidney Care Centre, Tirunelveli, Tamil Nadu, India
| | - A Dutta
- Department of Nephrology, Fortis Hospital and Kidney Institute, Kolkata, West Bengal, India
| | - Gokulnath
- Department of Nephrology, Apollo Hospital, Bengaluru, Karnataka, India
| | - Amit Gupta
- Department of Nephrology, Sanjay Gandhi Post Graduate Institute, Lucknow, Uttar Pradesh, India
| | - V Jha
- The George Institute for Global Health, New Delhi, India
| | - Umesh Khanna
- Department of Nephrology, Lancelot Kidney and GI Centre, Mumbai, Maharashtra, India
| | - Sandeep Mahajan
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - K S Nayak
- Department of Nephrology, Virinchi Hospitals, Hyderabad, Telangana, India
| | - K N Prasad
- Department of Microbiology, Sanjay Gandhi Post Graduate Institute, Lucknow, Uttar Pradesh, India
| | - Narayan Prasad
- Department of Nephrology, Sanjay Gandhi Post Graduate Institute, Lucknow, Uttar Pradesh, India
| | - Manish Rathi
- Department of Nephrology, Post Graduate Institute, Chandigarh, India
| | - Sreebhushan Raju
- Department of Nephrology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Anusha Rohit
- Department of Microbiology, Madras Medical Mission, Chennai, Tamil Nadu, India
| | - Manisha Sahay
- Department of Nephrology, Osmania Hospital, Hyderabad, Telangana, India
| | - K Sampathkumar
- Department of Nephrology, Meenakshi Mission Hopsital and Research Centre, Madurai, Tamil Nadu, India
| | - V Sivakumar
- Department of Nephrology, SriVenkateshwara Institute of Medical sciences, Tirupati, Andhra Pradesh, India
| | - Santosh Varughese
- Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
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Dos Santos ACML, Hernandes RT, Montelli AC, Monteiro ACM, Barbosa TA, Camargo CH, Ferreira AM, Mondelli AL, de Lourdes Ribeiro de Souza da Cunha M, Barretti P. Clinical and microbiological factors predicting outcomes of nonfermenting gram-negative bacilli peritonitis in peritoneal dialysis. Sci Rep 2021; 11:12248. [PMID: 34112833 PMCID: PMC8192548 DOI: 10.1038/s41598-021-91410-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 05/18/2021] [Indexed: 01/02/2023] Open
Abstract
Peritonitis due to gram-negative bacilli (GNB), particularly nonfermenting GNB (NF-GNB), is a serious complication of peritoneal dialysis with a low resolution rate. Beyond the patient’s condition, microbiological properties such as antimicrobial resistance, biofilm production and other virulence factors can explain the poor outcomes. This study aimed to evaluate the influence of patient condition, microbiological characteristics, including biofilm production, and treatment on peritonitis outcome. We reviewed the records of 62 index episodes caused by NF-GNB that occurred between 1997 and 2015 in our center. The etiologies were species of Pseudomonas (51.6%), Acinetobacter (32.2%), and other NF-GNB (16.1%). There was a high (72.9%) proportion of biofilm producer lineages. The in vitro susceptibility rate of Pseudomonas spp. to amikacin, ciprofloxacin, and ceftazidime was significantly greater than that of Acinetobacter spp. and other species; however, there was a similar low resolution rate (< 45%) among the episodes attributable to them. Preexisting exit-site infection was independently associated with nonresolution. No other factor, including biofilm production, was associated with the outcome. The higher in vitro susceptibility of Pseudomonas compared to other NF-GNB that presented a similar resolution rate suggests that bacterial virulence factors such as biofilms can act in concert, thereby worsening the outcome.
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Affiliation(s)
| | - Rodrigo Tavanelli Hernandes
- Biosciences Institute of Botucatu, Sao Paulo State University Julio de Mesquita Filho (UNESP), Botucatu, Brazil
| | - Augusto Cezar Montelli
- Biosciences Institute of Botucatu, Sao Paulo State University Julio de Mesquita Filho (UNESP), Botucatu, Brazil.,Botucatu Medical School, Sao Paulo State University Julio de Mesquita Filho (UNESP), Botucatu, Brazil
| | | | - Thais Alves Barbosa
- Biosciences Institute of Botucatu, Sao Paulo State University Julio de Mesquita Filho (UNESP), Botucatu, Brazil
| | | | | | - Alessandro Lia Mondelli
- Botucatu Medical School Clinics Hospital, Botucatu, Brazil.,Botucatu Medical School, Sao Paulo State University Julio de Mesquita Filho (UNESP), Botucatu, Brazil
| | | | - Pasqual Barretti
- Botucatu Medical School, Sao Paulo State University Julio de Mesquita Filho (UNESP), Botucatu, Brazil.
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Au CWH, Yap DYH, Chan JFW, Yip TPS, Chan TM. Exit site infection and peritonitis due to Serratia species in patients receiving peritoneal dialysis: Epidemiology and clinical outcomes. Nephrology (Carlton) 2020; 26:255-261. [PMID: 33150699 DOI: 10.1111/nep.13813] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 10/24/2020] [Accepted: 10/26/2020] [Indexed: 11/27/2022]
Abstract
AIM To study the epidemiology and clinical outcomes of catheter-related infections of Serratia species in peritoneal dialysis (PD) patients. METHODS We retrospectively reviewed the patient characteristics, antibiotics susceptibility/resistance patterns and treatment outcomes of exit site infection (ESI) and peritonitis due to Serratia in PD patients during the period of 2004 to 2017. RESULTS One hundred and sixty-one patients had Serratia ESI, of which 10 (6.2%) progressed to tunnel tract involvement and 11 (6.8%) developed PD peritonitis. Nineteen (11.8%) patients with Serratia ESI failed to respond to medical treatment and required catheter removal. Fifty-six (34.8%) patients had repeat Serratia ESI, which occurred at 12.9 ± 13.6 months after the previous episode. Twenty-two patients had Serratia peritonitis, which accounted for 1% of peritonitis during the study period. Ten (45.5%) patients responded to medical treatment while 12 (54.5%) patients required catheter removal. Nine patients (36.4%) failed to resume PD and were converted to long-term haemodialysis. Two patients had repeat peritonitis at 2 months and 3 years, respectively, after the initial episode. Serratia species in PD patients showed high rates of resistance to ampicillin, and first- and second-generation cephalosporins, but were generally susceptible to aminoglycosides, carboxy-/ureido-penicillins and carbapenems. CONCLUSION Our results suggest that Serratia ESI show low risk of progression to peritonitis and favourable response to medical therapy, while Serratia peritonitis was associated with high rates of catheter removal and peritoneal failure.
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Affiliation(s)
- Christy W H Au
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Desmond Y H Yap
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Jasper F W Chan
- Department of Microbiology, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | | | - Tak M Chan
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
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6
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Obata Y, Murashima M, Toda N, Yamamoto S, Tsujimoto Y, Tsujimoto Y, Tsujimoto H, Yuasa H, Ryuzaki M, Ito Y, Tomo T, Nakamoto H. Topical application of mupirocin to exit sites in patients on peritoneal dialysis: a systematic review and meta-analysis of randomized controlled trials. RENAL REPLACEMENT THERAPY 2020. [DOI: 10.1186/s41100-020-00261-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The International Society for Peritoneal Dialysis guidelines recommends the topical application of antibiotics on the exit site for the prevention of peritoneal dialysis (PD)-related infections. However, the recommendation is based on meta-analyses on applying nasal mupirocin ointment or observational or retrospective studies. Here, we evaluated the efficacy of topical application of mupirocin on the exit site for the prevention of PD-related infections.
Methods
We searched the databases, MEDLINE and CENTRAL, documenting the topical application of antibiotics on the exit site in PD patients in April 2017. We included only randomized controlled trials (RCTs) with adult patients wherein the effects of mupirocin were examined. Exit site infection (ESI), peritonitis, and technical failure were assessed as the main outcomes.
Results
Overall, six RCTs were included in this study. It was uncertain whether the application of mupirocin ointment prevents ESI (rate ratio (RR), 0.36; 95% CI, 0.13–1.05), peritonitis (RR 0.78, 95% CI 0.50–1.21), and technical failure (RR, 1.35; 95% CI, 0.25–7.21). Moreover, a comparison between mupirocin and gentamicin showed no difference in the incidence of ESI (RR, 1.14; 95% CI, 0.27–4.81), peritonitis (RR, 0.85; 95% CI, 0.32–2.26), and technical failure (RR, 0.58; 95% CI, 0.28–1.20).
Conclusions
It remains unclear whether topical application of mupirocin on the exit site has any significant effects on PD-related infection or technical failure. Large-scale RCTs with high methodological quality are required to confirm the efficacy of topical application of antibiotics on the exit site.
