Infections and Related Conditions

July 27, 2006

Question

With regard to exit site care, what is the role of hypertonic compresses and your experience with them?

Submitted by PDU Administration - 06/09/2005

Response from

Not much good literature on this but we use as adjunct for exit site infections and I also use it to treat equivocal exit site infections if I am reluctant to give antibiotics.

Response from

We rarely use hypertonic compresses any more.

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I agree with Beth on compresses.

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Question

We have a CCPD patient who has no further HD access options and is not a candidate for transplantation. He did well for the 1st yr of CCPD but has now had 3 bouts of peritonitis (diptheroids) since May. His exit site and tunnel look OK. I will image to make sure there is no fluid collection. He is currently on his third course of IP vanc and symptomatically is doing better. Cell count improving.Has anyone had success with stripping "slime" from the catheter with TPA and if so is there a protocol available for how to best do this? Secondly, would anyone consider placement of a new catheter in a different site while leaving the current catheter in place for ongoing IP antibiotics.

Submitted by Valerie Kubacki - 9/22/2004

Response from

For this case, I suggest a same day removal and re-insertion after the current peritonitis is under control, i.e. WBC<150.

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Question

How soon after pleurodesis can a patient return to PD? He had the pleurodesis for recurrent hydrothorax secondary to PD.

Submitted anonymously - 10/18/2004

Response from

Interestingly, we have a patient on the ward now who just underwent talcpleurodesis, and the surgeon told the team to re-start PD the day after removal of the chest tube.

On the basis of no evidence, I think that it is WAY too fast. If one is proposing induction of an inflammatory / fibrotic reaction, then it should be left for a couple of weeks at least. Not only is there the issue of allowing time for the pleurodesis to pleurodese, there is the theoretical risk of the agent (talc, whatever) washing into the peritoneal cavity. So I would leave it alone for as long as possible, but a minimum of two weeks.

This is often not a big problem since the hydrothorax typically occurs at the beginning of PD, when the patient has enough RRF that they can go without dialysis for a couple of weeks. That is the case with our patient, and we are going to keep our fingers crossed and wait.

Response from

Scarring is probably maxed at 6 weeks by the firbrosis literature. Anytime practical less than 6 weeks thus is logical, so the nature of the PD would matter (supine, other reasons to increase IAP, tolerance of low volumes, degree of RRF, etc).

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A quick review of some of the literature suggests that 3 weeks is rather standard, although in one case, PD was resumed safely after 2 weeks.

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Question

Can a PD Catheter be saved in a patient with VRE peritonitis? This patient has severe HD access problems. She is responding poorly to PO Zyvox. Can Zyvox be used IP? What is the dose for this as I cannot find it anywhere. Patient is not systemically ill and apart from mild abdominal pain and cloudy effluent she does not have any other overt issue for now. Her PD cell count is 2 to 300 range and WBC count is normal.

Submitted by S.K. Masood -10/25/2004

Response from

Give IP linezolid 300 mg/L for two days to get IP levels high. During this time increase CAPD to 6 exchanges each day Then remove catheter, at this point switch linezolid to po or IV Wait 3 days, then replace catheter Resume PD using cycler at night, no day dwell for one week, then resume CAPD---during this time continue linezolid. Might be prudent to give this patient diflucan 100 mg each day prophylaxis against fungus.

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Question

Regarding intraperitoneal antibiotics, mainly Vancomycin and Gentamicin, should levels be done especially if anuric? Also if levels are done should we follow the "usual" blood recommended? Shouldn't intraperitoneal use of antibiotics permit "lower blood" levels?

Submitted by Talha Imam - 10/26/2004

Response from

Intraperitoneal intermittent antibiotics work by being absorbed and then crossing back over into peritoneum. Therefore, PD fluid levels (in exchanges other than the one administered) are about 1/2 that of serum. I re-dose when level is 15 mcg/ml for vancomycin. Usually this is at about 5 days. For gentamicin, depends on the dose given. At 20 mg/L in one exchange one would not expect high levels. Gentamicin seems to work differently in that short periods with high IP levels seem to 'stun' the bacteria and works fairly effectively.

