1. Infections in PD Prevention and Management

2. Peritonitis a cause of…
Peritoneal membrane damage
Hospitalization and pain
Catheter loss
Technique failure
Death

3. Peritonitis: cells in effluent

5. Peritonitis: Infiltration

6. Pathogen Pathway

7. Tunnel Infection

8. Complications of Peritonitis
Temporary loss of UF
Increased protein losses
Catheter loss
Adhesions
Sclerosing encapsulating peritonitis
Transfer to HD
Death

9. Peritonitis DEFINITION 1. Signs and symptoms
2. Cloudy fluid - >100 wbc/ml; >50%N
3. Identification of organism
Two of three required for diagnosis
RELAPSING PERITONITIS
Another episode of peritonitis caused by the same genus/species within 4 weeks of completing antibiotic course

10. Cell count, with differential
Peritonitis Diagnosis
Cloudy fluid +/- abdominal pain +/- fever
Dialysate effluent should be obtained for laboratory evaluation (>4 hrs’ dwell time):
Culture
Cell count, with differential
Gram Stain
Confirmation
WBC count >100/mm3 , of which 50% are polymorphonuclear neutrophils (PMN), is confirmation of microbial-induced peritonitis

11. Clinical Course in CAPD Peritonitis
Introduction of bacteria into peritoneum
Bacteria Peritoneal wall Multiply
ASYMPTOMATIC FOR HRS
Shed into PD fluid
Abdo pain + Cloudy fluid = peritonitis

12. Micro-Organisms Causing Peritonitis
Harwell PDI 1997;17:

13. Routes of Peritoneal Infection
Exchange
procedure
Haematogenous
Titaneum/transfer set
Pericatheter
Transcolonic

14. Sources of Peritonitis, %
Harwell PDI 1997
Contamination 41
Catheter related 23
Enteric injury 11
Perioperative 6
Diarrhoea/UTI 4
Sepsis 1
Unknown 14

15. Peritonitis - Yset Systems
P risk % (Maiorca Lancet 1983)
Y-set first by
Buoncristianti 1980
Long Y with
disinfectant
Flush before fill
Proliferation of
disconnect systems
standard
Y set
Months

16. CAPD vs APD

17. Initial assessment Symptoms: cloudy fluid and abdominal pain
Do cell count/differential
Gram stain and culture
- on initial drainage
Initiate empiric therapy
Choice of final therapy should always be guided by antibiotic sensitivities

18. Gram Staining
A gram stain is positive in 9-40% of peritonitis episodes
When positive it is predictive of eventual culture results in 85% of cases
It is particularly useful in early recognition of fungal peritonitis through revealing presence of yeast
If on initial evaluation, a gram stain is +ve, a single antibiotic with activity against gram +ve organisms should be started
Identification of a single organism on Gram stain does not preclude the presence of other organisms in lesser concentrations
Finding gram +ve cocci and gram-negative rods together may indicate perforated abdominal viscous

19. Possible Causes of Culture Negative Peritonitis
Culture methods of low sensitivity used – the culture techniques for PD effluent is specialized
Culture volumes are too small
Causative organism requires specialised culture media
Cultures are taken from patients on antibiotic treatment
The symptoms and signs are not due to infectious agents

20. Cloudy Effluent: Cellular Causes – Increased PMN
Infectious causes
Intraperitoneal visceral inflammation (eg, cholecystitis, appendicitis, bowel ischemia or obstruction)
Juxtaperitoneal visceral inflammation (eg, pancreatitis, splenic infarction, abscess)
Endotoxin-contaminated PD fluid
Drug associated (eg amphotericin, vancomycin)

21. Cloudy Effluent: Cellular Causes – Increased Eosinophils
Allergic reaction to constituent of dialysis system (e.g., sterilant, plasticizer)
Drug associated (eg, vancomycin, streptokinase)
Air-induced peritoneal irritation
Blood-induced peritoneal irritation (e.g., retrograde menstruation)

22. Cloudy Effluent: Cellular Causes – Increased RBC
Reproductive: Retrograde menstruation, Ovulation, Ectopic pregnancy
Cyst rupture (ovarian or hepatic)
Peritoneal adhesion formation
Strenuous exercise
Catheter-associated trauma
Post-procedure: laparoscopy, colonoscopy
Encapsulating peritoneal sclerosis
Anticoagulation therapy
Acute or chronic pancreatitis
Post radiation

23. Lessons Organisms suggest causation: Outcomes depend on:
S. Epidermis = touch contamination
S. Aureus = catheter infection
Outcomes depend on:
Causative organisms and severity
- Gram negative >> S. Aureus >> S. Epidermidis
Associated conditions and severity
Peritonitis + tunnel >> Peritonitis + ESI
Peritonitis + ESI >> Peritonitis