Trial registration
UMINR000039267
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7
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Piraino B, Bailie GR, Bernardini J, Boeschoten E, Gupta A, Holmes C, Kuijper EJ, Li PKT, Lye WC, Mujais S, Paterson DL, Fontan MP, Ramos A, Schaefer F, Uttley L. Peritoneal Dialysis-Related Infections Recommendations: 2005 Update. Perit Dial Int 2020. [DOI: 10.1177/089686080502500203] [Citation(s) in RCA: 516] [Impact Index Per Article: 129.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Beth Piraino
- Renal Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Judith Bernardini
- Renal Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Amit Gupta
- Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Clifford Holmes
- Renal Division, Baxter Healthcare Corporation, McGaw Park, Illinois, USA
| | - Ed J. Kuijper
- Department of Medical Microbiology, University Medical Center, Leiden, The Netherlands
| | - Philip Kam-Tao Li
- Department of Medicine & Therapeutics, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong
| | - Wai-Choong Lye
- Centre for Kidney Diseases, Mount Elizabeth Medical Centre, Singapore
| | - Salim Mujais
- Renal Division, Baxter Healthcare Corporation, McGaw Park, Illinois, USA
| | - David L. Paterson
- Division of Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | - Alfonso Ramos
- Division of Nephrology, Hospital General de Zona #2, Instituto Mexicano del Seguro Social, Hermosillo, Mexico
| | - Franz Schaefer
- Pediatric Nephrology Division, University Children's Hospital, Heidelberg, Germany
| | - Linda Uttley
- Renal Dialysis Treatment, Manchester Royal Infirmary, Manchester, United Kingdom
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Mahajan S, Tiwari SC, Kalra V, Bhowmik DM, Agarwal SK, Dash SC, Kumar P. Effect of Local Mupirocin Application on Exit-Site Infection and Peritonitis in an Indian Peritoneal Dialysis Population. Perit Dial Int 2020. [DOI: 10.1177/089686080502500512] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Staphylococcus aureus-associated peritonitis and catheter exit-site infections (ESIs) are important causes of hospitalization and catheter loss in patients undergoing chronic peritoneal dialysis. Intranasal and topical use of mupirocin has been found to be an effective strategy in decreasing S. aureus-related infectious complications in persons who are carriers of S. aureus; however, there is no consensus regarding the prophylactic use of mupirocin irrespective of carrier status. We aimed to determine the potential effectiveness of application of mupirocin cream at the catheter exit site in preventing ESI and peritonitis irrespective of carrier status in a tropical country such as India. Methods This prospective historically controlled study was done in a total of 40 patients. From August 2003, all patients, incident and prevalent, were instructed to apply 2% mupirocin cream daily to the exit site instead of the older practice of povidone-iodine and gauze dressing. Patients were not screened to determine whether they were S. aureus carriers. The infection-related data for 1 year, until July 2004, were compared with the historical control, which was infection-related data for the year preceding the year of mupirocin application. Results Mean age of the study population was 62 years, with 61.8% being male and 64.3% being diabetic. Local application of mupirocin led to a significant reduction in the incidence density per patient-month of both ESI and peritonitis compared to controls (0.15 vs 0.37 and 0.37 vs 0.67, p = 0.01 for both). This amounted to a relative reduction of 60.5% and 55% respectively. ESI and peritonitis due to S. aureus were also significantly lower in the study group compared to controls (incidence density per patient-month 0.05 vs 0.13 and zero vs 0.17 respectively, p < 0.01 for both). There occurred no catheter removal due to infection-related complications during the study period compared to two during the control period. None of the patients reported a mupirocin-related adverse effect. Conclusions Daily application of mupirocin at the exit site is a well-tolerated and effective strategy in reducing the incidence of ESI and peritonitis in a tropical country such as India. It can thus significantly reduce morbidity, catheter loss, and transfer to hemodialysis in peritoneal dialysis patients.
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Affiliation(s)
- Sandeep Mahajan
- Department of Nephrology, All India Institute of Medical Sciences, Ansari Nagar
| | - Suresh C. Tiwari
- Department of Nephrology, All India Institute of Medical Sciences, Ansari Nagar
| | - Vikram Kalra
- Department of Nephrology, All India Institute of Medical Sciences, Ansari Nagar
| | - Dipankar M. Bhowmik
- Department of Nephrology, All India Institute of Medical Sciences, Ansari Nagar
| | - Sanjay K. Agarwal
- Department of Nephrology, All India Institute of Medical Sciences, Ansari Nagar
| | - Suresh C. Dash
- Department of Nephrology, All India Institute of Medical Sciences, Ansari Nagar
| | - Parveen Kumar
- Directorate of Health Services, Delhi Government, DHS Headquarters, New Delhi, India
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9
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Lew S, Gruia A. Pseudomonas Putida Causing Peritoneal Dialysis-Associated Peritonitis. Perit Dial Int 2020. [DOI: 10.1177/089686080502500519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- S.Q. Lew
- Division of Renal Diseases and Hypertension, University Gambro Healthcare Washington, DC, USA
| | - A. Gruia
- Department of Medicine George Washington University Gambro Healthcare Washington, DC, USA
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10
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Jassal SV, Lok CE. A Randomized Controlled Trial Comparing Mupirocin versus Polysporin Triple for the Prevention of Catheter-Related Infections in Peritoneal Dialysis Patients (The MP3 Study). Perit Dial Int 2020. [DOI: 10.1177/089686080802800112] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BackgroundPeritonitis remains the most serious complication of peritoneal dialysis (PD). Gram-positive organisms are among the most common causes of PD peritonitis; however, recent trends show increasing rates of gram-negative and fungal infections. Strategies to prevent peritonitis include the use of prophylactic topical mupirocin at the site where the PD catheter exits from the abdominal wall; however, mupirocin does not afford protection against gram-negative or fungal infections. The aim of this study is to determine if the incidence of catheter-related infections (exit-site infection, tunnel infection, or peritonitis) is significantly reduced by the routine application of Polysporin Triple antibiotic ointment (Pfizer Canada, Markham, Ontario, Canada) in comparison to mupirocin ointment.Methods and DesignThe Mupirocin Versus Polysporin Triple Study (MP3) is a multicenter, randomized, double-blinded controlled study comparing Polysporin Triple (P3) against the current standard of care. The aim of the study is to recruit 200 patients being treated with or starting on PD and randomize them to receive either mupirocin or P3 at the catheter exit site. Patients will be followed for 18 months or until death or transfer from PD to an alternate treatment modality. The primary outcome will be the time to first catheter-related infection. Catheter-related infections will be strictly defined using current guidelines and categorized into exit-site infections, infective peritonitis, or tunnel infections. The primary analysis will be an intention-to-treat analysis.DiscussionThe results of this study will help determine if the use of P3 is superior to mupirocin ointment in the prevention of catheter-related infections and will help guide evidence-based best practices.
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Affiliation(s)
- Sarbjit V. Jassal
- Department of Medicine, University of Toronto, and Division of Nephrology, University Health Network, Toronto, Ontario, Canada
| | - Charmaine E. Lok
- Department of Medicine, University of Toronto, and Division of Nephrology, University Health Network, Toronto, Ontario, Canada
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11
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Piraino B, Bernardini J, Bender FH. An Analysis of Methods to Prevent Peritoneal Dialysis Catheter Infections. Perit Dial Int 2020. [DOI: 10.1177/089686080802800502] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Beth Piraino
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Judith Bernardini
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Filitsa H. Bender
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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12
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Selvin J, Lanong S, Syiem D, De Mandal S, Kayang H, Kumar NS, Kiran GS. Culture-dependent and metagenomic analysis of lesser horseshoe bats' gut microbiome revealing unique bacterial diversity and signatures of potential human pathogens. Microb Pathog 2019; 137:103675. [PMID: 31473248 PMCID: PMC7127535 DOI: 10.1016/j.micpath.2019.103675] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 08/15/2019] [Accepted: 08/19/2019] [Indexed: 12/26/2022]
Abstract
Bats are highly diverse and ecologically important mammals. They harbor various bacteria, viruses, and fungal communities that are either beneficial or potentially pathogenic. Extensive metagenomic studies in bats are limited, particularly for the gut, and to date, there are no reports on the bacterial diversity of Rhinolophus monoceros from Meghalaya, India. There are limited studies on the isolation of potential harmful or beneficial bacteria and their interactions with the environment through culture-dependent approaches. Therefore, high-throughput screening was used to understand the population structure, genetic diversity, and ecological role of the microorganisms. High-throughput sequencing of the 16S rRNA marker for gene mapping showed that the gut samples constitute a diverse group of bacteria that is dominated by Proteobacteria, followed by Firmicutes. The bacterial genera Corynebacterium and Mycobacterium were also observed in the Illumina dataset. Illumina sequencing revealed eight bacterial phyla composed of 112 genera. The metagenomic analysis of the OTUs from the gut revealed diverse bacterial communities as well as zoonotic and human pathogens. There were differences in the bacterial communities between the two methods used in this study, which could be related to host specificity, diet, and habitat. The culture-dependent technique resulted in the isolation of 35 bacterial isolates, of which Bacillus cereus and B. anthracis are well-known bacterial pathogens that show virulent traits including hemolytic and proteolytic activities. Pseudomonas stutzeri is an opportunistic human pathogen that was also isolated and showed similar traits. Antibiotic sensitivity tests were performed on all 35 isolates, and different antibiotics were used for Gram-positive and -negative bacteria. The result showed that some isolates are resistant to antibiotics such as penicillin G and Cefoxitin. This report on gut bacterial communities could attract interest in the possibility of isolating and characterizing bacteria for the production of antibiotics, enzymes, plant growth promoters, and probiotics. However, the presence of potential pathogenic bacteria that may impose health hazards cannot be ignored and needs to be studied further.
