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PubMedDate not supplied

Increased severity of Escherichia coli peritonitis in peritoneal dialysis patients independent of changes in in vitro antimicrobial susceptibility testing.

OBJECTIVE: Despite improvements in peritoneal dialysis (PD) technique, peritonitis continues to be one of the most frequent complications of PD. Nonresolving peritonitis remains a risk for severe anatomical peritoneal changes that may limit the viability of the membrane for dialysis purposes. We have observed remarkably poor outcome of peritonitis caused by Escherichia coli in the past 6 years. With its very low response rate to broad-spectrum antibiotics, the increased severity of E. coli peritonitis deteriorates peritoneal function and affects patient outcome. DESIGN: Retrospective study. SETTING: Two large PD units in two university hospitals. PATIENTS AND METHODS: The total number of patients reviewed was 456. The records of 49 E. coli peritonitis episodes were studied.The observation period started in 1980 and ended in March 2001. Sixteen males and 19 females were included. Severity was defined in terms of days of peritoneal inflammation, lack of response to a potentially useful antibiotic, requirement for catheter removal, and/or laparotomy. Study cases (study group) were those episodes appearing after 1996 (when the first severe cases appeared) and historic controls were episodes occurring before 1996. RESULTS: In the study group, 18 peritonitis episodes developed in 15 patients. In the control group, 31 peritonitis episodes developed in 20 patients. There were no significant differences in clinical presentation; however, the outcome was significantly poorer for the later period. A severe outcome occurred in 50% of study versus 10% of control patients. In fact, 68% of the episodes registered before 1996 were cured in 3 days or less. Concurring with this trend, the numbers of surgical interventions and catheter removals were also higher in the study group. Strikingly, E. coli did not show changes in in vitro susceptibility testing to antibiotics, although the in vivo response was much worse. CONCLUSIONS: We describe a change in the virulence of E. coli peritonitis episodes over the past 5 years leading to a high percentage of treatment failure, which does not depend on antibiotic sensitivity and seems to be dependent on changes in host response mechanisms.

Adult↗
PubMedDate not supplied

Procalcitonin and conventional markers of inflammation in peritoneal dialysis patients and peritonitis.

OBJECTIVES: To determine the significance of a newly described marker of inflammation procalcitonin (PCT), and to investigate its relationship to conventional markers of inflammation, such as C-reactive protein (CRP), fibrinogen, and erythrocyte sedimentation rate (ESR), in patients on peritoneal dialysis (PD) and with peritonitis. DESIGN: A prospective, observational clinical study. SETTING: The Nephrology Division of a University-affiliated teaching hospital. PATIENTS AND METHODS: 51 consecutive patients on PD were included in the study. Of this number, 16 developed peritonitis during the observational period. Baseline PCT, CRP, and fibrinogen concentrations and ESR of 51 PD patients were determined at a time point (TB) prior to any evidence of infection. These results were compared with laboratory values from 74 hemodialysis patients and 34 nonuremic control subjects. All PD patients then were followed prospectively for evidence of peritonitis. In addition to routine blood tests, including hemoglobin and leukocyte count, and routine biochemical tests, blood samples were taken to measure PCT, CRP, and fibrinogen concentrations and ESR at the time (T0) when patients first were diagnosed with PD peritonitis and also on the 4th (T4) and the 14th (T14) days after treatment for peritonitis was initiated. PCT was assayed by immunoluminometry. RESULTS: No significant difference was observed between baseline median serum PCT concentrations in PD and hemodialysis patients; however, in both groups, baseline median PCT concentrations were significantly higher than those of nonuremic controls (p < 0.05). The 16 patients on PD who developed peritonitis had 21 PD peritonitis episodes during the study period. The increased PCT concentration observed at T0 in PD peritonitis episodes decreased with therapy, and this change was statistically significant (p < 0.05). In a receiver operating characteristic curve analysis for peritonitis, the area under the curve (AUC) for PCT was 0.80, which was significantly lower than the AUC for CRP and greater than the AUCs for fibrinogen and ESR. The sensitivity of PCT for peritonitis was lower than the sensitivity of conventional markers of inflammation; however, the specificity of PCT was higher. CONCLUSIONS: Median serum PCT concentration in PD patients was significantly higher than in nonuremic controls but not hemodialysis patients. Serum PCT concentrations may serve as a useful adjunct to traditional markers of inflammation in detecting and monitoring inflammation and peritonitis in PD patients.

Adult↗
PubMed2006

Peritonitis during the first year after commencement of peritoneal dialysis has an impact on technique survival and patient morbidity.

