Infective Complications In Pd

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Dr Lawrence Hii
Kuching
Sarawak

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Infective Complications In Pd

  1. 1. INFECTIVE COMPLICATIONS IN PERITONEAL DIALYSIS
  2. 2. Contents <ul><li>Peritonitis </li></ul><ul><li>Exit site and tunnel infections </li></ul><ul><li>Prophylaxis </li></ul><ul><li>Catheter placement and removal </li></ul>
  3. 3. Peritonitis- Consequences <ul><li>Leads to technique failure, hospitalisation and death. </li></ul><ul><li>Association between peritonitis and death well documented (for every 0.5/yr increase in peritonitis rate, risk of death increase by 10%) </li></ul><ul><li>Most common cause of conversion to HD (Burkart et al PDI 1996) </li></ul>
  4. 4. Peritonitis-Clinical Presentation <ul><li>Abd. Pain, fever, cloudy effluent </li></ul><ul><li>Dialysate effluent: wbc >100/mm3, > 50% PMN </li></ul><ul><li>Consider even if PD fluid clear (small %) </li></ul><ul><li>Abd. Pain less with CoNS, more with Staph aureus, strept, G-ve rods </li></ul>
  5. 5. Peritonitis <ul><li>Common, past decade ~ 1 per 24 pt-treatment-months </li></ul><ul><li>Disconnect system reduce incidence </li></ul><ul><li>Organisms: G +ve </li></ul><ul><li>With disconnect, reduced G+ve, relatively increased G-ve </li></ul><ul><li>No single regimen most efficacious </li></ul>
  6. 6. Peritonitis <ul><li>Ultra twin bag significantly lower peritonitis rate (1 in 33.9 pt-month) than Y set (1 in 11.7 pt-month) Kiernan et al JASN 1995 </li></ul><ul><li>Mixed results in regards to APD vs CAPD </li></ul><ul><li>European APD Outcome Study: CAPD 1 in 22.5 pt-month, APD 1 in 29.1 pt-month </li></ul>
  7. 7. Differential Diagnosis of Cloudy Effluent <ul><li>Infectious peritonitis (culture positive or sterile) </li></ul><ul><li>Chemical peritonitis </li></ul><ul><li>Eosinophilia </li></ul><ul><li>Hemoperitoneum </li></ul><ul><li>Dry abdomen specimen (APD) </li></ul><ul><li>Malignancy, chylous (rare) </li></ul>
  8. 8. Eosinophilic Peritonitis <ul><li>> 10% cells eosinophils </li></ul><ul><li>Must be treated as bacterial peritonitis until proven otherwise </li></ul><ul><li>Fungal, viral, parasitic, icodextrin, chemical (IP Vancomycin), idiopathic/culture negative </li></ul>
  9. 9. Icodextrin Peritonitis <ul><li>Immediately or after several months of exposure </li></ul><ul><li>Mild abd pain, no systemic sx, cloudy effluent, sterile culture, predominance of monocytes/macrophages </li></ul><ul><li>Mechanism unclear, ? Peptidoglycan contamination </li></ul>
  10. 10. APD- Diagnosis <ul><li>Occ. initial drain cloudy, but mononuclear cells, no abd. pain, fluid rapidly clears on initiation of APD </li></ul><ul><li>Use % of PMN rather than absolute no. of cells to diagnose </li></ul><ul><li>No daytime dwell: 1L 1-2 hour dwell </li></ul><ul><li>Equivocal cases, sx with clear effluent: 2 nd exchange with at least 2 hours dwell </li></ul>
  11. 11. Peritonitis <ul><li>Enquire break in technique, recent ESI, last episode of peritonitis, constipation or diarrhoea </li></ul><ul><li>Examine : abdomen for tenderness, exit site and tunnel inspection (any discharge cultured) </li></ul><ul><li>Find root cause </li></ul><ul><li>If necessary, retraining </li></ul>
  12. 12. Specimen Processing <ul><li>Standard culture technique: directly inject effluent into blood culture bottles (culture negative 20%) </li></ul><ul><li>Culturing the sediment after centrifuging 50ml of effluent in standard blood culture and solid culture medium < 5% culture negative </li></ul><ul><li>Antibiotic removal technique </li></ul><ul><li>>75%, culture positive within 72 hours </li></ul>
  13. 13. EMPIRIC THERAPY <ul><li>Covers both G+ve and G-ve (not based on Gram stain , except if yeast seen) </li></ul><ul><li>Likelihood same with most recent infection </li></ul><ul><li>Frequent peritonitis: relapse </li></ul><ul><li>Exit site infection </li></ul><ul><li>Prompt home antimicrobial for pts residing far away from hospital </li></ul>