24. Causative Organisms
Bunke et al, KI 52: , 1997

25. Gram Positive Organisms
Bunke et al, KI 52: , 1997

26. Organisms and Outcomes
Bunke et al, KI 52: , 1997

27. % of all episodes (without ESI/TI)
Outcomes of Peritonitis
Bunke, et al., KI 1997
% of all episodes (without ESI/TI)

28. *p<0.05 vs baseline for all times
Time Course of UF After Peritonitis
Ates, et al., PDI 20;2000:
*p<0.05 vs baseline for all times

29. Prevention of Peritonitis Due to Contamination
Disconnect systems
Careful training
Patient selection
Assessment of home environment

30. Exit Site Infections - Prevention
Staph aureus ESI occurs mainly in nasal carriers
Incidence can be reduced by treating with mupirocin (M)
(M) can be given intranasally twice daily x 5 days each month, or
Applied (M) to exit site intermittently or daily as part of exit site care

31. S aureus CAPD related infections are associated with nasal carriage
S. aureus episodes/year
Data from Lye et al, Nasal carriage defined as min of 2 of 3 NC +ve

32. Effect of S aureus prophylaxis on prevention of S aureus peritonitis
S aureus peritonitis/year
Perez-Fontan
Mupirocin
Study Group
Bernardini
Thodis

33. Exit site/Tunnel and Outcomes
Bunke et al, KI 52: , 1997

34. Exit site/Tunnel and Outcomes
Bunke et al, KI 52: , 1997

35. Exit site/Tunnel and Outcomes
Bunke et al, KI 52: , 1997

36. Tunnel Ultrasonography
Vychytil et al, AJKD 33:722-27, 1999
Indications
Exit site infection (S. Aureus)
Follow up of tunnel infection
Peritonitis with exit site infection
Recurrent/persistent peritonitis
No indications
Routine screening
Search for foci in absence of ESI
Peritonitis without ESI
Tunnel pain with no other signs or symptoms

37. Peritonitis Rates Prevention is a realistic goal. Proof:
Japan 1:45 to 1:60 patient/months
Taiwan 1:35 to 1:45 patient/months
Europe 1:26 to 1:38 patient/months
Singapore 1:28 patient/months
Mexico 1:24 to 1:26 patient/months

38. Peritonitis Rates 50% of patients account for 90% of infections
Crabtree et al, ASAIO 45:574-80, 1999; Golper et al AJKD 28:428-36, 1996
50% of patients account for 90% of infections
Patients with one infection episode are more likely to have another than those with none
Most “repeat offenders” develop their infection early in the course of therapy: The earlier in dialysis history an infection develops, the more infection prone the patient continues to be.
A high risk period for ESI/TI is in the 12 months post implant.

39. S. Aureus Nasal Carriage
JASN 7:2403-8, 1996
Multicenter study in 9 European countries
1144 CAPD patients screened
267 (23%) carriers of S.Aureus (2 +ve swabs)
JASN 9:669-76, 1998
Single center prospective
76 patients cultured monthly for 3 years
One positive culture in 65.8% of all patients, 73% of diabetics, 72% of immunosuppressive Rx, 59% of others

40. Carriers State and Infection
Vychytil et al, JASN 9: , 1998

41. Staph Aureus Prophylaxis
Bernardini et al, AJKD 27: , 1996

42. EXIT SITE INFECTION (ESI)
DEFINITIONS
Acute ESI - purulent exit site drainage
Additional features include redness, tenderness, edema and granulation tissue

43. Chronic Exit Site Infection
ESI is chronic if it persists > 4 weeks
Often there is crusting or scabbing
Exuberant tissue, pus, redness With therapy improvement;
epithelium spreads over
granulation

44. Tunnel Infection
Redness, edema and/or tenderness over the subcutaneous tunnel
Often, there is associated ESI but some cases are occult
May need ultrasound to diagnose

45. Exit Site Management Antibiotics Intensified local care
Local debridement

46. Exit Site Management Local Debridement or Exteriorisation of cuff
Can involve shaving external catheter cuff or revising tunnel
Results are variable and many prefer catheter removal

47. Exit Site Infection PREVENTION
Staph aureus ESI occurs mainly in nasal carriers
Incidence can be reduced by treating with mupirocin (M)
M can be given intranasally twice daily x 5 days each month
Some apply M to exit site intermittently or daily as part of exit site care

48. Summary Keys to low infection rates include:
Experienced personnel and careful training
Minimize use of manual spike systems
Continuous monitoring of infection rates and organisms
Protocols for prevention, such as exit site mupirocin for S. aureus

49. Infectious Complications Predictable and Preventable!