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Affiliation(s)
- Joseph Selvin
- Department of Microbiology, School of Life Sciences, Pondicherry University, Puducherry, 605014, India.
| | - Sheryl Lanong
- Department of Microbiology, School of Life Sciences, Pondicherry University, Puducherry, 605014, India
| | - Donkupar Syiem
- Department of Biochemistry, North Eastern Hill University, Shillong, 793022, India
| | - Surajit De Mandal
- Department of Biotechnology, Mizoram University, Aizawl, 796004, India; College of Agriculture, South China Agricultural University, Key Laboratory of Bio-Pesticide Innovation and Application of Guangdong Province, Guangzhou, 510642, PR China
| | - Highland Kayang
- Department of Botany, North Eastern Hill University, Shillong, 793022, India
| | | | - G Seghal Kiran
- Department of Food science and Technology, Pondicherry University, Puducherry, 605014, India
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Carvalho Fiel D, Pérez-Fontán M, López Iglesias A, Bravo González-Blas L, García Gago L, García Falcón T, Rodríguez-Carmona A. Persistent overhydration is associated with a significant risk of peritoneal infection by enteric pathogens in patients treated with peritoneal dialysis. Nefrologia 2019; 39:638-645. [PMID: 31023497 DOI: 10.1016/j.nefro.2019.01.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 11/11/2018] [Accepted: 01/14/2019] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Overhydration (OH) complicates frequently the clinical course of Peritoneal Dialysis (PD) patients, and keeps a controversial association with the risk of peritoneal infection. The main objective of this study was to disclose an association between persistent OH and the risk of enteric peritonitis in a relatively large sample of patients undergoing PD. METHOD Following a prospective design, we monitorized systematically body composition of patients treated with PD in our unit (2011-2016), searching for a correlation with the ensuing risk of peritonitis, with an emphasis on the association between persistent OH (main study variable) and the risk of infection by enteric pathogens (main outcome). Essential demographic, clinical and laboratory variables with a potential influence on the risk of peritonitis were recorded. We used multivariate survival analysis to clarify the specific effect of different body composition parameters on the main outcome. MAIN RESULTS We included 139 patients for analysis (mean follow-up 24 months). Sixty-three patients suffered at least one peritonitis, and 17 had at least one diagnosis of enteric peritonitis. Univariate analysis disclosed a general trend to an increased risk of enteric peritonitis in overhydrated patients, as evidenced by associations of this outcome with mean extracellular water/intracellular water (ECW/ICW) (p=.007), OH/ECW (p=.033) and ECW/total body water (ECW/TBW) (p=.004) ratios, but not with absolute OH values. Multivariate analysis confirmed similar associations or trends (RR: 3.48, 95% CI: 1.03-14.59; p=.046, highest versus lowest tertile of ECW/ICW, RR: 2.31, 95% CI: 0.98-6.56; p=.061, highest versus lowest tertile of OH/ECW, and RR: 6.33, 95% CI: 1.37-19.37; p=.011, highest versus lowest tertile of ECW/TBW). On the contrary, no apparent association was detected between OH and the overall risk of peritoneal infection. CONCLUSION Persistent overhydration portends a significant risk of peritoneal infection by enteric pathogens, among patients undergoing chronic PD.
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Affiliation(s)
| | - Miguel Pérez-Fontán
- Servicio de Nefrología, Hospital Universitario de A Coruña, A Coruña, España.
| | | | | | - Leticia García Gago
- Servicio de Nefrología, Hospital Universitario de A Coruña, A Coruña, España
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14
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Szeto CC, Lo WK, Li PK. Clinical practice guidelines for the provision of renal service in Hong Kong: Peritoneal Dialysis. Nephrology (Carlton) 2019; 24 Suppl 1:27-40. [PMID: 30900337 DOI: 10.1111/nep.13505] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Cheuk Chun Szeto
- Carol and Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine and TherapeuticsPrince of Wales Hospital, The Chinese University of Hong Kong Shatin Hong Kong SAR, China
| | - Wai Kei Lo
- Department of MedicineTung Wah Hospital Hong Kong SAR, China
- Dialysis CentreGleneagles Hospital Hong Kong SAR, China
| | - Philip Kam‐Tao Li
- Carol and Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine and TherapeuticsPrince of Wales Hospital, The Chinese University of Hong Kong Shatin Hong Kong SAR, China
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15
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Lui SL, Yap D, Cheng V, Chan TM, Yuen KY. Clinical practice guidelines for the provision of renal service in Hong Kong: Infection Control in Renal Service. Nephrology (Carlton) 2019; 24 Suppl 1:98-129. [PMID: 30900339 PMCID: PMC7167703 DOI: 10.1111/nep.13497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
| | - Desmond Yap
- Department of MedicineThe University of Hong KongHong Kong
| | - Vincent Cheng
- Department of MicrobiologyQueen Mary HospitalHong Kong
| | - Tak Mao Chan
- Department of MedicineThe University of Hong KongHong Kong
| | - Kwok Yung Yuen
- Department of MicrobiologyThe University of Hong KongHong Kong
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16
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Szeto CC, Li PKT, Johnson DW, Bernardini J, Dong J, Figueiredo AE, Ito Y, Kazancioglu R, Moraes T, Van Esch S, Brown EA. ISPD Catheter-Related Infection Recommendations: 2017 Update. Perit Dial Int 2017; 37:141-154. [DOI: 10.3747/pdi.2016.00120] [Citation(s) in RCA: 193] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 09/15/2016] [Indexed: 12/18/2022] Open
Affiliation(s)
- Cheuk-Chun Szeto
- Department of Medicine and Therapeutics, Hammersmith Hospital, London, UK
| | - Philip Kam-Tao Li
- Department of Medicine and Therapeutics, Hammersmith Hospital, London, UK
| | - David W. Johnson
- Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong; Department of Nephrology, Hammersmith Hospital, London, UK
| | - Judith Bernardini
- University of Queensland at Princess Alexandra Hospital, Brisbane, Australia; Renal Electrolyte Division, Hammersmith Hospital, London, UK
| | - Jie Dong
- University of Pittsburgh School of Medicine Pittsburgh, PA, USA; Renal Division, Hammersmith Hospital, London, UK
| | - Ana E. Figueiredo
- Department of Medicine, Peking University First Hospital, Beijing, China; Pontifícia Universidade Católica do Rio Grande do Sul, Hammersmith Hospital, London, UK
| | - Yasuhiko Ito
- FAENFI, Porto Alegre, Brazil; Division of Nephrology, Hammersmith Hospital, London, UK
| | - Rumeyza Kazancioglu
- Nagoya University Graduate School of Medicine, Nagoya, Japan; Division of Nephrology, Hammersmith Hospital, London, UK
| | - Thyago Moraes
- Bezmialem Vakif University, Medical Faculty, Istanbul, Turkey; Pontifícia Universidade Católica do Paraná, Hammersmith Hospital, London, UK
| | - Sadie Van Esch
- Curitiba, Brazil; Elisabeth Tweesteden Hospital, Hammersmith Hospital, London, UK
| | - Edwina A. Brown
- Nephrology Department and Internal Medicine, Tilburg, Netherlands; and Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, UK
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17
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Banskar S, Bhute SS, Suryavanshi MV, Punekar S, Shouche YS. Microbiome analysis reveals the abundance of bacterial pathogens in Rousettus leschenaultii guano. Sci Rep 2016; 6:36948. [PMID: 27845426 PMCID: PMC5109407 DOI: 10.1038/srep36948] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 10/24/2016] [Indexed: 12/11/2022] Open
Abstract
Bats are crucial for proper functioning of an ecosystem. They provide various important services to ecosystem and environment. While, bats are well-known carrier of pathogenic viruses, their possible role as a potential carrier of pathogenic bacteria is under-explored. Here, using culture-based approach, employing multiple bacteriological media, over thousand bacteria were cultivated and identified from Rousettus leschenaultii (a frugivorous bat species), the majority of which were from the family Enterobacteriaceae and putative pathogens. Next, pathogenic potential of most frequently cultivated component of microbiome i.e. Escherichia coli was assessed to identify its known pathotypes which revealed the presence of virulent factors in many cultivated E. coli isolates. Applying in-depth bacterial community analysis using high-throughput 16 S rRNA gene sequencing, a high inter-individual variation was observed among the studied guano samples. Interestingly, a higher diversity of bacterial communities was observed in decaying guano representative. The search against human pathogenic bacteria database at 97% identity, a small proportion of sequences were found associated to well-known human pathogens. The present study thus indicates that this bat species may carry potential bacterial pathogens and advice to study the effect of these pathogens on bats itself and the probable mode of transmission to humans and other animals.
