Contamination and antimicrobial prophylaxis in Peritoneal Dialysis

Contamination & Antimicrobial Prophylaxis in Peritoneal Dialysis

By

Dr Ahmed Moustafa Taha Mohamed

Davita KSA Buraydah Center

PD Orientation Program

What is Contamination ?

Simply

We can define Contamination as “ any Breach in The Sterility of PD Technique that can cause Peritonitis or Infection . “

Patient Must be Trained to Recognize Contamination and Infection , and How to Act on each Case.

What are Contamination Types

Touch contamination prior to infusion of dialysate can be treated with a sterile transfer set change only if the clamp on the transfer set remains closed and no fluid infused. No antibiotics are needed in this case. Thus, a patient could report a touch contamination of their transfer set with the clamp closed during the set-up for the cycler at bedtime or during the fourth CAPD exchange, and not do their dialysis that night but report to the dialysis center in the morning for a sterile transfer set change. When in doubt of whether the patient infused after the contamination, antibiotics should be prescribed.Coagulasenegative Staph. Is very famouse for this type of contamination

Pets

Contamination may also occur if pets, particularly cats,are allowed in the room where the dialysis is performed. Pet fur creates a risk of air contamination during sterile connections as does a fan or strong breeze. Cycler tubing may move with the action of the cycler pump and entice a cat to bite the tubing. There are numerous reports in the literature regarding cat-related (Pastuerella) peritonitis.

Patients should be instructed during training that pets are never to be in the room where their dialysis occurs to reduce the risk of peritonitis.

Disconnections

Contamination may also occur if the sterile connections anywhere in the system become disconnected during a PD treatment or there is an equipment failure such as a hole in the solution bag that is not noticed until after infusion. These contaminations must be treated with both sterile transfer set changes and antibiotic prophylaxis as soon as possible to reduce the risk of developing peritonitis. If there is a hole in tubing or dialysate was infused post contamination, a cell count and culture should be obtained even if the effluent is clear. If the culture is positive, even if the cell count is unremarkable, the patient should be treated with further antibiotic therapy.

Spiking bags

Spiking of bags is a high-risk procedure for patients. It is difficult to teach a patient to perform this safely and spiking should be avoided whenever possible. Some dialysis equipment is designed to avoid a spike with the use of luer lock connections. These are the easiest for patients to learn and use safely. For dialysis equipment that still requires a spike, assist devices are available for safely inserting a spike into a bag and in our opinion should always be used as opposed to manual spiking to reduce the risk of touch contamination. Connection devices should always employ the flush before fill technique, which has been shown to reduce the risk of contamination

Spiking Vs Luer Lock

Cassettes reuse

Cassettes for the cycler must never be reused. This is not recommended by the manufacturer and has been reported to lead to severe Gram-negative peritonitis

Simplified Approach

Some Useful Hints to know

If it is unclear whether the tubing clamp was closed or open, it should be assumed it was open and antibiotic prophylaxis should be initiated.

antibiotics prescribed for contamination should cover both Gram-positive and Gram-negative organisms Since skin of dialysis patient is colonized with various types of organisms .

Some authors have developed the practice of culturing effluent postcontamination and if the culture is positive, treating this episode with a full course of antibiotics for peritonitis

Such positive cultures should not be considered equivalent with peritonitis for prognostic

and continous quality improvement (CQI) purposes, as treatment most likely will prevent the development of an inflammatory response of the peritoneum

Contamination Management

Major Contamination: Major contamination is defined as an episode in which there is a substantial or prolonged period during which the catheter or dialysate drainage system is in direct communication with the environment e.g. major leak of dialysate fluid, hole in the catheter, separation of the extension tubing or titanium or “minicap” from the catheter, etc. In this situation, the episode should be treated with the same protocol as is used for peritonitis ie. Cefazolin 1gm IP stat and Ceftazidime 1gm IP stat. (Back up medications: Vancomycin 2gm IP and/or Tobramycin 1.7mg/kg if penicillin or Cephalosporin allergic).

