Infections in PD Prevention and Management

Infectious Complications: Predictable and Preventable

Infections in PD Infections in PD

Prevention and ManagementPrevention and Management


Peritonitisa 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

Temporary loss of UF

Increased protein losses

Catheter loss

Adhesions

Sclerosing encapsulating peritonitis

Transfer to HD

Death


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


Peritonitis Diagnosis 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


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


Micro-Organisms Causing Peritonitis

Harwell PDI 1997;17:586-594


Routes of Peritoneal Infection

Exchangeprocedure

Titaneum/transfer set

PericatheterTranscolonic

Haematogenous


Sources of Peritonitis, %

Contamination 41

Catheter related 23

Enteric injury 11

Perioperative 6

Diarrhoea/UTI 4

Sepsis 1

Unknown 14

Harwell PDI 1997


Peritonitis - Yset Systems

P risk % (Maiorca Lancet 1983)

0

10

20

30

40

50

60

70

80

90

0 3 6 9 12 15 18

Months

standard

Y set

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


Sept 15, 2000

Peritonit is in CAPD compared to APD

0

0.05

0.1

0.15

0.2

S aureus CNS Other

GPC

GN polymicr

CAPD

APD

Episodes per year

From Rodriguez-Carmona PDI 19; 1999Peritonit is rates--lower on APD than CAPD0.31 versus 0.64 per year at risk

CAPD vs APD


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


Gram StainingGram Staining

A gram stain is positive in 9-40%9-40% of peritonitis episodes When positive it is predictive of eventual culture results in 85%85%

of cases It is particularly useful in early recognition of fungal 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


Possible Causes of Possible Causes of Culture Negative PeritonitisCulture 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


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)


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)


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


Lessons

Organisms suggest causation:S. Epidermis = touch contaminationS. 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


Causative Organisms

69

31

0

10

20

30

40

50

60

70

80

Gram +ve Gram -ve

Bunke et al, KI 52:524-529, 1997


Gram Positive Organisms

28

42

4

5

21

0 10 20 30 40 50

S. Aureus

S. Epidermis

Other Staph

Enterococcus

Other gram +ve

Bunke et al, KI 52:524-529, 1997


Organisms and Outcomes

0102030405060708090

Resolved Catheterremoved

Hospital. Transfer toHD

% o

f P

atie

nts

CNS (N=242)

S. Aureus (N=149)

GN (N=136)

Bunke et al, KI 52:524-529, 1997


Outcomes of Peritonitis

Bunke, et al., KI 1997

% of all episodes(without ESI/TI)


Time Course of UF After Peritonitis

Ates, et al., PDI 20;2000:220-226

*p<0.05 vs baseline for all times*p<0.05 vs baseline for all times


Prevention of PeritonitisDue to Contamination

Disconnect systems

Careful training

Patient selection

Assessment of home environment


Exit Site Infections - Prevention 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


S aureus CAPD related infections are associated with nasal carriage

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

exit site infection peritonitis catheter loss

nasal carrier non carrierS. aureus episodes/year

Data from Lye et al, 1994 Nasal carriage defined as min of 2 of 3 NC +ve


Effect of S aureus prophylaxis on prevention of S aureus peritonitis

0

0.05

0.1

0.15

0.2

0.25

intranasalmupirocin

intranasalmupirocin

exit sitemupirocin

exit sitemupirocin

control prophylaxisS aureus peritonitis/year

Perez-Fontan

Mupirocin Study Group

Bernardini Thodis


Exit site/Tunnel and Outcomes

0102030405060708090



% o

f P

atie

nts

CNS (N=230) CNS + Exit (N=12)

Bunke et al, KI 52:524-529, 1997



0102030405060708090



% o

f P

atie

nts

S. Aureus (N=104) S. Aureus + Exit (N=45)

Bunke et al, KI 52:524-529, 1997



0

10

20

30

40

50

60

70



% o

f P

atie

nts

NPGN (N=114) NPGN + Exit (N=22)

Bunke et al, KI 52:524-529, 1997


Tunnel Ultrasonography

• 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

Vychytil et al, AJKD 33:722-27, 1999


Peritonitis Rates

Prevention is a realistic goal.

Proof:Japan 1:45 to 1:60 patient/monthsTaiwan 1:35 to 1:45 patient/monthsEurope 1:26 to 1:38 patient/monthsSingapore 1:28 patient/monthsMexico 1:24 to 1:26 patient/months


Peritonitis Rates

• 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.

Crabtree et al, ASAIO 45:574-80, 1999; Golper et al AJKD 28:428-36, 1996


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


Carriers State and Infection

0

0.2

0.4

0.6

0.8

1

1.2

1.4

Diabetics Immunosuppressed

Others

S. Aureus Catheter Infection

Rat

e p

er y

ear

Overall

Carrier

Non-Carrier

Vychytil et al, JASN 9:669-676, 1998


Staph Aureus Prophylaxis

0

0.1

0.2

0.3

0.4

0.5

CatheterInfection

Peritonitis Catheter loss

Staph Aureus Related

Rat

e p

er y

ear Historical Control

Rifampin, oral N=41

Mupirocin at ESN=41

Bernardini et al, AJKD 27:695-700, 1996


EXIT SITE INFECTION (ESI)

DEFINITIONS Acute ESI - purulent

exit site drainage Additional features

include redness, tenderness, edema and granulation tissue


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


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


Exit Site Management

Antibiotics

Intensified local care

Local debridement


Exit Site Management

Local Debridement or Exteriorisation of cuff

Can involve shaving external catheter cuff or revising tunnel

Results are variable and many prefer catheter removal


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


Summary

Keys to low infection rates include: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


Infectious ComplicationsInfectious ComplicationsPredictable and Preventable!Predictable and Preventable!

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Infections in PD Prevention and Management