capd peritonitis mortalty
TRANSCRIPT
CAPD peritonitis
Content
• Introduction• ISPD guideline • Hospital Pulau Pinang clinical audit on CAPD
peritonitis
PERITONEAL DIALYSIS
ContinuousAmbulatoryPeritonealDialysis
AutomatedPeritonealDialysis
PERITONEAL DIALYSIS
CAPD peritonitis
• Peritonitis is a common clinical problem that occurs in patients treated by peritoneal dialysis
• The incidence of peritonitis varies from center to center
• During the past decade approximately 1 episode every 24 patient-treatment-months was observed
• because of exceptional patient education, as well as new connector and catheter technologies
• A variety of different regimens have been proposed based upon these experiences
• Antibiotics have been administered intraperitoneally (IP), or intravenously (IV), or orally, and a number of different dosing regimens have been utilized
• Unfortunately, no single regimen has been shown in appropriate clinical trials to be most efficacious.
ISPD Guidelines/Recommendations ADULT PERITONEAL DIALYSIS-RELATED
PERITONITIS TREATMENTRECOMMENDATIONS: 2005 Update
William F. Keane,1 George R. Bailie,2 Elizabeth Boeschoten,3 Ram Gokal,4 Thomas A. Golper,5 Clifford J. Holmes,6 Yoshindo Kawaguchi,7 Beth
Piraino,8 Miguel Riella,9 Stephen Vas10
DEFINITION OF CAPD PERITONITIS
2 out of 3 of the following criteria 1. Abdominal pain2. Cloudy effluent with
a cell count > 100 cells/ mm3 ; 50% of which is PMN
3. Culture positive
Initial Clinical Evaluation of Patient with Suspected Peritoneal Dialysis-Related Peritonitis
• Symptoms: cloudy fluid and abdominal pain • Do cell count and differential • Gram stain and culture on initial drainage • Initiate empiric therapy • Choice of final therapy should always be
guided by antibiotic sensitivities
• on many occasions the Gram stain is unavailable, delayed, or negative for any specific organisms Empiric therapy is indicated in these conditions
• There is a slight statistical likelihood that the causative pathogen will be the same as the most recent infection
• If the exit site is infected with pseudomonas or S. aureus when peritonitis presents, there is a high probability that the peritonitis is caused by the same organism
• If the patient is having frequent peritonitis episodes, then relapse or recurrence with the same organism is likely.
Empiric Initial Therapy, for Peritoneal Dialysis-Related Peritonitis, Stratified for Residual Urine
VolumeAntibiotic Residual urine output
< 100 mL/dayResidual urine output> 100 mL/day
Cefazolin or cephalothin 1 g/bag, q.d. 20 mg/kg BW/bag, q.d.
or
15 mg/kg BW/bag, q.d.
Ceftazidime 1 g/bag, q.d. 20 mg/kg BW/bag, q.d.Gentamicin, tobramycin, netilmycin
0.6 mg/kg BW/bag, q.d. Not recommended
Amikacin 2 mg/kg BW/bag, q.d. Not recommended
?vancomycin• Internationally, the prevalence of vancomycin-resistant
organisms has dramatically increased and this increase has been particularly evident in larger university hospitals where up to 14% of enterococci may be resistant
• Vancomycin resistance has been associated with resistance to other penicillins and aminoglycosides, thus presenting a treatment dilemma
• This change in vancomycin sensitivity has prompted a number of worldwide agencies to discourage routine use of vancomycin for prophylaxis, for empiric therapy, or for oral use for Clostridium difficile enterocolitis.
• The major concern is that the vancomycin-resistance gene is transmitted to staphylococcal strains, creating an issue of major epidemiological importance
• It is recommended for use in methicillin-resistant S. aureus (MRSA) infections and in treatment of infections due to beta-lactam-resistant organisms, as well as in treatment for infections in patients that have serious gram-positive infections and that are allergic to other agents.
