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Infectious Complications of PD: Peritonitis and Exit Site / Tunnel Infections. Download Presentation at: www.pedpd.org. Franz Schaefer Pediatric Nephrology Division Center for Pediatric and Adolescent Medicine University of Heidelberg, Germany. Reasons for Hospitalizations. - PowerPoint PPT Presentation
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Infectious Complications of PD: Infectious Complications of PD: Peritonitis and Exit Site / Tunnel InfectionsPeritonitis and Exit Site / Tunnel Infections
Infectious Complications of PD: Infectious Complications of PD: Peritonitis and Exit Site / Tunnel InfectionsPeritonitis and Exit Site / Tunnel Infections
Franz SchaeferFranz Schaefer
Pediatric Nephrology DivisionPediatric Nephrology Division
Center for Pediatric and Adolescent MedicineCenter for Pediatric and Adolescent Medicine
University of Heidelberg, GermanyUniversity of Heidelberg, Germany
Download Presentation at: Download Presentation at:
www.pedpd.orgwww.pedpd.org
0 10 20 30 40 50
Anemia
non-compliance
hernia surgery
catheter surgery
other infections
dehydration
hypervolemia
peritonitis
Reasons for Hospitalizations
Reasons for Change of Dialysis Modality*Reasons for Change of Dialysis Modality*
0
10
20
30
40
50
ExcessiveInfection
FamilyChoice
AccessFailure
Other
PD HD
Per
cen
t
NAPRTCS, 2006 * Other than transplantation
Causes of Death for Prevalent Pediatric PD Patients (2000-02)Causes of Death for Prevalent Pediatric PD Patients (2000-02)
0
2
4
6
8
10
12
14
Cardiacarrest
Cardiac,other
Infection Malignancy
USRDS, 2004
Mor
tali
ty p
er 1
000
pati
ent
year
s at
ris
k
www.peritonitis.orgwww.peritonitis.org
Prevention of PeritonitisPrevention of Peritonitis
Catheter-related factorsPrevention of exit-site and tunnel infections
Direct tunnel downward or use swan-neck catheterUse double-cuff cathetersUse exit-site mupirocin
Timely replacement of the catheter for catheter-related peritonitis
ContaminationExperienced nursing personnelAvoidance of spiking technologyLong training periodTraining protocols
Antibiotic prophylaxisPreoperative antibiotics at catheter insertionContamination at time of exchangeDialysate leak at catheter exit siteInvasive proceduresExit site mupirocin
Warady & Schaefer, In: Chap. 24, Pediatric Dialysis, 2004
Peritonitis: Diagnostic CriteriaPeritonitis: Diagnostic CriteriaPeritonitis: Diagnostic CriteriaPeritonitis: Diagnostic Criteria
• Cloudy effluent
• Dialysate WBC count >100/uL
• >50% polymorphonuclear leukocytes
• Positive culture
Marked70%
No4%
Slight26%
Peritonitis: Effluent CloudinessPeritonitis: Effluent Cloudiness
Peritonitis: Source of Infection
Unknown: 70 % !
0 2 4 6 8 10 12 14
Urinary Tract Surgery
Noncompliance, poor social situation
Procedure related to Gastric Tube / PEG
Catheter insertion
Other abdominal surgery
Accidental disconnection
Catheter perforation/leakage
Exit site/tunnel infection
Touch contamination
Episodes (%)
Spectrum of Causative Organisms
0 5 10 15 20 25 30 35 40
fungal
enterococci
streptococci
coag.neg. staph
s.aureus
gram-negative
sterile
(% of positive cultures)
Schaefer et al. Kidney Int 2007
Argen
tina
USA
Easte
rn E
urope
West
ern E
urope
Asia
Turkey
Mex
ico
fungal
culture-negative
gram-negative
gram-positive
0
10
20
30
40
50
60
70
%
Regional Distribution of Culture ResultsRegional Distribution of Culture Results
Schaefer et al. Kidney Int 2007
If the patient presents with:-No fever-Mild or no abdominal pain-No risk factors for severe infection
Glycopeptide (e.g. vancomycin, 30 mg/l cont.
or 30 mg/kg q.5-7 days) andCeftazidime
(continuous 125 mg/L or 250 mg/L o.d.)
