infections in pd prevention and management
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Infections in PD Prevention and Management. Peritonitis a cause of…. Peritoneal membrane damage Hospitalization and pain Catheter loss Technique failure Death. Peritonitis: cells in effluent. Peritonitis: Infiltration. Pathogen Pathway. Tunnel Infection. Complications of Peritonitis. - PowerPoint PPT PresentationTRANSCRIPT
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Infectious Complications: Predictable and Preventable
Infections in PD Infections in PD
Prevention and ManagementPrevention and Management
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Infectious Complications: Predictable and Preventable
Peritonitisa cause of…
• Peritoneal membrane damage
• Hospitalization and pain
• Catheter loss
• Technique failure
• Death
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Infectious Complications: Predictable and Preventable
Peritonitis: cells in effluent
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Infectious Complications: Predictable and Preventable
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Infectious Complications: Predictable and Preventable
Peritonitis: Infiltration
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Infectious Complications: Predictable and Preventable
Pathogen Pathway
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Infectious Complications: Predictable and Preventable
Tunnel Infection
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Infectious Complications: Predictable and Preventable
Complications of Peritonitis
Temporary loss of UF
Increased protein losses
Catheter loss
Adhesions
Sclerosing encapsulating peritonitis
Transfer to HD
Death
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Infectious Complications: Predictable and Preventable
Peritonitis
DEFINITION
1. Signs and symptoms
2. Cloudy fluid - >100 wbc/ml; >50%N
3. Identification of organism
Two of three required for diagnosis
RELAPSING PERITONITIS
Another episode of peritonitis caused by the same genus/species within 4 weeks of completing antibiotic course
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Infectious Complications: Predictable and Preventable
Peritonitis Diagnosis Peritonitis Diagnosis
• Cloudy fluid +/- abdominal pain +/- fever• Dialysate effluent should be obtained for
laboratory evaluation (>4 hrs’ dwell time):
Culture
Cell count, with differential
Gram Stain
Confirmation• WBC count >100/mm3 , of which 50% are
polymorphonuclear neutrophils (PMN), is confirmation of microbial-induced peritonitis
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Infectious Complications: Predictable and Preventable
Clinical Course in CAPD Peritonitis
Introduction of bacteria into peritoneum
Bacteria Peritoneal wall Multiply
ASYMPTOMATIC FOR 24 - 48 HRS
Shed into PD fluid
Abdo pain + Cloudy fluid = peritonitis
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Infectious Complications: Predictable and Preventable
Micro-Organisms Causing Peritonitis
Harwell PDI 1997;17:586-594
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Infectious Complications: Predictable and Preventable
Routes of Peritoneal Infection
Exchangeprocedure
Titaneum/transfer set
PericatheterTranscolonic
Haematogenous
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Infectious Complications: Predictable and Preventable
Sources of Peritonitis, %
Contamination 41
Catheter related 23
Enteric injury 11
Perioperative 6
Diarrhoea/UTI 4
Sepsis 1
Unknown 14
Harwell PDI 1997
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Infectious Complications: Predictable and Preventable
Peritonitis - Yset Systems
P risk % (Maiorca Lancet 1983)
0
10
20
30
40
50
60
70
80
90
0 3 6 9 12 15 18
Months
standard
Y set
• Y-set first by Buoncristianti 1980Long Y with disinfectant• Flush before fill• Proliferation ofdisconnect systems
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Infectious Complications: Predictable and Preventable
Sept 15, 2000
Peritonit is in CAPD compared to APD
0
0.05
0.1
0.15
0.2
S aureus CNS Other
GPC
GN polymicr
CAPD
APD
Episodes per year
From Rodriguez-Carmona PDI 19; 1999Peritonit is rates--lower on APD than CAPD0.31 versus 0.64 per year at risk
CAPD vs APD
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Infectious Complications: Predictable and Preventable
Initial assessment
Symptoms: cloudy fluid and abdominal pain Do cell count/differential Gram stain and culture
- on initial drainage Initiate empiric therapy Choice of final therapy should always be guided
by antibiotic sensitivities
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Infectious Complications: Predictable and Preventable
Gram StainingGram Staining
A gram stain is positive in 9-40%9-40% of peritonitis episodes When positive it is predictive of eventual culture results in 85%85%
of cases It is particularly useful in early recognition of fungal fungal peritonitis
through revealing presence of yeast If on initial evaluation, a gram stain is +ve, a single antibiotic
with activity against gram +ve organisms should be started Identification of a single organism on Gram stain does not
preclude the presence of other organisms in lesser concentrations
Finding gram +ve cocci and gram-negative rods together may indicate perforated abdominal viscous
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Infectious Complications: Predictable and Preventable
Possible Causes of Possible Causes of Culture Negative PeritonitisCulture Negative Peritonitis
1. Culture methods of low sensitivity used – the culture techniques for PD effluent is specialized
2. Culture volumes are too small
3. Causative organism requires specialised culture media
4. Cultures are taken from patients on antibiotic treatment
5. The symptoms and signs are not due to infectious agents
