Current Issues Current Issues in in

PD PeritonitisPD Peritonitis

Baxter Healthcare

Objectives

Participants Will ReviewParticipants Will Review

Current Issues Related to Peritonitis Current Issues Related to Peritonitis

Current Treatment Recommendations Current Treatment Recommendations

Prophylactic Antibiotic RecommendationsProphylactic Antibiotic Recommendations

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Incidence and Impact

IncidenceIncidence1

Approximately 1:24 patient months (US)

1:48 (Japan)

Results center - dependent

Peritonitis Causes Peritonitis Causes 2,32,3. . .. . . Hospitalization Catheter Loss Technique Failure Increased Albumin Losses Ultrafiltration Failure Increased Risk of Death

1. Keane, 20002. Burrows and Prowant, 19983. Piraino, 1998

Baxter Healthcare

Psychosocial16%

Peritonitis

25%Other Medical

9%

Inadequate

Dialysis

20%

Catheter

Related

30%

Baxter 1999 Internal Data

Causes of Dropout from PD

Baxter Healthcare

Causes Of PeritonitisCauses Of Peritonitis 55-80% - Gram Positives55-80% - Gram Positives

Skin Organisms/Touch Contamination Staph Epi, Staph Aureus, Streptococcus

17 - 30% - Gram Negatives17 - 30% - Gram Negatives Bowel Leak, Water Contamination Proteus, E-Coli, Klebsiella, Enterobacter,

Acinetobacter, Pseudomonas

2-10% - Fungal Infections2-10% - Fungal Infections Candida Albicans primarily

Brunier, 1995

Baxter Healthcare

Organisms and OutcomesOrganisms and Outcomes

0

10

20

30

40

50

60

70

80

90

Resolved Catheterremoved

Hospital. Transfer toHD

% p

f Pati

ents

CNS (N=242)

S. Aureus(N=149)

NPGN (N=136)

Bunke et al, KI 52:524-529, 1997

Baxter Healthcare

Identifying Peritonitis Identifying Peritonitis

Key Findings - cloudy effluent, Key Findings - cloudy effluent, abdominal pain and/or feverabdominal pain and/or fever

Diagnosis - 2 of the following 3Diagnosis - 2 of the following 31. Symptoms of peritoneal inflammation;

(fever, pain, chills, nausea, tenderness)

2. Cloudy fluid with WBC > 100/mm3 ; 50% polymorphonuclear neutrophils (PMN)

3. Identification of organism on gram stain or culture

Burrows L, Prowant 1998

Baxter Healthcare

Baxter Healthcare

Relapsing PeritonitisRelapsing Peritonitis

DefinitionDefinition Peritonitis caused by the same

genus/species responsible for the immediately preceding episode, within 4 weeks of completion of the antibiotic course

Burrows and Prowant, 1998

Baxter Healthcare

Causes of a Cloudy Bag Infectious peritonitisInfectious peritonitis Peritoneal fluid eosinophiliaPeritoneal fluid eosinophilia Blood tinged dialysate Blood tinged dialysate (ovulation, menstruation, etc...)(ovulation, menstruation, etc...)

Fibrin filamentsFibrin filaments Chylous peritoneumChylous peritoneum Intra-abdominal pathologies Intra-abdominal pathologies (Cholecystitis, appendicitis, (Cholecystitis, appendicitis,

pancreatitis, salpingitis, malignancy etc…)pancreatitis, salpingitis, malignancy etc…)

DiarrheaDiarrhea

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Portals of Entry of Organisms

Exogenous - TransluminalExogenous - Transluminal Exogenous - PeriluminalExogenous - Periluminal EndogenousEndogenous Procedure relatedProcedure related

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Changes in Transport with Peritonitis

Decreased net ultrafiltrationDecreased net ultrafiltration Increased peritoneal fluid Increased peritoneal fluid

absorptionabsorption Increased small solute transportIncreased small solute transport Increased protein clearancesIncreased protein clearances

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Portals of Entry of Organisms

Exogenous - TransluminalExogenous - Transluminal Bag exchangeBag exchange Transfer set exchangeTransfer set exchange Injection of drugsInjection of drugs Accidental disconnectionAccidental disconnection Defective PD SystemDefective PD System Contaminated PD fluidContaminated PD fluid