If any of the following is present:-Fever, severe abdominal pain, age <2 yrs-History of MRSA infection or carrier-Recent or current exit site/tunnel infection
Initiate empiric therapy
Peritoneal effluent evaluationCell count and differential
Gram stain, culture
Cloudy effluent
Cefazolin (250/125 mg/l) and
Ceftazidime(continuous 125 mg/L
or 250 mg/L o.d.)
EMPIRIC THERAPYEMPIRIC THERAPY
Cefazolin/
Ceftazidime
Glycopeptide/
CeftazidimeAny Treatment
Gram positive 5/90 (5.6%) 4/129 (3.1%) 9/219 (4.1%)
Gram negative 4/56 (7.1%) 12/65 (18.5%) 16/121 (13.2%)*
Culture negative 4/92 (4.4%) 2/59 (3.4%) 6/151 (4.0%)
Any culture result 13/238 (5.5%) 18/253 (7.1%) 31/491 (6.3%)
Clinical Response Failure after 72h Empiric Antibiotic
Treatment
Warady et al. JASN 2007; 18:2172
Risk of Day 3 Clinical Response Failure
Odds ratio (95% Cl) P
Gram-negative causative organism
3.61 (1.73 - 7.54) P <0.001
Intermittent ceftazidime administration
(only gram-negative)6.65 (2.07 – 21.4) P <0.005
APD modality:'dry day' vs. 'wet day'
2.53 (1.18 - 5.42) P <0.01
Exit site score >2(only gram-positive)
5.46 (1.02 - 29.7) P <0.05
No effect: choice of empiric therapy, risk assignment
In vitro Resistance Predicts
Empiric Therapy Failure
Odds ratio 95% CI
Gram-positive 16.3 1.5 - 180
Gram-negative 9.3 1.6 - 52
In vitro Sensitivities by Gram
0102030405060708090
100C
efazo
lin
Van
co/T
eic
o
Cef
tazi
dim
e
Am
inogly
cosi
de
Cef
azo
lin/C
efta
zidim
e
Gly
copep
tide/
Cef
tazi
dim
e
Cef
azo
lin/
A
min
ogly
cosi
de
Gly
copep
tide/
Am
inogly
cosi
de
Imip
enem
Cip
rofloxac
in
% s
ensi
tive
gram pos gram neg
0
20
40
60
80
Vancomycin
Aminoglycosides
Ceftazidime
Cefazoline
Schaefer et al. Kidney Int 2007
In vitro Resistance Rates
Final OutcomeFinal Outcome
OutcomePD
ContinuedPD Discontinued Total
Temporary Permanent
Full functional recovery
420 9 0 429 (89%)
Ultrafiltration problems
8 1 7 16 (3.3%)
Adhesions 3 1 11 15 (3.1%)
Uncontrolled infection
0 1 11 12 (2.5%)
Secondary fungal peritonitis
0 0 4 4(0.8%)
General therapy failure
0 0 6 6 (1.3%)
Total 431 (89%) 12 (3%) 39 (8%) 482 (100%)
Outcome by Causative Organism
75
80
85
90
95
100
3 day responserate
Full recovery Techniquesurvival
No relapse
S. aureus Coag. Neg. StaphOther Gram-positive Gram-negativeSterile
Rat
e of
su
cces
sfu
l out
com
e (%
)
Risk of Incomplete Functional RecoveryRisk of Incomplete
Functional Recovery
OR (95% CI) P
Disease Severity Score day 3
3.68 (1.72 – 7.84) < 0.0005
Straight vs. curled catheter
2.70 (1.24 – 5.87) < 0.005
Exit-site score 1.34 (1.05 – 1.71) < 0.005
Pseudomonas on culture
3.57 (1.11 – 11.5) < 0.05
No effect: choice of empiric therapy, risk assignment
Monitor local staphylococcal methicillin, gram-negative ceftazidime
resistance patterns
Cefazolin OR Glycopeptide and
Aminoglycoside OR (continuous) Ceftazidime
Initiate empiric therapy
Peritoneal effluent evaluationCell count and differential
Gram stain, culture
Cloudy effluent
Revised Guideline: Empiric Antibiotic Therapy
Revised Guideline:Modification for Culture Negative Episodes
If improved clinically:
Continue 1st generation cephalosporin or glycopeptide for 14 days
Discontinue aminoglycoside after 3 days
Add/continue ceftazidime after 3 days
If not improved clinically:
Remove catheter
Exit Site Exit Site
InfectionInfection
Exit Site Exit Site
InfectionInfection
Diagnosis of Exit-Site InfectionDiagnosis of Exit-Site Infection
The diagnosis of a catheter exit-site infection The diagnosis of a catheter exit-site infection should be made in the presence of a should be made in the presence of a purulent purulent dischargedischarge from the sinus tract or marked from the sinus tract or marked pericatheter pericatheter swellingswelling, , rednessredness and/or and/or tendernesstenderness with or without a pathogenic with or without a pathogenic organism cultured from the exit-site. organism cultured from the exit-site. Infectious symptoms should be rated according Infectious symptoms should be rated according to an to an objective scoring system.objective scoring system.
