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Infectious Complications of PD: Infectious Complications of PD: Peritonitis and Exit Site / Tunnel Peritonitis and Exit Site / Tunnel Infections Infections Franz Schaefer Franz Schaefer Pediatric Nephrology Division Pediatric Nephrology Division Center for Pediatric and Adolescent Center for Pediatric and Adolescent Medicine Medicine University of Heidelberg, Germany University of Heidelberg, Germany Download Presentation at: Download Presentation at: www.pedpd.org www.pedpd.org

Infectious Complications of PD: Peritonitis and Exit Site / Tunnel Infections

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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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Page 1: Infectious Complications of PD:  Peritonitis and Exit Site / Tunnel Infections

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

Page 2: Infectious Complications of PD:  Peritonitis and Exit Site / Tunnel Infections

0 10 20 30 40 50

Anemia

non-compliance

hernia surgery

catheter surgery

other infections

dehydration

hypervolemia

peritonitis

Reasons for Hospitalizations

Page 3: Infectious Complications of PD:  Peritonitis and Exit Site / Tunnel Infections

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

Page 4: Infectious Complications of PD:  Peritonitis and Exit Site / Tunnel Infections

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

Page 5: Infectious Complications of PD:  Peritonitis and Exit Site / Tunnel Infections

www.peritonitis.orgwww.peritonitis.org

Page 6: Infectious Complications of PD:  Peritonitis and Exit Site / Tunnel Infections

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

Page 7: Infectious Complications of PD:  Peritonitis and Exit Site / Tunnel Infections

Peritonitis: Diagnostic CriteriaPeritonitis: Diagnostic CriteriaPeritonitis: Diagnostic CriteriaPeritonitis: Diagnostic Criteria

• Cloudy effluent

• Dialysate WBC count >100/uL

• >50% polymorphonuclear leukocytes

• Positive culture

Page 8: Infectious Complications of PD:  Peritonitis and Exit Site / Tunnel Infections

Marked70%

No4%

Slight26%

Peritonitis: Effluent CloudinessPeritonitis: Effluent Cloudiness

Page 9: Infectious Complications of PD:  Peritonitis and Exit Site / Tunnel Infections
Page 10: Infectious Complications of PD:  Peritonitis and Exit Site / Tunnel Infections

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 (%)

Page 11: Infectious Complications of PD:  Peritonitis and Exit Site / Tunnel Infections

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

Page 12: Infectious Complications of PD:  Peritonitis and Exit Site / Tunnel Infections

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

Page 13: Infectious Complications of PD:  Peritonitis and Exit Site / Tunnel Infections

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

Page 14: Infectious Complications of PD:  Peritonitis and Exit Site / Tunnel Infections

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

Page 15: Infectious Complications of PD:  Peritonitis and Exit Site / Tunnel Infections

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

Page 16: Infectious Complications of PD:  Peritonitis and Exit Site / Tunnel Infections

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

Page 17: Infectious Complications of PD:  Peritonitis and Exit Site / Tunnel Infections

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

Page 18: Infectious Complications of PD:  Peritonitis and Exit Site / Tunnel Infections

0

20

40

60

80

Vancomycin

Aminoglycosides

Ceftazidime

Cefazoline

Schaefer et al. Kidney Int 2007

In vitro Resistance Rates

Page 19: Infectious Complications of PD:  Peritonitis and Exit Site / Tunnel Infections

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%)

Page 20: Infectious Complications of PD:  Peritonitis and Exit Site / Tunnel Infections

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 (%

)

Page 21: Infectious Complications of PD:  Peritonitis and Exit Site / Tunnel Infections

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

Page 22: Infectious Complications of PD:  Peritonitis and Exit Site / Tunnel Infections

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

Page 23: Infectious Complications of PD:  Peritonitis and Exit Site / Tunnel Infections

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

Page 24: Infectious Complications of PD:  Peritonitis and Exit Site / Tunnel Infections

Exit Site Exit Site

InfectionInfection

Exit Site Exit Site

InfectionInfection

Page 25: Infectious Complications of PD:  Peritonitis and Exit Site / Tunnel Infections

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

Page 26: Infectious Complications of PD:  Peritonitis and Exit Site / Tunnel Infections

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.

Page 27: Infectious Complications of PD:  Peritonitis and Exit Site / Tunnel Infections

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

Page 28: Infectious Complications of PD:  Peritonitis and Exit Site / Tunnel Infections

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

Page 29: Infectious Complications of PD:  Peritonitis and Exit Site / Tunnel Infections

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

Page 30: Infectious Complications of PD:  Peritonitis and Exit Site / Tunnel Infections

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

Page 31: Infectious Complications of PD:  Peritonitis and Exit Site / Tunnel Infections

Options for Prevention of Exit-Site Infections

Page 32: Infectious Complications of PD:  Peritonitis and Exit Site / Tunnel Infections

Topical S.Aureus Prophylaxis

Page 33: Infectious Complications of PD:  Peritonitis and Exit Site / Tunnel Infections

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

Page 34: Infectious Complications of PD:  Peritonitis and Exit Site / Tunnel Infections

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)

Page 35: Infectious Complications of PD:  Peritonitis and Exit Site / Tunnel Infections

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

Page 36: Infectious Complications of PD:  Peritonitis and Exit Site / Tunnel Infections

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