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

1. 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

2. Reasons for Hospitalizations

3. Reasons for Change of Dialysis Modality* Percent NAPRTCS, 2006 * Other than transplantation

4. Causes of Death for Prevalent Pediatric PD Patients (2000-02) Mortality per 1000 patient years at risk USRDS, 2004

5. www.peritonitis.org

6. Prevention of Peritonitis Catheter-related factors Prevention of exit-site and tunnel infections Direct tunnel downward or use swan-neck catheter Use double-cuff catheters Use exit-site mupirocin Timely replacement of the catheter for catheter-related peritonitis Contamination Experienced nursing personnel Avoidance of spiking technology Long training period Training protocols Antibiotic prophylaxis Preoperative antibiotics at catheter insertion Contamination at time of exchange Dialysate leak at catheter exit site Invasive procedures Exit site mupirocin Warady & Schaefer, In: Chap. 24, Pediatric Dialysis, 2004

7. Peritonitis: Diagnostic Criteria • Cloudy effluent • Dialysate WBC count >100/uL • >50% polymorphonuclear leukocytes • Positive culture

8. Peritonitis: Effluent Cloudiness

10. Peritonitis: Source of Infection Unknown: 70 % ! Episodes (%)

11. Spectrum of Causative Organisms Schaefer et al. Kidney Int 2007

12. Regional Distribution of Culture Results Schaefer et al. Kidney Int 2007

13. EMPIRIC THERAPY Cloudy effluent Peritoneal effluent evaluation Cell count and differential Gram stain, culture Initiate empiric therapy If the patient presents with: -No fever -Mild or no abdominal pain -No risk factors for severe infection 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 Cefazolin (250/125 mg/l) and Ceftazidime(continuous 125 mg/L or 250 mg/L o.d.) Glycopeptide (e.g. vancomycin, 30 mg/l cont. or 30 mg/kg q.5-7 days) and Ceftazidime (continuous 125 mg/L or 250 mg/L o.d.)

14. Clinical Response Failure after 72h Empiric Antibiotic Treatment Warady et al. JASN 2007; 18:2172

15. Risk of Day 3 Clinical Response Failure No effect: choice of empiric therapy, risk assignment

16. 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

17. In vitro Sensitivities by Gram

18. In vitro Resistance Rates Schaefer et al. Kidney Int 2007

19. Final Outcome

20. Outcome by Causative Organism Rate of successful outcome (%)

21. Risk of Incomplete Functional Recovery No effect: choice of empiric therapy, risk assignment

22. Revised Guideline: Empiric Antibiotic Therapy Cloudy effluent Peritoneal effluent evaluation Cell count and differential Gram stain, culture Monitor local staphylococcal methicillin, gram-negative ceftazidime resistance patterns Initiate empiric therapy Cefazolin OR Glycopeptide andAminoglycoside OR (continuous) Ceftazidime

23. Revised Guideline:Modification for Culture Negative Episodes If improved clinically: Continue 1st generation cephalosporin or glycopeptide for 14 daysDiscontinue aminoglycoside after 3 daysAdd/continue ceftazidime after 3 days If not improved clinically: Remove catheter

24. Exit Site Infection

25. The diagnosis of a catheter exit-site infection should be made in the presence of a purulent discharge from the sinus tract or marked pericatheter swelling, redness and/or tenderness with or without a pathogenic organism cultured from the exit-site. Infectious symptoms should be rated according to an objective scoring system. Diagnosis of Exit-Site Infection GUIDELINE 14 Warady, Schaefer et al., Peritonitis Guidelines, PDI, 2000

26. Exit-Site Scoring System 0 Points 1 Point 2 Points Swelling no Exit only (<0.5 cm) Including part of or 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 aInfection should be assumed with a cumulative exit-site score of 4 or greater. Schaefer F. et al. J Am Soc Nephrol 10:136-145, 1999

27. Causative Organisms at Exit Site % of 58 episodes

28. 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

29. S.Aureus Infection Rate Nasal Carriers Noncarriers Exit-site infection rate 0.34 0.02 Tunnel infection rate 0.09 0.02 Peritonitis rate 0.17 0 Luzar et al, NEJM, 1990

30. Nasal S.Aureus Decontamination S. aureus Peritonitis, Episodes / y Piraino B, J Am Soc Nephrol, 1998

31. Options for Prevention of Exit-Site Infections

32. Topical S.Aureus Prophylaxis

33. Prophylaxis for S. AureusNasal 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 Warady et al., Peritonitis Guidelines, PDI 2000

34. Exit Site and Peritonitis Exit site co-colonizationis associated with 2-fold likelihood of peritonitis treatment failure 3-fold likelihood of catheter exchange 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) Schaefer et al. Kidney Int 2007

35. 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

36. International Pediatric PD Network www.pedpd.org