Judith Bernardini

PERITONEAL DIALYSIS-RELATED INFECTIONS RECOMMENDATIONS: 2010 UPDATE

Department of Medicine and Therapeutics,1 Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong; University of Pittsburgh School of Medicine,2 Pittsburgh, PA, USA; Faculdade de Enfermagem, Nutrição e Fisioterapia,3 Pontifícia Universidade Católica do Rio Grande do Sul, Brazil; Sanjay Gandhi Postgraduate Institute of Medical Sciences,4 Lucknow, India; Department of Nephrology,5 Princess Alexandra Hospital, and School of Medicine, University of Queensland, Brisbane, Australia; Department of Medical Microbiology,6 Leiden University Medical Center, Leiden, The Netherlands; Centre for Kidney Diseases,7 Mount Elizabeth Medical Centre, Singapore; Section of Infectious Disease,8 Department of Internal Medicine, University of Missouri-Columbia School of Medicine, Columbia, MO, USA; Pediatric Nephrology Division,9 University Children’s Hospital, Heidelberg, Germany; Dianet Dialysis Centers,10 Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands

A randomized trial of staphylococcus aureus prophylaxis in peritoneal dialysis patients: Mupirocin calcium ointment 2% applied to the exit site versus cyclic oral rifampin

The objective of this study was to compare prophylaxis for Staphylococcus aureus infections in peritoneal dialysis patients using 600 mg cyclic oral rifampin for 5 days every 3 months versus mupirocin calcium ointment 2% applied daily to the exit site. The study design was a prospective randomized trial, controlling for S aureus nasal carriage. Eighty-two continuous ambulatory and continuous cyclic peritoneal dialysis patients (54% male, 71 % white, 34% insulin-dependent, mean prestudy time on peritoneal dialysis 1.2 years) were randomly assigned to cyclic rifampin (n = 41 patients) or daily exit site mupirocin prophylaxis (n = 41 patients). Mean follow-up was 1 year. S aureus catheter infection rates were 0.13/yr with mupirocin and 0.15/yr with rifampin (P = NS). Both rates were significantly lower than the centers historical rate (the period between 1983 and 1992) of 0.46/yr prior to the study (P < 0.001). S aureus peritonitis rates were 0.04/yr with mupirocin and 0.02/yr with rifampin (P = NS), both significantly lower than the centers historical rate of 0.16/yr (P < 0.02). Catheter loss due to S aureus infections was 0.02/yr with mupirocin and 0/yr with rifampin (P = NS), both significantly lower than the centers historical rate of 0.12/yr (P < 0.001). There were no side effects in patients using mupirocin, but 12% were unable to continue rifampin due to side effects. We conclude that mupirocin ointment at the exit site and cyclic oral rifampin are equally effective in reducing S aureus catheter infections. In addition, rifampin or mupirocin significantly reduced S aureus peritonitis and catheter loss due to S aureus infections. Mupirocin at the exit site provides an excellent alternative prophylaxis for S aureus infections, particularly in patients who cannot tolerate oral rifampin therapy.

Randomized, Double-Blind Trial of Antibiotic Exit Site Cream for Prevention of Exit Site Infection in Peritoneal Dialysis Patients

Infection is the Achilles heel of peritoneal dialysis. Exit site mupirocin prevents Staphylococcus aureus peritoneal dialysis (PD) infections but does not reduce Pseudomonas aeruginosa or other Gram-negative infections, which are associated with considerable morbidity and sometimes death. Patients from three centers (53% incident to PD and 47% prevalent) were randomized in a double-blinded manner to daily mupirocin or gentamicin cream to the catheter exit site. Infections were tracked prospectively by organism and expressed as episodes per dialysis-year at risk. A total of 133 patients were randomized, 67 to gentamicin and 66 to mupirocin cream. Catheter infection rates were 0.23/yr with gentamicin cream versus 0.54/yr with mupirocin (P = 0.005). Time to first catheter infection was longer using gentamicin (P = 0.03). There were no P. aeruginosa catheter infections using gentamicin compared with 0.11/yr using mupirocin (P < 0.003). S. aureus exit site infections were infrequent in both groups (0.06 and 0.08/yr; P = 0.44). Peritonitis rates were 0.34/yr versus 0.52/yr (P = 0.03), with a striking decrease in Gram-negative peritonitis (0.02/yr versus 0.15/yr; P = 0.003) using gentamicin compared with mupirocin cream, respectively. Gentamicin use was a significant predictor of lower peritonitis rates (relative risk, 0.52; 95% confidence interval, 0.29 to 0.93; P < 0.03), controlling for center and incident versus prevalent patients. Gentamicin cream applied daily to the peritoneal catheter exit site reduced P. aeruginosa and other Gram-negative catheter infections and reduced peritonitis by 35%, particularly Gram-negative organisms. Gentamicin cream was as effective as mupirocin in preventing S. aureus infections. Daily gentamicin cream at the exit site should be the prophylaxis of choice for PD patients.

