Le Peritoniti

Le Peritoniti
Flavia Caputo
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. 2009 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:
• Drop-out per peritonite: 5-10% dei paz/anno
• Peritonite come causa di drop-out: 25- 40%
• Degenza ospedaliera: 5 giorni/anno paziente
in trattamento
• Mortalità per peritonite 2-12%
Peritonitis as a Cause of Peritoneal Dialysis
Technique Failure
Study
Study period
Study patients
Initial Cure
Tecniques
failure due to
peritonitis
Kavanagh et
al., 2004
1992-2002
All adult
patients in
Scotland
75%
42.6%
Johnson et al.,
2007
2004-2006
All centers in
Australia
78% (2006 data 29%
only)
Davenport,
2009
2002-2003
All centers in
London, UK
>80% in only 2
of 12 units
41.7%
Mactier R.Perit Dial Int. 2009 May-Jun;29
Factors affecting the rate of
tecnique failure:
Kavanagh D, Prescott GJ, Mactier RA, NDT 2004;19
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: 2010.
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
other’s work groups. Projected time table: completion by mid 2009. The committee will be
asked if they agree with this approach.
First published in 1983 and revised in 1989,
1993, 1996 and 1995
2010 UPDATE
Every program should regularly monitor
infection rates, at a minimum, on a yearly basis
Opinion
ISPD 2010
The center’s 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, 40. 373
Choi KH, Perit Dial Int 2004: 424-432
ISPD 2010
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
Study (Ref.
Study
period
Study
location
Patients (n)
PD system
Months
between
Comparison of Peritonitis Rates in Peritoneal Dialysis
episodes of
peritonitis
(PD) Patients Using the Double-Bag Disconnect System
Monteon et al.,
1998 (8)
-
Multicenter; 147
Mexico
CAPD
24,8
Li et al., 1999 (9)
-
Multicenter; 120
Hong Kong
CAPD
33,5
Huang et al.,
2001 (10)
1993–2001
Single
center;
Taipei,
Taiwan
117
CAPD
45,4
Katz et al., 2001
(11)
1998-1999
Single
center;
Soweto,
South Africa
84
CAPiva a 45
D
27,9
Kavanagh et al.,
2004 (5)
1999–2002
All centers
in Scotland
1205
APD/CAPD
19,2
Johnson et al.,
2007 (6
2006
All centers
in Australia
2021
APD/CAPD
21,0
Davenport, 2009
(7)
2002–2003
All centers
in London,
863 at the
end of 2002
APD/CAPD
15,9
Esperienza del nostro centro
Dati 2008
Dati 2009
o 25 episodi in 66 pazienti
 20 episodi in 58 pazienti
o 1 episodio ogni
25mesi/pz
 1 episodio ogni 29
mesi/pz
o 0.48 ep/anno/paz.
 0.41 ep/anno/paz.
ISPD 2010
PERITONITIS
Peritoneal dialysis patients presenting with cloud
effluent OR abdominal pain
Diagnosis is confirmed with cell count and culture
1. ≥100 WBC per mcL with more than 50% PMN
2. Positive culture
EVIDENCE
ISPD 2010
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
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
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
Vie di contaminazione e microrganismi
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
Colibacilli (25/30%)
Transmurale
Enterobacteriacee
Anaerobi
Ematogena
Streptococchi (5/10%)
M. Tubercolosis
Ascendente
Lactobacilli (2/5%)
Funghi
Vie di contaminazione
ESOGENA
ENDOGENA
• Endoluminale
30-40%
• Periluminale
20-30%
Adeguato training
• Transmurale
25-30%
• Ascendente
2-5%
• Ematogena/Linfatica
5-10%
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
L’utilizzo 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
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 dell’ESI e del TI
Vie di contaminazione
ESOGENA
• Endoluminale
Adeguato training
30-40%
• Periluminale
ESI / TI
20-30%
Carriage Staph. Aureus
ENDOGENA
• Transmurale
25-30%
• Ascendente
2-5%
• Ematogena/Linfatica
5-10%
Peritonitis associated with exit-site
infections
B. Piraino- AJKD, 1996
Mupirocin
Gentamicin
Pvalue
Episodes per year at risk
P. aerginosa
0.04
0
0.14
Other Gram
negative
0.11
0.02
0.02
0
0.03
NS
Fungal
0.04
0.03
NS
Peritonitis overall
0.52
0.34
0.03
S. aureus
Bernardini J, Piraino B, JASN 2005 Feb; 16: 539-45
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: 539-45
Vie di contaminazione
ESOGENA
• Endoluminale
Adeguato training
30-40%
• Periluminale
Exit-siteinfection
20-30%
CarriageStaph. Aureus
ENDOGENA
• Transmurale Profilassi antibiotica
Evitare la stipsi
25-30%
• Ascendente
2-5%
• Ematogena/Linfatica
5-10%
ISPD 2005
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!
