Continuous Ambulatory Peritoneal Dialysis-related Peritonitis Research Articles

Pharmacokinetic analysis of ceftazidime and cefazolin in the treatment of continuous ambulatory peritoneal dialysis-related peritonitis

Objective Peritoneal dialysis-related peritonitis (PDRP) presents a significant challenge for nephrologists. Continuous intraperitoneal cefazolin and ceftazidime are recommended for the treatment of peritonitis. However, some pharmacokinetic studies have shown that doses of 15–20 mg/kg/d may not achieve sufficient therapeutic levels. In this study, we investigated the pharmacokinetics of ceftazidime and cefazolin in patients with continuous ambulatory peritoneal dialysis-related peritonitis and compared the pharmacokinetic characteristics between traditional and modified treatment groups. Methods From February 2017 to December 2019, 42 PDRP patients (17 males, 25 females; mean age: 50.7 ± 12.1 years; mean body weight: 60.9 ± 11.8 kg) were recruited for the study, all participants were anuric. Twenty patients were enrolled in the traditional group and treated with cefazolin (1.0 g) and ceftazidime (1.0 g) via intraperitoneal administration once daily for 14 days. Twenty-two patients were enrolled in the modified group and received the same dose of antibiotics twice daily for the initial five days, followed by once daily for the subsequent nine days. Serum and dialysate samples were collected after days 1, 2, 3, 5, 7, 10, and 14 and analyzed via liquid chromatography-mass spectrometry. Results In the traditional group, the highest and lowest serum concentrations of ceftazidime were 35.9 and 21.7 µg/mL, respectively. The highest concentration of cefazolin was 54.6 µg/mL on day 5 and the lowest concentration was 30.4 µg/mL on day 1. In the modified group, the highest and lowest serum concentrations of ceftazidime were 102.2 and 54.8 µg/mL, respectively. The highest concentration of cefazolin was 141.7 µg/mL and the lowest concentration was 79.8 µg/mL. All antibiotic concentrations were above the minimum inhibitory concentration (MIC) level (8 µg/mL of ceftazidime and 2 µg/mL of cefazolin) throughout the treatment period. However, on day 1, the concentration of ceftazidime in the third bag of dialysate effluent from the traditional group fell below the MIC level. Despite remaining above the MIC, cefazolin concentration was consistently lower in the third bag of dialysate effluent from the traditional group throughout the treatment period. Conclusions Intraperitoneal administration of cefazolin and ceftazidime at a dose of 1 g twice daily for 5 days and then once daily for the rest of the treatment period ensured adequate therapeutic levels of antibiotics for treating anuric PDRP patients.

MO707: Efficacy and Safety of ‘Helping Hands’: A 3D-Printed Device of Peritoneal Dialysis Adopted in Continuous Ambulatory Peritoneal Dialysis: A Randomized Controlled Trial

Abstract BACKGROUND AND AIMS Touch contamination during bag exchange in continuous ambulatory peritoneal dialysis (CAPD) is a common cause of peritonitis, especially for renal failure patients with fair eye–hand coordination plus and minus poor vision who fail to do the aseptic technique in connecting tubing (Hsieh et al. The negative impact of early peritonitis on continuous ambulatory peritoneal dialysis patients. Perit Dial Int. 2014;34(6):627–35; Woten and Cabrera. Peritonitis: prevention of peritoneal dialysis-induced peritonitis in adults. CINAHL Nursing Guide EBSCO Publishing, 16 November 2018). Those who are unable to execute CAPD by themselves resulted in high restriction in independent living where support from helper or institutional care is required. Up till now, no commercially available CAPD device could be utilized to solve this issue. ‘Helping Hands’ is a device designed with distinctive features including tunnel container for catheter fixation and comfortable handle and clips for parallel point-to-point movement with embedded magnets, and the use of this device might enable those CAPD patients with poor vision and/or eye–hand coordination to perform bag exchange procedure safely and independently. In this study, we hypothesized the use of ‘Helping Hands’ device could reduce the risk of CAPD related peritonitis by allowing CAPD users to work through a safer connection process without direct touch on tubing during bag exchange procedures. METHOD This is a randomized, paralleled, controlled pilot trial in public hospital setting. An interdisciplinary collaboration workgroup was established at Queen Elizabeth Hospital in May 2019. The Renal Unit of Department of Medicine together with the Multi-disciplinary Simulation and Skill Centre designed, prototyped, and then fabricated a CAPD device named ‘Helping Hands’ using 3D-printing technology. All new CAPD patients using ultra-bag peritoneal dialysis (PD) system and attaining ‘high to moderate readiness’ in assessment with occupational therapists were invited to participate in this program. All consented participants were randomly assigned to either intervention group (training + ‘Helping Hands’ provided for CAPD bag exchange) or control group (training alone + CAPD bag exchange without ‘Helping Hands’) using computer-generated numbers. RESULTS From December 2020 to November 2021, 17 patients, with their demographic shown in Fig. 1 were recruited into the study. Nine (53%) and eight (47%) were assigned to intervention group and control group, respectively. Within comparable study period (41 patient-month for both groups), peritonitis rate of intervention group was significantly lower than that of control group, 0.29 versus 1.18/patient-year (P < .01). The peritonitis rate in the intervention group was also lower than the overall peritonitis rate in the Queen Elizabeth Hospital within the same study period, which was 0.31/patient-year (4193 patient-month; peritonitis episode = 108). Investigation report found that the episode of peritonitis identified in intervention group was due to patient not clamping the transfer set before disconnection in performing the bag exchange as opposed to device safety issues. CONCLUSION The use of ‘Helping Hands’ device is safe and can significantly reduce the risk of CAPD-related peritonitis by no direct touching on tubing during bag exchange procedures. The distinctive features of ‘Helping Hands’ might enable those PD patients with poor vision and/or eye–hand coordination to perform bag exchange procedure safely and independently.