ISPD Position Statement on Reducing the Risks of Peritoneal Dialysis–Related Infections

University of Pittsburgh School of Medicine,1 Pittsburgh, Pennsylvania, USA; Imperial College Healthcare NHS Trust,2 London, UK; Faculdade de Enfermagem,3 Nutriccao e Fisioterapia, Pontificia Universidade Catolica do Rio Grande do Sul, Brazil; Princess Alexandra Hospital and School of Medicine,4 University of Queensland, Brisbane, Australia; Mount Elizabeth Medical Centre,5 Singapore; Saint John Regional Hospital,6 Horizon Health Network, St. John, New Brunswick, Canada; Sri Ramachandra University No 1,7 Ramachandra Nagar, Porur, Chennai, India; and Department of Medicine and Therapeutics,8 Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, PR China SPECIAL ARTICLE

Comparison of Infectious Complications between Incident Hemodialysis and Peritoneal Dialysis Patients

The impact of dialysis modality on infection, especially early in the course of dialysis, has not been well studied. This study compared infection between hemodialysis (HD) and peritoneal dialysis (PD) from the start of dialysis and evaluated factors that have an impact on infection risk. In this observational cohort study, all incident dialysis patients (n = 181; HD 119 and PD 62) at a single center from 1999 to 2005 had data collected prospectively beginning day 1 of dialysis. Excluded were those with any previous ESRD therapy. Infection rates were evaluated using multivariate Poisson regression. Overall infection rates were similar (HD 0.77 versus PD 0.86/yr; P = 0.24). Only HD patients had bacteremia (0.16/yr), and only PD patients had peritonitis (0.24/yr). Bacteremia that occurred < or =90 d after start of HD was 0.44/yr, increased compared with overall rate of 0.16/yr (P < 0.004). HD catheters, used in 67% of patients who started HD, were associated with a strikingly increased rate of bacteremia. Peritonitis < or =90 d was 0.22/yr, no different from the overall rate. Modality was not an independent predictor of overall infections (PD versus HD: relative risk 1.30; 95% confidence interval 0.93 to 1.8; P = 0.12) using multivariate analysis. PD and HD patients had similar infection rates overall, but type of infection and risk over time varied. HD patients had an especially high risk for bacteremia in the first 90 d, whereas the risk for peritonitis for the PD cohort was not different over time. These results support the placement of permanent accesses (fistula or PD catheter) before the start of dialysis to avoid use of HD catheters.

Assessment of Renal Function During Pregnancy Using a Random Urine Protein to Creatinine Ratio and Cockcroft-Gault Formula

The current standard for assessment of renal function in pregnant women is a 24-hour urine collection to determine creatinine clearance and proteinuria. It is easier to use the random urine protein to creatinine (P:C) ratio and the Cockcroft-Gault (CG) formula to estimate protein excretion and glomerular filtration rate, but the reliability of these formulae in combination for assessing renal function in pregnant women with renal disease is unknown. We compared the results of the P:C ratio with the 24-hour urinary protein excretion and the results of the CG clearance estimate with the 24-hour urine creatinine clearance in 34 pregnant women with underlying renal disease. Comparisons were made once in each trimester and postpartum. Prepregnancy weights were used in the CG formula: (140 - age x weight [kg] x 0.85)/72 x serum creatinine (mg/dL). Twenty-six first trimester, 33 second trimester, 21 third trimester, and 15 postpartum comparisons were made for creatinine clearance and 16 first trimester, 29 second trimester, 15 third trimester, and 15 postpartum comparisons were made for protein excretion. Measured creatinine clearance for the three trimesters combined (105 +/- 40 mL/min [mean +/- SD]) correlated significantly with CG clearances (113 +/- 52 mL/min; r = 0.87). The mean P:C values (2.03 +/- 3.15) for the three trimesters combined correlated significantly with 24-hour urine protein (2.25 +/- 4.21 g; r = 0.92). Our study demonstrates excellent correlations between the CG formula using prepregnancy weights and 24-hour creatinine clearance and between the P:C and 24-hour urinary protein in this population.(ABSTRACT TRUNCATED AT 250 WORDS)

Infecting Organisms in Continuous Ambulatory Peritoneal Dialysis Patients on the Y-set

Disconnect systems for performing continuous ambulatory peritoneal dialysis (CAPD) use a flush-before-fill technique that should theoretically reduce the peritonitis caused by touch contamination. However, little information about the infecting organisms in CAPD-related infections using disconnect systems is available. We performed a retrospective matched-case controlled study to define the organisms responsible for the peritonitis and catheter infections seen in CAPD patients using the Y-set without disinfectant. One hundred nineteen patients who began CAPD on the Y-set were matched with 119 patients who began CAPD on the standard spike system. Patients were matched for age, sex, race, insulin dependence, and time on CAPD. Infection data were prospectively collected for all patients. Peritonitis, exit site, and tunnel infection rates (expressed as number of episodes per patient-year) were all significantly lower in the Y-set patients (0.56 v 0.94, 0.68 v 1.08, and 0.14 v 0.22, respectively). The lower peritonitis rate in the Y-set patients compared with that found in the standard spike system patients was due to a reduction in Staphylococcus epidermidis (0.17 v 0.26, P = 0.02), polymicrobial (0.014 v 0.06, P = 0.01), other gram-positive (0.007 v 0.09, P = 0.001), and sterile (0.10 v 0.19, P = 0.008) peritonitis. Rates of Staphylococcus aureus and gram-negative peritonitis were not different among the two groups. S epidermidis (0.12 v 0.23, P = 0.0014) and gram-negative (0.12 v 0.18, P = 0.04) exit site infection rates were also lower in the Y-set patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Hospitalization in peritoneal dialysis patients

