신장내과 이지연 Peritoneal dialysis-related infection ISPD guidelines 2010 update

Peritoneal dialysis-related infection CAPD Peritonitis  Major complication of peritoneal dialysis (PD)  contributing factor to death on 16% of death on PD  why patients switch from PD to HD

Cause of peritonitis Touch contamination Catheter-related infection Transvisceral migration due to intraabdominal pathology (eg, bowel leak) Hematogenous Vaginal leak- very rare

Exit-site and tunnel infection Definition Purulent drainage from the exit site indicates the presence of infection. Erythema may or may not represent infection Therapy The most serious and common exit-site pathogens :Staphylococcus aureus, Pseudomonas aeruginosa Oral antibiotic therapy is generally recommended, with the exception of methicillin-resistant S. aureus (MRSA)

Equivocal Acute infection chronic infection

Tunnel infection

G(+) organism Slowly resolving or severe S.aureus P.Aeruginosa

Exit-site and tunnel infection Pseudomonas aeruginosa  1 st choice : quinolone  sevelamer, calcium, oral iron, zinc preparations, sucralfate, magnesium–aluminum antacids, milk, chelation interactions Quinolone + IP aminoglycoside, ceftazidime, cefepime, piperacillin, imipenem–cilastatin, meropenem

Exit-site and tunnel infection Ultrasonography  useful adjunctive tool in the management of exit-site and tunnel infections involvement of the proximal cuff: poor clinical outcome Treatment duration until the exit site appears entirely normal 2weeks is the minimum length of treatment P. aeruginosa : for 3 weeks

Exit-site and tunnel infection Catheter removal  Exit-site infection  peritonitis (same organism)  P.aeruginosa (should be considered earlier)  Prolonged peritonitis  Relapsing peritonits

Initial presentation and management of peritonitis  Abdominal pain — 79 %  Fever (greater than 37.5ºC) — 53 %  Nausea — 31 %  Diarrhea — 7 %  Abdominal tenderness — 70 %  Rebound tenderness — 50 %

Initial presentation and management of peritonitis Diagnosis  cloudy effluent, abdominal pain,fever, N/V,diarrhea  Dialysate WBC >100/mL (least 50% PMN) (after a dwell time of at least 4 hours)  Gram stain or culture (+) Peritonitis, but WBC< 100/mL (10%)  poor host immune response  short length of the dwell (ex, APD)

Differential diagnosis of cloudy effluent

Initial presentation and management of peritonitis cloudy effluent heparin(500u/L) to the dialysate to prevent occlusion of the catheter by fibrin empiric antibiotic therapy for PD-associated peritonitis as soon as possible

Specimen processing  Culture-negative peritonitis <20%  Standard culture technique : use of blood-culture bottles but a large-volume culture (e.g., culturing the sediment after centrifuging 50 mL of effluent) + bedside inoculation of 5-10ml effluent in two blood culture bottle  leukocyte esterase, broad-spectrum polymerase chain reaction (PCR), quantitative bacterial DNA PCR

Imaging  Abdominal series  Abdomen CT  Magnetic resonance imaging (MRI)  Radionuclide scanning  D/Dx secondary peritonitis

Empirical antibiotic selection

Vancomycin Intermittent dosing  interval : 4-5days  modify dose based on serum drug concentration  redosing : vancomycin level < 15ug/mL Continuous administration Intermittent administration

Peritonitis in APD patients APD  CAPD?  unclear  not familiar with CAPD technique  resetting the cycler – longer exchange time Intermittent administration

Terminology of peritonitis Recurrent  An episode that occurs within 4 weeks of completion of therapy of a prior episode but with a different organism Relapsing  An episode that occurs within 4 weeks of completion of therapy of a prior episode with the same organism or 1 sterile episode Repeat  An episode that occurs more than 4 weeks after completion of therapy of a prior episode with the same organism Refractory  Failure of the effluent to clear after 5 days of appropriate antibiotics

Indication for catheter removal