Peritoneal Dialysis Guidelines 2019 Part 1 (Position paper of the Japanese Society for Dialysis Therapy)

Approximately 10 years have passed since the Peritoneal Dialysis Guidelines were formulated in 2009. Much evidence has been reported during the succeeding years, which were not taken into consideration in the previous guidelines, e.g., the next peritoneal dialysis PD trial of encapsulating peritoneal sclerosis (EPS) in Japan, the significance of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), the effects of icodextrin solution, new developments in peritoneal pathology, and a new international recommendation on a proposal for exit-site management. It is essential to incorporate these new developments into the new clinical practice guidelines. Meanwhile, the process of creating such guidelines has changed dramatically worldwide and differs from the process of creating what were “clinical practice guides.” For this revision, we not only conducted systematic reviews using global standard methods but also decided to adopt a two-part structure to create a reference tool, which could be used widely by the society’s members attending a variety of patients. Through a working group consensus, it was decided that Part 1 would present conventional descriptions and Part 2 would pose clinical questions (CQs) in a systematic review format. Thus, Part 1 vastly covers PD that would satisfy the requirements of the members of the Japanese Society for Dialysis Therapy (JSDT). This article is the duplicated publication from the Japanese version of the guidelines and has been reproduced with permission from the JSDT.

Bacterial colonization of non-permanent central venous catheters in hemodialysis dogs

Non-permanent central venous catheters (CVCs), are the most commonly used vascular access in veterinary patients undergoing hemodialysis. In human dialysis patients, CVC infection represents a common cause of morbidity and mortality. The aim of this retrospective observational study was to evaluate the prevalence of bacterial colonization of CVCs in dogs submitted to hemodialysis treatment at time of CVC removal.

The CVCs of all dogs submitted to hemodialysis (n = 23) at the Veterinary Teaching Hospital ''Mario Modenato'' of the University of Pisa between January 2015 and December 2016 were considered. For all dogs, data regarding signalment, reason for hemodialysis treatment, duration of catheterization (≤15 or >15 days), CVC complications, and 30-day survival were considered. Statistical analysis was performed using Graph Pad Prism™. Five over 23 dogs (22%) showed positive bacterial culture of CVC (+), and 18/23 dogs (78%) negative culture of CVC (-). The most prevalent microorganism was Staphylococcus Spp (3/5; 60%). No significant difference was found in the prevalence of CVC infection according to age, gender, reason for hemodialysis, CVC complications, duration of catheterization, and outcome. No statistically significant difference (p = 0.64) in survival curves was reported at log rank analysis between dogs with CVC - and CVC +.

The prevalence of bacterial CVC contamination in our dialysis dogs showed relatively low. Exclusive use of CVC for hemodialysis, good hygiene practice during CVC management, and use of chlorhexidine as an antiseptic should be strongly encouraged.

The Relationship between Extensively Drug-Resistant Tuberculosis and Multidrug-Resistant Gram-Negative Bacilli

OBJECTIVE

The relationship between extensively drug-resistant tuberculosis (XDR-TB) and multidrug-resistant Gram-negative bacilli (MDR-GNB) is unclear. Identification of the relationship between XDR-TB and MDR-GNB would have important implications for patient care.

METHODS

We conducted a retrospective study reviewing the records of patients admitted with a confirmed pulmonary TB from 2011 to 2014. To identify the relationship between XDR-TB and MDR-GNB, univariable comparison and multivariable logistic regression were performed.

RESULTS

Among 2962 pulmonary TB patients, 45(1.5%) patients had a diagnosis of XDR-TB. A total of 165 MDR-GNB strains were detected in 143 (4.8%) pulmonary TB patients. XDR-TB patients had a significantly higher occurrence of MDR-GNB than non-XDR-TB patients (24.4% vs. 4.5%; P<0.001). Age (OR 1.02, 95% CI 1.01-1.03), hypoalbuminemia (OR 1.48, 95% CI 1.18-1.85), chronic renal failure (OR 6.67, 95% CI 1.42-31.47), chronic hepatic insufficiency (OR 1.99, 95% CI 1.15-3.43), presence of XDR-TB (OR 6.56, 95% CI 1.61-26.69), and duration of TB diagnostic delay (OR 1.01, 95% CI 1.00-1.02) were the independent risk factors for MDR-GNB infection.

CONCLUSIONS

Patients with XDR-TB have a significantly higher risk of being affected by MDR-GNB pathogen. The underlying mechanism association warrant further studies.

Effects of a Statewide Protocol for the Management of Peritoneal Dialysis-Related Peritonitis on Microbial Profiles and Antimicrobial Susceptibilities: A Retrospective Five-Year Review

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BACKGROUND

Peritonitis is a major complication of peritoneal dialysis (PD) and is associated with significant morbidity and mortality. Early empirical antibiotic therapy is recommended, with the choice of agents guided by local resistance patterns. As routine use of specific antimicrobial agents can drive resistance, regular assessment of causative organisms and their susceptibility to empirical therapy is essential. ♦

METHODS

We conducted a retrospective review of all PD peritonitis cases and positive PD fluid cultures obtained over a 5-year period in Western Australia following the introduction of a statewide protocol for the initial management of PD peritonitis with intraperitoneal vancomycin and gentamicin. ♦

