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CAPD peritonitis
Content
• Introduction
• ISPD guideline
• Hospital Pulau Pinang clinical audit on CAPD
peritonitis
PERITONEAL DIALYSIS
Continuous
Ambulatory
Peritoneal
Dialysis
Automated
Peritoneal
Dialysis
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 TREATMENT
RECOMMENDATIONS: 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 pain
2. 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
Volume
Antibiotic Residual urine output
< 100 mL/day
Residual 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 cephalosporins
Stop 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/stenotrophom
onas
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/trimethopri
m 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 improvement
Discontinue 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 peritonitis
o outcome of peritonitis
o types of organsims causing peritonitis
RESULTS
CHARACTERISTICS of all PD patients
Total Number of patients 196
Age Mean : 47 years, SD:20.6
Range : 6 – 87 years
Duration on PD Mean : 37.9 months ,SD :34.7
Range : 0.5 – 172 months
Male : Female ratio 95 : 101
(48%) (52%)
Primary disease causing ESRD
Diabetes mellitus
HPT
GN
Unknown
Others
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 ORGANISMS
Number
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 !

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Capd peritonitis mortalty

  • 2. Content • Introduction • ISPD guideline • Hospital Pulau Pinang clinical audit on CAPD peritonitis
  • 5. 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
  • 6. • 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.
  • 7. ISPD Guidelines/Recommendations ADULT PERITONEAL DIALYSIS-RELATED PERITONITIS TREATMENT RECOMMENDATIONS: 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
  • 8. DEFINITION OF CAPD PERITONITIS 2 out of 3 of the following criteria 1. Abdominal pain 2. Cloudy effluent with a cell count > 100 cells/ mm3 ; 50% of which is PMN 3. Culture positive
  • 9. 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
  • 10. • 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.
  • 11. Empiric Initial Therapy, for Peritoneal Dialysis- Related Peritonitis, Stratified for Residual Urine Volume Antibiotic Residual urine output < 100 mL/day Residual 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
  • 12. ?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.
  • 13. • 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.
  • 14. 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 cephalosporins Stop 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
  • 15. 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/stenotrophom onas 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/trimethopri m 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
  • 16. 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 improvement Discontinue 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
  • 17. 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
  • 18. AUDIT: PERITONITIS RATE IN THE CAPD UNIT CAPD UNIT HOSPITAL PULAU PINANG
  • 19. OBJECTIVES To determine o the incidence of peritonitis o outcome of peritonitis o types of organsims causing peritonitis
  • 21. CHARACTERISTICS of all PD patients Total Number of patients 196 Age Mean : 47 years, SD:20.6 Range : 6 – 87 years Duration on PD Mean : 37.9 months ,SD :34.7 Range : 0.5 – 172 months Male : Female ratio 95 : 101 (48%) (52%) Primary disease causing ESRD Diabetes mellitus HPT GN Unknown Others 80 (41%) 21 (11%) 22 (11%) 22 (11%) 51 (26%)
  • 22. 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%)
  • 23. 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
  • 24. PERITONITIS CULTURE YIELD Culture positive yield rate is below recommended international rate of at least 80%
  • 26. CAUSATIVE ORGANISMS Number 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
  • 27. 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
  • 28. 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
  • 29. Thank you for your attention !