Continuous Ambulatory Peritoneal Dialysis Peritonitis Guidelines - Consensus Statement of Peritoneal Dialysis Society of India - 2020.

Continuous ambulatory peritoneal dialysis (CAPD) related peritonitis is a major cause of technique failure, morbidity, and mortality in patients on CAPD. Its prevention and management is key to success of CAPD program. Due to variability in practice, microbiological trends and sensitivity towards antibiotics, there is a need for customized guidelines for management of CAPD related peritonitis (CAPDRP) in India. With this need, Peritoneal Dialysis Society of India (PDSI) organized a structured meeting to discuss various aspects of management of CAPDRP and formulated a consensus agreement which will help in management of patients with CAPDRP.

Aeromonas Sobria: a Rare Cause of Continuous Ambulatory Peritoneal Dialysis-Related Peritonitis

Peritonitis is a very common complication in patients treated with continuous ambulatory peritoneal dialysis. The most common causes are gram positive cocci (part of the normal skin flora), and then gram negative bacteria, while fungi are listed as a rare cause of peritonitis. Aeromonas species are identified as a rare cause of continuous ambulatory peritoneal dialysis-related peritonitis. Among them, Aeromonas hydrophila is somewhat more common, followed by Aeromonas caviae.Case presentation. We reported a case of continuous ambulatory peritoneal dialysis peritonitis caused by Aeromonas sobria that is extremely rare cause of this type of peritonitis. In our patient, pseudomembranous colitis occured as a complication and, reinfection – another episode of peritonitis with Klebsiella pneumoniae. Treatment with third-episode cephalosporins was successful and patient continued treatment with continuous ambulatory peritoneal dialysis. Conclusions. The rare causes of peritonitis should not be ignored, especially those which lead to increased morbidity and mortality of patients.

Uncommon presentation of CAPD-related peritonitis with unusual organism: Kocuria kristinae. Case report and review of the literature

Kocuria kristinae is a gram-positive coccus of Micrococcaceae family. Kocuria kristinae inhabits the skin and mucous membranes. It can cause opportunistic infections in patients with indwelling devices and severe underlying diseases. We describe here a case of acute peritonitis caused by Kocuria kristinae in a patient on continuous ambulatory peritoneal dialysis (CAPD). Additionally, a review of other reported CAPD related peritonitis by Kocuria kristinae is provided. The importance of Kocuria kristinae as a pathogen in patients with CAPD peritonitis should not be underestimated.

Pathogenic bacteria and drug resistance in peritoneal dialysis related peritonitis