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Infectious Complications: Predictable and Preventable
Cloudy Effluent: Cellular Causes – Increased PMN
Infectious causes Intraperitoneal visceral inflammation (eg,
cholecystitis, appendicitis, bowel ischemia or obstruction)
Juxtaperitoneal visceral inflammation (eg, pancreatitis, splenic infarction, abscess)
Endotoxin-contaminated PD fluid Drug associated (eg amphotericin, vancomycin)
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Infectious Complications: Predictable and Preventable
Cloudy Effluent: Cellular Causes – Increased Eosinophils
Allergic reaction to constituent of dialysis system (e.g., sterilant, plasticizer)
Drug associated (eg, vancomycin, streptokinase) Air-induced peritoneal irritation Blood-induced peritoneal irritation (e.g., retrograde
menstruation)
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Infectious Complications: Predictable and Preventable
Cloudy Effluent: Cellular Causes – Increased RBC
Reproductive: Retrograde menstruation, Ovulation, Ectopic pregnancy
Cyst rupture (ovarian or hepatic) Peritoneal adhesion formation Strenuous exercise Catheter-associated trauma Post-procedure: laparoscopy, colonoscopy Encapsulating peritoneal sclerosis Anticoagulation therapy Acute or chronic pancreatitis Post radiation
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Infectious Complications: Predictable and Preventable
Lessons
Organisms suggest causation:S. Epidermis = touch contaminationS. Aureus = catheter infection
Outcomes depend on:Causative organisms and severity
- Gram negative >> S. Aureus >> S. Epidermidis
Associated conditions and severity- Peritonitis + tunnel >> Peritonitis + ESI- Peritonitis + ESI >> Peritonitis
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Infectious Complications: Predictable and Preventable
Causative Organisms
69
31
0
10
20
30
40
50
60
70
80
Gram +ve Gram -ve
Bunke et al, KI 52:524-529, 1997
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Infectious Complications: Predictable and Preventable
Gram Positive Organisms
28
42
4
5
21
0 10 20 30 40 50
S. Aureus
S. Epidermis
Other Staph
Enterococcus
Other gram +ve
Bunke et al, KI 52:524-529, 1997
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Infectious Complications: Predictable and Preventable
Organisms and Outcomes
0102030405060708090
Resolved Catheterremoved
Hospital. Transfer toHD
% o
f P
atie
nts
CNS (N=242)
S. Aureus (N=149)
GN (N=136)
Bunke et al, KI 52:524-529, 1997
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Infectious Complications: Predictable and Preventable
Outcomes of Peritonitis
Bunke, et al., KI 1997
% of all episodes(without ESI/TI)
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Infectious Complications: Predictable and Preventable
Time Course of UF After Peritonitis
Ates, et al., PDI 20;2000:220-226
*p<0.05 vs baseline for all times*p<0.05 vs baseline for all times
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Infectious Complications: Predictable and Preventable
Prevention of PeritonitisDue to Contamination
Disconnect systems
Careful training
Patient selection
Assessment of home environment
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Infectious Complications: Predictable and Preventable
Exit Site Infections - Prevention Exit Site Infections - Prevention
• Staph aureus ESI occurs mainly in nasal carriers• Incidence can be reduced by treating with mupirocin
(M)• (M) can be given intranasally twice daily x 5 days
each month, or• Applied (M) to exit site intermittently or daily as part
of exit site care
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Infectious Complications: Predictable and Preventable
S aureus CAPD related infections are associated with nasal carriage
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
exit site infection peritonitis catheter loss
nasal carrier non carrierS. aureus episodes/year
Data from Lye et al, 1994 Nasal carriage defined as min of 2 of 3 NC +ve
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Infectious Complications: Predictable and Preventable
Effect of S aureus prophylaxis on prevention of S aureus peritonitis
0
0.05
0.1
0.15
0.2
0.25
intranasalmupirocin
intranasalmupirocin
exit sitemupirocin
exit sitemupirocin
control prophylaxisS aureus peritonitis/year
Perez-Fontan
Mupirocin Study Group
Bernardini Thodis
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Infectious Complications: Predictable and Preventable
Exit site/Tunnel and Outcomes
0102030405060708090
Resolved Catheterremoved
Hospital. Transfer toHD
% o
f P
atie
nts
CNS (N=230) CNS + Exit (N=12)
Bunke et al, KI 52:524-529, 1997
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Infectious Complications: Predictable and Preventable
Exit site/Tunnel and Outcomes
0102030405060708090
Resolved Catheterremoved
Hospital. Transfer toHD
% o
f P
atie
nts
S. Aureus (N=104) S. Aureus + Exit (N=45)
Bunke et al, KI 52:524-529, 1997
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Infectious Complications: Predictable and Preventable
Exit site/Tunnel and Outcomes
0
10
20
30
40
50
60
70
Resolved Catheterremoved
Hospital. Transfer toHD
% o
f P
atie
nts
NPGN (N=114) NPGN + Exit (N=22)
Bunke et al, KI 52:524-529, 1997
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Infectious Complications: Predictable and Preventable
Tunnel Ultrasonography
• Indications– Exit site infection (S. Aureus)– Follow up of tunnel infection– Peritonitis with exit site infection– Recurrent/persistent peritonitis
• No indications– Routine screening– Search for foci in absence of ESI– Peritonitis without ESI– Tunnel pain with no other signs or symptoms
Vychytil et al, AJKD 33:722-27, 1999
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Infectious Complications: Predictable and Preventable
Peritonitis Rates
Prevention is a realistic goal.
