Presentation is loading. Please wait.

Presentation is loading. Please wait.

ΕΙΔΙΚΗ ΑΝΤΙΜΕΤΩΠΙΣΗ ΠΕΡΙΤΟΝΙΤΙΔΑΣ ΚΛΙΝΙΚΕΣ ΟΔΗΓΙΕΣ ISPD ΠΗΝΕΛΟΠΗ ΧΡ. ΚΟΥΚΗ «ΙΠΠΟΚΡΑΤΕΙΟ» Γ.Ν.Α ΠΗΝΕΛΟΠΗ ΧΡ. ΚΟΥΚΗ «ΙΠΠΟΚΡΑΤΕΙΟ» Γ.Ν.Α.

Similar presentations


Presentation on theme: "ΕΙΔΙΚΗ ΑΝΤΙΜΕΤΩΠΙΣΗ ΠΕΡΙΤΟΝΙΤΙΔΑΣ ΚΛΙΝΙΚΕΣ ΟΔΗΓΙΕΣ ISPD ΠΗΝΕΛΟΠΗ ΧΡ. ΚΟΥΚΗ «ΙΠΠΟΚΡΑΤΕΙΟ» Γ.Ν.Α ΠΗΝΕΛΟΠΗ ΧΡ. ΚΟΥΚΗ «ΙΠΠΟΚΡΑΤΕΙΟ» Γ.Ν.Α."— Presentation transcript:

1 ΕΙΔΙΚΗ ΑΝΤΙΜΕΤΩΠΙΣΗ ΠΕΡΙΤΟΝΙΤΙΔΑΣ ΚΛΙΝΙΚΕΣ ΟΔΗΓΙΕΣ ISPD ΠΗΝΕΛΟΠΗ ΧΡ. ΚΟΥΚΗ «ΙΠΠΟΚΡΑΤΕΙΟ» Γ.Ν.Α ΠΗΝΕΛΟΠΗ ΧΡ. ΚΟΥΚΗ «ΙΠΠΟΚΡΑΤΕΙΟ» Γ.Ν.Α

2 REFRACTORY(ANΘΕΚΤΙΚΗ) PERITONITIS Failure of the effluent to clear after 5 days of appropriate antibiotics RECURRENT (YΠΟΣΤΡΟΦΟΣ) PERITONITIS Αn episode that occurs within 4 weeks of completion of therapy of a prior episode but with a different organism

3 RELAPSING (ΥΠΟΤΡΟΠΙΑΖΟΥΣΑ) PERITONITIS An episode that occurs within 4 weeks of completion of therapy of a prior episode with the same organism or 1 sterile episode REPEATED (ΕΠΑΝΑΛΑΜΒΑΝΟΜΕΝΗ) PERITONITIS An episode that occurs more than 4 weeks after completion of therapy of a prior episode with the same organism

4 Relapsing and Recurrent Peritoneal Dialysis –Associated Peritonitis : A Multicenter Registry Study. Burke M et al. Am J Kidney Dis. 2011;58(3):

5

6 Frequency Repeat Non-Repeat Time since previous peritonitis episode (months) Histogram shows timing of occurrence of repeated versus non repeated peritonitis after a prior episode of peritonitis in Australian peritoneal dialysis patients in

7 Repeated peritoneal dalysis associated peritonitis A multicenter registry study. Thirugnanasambathan T et al.Am J Kidkey Dis xx(x)xxx

8 ROC curve of dialysate white counts False-positive proportion (1-Specificity) True-positive proportion (Sensitivity) White count on day 5 White count on day 3 White count on day Sensitivity and specificity of dialysate white cell counts at various time points of the peritonitis to predict treatment failure, assessed by receiver-operating characteristic (ROC) curve analysis. Predictive value of dialysate cell counts in peritonitis complicating peritoneal dialysis. Kai Ming Chow..Clin J Am Soc Nephrol2006;1: > 1090/mm 3

