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IN THE NAME OF GOD

IN THE NAME OF GOD. F.SAMADIAN NEPHROLOGIST. Peritonitis and Exit Site Infection. the introduction of Y-set and double-bag disconnect systems has reduced this to approximately one episode per patient every 24 months. Potential routes of infection: Intraluminal Periluminal Transmural

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IN THE NAME OF GOD

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  1. IN THE NAME OF GOD F.SAMADIAN NEPHROLOGIST

  2. Peritonitis and Exit Site Infection

  3. the introduction of Y-set and double-bag disconnect systems has reduced this to approximately one episode per patient every 24 months

  4. Potential routes of infection: • Intraluminal • Periluminal • Transmural • Hematogenous • Transvaginal

  5. Intraluminal: This allows bacteria to gain access to the peritoneal cavity via the catheter lumen

  6. Periluminal: Bacteria present on the skin surface can enter the peritoneal cavity via the peritoneal catheter tract

  7. Transmural: Bacteria of intestinal origin can enter the peritoneal cavity by migrating through the bowel wall This is the usual mechanism of peritonitis associated with diarrheal states and/or instrumentation of the colon and may be seen also with strangulated hernia

  8. Hematogenous: Less commonly, peritonitis is due to bacteria that have seeded the peritoneum from a distant site by way of the bloodstream

  9. Transvaginal: it may explain some instances of Candida peritonitis

  10. The responsible pathogen is almost always a bacterium, usually of the Gram-positive variety

  11. The occurrence of fungal peritonitis (e.g., Candida) is uncommon

  12. Infections with Mycobacterium tuberculosis or other type of mycobacteria have been reported but are unusual

  13. Diagnostic criteria for peritonitis: At least two of the following three conditions should be present: • symptoms and signs of peritoneal inflammation • cloudy peritoneal fluid with an elevated peritoneal fluid cell count (more than 100/mcL) due predominantly (more than 50%) to neutrophils • demonstration of bacteria in the peritoneal effluent by Gram stain or culture

  14. Symptoms and signs: • The most common symptom of peritonitis is abdominal pain • However, peritonitis should be suspected whenever a patient suffers from generalized malaise, particularly if nausea, vomiting, or diarrhea is also present

  15. Not all abdominal pain in a patient receiving PD is peritonitis

  16. Strangulated hernia is a common mimic for peritonitis

  17. Cloudiness of the fluid: The peritoneal fluid generally becomes cloudy when the cell count exceeds 50-100/mcL

  18. In most patients, sudden onset of cloudy fluid with appropriate abdominal symptoms is sufficient evidence of peritonitis to warrant initiation of antimicrobial therapy

  19. However, peritoneal fluid cloudiness may be due to other factors (e.g., fibrin, blood, or, rarely, malignancy or chyle)

  20. On the other hand, a relatively translucent peritoneal fluid does not completely exclude the possibility that peritonitis is present (early in the course of peritonitis)

  21. The absolute peritoneal fluid cell count in CAPD patients is usually <50 cells/mcL and is often <10 cells/mcL

  22. Normally, the peritoneal fluid contains predominantly mononuclear cells (macrophages, monocytes, and, to a lesser extent, lymphocytes)

  23. The percentage of neutrophils does not normally exceed 15% of the total nonerythrocyte cell count and a value >50% strongly suggests peritonitis, whereas one >35% should raise suspicion

  24. Vancomycin or a first-generation cephalosporin such as cefazolin or cephalothin is used in combination with an antibiotic to cover Gram-negative organisms such as ceftazidime

  25. It is now recommended that aminoglycosides be avoided if possible in patients with residual renal function because of their nephrotoxicity

  26. CAPD • Loading dose: Infuse 2 L of 1.5% dextrose dialysis solution containing:1 g ceftazidime1 g cefazolin1,000 units/L heparin  Allow to dwell for 3-4 hours. • Continue regular CAPD schedule. Add 125 mg per L ceftazidime, 125 mg/L cefazolin, and 1,000 units/L heparin to each dialysis solution bag

  27. If a patient appears toxic recommend a single loading dose IV

  28. Duration of therapy: • If patient improvement is prompt, antimicrobial therapy should be continued for a total of 14 days • If a cephalosporin is being used, then some physicians will switch to PO therapy after the first 5 days

  29. Severe S. aureus infections require antimicrobials for 3 weeks, and treatment with one IP antistaphylococcal drug plus PO rifampin is recommended

  30. Patients in whom S. aureus peritonitis develops not uncommonly are found to carry this organism in the nose

  31. This can be accomplished with intranasal mupirocin (b.i.d. for 5 days every 4 weeks) or oral rifampin (300 mg b.i.d. for 5 days every 3 months

  32. Exit site infection Approximately one fifth of peritonitis episodes are temporally associated with exit site and tunnel infections

  33. Etiology and pathogenesis: • Exit site infections are predominantly due to S. aureus or Gram-negative organisms, particularly Pseudomona • In contrast to peritonitis, S. epidermidis is the causative organism in <20% of patients eradication of the carrier state is very helpful to effective management

  34. Treatment is dependent on whether there is erythema alone or erythema in conjunction with purulent drainage • In the former case, topical treatment with hypertonic saline compresses, hydrogen peroxide, or mupirocin 2% ointment is usually sufficient

  35. Treatment is more problematic and more prone to failure when there is purulent drainage • some exit site infections extend into the subcutaneous tunnel

  36. The major risk factor for exit site infection is staphylococcal nasal carriage

  37. Persistently positive nasal cultures are associated with a 3-4 fold increase in risk of staphylococcal exit site infection

  38. Protocols used include -rifampin (600 mg PO for 5 days), -mupirocin (2% ointment twice daily for 5 days every 4 weeks) -trimethoprim-sulfamethoxazole (single-strength tablet three times weekly)

  39. Mechanical Complications of Peritoneal Dialysis

  40. The instillation of dialysis fluid into the peritoneal cavity is accompanied by an increase in intra-abdominal pressure (IAP)

  41. The two principal determinants of the magnitude of the increased IAP are dialysate volume and the position of the patient during the dwell

  42. The supine position is associated with the lowest IAP for a given dialysate volume; sitting entails the highest

  43. Hernia formation as many as 10%-20% of patients may develop a hernia at some time on peritoneal dialysis

  44. Potential risk factors for hernia formation -Large dialysis solution volume -Sitting position -Isometric exercise -Valsalva maneuver (e.g., coughing) -Recent abdominal surgery -Pericatheter leak or hematoma -Obesity -Multiparity -Congenital anatomical defects

  45. Many different types of hernias have been described in the peritoneal dialysis patient

  46. Types of hernias reported in peritoneal dialysis patientsVentralEpigastricPericatheterUmbilicalInguinal (direct and indirect)FemoralSpigelianRichterForamen of MorgagniCystoceleEnterocele

  47. Pericatheter hernias need to be differentiated from masses caused by a hematoma, seroma, or abscess

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