The timing of the first episode of peritonitis in peritoneal dialysis (PD) might have some special characteristics and may depend on many factors such as a patient's attitudes, age, comorbidity, or training capacity. It may also have a significant impact on further peritonitis episodes and technique failure. We retrospectively analyzed data for 168 PD patients who were undergoing continuous ambulatory PD by a twin-bag system, automated PD, or in-center intermittent PD over 12 years. There were 121 cases of peritonitis recorded in 60 patients, with an overall peritonitis rate of 1 episode per 45.75 patient-months. The mean time to the first episode of peritonitis after commencement of PD was 26.4 +/- 22 months (range: 1-110 months). In 20 patients, a first peritonitis episode presented rather early--during the first 12 months on PD (group A)--and in 27 patients, a first episode presented rather late-after at least 24 months on PD (group B). Group A had lower technique survival (30.4 +/- 26.5 months), were more prone to further episodes of peritonitis during follow-up, and had a total peritonitis rate of 1 episode per 14.85 patient-months. In group B, technique survival was longer (69.3 +/- 33.8 months), and the total peritonitis rate was 1 episode per 45.68 patient-months. We observed no differences between the two groups in comorbidity, age, or PD modality. These results indicate that patients with early-onset peritonitis are prone to making mistakes during connection, resulting usually in infection with gram-positive pathogens. These patients may present repeated peritonitis episodes and experience decreased technique survival.

Adolescent↗
PubMed2006

Aseptic peritonitis in a peritoneal dialysis patient.

INTRODUCTION: Patients who have repeatedly sterile peritoneal fluid cultures despite elevated peritoneal fluid white cell count should be evaluated for disorders other than usual bacterial peritonitis. Intra-abdominal pathology was responsible for less than 6 percent of cases of peritonitis. Still, the clinical outcome is these situations are much worse than in other commoner causes. CASE REPORT: A 25-year-old male non-diabetic patient in PD started his complains with diffuse abdominal pain with spontaneous remissions and exacerbations, anorexia and vomiting with 3 days evolution. Laboratory results with persistent culture-negative peritoneal fluid results seemed compatible with the diagnosis of aseptic peritonitis. However, clinical status progression and peritoneal fluid amylase levels above 50 UI/L led to perform an abdominal ultrasound that showed a painful non-compressible tubular structure with a diameter of >6 mm at the base of the cecum. The patient was then submitted to a laparotomy with appendix removal. DISCUSSION: When assessing a patient with abdominal pain and clear or cloudy but aseptic peritoneal liquid, causes other than peritonitis should be excluded. Under antibiotic therapy, their clinical picture and evolution may be masked, delaying surgical resolution. In appendicitis, this delay may lead to perforation and consequent faecal peritonitis. All patients should be screened for peritoneal fluid amylase levels in order to differentiate bacterial peritonitis from intra-abdominal pathology. In all cases similar to the present one, an abdominal US/CAT scan should be promptly made.

Adult↗
PubMed1983

Irrigation of the peritoneal cavity and local antibiotics in the treatment of peritonitis.

Peritonitis was induced in the Sprague-Dawley rats by the implantation of gelatin capsules containing 0.3 milliliter of human fecal suspension into the peritoneal cavity. The rats were then treated with systemic antibiotics or peritoneal irrigation with normal saline solution alone or cephalotin solution, 2,000 micrograms per liter, or both. The results show that peritoneal irrigation with normal saline solution or with cephalotin alone was ineffective, even though the cephalotin concentration used inhibited the growth of all bacterial species isolated during the free stage of peritonitis in vitro. Systemic antibiotics alone as well as in combination with peritoneal irrigation significantly improved the survival rate, p less than or equal to 0.05 and p less than or equal to 0.02, respectively. However, only systemic antibiotics in combination with peritoneal irrigation resulted in a significant cure rate compared with the control group and the group treated with systemic antibiotics alone, p less than or equal to 0.002. There was no increase in the cure or survival rates when antibiotics were added to the peritoneal irrigation fluid. In the second experiment, seven of ten rats treated with systemic antibiotics survived, but only two rats had no intraperitoneal abscesses at autopsy. Intraperitoneal application of antibiotics did not improve these results: six rats survived, and one rat was cured. We conclude that peritoneal irrigation alone is ineffective in the treatment of peritonitis. The addition of peritoneal irrigation to systemic antibiotic therapy, however, resulted in a significantly increased cure rate. The addition of antibiotics to the irrigant does not further improve the results, and local antibiotics are not more effective than systemic antibiotics. We believe that benefit of peritoneal irrigation is due to its mechanical effect.

Animals↗
PubMed1995

[Peritonitis among patients treated with continuous ambulatory peritoneal dialysis].