Response from

We do measure the Vancomycyin levels and do so more frequently in patients with residual renal function. We target the usual therapeutic levels. For gentamicin, we also do levels, but we are more looking for toxicity levels. They tend to run in the low therapeutic range, which I accept if they are responding to treatment. It may be that the peak level given once a day with the gentamicin is adequate without reaching systemic levels that are usually therapeutic.

Response from

I almost never draw levels on vancomycin, but if you are concerned, you could draw a peak and a trough at 4-5 days. I would however recommend serum levels with aminoglycosides when they are administered over several weeks. I have seen patients develop inner ear problems from inappropriate drug levels.

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Question

I have 2 questions on a patient who developed peritonitis with Klebsiella and treated with avelox for 2 weeks but afterward had a course with intermittent increase in PD fluid WBC count with negative cultures and intermittent treatment with vancomycin and gentamicin. On his description his fluid turns cloudy when he becomes constipated and straining. Finally we switched him to Hemo and he is on zosyn and diflucan empirically. 1) Do you think straining causes his cloudy fluid? Or could it be catheter infection? 2) Would you try PD again in few weeks?

Submitted by Abdullah Hamad - 12/27/2004

Response from

  1. I am curious why a fluoroquinolone was used versus cefazolin/gentamicin to treat the klebsiella. Was the avelox administered IP?

  2. The cloudy fluid with straining/constipation may indicate diverticulitis?

  3. Was the catheter pulled in the switch to hemo? If you believe that the patient may have fungal peritonitis, the catheter will need to be removed. A new catheter can be placed after 2-4 weeks and the patient restarted.

Response from

Yes, I think he may have had translocation across the bowel wall of micro-organisms. Constipation should be avoided. Yes, I think if the patient wishes to return to PD then this is reasonable option.

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I agree with Beth.

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Yes to both. If he strains he'll rupture something, so stop that.

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Question

Studies have shown the use of ultra pure water in the dialysate reduces chronic inflammatory state and also prevalence of carpal tunnel syndrome. Is there any evidence to show these disease entities have a much lesser prevalence in PD patients when compared HD, since the peritoneal membrane is a better barrier?

Submitted by Mohammad Rafey - 01/10/2005

Response from

Overall, there is no direct evidence that carpal tunnel is decreased with ultrapure water use. While inflammation plays a role, there are a number of other factors that impact on the incidence of carpal tunnel ie the removal rate of Beta 2 compounds etc. This is an intriguing thought however.

Response from

I can't comment about the chronic inflammatory state, because I don't think we know how to assess that complex condition. With respect to carpal tunnel syndrome, as a result of accumulation of beta-2 microglobulin, there is much less prevalence of these amyloid syndromes in PD patients compared to the older vintage hemo patients. The 2 contributing factors, though, don't have much to do with inflammation directly: 1) Less time spent on PD, so less time for development of these chronic types of complications (ie greater proportion of hemo patients stay on hemo for >10 years than PD patients stay on PD for >10 years). 2) Residual renal function in PD allows for excretion of more beta-2 microglobulin so blood levels are lower, this may mitigate against the development of B2M amyloid. I don't know about respective prevalence with the newer hemo membranes.

Response from

I agree with Joanne's assessment---less time on PD and the protection of RRF lead to less amyloid problems on PD. Having said that I have a woman on PD 17 years with no obvious amyloid, always on continuous PD with good clearance (lost her RRF years ago). But, this is anecdotal. Another lady on 9 years until trxplt had knee pain which I suspected was amyloid (no proof) which resolved after txplt. The question of the inflammatory state (I presume measured by CRP) is quite interesting and I don't believe I have seen a comparison. We measure CRP now yearly in PD and most patients have low levels. Heimburger et al from Sweden published a nice paper on risk of elevated CRP and death in PD patients (there was a relationship). But, no comparison to HD.

