A nice summary of complications of PD

1. Complications of Peritoneal Dialysis Abhijit Kontamwar,MD Renal Consultants, Inc Clinical Assistant Professor of Internal Medicine at NEOUCOM (Northeastern Ohio Universities Colleges of Medicine and Pharmacy).

5. Causes of transfer to HD among PD patients Mujais et al; Kidney Int Suppl 2006; 70: S21-36

6. Hospitalization rates for access related infections Chavers et al, J Am Soc Nephrol 18: 952 – 959, 2007

13. Microbiology Friedrich et al, Kidney Int, Oct 1992; 42: 967-974

14. Microbiology Mujais, S. Microbiology and outcomes of peritonitis in North America. Kidney Int 2006; 70:S55

19. Empiric Therapy Initiate empiric therapy Simultaneous gram +ve and gram –ve coverage For prevention of fibrin occlusion heparin 500 U/L can be used Gram +ve coverage: 1 st generation cephalosporin or vancomycin Gram –ve coverage: 3 rd generation cephalosporin or aminoglycoside

22. Staph. aureus peritonitis Staph. Aureus on culture D/c gram –ve coverage, cont. gram +ve coverage for 3 weeks If MRSA change to Vancomycin and rifampin can be added (600 mg/day for 1 week) If clinical improvement continue for 3 weeks If no clinical improvement reculture and revaluate for exit-site or tunnel Infection or intra-abd abscess If peritonitis with exit-site or tunnel Infection – remove catheter Allow 2 weeks rest period before reinitiating PD If no improvement in 5 days on appropriate antibiotics, remove catheter

23. Enterococcus/Streptococcus peritonitis Enterococcus/Strep on culture D/c empiric coverage Start continuous Ampicillin 125 mg/L each bag Consider adding aminoglycoside for enterococcus If ampicillin resistant, start vanco; If VRE consider quinupristin/dalfopristin or linezolid Clinical improvement; treat for 2 weeks – strep 3 weeks - enterococcus No improvement, reculture and evaluate for exit-site or tunnel infection Peritonitis with exit or tunnel infection Consider catheter removal Treat for 3 weeks In no improvement by 5 days, remove catheter

24. Pseudomonas peritonitis Pseudomonas on culture W/o exit-site/tunnel infection With exit-site/tunnel infection Remove catheter Use 2 abx with different mechanism Oral quinolone, cephalosporin, piperacillin based on sensitivities If clinical improvement Treat for 3 weeks If no improvement reculture and evaluate If no improvement by 5 days on appropriate abx, remove catheter

25. Gram negative organism peritonitis Single gram –ve organism on culture E. coli, klebsiella or proteus Stenotrophomonas 3 rd generation cephalosporin: ceftazidime or cefepime Two drugs with different mechanisms based on sensitivity pattern Duration of therapy: 3 weeks Duration of therapy: 3-4 weeks If no clinical improvement by 5 days, remove catheter

26. Polymicrobial peritonitis Polymicrobial peritonitis Multiple gram –ve organisms Multiple gram +ve organisms Change to metronidazole In conjunction with ampicillin, Ceftazidime or aminoglycoside Surgical evaluation Laprotomy for suspected intra-abd pathology/abscess with catheter removal Continue therapy based on sensitivities W/o catheter infection, treat for 3 weeks With catheter infection, remove catheter

27. Culture negative peritonitis Culture negative peritonitis 24-48 hours Continue initial therapy If culture negative for 72 hours Repeat cell count and diff Infection resolving, pt improving Infection not resolving Cont initial therapy for 2 weeks, But D/c aminoglycoside if used initially Special culture techniques for Mycobacteria or legionella Culture positive Culture negative Adjust therapy as per sensitivity patterns If no improvement in 5 days, Consider catheter removal

29. Antibiotic dosing recommendations for CAPD LD: loading dose in mg, MD: maintenance dose in mg Antibiotic Intermittent Continuous Gentamicin 0.6 mg/kg LD 8, MD 4 Amikacin 2 mg/kg LD 25, MD 12 Cefazolin 15 mg/kg LD 500, MD 125 Cefepime 1 gm LD 500, MD 125 Cephalothin 15 mg/kg LD 500, MD 125 Ceftazidime 1 – 1.5 gm LD 500, MD 125 Ciprofloxacin No data LD 50, MD 25 Vancomycin 15-30 mg/kg every 5-7 days LD 1000, MD 25 Aztreonam No data LD 1000, MD 250 Amphotericin NA 1.5 Imipenem/cilistatin 1 gm bid LD 500, MD 200

39. Treatment of exit-site/tunnel infection Purulent discharge from exit-site Do culture/gram stain Gram +ve organism Gram –ve organism 1 st generation Cephalosporin PO PO Quinolones If slow improvement or severe Cases add Rifampin 600mg/day If Pseudomonas and no improvement add 2 nd anti-pseudomonal; ceftazidime IP Infection resolving; cont treatment for 2 weeks Infection resolving; cont treatment for 2 weeks Infection unresolved in 3-4 weeks; consider catheter revision/removal Infection unresolved in 3-4 weeks; consider catheter revision/removal

69. Peritoneal Scintigram