Minor Contamination

Minor Contamination: This is defined as an episode in which there is a lapse of technique with the potential contamination of the catheter or extension tubing or a transient leak of dialysate. This would include situations where dialysate briefly leaks out due to failure to clamp the extension tubing adequately. In this situation, the recommended treatment is Cephalexin 250mg po tid x 5 days. If the patient is allergic to penicillins or cephalosporins, Ciprofloxacin 500 mg OD x 5 days is an alternative.

An episode where the patient accidentally touches the open end of the extension tubing does not require antibiotics. A new “minicap” should be put on the extension tubing and left in place for 10 minutes before proceeding.

RISK FACTORS AND OUTCOME OF CONTAMINATION IN PATIENTS ON PERITONEAL DIALYSIS—A SINGLE-CENTER

EXPERIENCE OF 15 YEARS

Of 548 episodes of touch contamination, 246 involved dry contamination, and 302, wet contamination. After contamination, 17 episodes of peritonitis (3.1%) developed; all episodes occurred in the wet contamination group (p < 0.001). The incidence of peritonitis after wet contamination was 5.63%. Prophylactic antibiotics significantly reduced the risk of peritonitis (1 of 182 episodes, p < 0.001). Half the patients experiencing peritonitis had either culture-negative or staphylococcal episodes, and most of those episodes responded to intraperitoneal antibiotics. In 2 patients, peritonitis was attributable to Pseudomonas, and in 3, to Acinetobacter. In these latter patients, outcomes were less favorable, with catheter removal being required in 4 of the 5 episodes.

The overall rate of peritonitis was low after contamination. Wet contamination was associated with a much higher risk of peritonitis. Prophylactic antibiotics after wet contamination were effective in pre-venting peritonitis.

Peritoneal Dialysis International, Vol. 32, pp. 612–616

Antimicrobial Prophylaxis

We aim to decrease incidence of Peritonitis , but sometimes our patients are exposed to some Medical interventions and Procedures that found to carry some risk of Peritonitis for the Peritoneal Dialysis Patients

Like Dental , GIT Procedures , Gynecologic Procedures ..etc

So to what extent the procedures can cause Peritonitis , and to what extent this Antimicrobial Prophylaxis is Effective ?

We Will see

Case

A 41-year-old woman had been on CAPD since 2004 because of immunoglobulin A nephropathy. In April 2009, a Pap smear resulted in a report of cervical intraepithelial neoplasia grade III. The patient underwent cervical conization and endocervical curettage under colposcopy. About 2 weeks later, she experienced the first episode of peritonitis, with the dialysate culture being positive for Stenotrophomonas maltophilia. This peritonitis was successfully treated with intraperitoneal (IP) cefazolin 200 mg and gentamicin 8 mg in each bag for the first 3 days, and then with IP ciprofloxacin 100 mg in the last daily bag for the next 12 days.

After 9 months, the patient underwent a follow-up Pap smear. On the day after that test, she found cloudy effluent, which revealed a white cell count of 1168/μL, with 100% neutrophils. Dialysate culture yielded Streptococcus viridans.

Peritoneal Dialysis International, 2012 - Vol. 32, No. 1

Continued

This peritonitis subsided after treatment with IP cefazolin and gentamicin for 2 weeks. However, 2 weeks later, another episode of culture-negative peritonitis occurred. The Tenckhoff catheter was removed, and the patient was temporarily switched to hemodialysis for 1 month because of treatment failure after 2 weeks of vancomycin.

In October 2010, the patient had another Pap smear, and again, the dialysis effluent became cloudy on the following day. Effluent analysis revealed a white cell count of 663/μL with 99% neutrophils. Cultures of effluent and blood were negative. This episode of peritonitis was successfully treated with 2 weeks of IP cefazolin 200 mg and gentamicin 8 mg in each bag.


