Attacks Of Peritonitis Research Articles

Effect of bevacizumab, a vascular endothelial growth factor inhibitor, on a rat model of peritoneal sclerosis.

Peritoneal fibrosis is almost uniform feature encountered in peritoneal dialysis patients. The transition of epithelial cells to mesenchymal phenotype, neovascularization, and consequently development of peritoneal fibrosis occur due to the involvement of peritoneal membrane by various insults such as uremia itself, peritonitis attacks, and exposure to bio-incompatible peritoneal dialysis fluids. Bevacizumab is a monoclonal antihuman antibody developed against vascular endothelial growth factor and can reduce fibrosis by preventing neovascularization. There has been no study so far that demonstrates the effect of bevacizumab on peritoneal fibrosis in a rat model. A total of 41 female Wistar albino rats were divided into six groups. The control group (C) received 0.9 % isotonic saline (2 ml/day) intraperitoneally (i.p) for 21 days. Chlorhexidine group (CH) received 15 % ethyl alcohol and 0.1 % chlorhexidine gluconate (CG) in saline (2 ml/day) i.p for 21 days. The resting group (R) received CG 2 ml/day i.p for 21 days. The bevacizumab-1 group (B1) received CG 2 ml/day i.p for 21 days and bevacizumab 2.5 mg/kg i.p as a single dose on day 21. The bevacizumab-2 group (B2) received CG 2 ml/day for 21 days and bevacizumab 2.5 mg/kg i.p on day 0 and day 21. The bevacizumab-3 group (B3) received bevacizumab 2.5 mg/kg i.p on day 0 and day 21. Peritoneal samples were taken from the left anterior abdominal wall. The thickness, vascularization, and fibrosis scores in the peritoneal samples were assessed using a light microscope. On histopathological evaluations, peritoneum thicknesses, vascularization scores, and fibrosis significantly decreased in bevacizumab groups B1 and B2. Histopathologically, bevacizumab was proven to attenuate fibrotic process in experimental peritoneal sclerosis model.

Does the age at disease onset cause a delay in diagnosis and affect disease severity in the children with familial Mediterranean fever?

Familial Mediterranean fever (FMF) is a systemic autoinflammatory disease characterized by recurrent attacks of fever and sterile peritonitis, pleuritis, arthritis or erysipelas-like erythema. Symptoms related with FMF can begin at very early ages of life. However, since most symptoms related to FMF are often well-known only when children become more verbal, and fever in children in the first years of life are common, attacks of fever alone may cause or contribute to diagnosis delay.

Clinical and subclinical features and MEFV mutation distribution in of FMF patients’ siblings

Objective Familial Mediterranean fever (FMF) is an autosomal recessive disease characterized by recurrent attacks of fever and peritonitis, pleuritis, arthritis or an erysipelaslike skin disorder. The disease may present at any age, more than 80% of patients being symptomatic by the age of 20 yr. Its main long-term complication is amyloid A (AA) amyloidosis, a severe manifestation with poor prognosis. Mutations in the MEFV gene, on chromosome 16, is encoding a protein named as pyrin. We aim to analyze clinical characteristics, subclinical inflammation, and carried MEFV mutation in siblings with FMF.

Is Mean Platelet Volume a Possible Marker in Acute Peritonitis?

MPV (mean platelet volume) is one of the determinants of the platelet function which is situated in the routine complete blood count tests and was shown to be inversely correlated with inflammation. We aimed to evaluate MPV values in patients with peritoneal dialysis and in acute peritonitis attacks. 37 patients with PD and 42 healthy subjects were included in the study. 42 peritonitis attacks of the patients were recorded. C reactive protein (CRP) levels and complete blood count tests were analyzed. Mean MPV values were significantly higher in patients with PD in the stable period compared with the control group (p <0.001). Mean MPV values were significantly lower and CRP values were significantly higher in peritonitis attack periods, compared with the stable period of the same PD patients, both (p <0.001). In the correlation analysis, MPV levels in the peritonitis attack were negatively correlated with CRP levels, hospitalization day, peritoneal fluid and plasma leukocyte count (r= -0.751, p<0.001); (r= -0.355, p=0.002, ; ( r= -0.851, p<0.001) ; (r= - 0.579, p<0.001) respectively. In conclusion, our results suggest that assessment of MPV in acute peritonitis in PD patients may indicate systemic inflammation. MPV may be used as an hepler marker to predict the severity of acute peritonitis.

