Infectious complications of Peritoneal Dialysis · Peritonitis Is a possible cause of…...
Transcript of Infectious complications of Peritoneal Dialysis · Peritonitis Is a possible cause of…...
Infectious complicationsof Peritoneal Dialysis
Infectious complicationsof Peritoneal Dialysis
Prevention and managementPrevention and management
From 30 years of our experiencewhen confirmed by ISPD Guidelines 2005
From 30 years of our experiencewhen confirmed by ISPD Guidelines 2005 ISPD
2005ISPD2005
Alain Slingeneyer : MontpellierAlain Slingeneyer : Montpellier
Main concern = PERITONITISMain concern = PERITONITIS
1) Peritoneal infection may present• as a light complication, treated at home• as a deadly severe surgical peritonitis
2) Infection of peritoneal catheter maylead to peritoneal infection
1) Peritoneal infection may present• as a light complication, treated at home• as a deadly severe surgical peritonitis
2) Infection of peritoneal catheter maylead to peritoneal infection
PeritonitisIs a possible cause of…
PeritonitisIs a possible cause of…
Peritoneal membrane damage (sclerosis)
Hospitalization and painTemporary loss of UFMalnutrition (via increased protein losses)
Extra cost Technique failureCatheter lossPossible death
Peritoneal membrane damage (sclerosis)
Hospitalization and painTemporary loss of UFMalnutrition (via increased protein losses)
Extra cost Technique failureCatheter lossPossible death
Hospitalization in PD PatientsHospitalization in PD Patients
OtherInfections
19%
OtherInfections
19%
Surgery18%
Surgery18%
PVD11%PVD11%
Cardiac27%
Cardiac27%
Peritonitis25%
Peritonitis25%
Fried, at al., AJKD 1999;33:929Fried, at al., AJKD 1999;33:929
Time Course of UFafter peritonitis
Time Course of UFafter peritonitis
Ates, et al., PDI 20;2000:220-226Ates, et al., PDI 20;2000:220-226
00
100100
200200
300300
400400
500500
baselinebaseline day 1day 1 week 1week 1 week 2week 2 week 4week 4 week 12week 12 week 24week 24
UF, ml/exchangeUF, ml/exchange
*p<0.05 vs baseline for all times*p<0.05 vs baseline for all times*p<0.05 vs baseline for all times
Peritoneal Infection Peritoneal Infection
DEFINITION :1. Cloudy effluent : >100 wbc/ml and > 50%N
2. Signs and symptoms
3. Identification of organism
Two of three required for diagnosis
DEFINITION :1. Cloudy effluent : >100 wbc/ml and > 50%N
2. Signs and symptoms
3. Identification of organism
Two of three required for diagnosis
Unused bag
Unused bag
Cloudy effluentCloudy effluent
Normal effluentNormal effluent
Clinical course in PERITONEAL INFECTION
Clinical course in PERITONEAL INFECTION
Introduction of bacteria into peritoneal cavity
Bacteria Peritoneal wall Multiplication
ASYMPTOMATIC FOR 24 - 48 HRS
Shed into PD fluid
Introduction of bacteria into peritoneal cavity
Bacteria Peritoneal wall Multiplication
ASYMPTOMATIC FOR 24 - 48 HRS
Shed into PD fluid
Peritoneal immunologicalresponse
Peritoneal Peritoneal immunologicalimmunologicalresponseresponse
Abdominal paincloudy effluent
= diagnosis of infection
Abdominal painAbdominal paincloudy effluentcloudy effluent
= diagnosis of infection= diagnosis of infection
Is peritonitis ineluctable ?
What are the routes of infection ?
How to prevent peritoneal infection ?
Is peritonitis ineluctable ?
What are the routes of infection ?
How to prevent peritoneal infection ?
Many patients don’t get peritonitis!Many patients don’t get peritonitis!
00
1010
2020
3030
4040
5050
6060
7070
None None oneone twotwo threethree fourfour
Overall rate 0.5 episodes/yearOverall rate 0.5 episodes/year
Rippe KI 2001; 59:348-357Rippe KI 2001; 59:348-357
% o
f PD
pat
ient
s by
epis
odes
of p
erito
nitis
ove
r tw
o ye
ars
% o
f PD
pat
ient
s by
epis
odes
of p
erito
nitis
ove
r tw
o ye
ars
Finkelstein AJKD 2002;39:1278-1286Finkelstein AJKD 2002;39:1278-1286
A minority of PD patients have the majority of peritonitis episodesA minority of PD patients have the majority of peritonitis episodes
Routes of Peritoneal InfectionRoutes of Peritoneal Infection
Exchange procedure“Touch contamination”
Titanium/transfer set
Peri-catheterTranscolonic
Haematogenous
Sources of Peritonitis, %Sources of Peritonitis, %
• Contamination 41
• Catheter related 23
• Enteric injury 11
• Perioperative 6
• Diarrhea/UTI 4
• Sepsis 1
• Unknown 14
• Contamination 41
• Catheter related 23
• Enteric injury 11
• Perioperative 6
• Diarrhea/UTI 4
• Sepsis 1
• Unknown 14Harwell PDI 1997Harwell PDI 1997
ISOLATION OF RESPONSIBLE
ORGANISM IS CRUCIAL
ISOLATION OF RESPONSIBLE
ORGANISM IS CRUCIAL
Micro-Organismscausing peritonitisMicro-Organisms
causing peritonitis
CNSCNSS. aureusS. aureusPseudo/XanthPseudo/Xanthother GPCother GPCenterococcusenterococcusother GNother GNbacteroidesbacteroidesmultiplemultiplefungusfungusno growthno growth
22%22%
13%13%
7%7%8%8%2%2%
18%18%
4%4%
22%22%
1%1%3%3%
Harwell PDI 1997;17:586-594Harwell PDI 1997;17:586-594
Identification of bacteria is helpful to understand the route of contaminationIdentification of bacteria is helpful to
understand the route of contamination
• Coagulase - Staphylococci• Staphylococcus aureus• Pseudomonas-Xanthomonas• Other Gram - bacteria• Enterococcus• Bacteroides• Multiple• Fungus• No growth
• Coagulase - Staphylococci• Staphylococcus aureus• Pseudomonas-Xanthomonas• Other Gram - bacteria• Enterococcus• Bacteroides• Multiple• Fungus• No growth
HandsHands
WaterWater
ColonColon
MicrobiologyProblem
MicrobiologyProblem
Outcomes of PeritonitisOutcomes of Peritonitis
05
1015202530354045
Hospitalization Catheter removed Transfer
CNS S. aureus GN
05
1015202530354045
Hospitalization Catheter removed Transfer
CNS S. aureus GN
Bunke, et al., KI 1997Bunke, et al., KI 1997
% of all episodes(without ESI/TI)
% of all episodes(without ESI/TI)
Terminology for Peritonitis Terminology for Peritonitis ISPD2005ISPD2005
Episode Therapy Organism
Recurrent New < 4 weeksof completion
Different
Relapsing New < 4 weeksof completion
Sameor sterile
Repeat New > 4 weeksof completion
Same
Refractory Same > 5 daysof appropriate
Same
Catheter-related ESIor tunnel
Within 2months
Same
Episode Therapy Organism
Recurrent New < 4 weeksof completion
Different
Relapsing New < 4 weeksof completion
Sameor sterile
Repeat New > 4 weeksof completion
Same
Refractory Same > 5 daysof appropriate
Same
Catheter-related ESIor tunnel
Within 2months
Same
What about
Touch Contamination ?
