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Le Peritoniti Flavia Caputo. Although incidence rates of peritonitis have decreased substantially with the introduction of the flush-before-fill double-bag.

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Presentation on theme: "Le Peritoniti Flavia Caputo. Although incidence rates of peritonitis have decreased substantially with the introduction of the flush-before-fill double-bag."— Presentation transcript:

1 Le Peritoniti Flavia Caputo

2 Although incidence rates of peritonitis have decreased substantially with the introduction of the flush-before-fill double-bag principle, and the emergence of improved connection systems… Peritonitis is still the achilles'heel of peritoneal dialysis Mactier R.Perit Dial Int May-Jun;29 Peritoneal dialysis-associated peritonitis is the most common acute complication of PD and has been the main cause of technique failure. Repetitive or protracted peritonitis episodes can also damage the peritoneal membrane Selgas R, Paiva A, Bajo MA et al. Adv Perit Dial1998; 14:

3 Drop-out per peritonite: 5-10% dei paz/anno Peritonite come causa di drop-out: % Degenza ospedaliera: 5 giorni/anno paziente in trattamento Mortalità per peritonite 2-12%

4 Peritonitis as a Cause of Peritoneal Dialysis Technique Failure StudyStudy periodStudy patientsInitial CureTecniques failure due to peritonitis Kavanagh et al., All adult patients in Scotland 75%42.6% Johnson et al., All centers in Australia 78% (2006 data only) 29% Davenport, All centers in London, UK >80% in only 2 of 12 units 41.7% Mactier R.Perit Dial Int May-Jun;29

5 Factors affecting the rate of tecnique failure: Kavanagh D, Prescott GJ, Mactier RA, NDT 2004;19

6 ISPD Standards and Guidelines Committee Minutes from the June 2008 Meeting in Istanbul In attendance: Beth Piraino, Frank Schaefer, Judith Bernardini, Edwina Brown, Flavia Caputo, Ana Figueiredo, Valerie Price Update on Peritoneal Dialysis- Related Infections, 2005 published in 2005 in PDI The committee felt that it was time to renew this guideline. It will be split into two parts. One will deal with Management of PD Related Infections. This guideline will be led by Dr Philip Li who has been invited to join the committee to ensure good communication. He will put together the working group. Projected complete date: Addendum: The part of the previous guideline on Prevention of PD related infections will be separated and developed as a position paper as there is not enough rigorous data for guidelines. This will be led by Dr Beth Piraino. Dr Philip Li and Dr Beth Piraino will sit on each others work groups. Projected time table: completion by mid The committee will be asked if they agree with this approach.

7 First published in 1983 and revised in 1989, 1993, 1996 and UPDATE Every program should regularly monitor infection rates, at a minimum, on a yearly basis Opinion

8 The centers peritonitis rate should be no more than 1 episode every 18 months (0,67/year) Reported <0,29-0,23/year GOAL to achieve! Cheng YL, AJKD 2002, Choi KH, Perit Dial Int 2004: ISPD 2010

9 Methods 1.As rates Interval in months between episodes Episodes for year 2. As percentage of patients per period of time who are peritonitis free 3. As median peritonitis rate for the program ISPD 2010

10 Comparison of Peritonitis Rates in Peritoneal Dialysis (PD) Patients Using the Double-Bag Disconnect System Study (Ref.Study period Study location Patients (n)PD systemMonths between episodes of peritonitis Monteon et al., 1998 (8) -Multicenter; Mexico 147CAPD24,8 Li et al., 1999 (9)-Multicenter; Hong Kong 120CAPD33,5 Huang et al., 2001 (10) 1993–2001Single center; Taipei, Taiwan 117CAPD45,4 Katz et al., 2001 (11) Single center; Soweto, South Africa 84CAPiva a 45 D 27,9 Kavanagh et al., 2004 (5) 1999–2002All centers in Scotland 1205APD/CAPD19,2 Johnson et al., 2007 (6 2006All centers in Australia 2021APD/CAPD21,0 Davenport, 2009 (7) 2002–2003All centers in London, UK 863 at the end of at the end of 2003 APD/CAPD15,9

11 Esperienza del nostro centro Dati 2008 o 25 episodi in 66 pazienti o 1 episodio ogni 25mesi/pz o 0.48 ep/anno/paz. Dati episodi in 58 pazienti 1 episodio ogni 29 mesi/pz 0.41 ep/anno/paz.

