The ADEMEX Study A Greater Understanding of Peritoneal Dialysis

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Infections in PD Prevention and Management
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Peritonitisa cause of

• Peritoneal membrane damage
• Hospitalization and pain
• Catheter loss
• Technique failure
• Death

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Peritonitis cells in effluent

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Peritonitis Infiltration
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Pathogen Pathway
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Tunnel Infection
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Complications of Peritonitis

• Temporary loss of UF
• Increased protein losses
• Catheter loss
• Adhesions
• Sclerosing encapsulating peritonitis
• Transfer to HD
• Death

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Peritonitis
DEFINITION 1. Signs and symptoms 2.
Cloudy fluid - gt100 wbc/ml gt50N 3.
Identification of organism Two of three required
for diagnosis RELAPSING PERITONITIS Another
episode of peritonitis caused by the same
genus/species within 4 weeks of completing
antibiotic course
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Peritonitis Diagnosis

• Cloudy fluid /- abdominal pain /- fever
• Dialysate effluent should be obtained for
  laboratory evaluation (gt4 hrs dwell time)
• Culture
• Cell count, with differential
• Gram Stain
• Confirmation
• WBC count gt100/mm3 , of which 50 are
  polymorphonuclear neutrophils (PMN), is
  confirmation of microbial-induced peritonitis

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Clinical Course in CAPD Peritonitis
Introduction of bacteria into
peritoneum Bacteria Peritoneal
wall Multiply
ASYMPTOMATIC FOR 24 - 48 HRS
Shed into PD fluid Abdo
pain Cloudy fluid peritonitis
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Micro-Organisms Causing Peritonitis
Harwell PDI 199717586-594
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Routes of Peritoneal Infection
Exchange procedure
Haematogenous
Titaneum/transfer set
Pericatheter
Transcolonic
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Sources of Peritonitis,
Harwell PDI 1997

• Contamination 41
• Catheter related 23
• Enteric injury 11
• Perioperative 6
• Diarrhoea/UTI 4
• Sepsis 1
• Unknown 14

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Peritonitis - Yset Systems
P risk (Maiorca Lancet 1983)

• Y-set first by
• Buoncristianti 1980
• Long Y with
• disinfectant
• Flush before fill
• Proliferation of
• disconnect systems

standard
Y set
Months
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CAPD vs APD
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Initial assessment

• Symptoms cloudy fluid and abdominal pain
• Do cell count/differential
• Gram stain and culture
• - on initial drainage
• Initiate empiric therapy
• Choice of final therapy should always be guided
  by antibiotic sensitivities

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Gram Staining

• A gram stain is positive in 9-40 of peritonitis
  episodes
• When positive it is predictive of eventual
  culture results in 85 of cases
• It is particularly useful in early recognition of
  fungal peritonitis through revealing presence of
  yeast
• If on initial evaluation, a gram stain is ve, a
  single antibiotic with activity against gram ve
  organisms should be started
• Identification of a single organism on Gram stain
  does not preclude the presence of other organisms
  in lesser concentrations
• Finding gram ve cocci and gram-negative rods
  together may indicate perforated abdominal viscous

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Possible Causes of Culture Negative Peritonitis

1. Culture methods of low sensitivity used the
   culture techniques for PD effluent is specialized
2. Culture volumes are too small
3. Causative organism requires specialised culture
   media
4. Cultures are taken from patients on antibiotic
   treatment
5. The symptoms and signs are not due to infectious
   agents

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Cloudy Effluent Cellular Causes Increased PMN

• Infectious causes
• Intraperitoneal visceral inflammation (eg,
  cholecystitis, appendicitis, bowel ischemia or
  obstruction)
• Juxtaperitoneal visceral inflammation (eg,
  pancreatitis, splenic infarction, abscess)
• Endotoxin-contaminated PD fluid
• Drug associated (eg amphotericin, vancomycin)

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Cloudy Effluent Cellular Causes Increased
Eosinophils

• Allergic reaction to constituent of dialysis
  system (e.g., sterilant, plasticizer)
• Drug associated (eg, vancomycin, streptokinase)
• Air-induced peritoneal irritation
• Blood-induced peritoneal irritation (e.g.,
  retrograde menstruation)

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Cloudy Effluent Cellular Causes Increased RBC

• Reproductive Retrograde menstruation, Ovulation,
  Ectopic pregnancy
• Cyst rupture (ovarian or hepatic)
• Peritoneal adhesion formation
• Strenuous exercise
• Catheter-associated trauma
• Post-procedure laparoscopy, colonoscopy
• Encapsulating peritoneal sclerosis
• Anticoagulation therapy
• Acute or chronic pancreatitis
• Post radiation