What about
Touch Contamination ?
Peritonitis - Connectology Peritonitis - Connectology
00
55
1010
1515
2020
2525
3030
3535
19701970 19801980 19901990 20002000
Glass bottlesGlass bottles
Plastic bagsPlastic bagstitaniumtitanium
OsetOset
disconnectdisconnect
st line Y setStaph epi 0.34 0.17Staph aur 0.15 0.13Gram -ve 0.12 0.10Fungal 0.02 0.01
st line Y setStaphStaph epiepi 0.340.34 0.170.17StaphStaph auraur 0.150.15 0.130.13Gram Gram --veve 0.120.12 0.100.10FungalFungal 0.020.02 0.010.01
Pe r
ito n
itis
rat
e ep
isod
es/ p
t m
ont h
Pe r
ito n
itis
rat
e ep
isod
es/ p
t m
ont h
Peritonitis rates have improved over the yearswith new systems
Peritonitis rates have improved over the yearswith new systems
- But serious peritonitisis unchanged
- But serious peritonitisis unchanged
ISPD2005ISPD2005
Holly AJKD 1994Holly AJKD 1994
Peritonitis rate is reduced with APDPeritonitis rate is reduced with APD
Sept 15, 2000
Peritonitis in CAPD compared to APD
0
0.05
0.1
0.15
0.2
S aureus CNS OtherGPC
GN polymicr
CAPDAPD
Episodes per year
From Rodriguez-Carmona PDI 19; 1999Peritonit is rates--lower on APD than CAPD0.31 versus 0.64 per year at risk
Prevention of contaminationvia the connections
Prevention of contaminationvia the connections
Perfect hands washing (alcohol !)
Perfect hands drying
Cap and mask
Education on fingers position
Every body do the same : training and retraining
Perfect hands washing (alcohol !)
Perfect hands drying
Cap and mask
Education on fingers position
Every body do the same : training and retraining
ProtocolsProtocols
ISPD2005ISPD2005
ISPD2005ISPD2005
ISPD2005ISPD2005
ISPD2005ISPD2005
CATHETER RELATED
INFECTIONS
CATHETER RELATED
INFECTIONS
Peritonitis related to catheter infection
Peritonitis related to catheter infection
• Bacteria more often encountered– Staphylococcus aureus– Pseudomonas species
• Biofilm related problems
• Changing a catheter is less dangerous than a severe peritonitis
• Bacteria more often encountered– Staphylococcus aureus– Pseudomonas species
• Biofilm related problems
• Changing a catheter is less dangerous than a severe peritonitis
ISPD2005ISPD2005
ISPD2005ISPD2005
BASIC RULES FOR A HEALTHY EXIT SITE
BASIC RULES FOR BASIC RULES FOR A HEALTHY EXIT SITEA HEALTHY EXIT SITE
Fibrosis maturation impeded by :– micro-organisms (even without infection)– air– antiseptics (Povidone-iodine)
Two months are necessary for– complete fibrosis around the cuffs– sinus epithelialisation
Any trauma of exit site favourites infection(proven in 10% of cases )
Fibrosis maturation impeded by :Fibrosis maturation impeded by :–– micromicro--organisms organisms (even without infection)(even without infection)–– airair–– antiseptics antiseptics ((PovidonePovidone--iodine)iodine)
Two months are necessary forTwo months are necessary for–– complete fibrosis around the cuffscomplete fibrosis around the cuffs–– sinus sinus epithelialisationepithelialisation
Any trauma of exit site favourites infectionAny trauma of exit site favourites infection(proven in 10% of cases )(proven in 10% of cases )
Outer dacron cuffOuter Outer dacron dacron cuffcuff
Sub-cutaneous fat tissuesSub-cutaneous fat tissues
DermisDermis
EpidermisEpidermis
Sinus formationSinus formation
A PERFECT EPITHELIALISATION OF THE SINUS = A HEALTHY EXIT SITE
A PERFECT EPITHELIALISATION OF THE SINUS A PERFECT EPITHELIALISATION OF THE SINUS = A HEALTHY EXIT SITE= A HEALTHY EXIT SITE
The TWO first months are critical ...The TWO first months are critical ...The TWO first months are critical ...
