Staph, Fungal & Tuberculous...

Objectives & Background Definition Rehab

Process Outcomes Nephrology Roles ConclusionsObjectives S. aureus Fungal ConclusionMycobacteria

“Staph, Fungal & Tuberculous Peritonitis”

Long Beach CA, (March 2017)

S. Vanita JassalProfessor of Medicine, Univ. of Toronto &

Staff Nephrologist, University Health Network

Objectives S. aureus Fungal ConclusionMycobacteria

Disclosures

• Investigator led funding from Fresenius Health Care 2015

• Salary benefits: Ontario Renal Network

Objectives


Objectives

• To recognize and treat peritonitis caused by – Staphylococcus aureus– Fungal organisms– Mycobacteria

Objectives


Process Outcomes Nephrology Roles Conclusions

STAPHYLOCOCCUS AUREUS


ISPD Recommendations 2016

• Empiric treatment includes antibiotics that cover S Aureus

• Treatment modified based on cultures • Cefazolin IP• Methicillen resistant organisms Vancomycin IP• Duration of treatment 3 weeks

www.ispd.org



• Other agents include teicoplanin and daptomycin

• +/- Rifampicin 5-7 days

• Consider rapid peritoneal lavage – severe abdominal pain – “toxic shock”-type presentation

www.ispd.org




• Other adjunctive treatments to consider:– rapid peritoneal lavage for severe abdominal pain

and/or “toxic shock”-type presentation (s. aureus)– peritoneal “resting” for 2 to 3 days if bowel leak

(multiple gram negative organisms)

www.ispd.org


ISPD Recommendations 2016Li et al, Perit Dial Int 2016; 36(5):481–508


Relapse Risk - S Aureus

0

5

10

15

20

25

30

% Control (n = 2021) % Relapsed (n = 356)

Burke et a, AJKD 2011: 58; 429-436



Relapse Risk - S Aureus• High association with exit site and tunnel infections

• Consider removal of the PD catheter if little or no improvement in 4-5 days

• Consider if patient has S Aureus nasal carriage



FUNGAL PERITONITIS



Prevention of Fungal Peritonitis

• Accounts for 1 – 15% of peritonitis episodes• Mortality rate 5 – 53%• Trend over time for non-Albicans Candida

• Often requires catheter removal • Leading cause of PD-peritonitis related technique failure



Risk Factors for Fungal Peritonitis

• frequent peritonitis **• antibiotic therapy **• immunosuppression• low serum albumin concentration• PEG tubes• peritoneo-vaginal communication


Yeast or Fungi on the Gram Stain

TIP!

• sometimes PD fluid will be sent in someone with abdominal pain or just walking into the ER

• if there is no leukocytosis, but the gram stain shows yeast, don’t rush to take out the catheter

• repeat the sample and see if a leukocytosis is developing• sometimes yeast (indeed, other bacteria too) appears in the PD

fluid but doesn’t lead to peritonitis– be careful of drive-by cultures

Slide courtesy of Dr. Joanne Bargman



Prevention of Fungal Peritonitis

• Can prophylactic anti-fungal therapy at the time of antibiotic administration prevent fungal overgrowth?

• Could this therapy prevent the development of antibiotic-related fungal peritonitis?



Fungal Prophylaxis

• Success rate of prophylaxis will depend on baseline rate of fungal peritonitis– Units with high rates have demonstrated reduction of fungal

peritonitis rates with prophylactic anti-fungal therapy

• Oral nystatin may be inconvenient, but– it’s a safe medication– resistance not reported, but not likely a problem even if it

were



ISPD recommended treatmentYeast / Fungus

– PD catheter removal (1C recommendation)– Duration of Rx 2 weeks after catheter removal (2C)

– Amphotericin 25 mg IV/day plus Flucytosine for 4-6 weeks

OR– Fluconazole 150 mg IP/q2d plus oral post-removal– (case reports of intra-catheter amphotericin)

Candida and Crypotococcus



Species (Probable) Choice AgentsCandida albicans Fluconazole

Crytpococcus spp. Fluconazole

Aspergillus spp. Caspofungin; micofungin

Non-albicans Candidaeg C. glabrata, C. rugosa, C. parapsilosis, C. tropicalis andC. dubliniensis

Caspofungin; micofungin

Others filamentous fungi Voriconazole; posaconazole



Yeast/Fungal Peritonitis: outcomes

• The high mortality rate is related to co-morbidity: some very ill, dying patients will get fungal peritonitis as an agonal event

• In Toronto cohort, 33% of patients were able to return to PD

Nadeau-Fredette and Bargman Perit Dial Int 2013


Early catheter removal associated with better outcomes

• Retrospective study of 94 episodes of fungal peritonitis– Catheter removal within 24 hours in 42%– Catheter removal 2-9 days later in 45%– Mortality rate significantly higher with delayed

catheter removal (32 vs. 13%)

Chang et al, PDI 2011


Unclear role for prophylaxis...

• Pre-procedural antibiotics– Colonoscopy, cystoscopy, hysteroscopy,

colposcopy, PD catheter manipulation– Regimens for colonoscopy should cover

enterococcus, enteric gram negatives and anaerobes


Fungal Peritonitis

• Patients should receive fungal prophylaxis with any course of antibiotics

• Can use nystatin or fluconazole• As soon as fungal peritonitis diagnosed,

arrange early catheter removal



MYCOBACTERIAL INFECTIONS


Mycobacteria

• Slow growing– M. tuberculosis– M. bovis– M. avium complex

• Fast growing– M. chelonae– M. fortuitum


Consider M. tuberculosis when

• Endemic area• Culture negative, poor response• Culture positive with worsening or poor

response• Systemic illness consistent with TB


M. tuberculosis is “tricky” to find

• Initial presentation is often with a neutrophil response (not lymphocytic)

• Classic ZN stains may not be sensitive– Centrifuge 50-100mls and then plate– Liquid media – Longer incubation

• DNA PCR studies have high rates of false positives


Lymphocytic features are not always present

Tamayo-Isla et al, Perit Dial Int 2016; 36(2):218–222


..nor are cultures always +ve

Tamayo-Isla et al, Perit Dial Int 2016; 36(2):218–222


Treatment

• Local sensitivity and resistance patterns will influence medications used

• Often 4 drugs in combination: – rifampicin, isoniazid x 12-18 months– pyrazinamide & ofloxacin x 2 months– IP rifampicin if possible

• Pyridoxine 50-100 mg daily (with isoniazid)

www.ispd.org


Catheter removal

• Controversial– Limpopo series – recommend it strongly– India series – not always needed

• ISPD recommendation uses the word “may” remove the catheter


Non-tuberculous Mycobacteriae

• Emerging more commonly• Australian series 2013

– 12 cases– 1 in 1000 patient-years (0.6-1.4)– Recovery in 11 cases (3 no cath removal)

• Possible association with gentamicin– Lo et al, PDI 2013 33:267-72

Jiang et al, Int Urol Nephrol 2013 Oct;45(5):1423-8


TreatmentsJiang et al, Int Urol Nephrol 2013 Oct;45(5):1423-8


Conclusions

• Difficult to treat infections• All require high vigilance• Prevention is better than cure• Treatment is best with consultation with

local infectious disease specialists and use of ISPD guidelines


University of Toronto Geriatric Nephrology Fellowship

Areas of specific focus will include one or more of the following areas: dialysis rehabilitation, care for residents in long-term care facilities, non-dialysis care and symptom management. Research

mentorship available includes Clinical Epidemiology or Translational Research

For details contact: [email protected]

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