A retrospective study of 51 consecutive patients treated with continuous ambulatory peritoneal dialysis (CAPD) during a total of 736 months is presented. Forty-one episodes of peritonitis were found. Thirty-three patients did not experience peritonitis. One patient had six episodes of peritonitis. The time to first and second episode of peritonitis was 487 days (16.2 months) and 1005 days (33.5 months) respectively. The incidence of peritonitis was 0.67 episodes per patient-year, and was not influenced by either sex, diabetes or previous abdominal surgery. The time to the first episode of peritonitis was equal in patients suffering from one vs two or more episodes of peritonitis. Two patients suffered from tunnel infection. Initial treatment with vancomysin and gentamycin (before knowing the results of microbiological culturing) was adequate in 90% of the peritonitis episodes. Sterile peritonitis was found in 12% of the cases. No relapse of peritonitis was observed. Six patients suffered from eleven cases of reinfection. An optimal surgical strategy as well as vancomycin plus gentamicin treatment of peritonitis are advised when a reduction in infection rates is required

Adolescent↗
PubMed1993

Poor response to oral ciprofloxacin in the treatment of peritonitis in patients on intermittent peritoneal dialysis.

OBJECTIVES: To assess the clinical value of oral ciprofloxacin in the treatment of peritonitis in an intermittent peritoneal dialysis (IPD) population. DESIGN: Open nonrandomized prospective study. SETTING: Nephrology Peritoneal Dialysis Unit in a tertiary care, teaching hospital of the University of Toronto. PATIENTS: Subjects were participants of the IPD program with an acute episode of peritonitis defined as at least two of the following: 1. signs and symptoms of peritonitis, 2. cloudy peritoneal fluid with a white blood cell count of > 100/microL, 3. demonstration of bacteria in peritoneal effluent by gram stain or culture. Ten patients were enrolled in the study, but two were withdrawn because of side effects and growth of a resistant bacteria. INTERVENTIONS: Ciprofloxacin 750 mg po q12h for 2 doses, then 750 mg daily or 500 mg twice daily for 10 days. MAIN OUTCOME MEASURES: Efficacy was determined by clinical and microbiological assessment. Cure was defined as resolution of signs and symptoms with eradication of the causative organism. Peritoneal effluent and blood samples were analyzed for ciprofloxacin concentration. RESULTS: Ciprofloxacin was effective in treating only one of ten episodes of peritonitis. Seven patients were defined as microbiological failures (persistence or relapse of organisms). The signs and symptoms of peritonitis improved in 2 patients, but the remaining 5 failed clinically. Only Gram-positive organisms were cultured. CONCLUSIONS: Ciprofloxacin cannot be recommended for the treatment of intermittent peritoneal dialysis-related Gram-positive bacterial peritonitis.

Acute Disease↗
PubMed1997

Peritoneal dialysis effluent, cytokine levels, and peritoneal mesothelial cell viability in CAPD: a possible relationship.

Recent studies have emphasized the role of peritoneal mesothelial cell (PMC) in peritoneal immune defense mechanisms in continuous ambulatory peritoneal dialysis (CAPD). The aim of this study was to evaluate a possible relationship between peritoneal dialysis effluent (PDE), cytokine (Cy) levels, and PMC viability and their impact on peritonitis morbidity. Fifteen patients initiating CAPD for end-stage renal failure participated in the study. The following parameters were evaluated: (1) the levels of interleukin-1 beta (IL-1 beta), tumor necrosis factor-alpha (TNF-alpha), interferon-gamma (IFN-gamma), interleukin-6 (IL-6), and interleukin-8 (IL-8) in PDE samples taken 7 days after initiating CAPD, at the end of the first, third, and sixth month of CAPD (determined by a solid phase enzyme amplified sensitivity immunoassay EASIA); (2) peritoneal mesothelial cell viability [determined by the release of lactate dehydrogenase (LDH) and by trypan blue extrusion test] by isolating and culturing peritoneal mesothelial cells at the moment of the placement of the peritoneal catheter and at the sixth month of CAPD; (3) peritonitis incidence during the 24 months after starting CAPD. At the first month of CAPD in all patients there was a slight increase in PDE IL-1 beta and TNF-alpha levels, while other Cy were almost undetectable. Time course studies showed that in 10 patients (Group I) there was a significant increase in PDE levels of IL-6, IL-8, and INF-gamma (p < 0.0005) in comparison to other Cy and a good PMC viability. In the other 5 patients (Group II) there were higher PDE levels of IL-1 beta and TNF-alpha (p < 0.0005). This was associated with a marked reduction in PMC viability determined by the release of LDH and by the trypan blue extrusion test. During the 24 months after starting CAPD, incidence of peritonitis was one episode per 24 patient-months in Group I and one episode per 9.2 patient-months in Group II. Our results show that from the beginning of CAPD there are distinct patterns of Cy in the PDE that correlate with a different PMC viability and peritonitis morbidity. Thus the analysis of the above-mentioned parameters may be useful in the early identification of the risk of peritonitis, thus allowing preventive measures.

Cell Survival↗