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Lessons

• Organisms suggest causation
• S. Epidermis touch contamination
• S. Aureus catheter infection
• Outcomes depend on
• Causative organisms and severity
• - Gram negative gtgt S. Aureus gtgt S. Epidermidis
• Associated conditions and severity
• Peritonitis tunnel gtgt Peritonitis ESI
• Peritonitis ESI gtgt Peritonitis

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Causative Organisms
Bunke et al, KI 52524-529, 1997
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Gram Positive Organisms
Bunke et al, KI 52524-529, 1997
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Organisms and Outcomes
Bunke et al, KI 52524-529, 1997
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Outcomes of Peritonitis
Bunke, et al., KI 1997
of all episodes(without ESI/TI)
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Time Course of UF After Peritonitis
Ates, et al., PDI 202000220-226
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Prevention of PeritonitisDue to Contamination

• Disconnect systems
• Careful training
• Patient selection
• Assessment of home environment

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Exit Site Infections - Prevention

• Staph aureus ESI occurs mainly in nasal carriers
• Incidence can be reduced by treating with
  mupirocin (M)
• (M) can be given intranasally twice daily x 5
  days each month, or
• Applied (M) to exit site intermittently or daily
  as part of exit site care

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S aureus CAPD related infections are associated
with nasal carriage
S. aureus episodes/year
Data from Lye et al, 1994 Nasal carriage
defined as min of 2 of 3 NC ve
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Effect of S aureus prophylaxis on prevention of S
aureus peritonitis
S aureus peritonitis/year
Perez-Fontan
Mupirocin Study Group
Bernardini
Thodis
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Exit site/Tunnel and Outcomes
Bunke et al, KI 52524-529, 1997
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Exit site/Tunnel and Outcomes
Bunke et al, KI 52524-529, 1997
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Exit site/Tunnel and Outcomes
Bunke et al, KI 52524-529, 1997
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Tunnel Ultrasonography
Vychytil et al, AJKD 33722-27, 1999

• Indications
• Exit site infection (S. Aureus)
• Follow up of tunnel infection
• Peritonitis with exit site infection
• Recurrent/persistent peritonitis
• No indications
• Routine screening
• Search for foci in absence of ESI
• Peritonitis without ESI
• Tunnel pain with no other signs or symptoms

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Peritonitis Rates

• Prevention is a realistic goal.
• Proof
• Japan 145 to 160 patient/months
• Taiwan 135 to 145 patient/months
• Europe 126 to 138 patient/months
• Singapore 128 patient/months
• Mexico 124 to 126 patient/months

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Peritonitis Rates
Crabtree et al, ASAIO 45574-80, 1999 Golper et
al AJKD 28428-36, 1996

• 50 of patients account for 90 of infections
• Patients with one infection episode are more
  likely to have another than those with none
• Most repeat offenders develop their infection
  early in the course of therapy The earlier in
  dialysis history an infection develops, the more
  infection prone the patient continues to be.
• A high risk period for ESI/TI is in the 12 months
  post implant.

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S. Aureus Nasal Carriage

• JASN 72403-8, 1996
• Multicenter study in 9 European countries
• 1144 CAPD patients screened
• 267 (23) carriers of S.Aureus (2 ve swabs)
• JASN 9669-76, 1998
• Single center prospective
• 76 patients cultured monthly for 3 years
• One positive culture in 65.8 of all patients,
  73 of diabetics, 72 of immunosuppressive Rx,
  59 of others

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Carriers State and Infection
Vychytil et al, JASN 9669-676, 1998
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Staph Aureus Prophylaxis
Bernardini et al, AJKD 27695-700, 1996
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EXIT SITE INFECTION (ESI)

• DEFINITIONS
• Acute ESI - purulent exit site drainage
• Additional features include redness, tenderness,
  edema and granulation tissue

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Chronic Exit Site Infection

• ESI is chronic if it persists gt 4 weeks
• Often there is crusting or scabbing

Exuberant tissue, pus, redness With
therapy improvement epithelium
spreads over granulation
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Tunnel Infection

• Redness, edema and/or tenderness over the
  subcutaneous tunnel
• Often, there is associated ESI but some cases are
  occult
• May need ultrasound to diagnose

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Exit Site Management

• Antibiotics
• Intensified local care
• Local debridement

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Exit Site ManagementLocal Debridement or
Exteriorisation of cuff

• Can involve shaving external catheter cuff or
  revising tunnel
• Results are variable and many prefer catheter
  removal

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Exit Site Infection PREVENTION

• Staph aureus ESI occurs mainly in nasal carriers
• Incidence can be reduced by treating with
  mupirocin (M)
• M can be given intranasally twice daily x 5 days
  each month
• Some apply M to exit site intermittently or daily
  as part of exit site care

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Summary

• Keys to low infection rates include
• Experienced personnel and careful training
• Minimize use of manual spike systems
• Continuous monitoring of infection rates and
  organisms
• Protocols for prevention, such as exit site
  mupirocin for S. aureus

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Infectious ComplicationsPredictable and
Preventable!