GU
IDE
LIN
E
14
Warady, Schaefer et al., Peritonitis Guidelines, PDI, 2000
Exit-Site Scoring SystemExit-Site Scoring System
0 Points 1 Point 2 Points
Swelling no Exit only (<0.5 cm) Including part ofor entire tunnel
Crust no <0.5 cm > 0.5 cm
Redness no <0.5 cm >0.5 cm
Pain on pressure no Slight Severe
Secretion no Serous Purulent
Schaefer F. et al. J Am Soc Nephrol 10:136-145, 1999
aInfection should be assumed with a cumulative exit-site score of 4 or greater.
Causative Organisms at Exit Site
0 10 20 30 40 50
S. aureus non-MRSA / MRSA
S. epi. / other coag. neg. Staph.
Pseudomonas
Streptococci
E.coli
Other grampositive
Other gramnegative
Enterococci
% of 58 episodes
Therapy of Exit Site Infection
• Usually oral
• Usually upon culture results
• Grampositive usually penicillinase-resistant penicillin or cefalexin
• Length of therapy at least two weeks
• One-stage catheter replacement for refractory ESI
Exit-site infection rate 0.34 0.02
Tunnel infection rate 0.09 0.02
Peritonitis rate 0.17 0
Nasal CarriersNasal Carriers NoncarriersNoncarriers
S.Aureus Infection RateS.Aureus Infection Rate
Luzar et al, NEJM, 1990
Nasal S.Aureus DecontaminationNasal S.Aureus DecontaminationNasal S.Aureus DecontaminationNasal S.Aureus Decontamination
0
0.05
0.1
0.15
0.2
0.25
ES mup ES mup Rifampin IN mup IN mup
no prophylaxis prophylaxis
Piraino B, J Am Soc Nephrol, 1998 Piraino B, J Am Soc Nephrol, 1998
S. a
ure
us
Pe
rito
nit
is,
Ep
iso
des
/ y
Options for Prevention of Exit-Site Infections
Topical S.Aureus Prophylaxis
Warady et al., Peritonitis Guidelines, PDI 2000
Prophylaxis for S. Aureus
Nasal Carriage
Nasal culture every 2-4 wksuntil positive x 1 or negative x 6
If negative x 6: no prophylaxis
needed
If positive
Mupirocinintra-
nasally BID x 5 d
every 4 wks
Mupirocinat exit site daily
Exit Site and Peritonitis
Exit site co-colonization is associated with
2-fold likelihood of peritonitis treatment failure
3-fold likelihood of catheter exchange
Schaefer et al. Kidney Int 2007
Pseudomonas peritonitis is associated with
Use of saline or soap for cleansing (p<0.001)
Exit site care > twice per week (p<0.005)
Use of exit site mupirocin (p<0.005)
Being United States resident (OR 2.95, p<0.01)
Indications for Catheter Removal
• Failure to respond to appropriate
antibiotics within 5 days
• Fungal peritonitis
• Peritonitis with exit site/tunnel infection
• Recurrent peritonitis
• Chronic exit site infection
International Pediatric PD International Pediatric PD NetworkNetwork
www.pedpd.orgwww.pedpd.org