9 Gram- Positive Organisms, Including Coagulase- Negative Staphylococcus, on Culture Due primarily to touch contamination Leads sometimes to relapsing peritonitis due to biofilm involve –replacing the cathe ter under antibiotic coverage as a single procedure once the effluent clears Gram- Positive Organisms, Including Coagulase- Negative Staphylococcus, on Culture Due primarily to touch contamination Leads sometimes to relapsing peritonitis due to biofilm involve –replacing the cathe ter under antibiotic coverage as a single procedure once the effluent clears Continue gram-positive coverage based on sensitivities Stop gram-negative coverage If Methicillin resistance : Definition based on MIC levels and the presence of mec A gene Defined as the presence of the mecA gene and indicates that the organism is considered resistant to all beta lactam related antibiotics, including penicillins, cephalosporins, and carbapenems. Continue gram-positive coverage based on sensitivities Stop gram-negative coverage If Methicillin resistance : Definition based on MIC levels and the presence of mec A gene Defined as the presence of the mecA gene and indicates that the organism is considered resistant to all beta lactam related antibiotics, including penicillins, cephalosporins, and carbapenems. Assess clinical improvement, repeat dialysis effluent cell count and culture at days 3-5 Assess clinical improvement, repeat dialysis effluent cell count and culture at days 3-5

10 Clinical improvement (symptoms resolve; bags clear): -Continue antibiotics; -Reevaluate for exit-site or occult tunnel infection, intra – abdominal abscess, catheter colonization Clinical improvement (symptoms resolve; bags clear): -Continue antibiotics; -Reevaluate for exit-site or occult tunnel infection, intra – abdominal abscess, catheter colonization Duration of therapy : 14 days Peritonitis with exit-site or tunnel infection: Consider catheter removal. Duration of therapy :14-21 days

11 No clinical improvement (symptoms persist; effluent remains cloudy): -Reculture and evaluate No clinical improvement (symptoms persist; effluent remains cloudy): -Reculture and evaluate No clinical improvement by 5 days on appropriate antibiotics: Remove catheter No clinical improvement by 5 days on appropriate antibiotics: Remove catheter

12 Enterococcus/ Streptococcus on Culture -Touch contamination- Intra abdominal pathology- Exit site and tunnel infection- Dental hygiene Enterococcus/ Streptococcus on Culture -Touch contamination- Intra abdominal pathology- Exit site and tunnel infection- Dental hygiene Discontinue starting antibiotics Start continuous ampicillin 125mg/L each bag;consider adding aminoglycoside once daily IP as 20mg/L for Enterococcus The manifacturer’s precaution label states that these antibiotics should not be mixed together in the same solution container Discontinue starting antibiotics Start continuous ampicillin 125mg/L each bag;consider adding aminoglycoside once daily IP as 20mg/L for Enterococcus The manifacturer’s precaution label states that these antibiotics should not be mixed together in the same solution container If ampicillin resistant, start vancomycin; If vancomycin – resistant enterococcus, consider quinupristin/dalfopristin, daptomycin or linezolid ( Bone marrow suppresion after days) If ampicillin resistant, start vancomycin; If vancomycin – resistant enterococcus, consider quinupristin/dalfopristin, daptomycin or linezolid ( Bone marrow suppresion after days) Assess clinical improvement, repeat dialysis effluent cell count and culture at days 3-5 Assess clinical improvement, repeat dialysis effluent cell count and culture at days 3-5

13 Clinical improvement (symptoms resolve; bags clear): -Continue antibiotics; -Reevaluate for exit-site or occult tunnel infection, intra – abdominal abscess, catheter colonization Clinical improvement (symptoms resolve; bags clear): -Continue antibiotics; -Reevaluate for exit-site or occult tunnel infection, intra – abdominal abscess, catheter colonization Duration of therapy : 14 days (Streptococcus) 21 days (Enterococcus) Duration of therapy : 14 days (Streptococcus) 21 days (Enterococcus) Peritonitis with exit-site or tunnel infection: Consider catheter removal. Duration of therapy :21 days

14 No clinical improvement (symptoms persist; effluent remains cloudy): -Reculture and evaluate No clinical improvement (symptoms persist; effluent remains cloudy): -Reculture and evaluate No clinical improvement by 5 days on appropriate antibiotics: Remove catheter No clinical improvement by 5 days on appropriate antibiotics: Remove catheter

15 Treatment characteristics and clinical outcomes of PD associated peritonitis due to streptococci or other organisms in Australia Treatment characteristics and clinical outcomes of PD associated peritonitis due to streptococci or other organisms in Australia Streptococcal peritonitis in Australian peritoneal dialysis patients: predictors, treatment and outcomes in 287 cases. Stace O’Shea et al. BMJ Nephrology 2009, 10;19

16 Treatment characteristics and clinical outcomes of PD associated peritonitis due to pure enterococcal, polymicrobial entedrococcal and non-enterococcal in Australia Treatment characteristics and clinical outcomes of PD associated peritonitis due to pure enterococcal, polymicrobial entedrococcal and non-enterococcal in Australia Enterococcal peritonitis in Australian peritoneal dialysis patients: predictors, treatment and outcomes in 116 cases. Edey M et al. NDT :