To investigate the pathogens and their resistance in continuous ambulatory peritoneal dialysis (CAPD) related peritonitis. A total of 78 cases with CAPD related peritonitis from Xiangya Hospital between January 2007 and January 2011 were reviewed. Pathogens, resistance and outcomes of the 78 cases CAPD related peritonitis were analyzed retrospectively. Among them, 53 cases cultured positive (66.67%), 3 of which were combined infection and 2 strains were cultured. A total of 55 strains were cultured, including 32 gram-positive strains (58.18%), 18 gram-negative strains (32.72%) and 5 fungi (9.09%). The most common pathogens were coagulase negative staphylococcus, staphylococcus aureus and Escherichia coli. Drug sensitivity test of the gram-positive strains showed that the three with lowest antibiotic resistance were linezolid (0), teicoplanin (3.13%) and vancomycin (4.0%). Drug sensitivity test of the gram-negative bacteria showed that antibiotics with the lowest resistance were amikacin and imipenem, followed by piperacillin/tazobactam and cepoperazon/sulbactam. Cephazolin had the highest resistance rate of 83.33%. Clinical outcomes: 63 cases cured (80.77%); 11 cases transferred to hemodialysis (14.1%); 4 cases died (5.13%), including 2 cases fungus infections, 1 gram-negative bacteria infection and 1 combined infection. The most common pathogens causing peritoneal dialysis associated peritonitis is gram positive bacteria. In the empirical treatment, in addition to traditional treatment of Cefazolin combined with aminoglycosides, cefazolin combined with piperacillin/tazobactam or cepoperazon/sulbactam is preferable for CAPD associated peritonitis.

Outbreak of Peritonitis in a Continuous Ambulatory Peritoneal Dialysis Population Following the Use of Contaminated Peritoneal Dialysis Fluids

Introduction: Most cases of peritonitis during continuous ambulatory peritoneal dialysis (CAPD) are attributed to breaches of the aseptic technique. In this report, we describe an outbreak of CAPD related peritonitis that followed the use of potentially contaminated PD fluid. Outbreak report: CAPD was introduced in the adult nephrology unit at Soba University Hospital in December 2008 with fairly satisfactory functioning and results. In June 2009, we obtained a new supply of PD fluids and started using it. Soon afterwards, a mould was found inside a new unused dialysate bag. During the following days, six patients were diagnosed to have PD related peritonitis. All patients in the unit were immediately shifted to another brand of PD fluids. Enquiry revealed that this supply of PD fluid was stored in a warm and humid environment. We surveyed the 1469 bags in the hospital stock and found another three bags (0.2%) that contained visible mould by the naked eye. The four contaminated bags contained 2.5% dextrose and were from different batches. All of them had lost the negative vacuum between the inner bag and the outer plastic envelope, but had no obvious tears in the envelope and no obvious fluid leakage. Our peritonitis rate before the outbreak was one episode in 21.7 patient-months. This sharply rose to one episode in 2.5 patient-months during the month of the outbreak, and dropped down to one episode in 17.8 patient-months in the 6-months following the outbreak. Conclusion: Contamination of PD fluids can occur during handling and storage. Patients should meticulously examine each bag before usage. Any bag that has lost the vacuum between the inner bag and its outer envelope is potentially breached and should not be used. Keywords: Contamination; Fungal peritonitis; Outbreak; Penicillium spp.; Peritoneal dialysis

Roles of Neutrophil Gelatinase-Associated Lipocalin in Continuous Ambulatory Peritoneal Dialysis-Related Peritonitis

We measured the neutrophil gelatinase-associated lipocalin (NGAL) concentration in peritoneal dialysate effluent (PDE) collected following an acute episode of continuous ambulatory peritoneal dialysis (CAPD)-related peritonitis. NGAL concentration in PDE increased in the first 3 days after developing peritonitis and correlated well with the neutrophil count. In patients with culture-negative peritonitis, the NGAL in PDE was lower than that in patients with gram-positive or gram-negative peritonitis. Apart from providing additional diagnostic support to bacterial-induced peritonitis, measurement of NGAL in PDE may be useful to differentiate the neutrophil-dependent culture-negative peritonitis from that associated with non-bacterial or non-cellular etiologies. Human peritoneal mesothelial cell (HPMC) is another source of NGAL during peritonitis. NGAL was specifically induced in HPMC by IL-1beta. Incubation of HPMC with recombinant NGAL reversed the transforming growth factor-beta-induced up-regulation of Snail and vimentin but rescued the down-regulation of E-cadherin. Our data suggest that NGAL may exert a protective effect in modulating the epithelial-to-mesenchymal transition activated following peritonitis.