12 PERITONITIS Peritoneal dialysis patients presenting with cloud effluent OR abdominal pain Diagnosis is confirmed with cell count and culture WBC per mcL with more than 50% PMN 2.Positive culture EVIDENCE ISPD 2010

13 Differential Diagnosis of Cloud Effluent Culture positive infectious peritonitis Infectious peritonitis with sterile cultures Chemical peritonitis Eosinophilia of the effluent Hemoperitoneum Malignacy (rare) Chylous effluent (rare) ISPD 2010

14 Culture-negative peritonitis should not be greater than 20% episodes Standard culture technique is the use of blood- culture bottles, but culturing the sediment after centrifuting 50 mL of effluent is ideal for low culture-negative results EVIDENCE ISPD Guidelines 2010 In the ideal situation less than 10% rate of culture negative peritonitis ISPD 2010

15 The correct microbiological culturing of peritoneal effluent is of the most importance to establish the microrganism responsible. Centrifugation 50 mLperitoneal effluent at 3000g for 15 minutes…… Rapidblood-culturetechniques (BACTEC) Other novel diagnostic techniques: Leukocyte esterase reagent strip PCR withRNA/DNA assays MMP 9 ISPD 2010

16 Intraluminale Staf.epidermidis e altri SCN Staf.aureo (30/40%) Strept.Viridans Periluminale Staf. Epidermidis e altri SCN Staf.Aureo (20/30%) Pseudomonas Difterici Funghi Transmurale Colibacilli (25/30%) Enterobacteriacee Anaerobi Ematogena Streptococchi (5/10%) M. Tubercolosis Ascendente Lactobacilli (2/5%) Funghi Vie di contaminazione e microrganismi

17 Vie di contaminazione ESOGENA ENDOGENA Endoluminale 30-40% Periluminale 20-30% Transmurale 25-30% Ascendente 2-5% Ematogena/Linfatica 5-10% Adeguato training

18 via endoluminale La via endoluminale rappresenta il 40% delle vie di contaminazione Cause: Manovre non corrette nel cambio sacca Tramite rotture della sacca o del set Disconnessioni accidentali Soluzioni non sterili Per tale motivo il TRAININGriveste un ruolo fondamentale nella prevenzione delle peritoniti Lutilizzo di un incrementato metodo di training è positivamente associato con il migliorato esito del paziente (evidence) New directions in dialysis patient training Nephrol. Nurs. 2004

19 Il metodo di training influenza il rischio di infezioni in dialisi peritoneale (Evidence). EXIT SITE CARE ISPD GUIDELINES/RECOMMENDATIONS 2005 Le PD nurses sono fondamentali per un programma di dialisi peritoneale con un basso indice di infezioni: - Lavaggio mani - Exit site care - Uso della mascherina - Diagnosi precoce dellESI e del TI

20 Vie di contaminazione ESOGENA ENDOGENA Endoluminale 30-40% Periluminale 20-30% Transmurale 25-30% Ascendente 2-5% Ematogena/Linfatica 5-10% Adeguato training ESI / TI Carriage Staph. Aureus

21 Peritonitis associated with exit-site infections B. Piraino- AJKD, 1996

22 Episodes per year at risk Bernardini J, Piraino B, JASN 2005 Feb; 16:

23 Gentamicin cream applied daily to the exit-site compared to mupirocin significantly reduced EXITE SITE INFECTION (57%) PERITONITIS (35%) Bernardini J, Piraino B JASN 2005 Feb; 16:

24 Vie di contaminazione ESOGENA ENDOGENA Endoluminale 30-40% Periluminale 20-30% Transmurale 25-30% Ascendente 2-5% Ematogena/Linfatica 5-10% Adeguato training Exit-siteinfection CarriageStaph. Aureus Profilassi antibiotica Evitare la stipsi

25 There is an association between both severe constipation and enteritis and peritonitis due to enteric organisms EVIDENCE ISPD Guidelines 2005 Possibly, peritonitis results from trans migration of micro-organisms across the bowel wall. Hipomotility disorders Drugs contributing (oral iron, oral calcium, some analgesics) Hypokaliemia Training: AVOIDANCE OF CONSTIPATION! ISPD 2005