Baxter Healthcare

Portals of Entry of Organisms

Exogenous - PeriluminalExogenous - Periluminal Exit site infectionExit site infection Cuff and tunnel infectionCuff and tunnel infection

EndogenousEndogenous Enteric/abdominal sourceEnteric/abdominal source BacteremiaBacteremia Gynecologic in originGynecologic in origin

Procedure relatedProcedure related

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Portals of Entry of Organisms

Exogenous - TransluminalExogenous - Transluminal Exogenous - PeriluminalExogenous - Periluminal EndogenousEndogenous Procedure relatedProcedure related

ColonoscopyColonoscopy EndoscopyEndoscopy Dental proceduresDental procedures

Baxter Healthcare

Portals of Entry of Organisms

Exogenous - TransluminalExogenous - Transluminal S. Epidermidis, AcinetobacterS. Epidermidis, Acinetobacter

Exogenous - PeriluminalExogenous - Periluminal S. Epidermidis, S. Aureus, S. Epidermidis, S. Aureus,

Pseudomonas, YeastPseudomonas, Yeast EndogenousEndogenous

Enteric: gram negative, anaerobesEnteric: gram negative, anaerobes Bacteremia: Strep, anaerobesBacteremia: Strep, anaerobes Gynecologic: Lactobacillus, yeastGynecologic: Lactobacillus, yeast

Calculating Peritonitis Rates

One (1) episode per Patient MonthsOne (1) episode per Patient Months at at RiskRisk

Determine months at riskDetermine months at risk number of patient days /30.42 (avg.days per mo) number of patient days /30.42 (avg.days per mo) ex: 92 days X 30 pts = 2760/ 30.42 = 90.73 monthsex: 92 days X 30 pts = 2760/ 30.42 = 90.73 months

Divide months at risk by episodes within time periodDivide months at risk by episodes within time period

ex: 90.73/ 3 = 1: 30.24 mos. ex: 90.73/ 3 = 1: 30.24 mos.

Episodes per Patient YearEpisodes per Patient Year Determine years at riskDetermine years at risk

number of patient days / 365ex: 92 days X 30 patients = 2760/ 365 = 7.56 yearsex: 92 days X 30 patients = 2760/ 365 = 7.56 years

Divide number of reported episodes by years at riskDivide number of reported episodes by years at risk

ex: 3/ 7.56 = 0.40 episodes per yearex: 3/ 7.56 = 0.40 episodes per yearBurrows and Prowant, 1998

Baxter Healthcare

Culture Considerations Culture Considerations

““Appropriate” Effluent for CultureAppropriate” Effluent for Culture

First Cloudy effluent best odds of positive culture

Collect large volume ( 50 mL)

If turbid, length of dwell irrelevant

Collect 2nd sample if clear or unsure CAPD – > 4 hour dwell APD – 2* hour dwell

Keane, 2000* changed from ‘96

Baxter Healthcare

Laboratory ProcedureLaboratory Procedure To improve recovery of organismsTo improve recovery of organisms

Wash specimen with sterile saline Treat with antibiotic removing resin

Concentrate sample (> 50 mL)Concentrate sample (> 50 mL) Centrifuge (3000g x 15 min) Re-suspend sediment in 3-5 mL of NSS Inoculate into blood culture medium

Culture Considerations Culture Considerations

Keane, 2000

Baxter Healthcare

Limited Vancomycin UseLimited Vancomycin Use

Limited Aminoglycoside Use if RRF*Limited Aminoglycoside Use if RRF*

Empiric TherapyEmpiric Therapy

Culture-Sensitive TherapyCulture-Sensitive Therapy

Current Treatment Recommendations

Keane, 2000* changed from ‘96

Baxter Healthcare

Vanco Vanco WAS empiric Rx of choiceempiric Rx of choice

~ 14% of enterococci in larger university ~ 14% of enterococci in larger university hospitals now Vanco resistant !hospitals now Vanco resistant !