Catheter must be perfectly stabilised• First dressing changed after 15 days• Extension placed in the operating room
No traumatic care• No anxiety to see what happens underneath the
catheter
No contact with tape water- Water proof dressing for shower and bath- During two first months after catheter insertion or
catheter exteriorisation (Moncrief technique)- Dressing redone after shower
Catheter must be perfectly stabilisedCatheter must be perfectly stabilised•• First dressing changed after 15 daysFirst dressing changed after 15 days•• Extension placed in the operating roomExtension placed in the operating room
No traumatic careNo traumatic care•• No anxiety to see what happens underneath the No anxiety to see what happens underneath the
cathetercatheter
No contact with tape waterNo contact with tape water-- Water proof dressing for shower and bathWater proof dressing for shower and bath-- During two first months after catheter insertion or During two first months after catheter insertion or
catheter exteriorisation (catheter exteriorisation (Moncrief Moncrief technique)technique)-- Dressing redone after showerDressing redone after shower
Exit site infection : diagnosisExit site infection : Exit site infection : diagnosisdiagnosis• Redness > 3 mm at exit site• Pus flow (spontaneously or on cuff pressure)• Tumour, pain (above the tunnel)• Fleshy granuloma• Disruption of the epithelium, along the sinus• Positive bacteriological cultures
Bacterio + alone is not an infection
Be vigilant aboutStaph. aureus and Pseud. aeruginosa
•• Redness > 3 mm at exit siteRedness > 3 mm at exit site•• Pus flow (spontaneously or on cuff pressure)Pus flow (spontaneously or on cuff pressure)•• Tumour, pain (above the tunnel)Tumour, pain (above the tunnel)•• Fleshy Fleshy granulomagranuloma•• Disruption of the epithelium, along the sinusDisruption of the epithelium, along the sinus•• Positive bacteriological culturesPositive bacteriological cultures
BacterioBacterio + alone is not an infection+ alone is not an infection
Be vigilant aboutBe vigilant aboutStaphStaph. . aureusaureus and and PseudPseud. . aeruginosaaeruginosa
ISPD2005ISPD2005
Site of infectionSite of infectionSite of infection
1) Sinus1) Sinus1) Sinus
2) Outercuff
2) Outer2) Outercuffcuff
3) Tunnel3) Tunnel3) Tunnel
4) Peritoneum4) Peritoneum4) Peritoneum
4) Innercuff
4) Inner4) Innercuffcuff
Intra peritonealsection
Intra peritonealIntra peritonealsectionsection
Diagnosis ofINFECTION SITE
Diagnosis ofINFECTION SITE
50 % of peritonitis are related to unsolved
exit site/tunnel infection
Scalamona, Am. J. Kidney Dis. 1991
50 % of peritonitis are related to unsolved
exit site/tunnel infection
Scalamona, Am. J. Kidney Dis. 1991
HEMATOMA POST TRAUMAGRADE 1 OF INFECTION
HEMATOMA POST TRAUMAHEMATOMA POST TRAUMAGRADE 1 OF INFECTIONGRADE 1 OF INFECTION
ACCUTE INFECTION OF EXIT SITE
ACCUTE INFECTION ACCUTE INFECTION OF EXIT SITEOF EXIT SITE
CHRONIC INFECTIONOF EXIT SITE
CHRONIC INFECTIONCHRONIC INFECTIONOF EXIT SITEOF EXIT SITE
CHRONIC INFECTION Treatment ...
CHRONIC INFECTION CHRONIC INFECTION Treatment ...Treatment ...
Never accept it !
Insertion of a new catheter= lower risk than a severe peritonitis
Never accept it !Never accept it !
Insertion of a newInsertion of a new cathetercatheter= lower risk than a= lower risk than a severe peritonitissevere peritonitis
Peritoneal catheters and exit-site practice.Toward optimum peritoneal access
P.D.I. vol 18 N° 1, 1998, Table 2
ISPD2005ISPD2005
« Botryomycoma » or
“ fleshy granuloma “ or
« like-raspberry tumour »
too long neglected
«« BotryomycomaBotryomycoma »» oror
““ fleshy fleshy granuloma granuloma ““ oror
«« likelike--raspberry tumourraspberry tumour »»
too long neglectedtoo long neglected
TUNNEL INFECTIONTUNNEL INFECTION
• Redness, edema and/or tenderness over the subcutaneous tunnel
• Often ESI is associated but some cases are occult
• May need ultrasound to diagnose- clinical criteria: rate 0.13 ep/year- ultrasound criteria: rate0.35 ep/year- negative US: 0% catheter loss- positive US: 50% catheter loss
• Redness, edema and/or tenderness over the subcutaneous tunnel
• Often ESI is associated but some cases are occult
• May need ultrasound to diagnose- clinical criteria: rate 0.13 ep/year- ultrasound criteria: rate0.35 ep/year- negative US: 0% catheter loss- positive US: 50% catheter loss
(Plum AJKD 1994;23:94)(Plum AJKD 1994;23:94)
TREATMENTS OF EXIT SITE INFECTION
TREATMENTS OF EXIT SITE INFECTION
Prevention is BETTER than cure,
but if curative action is needed use both
medicalsurgical
Prevention is BETTER than cure,
but if curative action is needed use both
medicalsurgical
ISPD2005ISPD2005
CATHETER INFECTION :Prevention ...
CATHETER INFECTION :CATHETER INFECTION :Prevention ...Prevention ... ISPD
2005ISPD2005
Exit site orientated downward
Double cuff catheter
Prophylactic antibiotics at insertion( Vancomycin 1g IV superior to Cephalosporin 1g IV )
Avoid haematoma and trauma
First dressing redone after 15 days
Exit site orientated downwardExit site orientated downward
Double cuff catheter Double cuff catheter
Prophylactic antibiotics at insertionProphylactic antibiotics at insertion( ( Vancomycin Vancomycin 1g IV superior to Cephalosporin 1g IV )1g IV superior to Cephalosporin 1g IV )
Avoid haematoma and traumaAvoid haematoma and trauma
First dressing redone after 15 daysFirst dressing redone after 15 days
CATHETER INFECTION :Prevention ...
CATHETER INFECTION :CATHETER INFECTION :Prevention ...Prevention ... ISPD
2005ISPD2005
Permanent careful stabilisation (with or without dressing)Permanent careful stabilisation Permanent careful stabilisation (with or without dressing)(with or without dressing)
CATHETER INFECTION :Prevention ...
CATHETER INFECTION :CATHETER INFECTION :Prevention ...Prevention ...