26 Vie di contaminazione ESOGENA ENDOGENA Endoluminale 30-40% Periluminale 20-30% Transmurale 25-30% Ascendente 2-5% Ematogena/Linfatica 5-10% Adeguato training Exit-siteinfection CarriageStaph. Aureus Profilassi antibiotica Evitare la stipsi Fistole vaginali Ascessi retroperitoneali

27 Vie di contaminazione ESOGENA ENDOGENA Endoluminale 30-40% Periluminale 20-30% Transmurale 25-30% Ascendente 2-5% Ematogena/Linfatica 5-10% Adeguato training Exit-siteinfection CarriageStaph. Aureus Profilassi antibiotica Evitare la stipsi Fistole vaginali Ascessi retroperitoneali Profilassi antibiotica in corso di procedure invasive

28 Invasive procedure may infrequently cause peritonitis in PD patients EVIDENCE ISPD Guidelines 2005 Antibiotic prophylaxis: A single oral dose of amoxicillin (2g) 2 hours before extensive dental procedure Opinion Patients undergoing colonscopy with polypectomy: Ampicillin 1g+ a single dose of an aminoglycoside ± metroinidazole, given i.v. just prior the procedure Opinion N.B. The abdomen must be empty of fluid prior to all procedures involved the abdomen or pelvis (colonsopy, renal transplantation, endometrialbiopsy) Opinion ISPD 2005

29 Disconnect systems Prompt antibiotic therapy after accidental contamination Hand disinfection technique Patient training and periodic retraining Patient selection Prevention of touch contamination Prophylactic antibiotics at the time of catheter insertion Downward facing exit-site Immobilization of newly inserted catheter Prophylactic antibiotics to the exit-site Prevention of catheter-related infection Avoid constipation Empty peritoneal cavity and prophylactic antibiotics before endoscopy, colonscopy, or barium enema Prevention of enteric infection Adequate antibiotics therapy for 2-3 weeks Removal of the catheter if Staphylococcus aereus or Pseudomonas exit-site or tunnel infection Oral nystatin during courses of antibiotics Prevention of recurrent peritonitis A Bundle of Care of Clinical Practice to Reduce Risk of peritonitis Mactier R.Perit Dial Int May-Jun;29

30 Therapy should be initiated as soon is possible, after appropriate microbiological specimen have been obtained PATIENT EDUCATIONAL ISPD 2010

31 PATIENT EDUCATIONAL Immediately report cloudy effluent, abdominal pain and/or fever to PD unit Save drained cloudy dialysate and bring to clinic Treatment will be adding intraperitoneal antibiotics for up to 3 weeks Report worsening symptoms or persistent cloudiness to PD unit Schedule retraining for technique issues ISPD 2010

32 Start intraperitoneal antibiotics as soon as possible Allow to dwell for at least 6 hours Ensure gram-positive and gram negative coverage* Base selection on historical patient and center sensitivity patterns as available Gram-positive coverage Either Vancomycin** or first generation cephalosporin Gram-negative coverage Either third-generation cephalosporin*** or aminoglycoside 0-6 hours Determine and prescribe ongoing antibiotic treatment Ensure follow-up arrangements are clear or patient admitted Await sensitivity results 6-8 hours ISPD 2010 INITIAL MANAGEMENT OF PERITONITIS

33 La dose I.P. è sempre preferibile. IP administration has the advantage of a high concentration of the antibiotic at the site of infection. The major drawback is that injection of the antibiotic into the bag induces a potential extra risk of contamination. In this regard, once-daily IP administration has great advantages. Intravenous administration should be avoided as this can destroy vascular access possibilities that are precious for the future Van Biesen W, Vanholder R, Lameire N. Perit Dial Int 2000; 20 Intraperitoneal Drug Therapy: An Advantage. Chaudhary Curr Clin Pharmacol. 2010

34 THERAPY 1.EMPIRIC THERAPY (therapy is initiated prior to knowledge of causative organism) The Committee reccomends center-specific selection of empiric therapy, dependent on the local history of sensitivies of organismies causing peritonitis The protocol must cover all serious pathogens that are likely to be present Opinion ISPD 2010

35 EMPIRIC THERAPY and N.B. Short-term use of aminoglycoside therapy appears to be safe for the risk of ototoxicity (once day dose) ISPD 2010 Cefazolin Or Vancomicin Ceftazidime Or Gentamicin