Discussion

This is a case of Recurrent Peritonitis Episodes in a Continuous Ambulatory Peritoneal Dialysis Patient After Gynecologic Procedures

First episode of Steno. Maltophilia which is common environment saprophyte and can be found in soil , water , hospital equipments , and at that time a lot of procedures done ( pap smear , cervical conization and endocervical curettage under colposcopy ) So any can be suspected .

Second and third episode : strept.viridans is mostly common in oral and Dental surgeries and gastroscopy , but her neither is done , but we should know it’s a normal flora in vagina too , so with only Pap smear peritonitis happened !!

It was suggested to give antibiotics as Prophylaxis for PD patients before Gynecologic procedures even the Pap smear .


Case of Gastroscopy-Related Peritonitis in Peritoneal Dialysis Patients

A 28-year-old man with chronic obstructive uropathy on continuous ambulatory PD for 9 years. One month after starting PD, he developed an episode ofCitrobacter braakii peritonitis and was treated with intraperitoneal tobramycin and oral ciprofloxacin. The patient’s PD history was peritonitis-free for the subsequent 9 years, until an elective gastroscopy because of symptoms suggestive of gastroesophageal reflux. The gastroscopy showed high-grade esophagitis (Los Angeles class D), with esophageal ulcers. The following day, the patient reported abdominal pain, and the day after that, he presented to the hospital with cloudy effluent, nausea, and vomiting.

An effluent white blood cell (WBC) count showed 1850 cells/mm3, with 86% neutrophils. The patient was started on vancomycin and tobramycin. An effluent culture was positive for Bacteroidesfragilis. Despite antibiotic therapy and the addition of metronidazole, the effluent culture stayed positive for more than a week. No visceral or intestinal perforations were seen on abdominal computed tomography imaging. The patient remained highly symptomatic and had a complicated hospitalization.

Peritoneal effluent cultures subsequently showed multiple bacteria, including Klebsiella pneumoniae, Morganella morganii, B. fragilis, Prevotella species, Clostridium clostridioforme, Cit. koseri, and Enterococcus faecium. The peritoneal catheter was removed, but the peritonitis persisted despite aggressive treatment. The patient died of ongoing complications 4 months after the gastroscopy.

A Second Case of Gastroscopy-Related Peritonitis in Peritoneal Dialysis Patients

A 73-year-old man with a 3-year history of continuous ambulatory PD for chronic glomerulopathy. He had experienced only 1 previous episode of culture-negative peritonitis treated with cefazolin 2 years after PD initiation. The patient was admitted for uremic encephalopathy secondary to non-adherence to dialysis therapy. Extended blood work and cultures, including effluent cultures at admission, all came back negative.

Uremic symptoms improved with re-commencement of PD. However, 10 days after his admission, the patient developed upper gastrointestinal bleeding. He underwent a gastroscopy that revealed active bleeding from a large duodenal ulcer. Epinephrine was injected, and clips were placed. A second gastroscopy performed 2 days later observed no active bleeding. That day, the patient reported abdominal pain and cloudy effluent.

An effluent WBC count was elevated at 2930 cells/mm3, with 93% neutrophils, and an effluent culture was positive for Escherichia coli. The WBC count remained elevated for 6 days. The patient was treated empirically with tobramycin and cefazolin until receipt of the definitive culture results; the antibiotic course was completed with ciprofloxacin treatment for a total of 21 days.

The patient was discharged home a few days after his peritonitis without any further complications.

Perit Dial Int. 2014 Sep-Oct; 34(6): 667–670.

Discussion

So from those 2 patients we can Conclude the following

Patient on PD can continue without Peritonitis episodes for long periods and just after one GIT procedure he got sever peritonitis that may complicate Up to DEATH as First Patient or can resolve as second Patient

Also Multiple organisms can cause peritonitis after Gastroscopy as Bacteroid fragilis, E.Coli , Strept. Viridians , Ent.faecalis , Klebsiella pneumoniae, Morganellamorganii , Clostridium clostridioforme, Cit. koseri , and many others.