Diagnosis and treatment of S. aureus carriageDiagnosis and treatment of S. Diagnosis and treatment of S. aureusaureus carriagecarriage
Diagnosis of Staphylococcus aureus carriage
Diagnosis of Staphylococcus aureus carriage
• 10 days away from antibiotic treatment• Wet and deep swab of the two nostrils• Two swabs at 2 days interval
Two positive cultures = carrierOne + and one - third swab
• 10 days away from antibiotic treatment• Wet and deep swab of the two nostrils• Two swabs at 2 days interval
Two positive cultures = carrierOne + and one - third swab
Mupirocin prophylactic treatmentMupirocin prophylactic treatment
CARI Guidelines 2004(Level II evidence)
Prophylactic therapy using mupirocin ointment, especially for Staphylococcus aureus carriage intranasally
is recommended to decrease the risk of S. aureus catheter exit site/tunnel infections and peritonitis
CARI Guidelines 2004(Level II evidence)
Prophylactic therapy using mupirocin ointment, especially for Staphylococcus aureus carriage intranasally
is recommended to decrease the risk of S. aureus catheter exit site/tunnel infections and peritonitis
Intranasal mupirocin twice daily x 5 days/monthIntranasal mupirocin twice daily x 5 days/month
Prophylactic antibiotic at exit siteProphylactic antibiotic at exit site ISPD2005ISPD2005
Effective on
Mupirocin cream Staphylo. aureus
Gentamicin cream Staphylo. aureusPseudo. aeruginosa
Ciprofloxacinotologic solution
Staphylo. aureusPseudo. aeruginosa
Effective on
Mupirocin cream Staphylo. aureus
Gentamicin cream Staphylo. aureusPseudo. aeruginosa
Ciprofloxacinotologic solution
Staphylo. aureusPseudo. aeruginosa
Protocol to be adaptedto local microbiological observations
Protocol to be adaptedto local microbiological observations
S. aureus exit site infectionsare reduced with mupirocin prophylaxis
S. aureus exit site infectionsare reduced with mupirocin prophylaxis
000,10,10,20,20,30,30,40,40,50,5
intra-intra-nasalnasal
intra-intra-nasalnasal exit siteexit site exit siteexit site exit siteexit site
controlcontrol prophylaxisprophylaxis
S. a
ureu
sES
I/yea
rS.
aur
eus
ESI/y
ear
Perez-FontanPerezPerez--FontanFontan Mupirocin Study GroupMupirocin Mupirocin
Study GroupStudy Group
BernardiniBernardiniBernardini ThodisThodisThodis ThodisThodisThodis
CATHETER INFECTION :Prevention ...
CATHETER INFECTION :CATHETER INFECTION :Prevention ...Prevention ...
ISPD2005ISPD2005
Monitoring of infection rates (ESI and peritonitis)
Scoring system for ESI
Education of nurses and patient
At the slightest doubt
The nephrologist is also concerned
Monitoring of infection ratesMonitoring of infection rates (ESI and peritonitis)(ESI and peritonitis)
Scoring system for ESIScoring system for ESI
Education of nurses Education of nurses andand patientpatient
At the slightest doubt At the slightest doubt
The The nephrologistnephrologist is also concernedis also concerned
MEDICAL TREATMENTMEDICAL TREATMENTMEDICAL TREATMENT
• Dressing every day
• Skin soaping ( before antiseptic application )– antiseptic scrub– “Soap of Marseille”
• Cleaning the crusts – Hydrogen peroxide (20 volumes) – Diluted bleach
•• Dressing every dayDressing every day
•• Skin soapingSkin soaping ( before antiseptic application )( before antiseptic application )–– antiseptic scrubantiseptic scrub–– ““Soap of MarseilleSoap of Marseille””
•• Cleaning the crusts Cleaning the crusts –– Hydrogen peroxide (20 volumes) Hydrogen peroxide (20 volumes) –– Diluted bleachDiluted bleach
ANTIBIOTHERAPYaccording Gram stain or history
ANTIBIOTHERAPYANTIBIOTHERAPYaccording Gram stain or historyaccording Gram stain or history
LOCAL( always )
• St. aureus :– Rifampicine ( 600 mg ) +
Protamine ( 1000 U )– Mupirocin cream– Fucidin cream
• Gram - :– Gentamicin cream– Ciprofloxacin solution
LOCALLOCAL( always )( always )
•• St. St. aureusaureus ::–– RifampicineRifampicine ( 600 mg ) + ( 600 mg ) +
ProtamineProtamine ( 1000 U )( 1000 U )–– Mupirocin Mupirocin creamcream–– Fucidin Fucidin creamcream
•• Gram Gram -- ::–– Gentamicin Gentamicin creamcream–– Ciprofloxacin solutionCiprofloxacin solution
GENERAL( according severity )
(PO or IP)
• St. aureus :– First generation cephalosporin– Vancomycine if MRSA– Rifampicin in association
• Gram - :– Quinolone ( 2 hours before others)– 3rd generation cephalosporin
GENERALGENERAL( according severity )( according severity )
(PO or IP)(PO or IP)
•• St. St. aureusaureus ::–– First generation cephalosporinFirst generation cephalosporin–– VancomycineVancomycine if MRSAif MRSA–– Rifampicin Rifampicin in associationin association
•• Gram Gram -- ::–– Quinolone Quinolone ( 2 hours before others)( 2 hours before others)–– 33rdrd generation cephalosporingeneration cephalosporin
Duration : 2 to 4 weeksDuration : 2 to 4 weeks
SURGICAL TREATMENTSURGICAL TREATMENTSURGICAL TREATMENT
• Fleshy granuloma : – Silver nitrate pen or electrocoagulation
• Sinus :– Reduce the length of the sinus :
•• Fleshy Fleshy granuloma granuloma : : –– Silver nitrate pen or Silver nitrate pen or electrocoagulationelectrocoagulation
•• Sinus :Sinus :–– Reduce the length of the sinus :Reduce the length of the sinus :
OPENING THE SINUSTO TREAT LOCALISED INFECTION
OPENING THE SINUSOPENING THE SINUSTO TREAT LOCALISED INFECTIONTO TREAT LOCALISED INFECTION
SURGICAL TREATMENTSURGICAL TREATMENTSURGICAL TREATMENT
• Fleshy granuloma :
• Sinus :
• Outer cuff :– Unroofing technique– Peel away the cuff (shaving technique)
•• Fleshy Fleshy granuloma granuloma ::
•• Sinus :Sinus :
•• Outer cuff :Outer cuff :–– UnroofingUnroofing techniquetechnique–– Peel away the cuff (shaving technique)Peel away the cuff (shaving technique)
Forceps
Pealing offouter cuff
Scalpel
sub-cutaneousportion
Umbilicus
Externalportion
Opening ofthe sinus
The unroofingshaving
technique
The unroofingshaving
technique
SURGICAL TREATMENTSURGICAL TREATMENTSURGICAL TREATMENT
• Fleshy granuloma :
• Sinus :
• Outer cuff :
• Tunnel :– Shorten the tunnel length– Peel away the outer cuff
• Peritonitis :If same organism at the exit site, remove the catheter
•• Fleshy Fleshy granuloma granuloma ::
•• Sinus :Sinus :
•• Outer cuff :Outer cuff :
•• Tunnel :Tunnel :–– Shorten the tunnel lengthShorten the tunnel length–– Peel away the outer cuffPeel away the outer cuff
•• Peritonitis :Peritonitis :If same organism at the exit site, remove the catheterIf same organism at the exit site, remove the catheter
GOOD RESULTS
ARE POSSIBLE !!