36 Monotherapy: Imipenem/cilastatin 50mg = cefazolin+ceftazidime Leung CB, Szeto CC, Chow KM, Perit Dial Int, 24: 440, 2004 Cefepime 2 g = vancomycin+netilmicin Wong KM, Chan CY, Cheung CY, Leung SH, Am J Kidney Dis 38: 127, 2001 Quinolones (oral levofloxacin 250 mg/day or perfloxacin 400 mg/day) = aminoglycosides for gram- negative Yeung SM, Walker SE, Tailor SA, Perit Dial Int 18: 371, 2004 ISPD 2010

37 Other gram-positive organisms including coagulase negative staphylococcus on culture Continue gram-positive coverage based on sensitivities Stop gram-negative coverage Assess clinical improvement, repeat dialysis effluent cell count and culture at days Symptoms resolved - Bags clear Clinical improvement - Continue antibiotics; - duration of therapy: 14 days No clinical improvement - Re-culture & evaluate* Re-evaluate for exit-site or occult tunnel infection, intraabdominal abscess, catheter colonization etc Peritonitis with exit-site or tunnel infection consider catheter removal** Duration of therapy: 21 days No clinical improvement by 5 days on appropriate antibiotics, remove catheter ISPD 2010

38 Staphylococcus aureus on culture Continue gram-positive coverage based on sensitivities* Stop gram-negative coverage, assess exit site again If methicillin resistant, adjust coverage to vancomycin or teicoplanin** Add rifampin 600 mg/day orally (in single or split dose) for 5 to 7 days (450 mg/day if BW < 50 kg) Assess clinical improvement, repeat dialysis effluent cell count and culture at days Symptoms resolved - Bags clear Clinical improvement - Continue antibiotics - Duration of therapy 21 days No clinical improvement - Re-culture & evaluate Re-evaluate for exit-site or occult tunnel infection, intraabdominal abscess, catheter colonization etc Peritonitis with exit-site or tunnel infection may prove to be refractory**** and the catheter must be removed. Allow a minimum rest period of 3 weeks before re-initiating PD***** No clinical improvement by 5 days on appropriate antibiotics, remove catheter ISPD 2010

39 Enterococcus/Streptococcus on culture Discontinue starting antibiotics* Start continuous ampicillin 125 mg/L each bag; consider adding aminoglycoside for enterococcus** If ampicillin resistant, start vancomycin; If vancomycin resistant enterococcus, consider quinupristin/dalfopristin, daptomycin, or linezolid Assess clinical improvement, repeat dialysis effluent cell count and culture at days Symptoms resolved - Bags clear Clinical improvement - Continue antibiotics; duration of therapy: 14 days (streptococcus) 21 days (enterococcus) No clinical improvement - Re-culture & evaluate Re-evaluate for exit-site or occult tunnel infection, intraabdominal abscess, catheter colonization etc Peritonitis with exit-site or tunnel infection consider catheter removal*** Duration of therapy: 21 days No clinical improvement by 5 days on appropriate antibiotics, remove catheter ISPD 2010

40 Culture negative on day 1 & 2 Infection resolving Patient improvement clinically Infection not resolving Special culture technique for unusual causes (e.g. viral, mycoplasma, mycobacteria, legionella). Consider fungi Continue initial therapy for 14 days Now culture positiveStill culture negative Continue initial therapy Day 3: Culture still negative Clinical assessment Repeat PD Fluid white cell count and differential Adjust therapy according to sensitivity patterns Duration of therapy based on organism identified Clinical improvement Continue antibiotic Duration of therapy: 14 days No clinical improvement after 5 days Remove catheter* Continue antibiotics for at least 14 days ISPD 2010

41 Pseudomonas species on culture Without catheter infection (exit-site/tunnel) With catheter infection(exit- site/tunnel) current or prior to peritonitis Give 2 different antibiotics acting in different ways that organism is sensitive to eg oral quinolone, ceftazidime, cefapime, tobramycin, piperacillin Assess clinical improvement, repeat dialysis effluent cell count and culture at days 3-5: - Symptoms resolved - Bags clear Catheter removal* Continue oral and/or systemic antibiotics for at least two weeks No clinical improvement - Re-culture & evaluate - Consider changing antibiotics No clinical improvement by 5 days on appropriate antibiotics, remove catheter Clinical improvement - Continue antibiotics; - duration of therapy: 21 days ISPD 2010

