Case report: Ulocladium spp. (mold) catheter-related peritoneal dialysis-associated peritonitis.

The CARI guidelines. Evidence for peritonitis treatment and prophylaxis: peritoneal dialysis-associated peritonitis in children.

Fungal peritonitis is less commonly seen than bacterial peritonitis in patients undergoing peritoneal dialysis (PD), but it is a serious complication with high morbidity and mortality. It often results in catheter loss and modifying therapy from PD to hemodialysis. The causative organisms are often Candida species. In this report, a PD-associated peritonitis caused by Wickerhamomyces anomalus (Candida pelliculosa), a rare fungal infection agent with increasing clinical importance by causing different clinical pictures was presented. An outpatient peritoneal fluid culture was sent from a 48-yearold male patient, who had been undergoing continuous peritoneal dialysis (CAPD) for 9 years, due to abdominal pain and blur in peritoneal fluid during dialysis. The patient admitted to the emergency department four days later due to the persistence of his complaints. A sample of peritoneal fluid was taken in the emergency department and sent to the laboratory for microbiological analysis. In the direct microscopical examination of the peritoneal fluid; cell number was determined as 210/mm3, and no microorganisms were seen in the Gram and methylene blue staining. The patient was admitted to the nephrology service with a pre-diagnosis of PD-associated peritonitis. Enterobacter aerogenes was grown in the peritoneal fluid culture which was sent from the dialysis outpatient clinic four days ago. The peritoneal fluid sample sent from the emergency department was inoculated on 5% sheep blood , EMB and chocolate agars and no growth was detected. As the patient's complaints and peritoneal fluid leukocyte count continued to increase, peritoneal fluid cultures were repeated and recurrent growth of yeast was detected in cultures. The yeast was identified as Candida pelliculosa by matrix assisted laser desorption ionization time-of-flight mass spectrofotometry (MALDI-TOF) VITEK®MS (bioMerieux, France). The species identification was confirmed by sequencing the target ITS gene regions on the rRNA and the isolate was identified as 100% Wickerhamomyces anomalus (sexual reproduction form of Candida pelliculosa, teleomorph). The reference microdilution method was performed according to the recommendations of the Clinical and Laboratory Standards Institute (CLSI) in order to test the antifungal susceptibility. After 24 hour incubation, the minimal inhibitory concentrations (MIC) were determined as 0.03 μg/ml for amphotericin B, 0.125 μg/ml for caspofungin 0.125 μg/ml for voriconazole, 0.03 μg/ ml for itraconazole and 4 μg/ml for fluconazole. Fluconazole and anidulafungin were started for the treatment of fungal peritonitis. The patient's peritoneal dialysis catheter was removed and hemodialysis was applied to the patient. Clinical and laboratory symptoms regressed with antifungal therapy and the patient's anidulafungin treatment was discontinued for 14 days after the catheter removal. In conclusion, in patients undergoing CAPD, as in our case, fungal pathogens should also be considered although it is rare, when there is no laboratory and clinical improvement, and the response to treatment is not complete in PD-associated peritonitis to prevent delays in diagnosis and treatment.

After completing this article, readers should be able to: 1. List the indications for peritoneal dialysis (PD) in neonates. 2. Delineate neonates who are poor candidates for PD. 3. Review the parameters of the PD prescription. 4. Review special nutrition considerations for neonates who are undergoing PD. 5. Review potential complications of PD in neonates. Peritoneal dialysis (PD) is generally considered the optimal dialysis modality for neonates. PD allows for the slow removal of fluid and solutes while avoiding hemodynamic instability. It is technically simple and, when necessary, can be performed continuously in the neonate hospitalized in the neonatal intensive care unit. In this review, we discuss the salient features of neonatal PD, including the rationale and indications for PD, its advantages and disadvantages, the PD prescription, nutritional considerations for the neonate undergoing PD, and the management of peritonitis. ### Rationale and Indications for Dialysis in Neonates Acute renal failure is common, occurring in as many as 23% of neonates hospitalized in neonatal intensive care units. There are excellent reviews in the literature that discuss the causes, pathophysiology, and medical management of acute renal failure in the neonate (see Acute Renal Failure Management in the Neonate in this issue of NeoReviews ). A partial list of the causes of acute renal failure in neonates is provided in Table 1. | Prerenal | || | | | Intrinsic | | | | Postrenal | | | Table 1. Causes of Acute Renal Failure The decision to initiate dialysis typically is necessitated by recalcitrant electrolyte abnormalities, worsening uremia, fluid overload, persistent acid-base abnormalities, …

Peritoneal Dialysis Access Associated Infections.