17 Staphylococcus aureus on Culture Touch contamination-Exit-site or tunnel infection Staphylococcus aureus on Culture Touch contamination-Exit-site or tunnel infection Continue gram-positive based on sensitivities Stop gram-negative coverage, assess exit site again Continue gram-positive based on sensitivities Stop gram-negative coverage, assess exit site again If methicillin resistant, adjust coverage to vancomycin (1gr IP every 5 days) or teicoplanin If vancomycin – resistant S aureus, consider quinupristin/dalfopristin, daptomycin or linezolid ( Bone marrow suppresion after days) Teicoplanin can be used in a dose of 15mg/kg once daily Add Rifampin 600mg/day orally for 5-7 days( 450 mg/day if BW < 50kg) If methicillin resistant, adjust coverage to vancomycin (1gr IP every 5 days) or teicoplanin If vancomycin – resistant S aureus, consider quinupristin/dalfopristin, daptomycin or linezolid ( Bone marrow suppresion after days) Teicoplanin can be used in a dose of 15mg/kg once daily Add Rifampin 600mg/day orally for 5-7 days( 450 mg/day if BW < 50kg) Assess clinical improvement, repeat dialysis effluent cell count and culture at days 3-5 Assess clinical improvement, repeat dialysis effluent cell count and culture at days 3-5

18 Clinical improvement (symptoms resolve; bags clear): -Continue antibiotics; -Reevaluate for exit-site or occult tunnel infection, intra – abdominal abscess, catheter colonization Clinical improvement (symptoms resolve; bags clear): -Continue antibiotics; -Reevaluate for exit-site or occult tunnel infection, intra – abdominal abscess, catheter colonization Duration of therapy : At least 21 days Duration of therapy : At least 21 days Peritonitis with exit-site or tunnel infection may prove to be refractory and catheter removal should be considered Allow a minimum rest period of 3 weeks before reinitiating PD Peritonitis with exit-site or tunnel infection may prove to be refractory and catheter removal should be considered Allow a minimum rest period of 3 weeks before reinitiating PD

19 No clinical improvement (symptoms persist; effluent remains cloudy): -Reculture and evaluate No clinical improvement (symptoms persist; effluent remains cloudy): -Reculture and evaluate No clinical improvement by 5 days on appropriate antibiotics: Remove catheter No clinical improvement by 5 days on appropriate antibiotics: Remove catheter

20 Treatment characteristics and clinical outcomes of PD associated peritonitis due to to Staphylococcus aureus or other organisms in Austalia Treatment characteristics and clinical outcomes of PD associated peritonitis due to to Staphylococcus aureus or other organisms in Austalia Staphylococcus aureus peritonitis in Australian peritoneal dialysis patients: predictors, treatment and outcomes in 503 cases. Govindarajulu S et al.Per Dial Inter. 30;

21 Treatment characteristics and clinical outcomes of PD associated peritonitis due to to MSSA and MRSA in Australia Treatment characteristics and clinical outcomes of PD associated peritonitis due to to MSSA and MRSA in Australia

22 Culture negative on Days I and 2 Clinical features of peritonitis (abdominal pain or cloudy dialysate), dialysate leukocytosis ( white blood cell count >100/μL with >50% neutrophils) and negative dialysate culture result for any organism ( including fungi and my cobacteria) ( Program with >20% culture negative peritonitis- reviewed and improved) Culture negative on Days I and 2 Clinical features of peritonitis (abdominal pain or cloudy dialysate), dialysate leukocytosis ( white blood cell count >100/μL with >50% neutrophils) and negative dialysate culture result for any organism ( including fungi and my cobacteria) ( Program with >20% culture negative peritonitis- reviewed and improved) Continue initial therapy Day 3 : culture still negative Clinical assessment Repeat PD fluid white cell count and differential Day 3 : culture still negative Clinical assessment Repeat PD fluid white cell count and differential

23 Infection resolving Patient improvement clinically Infection resolving Patient improvement clinically Continue initial therapy for 14 days Continue initial therapy for 14 days

24 Infection not resolving Special culture technique for unusual causes ( e.g viral, mycoplasma, mycobacteria, legionella, fungi) Infection not resolving Special culture technique for unusual causes ( e.g viral, mycoplasma, mycobacteria, legionella, fungi) Now culture positive Still culture negative Adjust therapy according to sensitivity patterns. Duration of therapy based on organism identified Adjust therapy according to sensitivity patterns. Duration of therapy based on organism identified Clinical improvement: Continue antibiotic therapy Duration of therapy:14 days Clinical improvement: Continue antibiotic therapy Duration of therapy:14 days No clinical improvement after 5 days: Remove catheter No clinical improvement after 5 days: Remove catheter Continue antibiotics for at least 14 days after catheter removal