Peritonitis incidence was correlated with duration of peritoneal dialysis rather than leptin or neutrophil to lymphocyte (n/l) ratio in peritoneal dialysis patients.

End stage renal disease (ESRD) has a high worldwide prevalence and incidence. Peritonitis is one of the leading causes of hospitalization in peritoneal dialysis patients. Although inflammatory markers show increased inflammatory responses, cellular immune response was decreased in ESRD patients. Leptin is an adipocyte-derived hormone that has activity in energy, nutrition and immune system. Neutrophil to lymphocyte ratio (N/L) was emerged as a predictive and prognostic criterion in many instances. In this study, we aimed to investigate the relationships between increased inflammation in peritoneal dialysis patients and leptin, N/L ratio. Forty-one ESRD patients, who were been at least 12 months of peritoneal dialysis therapy, were included in the study. Patients' demographic properties were recorded. Serum leptin level, WBC count, C-reactive protein, erythrocyte sedimentation rate and biochemical markers were measured. Patients with active viral or bacterial infection, malignancy, inflammatory disease, immunosuppressive medication users were all excluded from the study. Age and sex-matched healthy control group was included in the study only for their leptin levels. The measured mean serum leptin level of the patient group was statistically significantly higher than control group (1624.88±1608.16 and 416±439.85). The calculated mean peritonitis incidence was 0.041±0.047 peritonitis/per year. The number of peritonitis attack was significantly correlated with duration of peritoneal dialysis, body mass index (BMI), age and presence of cardiovascular disease. Serum leptin level was significantly correlated with sex, age, primary cause of ESRD, BMI, blood glucose level and duration of peritoneal dialysis (PD). We detected that ESRD patients have higher serum leptin levels compare to healthy adults. Increased leptin was correlated with sex, age, BMI, primary cause of ESRD and serum glucose level. Number of peritonitis attack and peritonitis incidence was significantly correlated with the duration of PD, BMI and sex. We weren't able to show the predictive N/L value in PD patients in case of peritonitis.

Preventing amikacin related ototoxicity with N-acetylcysteine in patients undergoing peritoneal dialysis

Amikacin is a frequently used antibiotic in the treatment of peritoneal dialysis (PD)-related peritonitis. Ototoxicity is a well-known complication of amikacin for which increased oxidative stress and free oxygen radicals are thought to be responsible. In this study, the effect of N-acetyl-cysteine (NAC) on cochlear function and oxidant situation in the amikacin related ototoxicity in PD-related peritonitis patients are investigated. Forty-six patients who had their first PD-related peritonitis attacks receiving empirical amikacin treatment were enrolled in the study. The patients were randomized into two groups; the first group (n = 23) as NAC receiving and the second group (n = 23) as a placebo receiving, control group. Otoacoustic emissions were measured before, 1 week after and 4 weeks after the treatment. Oxidative stress measurements were performed concurrently in order to evaluate the effectiveness of NAC. The results of screening with otoacoustic emission testing after amikacin treatment showed that cochlear function is protected especially in higher frequencies in NAC group when compared with the control group. Evaluation of the antioxidant status of the two groups showed no differences in the basal values, but at the first week there was an increase in the NAC group compared with the control group, and this increase became significant at the fourth week. NAC is found to be safe and effective in amikacin-related ototoxicity in patients with PD-related peritonitis. We suggest a close monitoring of the patients receiving amikacin containing treatment protocols and if amikacin is administrated supplementing the treatment with NAC.

The impact of familial Mediterranean fever on reproductive system.

Familial Mediterranean fever (FMF) is an autosomal recessive disease characterized by recurrent attacks of fever, peritonitis, pleuritis, arthritis, or erysipelas-like skin lesion. FMF is the most common periodic febrile syndrome affecting more than 150,000 people worldwide. The majority of patients develop FMF before the age of 20. FMF may cause amyloidosis, which mainly affects the kidneys but may also be accumulated in other organs such as the heart, gastrointestinal tract, and reproductive organs. FMF being a systemic disorder with a risk for amyloidosis, affecting patients in their childbearing years, and with its lifelong colchicine therapy raises concern about its effect on the reproductive system. In this article, we review the impact of FMF and its treatment to the reproductive system of male and female patients, pregnancy, and lactation.