Peritonitis is a common and severe complication in peritoneal dialysis (PD). Detailed recommendations on the prevention and treatment of PD-associated peritonitis have been published by the International Society for Peritoneal Dialysis (ISPD), but there is a substantial variation in clinical practice among dialysis units. Prophylactic antibiotics administered before PD catheter insertion, colonoscopy, or invasive gynecologic procedures, daily topical application of antibiotic cream or ointment to the catheter exit site, and prompt treatment of exit site or catheter infection are key measures to prevent PD-associated peritonitis. When a patient on PD presents with clinical features compatible with PD-associated peritonitis, empirical antibiotic therapy, with coverage of both Gram-positive and Gram-negative organisms (including Pseudomonas species), should be started once the appropriate microbiologic specimens have been obtained. Intraperitoneal is the preferred route of administration. Antifungal prophylaxis, preferably oral nystatin, should be added to prevent secondary fungal peritonitis. Once the PD effluent Gram stain or culture and sensitivity results are available, antibiotic therapy can be adjusted accordingly. A detailed description on the dosage of individual antibiotic can be found in the latest recommendations by the ISPD. The duration of antibiotics is usually 2-3 weeks, depending on the specific organisms identified. Catheter removal and temporary hemodialysis support is recommended for refractory, relapsing, or fungal peritonitis. In some patients, a new PD catheter could be inserted after complete resolution of the peritonitis. PD catheter removal should also be considered for refractory exit site or tunnel infections. After the improvement in clinical practice, there is a worldwide trend of reduction in PD-associated peritonitis rate, supporting the use of PD as a first-line dialysis modality.

The CARI guidelines. Evidence for peritonitis treatment and prophylaxis: indications for the use of urokinase in peritoneal dialysis-associated peritonitis.

To determine if discordance in culture results between the effluent and the tip of the peritoneal catheter had an effect on outcome in patients whose peritoneal dialysis (PD) catheter was removed mostly for nonresolving peritonitis. Reasons for and outcomes of PD catheter removal were also analyzed. We retrospectively reviewed the charts of all PD patients with recent peritonitis for which the PD catheter was removed between 1 January 2003 and 30 April 2009. Data including basic demographics, the organism isolated from effluent and from the PD catheter, reason for catheter removal, duration of hospitalization, and development of intra-abdominal collection were extracted as well as mortality within 8 weeks post removal and return to PD after catheter removal. Fungal peritonitis was the most common reason for PD catheter removal. 20% of the patients developed an intra-abdominal collection. Mortality related to PD catheter removal was low (3/53; 5.6%). The patients (n =53) were divided into 3 groups: group 1 (n = 20) had the same culture result of effluent and catheter tip; group 2 (n = 19) had a negative culture of the catheter tip; and group 3 (n = 14) had different organism(s) growing from effluent and catheter tip. We found no remarkable differences in duration of PD, catheter age, peritonitis rate, or mortality. Patients in group 1 had significantly more fungal peritonitis than the other 2 groups. In only 4 of the 53 patients (7.5%), the anti-infectious management was changed according to the catheter culture result. Discordant results between catheter tip culture and effluent culture did not have a significant impact on patient outcome. Sending PD catheters for culture has limited clinical importance.