GOOD RESULTSGOOD RESULTS
ARE POSSIBLE !!ARE POSSIBLE !!
Comparison of frequency1 event / 1 patient-year
Comparison of frequencyComparison of frequency1 event / 1 patient1 event / 1 patient--yearyear
Literature*LiteratureLiterature** Our experience**Our experienceOur experience****
000to 0.017to 0.017to 0.017
0.0070.0070.007LeakageLeakageLeakage
000to 0.21to 0.21to 0.21
Drainage prob.Drainage prob.Drainage prob. 0.020.020.02
0.050.050.05to 0.65to 0.65to 0.65 0.050.050.05Exit site infect.Exit site infect.
**1119 Tenckhoff (straight and curl)**1119 Tenckhoff (straight and curl)* Meta-analyse by Ash* Meta-analyse by Ash
HAEMATOGENOUS
and
TRANS COLONIC CONTAMINATION
HAEMATOGENOUS
and
TRANS COLONIC CONTAMINATION
Antibiotic prophylaxis
for extensive dental procedures
Antibiotic prophylaxis
for extensive dental procedures ISPD2005ISPD2005
Single oral dose ofamoxicillin 2 g
two hours before
Single oral dose ofamoxicillin 2 g
two hours before
Abdominal Catastrophe with Associated Peritonitis
Abdominal Catastrophe with Associated Peritonitis
• Ischemic bowel disease
• Ruptured sigmoid diverticula
• Appendicitis
• Gangrenous cholecystitis
• Perforation in association with ulcer, endoscopy, polypectomy
• Ischemic bowel disease
• Ruptured sigmoid diverticula
• Appendicitis
• Gangrenous cholecystitis
• Perforation in association with ulcer, endoscopy, polypectomy
Harwell PDI 1997Harwell PDI 1997
MULTI-ORGANISM PERITONITISMULTI-ORGANISM PERITONITISMore than one organism in 9% of episodes
Gram positive - staph epi and aureus; - contamination and/or catheter infection- low mortality
Gram negative - bowel should be suspected- anaerobes, 2 bacilli or fungus- or Enterococcus + G- bacillus- bowel perforation or across wall ?- laparotomy should be considered
Intra abdominal abscesses
More than one organism in 9% of episodes
Gram positive - staph epi and aureus; - contamination and/or catheter infection- low mortality
Gram negative - bowel should be suspected- anaerobes, 2 bacilli or fungus- or Enterococcus + G- bacillus- bowel perforation or across wall ?- laparotomy should be considered
Intra abdominal abscesses
Outcome of Enteric PeritonitisOutcome of Enteric Peritonitis
peritonitis with intra-abdominal diseaseperitonitis with intra-abdominal disease all other episodesall other episodes
001010202030304040505060607070
resolvedresolved recurredrecurred catheter lostcatheter lost dieddied
% o
f Epi
sode
s%
of E
piso
des
Harwell PDI 1997Harwell PDI 1997
Preventionagainst enteric peritonitis
Preventionagainst enteric peritonitis
• Fight against constipation ( hypokaliemia)
• No enema
• Treat rapidly diarrhoea and gastro-enteritis– Nifuroxazide, – diosmectite, – ioperamide
• Prophylactic antibiotic treatment when enteroscopy prescribed (prior, 3 days after)
• Fight against constipation ( hypokaliemia)
• No enema
• Treat rapidly diarrhoea and gastro-enteritis– Nifuroxazide, – diosmectite, – ioperamide
• Prophylactic antibiotic treatment when enteroscopy prescribed (prior, 3 days after)
Antibiotic prophylaxisbefore endo-luminal procedures
Antibiotic prophylaxisbefore endo-luminal procedures
Colonoscopy, polypectomy, endometrial biopsy,renal transplantation …
• Empty abdomen and
• Ampicillin 1 g +• Aminoglycoside + 1 single dose IV• Metronidazole
Colonoscopy, polypectomy, endometrial biopsy,renal transplantation …
• Empty abdomen and
• Ampicillin 1 g +• Aminoglycoside + 1 single dose IV• Metronidazole
ISPD2005ISPD2005
TREATMENT and
ANTIBIOTIC PRESCRIPTION
in
PERITONEAL INFECTIONS
TREATMENT and
ANTIBIOTIC PRESCRIPTION
in
PERITONEAL INFECTIONS
Prophylactic Antibiotic UseProphylactic Antibiotic Use
• Extended use :- does not prevent peritonitis- been shown for penicillins and septrin
• Short term use :- in case of invasive procedures with transient
bacteraemia (colonoscopy, dental)
• After technique break ?- no evidence to support prophylactic use
• Extended use :- does not prevent peritonitis- been shown for penicillins and septrin
• Short term use :- in case of invasive procedures with transient
bacteraemia (colonoscopy, dental)
• After technique break ?- no evidence to support prophylactic use
Trimethoprim/sulfamethoxazoleprophylaxis to prevent peritonitisTrimethoprim/sulfamethoxazole
prophylaxis to prevent peritonitis
001010202030304040
5050606070708080
% p
atie
nts f
ree
of p
erito
nitis
at o
ne y
ear
% p
atie
nts f
ree
of p
erito
nitis
at o
ne y
ear
proven to have takenproven to have takencotrimoxazolecotrimoxazoleplaceboplacebo
Churchill PDI 1988; 8: 125-128Churchill PDI 1988; 8: 125-128
Use of Oral Nystatinto reduce fungal peritonitis
Use of Oral Nystatinto reduce fungal peritonitis
ISPD2005ISPD2005
Observational studies suggest that previous exposure to antibiotics within last month were more common in patient developing fungal peritonitis.
• Use of oral nystatin (or fluconazole, 100 mg) should be considered at time of administration of antibiotics to reduce fungal peritonitis
• Seems to be beneficial in programs with high baseline rate of fungal peritonitis
Observational studies suggest that previous exposure to antibiotics within last month were more common in patient developing fungal peritonitis.