THU0366 Blood Gases in Familial Mediterranean Fever: Correlations with Markers of Endothelial Dysfunction and Inflammation

BackgroundFamilial Mediterranean Fever (FMF) is an autosomal recessive disease characterized by recurrent inflammatory febrile attacks of peritonitis, pleuritis and arthritis. Vasculitis, pulmonary hemorrhage, infarction, or infiltrates1, diffuse opacities and hilar...

The Kidney in Familial Mediterranean Fever

Familial Mediterranean fever (FMF) is a hereditary periodic fever disease that presents with recurrent attacks of peritonitis, pleuritis, arthritis, or erysipelas-like erythema1. The attacks last up to 3 days, with varying degrees of frequency. One of the most devastating complications of the disease is amyloidosis, which primarily affects the kidneys but can involve the liver, intestines, and the heart. Colchicine is the drug of choice for FMF2,3. It controls acute attacks of FMF and fends off development of amyloidosis. Since the introduction of colchicine for treatment of FMF, amyloidosis is infrequently seen among compliant patients. In the past, the mere presence of proteinuria in a patient with FMF suggested a diagnosis of renal amyloidosis since it was the most common kidney involvement in this disease. Nevertheless, more than 30 years ago, Eliakim, et al already reported that patients with FMF could have renal diseases other than amyloidosis4. Among these are hemorrhagic glomerulonephritis, chronic glomerulonephritis, Henoch-Schonlein nephritis, and polyarteritis nodosa (PAN). In another report in which Eliakim, et al studied 106 FMF patients, amyloidosis was found in only 13 of 19 patients with persistent albuminuria5. Renal biopsies in 4 of the 6 cases without amyloidosis showed minimal nondiagnostic changes, focal glomerulonephritis, or segmental glomerular sclerosis. Both studies were published prior to the introduction of colchicine treatment. More recently, Said, et al reported kidney biopsy pathologies in 15 patients with FMF and proteinuria6. Thirteen had urine protein of more than 1 g/24 h. Only 7 had amyloidosis, while 6 had mesangial proliferative glomerulonephritis (with IgA or IgM deposition), and 2 had rapidly progressive glomerulonephritis. Most of the patients were noncompliant for colchicine. Owing to the high efficacy of colchicine treatment in preventing amyloidosis and to the possible existence of other … Address correspondence to Dr. Ben-Chetrit, Hadassah-Hebrew University Medical Center, Jerusalem, Israel, POB 12000. E-mail: eldad{at}hadassah.org.il

PW02-003 - Efficacy of anakinra in etanercept-resistant TRAPS

Tumor necrosis factor receptor-associated periodic syndrome (TRAPS) is an autoinflammatory disease inherited in an autosomal dominant fashion. TRAPS develops secondary to mutations in TNFRSF1A. Associated symptoms include periodic attacks of peritonitis, constipation, arthritis in large joints, arthralgia, migratory rash with underlying myalgia, periorbital edema, conjunctivitis, splenomegaly, and increased risk for AA amyloidosis. Typically, attacks last from days to weeks. The common treatment modalities are corticosteroids, the p75 TNFR:Fc fusion protein, etanercept, and IL-1 antagonists. Recent studies suggest that multiple cytokines are involved in the pathogenesis of TRAPS. To date, there are limited data comparing the efficacy of etanercept and IL-1 inhibitors in TRAPS.

AB1232 Mean platelet volume in patients with familial mediterranean fever

BackgroundFamilial Mediterranean fever (FMF) is an autosomal recessive hereditary disease which is characterized by recurrent attacks of fever and peritonitis, pleuritis, arthritis, or erysipelas-like skin disease.There are very limited study...

Does mean platelet volume influence the attack or attack-free period in the patients with Familial Mediterranean fever?