P1257 Assessment of risk factors in continuous ambulatory peritoneal dialysis-related peritonitis attacks

P1257 Assessment of risk factors in continuous ambulatory peritoneal dialysis-related peritonitis attacks

R2233 Evaluation of continuous ambulatory peritoneal dialysis-related peritonitis attacks in Ankara

R2233 Evaluation of continuous ambulatory peritoneal dialysis-related peritonitis attacks in Ankara

Changes in residual dextrose and amount of total protein loss in the effluent during the clinical course of continuous ambulatory peritoneal dialysis-related peritonitis

Solute permeability of the peritoneum accelerates considerably in continuous ambulatory peritoneal dialysis (CAPD)-related peritonitis. Residual dextrose (RD) (g/bag) and the amount of total protein loss (LP) (g/bag) in the effluent of dialysate were measured during the clinical course of 21 cases of CAPD-related peritonitis as markers of deranged peritoneal permeability. The following were the results obtained: 1) In 15 cases of intraluminal infection (simple peritonitis by microorganism contamination through the lumen of a peritoneal catheter), RD decreased on day 1 (p < 0.001) and day 3 (p < 0.001) after the onset of peritonitis, and LP increased on day 1 (p < 0.001) and day 3 (p < 0.01), compared to the values of the non-infected phase. Both parameters were restored on day 7 and day 14 by adequate therapeutic maneuver. 2) In 6 cases of periluminal infection (peritonitis caused by an organic lesion of infection along the peritoneal catheter), RD and LP persisted even on day 7 (p < 0.01), and recovered 10 days after surgical removal of the peritoneal catheter with simultaneous catheter replacement. It is concluded that both RD and LP are valuable markers in the evaluation of the clinical course of CAPD-related peritonitis, and are useful in deciding on therapeutic intervention.

The Response of Human Peritoneal Macrophages to Stimulation with Bacteria Isolated from Episodes of Continuous Ambulatory Peritoneal Dialysis-Related Peritonitis

The metabolism of arachidonic acid, by isolated peritoneal macrophages in response to stimulation with microorganisms isolated from continuous ambulatory peritoneal dialysis (CAPD) patients, is not specific to the individual strain but is determined by species. Isolates of Staphylococcus aureus (n = 7) and Staphylococcus epidermidis (n = 13) produced a significant increase in leukotriene B4 generation by peritoneal macrophages compared with unstimulated cells (P less than .001). The coincubation of peritoneal macrophages with gram-negative organisms (n = 3), however, did not result in an increase in leukotriene B4 synthesis. In contrast, all the organisms tested significantly inhibited the formation of prostaglandin E2 and thromboxane B2 but the degree of inhibition was species dependent. The above results were reproduced using bacteria-free supernatants, indicating that the interaction was dependent on a secreted bacterial product. Thus in response to certain bacterial species, the recruitment of neutrophils may be facilitated by the generation of leukotriene B4 from peritoneal macrophages. In addition, the reduction in synthesis of prostaglandin E2 may remove a regulatory effect that this metabolite has on the immune response.

Characterization of cell envelope proteins of Staphylococcus epidermidis cultured in human peritoneal dialysate

The cell envelope protein profiles of Staphylococcus epidermidis cultured in used human peritoneal dialysate (HPD) differed markedly from those of cells cultured in nutrient broth. Compared with broth-grown cells, many cell wall proteins were repressed in HPD, although three proteins of 42, 48, and 54 kDa predominated and an iron-repressible 130-kDa protein was induced. Growth in HPD also resulted in expression of two cell membrane proteins of 32 and 36 kDa which were iron repressible. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis and immunoblot analysis using monospecific polyclonal antisera raised against the 32- and 36-kDa proteins revealed considerable antigenic and molecular mass homology among 12 S. epidermidis isolates from patients with continuous ambulatory peritoneal dialysis-related peritonitis. The 32-kDa antiserum also cross-reacted with a 32-kDa S. aureus cell membrane protein. Immunoblots of S. epidermidis cell walls and membranes were also probed with normal human serum and serum and HPD from continuous ambulatory peritoneal dialysis patients. While the cell wall proteins of S. epidermidis appeared to be relatively poorly immunogenic, the 32- and 36-kDa membrane proteins reacted strongly with antibodies present in each of the body fluids evaluated. These results suggest that the highly conserved 32- and 36-kDa iron-repressible proteins are expressed during growth in vivo and may be involved in iron transport, since all 12 S. epidermidis strains examined also produced iron chelators.

Influence of carbon dioxide on the surface characteristics and adherence potential of coagulase-negative staphylococci

Coagulase-negative staphylococci obtained from patients with continuous ambulatory peritoneal dialysis-related peritonitis were cultured in nutrient broth in an atmosphere of air containing 5% carbon dioxide (reflecting the CO2 tension found in freshly used dialysate). Significant differences were observed between the surface chemistries of cells grown in the two atmospheres, as determined by X-ray photoelectron spectroscopy and changes in the cell wall protein profile. The growth atmosphere also influenced the adherence potential toward polystyrene and silicone in a proportion of strains examined. Thus, gaseous conditions can profoundly influence the nature of the staphylococcal surface, and this should be considered in any in vitro study of in vivo behavior.