• Use of oral nystatin (or fluconazole, 100 mg) should be considered at time of administration of antibiotics to reduce fungal peritonitis
• Seems to be beneficial in programs with high baseline rate of fungal peritonitis
Fungal Peritonitiswithout/with prophylaxis
Fungal Peritonitiswithout/with prophylaxis
ReferenceReferenceReference ProphylaxisProphylaxisProphylaxis Incidence*Incidence*Incidence*Zaruba 1991
Robitaille 1994
Wadhwa 1996
Lo 1996
Thodis 1998
Williams 2000
Zaruba 1991
Robitaille 1994
Wadhwa 1996
Lo 1996
Thodis 1998
Williams 2000
Nystatin tidNystatin or KetoFluconazole qidNystatin qidNystatin qidNystatin qid
Nystatin tidNystatin or KetoFluconazole qidNystatin qidNystatin qidNystatin qid
0.29 vs 0.030.14 vs 00.08 vs 0.010.02 vs 0.010.02 vs 0.020.01 vs 0.01
0.29 vs 0.030.14 vs 00.08 vs 0.010.02 vs 0.010.02 vs 0.020.01 vs 0.01
*antibiotic associated fungal peritonitis*antibiotic associated fungal peritonitis*antibiotic associated fungal peritonitis
Williams, et al., PDI 2000;20:352-353Williams, et al., PDI 2000;20:352-353
TREATMENT
The patient presents with
TREATMENT
The patient presents with
• Cloudy effluent• With or without ( Co Neg Staphylo.) othersigns and symptoms of infection
What to do ?
• Cloudy effluent• With or without ( Co Neg Staphylo.) othersigns and symptoms of infection
What to do ?
Treatment of PD Peritonitis : 1Treatment of PD Peritonitis : 1
• Patient questioning on last 48 h PD history
• Two to four rapid exchanges to relieve pain
• Analgesic medications ( opiate if necessary)
• Heparin (2500 U/l) in PD solutions
• Careful exam of exit site
• Careful abdominal exam (localised pain?)
• Effluent and blood samplings
• Prescription of empirical antibiotic treatment
• Patient questioning on last 48 h PD history
• Two to four rapid exchanges to relieve pain
• Analgesic medications ( opiate if necessary)
• Heparin (2500 U/l) in PD solutions
• Careful exam of exit site
• Careful abdominal exam (localised pain?)
• Effluent and blood samplings
• Prescription of empirical antibiotic treatment
Differential diagnosisof Cloudy Effluent
Differential diagnosisof Cloudy Effluent
ISPD2005ISPD2005
• Specimen taken from “dry” abdomen• Culture positive infectious peritonitis• Infectious peritonitis with sterile cultures• Chemical peritonitis• Eosinophilia of the effluent• Haemoperitoneum• Malignancy (rare)• Chylous effluent (rare)
• Specimen taken from “dry” abdomen• Culture positive infectious peritonitis• Infectious peritonitis with sterile cultures• Chemical peritonitis• Eosinophilia of the effluent• Haemoperitoneum• Malignancy (rare)• Chylous effluent (rare)
Treatment of PD Peritonitis : 2Empiric antibiotics
Treatment of PD Peritonitis : 2Empiric antibiotics
ISPD2005ISPD2005
• In peritoneal dialysis patients with the provisional diagnosis of peritonitis, treatment should commence with a combination of intraperitoneal antibiotics that provide adequate cover of both gram positive and negative organisms.
• Renal units should monitor isolates, base empiric antibiotic choices on isolate resistance patterns and undertake regular reviews of empiric antibiotic choices based on the local epidemiology.
• In peritoneal dialysis patients with the provisional diagnosis of peritonitis, treatment should commence with a combination of intraperitoneal antibiotics that provide adequate cover of both gram positive and negative organisms.
• Renal units should monitor isolates, base empiric antibiotic choices on isolate resistance patterns and undertake regular reviews of empiric antibiotic choices based on the local epidemiology.
Gram +Gram + Gram -Gram -
Vancomycinor 1st gener. cephalosporin
Vancomycinor 1st gener. cephalosporin
3d gener.cephalosporinor aminoglycoside
or quinolone
3d gener.cephalosporinor aminoglycoside
or quinolone++
Factors influencing empiric therapyFactors influencing empiric therapy
• Signs and symptoms at presentation
• Probable organisms according to the probable cause
• Organisms sensitivities in your team (MRSA?)
• Cephalosporin-allergic patients
• Ototoxicity, especially with long term aminoglycosides
• Emergence of vancomycin resistance : Staphy. / Strepto.
• Convenience, cost
• Signs and symptoms at presentation
• Probable organisms according to the probable cause
• Organisms sensitivities in your team (MRSA?)
• Cephalosporin-allergic patients
• Ototoxicity, especially with long term aminoglycosides
• Emergence of vancomycin resistance : Staphy. / Strepto.