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Affiliation(s)
- Sunil Banskar
- Microbial Culture Collection, National Centre for Cell Science, Pune, India
| | - Shrikant S Bhute
- Department of Zoology, Savitribai Phule Pune University, Pune, India
| | | | - Sachin Punekar
- Biosphere, Eshwari, 52/403, Lakshminagar, Parvati, Pune-411009 (Maharashtra), India
| | - Yogesh S Shouche
- Microbial Culture Collection, National Centre for Cell Science, Pune, India
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18
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Li PKT, Szeto CC, Piraino B, de Arteaga J, Fan S, Figueiredo AE, Fish DN, Goffin E, Kim YL, Salzer W, Struijk DG, Teitelbaum I, Johnson DW. ISPD Peritonitis Recommendations: 2016 Update on Prevention and Treatment. Perit Dial Int 2016; 36:481-508. [PMID: 27282851 PMCID: PMC5033625 DOI: 10.3747/pdi.2016.00078] [Citation(s) in RCA: 612] [Impact Index Per Article: 76.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 05/04/2016] [Indexed: 12/19/2022] Open
Affiliation(s)
- Philip Kam-Tao Li
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Cheuk Chun Szeto
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Beth Piraino
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Javier de Arteaga
- Department of Nephrology, Hospital Privado and Catholic University, Cordoba, Argentina
| | - Stanley Fan
- Department of Renal Medicine and Transplantation, Barts Health NHS Trust, London, UK
| | - Ana E Figueiredo
- Nursing School-FAENFI, Pontificia Universidade Catolica do Rio Grande do Sul, Porto Alegre, Brazil
| | - Douglas N Fish
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA
| | - Eric Goffin
- Department of Nephrology, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Belgium
| | - Yong-Lim Kim
- Department of Internal Medicine, Kyungpook National University School of Medicine, Clinical Research Center for End Stage Renal Disease, Daegu, Korea
| | - William Salzer
- University of Missouri-Columbia School of Medicine, Department of Internal Medicine, Section of Infectious Disease, MI, USA
| | - Dirk G Struijk
- Department of Nephrology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | | - David W Johnson
- Department of Nephrology, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia
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19
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Kowalewska PM, Nguyen UT, Burrows LL, Fox-Robichaud AE. Syndecan-1 (CD138) deficiency increases Staphylococcus aureus infection but has no effect on pathology in a mouse model of peritoneal dialysis. J Biomed Sci 2016; 23:20. [PMID: 26832929 PMCID: PMC4736699 DOI: 10.1186/s12929-016-0232-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 01/12/2016] [Indexed: 12/29/2022] Open
Abstract
Background Technique failure in peritoneal dialysis (PD) due to fibrosis and angiogenesis is complicated by peritonitis. Staphylococcus aureus infection is one of the most common causes of peritonitis in PD. The heparan sulfate proteoglycan, syndecan-1 (CD138), was reported to regulate fibrosis, angiogenesis, inflammation and S. aureus infection. The objectives of this study were to examine the effects of syndecan-1 on S. aureus infection and histopathology in a PD model. Results Syndecan-1-/- and wild type mice were dialyzed for 4 weeks and infected intraperitoneally with S. aureus. Tissues were collected after 4 h for histomorphometric analysis. Intravital microscopy was used to observe leukocyte recruitment and to quantify syndecan-1 in the parietal peritoneum microcirculation. The dialyzed syndecan-1-/- mice were more susceptible to S. aureus infection than undialyzed syndecan-1-/- controls and wild type animals. However, peritoneal fibrosis and neovascularization due to PD did not differ between syndecan-1-/- and wild type mice. Intravital microscopy showed that in S. aureus infection, syndecan-1 was removed from the subendothelial layer of peritoneal venules but syndecan-1 deficiency did not affect leukocyte recruitment. Conclusions This study indicates that, while syndecan-1 is important for providing a barrier to acute S. aureus infection in PD, it does not affect peritoneal fibrosis and angiogenesis.
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Affiliation(s)
- Paulina M Kowalewska
- Thrombosis and Atherosclerosis Research Institute and the Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Uyen T Nguyen
- Department of Biochemistry and Biomedical Sciences and the Michael G. DeGroote Institute for Infectious Diseases Research, McMaster University, Hamilton, ON, Canada
| | - Lori L Burrows
- Department of Biochemistry and Biomedical Sciences and the Michael G. DeGroote Institute for Infectious Diseases Research, McMaster University, Hamilton, ON, Canada
| | - Alison E Fox-Robichaud
- Thrombosis and Atherosclerosis Research Institute and the Department of Medicine, McMaster University, Hamilton, ON, Canada. .,David Braley Cardiac, Vascular and Stroke Research Institute, C5-106, 237 Barton Street East, Hamilton, ON, L8L 2X2, Canada.
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20
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Chen SS, Sheth H, Piraino B, Bender F. Long-Term Exit-Site Gentamicin Prophylaxis and Gentamicin Resistance in a Peritoneal Dialysis Program. Perit Dial Int 2015; 36:387-9. [PMID: 26634567 DOI: 10.3747/pdi.2015.00162] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 10/06/2015] [Indexed: 11/15/2022] Open
Abstract
UNLABELLED ♦ BACKGROUND Daily gentamicin cream exit-site prophylaxis reduces peritoneal dialysis (PD)-related gram-negative infections. However, there is a concern about the potential for increasing gentamicin resistance with the long-term use of prophylactic gentamicin. This study evaluated the incidence of gentamicin-resistant PD-related infections over more than 2 decades. ♦ METHODS Study data on prevalent PD patients were retrieved from a prospectively maintained institutional review board (IRB)-approved PD registry at a single center from January 1, 1991, to December 31, 2000, and January 1, 2004, to December 31, 2013. The rates of gram-negative infections, fungal infections and those infections with organisms resistant to gentamicin were examined for the 2 periods. Period 1 from 1991 to 2000 when S. aureus prophylaxis consisted initially of oral rifampin to treat nasal carriage with S. aureus, and was then daily exit-site mupirocin ointment for all PD patients, was compared to the period from 2004 to 2013 when daily exit-site gentamicin cream was prescribed as prophylaxis (Period 2). ♦ RESULTS The study included a total of 444 PD patients (265 and 179 in Period 1 and Period 2, respectively). No significant difference was noted in demographics between the 2 periods except race. The gram-negative exit-site infection rates for Period 1 and Period 2 were 0.109 versus 0.027 (p < 0.0001). Gram-negative peritonitis rates were similar. There were 3 episodes of gentamicin-resistant infections in each period. Fungal infections remained consistently low. ♦ CONCLUSION Despite a decade of exit-site gentamicin prophylaxis, gentamicin-resistant PD-related infections and fungal infections remained very low and similar to the prior period.
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Affiliation(s)
- Shan Shan Chen
- Nephrology Division, Department of Medicine at the University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Heena Sheth
- Renal-Electrolyte Division, Department of Medicine at the University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Beth Piraino
- Renal-Electrolyte Division, Department of Medicine at the University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Filitsa Bender
- Renal-Electrolyte Division, Department of Medicine at the University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Burkhalter F, Clemenger M, Haddoub SS, McGrory J, Hisole N, Brown E. Pseudomonas exit-site infection: treatment outcomes with topical gentamicin in addition to systemic antibiotics. Clin Kidney J 2015; 8:781-4. [PMID: 26613039 PMCID: PMC4655795 DOI: 10.1093/ckj/sfv089] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 08/12/2015] [Indexed: 11/12/2022] Open
Abstract
Background Although, Pseudomonas exit-site infection (ESI) is recognized as a major complication of peritoneal dialysis (PD) with high risk of catheter loss due to refractory/recurrent infection or peritonitis, there is remarkably little literature about treatment outcomes. International Society for Peritoneal Dialysis guidelines advise the use of one to two antibiotics; in addition, we change standard exit-site care by stopping prophylactic mupirocin and starting regular use of gentamicin 1% cream. Methods Retrospective review of outcomes of Pseudomonas ESI from January 2012 to March 2015. Results During the study period, a total of 135 patients were on PD with an overall incidence of any ESI of 0.36/patient-year. There were 14 patients with ESI episodes with Pseudomonas with a rate of 0.12/patient-year. In total, 13 of 14 patients with ESI episodes were treated with oral ciprofloxacin and/or intraperitoneal (IP) gentamicin or ceftazidime, plus topical gentamicin, with a success rate of 38% (5/13). One patient had gentamicin-resistant Pseudomonas species and was treated successfully with topical polymyxin/bacitracin cream. Median follow-up time in cured patients was 385 days (range 74–1107). Six patients had associated with Pseudomonas peritonitis, four during follow-up and two at initial presentation. Three patients had recurrent ESI with Pseudomonas, with one successfully re-treated with topical and IP gentamicin. In total, in only 50% of the patients was Pseudomonas ESI successfully treated. Five of the patients (36%) changed modality to permanent haemodialysis following catheter removal. Conclusion Eradication of Pseudomonas ESI remains difficult even with the addition of topical gentamicin to the exit site. There should be a low threshold for catheter replacement.
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Affiliation(s)
- Felix Burkhalter
- Clinic for Transplant Immunology and Nephrology , University Hospital Basel , Basel , Switzerland
| | - Michelle Clemenger
- Imperial College Renal and Transplant Centre , Hammersmith Hospital , London , UK
| | - San San Haddoub
- Imperial College Renal and Transplant Centre , Hammersmith Hospital , London , UK
| | - Jacqueline McGrory
- Imperial College Renal and Transplant Centre , Hammersmith Hospital , London , UK
| | - Nora Hisole
- Imperial College Renal and Transplant Centre , Hammersmith Hospital , London , UK
| | - Edwina Brown
- Imperial College Renal and Transplant Centre , Hammersmith Hospital , London , UK
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Abstract
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.