Conclusion :antibiotic prophylaxis should be contemplated in PD patients undergoing upper endoscopy.

Perit Dial Int. 2014 Sep-Oct; 34(6): 667–670.

Catheter insertion

ISPD POSITION STATEMENT ON REDUCING THE RISKS OF PERITONEAL DIALYSIS–RELATED INFECTIONS

Prophylactic antibiotics administered at the time of insertion decrease the infection risk (Evidence)

A single dose of intravenous (IV) antibiotic given at the time of catheter placement decreases the risk of subsequent infection. A firstgenerationcephalosporin has been most frequently used in that context. However, a randomized trial found that vancomycin (1 g IV, single dose) at the time of catheter placement is superior to cephalosporin (1 g IV, single dose) in preventing early peritonitis


Exit site infection Prophylaxis


An observational study in 740 incident PD patients showed that use of topical mupirocin was associated with a significant reduction in exit-site infection and peritonitis .In a meta-analysis of ten studies (three RCTs and seven historical cohort studies) of mupirocin prophylaxis to prevent S. aureus infection, PD patients using prophylaxis had a 63% reduction in the risk of S. aureus infection—peritonitis being reduced by 66% and exit-site infection by 62%.


Invasive GIT Procedures Prophylaxis


Invasive gastrointestinal procedures may infrequently cause peritonitis in PD patients. (Evidence) Intravenous antibiotic prophylaxis reduces early peritonitis in these patients (Evidence)

although the difference was not statistically significant. Antibiotics such as ampicillin (1 g) plus a single dose of aminoglycoside, with or without metronidazole, given intravenously just before the procedure may lower the risk of peritonitis

some might choose to administer prophylactic antibiotics by the intraperitoneal route the night before the procedure. The work group recommends that the abdomen be emptied of fluid before any procedure involving the abdomen or pelvis, including colonoscopy, renal transplantation, cholecystectomy, and endometrial biopsy.


Dental Procedures Prophylaxis


Transient bacteremia—for example, from dental work or dental abscess, or even poor dentition—can lead to peritonitis. A single oral dose of amoxicillin (2 g) 2 hours before extensive dental procedures are used in some programs as prophylaxis. Currently, no studies have evaluated antibiotic prophylaxis for dental work to prevent peritonitis in PD patients.


Gynecologic Procedures Prophylaxis


Gynecologic sources are unusual causes of peritonitis. Vaginal delivery was associated with peritonitis in a woman whose vaginal vault was colonized with Escherichia coli. Such a complication would seem to be preventable by giving prophylactic antibiotics before delivery. Hysteroscopy with biopsy can lead to severe peritonitis . Peritonitis has been reported secondary to a vaginal leak occurring after recurrent peritonitis, leading to formation of a subcompartment in the peritoneal cavity , or to a vaginal fistula presenting as a vaginal leak , and even to a vaginal leak in a prepubescent child on PD . Vaginal colonization with Streptococcus agalactiae can be the source of contamination for a female patient or for a male patient who is the partner of a colonized woman . Organisms are variable, but vaginal sources can lead to fungal peritonitis.


Fungal Prophylaxis

Fungal prophylaxis during antibiotic therapy may prevent some cases of Candida peritonitis in programs that have high rates of fungal peritonitis . (Evidence)

A number of studies have examined the use of prophylaxis— either oral nystatin or a drug such as fluconazole—given during antibiotic therapy to prevent fungal peritonitis, with mixed results. Programs with high baseline rates of fungal peritonitis found such a prophylactic approach to be beneficial; those with low baseline rates did not detect a benefit


Health & Medicine

Contamination and antimicrobial prophylaxis in Peritoneal Dialysis