Response from

The issue of water is just a small part of it, as was complement activation by low flux complement activating membranes, as well as duration of ESRD, RRF, and numerous unknown factors prior to any water exposure. Amyloid comes in part from WBCs, activated or stimulated to make more amyloid by exposure to water, membranes, bacterial by products, etc. Ultrapure water is good, highly desirable, but not the whole answer.

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I am carrying out studies in animals. We find that distilled, deionized and filtered water + salts still cause inflammation in the peritoneum.

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Question

Since using mupirocin routinely for catheter exit-site infection prophylaxis, we have seen two patients' catheters begin to deteriorate. Our surgeons use Cruz catheters, but I don't know the composition of the material they are made from. I have seen one 1998 article implicating polyurethane catheters as being susceptible to this problem. What is the latest word on this issue? And should Cruz catheters be avoided for this reason?

Submitted by Michael Jacobson - 8-2-04

Response from

Catheters are made of polyurethane and no antibiotic ointment should be placed around these catheters. This has been shown in two different studies (one published only in abstract form to my knowledge and presented at a meeting but had impressive pictures of catheter malformation--it was not only mupirocin used but also other antibiotic ointments). This has not been shown for silicone catheters. We use only silicone catheters and have seen no damage from either cream or ointment over more than 10 years.

To my knowledge the Cruz catheter is the only one commercially available that is polyurethane. I am also unaware of data on cream antibiotics as opposed to ointment.

Response from

I agree with Beth. Under no circumstances did we advocate ointment. We specified cream and our handouts (Ad Hoc Committee report) stated cream.

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I agree with Beth's note. The Cruz catheter deteriorates when exposed to alcohol, which is in the mupirocin ointments. In addition, we had several late leaks with the Cruz catheters. That is, after a couple of years. At the time of catheter removal, the inner cuff had disconnected from the catheter. This was also reported in an abstract at one of the ADC. Therefore, we stopped using them several years ago.

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Question

We have an APD patient who reported an accidental disconnect two days after disconnecting. Fluid was sent for C&S (neg), cell count (370 WBC), and gram stain (neg). Cefazolin and Fortaz started. Cell count dropped to 25, culture remained negative, and Fortaz discontinued. Three days later patient reported cloudy fluid and mild pain (previously asymptomatic). Reculture negative, cell count increased to 450, Fortaz restarted. Patient treated for two weeks for culture negative peritonitis. At the end of two weeks therapy C&S negative, WBC 114. Five days after end of therapy C&S negative but WBC 191. Pt. reporting mild abd pain with cycling. Cefazolin and Fortaz restarted along with Rifampin. Two days later cell count 1930. CT abdomen negative. Pt now on Cefazolin, Fortaz, Rifampin, and Diflucan. Cell count 220, patient aymptomatic.

Pt. is young, otherwise healthy, and dreading possible removal of catheter which will be our next step. Are we missing anything? Is three weeks of therapy the proper duration for culture negative relapsing peritonitis?

Submitted by Laurie Marino 9-15-04

Response from

This is a difficult case. Usually a disconnect would be a staph epi, but could be other things, could be a coincidence. So, I would have treated as emperic treatment for the full 14 days, then if you get a relapse, repeat the same. But with the course of antibiotics this patient has received, that is less obvious. It could be a staph epi that needs Vanco i.e. partial resistance to cephalosporins. The rifampin may be good for a slime layer.

The risk now after the time of treatment is a secondary problem e.g. fungus etc. So, since the patient has responded again, I would now treat for 2 weeks but I might use Vanco instead of the ceph. I agree with the fungal prophylaxis. I am not sure what Fortaz is (?different trade name from Canada).

Response from

Culture neg peritonitis in the absence of surreptitious antibiotics behaves like CNS. CNS may require vancomycin since resistance is relative. I have always advocated cefazolin as the first line, but if a CNS infection doesn't respond within 4 days or less, vancomycin should be used. Now perhaps this is not CNS. If it is fungal, it should grow and be isolated. It could represent an infected catheter. I'd try tPA and slow IP vancomycin infusion vs. a catheter lock with vanco, prior to cath removal. A cath removal does not mean d/c of PD. If the infection is still active, it is not prudent to do the cath change out in one procedure. This pt must be put on nystatin S & S.