Familial Mediterranean fever (FMF) is an autosomal recessive hereditary disease which is characterized by recurrent attacks of fever and peritonitis, pleuritis, arthritis, or erysipelas-like skin disease. Mean platelet volume (MPV) is a sign of platelet activation. There are limited studies in the literature about MPV levels in FMF patients. We aimed to investigate MPV levels during the attack period (group 1) and attack-free periods (group 2) in FMF patients, and to compare them with healthy controls (group 3). The study consisted of the data of: 60 group 1 patients, 120 group 2 patients, and 75 group 3 patients. Erythrocyte sedimentation rate, C-reactive protein, white blood cell count, platelet count, and MPV levels were retrospectively recorded from patient files. Statistical analyses showed that MPV was significantly lower in FMF patients both in group 1 and group 2 than in group 3 (p = 0.004, p = 0.002, respectively); however, there was no difference among group 1 and group 2 in patients with FMF (p = 0.279). The mean platelet count of group 1 was higher than that of group 3 (p = 0.010). In conclusion, this study results suggested that MPV level did not increase on the contrary, it decreased in patients with FMF both in group 1 and/or group 2 when compared to group 3. It was concluded that the lower MPV level was an expected result of secondary thrombocytosis in FMF patients.

Familial Mediterranean Fever Presenting as an Acute Abdomen: The Role of a Careful History in Making the Diagnosis

Purpose: Background: Familial Mediterranean fever (FMF) is a genetic disorder characterized by sporadic, paroxysmal attacks of fever and serositis. Typical manifestations include recurrent attacks of peritonitis (95% of patients), pleuritis, synovitis and fever. The pain, which can closely resemble an acute surgical abdomen, lasts one to three days and resolves spontaneously. Recognition of FMF is vital because the condition can lead to renal failure from secondary amyloidosis which is preventable with colchicine treatment. Case Report A 47-year-old Sephardic Jewish female originating from Turkey presented to the UCLA FMF Clinic with a more than 30 year history of recurrent fever and severe abdominal pain localized to the left upper quadrant. Her pain lasted approximately three days and was associated with fevers for one day. Menstruation could trigger the episodes. She experienced no episodes during pregnancy. She described occasional monoarticular joint pain during the episodes of abdominal pain. These attacks occurred initially once a month but increased to weekly over the two years prior to her first clinic visit. She was completely well in between attacks. During childhood, she noted frequent erysipeloid skin eruptions on her lower extremities which were associated with fever. She underwent appendectomy at the age of 12 which revealed a normal appendix. She underwent cholecystectomy at age 45 for gallstones, but experienced the same symptoms after the surgery. No other family members had the same symptoms. Physical examination was unremarkable. Urine dipstick was negative for protein. This constellation of recurrent symptoms raised concern for FMF. The patient was treated with colchicine 1 mg daily. Since starting treatment, she has experienced no episodes of fever or abdominal pain for 25 years. Conclusion: Our case demonstrates the classic presentation of FMF which remained undiagnosed for 30 years. Given the rarity of the disease, most FMF patients do not receive their diagnosis from general physicians, even though the diagnosis of FMF usually requires only a careful detailed history. Our case highlights the need for physician awareness of this treatable disorder. It also represents the importance of a careful history to diagnose a patient who presented with recurrent severe abdominal pain and fever. Had the correct diagnosis been made 30 years before, this patient would have had a better quality of life, avoided unnecessary surgery, and above all, would not have been placed at risk for developing amyloidosis with possible end-stage renal disease.

FAMILIAL MEDITERRANEAN FEVER AND HYPERCOAGULABILITY

Familial Mediterranean fever (FMF) is an autosomal recessive hereditary disease which is characterized by recurrent attacks of fever and peritonitis, pleuritis, arthritis, or erysipelas-like skin disease. As such, FMF is a prototype of autoinflammatory diseases where genetic changes lead to acute inflammatory episodes. Systemic inflammation – in general - may increase procoagulant factors, and decrease natural anticoagulants and fibrinolytic activity. Therefore, it is anticipated to see more thrombotic events among FMF patients compared with healthy subjects. However, reviewing the current available literature and based upon our personal experience, thrombotic events related purely to FMF are very rare. Possible explanation for this discrepancy is that along with the procoagulant activity during FMF acute attacks, anticoagulant and fibrinolytic changes are also taking place. Colchicine which is the treatment of choice in FMF may also play a role in reducing inflammation thereby decreasing hypercoagulability.

