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Initial treatment of peritoneal dialysis peritonitis without vancomycin with a once-daily cefazolin-based regimen
L Goldberg1, M Clemenger, B Azadian
1Departments of Renal Medicine and Medical Microbiology, Imperial College School of Medicine, Charing Cross Hospital, London, UK.
Insights
Once-daily intraperitoneal cefazolin and gentamicin offer an effective and well-tolerated alternative to vancomycin for treating peritoneal dialysis peritonitis, reducing vancomycin use. This regimen shows comparable efficacy to vancomycin-based treatments.
Area of Science:
- Nephrology
- Infectious Diseases
- Pharmacology
Background:
- Current International Society of Peritoneal Dialysis guidelines recommend intraperitoneal (IP) cefazolin or cephalothin with gentamicin for peritonitis.
- These recommendations present practical challenges in administration.
Purpose of the Study:
- To evaluate the efficacy of a simplified regimen using once-daily IP cefazolin (1.5 g) and gentamicin for primary peritoneal dialysis (PD) peritonitis.
Main Methods:
- A retrospective analysis of 69 episodes of PD peritonitis in 61 patients treated with once-daily IP cefazolin and gentamicin.
- Patient data included PD modality, infection type (gram-positive, gram-negative, culture-negative), treatment outcomes, and comparison with a historical vancomycin-gentamicin regimen.
Main Results:
- Successful treatment was achieved in 75.4% of episodes with cefazolin-gentamicin versus 57.5% with vancomycin-gentamicin (P = 0.058).
- Catheter removal was required in 14.5% of cases, predominantly in gram-negative infections.
- The relapse rate within 4 weeks was 8.9%.
Conclusions:
- Once-daily IP cefazolin and gentamicin is a viable and effective initial treatment for PD peritonitis.
- This regimen is at least as effective as vancomycin-based therapy and is well-tolerated, offering a practical alternative.
Abstract:
To reduce the use of vancomycin, the current recommendations of the International Society of Peritoneal Dialysis (PD) for the initial treatment of peritonitis complicating PD are to administer intraperitoneal (IP) cefazolin or cephalothin in every PD fluid bag, together with once-daily gentamicin. In view of the inherent impracticalities of this regimen, we studied the efficacy of once-daily cefazolin (1.5 g) IP with gentamicin IP as initial treatment for primary (nonrecurrent) PD peritonitis. This regimen has been used in all episodes of peritonitis not associated with tunnel or exit-site infections or fluid leaks. Sixty-nine episodes in 61 patients were analyzed (44 patients, continuous ambulatory PD; 22 patients, automated PD; and 3 patients, hospital-based intermittent PD), of which 38 episodes (55%) were gram-positive infections, 6 episodes (9%) were gram-negative infections, and 18 episodes (26%) had negative culture results. Four patients died within 4 weeks of infection (none considered attributable to inadequate treatment of their peritonitis). Ten catheters (14.5%) required removal to clear the infection; 7 catheters were in patients with gram-negative infections. The relapse rate within 4 weeks of ceasing antibiotic therapy was 8.9%. Compared with the results of 40 episodes of peritonitis treated initially with our previous IP vancomycin and gentamicin regimen, successful treatment (no death, catheter removal, or recurrence) was achieved in 52 of 69 episodes in the cefazolin group (75.4%) versus 23 of 40 episodes in the vancomycin group (57.5%; P: = 0.058). In conclusion, once-daily IP cefazolin and gentamicin for the initial treatment of PD peritonitis is at least as effective as a vancomycin-based regimen and is well tolerated.