Response from

I agree with what Tom has presented.

Response from

Agree with Tom. Think the original organism was likely MR CNS that needed vancomcyin. Now it is too late and would IMMEDIATELY remove the catheter. (And would treat with vancomycin and second drug for GNR coverage and leave on diflucan). If patient quickly then improves new catheter could be placed in 2 weeks or so. The patient is risking permanent peritoneal membrane damage by waiting at this point.

Response from

I agree with Tom. At the risk of adding more than 2 cents: Do as Tom says and ask about icodextrin use as it may occasionally cause culture negative peritonitis. If so, DC icodextrin. But otherwise Tom and Beth are "tha persons". (Please see important safety information for icodextrin at the end of this section).

Extraneal (icodextrin) important safety information:

  • EXTRANEAL is indicated for a single daily exchange for the long (8-16 hour) dwell during continuous ambulatory peritoneal dialysis (CAPD) or automated peritoneal dialysis (APD) for the management of chronic renal failure.

  • EXTRANEAL is contraindicated in patients with a known allergy to cornstarch or icodextrin or in patients with glycogen storage disease.

  • In clinical trials the most frequently reported adverse events occurring in ?10% of patients, and more common in EXTRANEAL patients than in control patients, were peritonitis (26% vs 25%), upper respiratory infection (15% vs 13%), hypertension (13% vs 8%), and rash (10% vs 5%). The most common treatment-related adverse event for EXTRANEAL patients was skin rash (5.5% vs 1.7%).

  • Since falsely elevated glucose levels have been observed with blood glucose monitoring devices and test strips that use glucose dehydrogenase pyrroloquinolinequinone (GDH PQQ)-based methods, GDH PQQ-based methods should not be used to measure glucose levels in patients administered EXTRANEAL. The manufacturer(s) of the monitor and test strips should be contacted to determine if icodextrin or maltose causes interference or falsely elevated glucose results.

  • Patients with insulin-dependent diabetes may require modification of insulin dosage following initiation of treatment.

  • Please see EXTRANEAL full prescribing information .

Response from


Question

Anybody with experience with cubucin? When? Success? I've used once in staph epi in patient allergic to vanco.

Submitted by Abdullah Hamad 4-15-04

Response from

I have discussed with the cubicin rep and they say it will work. However, I have seen no data for PD and have not used it. There are potential advantages over Vanc (no reported resistance) and it has the same spectrum. As far as cost- based on reimbursement if the patient was medicare only, our unit states that they would loose money (pay more than re-imbursement).

Response from

Cubicin (datomycin) is a good but potentially toxic antibiotic (rhabdo). It will need reduction in CKD and the studies are underway now. I hope the organism was MRSA, not MRSE, and the vanco allergy was real and occurred with ultraslow infusion.

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Question

What is a reasonable goal for peritonitis frequency? (One episode for how many patient-months?)

Submitted by Cathryn Wise 4-23-04

Response from

The frequency of peritonitis reported from various parts of the world can be used as an indicator of the achievable rates. While the national average in the US is close to 1:26 patient months, several centers in the US have decreased their peritonitis frequency to less than 1:48 and even 1:60 patient months. The same is true in other parts of the world. In Japan the national average is quoted to be close to 1:60 patient months. It is in the 1:36 to 1:40 in Korea and Taiwan, and close to 1:32 in Hong Kong. A reasonable goal would be an achievable goal in a US context considering the patient population and practice patterns. My suggestion is that if your peritonitis rate is less than 1:36 patient months, then you need to look closely at active interventions in the near term. If you are above 1:36, don't stop there. Try to match the best practices.

Response from

I would suggest one episode per 24 months.

Response from

I think Beth Piraino is best placed to answer. Current peritonitis rates are usually one in every 20-30 patient months. In Japan it is closer to 1 in 50-60 patients months. My program last year was 1 in 42 months. So there is considerable variability. I think more important than absolute rate is what causes the infection. If there is lots of staph epi, technique and connectology may be a problem. If staph aureus, better prophylaxis is necessary. If relapsing peritonitis is there, then first line treatment adequacy and length must be assessed e.g. is there a high local resistance to cephalosporins for staph epi, etc.