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Affiliation(s)
- Jonathan H Segal
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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Feng X, Yang X, Yi C, Guo Q, Mao H, Jiang Z, Li Z, Chen D, Cui Y, Yu X. Escherichia coli Peritonitis in peritoneal dialysis: the prevalence, antibiotic resistance and clinical outcomes in a South China dialysis center. Perit Dial Int 2014; 34:308-16. [PMID: 24497589 DOI: 10.3747/pdi.2013.00012] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Escherichia coli (E. coli) peritonitis is a frequent, serious complication of peritoneal dialysis (PD). The extended-spectrum β-lactamase (ESBL)-producing E. coli peritonitis is associated with poorer prognosis and its incidence has been on continuous increase during the last decades. However, the clinical course and outcomes of E. coli peritonitis remain largely unclear. METHODS All of the E. coli peritonitis episodes that occurred in our dialysis unit from 2006 to 2011 were reviewed. The polymicrobial episodes were excluded. RESULTS In total, ninety episodes of monomicrobial E. coli peritonitis occurred in 68 individuals, corresponding to a rate of 0.027 episodes per patient-year. E. coli was the leading cause (59.2%) of monomicrobial gram-negative peritonitis. ESBL-producing strains accounted for 35.5% of E. coli peritonitis. The complete cure rate and treatment failure rate of E. coli peritonitis were 77.8% and 10.0% respectively. Patients with preceding peritonitis had a higher risk of ESBL production as compared to those without peritonitis history [odds ratio (OR): 5.286; 95% confidence interval (CI): 2.018 - 13.843; p = 0.001]. The risk of treatment failure was significantly increased when the patient had a baseline score of Charlson Comorbidity Index (CCI) above 3 (OR: 6.155; 95% CI: 1.198 - 31.612; p = 0.03), or had diabetes mellitus (OR: 8.457; 95% CI: 1.838 - 38.91; p = 0.006), or hypoalbuminemia (≤ 30g/l) on admission (OR: 13.714; 95% CI: 1.602 - 117.428; p = 0.01). Prolonging the treatment course from 2 to 3 weeks or more reduced the risk of relapse and repeat significantly (p < 0.05). CONCLUSIONS E. coli peritonitis remains a common complication of PD. The clinical outcomes of E. coli peritonitis are relatively favorable despite the high ESBL rate. A history of peritonitis is associated with increased risk for ESBL development. The severity of baseline comorbidities, the presence of diabetes mellitus and hypoalbuminemia at admission are associated with poor outcomes.
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Affiliation(s)
- Xiaoran Feng
- Department of Nephrology, Epidemiology and Clinical Research Unit, and Department of Clinical Microbiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiao Yang
- Department of Nephrology, Epidemiology and Clinical Research Unit, and Department of Clinical Microbiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chunyan Yi
- Department of Nephrology, Epidemiology and Clinical Research Unit, and Department of Clinical Microbiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qunying Guo
- Department of Nephrology, Epidemiology and Clinical Research Unit, and Department of Clinical Microbiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Haiping Mao
- Department of Nephrology, Epidemiology and Clinical Research Unit, and Department of Clinical Microbiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zongpei Jiang
- Department of Nephrology, Epidemiology and Clinical Research Unit, and Department of Clinical Microbiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhibin Li
- Department of Nephrology, Epidemiology and Clinical Research Unit, and Department of Clinical Microbiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Dongmei Chen
- Department of Nephrology, Epidemiology and Clinical Research Unit, and Department of Clinical Microbiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yingpeng Cui
- Department of Nephrology, Epidemiology and Clinical Research Unit, and Department of Clinical Microbiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xueqing Yu
- Department of Nephrology, Epidemiology and Clinical Research Unit, and Department of Clinical Microbiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Núñez-Moral M, Sánchez-Álvarez E, González-Díaz I, Peláez-Requejo B, Fernández-Viña A, Quintana-Fernández A, Rodríguez-Suárez C. Exit-site infection of peritoneal catheter is reduced by the use of polyhexanide. results of a prospective randomized trial. Perit Dial Int 2014; 34:271-7. [PMID: 24497599 DOI: 10.3747/pdi.2012.00109] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND One of the most common and severe complications affecting peritoneal dialysis (PD) patients is exit-site infection of the peritoneal catheter; it is therefore of vital importance to prevent it. This complication has a negative impact on the success of the technique. In spite of this, there are no clear guidelines concerning how to take care of the exit site. The objective of this study was to assess the efficacy of polyhexanide in preventing exit-site infection over a 12-month period. METHODS We designed a single-center, prospective, open-labeled, randomized controlled clinical trial with parallel groups. Requirements for participation in the study included implantation of the peritoneal catheter at least six weeks before entering the study and no infectious complications requiring either hospital admission or antibiotic treatment for at least three months before entering into the study. Patients were randomized to be daily cured as follows: Group A: traditional care with saline serum and povidone-iodine; and Group B: polyhexanide solution. Exit sites were evaluated at baseline and every four to six weeks or if any event occurred, according to the Twardowski criteria. RESULTS Of the 60 included patients, 46 completed the 12-month follow-up period. Six underwent transplantation, five died and three were transferred to hemodialysis (HD). The treatment was well tolerated, with no side effects nor abandonments due to such effects. Throughout the study period, six patients (20%) undergoing traditional care and only two (6,7%) receiving polyhexanide developed an exit-site infection (p = 0.032). There were a total number of 12 infections; nine occurred in patients following the traditional approach and only three in patients treated with polyhexanide (p = 0.037). The germs responsible for the infections were: S. aureus (six cases), Corynebacterium jeikeium (two cases) and P. aeruginosa (one case) in the saline serum and povidone-iodine group and P. aeruginosa (three cases) in the polyhexanide group. The mean rate of exit-site infection was 1 episode/36.6 patient-months for the traditional care group and 1 episode/102.7 patient-months for the polyhexanide group (p = 0.017). Patients following the traditional treatment required fewer days to get infected than those using polyhexanide (p = 0.033; log rank: 4.2). CONCLUSIONS These results show that using polyhexanide is efficient for the prevention of exit-site infections. Patients treated with this product suffer from fewer infections and need more time to become infected. Polyhexanide application is painless, no allergies have been described and it is well tolerated by patients. We therefore propose that it may be used routinely from now on for the care of healthy exit site.
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Affiliation(s)
- M Núñez-Moral
- Nephrology Service, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - E Sánchez-Álvarez
- Nephrology Service, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - I González-Díaz
- Nephrology Service, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - B Peláez-Requejo
- Nephrology Service, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - A Fernández-Viña
- Nephrology Service, Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | - C Rodríguez-Suárez
- Nephrology Service, Hospital Universitario Central de Asturias, Oviedo, Spain
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Barraclough KA, Hawley CM, Playford EG, Johnson DW. Prevention of access-related infection in dialysis. Expert Rev Anti Infect Ther 2014; 7:1185-200. [DOI: 10.1586/eri.09.100] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Prevention of peritoneal dialysis catheter infections in Saudi peritoneal dialysis patients: the emergence of high-level mupirocin resistance. Int J Artif Organs 2013; 36:473-83. [PMID: 23897229 DOI: 10.5301/ijao.5000207] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2013] [Indexed: 11/20/2022]
Abstract
PURPOSE Exit-site infection (ESI) and peritonitis remain the major causes of morbidity and mortality in peritoneal dialysis (PD) patients. This study compared the effectiveness of local mupirocin ointment and gentamicin cream in preventing both gram-positive and gram-negative bacterial infections in PD patients. METHODS Patients from two centers (n = 203) were assigned to daily mupirocin ointment or gentamicin cream application. Infections were tracked prospectively by organisms and expressed as episodes per patient-year for both ESI and peritonitis. RESULTS The rate of gram-positive ESI was 0.31/episode/patient-year and 0.22 episodes/patient-year (p<0.05), whereas the rate of gram-negative ESI was 0.28 episode/patient-year and 0.11 episode/patient-year (p<0.01) in the mupirocin group and gentamicin group, respectively. Gram-positive ESI occurred in 17.1% vs 10.2% of patients (p<0.05), whereas 20% of and 5.1% of patients (p<0.001) had gram-negative ESI in the 2 groups respectively. S.aureus was cultured at exit-site in the mupirocin group in 27.8% patients, 60% (16.7% of the total Gram-positive isolates) of them being with high-level mupirocin-resistance. Pseudomonas aeruginosa was cultured in 21.8% of ESI in the mupirocin group, and in only 6.7% in the gentamicin group (p<0.01). Peritonitis rates were lower using gentamicin cream, 0.17 episode/patient-year compared with mupirocin, 0.39 episode/patient-year (p<0.01). With multivariate analysis, only gentamicin exit-site use was a significant predictor for lower catheter infection rate. CONCLUSION Prolonged use of mupirocin for ESI-prophylaxis is associated with the emergence of mupirocin-resistant S. aureus. Gentamicin cream is superior to mupirocin ointment in the prevention of PD catheter infections.
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Oliveira LG, Luengo J, Caramori JCT, Montelli AC, Cunha MDLRS, Barretti P. Peritonitis in recent years: clinical findings and predictors of treatment response of 170 episodes at a single Brazilian center. Int Urol Nephrol 2013; 44:1529-37. [PMID: 22302733 DOI: 10.1007/s11255-011-0107-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Accepted: 12/16/2011] [Indexed: 12/21/2022]
Abstract
PURPOSE Peritonitis continues to be a major cause of dropout in peritoneal dialysis (PD) patients. Changes in the prevalence of peritonitis etiologies and an increase in the frequency of methicillin-resistant coagulase-negative staphylococci (CoNS) and Gram-negative species resistant to commonly used antibiotics have been reported. As a consequence, the current clinical presentation and patient outcome may differ from classical descriptions. The objectives of this study were to describe the clinical and microbiological characteristics of PD-related peritonitis episodes that occurred over a period of 6 years at a single Brazilian dialysis center and to identify predictors of outcome. METHODS A total of 170 peritonitis episodes that occurred in 92 PD patients between January 2004 and December 2009 were reviewed. Multivariate analysis was used to identify demographic, clinical, and microbiological factors predicting endpoints (resolution and peritonitis-related death). Patients' characteristics and peritonitis incidence, etiology and outcomes were compared with a series of 232 episodes that occurred in the first 6 years (1995-2000) of the PD program at the same center. RESULTS The overall peritonitis rate was 0.65 episodes/patient-year. Gram-positive cocci were identified in 79 (46.5%) episodes, whereas Gram-negative bacilli were isolated from 48 (28.2%). CoNS were the main Gram-positive species identified in 48 episodes. Of these, 56.3% were resistant to methicillin. Among Gram-negative species, amikacin resistance was observed in 60% of non-fermentative Gram-negative bacilli (NFGNB) and in only 3.6% of Enterobacteriaceae. The overall resolution rate was 44.1%. Oxacillin resistance and NFGNB etiology were strong predictors of non-resolution, whereas older age was the only predictor of death. Antibiotic protocols did not influence outcome. Comparison with the results obtained for the 1990-1995 period showed a lower peritonitis rate, a strong decline in the proportion of Staphylococcus aureus episodes, a significant increase in the frequency of oxacillin-resistant CoNS and amikacin-resistant NFGNB, and a significantly lower resolution and higher death rate. CONCLUSIONS The current clinical characteristics and outcome suggest a greater severity of peritonitis episodes and higher risk of death, possibly due to bacterial resistance. Older age is a risk factor for death.