RESULTS

The incidence of PD peritonitis decreased from 1 in 16 patient months (0.75/year at risk) to 1 in 29 patient months (0.41/year at risk) over the 5 years. There were 1,319 culture-positive samples and 1,069 unique isolates identified. Gram-positive bacteria accounted for 69.9% of positive cultures, with vancomycin resistance averaging 2% over the study period. Gram-negative bacteria accounted for 25.4% of positive cultures, with gentamicin resistance identified in an average of 8% of organisms. No increase in antimicrobial resistance to vancomycin or gentamicin occurred over the 5 years and there was no change in the proportion of gram-positive (69.9%), gram-negative (25.4%) or fungal (4.4%) organisms causing PD peritonitis. ♦

CONCLUSIONS

Over time, the peritonitis rates have dramatically improved although the profile of causative organisms remains similar. Empirical treatment of PD peritonitis with intraperitoneal vancomycin and gentamicin remains efficacious, with high levels of susceptibility and no evidence that the introduction of this statewide empirical PD peritonitis treatment protocol is driving resistance to these agents.

Efficacy of silver treated catheters for haemodialysis in preventing bacterial adhesion

The growing resistance of many strains of bacteria to antibiotics and antiseptics is becoming a serious problem in medicine. Nano-silver is one of the most prominent products in medicine because it exhibits unusual physicochemical properties and a strong biological activity. In this work an innovative silver deposition technology was applied to temporary polyurethane catheters for haemodialysis. The working conditions of catheters were reproduced through laboratory equipment that ensured the flow of deionized water and simulated body fluid inside the lumina at corporeal temperature. The growth and the adhesion of Staphylococcus aureus on the surface of the device were studied through fluorescence microscopy. ICP-AES was adopted to calculate the amount of silver released from the substrate. The stability of the coating during the whole working life of the device was demonstrated through thermo-gravimetric analysis.

Fecal colonization of VIM-1-producing Klebsiella pneumoniae and in vivo transfer of multidrug-resistant IncN plasmid in a renal transplant patient

We report a case of long-term colonization of a carbapenemase (VIM)-producing Klebsiella pneumoniae clone in a renal transplant patient and demonstrate the in vivo transmission of a broad-host-range multidrug-resistant IncN plasmid containing bla(VIM), bla(SHV-12), and qnrS to Escherichia coli.

Pharmacokinetics and pharmacodynamics of intravenous daptomycin during continuous ambulatory peritoneal dialysis

BACKGROUND AND OBJECTIVES

This study sought to (1) characterize the pharmacokinetic (PK) profile of intravenous (i.v.) daptomycin among patients receiving continuous ambulatory peritoneal dialysis (CAPD); (2) identify optimal i.v. CAPD dosing schemes; and (3) determine extent of daptomycin penetration into the peritoneal space after i.v. administration.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A PK study was conducted among eight CAPD patients. Population PK modeling and Monte Carlo simulation (MCS) were used to identify CAPD dosing schemes providing efficacy and toxicity plasma profiles comparable with those obtained from MCS using the daptomycin population PK model derived from patients in the Staphylococcus aureus bacteremia-infective endocarditis (SAB-IE) study. The primary efficacy exposure target was the area under the curve (AUC). For toxicity, the goal was to identify CAPD dosing schemes that minimized plasma trough concentrations in excess of 24.3 mg/L. Finally, peritoneal cavity penetration was determined.

RESULTS

Administration of i.v. daptomycin 4 or 6 mg/kg, depending on indication, every 48 h was identified as the optimal CAPD dosing scheme. This regimen provided cumulative (AUC(0-48)) and daily partitioned (AUC(0-24 h) and AUC(24-48 h)) plasma AUC values similar to the SAB-IE or "typical patient" simulations. In addition, the proportion of patients likely to experience an elevated trough concentration in excess of 24.3 mg/L was similar between every 48 h CAPD dosing and the referent group. Penetration into the peritoneal cavity was 6% of plasma.

CONCLUSIONS

Daptomycin 4 or 6 mg/kg, on the basis of indication, i.v. every 48 h was found to be the optimal i.v. CAPD dosing scheme.

Risk factors for multidrug-resistant bacterial infection among patients with tuberculosis

Given that anti-tuberculosis medication itself has antibacterial activity and that broad-spectrum antibiotics are frequently used, the emergence of multidrug-resistant (MDR) bacteria among patients being treated for tuberculosis (TB) is likely. We used a case-control design to study the clinical predictors of MDR bacterial infection among TB patients. Both cases and controls were selected from among patients who were diagnosed and treated as having TB between 1 January 1996 and 31 August 2006. TB patients with MDR bacterial infection were included as cases and those with non-MDR bacterial infection were included as controls. Multiple logistic regression analysis was performed to elucidate the risk factors for MDR bacterial infection. During the study period 3667 patients were diagnosed with, and treated for, TB. A total of 123 experienced episodes of bacterial infection, of whom 59 (48.0%) were infected by an MDR strain at least once. The presence of chronic renal failure [adjusted odds ratio (OR): 4.96; 95% confidence interval (CI): 1.37-18.01] and the use of antimicrobials other than typical anti-TB drugs within three months (adjusted OR: 4.37; 95% CI: 1.74-10.95) were independent risk factors for MDR bacterial infection. Bacterial infection in TB patients is commonly multidrug resistant. Clinicians should be aware of the possibility of MDR bacterial infection among TB patients with chronic renal failure or recent use of other antimicrobials.