Vanco resistance often associated with Vanco resistance often associated with resistance to other agents, such as resistance to other agents, such as penicillin or aminoglycosidespenicillin or aminoglycosides

Resistance WAS confined to enterococci, Resistance WAS confined to enterococci, spreading to other organismsspreading to other organisms

If Vanco resistance reaches MRSA . . . . . If Vanco resistance reaches MRSA . . . . . No Rx availableNo Rx available

Vancomycin Resistance

Keane, 2000

Baxter Healthcare

Vanco should ONLY be used to Rx Vanco should ONLY be used to Rx

Methicillin Resistant Staph Aureus (MRSA)

Beta-lactam resistant organisms

SERIOUSSERIOUS Gm+ infection if allergic to other Rx

C. difficile enterocolitis unresponsive to metronidazole

Limited Use of Vancomycin

Keane, 2000

Baxter Healthcare

Broad spectrum (gram pos & gram neg)Broad spectrum (gram pos & gram neg)

WasWas Empiric Rx of choice in combination with 1st generation cephalosporins regardless of residual urine output

Regardless of residual urine output, was was part of recommended Rx regime for enterococci (+) staph aureus (+) pseudomonas/xanthomonas (-)

Generics Amikacin Gentamicin Netilmicin Tobramycin

Aminoglycosides

Keane, 1996

Baxter Healthcare

Aminoglycosides and Aminoglycosides and Residual Renal Function Residual Renal Function

(RRF) (RRF) Group 1 (n=29) Group 2 (n=26) Group 3 (n=17)

Peritonitis history & associated organisms

no peritonitis staph, gram (-) peritonitis

staph, gram (-) peritonitis

Antibiotics utilized No IV/ IP antibiotics

IV/ IP vancomycin, penicillin, cephalosporin, and/or quinolones

Same as Group II plus IV/ IP aminoglycoside

Rate of decline of renal creatinine clearance (ml/min/month)

-0.07 + 0.71

-0.21 + 0.39

- 0.66 + 0.58 a

Rate of decline in daily urine volume (ml/day/month)

-32 + 75

-15 + 48

- 74 + 62 b,c

Shemin et al, 1999

Baxter Healthcare

Ceftazadime with RRF (> 100 Ceftazadime with RRF (> 100 mL/day)mL/day) 3rd generation cephalosporin Broad Spectrum

Replace Aminoglycosides with RRFReplace Aminoglycosides with RRF In Empiric recommendations In Gram Negative Recommendations

Aminoglycoside Alternative*

Keane, 2000* Change from 1996

Baxter Healthcare

Gram + associated with peritonitisGram + associated with peritonitis Coagulase negative staphylococcusCoagulase negative staphylococcus CorynebacteriumCorynebacterium MicrococcusMicrococcus Staph aureusStaph aureus Staph epidermidisStaph epidermidis Streptococci (includes entercocci)Streptococci (includes entercocci)

Gram - associated with peritonitisGram - associated with peritonitis Escherichia coliEscherichia coli KlebseillaKlebseilla Pseudomonas/ XanthomonasPseudomonas/ Xanthomonas SerratiaSerratia ActinobacterActinobacter NeisseriaNeisseria Proteus MirabilisProteus Mirabilis

Some of the Common Some of the Common Bacterial Causes of Peritonitis Bacterial Causes of Peritonitis

Troidle, 1998

Baxter Healthcare

19961996

Cephalosporin Cephalosporin (1(1stst gen)gen)

and and

AminoglycosideAminoglycoside

Treating Empirically Treating Empirically (before culture results)(before culture results)

20002000 If No RRF (< 100 mL) If No RRF (< 100 mL)

Cephalosporin (1Cephalosporin (1stst gen)gen)

and and CeftazidimeCeftazidime

oror AminoglycosideAminoglycoside

If RRF (> 100 mL)If RRF (> 100 mL) Cephalosporin (1Cephalosporin (1stst

gen)gen)

and and CeftazidimeCeftazidime

Keane et al, 1996Keane et al, 2000

Baxter Healthcare

19961996

DC CephalosporinDC Cephalosporin

and continueand continue

Aminoglycoside

ADDADD

Ampicillin

Treating Gram Positive Treating Gram Positive EnterococciEnterococci

20002000 DC Cephalosporin DC Cephalosporin

andand DC CeftazidimeDC Ceftazidime

ADDADD AmpicillinAmpicillin

If Ampicillin- resistantIf Ampicillin- resistant Vanco or ClindamycinVanco or Clindamycin