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Affiliation(s)
- Luiz Gustavo Oliveira
- Department of Internal Medicine, Botucatu Medical School, Sao Paulo State University-UNESP, Botucatu, Sao Paulo 18618-970, Brazil
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Warady BA, Bakkaloglu S, Newland J, Cantwell M, Verrina E, Neu A, Chadha V, Yap HK, Schaefer F. Consensus guidelines for the prevention and treatment of catheter-related infections and peritonitis in pediatric patients receiving peritoneal dialysis: 2012 update. Perit Dial Int 2013; 32 Suppl 2:S32-86. [PMID: 22851742 DOI: 10.3747/pdi.2011.00091] [Citation(s) in RCA: 126] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Bradley A Warady
- Division of Pediatric Nephrology, Children's Mercy Hospitals and Clinics, Kansas City, Missouri 64108, USA.
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van Diepen ATN, Tomlinson GA, Jassal SV. The association between exit site infection and subsequent peritonitis among peritoneal dialysis patients. Clin J Am Soc Nephrol 2012; 7:1266-71. [PMID: 22745277 DOI: 10.2215/cjn.00980112] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Peritonitis is the most common infectious complication seen in peritoneal dialysis (PD). Traditionally, exit site infection (ESI) has been thought to predispose PD patients to peritonitis, although the risks have not been quantified. This study aimed to quantify the risk of PD peritonitis after ESI. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Data from 203 clinically stable PD patients >18 years of age who were followed as part of a randomized controlled trial over 18 months were used to estimate the risk of developing peritonitis within 30 days of an ESI compared with individuals who did not have a recent ESI. Sensitivity analyses were performed at 15, 45, and 60 days. RESULTS Patients were mostly male (64.5%) and Caucasian, with a mean age of 60.5 ± 14.4 years. There were 44 ESIs and 87 peritonitis episodes during the 18-month study. Seven patients had an ESI followed by peritonitis within 30 days. Using a frailty model, patients who had an ESI had a significantly higher risk of developing peritonitis within 30 days, even if the ESI was appropriately treated. This risk was maximal early on and diminished with time, with hazard ratios (95% confidence interval) of 11.1 at 15 days (HR=11.1, 95% CI=4.9-25.1), 5.3 at 45 days (2.5-11.3), and 4.9 at 60 days (2.4-9.9). In 2.3% of patients, subsequent peritonitis was caused by the same organism as the previous ESI. CONCLUSIONS A strong association between a treated ESI and subsequent PD peritonitis was present up to 60 days after initial diagnosis.
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Di Bonaventura G, Cerasoli P, Pompilio A, Arrizza F, Di Liberato L, Stingone A, Sirolli V, Arduini A, Bonomini M. In vitro microbiology studies on a new peritoneal dialysis connector. Perit Dial Int 2012; 32:552-7. [PMID: 22302771 DOI: 10.3747/pdi.2011.00089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We evaluated the ability of a recently developed peritoneal dialysis (PD) connector to prevent the risk of bacterial transfer to the fluid path after simulated touch and airborne contamination. METHODS Staphylococcus epidermidis ATCC1228 and Pseudomonas aeruginosa ATCC27853 strains were used. For touch contamination, 2 μL of a standardized inoculum [1×10(8) colony-forming units (CFU) per milliliter] were deposited on top of the pin closing the fluid path of the patient connector. For airborne contamination, the patient connector was exposed for 15 seconds to a nebulized standardized inoculum. To simulate the patient peritoneum and effluent, the patient connector was pre-attached to a 2-L bag of sterile PD solution. After contamination, the patient connector was attached to the transfer set, the pin was captured, flow control was turned to simulate "patient drain" into the empty bag, and then "patient fill" using the bag pre-attached to the connector. Finally, a new pin was recaptured. The PD solution collected in the bag pre-attached to the connector was run through a 0.20-μm filter for colony counts. RESULTS No infected connector transferred bacteria to the fluid path, regardless of the challenge procedure or the strain used. CONCLUSIONS Our results show that the new PD connector may fully obviate the risk of bacterial infection, even in the presence of heavy contamination. Further studies are in progress to test our PD connector in a clinical setting.
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Schaefer F, Warady BA. Peritoneal dialysis in children with end-stage renal disease. Nat Rev Nephrol 2011; 7:659-68. [PMID: 21947118 DOI: 10.1038/nrneph.2011.135] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Peritoneal dialysis is the preferred chronic dialysis modality for most children owing to its almost universal applicability and superior compatibility with lifestyle over other modalities. Although technological advances and increasing clinical experience have impacted favorably on patient and technique survival, clinical research in pediatric peritoneal dialysis has been hampered by the low incidence of end-stage renal disease (ESRD) in the pediatric population. To overcome this limitation, several international registries have emerged in the past few years to complement other long-standing registries, which together have provided useful information regarding technique-specific complications and comorbidities associated with ESRD in children undergoing chronic peritoneal dialysis. In this Review, we summarize the most relevant findings from these studies, highlighting the substantial variation in patient conditions, peritoneal dialysis practices and management of comorbidities encountered in different parts of the world.
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Affiliation(s)
- Franz Schaefer
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany.
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Piraino B, Bernardini J, Brown E, Figueiredo A, Johnson DW, Lye WC, Price V, Ramalakshmi S, Szeto CC. ISPD position statement on reducing the risks of peritoneal dialysis-related infections. Perit Dial Int 2011; 31:614-30. [PMID: 21880990 DOI: 10.3747/pdi.2011.00057] [Citation(s) in RCA: 209] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Beth Piraino
- University of Pittsburgh School of Medicine,1 Pittsburgh, Pennsylvania, USA.
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Abstract
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.
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Pajek J, Guček A, Škoberne A, Pintar T. Severe Peritonitis in Patients Treated With Peritoneal Dialysis: A Case Series Study. Ther Apher Dial 2011; 15:250-6. [DOI: 10.1111/j.1744-9987.2011.00946.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Chadha V, Schaefer FS, Warady BA. Dialysis-associated peritonitis in children. Pediatr Nephrol 2010; 25:425-40. [PMID: 19190935 PMCID: PMC2810362 DOI: 10.1007/s00467-008-1113-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2008] [Revised: 11/18/2008] [Accepted: 12/09/2008] [Indexed: 01/06/2023]
Abstract
Peritonitis remains a frequent complication of peritoneal dialysis in children and is the most common reason for technique failure. The microbiology is characterized by a predominance of Gram-positive organisms, with fungi responsible for less than 5% of episodes. Data collected by the International Pediatric Peritonitis Registry have revealed a worldwide variation in the bacterial etiology of peritonitis, as well as in the rate of culture-negative peritonitis. Risk factors for infection include young age, the absence of prophylactic antibiotics at catheter placement, spiking of dialysis bags, and the presence of a catheter exit-site or tunnel infection. Clinical symptoms at presentation are somewhat organism specific and can be objectively assessed with a Disease Severity Score. Whereas recommendations for empiric antibiotic therapy in children have been published by the International Society of Peritoneal Dialysis, epidemiologic data and antibiotic susceptibility data suggest that it may be desirable to take the patient- and center-specific history of microorganisms and their sensitivity patterns into account when prescribing initial therapy. The vast majority of patients are treated successfully and continue peritoneal dialysis, with the poorest outcome noted in patients with peritonitis secondary to Gram-negative organisms or fungi and in those with a relapsing infection.