25 Treatment characteristics and clinical outcomes of culture-negative and culture positive PD associated peritonitis in Australia Culture negative peritonitis in peritoneal dialysis patients in Australia; predictors, treatment and outcomes in 425 cases. Gahim M et al. Am J Kidney Dis 2010:

26 Pseudomonas Species on Culture Without catheter infection (exit-site/tunnel) Give 2 different antibiotics acting in different ways that organism is sensitive to e.g oral quinolone, ceftazidime. cefepime, tobramycin, piperacillin Assess clinical improvement, repeat dialysis effluent cell count and culture at days 3-5 Assess clinical improvement, repeat dialysis effluent cell count and culture at days 3-5

27 Clinical improvement (symptoms resolve; bags clear): -Continue antibiotics; Clinical improvement (symptoms resolve; bags clear): -Continue antibiotics; Duration of therapy : At least 21 days Duration of therapy : At least 21 days

28 No clinical improvement (symptoms persist; effluent remains cloudy): -Reculture and evaluate No clinical improvement (symptoms persist; effluent remains cloudy): -Reculture and evaluate No clinical improvement by 5 days on appropriate antibiotics: Remove catheter No clinical improvement by 5 days on appropriate antibiotics: Remove catheter Continue oral and/or systemic antibiotics for at least 14 days

29 Pseudomonas Species on Culture With catheter infection (exit-site/tunnel) current or prior to peritonitis With catheter infection (exit-site/tunnel) current or prior to peritonitis Remove catheter Continue oral and/or systemic antibiotics for at least 14 days

30 Pseudomonas Peritonitis is Australia: predictors, treatment and outcomes in 191 cases.Siva B et al. Clin J Am Soc Nephrol 2009;4: Prompt catheter removal and use of two anti-pseudomonal antibiotics are associated with better outcomes

31 Single Gram-Negative Organism on Culture Touch contamination-Exit site infection-Transmural migration from constipation, diverticulitis or colitis Single Gram-Negative Organism on Culture Touch contamination-Exit site infection-Transmural migration from constipation, diverticulitis or colitis Other –E.coli, Proteus, Klebsiella etc Stenotrophomonas (Prior therapy with carbapenemes, fluoroquinolones, and 3 and 4 generation cephalosporins) Stenotrophomonas (Prior therapy with carbapenemes, fluoroquinolones, and 3 and 4 generation cephalosporins) Adjust antibiotics to sensitivity pattern. Cefalosporin ( ceftazidime or cefepime) may be indicated- Fluoroquinolone Treat with 2 drugs with differing mechanisms based on sensitivity pattern ( oral trimethoprim/ sulfamethoxazol is preferred) (IP ticarcillin/clavulanate, per os minocycline) Treat with 2 drugs with differing mechanisms based on sensitivity pattern ( oral trimethoprim/ sulfamethoxazol is preferred) (IP ticarcillin/clavulanate, per os minocycline) Assess clinical improvement, repeat dialysis effluent cell count and culture at days 3-5 Assess clinical improvement, repeat dialysis effluent cell count and culture at days 3-5

32 Other –E.coli, Proteus, Klebsiella etc Stenotrophomonas Clinical improvement (symptoms resolve; bags clear): -Continue antibiotics; -Duration of therapy: days Clinical improvement (symptoms resolve; bags clear): -Continue antibiotics; -Duration of therapy: days Clinical improvement (symptoms resolve; bags clear): -Continue antibiotics; -Duration of therapy: days Clinical improvement (symptoms resolve; bags clear): -Continue antibiotics; -Duration of therapy: days No clinical improvement by 5 days on appropriate antibiotics (symptoms persist; effluent remains cloudy) : Remove catheter No clinical improvement by 5 days on appropriate antibiotics (symptoms persist; effluent remains cloudy) : Remove catheter

