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Infections in PD Prevention and Management

Infections in PD Prevention and Management. Peritonitis a cause of…. Peritoneal membrane damage Hospitalization and pain Catheter loss Technique failure Death. Peritonitis: cells in effluent. Peritonitis: Infiltration. Pathogen Pathway. Tunnel Infection. Complications of Peritonitis.

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Infections in PD Prevention and Management

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  1. Infections in PD Prevention and Management

  2. Peritonitisa cause of… • Peritoneal membrane damage • Hospitalization and pain • Catheter loss • Technique failure • Death

  3. Peritonitis: cells in effluent

  4. Peritonitis: Infiltration

  5. Pathogen Pathway

  6. Tunnel Infection

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

  8. Peritonitis DEFINITION 1. Signs and symptoms 2. Cloudy fluid - >100 wbc/ml; >50%N 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

  9. Peritonitis Diagnosis • Cloudy fluid +/- abdominal pain +/- fever • Dialysate effluent should be obtained for laboratory evaluation (>4 hrs’ dwell time): Culture Cell count, with differential Gram Stain Confirmation • WBC count >100/mm3 , of which 50% are polymorphonuclear neutrophils (PMN), is confirmation of microbial-induced peritonitis

  10. 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

  11. Micro-Organisms Causing Peritonitis Harwell PDI 1997;17:586-594

  12. Routes of Peritoneal Infection Exchange procedure Haematogenous Titaneum/transfer set Pericatheter Transcolonic

  13. Sources of Peritonitis, % Harwell PDI 1997 • Contamination 41 • Catheter related 23 • Enteric injury 11 • Perioperative 6 • Diarrhoea/UTI 4 • Sepsis 1 • Unknown 14

  14. 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

  15. CAPD vs APD

  16. 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

  17. 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

  18. Possible Causes of Culture Negative Peritonitis • Culture methods of low sensitivity used – the culture techniques for PD effluent is specialized • Culture volumes are too small • Causative organism requires specialised culture media • Cultures are taken from patients on antibiotic treatment • The symptoms and signs are not due to infectious agents

  19. 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)

  20. 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)

  21. 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

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

  23. Causative Organisms Bunke et al, KI 52:524-529, 1997

  24. Gram Positive Organisms Bunke et al, KI 52:524-529, 1997

  25. Organisms and Outcomes Bunke et al, KI 52:524-529, 1997

  26. Outcomes of Peritonitis Bunke, et al., KI 1997 % of all episodes(without ESI/TI)

  27. *p<0.05 vs baseline for all times Time Course of UF After Peritonitis Ates, et al., PDI 20;2000:220-226

  28. Prevention of PeritonitisDue to Contamination • Disconnect systems • Careful training • Patient selection • Assessment of home environment

  29. 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

  30. 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

  31. Effect of S aureus prophylaxis on prevention of S aureus peritonitis S aureus peritonitis/year Perez-Fontan Mupirocin Study Group Bernardini Thodis

  32. Exit site/Tunnel and Outcomes Bunke et al, KI 52:524-529, 1997

  33. Exit site/Tunnel and Outcomes Bunke et al, KI 52:524-529, 1997

  34. Exit site/Tunnel and Outcomes Bunke et al, KI 52:524-529, 1997

  35. Tunnel Ultrasonography Vychytil et al, AJKD 33:722-27, 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

  36. Peritonitis Rates Prevention is a realistic goal. Proof: • Japan 1:45 to 1:60 patient/months • Taiwan 1:35 to 1:45 patient/months • Europe 1:26 to 1:38 patient/months • Singapore 1:28 patient/months • Mexico 1:24 to 1:26 patient/months

  37. Peritonitis Rates Crabtree et al, ASAIO 45:574-80, 1999; Golper et al AJKD 28:428-36, 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.

  38. S. Aureus Nasal Carriage • JASN 7:2403-8, 1996 • Multicenter study in 9 European countries • 1144 CAPD patients screened • 267 (23%) carriers of S.Aureus (2 +ve swabs) • JASN 9:669-76, 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

  39. Carriers State and Infection Vychytil et al, JASN 9:669-676, 1998

  40. Staph Aureus Prophylaxis Bernardini et al, AJKD 27:695-700, 1996

  41. EXIT SITE INFECTION (ESI) DEFINITIONS • Acute ESI - purulent exit site drainage • Additional features include redness, tenderness, edema and granulation tissue

  42. Chronic Exit Site Infection • ESI is chronic if it persists > 4 weeks • Often there is crusting or scabbing Exuberant tissue, pus, redness With therapy improvement; epithelium spreads over granulation

  43. 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

  44. Exit Site Management • Antibiotics • Intensified local care • Local debridement

  45. 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

  46. 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

  47. 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

  48. Infectious ComplicationsPredictable and Preventable!

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