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Peritonitis in continuous ambulatory peritoneal dialysis (CAPD): diagnostic findings, therapeutic outcome and
A Tranaeus1, O Heimbürger, B Lindholm
1Department of Renal Medicine, Karolinska Institute, Huddinge University Hospital, Stockholm, Sweden.
Insights
Turbidity alone can diagnose peritonitis in continuous ambulatory peritoneal dialysis (CAPD) patients. First-generation cephalosporins are not recommended as initial CAPD peritonitis treatment due to high failure rates and complications.
Area of Science:
- Nephrology
- Infectious Diseases
- Clinical Medicine
Background:
- Peritonitis is a common complication in continuous ambulatory peritoneal dialysis (CAPD).
- Accurate and timely diagnosis of CAPD peritonitis is crucial for effective treatment and patient outcomes.
- Current diagnostic criteria for CAPD peritonitis may lead to over- or under-diagnosis.
Purpose of the Study:
- To analyze the diagnostic accuracy of various parameters in CAPD peritonitis.
- To evaluate the effectiveness of initial antibiotic therapy for CAPD peritonitis.
- To identify risk factors for complications and treatment failure in CAPD peritonitis.
Main Methods:
- Retrospective analysis of 128 CAPD peritonitis episodes over six years.
- Evaluation of dialysate white cell count (WCC), Gram stain, and culture results.
- Assessment of treatment outcomes, including cure rates, recurrence, and complications, based on initial antibiotic choice and patient demographics.
Main Results:
- 10% of episodes had initial dialysate WCC < 100 x 10(6)/L; 15% showed mononuclear cell predominance.
- Gram stain was consistent with culture in only 28% of cases and influenced initial therapy in 7%.
- Turbidity alone would have classified 9-31% more episodes as peritonitis.
- Staphylococcus aureus tunnel infections were more frequent than coagulase-negative staphylococci (p=0.009).
- Coagulase-negative staphylococci peritonitis had a milder course (p=0.02).
- Only 62% of cephradine-treated episodes were cured; 35% had complications.
- Complications were more frequent in women and diabetics (p=0.01, p=0.03).
- 6% of episodes led to CAPD dropout; 68% required hospitalization.
Conclusions:
- Turbidity is a reliable sole criterion for initial CAPD peritonitis diagnosis.
- First-generation cephalosporins are ineffective as first-line treatment for CAPD peritonitis.
- Treatment strategies and diagnostic approaches for CAPD peritonitis require revision.
Abstract:
The analysis of all episodes of peritonitis occurring in a uniformly treated continuous ambulatory peritoneal dialysis (CAPD) population (N = 128) at one centre during a six-year period showed the following major findings. The initial white cell count (WCC) of the dialysate was less than 100 x 10(6)/L in 10% of the episodes and showed a predominance of mononuclear cells in 15%. The Gram stain results were consistent with the findings of the culture in 28% of the episodes and influenced the initial therapy in only 7% of the cases. Between 9% and 31% of all episodes would not have been classified as peritonitis if positive culture, a WCC of greater than 100 x 10(6)/L in the dialysate, or clinical symptoms had been required for the diagnosis. The proportion of negative dialysate cultures was 2% after the introduction of pre-culture membrane filtration. Tunnel infection as a cause of peritonitis was more frequent in episodes due to Staphylococcus aureus than in episodes due to coagulase-negative staphylococci (p = 0.009). Peritonitis caused by coagulase negative staphylococci were followed by a milder course than other organisms (p = 0.02). Of all episodes initially treated with cephradine only 62% were cured with this antibiotic (or cloxacillin) and 35% were followed by recurrency, protracted course or catheter loss, despite intermediate or full in vitro susceptibility. In only 53% of all episodes no complication was observed. Complications were more frequent in women and diabetics than in men (p = 0.01) and non-diabetics (p = 0.03), and were more common in episodes with clinical symptoms (p = 0.02). Peritonitis resulted in drop-out from CAPD in 6% of all episodes. Hospital care was needed in 68% of all episodes. We conclude that turbidity can be used as the sole criterion for the initial diagnosis of peritonitis, and that a first generation cephalosporin should not be used as a first line antibiotic in the treatment of CAPD peritonitis.