  14. 14. Empiric Therapy <ul><li>G+ve: cloxacillin, 1 st generation cephalosporin, Vancomycin </li></ul><ul><li>G-ve: ceftazidime, aminoglycoside, cefepime, carbrpenem (oral quinolones can be used if local sensitivities support such use) </li></ul>
  15. 15. Empiric Therapy <ul><li>Aminoglycoside: no evidence short courses harm RRF, repeated/prolonged not advisable ( opinion ), once daily as effective as continuous </li></ul><ul><li>Monotherapy: imipenem/cilastatin as effective as cefazolin + ceftazidime (PDI 2004), cefepime as good as Vanco + netilmicin (AJKD 2001) </li></ul>
  16. 16. Duration of Therapy <ul><li>No good trials to define the length </li></ul><ul><li>Minimum 2 weeks, more severe 3 weeks ( opinion ) </li></ul>
  17. 17. Treatment strategies for Enterococcus/Streptococcus <ul><li>Severe pain </li></ul><ul><li>Ampicillin preferred (evidence ), consider aminoglycosides for synergy. </li></ul><ul><li>Ampicillin resistant: Vancomyin </li></ul><ul><li>VRE: ampicillin if susceptible, otherwise linezolid, quinupristin/dalfopristin </li></ul>
  18. 18. Staphylococcus aureus <ul><li>Severe </li></ul><ul><li>Often due to catheter infection, then unlikely to resolve without catheter removal ( evidence ) </li></ul><ul><li>If poor response/MRSA, can add rifampicin 600mg /day for 1 week. </li></ul><ul><li>Vancomycin resistance reported: linezolid, daptomycin, quinupristin/dalfopristin </li></ul><ul><li>21 days </li></ul>
  19. 19. Coagualase-negative Staphylococcus <ul><li>Mild, responds to treatment </li></ul><ul><li>Sometimes relapsing due to biofilm, catheter replacement advised (evidence) </li></ul>
  20. 20. Pseudomonas Aeruginosa <ul><li>Severe, 2 drugs ( evidence ), 21 days </li></ul><ul><li>Ceftazidime, piperazillin (IV 4g bd), cefepime. </li></ul><ul><li>Combination: aminoglycoside or quinolones </li></ul><ul><li>Often associated with catheter infection, then needs to be removed </li></ul><ul><li>Avoid P. aeruginosa peritonitis by replacing catheter for recurrent, relapsing or refractory ESI with P. aeruginosa. </li></ul>
  21. 21. Stenotrophomonas <ul><li>Only sensitive to a few antimicrobials </li></ul><ul><li>Usually not as severe as pseudomonas, not associated with ESI </li></ul><ul><li>2 drugs, 3-4 weeks </li></ul><ul><li>Other single G-ve: may be touch contamination, ESI or transmural migration. Treat based on sensitivities. </li></ul>
  22. 22. Polymicrobial Peritonitis <ul><li>Multiple G+ve: more common, usually responds to antibiotic ( evidence ) </li></ul><ul><li>Multiple enteric organisms: increased risk of death , surgical evaluation should be obtained ( evidence ). Catheter may need to be removed. </li></ul><ul><li>Ceftazidime or aminoglycoside + ampicillin/cloxacillin+ metronidazole (21 days) </li></ul>
  23. 23. Culture Negative or Not Performed <ul><li>Should be < 20% </li></ul><ul><li>Use of antibiotics before presentation </li></ul><ul><li>No growth by 3 days, repeat cell count/diff. If not improving, consider infrequent pathogens. </li></ul><ul><li>If improve, continue initial therapy 2 weeks (aminoglycoside may be discontinued) </li></ul><ul><li>Not improved by 5 days: consider remove catheter </li></ul>
  24. 24. Fungal Peritonitis <ul><li>Catheter removal indicated immediately (evidence) </li></ul><ul><li>Mortality 15% if catheter removed within 1 week, 50% if left in place (overall 25 %) </li></ul><ul><li>Flucytosine, fluconazole or itraconazole </li></ul><ul><li>No RCT comparing ampho B with imidazole/triazole, retrospective data as efficacious </li></ul><ul><li>IP ampho B causes chemical peritonitis and pain, IV ampho B poor peritoneal administration </li></ul><ul><li>Voriconazole for filamentous fungi </li></ul><ul><li>4-6 weeks, 2 weeks if catheter removed </li></ul>
  25. 25. Tuberculous Peritonitis <ul><li>Rare (higher in Asia), TB or non-TB mycobacteria </li></ul><ul><li>Not responding to a/b either culture negative or proven bacterial peritonitis </li></ul><ul><li>Effluent cell count (most PMN predominance)/AFB smear rarely helpful </li></ul><ul><li>TB culture: 6 weeks </li></ul><ul><li>Earlier diagnosis: biopsy, PCR </li></ul>
