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