33 Fungal peritonitis Immediately after fungi are identified by microscopy or culture :Remove catheter Strongly suspected after recent antibiotic treatment for bacterial peritonitis Immediately after fungi are identified by microscopy or culture :Remove catheter Strongly suspected after recent antibiotic treatment for bacterial peritonitis Amphotericin B and flucytosine Intraperitoneal use of amphotericin causes chemical peritonitis Trough serum flucytosine concentrations < 100μg/mL to avoid bone marrow toxicity Fluconazole Voriconazole ( 200mg IV twice daily for 5 weeks after catheter removal) Posaconazole ( 400mg twice daily for six months) Caspofungin Used successfully as monotherpy or in combination with amphotericin B Amphotericin B and flucytosine Intraperitoneal use of amphotericin causes chemical peritonitis Trough serum flucytosine concentrations < 100μg/mL to avoid bone marrow toxicity Fluconazole Voriconazole ( 200mg IV twice daily for 5 weeks after catheter removal) Posaconazole ( 400mg twice daily for six months) Caspofungin Used successfully as monotherpy or in combination with amphotericin B

34 Predictors and outcomes of fungal peritonitis in peritoneal dialysis patients. Miles R et al. Kidney Int : The risks of repeat fungal peritonitis and death were lowest with catheter removal combined with antifungal therapy when compared to either intervention alone Treatment characteristics and clinical outcomes of PD- associated peritonitis due to fungi or other organism in Australia Treatment characteristics and clinical outcomes of PD- associated peritonitis due to fungi or other organism in Australia

35 Effect of timing of catheter removal on subsequent clinical outcomes in 142 patients with fungal peritonitis requiring catheter removal

36 Indications for Catheter Removal for Peritoneal Dialysis-Related Infections Refractory peritonitis ( Simultaneous catheter removal not possible) Relapsing peritonitis ( Catheter removal as a single procedure can be done if the effluent can first be cleared. The procedure should be done under antibiotic coverage) Refractory exit-site and tunnel infection (Timely replacement of the catheter can prevent peritonitis –Permitting simultaneous replacement) Fungal peritonitis ( Simultaneous catheter removal not possible 2-3 weeks or later) Catheter removal may also be considered for Repeat peritonitis Mycobacterial peritonitis Multiple enteric organisms Refractory peritonitis ( Simultaneous catheter removal not possible) Relapsing peritonitis ( Catheter removal as a single procedure can be done if the effluent can first be cleared. The procedure should be done under antibiotic coverage) Refractory exit-site and tunnel infection (Timely replacement of the catheter can prevent peritonitis –Permitting simultaneous replacement) Fungal peritonitis ( Simultaneous catheter removal not possible 2-3 weeks or later) Catheter removal may also be considered for Repeat peritonitis Mycobacterial peritonitis Multiple enteric organisms

37 ISPD Definitions of Recurrent, Relapsing and Repeated Peritonitis

38

39 Relapsing and Recurrent Peritoneal Dialysis –Associated Peritonitis : A Multicenter Registry Study. Burke M et al. Am J Kidney Dis. 2011;58(3): Repeated peritoneal dialysis associated peritonitis A multicenter registry study. Thirugnanasambathan T et al.Am J Kidkey Dis xx(x)xxx Streptococcal peritonitis in Australian peritoneal dialysis patients: predictors, treatment and outcomes in 287 cases. Stace O’Shea et al. BMJ Nephrology 2009, 10;19 Enterococcal peritonitis in Australian peritoneal dialysis patients: predictors, treatment and outcomes in 116 cases. Edey M et al. NDT : Staphylococcus aureus peritonitis in Australian peritoneal dialysis patients: predictors, treatment and outcomes in 503 cases. Govindarajulu S et al. Per Dial Inter. 30; Culture negative peritonitis in peritoneal dialysis patients in Australia; predictors, treatment and outcomes in 425 cases. Gahim M et al. Am J Kidney Dis 2010: Pseudomonas Peritonitis is Australia: predictors, treatment and outcomes in 191 cases. Siva B et al. Clin J Am Sox Nephrol 2009;4: Predictors and outcomes of fungal peritonitis in peritoneal dialysis patients. Miles R et al. Kidney Int : Predictive value of dialysate cell counts in peritonitis complicating peritoneal dialysis. Kai Ming Chow Clin J Am Soc Nephrol 20061:


Download ppt "ΕΙΔΙΚΗ ΑΝΤΙΜΕΤΩΠΙΣΗ ΠΕΡΙΤΟΝΙΤΙΔΑΣ ΚΛΙΝΙΚΕΣ ΟΔΗΓΙΕΣ ISPD ΠΗΝΕΛΟΠΗ ΧΡ. ΚΟΥΚΗ «ΙΠΠΟΚΡΑΤΕΙΟ» Γ.Ν.Α ΠΗΝΕΛΟΠΗ ΧΡ. ΚΟΥΚΗ «ΙΠΠΟΚΡΑΤΕΙΟ» Γ.Ν.Α."

Similar presentations


Ads by Google