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Affiliation(s)
- Vimal Chadha
- Department of Pediatrics, Section of Nephrology, Virginia Commonwealth University Medical Center, Richmond, VA USA
| | - Franz S. Schaefer
- Center for Pediatric and Adolescent Medicine, Section of Pediatric Nephrology, University of Heidelberg, Heidelberg, Germany
| | - Bradley A. Warady
- Department of Pediatrics, Section of Nephrology, The Children’s Mercy Hospital, Kansas City, MO USA
- University of Missouri–Kansas City School of Medicine, The Children’s Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108 USA
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Piraino B. Mupirocin for preventing exit-site infection and peritonitis in patients undergoing peritoneal dialysis. Was it effective? Nephrol Dial Transplant 2009; 25:349-52. [PMID: 19934078 DOI: 10.1093/ndt/gfp615] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Xu G, Tu W, Xu C. Mupirocin for preventing exit-site infection and peritonitis in patients undergoing peritoneal dialysis. Nephrol Dial Transplant 2009; 25:587-92. [PMID: 19679557 DOI: 10.1093/ndt/gfp411] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVES Recently, there have been increasing concerns about the emergence of mupirocin resistance and increased infections due to lowered inhibition of Staphylococcus aureus. We conducted this systemic analysis to find out whether the application of mupirocin was effective for the prevention of exit-site infection (ESI) and peritonitis in patients undergoing peritoneal dialysis (PD). METHODS Recruited studies met the following criteria: they were randomized controlled trials or historical cohort studies; subjects consisted of adults (age, >or= 18 years) undergoing PD; mupirocin treatment was administered to the therapy group and placebo or no treatment was administered to the control group. The primary extracted data were the difference in the episodes of ESI and peritonitis S. aureus or other organisms among treatment and control groups. Results. Fourteen studies described in 13 articles and a total of 1,233 patients versus 1,217 controls were included in the analysis. Of the 13 articles, 6 were newly published articles that had not been analysed previously and 3 were randomized controlled trials. The application of mupirocin decreased the risk by 72% [95% confidence interval (CI): 0.60-0.81] in ESI and by 70% (95% CI 0.52-0.81) in peritonitis due to S. aureus among all patients undergoing PD. Treatment of mupirocin reduced the risks of ESI and peritonitis due to all organisms by 57% (95% CI: 0.46-0.66) and 41% (95% CI: 0.24-0.54), respectively. Based on the six newly published articles, the reduced risk rate for mupirocin therapy was found to be 80% (95% CI: 0.39-0.93, P = 0.004) in ESI and 91% (95% CI: 0.72-0.97, P < 0.0001) in peritonitis due to S. aureus; 70% (95% CI: 0.47-0.82, P < 0.0001) in ESI and 42% (95% CI: 0.25-0.55, P < 0.0001) in peritonitis due to all organisms among mupirocin-treated and -untreated subjects. Based on the three randomized controlled trials, ESI and peritonitis due to S. aureus were found to be reduced by 73% (95% CI: 0.63-0.80, P < 0.0001) and 40% (95% CI: 0.17-0.56, P = 0.002), respectively. Interestingly, although mupirocin treatment can reduce the risk rate of ESI by 46% (95% CI: 0.35-0.55, P < 0.00001), it cannot decrease the risk rate of peritonitis due to all organisms (P = 0.56). CONCLUSIONS Mupirocin prophylaxis was effective on preventing ESI and peritonitis due to S. aureus and other organisms in PD patients.
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Affiliation(s)
- Gaosi Xu
- Department of Nephrology, Second Affiliated Hospital, Nanchang University, Nanchang, China.
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Akman S, Bakkaloglu SA, Ekim M, Sever L, Noyan A, Aksu N. Peritonitis rates and common microorganisms in continuous ambulatory peritoneal dialysis and automated peritoneal dialysis. Pediatr Int 2009; 51:246-9. [PMID: 19405925 DOI: 10.1111/j.1442-200x.2008.02693.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The aim of the present study was to perform a multicenter investigation in Turkish children on chronic peritoneal dialysis by examining the rates of peritonitis as well as causative organisms according to year. METHODS Twelve pediatric renal units participated in this study and data were obtained by review of the medical records. RESULTS One hundred and thirty-two patients were on continuous ambulatory peritoneal dialysis (CAPD), 21 were on automated peritoneal dialysis (APD) and 59 were on CAPD and APD at different times. Mean durations of CAPD and APD were 24.2 +/- 21.1 months and 22.9 +/- 12.8 months, respectively. Seventy-one (33%) out of 212 patients had no peritonitis episode. Overall peritonitis rate was one episode per 15.5 patient-months. The peritonitis rate was one episode per 15.4 patient-months for APD and one episode per 15.6 patient-months for CAPD. Coagulase-negative staphylococcus was the most common cause of peritonitis among patients with positive culture (20.6%). While the incidence of Gram-negative infection remained unchanged according to year in patients on CAPD (P = 0.68), the rate of Gram-negative peritonitis in children on APD was significantly higher (P = 0.03). CONCLUSIONS Peritonitis rate was similar in CAPD and APD, but the risk of Gram-negative peritonitis in APD was higher than that of CAPD.
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Affiliation(s)
- Sema Akman
- Department of Pediatric Nephrology, Akdeniz University School of Medicine, Antalya, Turkey.
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Barretti P, Pereira D, Brasil MA, de Lourdes Cunha M, Caramori J, Montelli A. Evolution of Gram-Negative Bacilli Susceptibility in Peritoneal Dialysis-Related Peritonitis in Brazil: A Single Center's Experience over Nine Years. Perit Dial Int 2009. [DOI: 10.1177/089686080902900219] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Zurowska A, Feneberg R, Warady BA, Zimmering M, Monteverde M, Testa S, Calyskan S, Drozdz D, Salusky I, Kemper MJ, Ekim M, Verrina E, Misselwitz J, Schaefer F. Gram-negative peritonitis in children undergoing long-term peritoneal dialysis. Am J Kidney Dis 2008; 51:455-62. [PMID: 18295061 DOI: 10.1053/j.ajkd.2007.11.011] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2007] [Accepted: 11/28/2007] [Indexed: 11/11/2022]
Abstract
BACKGROUND The proportion of gram-negative causative organisms in peritoneal dialysis-associated peritonitis is increasing. Little published information for this complication exists in children. The objective of this study is to evaluate the clinical presentation, early and late response to treatment, and identification of factors influencing the outcome of gram-negative peritonitis (GNP) in children. STUDY DESIGN Case series. SETTING AND PARTICIPANTS 104 children (aged 7.9 +/- 5.9 years) with 121 GNP episodes reported to the International Pediatric Peritonitis Registry from October 2001 through December 2004. PREDICTORS Patient, clinical, bacteriological, and treatment features. OUTCOMES Initial response to empirical treatment was assessed after approximately 72 hours of therapy. Final outcome was judged according to the occurrence of death, technique failure, relapse, need for catheter exchange, and a composite end point defining full functional recovery. RESULTS 44% of episodes of GNP occurred in children younger than 5 years. Causative organisms included Pseudomonas species, 21%; Klebsiella species, 18%; Escherichia coli, 17%; and Acinetobacter species, 12%. Thirty-two percent of organisms classified as gram-negative were not identified further. Clinical manifestations were severe and uniform for all causative gram-negative agents. A substantial proportion (20%) of organisms were resistant to ceftazidime, with resulting suboptimal response to empirical therapy. By day 3 of initial empiric treatment, 85% of children with GNP had improved clinically (39%, complete resolution; 46%, improvement in symptoms), 10% showed poor response, and 5% had worsening of symptoms. Multivariate analysis identified severe abdominal pain, use of a single-cuff catheter, and intermittent (versus continuous) intraperitoneal ceftazidime administration as independent predictors of worse initial response to treatment. Full functional recovery was achieved in 86% of episodes. Nineteen patients (16%) required catheter removal, 11 (9%) experienced a relapse, 7 (6%) discontinued peritoneal dialysis therapy permanently, and 3 died. Lack of clinical improvement after 72 hours of therapy (odds ratio, 5.39; P < 0.01) and the presence of an exit-site infection (odds ratio, 7.69; P = 0.01) independently increased the risk of an incomplete functional recovery. LIMITATIONS The study was not designed to assess absolute incidence figures or risk factors for the development of GNP in children. CONCLUSIONS GNP is a significant complication of long-term peritoneal dialysis therapy in children, and a substantial proportion of affected children are at risk of permanent sequelae. Because results of empiric treatment with ceftazidime are suboptimal in the setting of this infection, alternative antimicrobial agents should be reconsidered.
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Affiliation(s)
- Aleksandra Zurowska
- Department of Paediatric and Adolescent Nephrology and Hypertension, Medical University of Gdansk, Poland
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Bender FH, Bernardini J, Piraino B. Prevention of infectious complications in peritoneal dialysis: best demonstrated practices. Kidney Int 2007:S44-54. [PMID: 17080111 DOI: 10.1038/sj.ki.5001915] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Peritoneal dialysis (PD) related infections continue to be a serious complication for PD patients. Peritonitis can be associated with pain, hospitalization and catheter loss as well as a risk of death. Peritonitis risk is not evenly spread across the PD population or programs. Very low rates of peritonitis in a program are possible if close attention is paid to the causes of peritonitis and protocols implemented to reduce the risk of infection. Protocols to decrease infection risk in PD patients include proper catheter placement, exit-site care that includes Staphylococcus aureus prophylaxis, careful training of patients with periodic retraining, treatment of contamination, and prevention of procedure-related and fungal peritonitis. Extensive data have been published on the use of antibiotic prophylaxis to prevent exit site infections. There are fewer data on training methods of patients to prevent infection risk. Quality improvement programs with continuous monitoring of infections, both of the catheter exit site and peritonitis, are important to decrease the PD related infections in PD programs. Continuous review of every episode of infection to determine the root cause of the event should be routine in PD programs. Further research is needed examining approaches to decrease infection risk.
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Affiliation(s)
- F H Bender
- Renal Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA.