Proof:Japan 1:45 to 1:60 patient/monthsTaiwan 1:35 to 1:45 patient/monthsEurope 1:26 to 1:38 patient/monthsSingapore 1:28 patient/monthsMexico 1:24 to 1:26 patient/months
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Infectious Complications: Predictable and Preventable
Peritonitis Rates
• 50% of patients account for 90% of infections• Patients with one infection episode are more likely
to have another than those with none• Most “repeat offenders” develop their infection
early in the course of therapy: The earlier in dialysis history an infection develops, the more infection prone the patient continues to be.
• A high risk period for ESI/TI is in the 12 months post implant.
Crabtree et al, ASAIO 45:574-80, 1999; Golper et al AJKD 28:428-36, 1996
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Infectious Complications: Predictable and Preventable
S. Aureus Nasal Carriage
• JASN 7:2403-8, 1996– Multicenter study in 9 European countries– 1144 CAPD patients screened– 267 (23%) carriers of S.Aureus (2 +ve swabs)
• JASN 9:669-76, 1998– Single center prospective– 76 patients cultured monthly for 3 years– One positive culture in 65.8% of all patients,
73% of diabetics, 72% of immunosuppressive Rx, 59% of others
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Infectious Complications: Predictable and Preventable
Carriers State and Infection
0
0.2
0.4
0.6
0.8
1
1.2
1.4
Diabetics Immunosuppressed
Others
S. Aureus Catheter Infection
Rat
e p
er y
ear
Overall
Carrier
Non-Carrier
Vychytil et al, JASN 9:669-676, 1998
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Infectious Complications: Predictable and Preventable
Staph Aureus Prophylaxis
0
0.1
0.2
0.3
0.4
0.5
CatheterInfection
Peritonitis Catheter loss
Staph Aureus Related
Rat
e p
er y
ear Historical Control
Rifampin, oral N=41
Mupirocin at ESN=41
Bernardini et al, AJKD 27:695-700, 1996
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Infectious Complications: Predictable and Preventable
EXIT SITE INFECTION (ESI)
DEFINITIONS Acute ESI - purulent
exit site drainage Additional features
include redness, tenderness, edema and granulation tissue
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Infectious Complications: Predictable and Preventable
Chronic Exit Site Infection
ESI is chronic if it persists > 4 weeks Often there is crusting or scabbing
Exuberant tissue, pus, redness With therapy improvement; epithelium spreads over
granulation
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Infectious Complications: Predictable and Preventable
Tunnel Infection
Redness, edema and/or tenderness over the subcutaneous tunnel
Often, there is associated ESI but some cases are occult
May need ultrasound to diagnose
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Infectious Complications: Predictable and Preventable
Exit Site Management
Antibiotics
Intensified local care
Local debridement
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Infectious Complications: Predictable and Preventable
Exit Site Management
Local Debridement or Exteriorisation of cuff
Can involve shaving external catheter cuff or revising tunnel
Results are variable and many prefer catheter removal
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Infectious Complications: Predictable and Preventable
Exit Site Infection PREVENTION
Staph aureus ESI occurs mainly in nasal carriers Incidence can be reduced by treating with mupirocin
(M) M can be given intranasally twice daily x 5 days each
month Some apply M to exit site intermittently or daily as
part of exit site care
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Infectious Complications: Predictable and Preventable
Summary
Keys to low infection rates include:Keys to low infection rates include:
Experienced personnel and careful training Minimize use of manual spike systems Continuous monitoring of infection rates and
organisms Protocols for prevention, such as exit site
mupirocin for S. aureus
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Infectious Complications: Predictable and Preventable
Infectious ComplicationsInfectious ComplicationsPredictable and Preventable!Predictable and Preventable!