1. Complications of Peritoneal Dialysis Abhijit Kontamwar,MD Renal Consultants, Inc Clinical Assistant Professor of Internal Medicine at NEOUCOM (Northeastern Ohio Universities Colleges of Medicine and Pharmacy).
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5. Causes of transfer to HD among PD patients Mujais et al; Kidney Int Suppl 2006; 70: S21-36
6. Hospitalization rates for access related infections Chavers et al, J Am Soc Nephrol 18: 952 – 959, 2007
14. Microbiology Mujais, S. Microbiology and outcomes of peritonitis in North America. Kidney Int 2006; 70:S55
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19. Empiric Therapy Initiate empiric therapy Simultaneous gram +ve and gram –ve coverage For prevention of fibrin occlusion heparin 500 U/L can be used Gram +ve coverage: 1 st generation cephalosporin or vancomycin Gram –ve coverage: 3 rd generation cephalosporin or aminoglycoside
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22. Staph. aureus peritonitis Staph. Aureus on culture D/c gram –ve coverage, cont. gram +ve coverage for 3 weeks If MRSA change to Vancomycin and rifampin can be added (600 mg/day for 1 week) If clinical improvement continue for 3 weeks If no clinical improvement reculture and revaluate for exit-site or tunnel Infection or intra-abd abscess If peritonitis with exit-site or tunnel Infection – remove catheter Allow 2 weeks rest period before reinitiating PD If no improvement in 5 days on appropriate antibiotics, remove catheter
23. Enterococcus/Streptococcus peritonitis Enterococcus/Strep on culture D/c empiric coverage Start continuous Ampicillin 125 mg/L each bag Consider adding aminoglycoside for enterococcus If ampicillin resistant, start vanco; If VRE consider quinupristin/dalfopristin or linezolid Clinical improvement; treat for 2 weeks – strep 3 weeks - enterococcus No improvement, reculture and evaluate for exit-site or tunnel infection Peritonitis with exit or tunnel infection Consider catheter removal Treat for 3 weeks In no improvement by 5 days, remove catheter
24. Pseudomonas peritonitis Pseudomonas on culture W/o exit-site/tunnel infection With exit-site/tunnel infection Remove catheter Use 2 abx with different mechanism Oral quinolone, cephalosporin, piperacillin based on sensitivities If clinical improvement Treat for 3 weeks If no improvement reculture and evaluate If no improvement by 5 days on appropriate abx, remove catheter
25. Gram negative organism peritonitis Single gram –ve organism on culture E. coli, klebsiella or proteus Stenotrophomonas 3 rd generation cephalosporin: ceftazidime or cefepime Two drugs with different mechanisms based on sensitivity pattern Duration of therapy: 3 weeks Duration of therapy: 3-4 weeks If no clinical improvement by 5 days, remove catheter
26. Polymicrobial peritonitis Polymicrobial peritonitis Multiple gram –ve organisms Multiple gram +ve organisms Change to metronidazole In conjunction with ampicillin, Ceftazidime or aminoglycoside Surgical evaluation Laprotomy for suspected intra-abd pathology/abscess with catheter removal Continue therapy based on sensitivities W/o catheter infection, treat for 3 weeks With catheter infection, remove catheter
27. Culture negative peritonitis Culture negative peritonitis 24-48 hours Continue initial therapy If culture negative for 72 hours Repeat cell count and diff Infection resolving, pt improving Infection not resolving Cont initial therapy for 2 weeks, But D/c aminoglycoside if used initially Special culture techniques for Mycobacteria or legionella Culture positive Culture negative Adjust therapy as per sensitivity patterns If no improvement in 5 days, Consider catheter removal
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29. Antibiotic dosing recommendations for CAPD LD: loading dose in mg, MD: maintenance dose in mg Antibiotic Intermittent Continuous Gentamicin 0.6 mg/kg LD 8, MD 4 Amikacin 2 mg/kg LD 25, MD 12 Cefazolin 15 mg/kg LD 500, MD 125 Cefepime 1 gm LD 500, MD 125 Cephalothin 15 mg/kg LD 500, MD 125 Ceftazidime 1 – 1.5 gm LD 500, MD 125 Ciprofloxacin No data LD 50, MD 25 Vancomycin 15-30 mg/kg every 5-7 days LD 1000, MD 25 Aztreonam No data LD 1000, MD 250 Amphotericin NA 1.5 Imipenem/cilistatin 1 gm bid LD 500, MD 200
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39. Treatment of exit-site/tunnel infection Purulent discharge from exit-site Do culture/gram stain Gram +ve organism Gram –ve organism 1 st generation Cephalosporin PO PO Quinolones If slow improvement or severe Cases add Rifampin 600mg/day If Pseudomonas and no improvement add 2 nd anti-pseudomonal; ceftazidime IP Infection resolving; cont treatment for 2 weeks Infection resolving; cont treatment for 2 weeks Infection unresolved in 3-4 weeks; consider catheter revision/removal Infection unresolved in 3-4 weeks; consider catheter revision/removal