Vie di contaminazione
ESOGENA
• Endoluminale
Adeguato training
30-40%
• Periluminale
Exit-siteinfection
20-30%
CarriageStaph. Aureus
ENDOGENA
• Transmurale Profilassi antibiotica
Evitare la stipsi
25-30%
• Ascendente Fistole vaginali
Ascessi
2-5%
retroperitoneali
• Ematogena/Linfatica
5-10%
Vie di contaminazione
ESOGENA
ENDOGENA
• Endoluminale
Adeguato training
30-40%
• Periluminale Exit-siteinfection
20-30%
CarriageStaph. Aureus
antibiotica
• Transmurale Profilassi
Evitare la stipsi
25-30%
• Ascendente Fistole vaginali
Ascessi
2-5%
retroperitoneali
• Ematogena/Linfatica
Profilassi antibiotica
5-10%
in corso di procedure
invasive
ISPD 2005
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
A Bundle of Care of Clinical Practice to Reduce Risk of peritonitis
Prevention of touch
contamination
• Disconnect systems
• Prompt antibiotic therapy after accidental
contamination
• Hand disinfection technique
• Patient training and periodic retraining
• Patient selection
Prevention of
catheter-related
infection
• 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 enteric
infection
• Avoid constipation
• Empty peritoneal cavity and prophylactic
antibiotics before endoscopy, colonscopy, or
barium enema
Prevention of
recurrent peritonitis
• 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
Mactier R.Perit Dial Int. 2009 May-Jun;29
ISPD 2010
Therapy should be initiated as soon is possible,
after appropriate microbiological specimen have
been obtained
PATIENT EDUCATIONAL
ISPD 2010
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
6-8 hours
0-6 hours
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
Determine and prescribe ongoing antibiotic treatment
Ensure follow-up arrangements are clear or patient
admitted
Await sensitivity results
INITIAL MANAGEMENT OF PERITONITIS
ISPD 2010
• 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
ISPD 2010
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
EMPIRIC THERAPY
Cefazolin
Or
Vancomicin
and
Ceftazidime
Or
Gentamicin
N.B. Short-term use of aminoglycoside therapy appears to be
safe for the risk of ototoxicity (once day dose)
ISPD 2010
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 gramnegative
Yeung SM, Walker SE, Tailor SA, Perit Dial Int 18: 371, 2004
ISPD 2010
ISPD 2010
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 3-5
- 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
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 3-5
- 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
ISPD 2010
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 3-5
- 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
Culture negative on day 1 & 2
Continue initial therapy
Day 3: Culture still negative
Clinical assessment
Repeat PD Fluid white cell count and differential
Infection resolving
Patient improvement clinically
Continue initial therapy for 14 days
Infection not resolving
Special culture technique for
unusual causes (e.g. viral,
mycoplasma, mycobacteria,
legionella). Consider fungi
Now culture positive
Adjust therapy according to
sensitivity patterns
Duration of therapy based on
organism identified
Still culture negative
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
Pseudomonas species on culture
Without catheter infection
(exit-site/tunnel)
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
Clinical
improvement
- Continue
antibiotics;
- duration of
therapy: 21
days
No clinical
improvement
- Re-culture & evaluate
- Consider changing
antibiotics
No clinical
improvement
by 5 days on
appropriate antibiotics,
remove catheter
With catheter infection(exitsite/tunnel) current or prior to
peritonitis
Catheter removal*
Continue oral and/or systemic
antibiotics for at least two weeks
ISPD 2010
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
Clinical improvement
- Continue antibiotics;
- Minimum 21 day
treatment
Assess clinical improvement at
days 3-5: - Symptoms resolved
- Bags clear
No clinical
improvement by 5
days on appropriate
antibiotics - remove
catheter
Clinical improvement
- Continue antibiotics:
21- 28 days
treatment
ISPD 2010
Polymicrobial peritonitis: days 1-3
Multiple gram-negative organisms
or mixed gram negative/gram
positive
- consider GI problem
Change therapy to metronidazole in
conjunction with ampicillin,
ceftazidime or aminoglycoside
Obtain urgent surgical assessment
In case of laparotomy indicating
intraabdominal pathology/abscess,
remove catheter*
Continue antibiotics – 14 days
Multiple gram-positive organisms
- Touch contamination
- Consider catheter infection
Continue therapy based on
sensitivities
Without exit
site or tunnel
infection –
continue
antibiotics
Duration of
therapy
minimum 21
days based on
clinical
response
With exit site
or tunnel
infection,
remove
catheter*
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
ISPD 2010
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
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 nontuberculosis mycobacteria, such as M. fortuitum, M. avium, M.
abscessus and M. chelonei
ISPD 2010
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
\
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
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
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
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