If Vanco – resistantIf Vanco – resistant Quinupristin or Quinupristin or

Dalfopristin Dalfopristin

Consider AddingConsider Adding AminoglycosidesAminoglycosides

Keane et al, 1996Keane et al, 2000

Baxter Healthcare

19961996

DC DC AminoglycosidesAminoglycosides

and continueand continue

CephalosporinCephalosporin

ADDADD

RifampinRifampin

Treating Gram Positive Staph Treating Gram Positive Staph AureusAureus

20002000

DC CeftazidimeDC Ceftazidime

oror DC DC AminoglycosidesAminoglycosides

and continueand continue Cephalosporin Cephalosporin (1(1stst gen) gen)

ADDADD RifampinRifampin

If MRSA, ADDIf MRSA, ADD Vanco or ClindamycinVanco or Clindamycin

Keane et al, 1996Keane et al, 2000

Baxter Healthcare

19961996

DC DC AminoglycosidesAminoglycosides

and continueand continue

CephalosporinCephalosporin

Treating Other Gram PositivesTreating Other Gram Positives

20002000

DC CeftazidimeDC Ceftazidime

oror

DC DC AminoglycosidesAminoglycosides

and continueand continue

Cephalosporin Cephalosporin (1(1stst gen)gen)

If MRSE, ADDIf MRSE, ADD

Vanco or Vanco or ClindamycinClindamycin

Keane et al, 1996Keane et al, 2000

Baxter Healthcare

19961996

Adjust Antibiotics Adjust Antibiotics to Sensitivity to Sensitivity PatternsPatterns

Treating Single Gram NegativesTreating Single Gram Negatives

20002000

Adjust Antibiotics Adjust Antibiotics to Sensitivity to Sensitivity PatternsPatterns

Keane et al, 1996Keane et al, 2000

Baxter Healthcare

19961996

DCDC CephalosporinCephalosporin

and continueand continue AminoglycosidesAminoglycosides

ADD anotherADD another Pseudomonas Pseudomonas

AgentAgent CeftazadimeCeftazadime PiperacillinPiperacillin CiprofloxacinCiprofloxacin AztreonamAztreonam ImipenememImipenemem SulfamethoxazoleSulfamethoxazole

Treating Pseudomonas/ Treating Pseudomonas/ XanthomonasXanthomonas

20002000 Con’t CeftazidimeCon’t Ceftazidime

andand If RRF > 100 mL , ADDIf RRF > 100 mL , ADD

Ciprofloxacin po --or-Ciprofloxacin po --or- Piperacillin IV –or—Piperacillin IV –or— Sulfamethoxazole –or—Sulfamethoxazole –or— Aztreonam IPAztreonam IP

If RRF < 100 mL , If RRF < 100 mL , Con’t AminoglycosidesCon’t Aminoglycosides

Keane et al, 1996Keane et al, 2000

Baxter Healthcare

19961996

Con’t Con’t CephalosporinCephalosporin

and and Con’t Con’t

AminoglycosideAminoglycoside

and and Add MetronidazoleAdd Metronidazole

and and Consider Surgical Consider Surgical

InterventionIntervention

Treating Multiple Gram Negatives Treating Multiple Gram Negatives and/or Anaerobesand/or Anaerobes

20002000

Con’t Con’t CephalosporinCephalosporin

and and Con’t CeftazadimeCon’t Ceftazadime

and and Add MetronidazoleAdd Metronidazole

and and Consider Surgical Consider Surgical

InterventionInterventionKeane et al, 1996Keane et al, 2000

Baxter Healthcare

19961996

DC CephalosporinsDC Cephalosporins

and and DC AminoglycosideDC Aminoglycoside

and Startand Start FlucytosineFlucytosine

and and FluconazoleFluconazole

Treating YeastTreating Yeast

20002000

DC CephalosporinsDC Cephalosporins

and and DC AminoglycosideDC Aminoglycoside

and Startand Start FlucytosineFlucytosine

and and FluconazoleFluconazole

if resistant organismif resistant organism

Consider Consider ItraconozoleItraconozoleKeane et al, 1996

Keane et al, 2000

Baxter Healthcare

Exit Site Mupirocin (Exit Site Mupirocin (may use intranasallymay use intranasally))