Background: The use of Peritoneal Dialysis (PD) catheters is an attractive option for many patients who require dialysis. These PD catheters are most commonly placed with a standard minimally invasive technique. However, multiple techniques can be applied to remove these catheters. At our institution, under a single surgeon, we perform PD catheter removals in the operating room under mild to moderate sedation. Sustained traction is applied to the PD catheter until the catheter is released from the cuffs and easily slides off with both the superficial and deep cuffs left behind. In the event of catheter breakage, general anesthesia is induced and the PD catheter will then be removed in the usual open approach. The objective of this study was to determine if the pull technique can be safely employed for PD catheter removal with no increased complication rate. Methods: A case series study was performed at a community teaching hospital. Thirty-one patients underwent PD catheter removal from July 2017 to December 2021 for any indication. Ten patients had their PD catheter removed secondary to peritoneal dialysis-related infections (32%), 12 patients had their PD catheter removed due to mechanical failure. Postoperative infection rate and complication rate after removal of PD catheter using the sustained traction technique was measured. Results: There were no postoperative infections necessitating cuff removal due to a retained cuff after removing the PD catheter in our patient cohort. The mean time for catheter removal with the sustained traction technique was 4 minutes. Only one patient required general anesthesia and conversion to open removal technique due to catheter breakage as the patient had an extension tubing with additional connection (3%). Conclusion: Our series shows that the sustained traction technique can be safely employed for PD catheter removal under minimal sedation with no increased complication rate. Background: The use of Peritoneal Dialysis (PD) catheters is an attractive option for many patients who require dialysis. These PD catheters are most commonly placed with a standard minimally invasive technique. However, multiple techniques can be applied to remove these catheters. At our institution, under a single surgeon, we perform PD catheter removals in the operating room under mild to moderate sedation. Sustained traction is applied to the PD catheter until the catheter is released from the cuffs and easily slides off with both the superficial and deep cuffs left behind. In the event of catheter breakage, general anesthesia is induced and the PD catheter will then be removed in the usual open approach. The objective of this study was to determine if the pull technique can be safely employed for PD catheter removal with no increased complication rate. Methods: A case series study was performed at a community teaching hospital. Thirty-one patients underwent PD catheter removal from July 2017 to December 2021 for any indication. Ten patients had their PD catheter removed secondary to peritoneal dialysis-related infections (32%), 12 patients had their PD catheter removed due to mechanical failure. Postoperative infection rate and complication rate after removal of PD catheter using the sustained traction technique was measured. Results: There were no postoperative infections necessitating cuff removal due to a retained cuff after removing the PD catheter in our patient cohort. The mean time for catheter removal with the sustained traction technique was 4 minutes. Only one patient required general anesthesia and conversion to open removal technique due to catheter breakage as the patient had an extension tubing with additional connection (3%). Conclusion: Our series shows that the sustained traction technique can be safely employed for PD catheter removal under minimal sedation with no increased complication rate.

Background Fungal peritonitis causes significant mortality for patients on peritoneal dialysis (PD). Antibiotic exposure is a major risk factor for fungal peritonitis amongst PD patients. The 2016 and 2022 International Society for Peritoneal Dialysis (ISPD) Guideline recommends the use of antifungal prophylaxis in PD patients on antibiotics. There is still no consensus on the optimal approach to prevent secondary fungal peritonitis. This study's objective was to evaluate the impact of antifungal prophylaxis on patients with PD-associated peritonitis as secondary prevention for fungal peritonitis. Methods This is a retrospective cohort study of patients on concomitant antifungal prophylaxis and those with no antifungal prophylaxis who had confirmed or suspected PD-associated peritonitis while on antibiotic therapy from 2018 to 2023. Descriptive analysis was used to compare the outcome of development of secondary fungal peritonitis. Side effects such as QTc prolongation are also described. Results Of the 101 patients with PD-associated peritonitis, there were 36 (35.6%) gram-positive infections, 24 (23.8%) gram-negative infections, 6 (5.9%) fungal infections, and 41 (40.6%) culture negative peritonitis. The most common isolates were Coagulase-negative Staphylococcus (14), eight of which were Staphylococcus epidermidis, followed by Pseudomonas aeruginosa (6). Among the 101 patients, 33 (32.7%) were co-prescribed with antifungal prophylaxis while 68 (67.3%) did not. Fluconazole 100 mg daily was the most common antifungal agent used (84.8%). Over a 1-year period, two patients developed secondary fungal peritonitis in patients with concomitant antifungal prophylaxis (6.1%; 95% CI: 0.74% to 20.23%), compared to 1 patient (1.5%; 95% CI: 0.037% to 7.92%) in patients without antifungal prophylaxis. Among 28 patients on fluconazole, 10 had repeat ECGs. Of these, 7 patients had a QTc greater than 460 ms (70%; 95% CI: 34.8% to 93.3%), and 3 were greater than 500 ms (30%; 95% CI: 6.7% to 65.2%). Conclusion Antifungal prophylaxis in the setting of PD-associated peritonitis does not correlate to fewer episodes of secondary fungal peritonitis. Increased QTc with azole use is a potential risk factor for cardiac arrhythmia. Disclosures All Authors: No reported disclosures