Protective effect of N-acetylcysteine from drug-induced ototoxicity in uraemic patients with CAPD peritonitis

Peritonitis is currently one of the leading complications of continuous ambulatory peritoneal dialysis (CAPD) treatment. Aminoglycosides and vancomycin are used in the treatment of CAPD peritonitis despite their potential risk for ototoxicity. N-acetylcysteine (NAC) is a molecule used in the treatment and prophylaxis of many diseases related to oxidative stress. The aim of this study was to examine whether ototoxicity due to antibiotics used in the treatment of CAPD peritonitis can be prevented by NAC. Sixty patients, who first developed CAPD peritonitis attacks from February 2008 to April 2010 were included in this study. Patients were divided into two groups, those taking an additional NAC treatment (n = 30) and a control group (n = 30). Low- and high-frequency hearing function tests were performed on the two groups before treatment (baseline), at the end of the first (early follow-up) and the fourth week after the treatment (late follow-up). Total doses of vancomycin and amikacin were recorded. There was no statistically significant difference between the groups in terms of hearing functions at the beginning. However, patients taking NAC had better hearing function test results 4 weeks after the treatment compared with those of the control group (P < 0.05). There were no statistical differences between posttreatment low-frequency hearing function tests conducted at the baseline and the first and the fourth weeks in patients taking NAC. The first and the fourth week's low-frequency hearing functions worsened when compared with the baseline low-frequency results in the control group (P < 0.001). It was found that NAC had a protective effect against ototoxicity on low-frequency (0.25-8 KHz) hearing functions. The first and the fourth week's high-frequency hearing functions improved when compared with baseline high-frequency hearing functions in patients taking NAC (P < 0.05), while they worsened. The first and fourth week's high-frequency tests worsened when compared with the baseline high-frequency tests in the control group (P < 0.001). The present study suggests that intraperitoneal aminoglycoside and vancomycin administration in CAPD patients may cause low- and high-frequency hearing loss, and this ototoxic effect is related to the dose given. It was found that when the antioxidant NAC is administered alone, it prevents ototoxicity, associated with intraperitoneal amikacin and vancomycin in patients with CAPD peritonitis. In addition, it was revealed that NAC may also have a curative effect on impaired high-frequency hearing functions.

Arthritis patterns in familial Mediterranean fever patients and association with M694V mutation

Familial Mediterranean fever (FMF) is an autosomal recessive disorder characterized by recurrent attacks of febrile peritonitis, pleuritis and synovitis. Arthritis is a common and important feature of FMF. The clinical spectrum of arthritis in 71 FMF patients was retrospectively investigated. Mutations in the familial Mediterranean (MEFV) gene were screened. Unlike the previous reports on arthritis of FMF, most of the FMF patients (59%) in this study had symmetric two-joint arthritis whereas monoarticular, oligoarticular and polyarticular arthritis was presented in 20, 8 and 10% of the patients, respectively. Knees were affected in 45 (63%) patients, ankles in 30 (42%), elbows in 11 (15%), wrists in 12 (17%), hips in 12 (17%), small joints of the hands 7 (10%), small joints of the feet 2 (3%) and sacroiliac in 1 (1%). Destruction of the hip was observed in 2 (3%) patients and required hip replacement. Amyloidosis developed in 2 (3%) of our patients. Mutations in the MEFV gene were identified in 50 (71%) patients and the most dominant mutation detected was M694V (64%). Since FMF can be diagnosed by a simple DNA mutation analysis, all arthritis patients of certain origins (Arabs, Turks, Armenians and Jews) should be tested for FMF in order to prevent the complications (amyloidosis and protracted arthritis) by introducing colchicine which is the treatment of choice for FMF.

