A Survey of CAPD Peritonitis Management and Outcomes in North and South Thames NHS Regions (U.K.): Support for the ISPD Guidelines

Objective

This survey examined the current management of continuous ambulatory peritoneal dialysis (CAPD) peritonitis and the effectiveness of the various antibiotic protocols in use.

Design

The information required was elicited via a postal questionnaire.

Setting

The questionnaire was posted to each renal dialysis unit offering CAPD throughout the North and South Thames National Health Service regions.

Patients

All patients using CAPD at each responding unit were eligible for inclusion.

Main Outcome Measures

Each unit provided details of their CAPD peritonitis episodes for 1997. Each unit's empirical treatment regimen for CAPD peritonitis was sought in addition to response rates. Also requested were numbers for peritonitis episodes, recurrences, and negative cultures, plus the peritonitis rate per patient-month.

Results

Thirteen units returned the questionnaire (87% of the survey population). Nine of the 13 units were using vancomycin regimens, with the remainder using cephalosporin regimens. The results were compared to the audit standards of the British Renal Association. Seventy percent of units reached the 80% mark for response rate; similar results were achieved with both the vancomycin and cephalosporin regimens. Ninety-two percent achieved the suggested peritonitis rate of 1 episode every 18 patient-months; 30% achieved the culture-negative rate of 10%. The average recurrence rate was 19%.

Conclusion

The units contacted achieved most of the standards suggested by the British Renal Association; however, wide variations did exist. Recent guidelines have suggested avoiding vancomycin-based regimens in order to reduce the incidence of vancomycin resistance. The suggested regimen of a cephalosporin with an aminoglycoside seems to represent a suitable alternative.

Vancomycin and Ciprofloxacin: Systemic Antibiotic Administration for Peritoneal Dialysis-Associated Peritonitis

Objectives

Peritonitis due to peritoneal dialysis (PD) is best treated empirically while waiting for the results of the dialysate culture. Thus, antibiotic therapy must cover both gram-positive and gram-negative micro-organisms. First, over a period of 9 years in a multicenter study we evaluated the efficiency of a vancomycin and ciprofloxacin combination given as the first-line treatment protocol for PD peritonitis. Second, we evaluated whether a systemic route of administration of the antibiotics could be an interesting alternative to the usual cumbersome intraperitoneal drug administration.

Methods

Vancomycin 15 mg/kg body weight, intravenous, and oral ciprofloxacin 250 mg two times per day (500 mg twice per day if residual creatinine clearance was above 3 mL/minute) were prescribed at diagnosis of peritonitis. Vancomycin injections were repeated (when blood trough level was expected to be below 12 μg/mL) in cases of gram-positive organisms for a total duration of 3 weeks. Ciprofloxacin was given for a total of 3 weeks in cases of gram-negative and a total of 10 days for susceptible gram-positive infections.

Results

A total of 129 episodes of peritonitis occurred; 28 of them were not included in the study because of protocol violation ( n = 15) or fungal ( n = 7) or fecal ( n = 6) peritonitis, leaving 101 peritonitis episodes for analysis. 52 (51.5%) gram-positive and 28 (27.7%) gram-negative organisms were grown; 38 gram-positive organisms were coagulase-negative staphylococci. No organism was identified in 8 peritonitis episodes, whereas 13 peritonitis episodes were caused by more than 1 organism. 35% of the coagulase-negative staphylococci were resistant to first-generation cephalosporin and methicillin, whereas all were susceptible to vancomycin. For gram-negative bacilli, the susceptibility rate was 96% and 95% for ciprofloxacin and ceftazidime respectively. The overall treatment success rate was 77.2% (78 of the 101 peritonitis episodes): 61.4% at first intention and 15.8% after optimization of the antibiotic therapy (second intention). The protocol failed in 22.8% of the peritonitis episodes. Hospitalization was required in 52% of the peritonitis episodes; average hospitalization was 11 (range 1 – 45) days.

Conclusion

Systemic vancomycin and ciprofloxacin administration is a simple and efficient first-line protocol antibiotic therapy for PD peritonitis. In our opinion, vancomycin should still be used for gram-positive infections because of its high susceptibility rate compared with first-generation cephalosporins, providing a close monitoring of the local epidemiology. Oral ciprofloxacin provides satisfactory results in gram-negative infections, comparable to those obtained with intraperitoneal ceftazidime or aminoglycosides.

Efficacy of antibiotic therapy for peritoneal dialysis-associated peritonitis: a proportional meta-analysis

Background

The choice of antimicrobials for initial treatment of peritoneal dialysis (PD)-related peritonitis is crucial for a favorable outcome. There is no consensus about the best therapy; few prospective controlled studies have been published, and the only published systematic reviews did not report superiority of any class of antimicrobials. The objective of this review was to analyze the results of PD peritonitis treatment in adult patients by employing a new methodology, the proportional meta-analysis.

Methods

A review of the literature was conducted. There was no language restriction. Studies were obtained from MEDLINE, EMBASE, and LILACS. The inclusion criteria were: (a) case series and RCTs with the number of reported patients in each study greater than five, (b) use of any antibiotic therapy for initial treatment (e.g., cefazolin plus gentamicin or vancomycin plus gentamicin), for Gram-positive (e.g., vancomycin or a first generation cephalosporin), or for Gram-negative rods (e.g., gentamicin, ceftazidime, and fluoroquinolone), (c) patients with PD-related peritonitis, and (d) studies specifying the rates of resolution. A proportional meta-analysis was performed on outcomes using a random-effects model, and the pooled resolution rates were calculated.

Results

A total of 64 studies (32 for initial treatment and negative culture, 28 reporting treatment for Gram-positive rods and 24 reporting treatment for Gram-negative rods) and 21 RCTs met all inclusion criteria (14 for initial treatment and negative culture, 8 reporting treatment for Gram-positive rods and 8 reporting treatment for Gram-negative rods). The pooled resolution rate of ceftazidime plus glycopeptide as initial treatment (pooled proportion = 86% [95% CI 0.82–0.89]) was significantly higher than first generation cephalosporin plus aminoglycosides (pooled proportion = 66% [95% CI 0.57–0.75]) and significantly higher than glycopeptides plus aminoglycosides (pooled proportion = 75% [95% CI 0.69–0.80]. Other comparisons of regimens used for either initial treatment, treatment for Gram-positive rods or Gram-negative rods did not show statistically significant differences.

Conclusion

We showed that the association of a glycopeptide plus ceftazidime is superior to other regimens for initial treatment of PD peritonitis. This result should be carefully analyzed and does not exclude the necessity of monitoring the local microbiologic profile in each dialysis center to choice the initial therapeutic protocol.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2334-14-445) contains supplementary material, which is available to authorized users.

Pasteurella multocida in peritoneal dialysis: a rare cause of peritonitis associated with exposure to domestic cats

Pasteurella multocida is a rare cause of peritonitis in peritoneal dialysis patients with only 10 cases reported in the literature so far. All cases were observed in patients with close contact with cats, usually with a direct puncture of the dialysis tubing. We report a case of Pasteurella multocida peritonitis in a patient maintained under continuous cycling peritoneal dialysis (CCPD), who had frequent and close contact with cats. Patients should be made aware of this potential complication and advised to keep domestic animals away from the location of their peritoneal exchanges.