Introduction: Peritoneal dialysis-associated peritonitis (PDAP) is a serious complication of peritoneal dialysis, associated with significant morbidity, modality transition, and mortality. Here, we provide an update on the national burden of this significant complication, highlighting trends in demographics, treatment practices, and in-hospital outcomes of PDAP from 2016 to 2020. Methods: Utilizing a national all-payer dataset of hospitalizations in the USA, we conducted a retrospective cohort study of adult hospitalizations with a primary diagnosis of PDAP from 2016 to 2020. We analyzed demographic, clinical, and hospital-level data, focusing on in-hospital mortality, PD catheter removal, length of stay, and healthcare expenses. Multivariable logistic regression adjusted for demographic and clinical covariates was employed to identify risk factors associated with adverse outcomes. Results: There was a stable burden of annual PDAP admissions from 2016 to 2020. Healthcare expenditures associated with PDAP were high, totaling over USD 75,000 per admission. Additionally, our data suggest geographic inconsistencies in treatment patterns, with treatment at western and teaching hospitals associated with increased rates of catheter removal relative to northeastern and non-teaching centers and a mean cost of nearly USD 55,000 more in Western states compared to Midwest states. 23.2% of episodes resulted in the removal of the PD catheter. Risk factors associated with adverse outcomes included older age, higher Charlson comorbidity index scores, peripheral vascular disease, and the need for vasopressors. Conclusion: PDAP is a major cause of mortality among PD patients, and there is a vital need for future studies to examine the impact of hospital location and teaching status on PDAP outcomes, which can inform treatment practices and resource allocation.

To analyze the clinical characteristics and treatment outcomes of the first episode of peritoneal dialysis-associated peritonitis (PDAP) in patients receiving long-term peritoneal dialysis. The clinical data of patients with the first episode of PDAP in 4 general hospitals in Jilin Province from 2013 to 2019 were collected retrospectively. According to the duration of dialysis, the patients were divided into long-term (≥36 months) and short-term (< 36 months) dialysis groups for comparison of the clinical data, treatment outcomes and long-term prognostic events. A total of 625 patients with PDAP were enrolled, including 93 on long-term and 532 on short-term dialysis. Compared with those on short-term dialysis, the patients on long-term dialysis had significantly higher hemoglobin levels and lower glomerular filtration rates when the first episode of PDAP occurred (P < 0.05), were more susceptible to gram-negative bacterial infections (P < 0.05), and had significantly lower initial treatment response rate (P=0.009) and complete cure rate (P=0.018) and higher extubation rate (P=0.017). Multivariate logistic regression analysis showed that in patients on long-term dialysis, the risks of extubation and treatment failure for the first episode of PDAP were 3.05 times (OR: 3.05, 95%CI: 1.35-6.91, P=0.008) and 2.81 times (OR: 2.81, 95%CI: 1.45-5.44, P=0.002) those in patients with short-term dialysis, respectively. Fungal infection (OR: 45.40, 95%CI: 1.488-1385.5, P=0.029) and mixed bacterial infection (OR: 16.50, 95%CI: 1.106-246.123, P=0.042) were independent risk factors for treatment failure of the first episode of PDAP in patients on long-term dialysis. Maintenance peritoneal dialysis, technical failure, or all-cause mortality did not differ significantly between the two groups. Multivariate Cox regression analysis suggested that long-term dialysis was not an independent risk factor for technical failure (OR: 1.36, 95%CI: 0.84-2.19, P=0.206) or all-cause mortality (OR: 1.51, 95%CI: 0.97-2.35, P=0.068) in patients with PDAP. Compared with those on short-term dialysis, patients on long-term dialysis are prone to gram-negative bacterial infection when the first episode of PDAP occurs with worse treatment outcomes but similar long-term outcomes. Long-term dialysis is an independent risk factor of extubation and treatment failure for the first episode of PDAP, and fungal and mixed bacterial infections are independent risk factors for treatment failure of the first PDAP in patients with long-term dialysis.