Specialist pediatric dialysis nursing improves outcomes in children on chronic peritoneal dialysis

Chronic peritoneal dialysis (PD) for children in Singapore was instituted in 1988 at the National University Hospital with adult nurses providing dialysis services during the first 10 years. In 1998, a specialist pediatric dialysis nursing team was recruited. This study was conducted to determine the impact of dialysis nursing service on PD-related outcomes during the two nursing periods. Comparing the adult (group 1) and pediatric (group 2) nursing periods, the peritonitis rate was significantly higher in group 1 (RR 1.90; 95%CI 1.27-2.84), and this association did not weaken after adjusting for age, gender, and exit site infections. Exit site infection rate (RR 2.16; 95%CI 1.44-3.23), risk of peritonitis during the first year (RR 3.65; 95%CI 1.68-7.90), and multiple peritonitis attacks (RR 2.45; 95%CI 1.32-4.55) were higher in group 1. The peritonitis rates for adult patients cared for by the same adult nurses declined sharply from 1.05 episodes per patient-year between 1989 and 1992 to 0.41 episodes per patient-year between 1995 and 1997, however the corresponding pediatric rates did not change (1.48 to 1.06 episodes per patient-year, respectively) until the second era when specialized pediatric nurses were available. In conclusion, establishment of a specialist pediatric dialysis nursing team resulted in significant improvement in infection-related PD outcomes.

Concerted action of wild-type and mutant TNF receptors enhances inflammation in TNF receptor 1-associated periodic fever syndrome

TNF, acting through p55 tumor necrosis factor receptor 1 (TNFR1), contributes to the pathogenesis of many inflammatory diseases. TNFR-associated periodic syndrome (TRAPS, OMIM 142680) is an autosomal dominant autoinflammatory disorder characterized by prolonged attacks of fevers, peritonitis, and soft tissue inflammation. TRAPS is caused by missense mutations in the extracellular domain of TNFR1 that affect receptor folding and trafficking. These mutations lead to loss of normal function rather than gain of function, and thus the pathogenesis of TRAPS is an enigma. Here we show that mutant TNFR1 accumulates intracellularly in peripheral blood mononuclear cells of TRAPS patients and in multiple cell types from two independent lines of knockin mice harboring TRAPS-associated TNFR1 mutations. Mutant TNFR1 did not function as a surface receptor for TNF but rather enhanced activation of MAPKs and secretion of proinflammatory cytokines upon stimulation with LPS. Enhanced inflammation depended on autocrine TNF secretion and WT TNFR1 in mouse and human myeloid cells but not in fibroblasts. Heterozygous TNFR1-mutant mice were hypersensitive to LPS-induced septic shock, whereas homozygous TNFR1-mutant mice resembled TNFR1-deficient mice and were resistant to septic shock. Thus WT and mutant TNFR1 act in concert from distinct cellular locations to potentiate inflammation in TRAPS. These findings establish a mechanism of pathogenesis in autosomal dominant diseases where full expression of the disease phenotype depends on functional cooperation between WT and mutant proteins and also may explain partial responses of TRAPS patients to TNF blockade.

Peritoneal cells at admission: do they have prognostic significance in peritonitis?

Peritonitis accounts for considerable morbidity and hospitalization in peritoneal dialysis (PD) patients. We investigated the factors related with time of hospital stay, especially focusing on the peritoneal cell profiles at the time of hospital admission in PD-related peritonitis. Eighty peritonitis attacks were evaluated. Data were collected at the time of hospital admission, clinical and biochemical parameters, including initial systemic and dialysate white cell counts (including percentage and differential count of neutrophils and lymphocytes) and length of hospital stay. Peritoneal leukocyte (r = +0.289, p = 0.009) and neutrophil counts (r = +0.403, p < 0.0001), peritoneal neutrophil percentage (r = +0.492, p < 0.0001), time of hospital admission (r = +0.498, p < 0.0001), and C-reactive protein (CRP) (r = +0.231, p = 0.042) were positively correlated; lymphomononuclear cell percentage (r = −0.650, p < 0.0001) was negatively correlated with hospitalization length. Hospital admission ≥24 hours of symptom onset was associated with higher CRP, dialysate leukocyte and neutrophil counts, longer hospitalization, and with lower dialysate lymphomononuclear cell percentage compared to admission < 24 hours (p = 0.04, p = 0.04, p = 0.005, p < 0.0001, and p = 0.04, respectively). In multiple linear regression, the time of hospital admission (p = 0.002), initial peritoneal neutrophil count (p = 0.011), and lymphomononuclear cell percentage (p < 0.0001) were independently associated with hospitalization length. Hospital admission within first 24 hours of peritonitis symptoms onset is of vital importance; delayed admission is associated with higher peritoneal leukocyte and neutrophil counts, and increased length of hospital stay.