Treatment strategies after identifying gram positive organism
TABLE 4
Treatment Strategies After Identification of Gram-Positive
Organism on Culture
Enterococcus Staphylococcus aureus Other gram-positive organism
(Coagulase-negative staphylococcus)
At 24 to 48 hours
Stop cephalosporinsStop ceftazidime or aminoglycoside Stop ceftazidime or aminoglycoside
Start ampicillin 125 mg/L/bag Continue cephalosporin Continue cephalosporin
Consider adding aminoglycoside
Add rifampin 600 mg/day, oral
If ampicillin-resistant, start If MRSA, start vancomycin If MRSE and clinically not
vancomycin or clindamycin or clindamycin responding, start vancomycin
If VRE, consider quinupristin/dalfopristin
or clindamycin
Duration of therapy
14 days 21 days 14 days
Treatment Recommendations if a Gram-Negative Organism Is Identified on Culture at 24 to 48 hours
Duration of therapy
Single gram-negative organism
Adjust antibiotics to sensitivity 14 days
< 100 mL urine, aminoglycoside
> 100 mL urine, ceftazidime
Pseudomonas/stenotrophomonas
Continue ceftazidime and add 21 days
< 100 mL urine, aminoglycoside (see Empiric Therapy, Table 2)
> 100 mL urine, ciprofloxacin 500 mg, p.o. b.i.d.
or piperacillin 4 g IV q.12 hours
or sulfamethoxazole/trimethoprim 1_2 DS/day
or aztreonam load 1 g/L; maintenance dose 250 mg/L IP/bag
Multiple gram-negatives and/or anaerobes
Continue cefazolin and ceftazidime and add
21 days
metronidazole, 500 mg q.8 hours, p.o., IV, or rectally
If no change in clinical status, consider surgical intervention
Treatment Strategies if Peritoneal Dialysis Fluid Cultures Are Negative at 24 to 48 Hours or Not
Performed Continue initial therapy Duration of therapy
If clinical improvementDiscontinue ceftazidime or aminoglycoside
Continue cephalosporin 14 days
If no clinical improvement at 96 hours
If culture positive, adjust therapy accordingly
Repeat cell count, Gram stain, and culture
14 days
If culture negative, continue antibiotics, consider infrequent pathogens and/or catheter removal
14 days
Catheter removal
• Should be considered when peritonitis is unlikely to resolve with catheter in situ – Fungal peritonitis– TB peritonitis – Perforated bowel – Persistent exit / tunnel infection – Not responsive to second line antibiotic – Relapsing peritonitis not responding to treatment
AUDIT:PERITONITIS RATE IN THE CAPD UNIT
CAPD UNIT HOSPITAL PULAU PINANG
OBJECTIVES
To determine o the incidence of peritonitiso outcome of peritonitiso types of organsims causing peritonitis
RESULTS
CHARACTERISTICS of all PD patientsTotal Number of patients 196Age Mean : 47 years, SD:20.6
Range : 6 – 87 years
Duration on PD Mean : 37.9 months ,SD :34.7Range : 0.5 – 172 months
Male : Female ratio 95 : 101(48%) (52%)
Primary disease causing ESRDDiabetes mellitusHPTGNUnknownOthers
80 (41%)21 (11%)22 (11%)22 (11%)51 (26%)
PD Peritonitis
• 28 episodes of peritonitis in 23 patients• Mean age = 52 years (range : 15- 81 yrs)• Male: Female ratio = 7 patients:16 patients
(1:2.2)• Self care in 9 patients (39 %) Assisted PD in 14 patients (61%)
PERITONITIS RATE
• 28 episodes of peritonitis (EOP) in 23 patients in 1006.6 patient-months
i.e. 1 in 36 patient-months KPI peritonitis rate is 1 in 24 patient-months Optimal standard for peritonitis rate is 1 in 42
patient-months
PERITONITIS CULTURE YIELD
Culture positive yield rate is below recommended international rate of at least 80%
PERITONITIS CULTURE YIELD
CAUSATIVE ORGANISMSNumber
Gram Negative(67%) E.Coli Pseudomonas aeruginosa Acinetobacter sp Haemophilus Influenza Sphingomonas paucibilis Serratia Marcesceus
3 2 2 1 1 1
Gram Positive (20%) Coagulase Negative Staph Staphylococcus aureus
2 1
Fungus (13%) Candida sp 2
TOTAL 15
OUTCOME OF PERITONITIS
28 episodes
17 resolved 7 T/C removal 4 died (60.7%) (25%) (14.2%)
Tenckhoff Removal
1 reinsertion 4 changed modality 2 still awaiting (continued CAPD) reinsertion
CONCLUSION Peritonitis rate is 1 in 36 patient-months
--below the optimal standard (1 in 42 patient-months) 60.7% of patients with CAPD peritonitis resolved with
treatment 25% required T/C removal 14.2% died (4) - 1 pt had advanced Ca cervix
- 3 pt had concomitant nosocomial sepsis
Majority of the organism isolated is Gram negative organism
Thank you for your attention !