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Question

For APD patients: Should I be concerned about higher antibiotic clearance in these patients? Is there any data to suggest that continuous versus intermittent antibiotic dosing is more effective?

Submitted by Cathryn Wise 4-23-04

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To my knowledge there are no trials of continuous vs intermittent dosing in APD but yes, you should be worried about higher clearance, and lower levels in APD with intermittent dosing. There is not enough information about this question (a very good one) yet.

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For APD patients, I dose them in the last bag option. The guidelines do give various ways of treating these patients. I do not switch to CAPD.

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Question

For antibiotic dosing according to weight do you recommend using ideal body weight or some type of adjustment for the obese patient?

Submitted by Cathryn Wise 4-23-04

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I would defer to a pharmacologist, but would suggest ideal body weight in the morbidly obese patient.

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For underweight patients we use actual body weight. For obese patients we use closer to ideal body weight.

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Question

We have noticed that fungal peritonitis tends to arise in patients on multiple antibiotics or multiple courses of antibiotics. Should consideration for prophylactic antifungal therapy be given to this group of patients?

Submitted by Cathryn Wise 4-23-04

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Yes, most definitely, mycostatin oral qid. There are 6-7 studies on using anti-fungal prophylaxis during courses of antibiotics. Approx 1/2 are negative studies, 1/2 are positive. Those programs with higher rates had the positive results. Therefore, I interpreted this to mean that if a patient receives prolonged antibiotics, then I use mycostatin. I recently forgot to do this and the patient developed fungal peritonitis.

Response from

At our center, we have had several episodes of fungal peritonitis and so, we routinely use oral nystatin as prophylaxis. We begin it simultaneously with antibiotic therapy and continue for at least one week after completion of antibiotics.

Response from

There are some studies that prophylax with anti fungal agents when there is prolonged antibiotic use with reduced fungal peritonitis rates. We do not because we have such a low rate of fungal peritonitis.

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Question

How do I dose peritonitis meds for my APD patients?

Submitted anonymously

Response from

If patients are performing all exchanges from their cycler, including the Last Bag Option (LBO): The antibiotics we use routinely are stable in dialysate for at least 48 hours. So the total daily antibiotics can be divided into each cycler bag (e.g. 3 x 5 liter bags hanging 125 mg Cefazolin/ L so each 5L bag would have 625mg placed in it. Then perform dialysis as usual.

If patients only perform APD and LBO from cycler, but do a manual later: Same as above. One can either add antibiotics to the manual bag or not. If not, then the amount of antibiotic that would have gone into the manual bag, can be added to one of the cycler bags to compensate.

If patients are NIPD, only do antibiotics during PD.

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Question

I am concerned about infection in my PD population, and have heard about the routine use of mupirocin to reduce risk of infection. Can you tell me more? Is this daily or intermittent application? Could I use polysporin instead, since it is cheaper?

Submitted anonymously

Response from

There are more than three papers on the efficacy of daily mupirocin. I recommend this daily, not intermittently, which has not been well studied. In the absence of data I would not recommend substituting polysporin.

References suggested by Beth Pirano, MD (there have been a few others, but these are the three important ones):

  1. Bernardini, Piraino et al. A Randomized trial of SA prophylaxis in PD patients: mupirocin calcium ointment 2% applied to the exit site versus cyclic oral rifampin Am J Kidney Dis 1996; 27: 695-700 [we were the first to examine exit site mupirocin and compared it to the Zimmerman protocol — both equally effective and more effective than historic controls with nothing]

  2. Thodis E, ....Oreopoulos. Decrease in SA exit site infections and peritonitis in CAPD Patients by local application of mupirocin ointment at the catheter exit site PDI 1998; 18; 261-270 [confirmed our results]

  3. Casey M ....Burkart. Application of mupirocin cream at the catheter exit site reduces exit-site infections and peritonitis in peritoneal dialysis patients PDI 2000;20:566-568. [confirms the results]

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