A single-dose vancomycin application after standard protocol in peritoneal dialysis patients with recurrent peritonitis.

Sir, Peritonitis remains the major cause of catheter removal in peritoneal dialysis (PD) patients suffering from recurrent attacks, despite appropriate antibiotic therapy. Bacteria such as coagulase-negative staphylococci (CNS) from the exit site of the catheter and contaminated dialysis fluids can grow into microcolonies in biofilms on the surface of the catheter [1,2]. In the preliminary study, we evaluated the outcome of administration of a single-dose intracatheterial vancomycin just after primary response to the treatment of the last peritonitis attack with cefazolin in continuous ambulatory PD patients with recurrent peritonitis. Among 166 patients who underwent routine PD, six cases with recurrent peritonitis attacks were treated with initial empiric antibiotic therapy consisting of intraperitoneal cefazolin given in each exchange for gram-positive organisms. The characteristics and data regarding peritonitis attacks are given in Table ​Table1.1. Six patients had three to five peritonitis attacks with intervals of ∼1–7 weeks following the completion of a standard 2- or 3-week course of antimicrobial therapy. Four cases out of six had no history of peritonitis, tunnel or exit-site infection before. One patient (fourth case in the table) had exit-site infection. For S. aureus positive culture, the patient received mupirocin pomade and Sodium Fusidate (1 g/day per oral for 7 days). After therapy, exit-site infection completely resolved, and the two cultures taken afterwards were negative. Then, she also had a peritonitis attack with S. aureus on 21 February 2006. The other patient (third case in the table) had a culture-negative peritonitis attack on 1 May 2006. They were treated with cefazolin. The wives of the two male patients (one having diabetic retinopathy) helped during the dialysis exchanges, and the remaining patients were on their own. Six patients and the two assistants (wives) were negative for nasal carriage state. However, prophylactic mupirocin was given to all patients, but the peritonitis attacks recurred. None of the patients had tunnel infection. After complete resolution of peritonitis by cefazolin alone in the last attack, 50 cc peritoneal dialysate was mixed with 2 g vancomycin after drainage of the entire peritoneal fluid and left in the catheter lumen for 8 h. Then, without drainage, a normal dialysis session was carried out. During the mean follow-up of 25 ± 0.8 months, none of the six patients had recurrence peritonitis. Table 1 Characteristics of peritoneal dialysis patients with recurrent gram-positive peritonitis Many episodes of peritonitis appear to be unrelated to obvious causes. Bacterial biofilm formation on the dialysis catheter represents a concern for PD patients in terms of our ability to eradicate the infection [2]. However, there is sometimes no clear relationship between biofilms and clinical peritonitis. Indeed, one exception may occur in patients with multiple episodes of peritonitis who were likely to have stable biofilms, positive biofilm cultures and a high incidence of catheter loss. Recently, examination by electron microscopy of catheters of patients who experienced PD peritonitis revealed biofilm formation; however, no biofilm formation was found in PD catheters removed from patients without infection [3]. The risk associated with administering cefazolin continuously (in every PD bag) is that the organisms survive and continue dividing in biofilms. Our current antimicrobial protocols may not permit adequate dosing to penetrate the biofilm and be a reason for recurrent episodes of peritonitis. To evaluate the differences in the antibiotic sensitivity patterns of CNS, minimum inhibitory concentrations (MIC) and minimum biofilm eradication concentration (MBEC) assays were compared in CNS isolates from patients with PD-associated peritonitis in a study [4]. In the PD effluent sample from patients with repeat infection, the rate of first-generation cephalosporin (FGC) or gentamicin or both resistances was higher. MBEC results were higher than those with standard MIC assays. Although no vancomycin resistance was observed with MIC assays, a small number of cases were identified with MBEC assays. There was no resistance when a vancomycin/rifampin 1:1 combination was used. All patients with repeat infections had high degrees of FGC resistance, and infection cycles were terminated when their treatment protocol included vancomycin. In conclusion, we assume that adequate antibiotic levels will be achieved within the catheter-contained biofilm with a single dose of vancomycin of 2 g at the end of the treatment course that will prevent recurrent peritonitis and catheter loss. These results are difficult to compare because patient numbers are small. In our opinion, this observation should be confirmed by other investigators. Conflict of interest statement. None declared.