  26. 26. TB Peritonitis <ul><li>Few data exist for optimal choice and duration of chemotherapy, based on experience of treatment of extra-pulmonary TB in ESRF </li></ul><ul><li>4 drugs (Isoniazid, rifampicin, pyrazinamide, ofloxacin), pyridoxine 50-100mg/day </li></ul><ul><li>IP Rifampicin? (low levels in dialysis fluid) </li></ul><ul><li>Streptomycin: ototoxic </li></ul><ul><li>Ethambutol: optic neuritis </li></ul><ul><li>Catheter removal? (reinsert 6 weeks) </li></ul>
  27. 27. Treatment in APD <ul><li>Little known about dosing in APD </li></ul><ul><li>Intermittent dosing , must dwell at least 6 hours to allow adequate absorption (rapid exchanges in APD inadequate time to achieve IP levels) </li></ul><ul><li>extensive evidence for efficacy of intermittent dosing of aminoglycoside and vancomycin in CAPD (Vanco in APD RCT in children) </li></ul>
  28. 28. APD <ul><li>Vancomycin: 50% absorption without peritonitis, 90% with. Re-entry during subsequent exchanges. Redosing once trough< 15mcg/ml (IP level < serum) </li></ul><ul><li>Cephalosporin: few data, night IP levels < MIC if daytime exchange only. Adding to each exchange ( opinion ). </li></ul><ul><li>Option oral antibiotics: lack pharmacokinetics study </li></ul>
  29. 29. APD <ul><li>Convert to CAPD (not always practical) </li></ul><ul><li>Increase dwell time on cycler (has not been well studied) </li></ul><ul><li>Conclusion: needs further research </li></ul>
  30. 30. Relapsing Peritonitis <ul><li>Another episode of peritonitis caused by same species within 4 weeks of antibiotic completion </li></ul><ul><li>Staph.: 4 weeks </li></ul><ul><li>Biofilm (CoNS): catheter replacement </li></ul><ul><li>Search for tunnel infection in staph. </li></ul><ul><li>Search for intra-abd. abscess in enterococcus/ G-ve </li></ul><ul><li>Pseudomonas: catheter removal </li></ul>
  31. 31. Refractory Peritonitis <ul><li>Failure to respond to appropriate antibiotic within 5 days </li></ul><ul><li>Catheter removal to protect peritoneal membrane for future use ( evidence ) </li></ul><ul><li>Prevent morbidity and mortality (risk of death highest with G-ve bacilli and fungus) </li></ul>
  32. 32. Adjunctive Therapy in Peritonitis <ul><li>2 or 3 rapid exchanges only symptomatic benefit </li></ul><ul><li>Heparin 500-1000U/L until effluent clears (extremely cloudy/ hemoperitoneum to prevent occlusion of catheter by fibrin) </li></ul><ul><li>Thrombolytic therapy occ useful in recurrent peritonitis (IP streptokinase: pain, fever and peritonitis like syndrome) </li></ul>
  33. 33. Exit Site and Tunnel Infections <ul><li>Purulent discharge : ESI (positive culture with normal appearance is colonization) </li></ul><ul><li>Tunnel infection: tenderness/erythema or edema over subcut. pathways but can be occult (rarely occurs alone) </li></ul><ul><li>Staph aureus and P. aeruginosa ESI most often concomitant tunnel infection, frequently leads to peritonitis ( evidence ) </li></ul>
  34. 35. Ultrasound of Tunnel Infection
  35. 36. Treatment of ES and Tunnel Infection <ul><li>Oral antibiotic = IP antibiotic (except MRSA) </li></ul><ul><li>Empiric therapy always covers Staph. Aureus </li></ul><ul><li>If previous Pseudomonas ESI, should cover it also </li></ul><ul><li>G+ve: cephalexin, amoxicillin, cloxacillin, clarithromycin (rifampicin combination if severe or slowly resolving) </li></ul><ul><li>Pseudomonas: difficult, prolonged therapy, oral quinolone 1 st choice, slow resolution/recurrence, add IP Fortum (often needs 2 antimicrobial) </li></ul>
  36. 37. Treatment of ES and Tunnel Infection <ul><li>Treatment until exit site appears normal </li></ul><ul><li>2 weeks minimum (opinion) </li></ul><ul><li>ESI that progresses to / in conjunction with peritonitis usually require catheter removal </li></ul><ul><li>(Exception: CoNS, readily treated) </li></ul>
  37. 38. Prophylaxis of ESI <ul><li>Staph aureus nasal carriage increases risk of ESI/tunnel infections, peritonitis and catheter loss </li></ul><ul><li>Intranasal mupirocin, exit site mupirocin and oral rifampicin effective in reducing ESI (Zimmerman et al 1991, Bernardini et al 1996) </li></ul><ul><li>Mupirocin negligible toxicity and less worried about resistance </li></ul>