42 Single gram-negative organism on cultureon culture* Other E. coli proteus, klebsiellaetc Stenotrophomonas Adjust antibiotics to sensitivity pattern Cephalosporin (ceftazidime or cefepime) may be indicated Treat with 2 drugs with differing mechanisms based on sensitivity pattern (trimethoprim / sulphamethoxazole is preferred) Assess clinical improvement, repeat dialysis effluent cell count and culture at days 3-5: - Symptoms resolved - Bags clear Assess clinical improvement at days 3-5: - Symptoms resolved - Bags clear Clinical improvement - Continue antibiotics; - Minimum 21 day treatment Clinical improvement - Continue antibiotics: days treatment No clinical improvement by 5 days on appropriate antibiotics - remove catheter ISPD 2010

43 Polymicrobial peritonitis: days 1-3 Multiple gram-negative organisms or mixed gram negative/gram positive - consider GI problem Multiple gram-positive organisms - Touch contamination - Consider catheter infection Change therapy to metronidazole in conjunction with ampicillin, ceftazidime or aminoglycoside Continue therapy based on sensitivities Obtain urgent surgical assessment Duration of therapy minimum 21 days based on clinical response In case of laparotomy indicating intraabdominal pathology/abscess, remove catheter* Continue antibiotics – 14 days With exit site or tunnel infection, remove catheter* Without exit site or tunnel infection – continue antibiotics ISPD 2010

44 The Commette feels that the minimum of therapy for peritonitis is 2 weeks, athough for more severe infections, 3 weeks is reccomended Opinion After initiation of antibiotic treatment clinical improvement shoud be present in the first 72 hours

45 Fungal peritonitis Fungal peritonitis is a serious complication leading to death in 25% or more episodes,should be strongly suspected after recent antibiotic treatment for bacterial peritonitis. Catheter removal is indicated immediately after fungi are identified by microscopy or culture EVIDENCE ISPD 2010

46 PERITONITIS DUE TO MYCOBACTERIA Mycobacteria are an infrequent cause of peritonitis but can be difficult to diagnose. When under clinical consideration, special attention must be paid to culture techniques. Treatment requires multiple drugs EVIDENCE They can be caused by Mycobacterium tuberculosis or non- tuberculosis mycobacteria, such as M. fortuitum, M. avium, M. abscessus and M. chelonei ISPD 2010

47 Terminology of peritonitis Terminology for peritonitis Recurrent: An episode that occurs within 4 weeks of completation of therapy for a prior episode but with a different organism Relapsing: An episode that occurs within 4 weeks of completation of therapy for a prior episode with the same organism or one sterile episode Repeat: An episode that occurs after 4 weeks of completation of therapy for a prior episode with the same organism Refractory: Failure of the effluent to clear after 5 days of appropriate antibiotics Catheter-related peritonitis: Peritonitis in conjunction with exit-site or tunnel infection with the same organism or one site sterile When calculating peritonitis rates, Relapsing episodes should not be counted as another peritonitis; while recurrent and repeat should be counted ISPD 2010

48 \ Indications for catheter removal: Relapsing peritonitis Refractory peritonitis Fungal peritonitis Refractory catheter infections The focus shoul be on preservation of the peritoneum rather than saving peritoneal catheter Opinion ISPD 2010

49 Catheter reinsertion A minimum period of 2-3 weeks between catheter removal and reinsertion of a new catheter is raccomanded, although some would reccomend later reinsertion in case of fungin peritonitis ISPD 2010

50 REFRACTORY PERITONITIS Refractory peritonitis, defined as failure to respond to appropriate antibiotics within 5 days, should be managed by removal of the catheter to protect the peritoneal membrane for future use ISPD 2010

51 OUTCOMES EVALUATION Collect data to include Date of culture, organism identified, drug therapy used Date infection resolved Recurrent organisms, date of drug therapy Method of interim renal replacement therapy Date of catheter removal Date of new catheter reinsertion Documentation of contributing factors – Break in technique, patient factors, exit-site infections, tunnel infections Date of re-education/training Enter data into catheter management database ISPD 2010


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