Enterococcal peritonitis in children receiving chronic peritoneal dialysis

BACKGROUND

Peritonitis is a common complication of chronic peritoneal dialysis (CPD) and can be associated with technique failure. Enterococcus is an uncommon peritoneal pathogen in children receiving CPD but represents a potential therapeutic challenge due to its innate resistance to cephalosporins and emerging resistance to glycopeptides.

METHODS

The International Pediatric Peritonitis Registry is a global consortium of 47 paediatric dialysis centres designed to address validation of the International Society for Peritoneal Dialysis paediatric peritonitis treatment guidelines. Between 2001 and 2004, peritonitis episodes were assessed in 392 participating children receiving CPD.

RESULTS

Among the 392 patients, 340 episodes of culture-positive peritonitis were evaluated. Twenty of these episodes were due to Enterococcus species (5.9%). There were no clinical characteristics uniquely associated with enterococcal peritonitis at presentation. After 3 days of therapy, 75% of patients were pain free, 95% had decreased effluent cloudiness and 90% were afebrile. Only one patient required a catheter exchange, and all patients experienced full functional recovery. Despite broad in vitro resistance to cephalosporins and 21% resistance to glycopeptides, neither in vitro resistance pattern nor choice of empiric antibiotic regimen affected short- or long-term outcomes.

CONCLUSIONS

Enterococci are likely responsible for ∼6% of culture-positive peritonitis episodes in children receiving CPD. Although it was not possible to identify patients with enterococcal peritonitis based on presentation, clinical response was not associated with in vitro resistance patterns, and patients who initially received a cephalosporin-based empiric regimen until culture results are available are likely to respond quickly and have full functional recovery.

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

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