Fungal peritonitis (FP) is an uncommon but serious complication of peritoneal dialysis (PD) and is associated with high morbidity and mortality. Although previous studies have demonstrated that abdominal pain and catheter in situ are associated with mortality in FP patients, the effect of early catheter removal on mortality remains largely unexplored. In this study, therefore, we not only determine the risk factors for mortality but also investigate the effect of immediate catheter removal on mortality in PD patients with FP. This retrospective study was conducted on 94 episodes of FP in 1926 patients that underwent PD at Yonsei University Health System from January 1992 to December 2008. Data including demographic characteristics, laboratory and clinical findings, management, and outcome were collected from medical records. Among a total of 2361 episodes of peritonitis, there were 94 episodes of FP in 92 patients, which accounted for 4.0% of all peritonitis episodes and occurred in 4.8% of patients. Mean age of patients was 52.1 years and mean duration of PD before contracting FP was 46.1 months. The presenting symptoms included turbid dialysate (93.6%), abdominal pain (84.0%), and fever (66.0%). Intestinal obstruction was complicated in 39 episodes (41.5%). 75% of FP was caused by Candida species, among which Candida albicans was the most common pathogen, accounting for 41.5% of all episodes of FP. The PD catheter was removed within 24 hours in 39 patients (41.5%), whereas catheter removal was performed between 2 and 9 days after the diagnosis of FP in 42 patients (44.7%). 27 patients (28.7%) died as a result of FP, 59 patients (62.8%) required a change to hemodialysis, and PD was resumed in 8 episodes (8.5%). In addition, the mortality rate was significantly higher in patients with delayed catheter removal (13/41, 31.7%) compared to patients with catheter removal within 24 hours (5/39, 12.8%) (p < 0.01). Multivariate logistic regression analysis revealed that delayed catheter removal, the presence of intestinal obstruction, and higher white blood cell counts in the blood and in the PD effluent were independently associated with mortality in FP patients. These results suggest that immediate catheter removal (i.e., within 24 hours after the diagnosis of FP) is mandatory in PD patients with FP.

Fungal peritonitis is a rare but serious complication in patients undergoing peritoneal dialysis (PD). We aimed to analyze the predisposing factors, clinical aspects, etiological agents, and treatment of fungal peritonitis in patients with PD in our hospital. The data of all patients with PD, who were followed-up between January 1995 and December 2009, were evaluated retrospectively. Twenty-one patients with fungal peritonitis were included into the study. Mean age was 46±13. Twelve of the 21 patients were females. Median PD duration was 48 (range 9 to 95) months. Candida species were the most common pathogens isolated from peritoneal effluent fluid (n: 16): Candida albicans (14), Candida rugosa (n: 1), and Candida glabrata (n: 1). The other involved fungi were Aspergillus species (n: 1), Saccharomyces species (n: 1), Acromonium species (n: 1), Fusarium species (n: 1), and Rhodotorula mucilaginosa (n: 1). The PD catheter was removed in all of the patients. Median time until the PD catheter removal was 1 (range 0 to 10) day. Before 2005, this duration was 4 (0-10) days, whereas after 2005 it was 0 (0-2) days (P: 0.001). Therapy with amphotericin B and fluconazole was continued after catheter removal in 19 and in 2 of the patients, respectively. As a result of fungal peritonitis, 19 patients were transferred to hemodialysis. Two patients died during the episode of peritonitis. Candida albicans was the most common pathogen. For the successful management of fungal peritonitis besides the antifungal therapy, peritoneal catheter removal was necessary in all of the patients.

With the implementation of best demonstrated clinical practices, peritonitis has become an infrequent complication of peritoneal dialysis in many centers around the world. Yet the gains in reduction in risk of peritonitis are not uniform. Most episodes of peritonitis do not require hospitalization and it is possible to achieve cure rates of 70%-80%. Some circumstances, however, necessitate the removal of the peritoneal dialysis catheter. These include patients with inadequate response to antimicrobial therapy, those with fungal peritonitis, or those with Staphylococcus aureus or Pseudomonas peritonitis with coexisting exit-site infection with the same organism. If the peritoneal dialysis catheter is removed in the presence of active intraperitoneal infection, replacement of the peritoneal dialysis catheter should be deferred by 2-4 weeks. However, simultaneous removal and replacement is possible in selected circumstances such as in patients with S. aureus or Pseudomonas peritonitis who also have exit-site infection with the same organism, after the intraperitoneal infection has responded to antibiotic therapy.

Despite progress in decreasing the incidence of and improving the therapy for bacterial peritonitis in patients receiving peritoneal dialysis, fungal peritonitis has emerged as a relatively common infection. Hospitalization, recent prior episodes of peritonitis, and antibacterial therapy appear to predispose patients to this infection. Clinically, fungal peritonitis cannot be differentiated from bacterial peritonitis except by gram stain and culture of the dialysate. The most commonly made serious error is the failure to initiate appropriate therapy quickly enough on the basis of these diagnostic parameters. For patients who no longer require dialysis, those for whom a change to hemodialysis is preferred, and those with concomitant life-threatening illness, the recommended therapy for fungal peritonitis is removal of the dialysis catheter and the institution of therapy with systemic antifungal agents. For patients who are hemodynamically and metabolically stable and for whom continued peritoneal dialysis is desirable, a trial of antifungal chemotherapy before removal of the catheter may be indicated.