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Infective Complications In Pd

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Dr Lawrence Hii

Dr Lawrence Hii
Kuching
Sarawak

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    Infective Complications In Pd Infective Complications In Pd Presentation Transcript

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