  38. 39. Other promising options <ul><li>Gentamicin cream was shown to be as good as mupirocin in reducing Staph ESI and P. aeruginosa ESI/peritonitis as well (Bernadini et al, 2005) </li></ul><ul><li>Ciprofloxacin otologic solution reduce ESI caused by SA and P. aeruginosa in a randomised trial </li></ul>
  39. 40. Prophylactic Antibiotics <ul><li>Long term use of penicillin/cephalosporin has not been shown to decrease peritonitis </li></ul><ul><li>Chronic ESI(> 4 weeks): no data whether long term antibiotic is preferable to replacing catheter </li></ul>
  40. 41. Short Term Prophylaxis <ul><li>Invasive procedures infrequently cause peritonitis (evidence) </li></ul><ul><li>Amoxicillin 2 g before dental procedure (opinion) </li></ul><ul><li>Colonoscopy with polypectomy: ampi + aminoglycoside (opinion) </li></ul><ul><li>Abdomen should be emptied of fluid prior to procedures involving abd/pelvis (opinion) </li></ul>
  41. 42. Prophylaxis After Technique Break <ul><li>No data but most give 1-2 day course of antibiotics </li></ul><ul><li>1 st gen. cephalosporin adequate </li></ul>
  42. 43. Prevention of Fungal Peritonitis <ul><li>Most fungal peritonitis preceded by courses of antibiotics (evidence) </li></ul><ul><li>Trials using Nystatin or fluconazole prophylaxis during antibiotic therapy to prevent fungal peritonitis: mixed results </li></ul><ul><li>Only programs with high baseline rates of fungal peritonitis showed benefit </li></ul>
  43. 44. Catheter Placement <ul><li>No particular catheter shown to be better than standard silicon Tenckhoff for prevention of peritonitis (evidence) </li></ul><ul><li>Prophylactic antibiotics given at time of insertion reduces infection risk (evidence) </li></ul><ul><li>Recent trial ( AJKD 2000) found Vanco better but 2005 review recommend 1 st or 2 nd generation cephalosporin </li></ul>
  44. 45. Catheter Placement <ul><li>Double cuff catheter better, less removal due to ESI (National CAPD Registry, PDI 88) </li></ul><ul><li>Downward directed tunnel may reduce peritonitis </li></ul><ul><li>Avoid trauma/haematoma </li></ul><ul><li>Suture increases infection </li></ul><ul><li>Treat nasal carriage of Staph aureus </li></ul>
  45. 46. Connection Methods <ul><li>Abundant data shows spiking leads to peritonitis: double bag system, avoid spiking </li></ul><ul><li>“Flush before fill” reduces contamination and peritonitis ( evidence ) </li></ul>
  46. 47. Training Methods <ul><li>Training and retraining reduces peritonitis ( evidence ) </li></ul><ul><li>Aseptic technique, hand washing, alcohol hand wash ( opinion ), response to contamination </li></ul><ul><li>PD nurses, best nurse to patient ratio (no studies) </li></ul><ul><li>Home visits if feasible </li></ul>
  47. 48. Prevention of Bowel Source of Infection <ul><li>Association between severe constipation, enteritis and peritonitis due to enteric organisms ( evidence ) </li></ul><ul><li>Transmigration across bowel walls </li></ul><ul><li>hypomotility (hypoK), drugs contributing to constipation (iron, Ca, ) </li></ul><ul><li>Colitis & diarrhoea: transmural migration, touch contamination (hand washing) </li></ul>
  48. 49. Indications of Catheter Removal <ul><li>Refractory peritonitis </li></ul><ul><li>Refractory catheter infection </li></ul><ul><li>Relapsing peritonitis </li></ul><ul><li>Fungal peritonitis </li></ul><ul><li>Consider if not responding in Mycobacterial peritonitis and multiple enteric organisms </li></ul>
  49. 50. Catheter Insertion after Removal <ul><li>Optimal period unknown, minimum 2-3 weeks ( opinion ), 4 weeks (CPG) </li></ul><ul><li>Simultaneous catheter removal and replacement in refractory tunnel infections and relapsing peritonitis (Swartz et al, 1991) </li></ul><ul><li>Limited to those with wbc<100, not for pseudomonas/fungi/TB/intra-abd abscess </li></ul>
  50. 51. THE END THANK YOU

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