• Convenience, cost
ISPD Guidelines 2005ISPD Guidelines 2005Cloudy effluentCloudy effluentCloudy effluent
Clinical evaluationEffluent evaluation
Gram stain and culture
Clinical evaluationClinical evaluationEffluent evaluationEffluent evaluation
Gram stain and cultureGram stain and culture
Initiate empiric therapy Initiate empiric therapy Initiate empiric therapy
No feverMild/no abdominal painNo risk factor for severe infection
No feverNo feverMild/no abdominal painMild/no abdominal painNo risk factor for severe infectionNo risk factor for severe infection
History of MRSA infection / carriageRecent-recurrent catheter infectionSevere clinical presentation
History of MRSA infection / carriageHistory of MRSA infection / carriageRecentRecent--recurrent catheter infectionrecurrent catheter infectionSevere clinical presentationSevere clinical presentation
1st generation cephalosporinand quinolone or ceftazidime
1st generation cephalosporin1st generation cephalosporinand and quinolone quinolone or or ceftazidime ceftazidime
Glycopeptideand ceftazidime
or aminoglycoside
GlycopeptideGlycopeptideand and ceftazidimeceftazidime
or or aminoglycoside aminoglycoside
ISPD2005ISPD2005
Possibletreatmentat home
Possibletreatmentat home
Hospitalisationrequired
Hospitalisationrequired
Adjusted antibiotic therapyonce culture and sensitivities are known Adjusted antibiotic therapy
once culture and sensitivities are known ISPD2005ISPD2005
• VRE/MRSA problem : largest use of vancomycin – re-dosing once serum level reaches 15 µg/ml
• Aminoglycosides should be discontinued as soon as possible (to prevent vestibular and ototoxicity)– not advisable if an alternative approach is possible
• Quinolone, PO– at least 2 hours before oral CaCO3, iron, sucralfate
• Rifampin should never be given as monotherapy– keep it in reserve if tuberculosis is endemic
• VRE/MRSA problem : largest use of vancomycin – re-dosing once serum level reaches 15 µg/ml
• Aminoglycosides should be discontinued as soon as possible (to prevent vestibular and ototoxicity)– not advisable if an alternative approach is possible
• Quinolone, PO– at least 2 hours before oral CaCO3, iron, sucralfate
• Rifampin should never be given as monotherapy– keep it in reserve if tuberculosis is endemic
VRE bacteria and Vancomycin VRE bacteria and Vancomycin • Screening for VRE in stool cultures
2 out of 37 were carriers (5.5 %)
• Over 6 month period 58 isolates of staphylococci17 staph aureus - all sensitive to V, M, R39 coagulase negative staph -
all sensitive to Vancomycin9 (23%) sensitive to Methicillin17(49%) sensitive to Gentamicin24(62%) sensitive to Ciprofloxcin28(72%) sensitive to Rifampicin
• Findings suggested that 50% CNS would not respond to cephalosporin as empiric treatment
• Screening for VRE in stool cultures2 out of 37 were carriers (5.5 %)
• Over 6 month period 58 isolates of staphylococci17 staph aureus - all sensitive to V, M, R39 coagulase negative staph -
all sensitive to Vancomycin9 (23%) sensitive to Methicillin17(49%) sensitive to Gentamicin24(62%) sensitive to Ciprofloxcin28(72%) sensitive to Rifampicin
• Findings suggested that 50% CNS would not respond to cephalosporin as empiric treatment
Sandoe, Gokal, Struthers, PDI 1997;17:617Sandoe, Gokal, Struthers, PDI 1997;17:617
ISPD2005ISPD2005Dosing of antibioticsDosing of antibiotics
Antibiotic administration is preferable• By IP route• After a loading dose (with dwell time > 6 h)• Continuous administration for cephalosporin• Intermittent (long dwell) for vancomycin/aminoglycoside• Transitory transfer of APD patient to CAPD (if possible)
• Treatment duration :– 2 weeks (general)– 3 weeks (Pseudomonas)– 4 weeks (fungal)
Antibiotic administration is preferable• By IP route• After a loading dose (with dwell time > 6 h)• Continuous administration for cephalosporin• Intermittent (long dwell) for vancomycin/aminoglycoside• Transitory transfer of APD patient to CAPD (if possible)
• Treatment duration :– 2 weeks (general)– 3 weeks (Pseudomonas)– 4 weeks (fungal)
• Adjust prescription to sensitivity• Clear effluent after 48 hours:
1 - No change in antibiotics2 - Change extension and connector3 - Consider urokinase prescription in the catheter4 - Review patient’s technique
• Still turbid effluent :– 2 and 3 as above– Consider vancomycin (if not yet prescribed)– Consider rifampin prescription ( 600 mg/day, PO)
• Relapsing episode :– Consider catheter replacement
• Adjust prescription to sensitivity• Clear effluent after 48 hours:
1 - No change in antibiotics2 - Change extension and connector3 - Consider urokinase prescription in the catheter4 - Review patient’s technique
• Still turbid effluent :– 2 and 3 as above– Consider vancomycin (if not yet prescribed)– Consider rifampin prescription ( 600 mg/day, PO)
• Relapsing episode :– Consider catheter replacement
Coag - Staphylococcus on cultureCoag - Staphylococcus on cultureISPD2005ISPD2005
ISPD2005ISPD2005Staphylococcus aureus on cultureStaphylococcus aureus on culture
• Severe symptoms– More often “catheter related” than touch contamination
• Antibiotic treatment according to sensitivity– Third generation cephalosporin– + Vancomycin (1 g IP every 5 days) or Teicoplanin– Rifampin if MRSA (600 mg every day)– Linezolid, quinupristin/dalfopristin if VRSA
• Consider catheter removal (2 weeks on HD)– If catheter related infection– or refractory peritonitis
• Consider urokinase if touch contamination
• Severe symptoms– More often “catheter related” than touch contamination
• Antibiotic treatment according to sensitivity– Third generation cephalosporin– + Vancomycin (1 g IP every 5 days) or Teicoplanin– Rifampin if MRSA (600 mg every day)– Linezolid, quinupristin/dalfopristin if VRSA
• Consider catheter removal (2 weeks on HD)– If catheter related infection– or refractory peritonitis
• Consider urokinase if touch contamination
ISPD2005ISPD2005Streptococcus - EnterococcusStreptococcus - Enterococcus
• Adjust prescription to sensitivity• Consider :
– ampicillin prescription (125 mg/l IP)– vancomycin if “ampicillin resistant”
• Possible intra-abdominal pathology : add• Third generation cephalosporins• or Quinolone• or Aminoglycoside (synergy) • and Antifungal prophylaxis
• Touch contamination is also possible– review patient’s technique
• Adjust prescription to sensitivity• Consider :
– ampicillin prescription (125 mg/l IP)– vancomycin if “ampicillin resistant”
• Possible intra-abdominal pathology : add• Third generation cephalosporins• or Quinolone• or Aminoglycoside (synergy) • and Antifungal prophylaxis
• Touch contamination is also possible– review patient’s technique
Pseudomonas - XanthomonasPseudomonas - Xanthomonas• Pseudomonas aeruginosa peritonitis is
– severe– often related to neglected catheter infection– permanent membrane damage may occur
• Other species are often tape water contaminant– review patient’s hand washing/drying
• Antibiotics to be chosen– Ceftazidime, cefipime (IP continuous)– + Oral quinolone– or piperacllin (4g IV every 12 hours)– or tobramycin
• Remove rapidly responsible infected catheter• Consider urokinase in other cases• Three weeks treatment
• Pseudomonas aeruginosa peritonitis is– severe– often related to neglected catheter infection– permanent membrane damage may occur
• Other species are often tape water contaminant– review patient’s hand washing/drying
• Antibiotics to be chosen– Ceftazidime, cefipime (IP continuous)– + Oral quinolone– or piperacllin (4g IV every 12 hours)– or tobramycin
• Remove rapidly responsible infected catheter• Consider urokinase in other cases• Three weeks treatment
ISPD2005ISPD2005
Multiple enteric organisms(+/- anaerobic bacteria)
Multiple enteric organisms(+/- anaerobic bacteria)
ISPD2005ISPD2005
• Search for intra-abdominal pathology– CT scan– Ultrasound
• Antibiotics– ampicillin – + ceftazidime or aminoglycoside– + metronidazole 500 mg every 8 h, IV or PO– + antifungal treatment– treat for 3 weeks
• Consider surgery ( and catheter removal)
• Search for intra-abdominal pathology– CT scan– Ultrasound
• Antibiotics– ampicillin – + ceftazidime or aminoglycoside– + metronidazole 500 mg every 8 h, IV or PO– + antifungal treatment– treat for 3 weeks
• Consider surgery ( and catheter removal)
Fungal PeritonitisFungal Peritonitis
• 2.5% of 1375 episodes
• Candida caused 97% (yeasts)
• 70.6% of patients had received multiple antibiotics in the preceding month
• 94% required catheter removal
• Mortality was 26.5%
• 2.5% of 1375 episodes
• Candida caused 97% (yeasts)
• 70.6% of patients had received multiple antibiotics in the preceding month
• 94% required catheter removal
• Mortality was 26.5%
TURP PDI 2000;20:339-340.TURP PDI 2000;20:339-340.