Hospitalization rates are declining more rapidly for peritoneal dialysis (PD) than for hemodialysis patients. This has been postulated to be caused in part by lower peritonitis rates. However, the causes of admission have not been reexamined in the setting of declining rates. We prospectively examined our hospitalization rates, causes of admission, and impact of peritonitis on hospitalization in adult PD patients at a single center over a 4-year period. There were 274 admissions in 168 patient-years for a rate of 1.6 admissions and 13.0 hospital days per patient-year. Rates were greater for men (1.8 v 1.5; P = 0.013), patients with diabetes (2.2 v 1.4, P < 0.001), and those with a higher peritoneal equilibration test result. Creatinine clearance and sex were independent predictors in a multivariate analysis. The most common causes for admission were cardiac disease (14.6%) and peritonitis (13.5%). Peritonitis accounted for 0.21 admissions and 2.0 hospital days per patient-year. Thirty percent of the incident patients were admitted during the first 90 days of dialysis. Admissions for dehydration and glucose abnormalities were more common in the first 90 days. Overall admission rates, as well as admission rates for peritonitis, did not change over time, although hospital days per year decreased. Those admitted for peritonitis had higher peritonitis rates, more time on PD, and were more likely to be black. Eighty-one percent of the admissions for peritonitis were caused by Staphylococcus aureus, Streptococcus spp, or gram-negative/fungal peritonitis. Patients with peritonitis caused by Staphylococcus epidermidis were less likely to be admitted than patients with peritonitis caused by other organisms. To conclude, peritonitis remains a common cause of hospitalization, despite low peritonitis rates. To decrease admissions for peritonitis, attention should be focused on preventing peritonitis caused by organisms other than S epidermidis.

Continuous Cycling Peritoneal Dialysis Is Associated With Lower Rates of Catheter Infections Than Continuous Ambulatory Peritoneal Dialysis

Continuous cycling peritoneal dialysis (CCPD), unlike continuous ambulatory peritoneal dialysis (CAPD), provides freedom from daytime exchanges and is associated with lower rates of peritonitis. However, catheter infection (CI) rates have not been reported for CCPD. Previous data suggested that a CAPD disconnect system (Y-set) was associated with lower rates of CI. These results suggested that patients on CCPD, which is also a disconnect system, might also have low CI rates. We evaluated our CCPD patients for infection rates and compared them with two groups of matched control CAPD patients, one using a spike system and one a Y-set disconnect system to evaluate this hypothesis. The CCPD patients had the lowest rates of CIs (0.5 episodes per year or one episode every 25 months), followed by the CAPD patients using the Y-set (0.8 episodes per year or one episode every 14 months). CAPD patients using the spike system had the highest rates of CIs (1.2 episodes per year or one episode every 10 months). Peritonitis rates followed the same pattern among the patient groups: CCPD, 0.3 episodes per year; CAPD, Y-set 0.5 episodes per year; CAPD, spike system 1.3 episodes per year. Our data suggest that disconnect systems, such as the CAPD Y-set and CCPD, reduce CIs, as well as peritonitis.

Catheter Infections as a Factor in the Transfer of Continuous Ambulatory Peritoneal Dialysis Patients to Hemodialysis

The effect of peritoneal catheter infections on the transfer of continuous ambulatory peritoneal dialysis (CAPD) patients to hemodialysis over a 9-year period were examined. Twenty-seven percent (68/247) of all patients were transferred permanently to hemodialysis after a mean of 15 +/- 14 months of CAPD. An additional 29% transferred temporarily one or more times during the study period (mean time of peritoneal dialysis, 35 +/- 23 months). The reasons for permanent transfer to hemodialysis were catheter infections (15/68, 22%), peritonitis (13/68, 19%), catheter infections associated with peritonitis (10/68, 15%), patient preference (9/68, 13%), mechanical problems (4/68, 6%), noncompliance (7/68, 10%), inadequate clearance or ultrafiltration (6/68, 9%), with other reasons for the remainder (4/68, 6%). Temporary transfers to hemodialysis were also mainly due to catheter infections (32%), peritonitis (23%), and simultaneous catheter infections and peritonitis (24%). Catheter infection rates were much higher in the groups that permanently and temporarily were transferred to hemodialysis in comparison with those patients who remained on peritoneal dialysis. We conclude that catheter infections are a leading cause of both temporary and permanent transfer of CAPD patients to hemodialysis.