Before procedures that may seed, such as Before procedures that may seed, such as

dental workdental work colonoscopycolonoscopy

Pre-catheter or post technique failurePre-catheter or post technique failure

Cephalosporin –1Cephalosporin –1stst generation generation

Avoid VancomycinAvoid Vancomycin

Prophylactic Antibiotic Use

Keane et al, 2000

Baxter Healthcare

Adults Only Adults Only Pediatric Recommendations Forthcoming

Avoid Aminoglycosides Avoid Aminoglycosides If residual urine output > 100 mL/ day Ceftazidime instead (3rd generation cephalosporin)

min dwell for APD culture to 2 hr (was 1 min dwell for APD culture to 2 hr (was 1 hr)hr) CAPD remains 4 hr

May consider oral treatment in APD May consider oral treatment in APD ONLY in UNCOMPLICATED coag neg staph

Peritonitis Update 2000 --- Peritonitis Update 2000 --- Summary of Changes (from ’96)Summary of Changes (from ’96)

Keane et al, 2000

Baxter Healthcare

Treat uncomplicated gram Neg for 21-day Treat uncomplicated gram Neg for 21-day minmin Previously 14-day minimum

Multiple Gram Negative InfectionsMultiple Gram Negative Infections Remove catheter even if improvement noted

TB PeritonitisTB Peritonitis Add Pyridoxine 100mg/ day Remove catheter in ALL cases

Peritonitis Update 2000 --- Peritonitis Update 2000 --- Summary of Changes (con’t)Summary of Changes (con’t)

Keane et al, 2000

Baxter Healthcare

Preventative TreatmentsPreventative Treatments Amoxicillin 2gm – “Reasonable” pre-dental 1-2 day course of cephalosporins after technique

break (altho no data available) Exit Site Mupirocin for ALL PD patients except those

with Cruz catheters Eliminates need for nasal swabs Mupirocin preferred over Rifampin

Catheter Reinsertion may be done Catheter Reinsertion may be done immediately ONLY if peritonitis 2immediately ONLY if peritonitis 2 Biofilm formation (typically due to coag neg staph) Tunnel involvement (typically due to SA relapse) WBC’s in effluent < 100L w/ antibiotics

Peritonitis Update 2000 --- Peritonitis Update 2000 --- Summary of Changes (con’t)Summary of Changes (con’t)

Keane et al, 2000

Baxter Healthcare

References1. Keane W, Baile G, Boeschoten E, Gokal R, Golper T, Holmes C, Kawaguchi Y,

Piraino B, Riella M, and Vas S. Adult Peritoneal Dialysis Related Treatment Recommendations: 2000 Update, Perit Dial Int, 20:396-411, 2000

2. Piraino B, Prevention of peritonitis, Perit Dial Int, 18: 244-246, 2000

3. Burrows L, Prowant : Peritoneal Dialysis, in Contemporary Nephrology Nursing, edited by Janel Parker, Pitman NJ, ANNA, 603-659, 1998

4. Brunier, G. Peritonitis in Patients on Peritoneal Dialysis. A Review of Pathophysiology and Treatment. ANNA Journal, 22:575-585, 1995

5. Keane W., Alexander S, Baile G, Boeschoten E, Gokal R, Golper T, Holmes C, Huang CC, Kawaguchi Y, Piraino B, Riella M, Schaefer F, and Vas S. Peritoneal dialysis related treatment recommendations: 1996 Update, Perit Dial Int, 16: 557-573, 1996

6. Bunke CM, Brier M, Golper T, Outcomes of single organism peritonitis in peritoneal dialysis: Gram negatives versus gram positives in the network 9 peritonitis study, Kidney Int, 52: 524-529, 1997

7. Shemin D, Maax D, Pierre DS, Kahn SI, Cgazan JA. Effects of aminoglycoside use on residual renal function in peritoneal dialysis , Am J Kidney Dis; 34:14-20, 1999

8. Troidle L, Gorban-Brennan, N, Kliger A, Finkelstein F. Differing Outcomes of Gram–Positive and Gram-Negative Peritonitis. Am J. Kidney Dis, 32: 623-628, 1998