Yeast (on Gram stain or culture)Yeast Yeast (on Gram stain or culture)(on Gram stain or culture)Flucytosine
- PO : load 2 g then 1 g daily - IP : 300 mg/l
associated with fluconazole, 200 mg PO/IP daily
If organism is resistant consider itraconozole, voriconazole
Flucytosine - PO : load 2 g then 1 g daily - IP : 300 mg/l
associated with fluconazole, 200 mg PO/IP daily
If organism is resistant consider itraconozole, voriconazole
If no clinical improvement,remove catheter and treatfor 10 additional days after
catheter removal
If clinical improvementDuration of therapy
4-6 weeks
If clinical improvementIf clinical improvementDuration of therapyDuration of therapy
44--6 weeks6 weeks
At 7 daysAt 7 days
Filamentous fungiFilamentous fungi
Catheter colonised by Dreschlera speciferaCatheter colonised by Dreschlera specifera
Catheter Removal for infectionCatheter Removal for infectionISPD2005ISPD2005
Membrane preservation overhangs catheter savingMembrane preservation overhangs catheter saving
• Catheter infection- associated peritonitis (related the same bacteria)- proven inner cuff infection- chronic infection (refractory to medical and surgical treatment)
• Peritonitis- catheter related- refractory (no response after 4-5 days of appropriate therapy)- severe (more than 10 days of turbid effluent)- relapsing (same organism within 4 weeks after compl.
treatment) - fungal :
• yeast : if no response after 7 days of appropriate therapy• filamentous fungi : immediate, at laboratory results
• Catheter infection- associated peritonitis (related the same bacteria)- proven inner cuff infection- chronic infection (refractory to medical and surgical treatment)
• Peritonitis- catheter related- refractory (no response after 4-5 days of appropriate therapy)- severe (more than 10 days of turbid effluent)- relapsing (same organism within 4 weeks after compl.
treatment) - fungal :
• yeast : if no response after 7 days of appropriate therapy• filamentous fungi : immediate, at laboratory results
CATHETER REMOVAL FOR REFRACTORY PERITONITISCATHETER REMOVAL FOR REFRACTORY PERITONITIS
• 9/191 patients with peritonitis died (5%)
• 18% episodes of peritonitis resulted in transfer to HD.
• If the fluid was still cloudy after 5 days, failure rate was 46%.
These results support ISPD guidelinesto remove catheter
if effluent fails to clear by 5 days.
• 9/191 patients with peritonitis died (5%)
• 18% episodes of peritonitis resulted in transfer to HD.
• If the fluid was still cloudy after 5 days, failure rate was 46%.
These results support ISPD guidelinesto remove catheter
if effluent fails to clear by 5 days.Krishnan PDI 2002;22: 573-581.Krishnan PDI 2002;22: 573-581.
Catheters removed for infectioncan be replaced within 2 weeksCatheters removed for infectioncan be replaced within 2 weeks
no re-infectionno re-infection re-infectionre-infection186 catheter replacements186 catheter replacements
0%0%
20%20%
40%40%
60%60%
80%80%
100%100%
RESULTS:Survival of replaced catheter was notrelated to the timing of replacement.
RESULTS:Survival of replaced catheter was notrelated to the timing of replacement.
0-15 days0-15 days 16-31 days16-31 days >31 days>31 days
Days to catheter replacementDays to catheter replacement
Gupta, Bernardini, Piraino unpublished dataGupta, Bernardini, Piraino unpublished data
Relapsing-recurrent peritonitisRelapsing-recurrent peritonitis
Another episode of peritonitis caused by the same genus/specieswithin 4 weeks of completing antibiotic course
Another episode of peritonitis caused by the same genus/specieswithin 4 weeks of completing antibiotic course
• S aureus, CNS are likely repeat offenders
• Often due to biofilm and/or catheter infections.
• Catheter change decreases likelihood of recurrence.
• S aureus, CNS are likely repeat offenders
• Often due to biofilm and/or catheter infections.
• Catheter change decreases likelihood of recurrence.
For recurrent peritonitis, catheter replacement can be done as same day procedure
For recurrent peritonitis, catheter replacement can be done as same day procedure
Finkelstein AJKD 2002;39:278-1286Finkelstein AJKD 2002;39:278-1286
Acceptable Peritonitis incidence ?1 epis. / patient month
Acceptable Peritonitis incidence ?1 epis. / patient month
• I.S.P.D. < 1/24
• In Montpellier :
–Since 1973 : 1/35.72
– 01/01/2004 to 31/12/2004 : 1/81.18
153 patients on PD treatment
• I.S.P.D. < 1/24
• In Montpellier :
–Since 1973 : 1/35.72
– 01/01/2004 to 31/12/2004 : 1/81.18
153 patients on PD treatment
ISPD2005ISPD2005
“Obsession” against bacteria may be fruitful“Obsession” against bacteria may be fruitful
PREVENTION = 10 g
has to be compared with
TREATMENT = 10 Kg
PREVENTION = 10 g
has to be compared with
TREATMENT = 10 Kg
CONCLUSIONCONCLUSION