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Auron A, Simon S, Andrews W, Jones L, Johnson S, Musharaf G, Warady BA. Prevention of peritonitis in children receiving peritoneal dialysis. Pediatr Nephrol 2007; 22:578-85. [PMID: 17216260 DOI: 10.1007/s00467-006-0375-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2006] [Revised: 09/27/2006] [Accepted: 10/18/2006] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Ari Auron
- Section of Pediatric Nephrology, The Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
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Leppänen H, Metsärinne KP, Nikoskelainen J, Tertti R. Three-year analysis of microbial aetiology and antimicrobial susceptibilities of PD peritonitis. ACTA ACUST UNITED AC 2006; 38:645-9. [PMID: 16857609 DOI: 10.1080/00365540600606390] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The first-line antibiotic treatment of peritoneal dialysis (PD) peritonitis has to cover the most common causative microorganisms. Our aim was to analyse antimicrobial sensitivities of different empirical protocols for initial therapy of PD peritonitis. We analysed the aetiological microorganisms of PD peritonitis and their antimicrobial sensitivities during a 36-month period. Clinical characteristics of the cases were recorded. Altogether 86 PD peritonitides were diagnosed during the study period. In 58 cases, microbial cultures were positive with 72 different causative agents. 28 cases (33%) were culture-negative. Over-representation of icodextrin users was noted among the culture-negative cases. Staphylococcus aureus was the most frequent causative agent, often leading to severe course of illness. Of antimicrobial protocols for initial treatment of peritonitis tested in vitro, the combination of a first-generation cephalosporin and an aminoglycoside was superior to the combination of a first-generation cephalosporin and ceftazidime as well as to fluoroquinolone monotherapy but similar to the combination of vancomycin and ceftazidime. Based on antimicrobial sensitivities we continue using an aminoglycoside in the empirical treatment of PD peritonitis. In the present material, users of icodextrin PD fluid were over-represented among patients with culture-negative peritonitis.
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Affiliation(s)
- Heidi Leppänen
- Department of Internal Medicine, Turku University Central Hospital, Turku, Finland
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Faber MD, Yee J. Diagnosis and management of enteric disease and abdominal catastrophe in peritoneal dialysis patients with peritonitis. Adv Chronic Kidney Dis 2006; 13:271-9. [PMID: 16815232 DOI: 10.1053/j.ackd.2006.04.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Peritoneal dialysis (PD)-associated peritonitis rates have decreased significantly in recent years, especially Staphylococcus epidermidis and Staphylococcus aureus infections. Rates of gram-negative, polymicrobial, and fungal peritonitis have remained steady. The reported mortality of gram-negative and polymicrobial peritonitis varies widely (4%-50%). Most likely, the reason for this variability is that prognosis depends on the underlying etiology more than the specific microorganisms isolated. Gram-negative, polymicrobial, and fungal infection have variable association with documented visceral disease, and the highest mortality occurs in reports with the highest prevalence of intra-abdominal pathology. The odds ratio of death in PD patients with documented abdominal catastrophe and peritonitis is reported to be 20:1 compared with all other causes. Further reductions in PD-associated peritonitis mortality are likely to depend on earlier diagnosis and better management of intra-abdominal pathology. Presentation with hypotension, sepsis, lactic acidosis, and/or elevation of peritoneal fluid amylase should raise immediate concern for "surgical" peritonitis. Suspicion for visceral disease should also be high in patients with gram-negative, polymicrobial, and fungal infection or those who fail to improve rapidly as judged by clinical signs and symptoms, cell counts, and repeat cultures. Nonlocalizing physical examination and negative or nonspecific results of abdominal computed tomography do not rule out serious intra-abdominal disease. Immediate initiation of broad antibiotic coverage including for anaerobic infection is indicated when bowel pathology is suspected. Urgent surgical consultation, with active discussion and participation by the nephrologist, is advisable when visceral pathology is suspected and the patient is unstable or fails to improve rapidly.
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Affiliation(s)
- Mark D Faber
- Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, MI 48202, USA.
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Narins RG, Halperin M, Danovitch G, Falk R, Bargman J. The Nephrology Quiz and Questionnaire: 2005. Clin J Am Soc Nephrol 2006; 1:592-608. [PMID: 17699263 DOI: 10.2215/cjn.00440206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Lim CTS, Wong KS, Foo MWY. The impact of topical mupirocin on peritoneal dialysis infection in Singapore General Hospital. Nephrol Dial Transplant 2005; 20:2202-6. [PMID: 16046516 DOI: 10.1093/ndt/gfi010] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Peritonitis and exit-site infections (ESI) are major causes of morbidity in peritoneal dialysis (PD) patients. The application of topical mupirocin to exit sites reduces such complications, and prolongs life in PD. Since the year 2000, this topical treatment has been used in our hospital on new PD patients. We analysed the results of this protocol, and studied the effects of comorbidities on the incidence of peritonitis. METHODS We studied 740 incident PD patients, who were divided into two groups based on year of entry into PD (Group 1 from January 1998 to December 1999 inclusive, topical mupirocin not used, and Group 2 from January 2000 to March 2004 inclusive, topical mupirocin used). The variables we studied included gender, age, diabetic status, ischaemic heart disease, peripheral vascular disease, cerebrovascular disease and serum albumin. RESULTS The application of topical mupirocin at the exit site led to a significant reduction in the rate of peritonitis (0.443 vs 0.339 episodes per patient-year; P<0.0005) and in ESI (0.168 vs 0.156 episodes per patient-year; P<0.005), results attributed primarily by the significant (P<0.005) reduction in Staphylococcus aureus infection. There was also an unexpected lowering of Pseudomonas aeruginosa peritonitis in the mupirocin group (P<0.005). Stepwise multiple logistic regression analysis revealed that only the application of mupirocin and serum albumin levels were significant predictors of peritonitis. CONCLUSIONS Our study, although retrospective, has demonstrated that the topical use of mupirocin was associated with a significant reduction in ESI and peritonitis and, unexpectedly, with findings of fewer incidences of Pseudomonas peritonitis. Serum albumin level before the initiation of PD was a strong predictor of subsequent peritonitis. Mupirocin, with its low toxicity, ease of application and demonstrable beneficial effect in reducing ESI and peritonitis is now used on all of our incident PD patients.
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Affiliation(s)
- Edwina A Brown
- Faculty of Medicine, Imperial College, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK.
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Lim CTS, Wong KS, Foo MWY. The impact of topical mupirocin on peritoneal dialysis infection rates in Singapore General Hospital. Nephrol Dial Transplant 2005; 20:1702-6. [PMID: 15855200 DOI: 10.1093/ndt/gfh860] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Peritonitis and exit-site infections (ESI) are major causes of technique failure and morbidity in peritoneal dialysis (PD) patients. Topical mupirocin on the exit-site has been shown to reduce such complications and prolong life in PD. Since the year 2000, such an approach has been adopted for our new incident PD population. We now report the results of this new protocol. We also studied the effect of co-morbidity on peritonitis occurrence. METHODS A total of 740 incident PD patients were studied. Patients were divided into two groups based on year of entry into PD (Group 1 from January 1998-December 1999 without topical mupirocin and Group 2 from January 2000-March 2004 with topical mupirocin). Variables studied included gender, age, diabetic status, ischaemic heart disease, peripheral vascular disease, cerebrovascular disease and serum albumin. RESULTS Topical mupirocin at the exit-site has led to a significant reduction in peritonitis rate (0.443 vs 0.339 episodes/patient-year; P<0.0005) and ESI (0.168 vs 0.156 episodes/patient-year; P<0.005) attributed primarily to the significant reduction in Staphylococcus aureus infections. There was an unexpected finding of lower Pseudomonas aeruginosa peritonitis in the mupirocin group (P<0.005). Stepwise multiple logistic regression analysis revealed that only mupirocin application and serum albumin were significant predictors of peritonitis. CONCLUSIONS Our study, although limited by its retrospective nature, demonstrated that topical mupirocin was associated with a significant reduction in ESI and peritonitis with unexpected findings of lower Pseudomonas peritonitis. Serum albumin prior to the initiation of PD was a strong predictor of subsequent peritonitis. Mupirocin, with its low toxicity, ease of application and demonstrable beneficial effect in reducing ESI and peritonitis is now used on all incident PD patients.
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Bernardini J, Bender F, Florio T, Sloand J, Palmmontalbano L, Fried L, Piraino B. Randomized, double-blind trial of antibiotic exit site cream for prevention of exit site infection in peritoneal dialysis patients. J Am Soc Nephrol 2004; 16:539-45. [PMID: 15625071 DOI: 10.1681/asn.2004090773] [Citation(s) in RCA: 185] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Infection is the Achilles heel of peritoneal dialysis. Exit site mupirocin prevents Staphylococcus aureus peritoneal dialysis (PD) infections but does not reduce Pseudomonas aeruginosa or other Gram-negative infections, which are associated with considerable morbidity and sometimes death. Patients from three centers (53% incident to PD and 47% prevalent) were randomized in a double-blinded manner to daily mupirocin or gentamicin cream to the catheter exit site. Infections were tracked prospectively by organism and expressed as episodes per dialysis-year at risk. A total of 133 patients were randomized, 67 to gentamicin and 66 to mupirocin cream. Catheter infection rates were 0.23/yr with gentamicin cream versus 0.54/yr with mupirocin (P = 0.005). Time to first catheter infection was longer using gentamicin (P = 0.03). There were no P. aeruginosa catheter infections using gentamicin compared with 0.11/yr using mupirocin (P < 0.003). S. aureus exit site infections were infrequent in both groups (0.06 and 0.08/yr; P = 0.44). Peritonitis rates were 0.34/yr versus 0.52/yr (P = 0.03), with a striking decrease in Gram-negative peritonitis (0.02/yr versus 0.15/yr; P = 0.003) using gentamicin compared with mupirocin cream, respectively. Gentamicin use was a significant predictor of lower peritonitis rates (relative risk, 0.52; 95% confidence interval, 0.29 to 0.93; P < 0.03), controlling for center and incident versus prevalent patients. Gentamicin cream applied daily to the peritoneal catheter exit site reduced P. aeruginosa and other Gram-negative catheter infections and reduced peritonitis by 35%, particularly Gram-negative organisms. Gentamicin cream was as effective as mupirocin in preventing S. aureus infections. Daily gentamicin cream at the exit site should be the prophylaxis of choice for PD patients.
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Affiliation(s)
- Judith Bernardini
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
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