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Capd peritonitis mortalty
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- 2. Content • Introduction • ISPDguideline • Hospital Pulau Pinang clinical audit on CAPD peritonitis
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- 5. CAPD peritonitis • Peritonitisis a common clinical problem that occurs in patients treated by peritoneal dialysis • The incidence of peritonitis varies from center to center • During the past decade approximately 1 episode every 24 patient-treatment-months was observed • because of exceptional patient education, as well as new connector and catheter technologies
- 6. • A varietyof different regimens have been proposed based upon these experiences • Antibiotics have been administered intraperitoneally (IP), or intravenously (IV), or orally, and a number of different dosing regimens have been utilized • Unfortunately, no single regimen has been shown in appropriate clinical trials to be most efficacious.
- 7. ISPD Guidelines/Recommendations ADULT PERITONEALDIALYSIS-RELATED PERITONITIS TREATMENT RECOMMENDATIONS: 2005 Update William F. Keane,1 George R. Bailie,2 Elizabeth Boeschoten,3 Ram Gokal,4 Thomas A. Golper,5 Clifford J. Holmes,6 Yoshindo Kawaguchi,7 Beth Piraino,8 Miguel Riella,9 Stephen Vas10
- 8. DEFINITION OF CAPDPERITONITIS 2 out of 3 of the following criteria 1. Abdominal pain 2. Cloudy effluent with a cell count > 100 cells/ mm3 ; 50% of which is PMN 3. Culture positive
- 9. Initial Clinical Evaluationof Patient with Suspected Peritoneal Dialysis-Related Peritonitis • Symptoms: cloudy fluid and abdominal pain • Do cell count and differential • Gram stain and culture on initial drainage • Initiate empiric therapy • Choice of final therapy should always be guided by antibiotic sensitivities
- 10. • on manyoccasions the Gram stain is unavailable, delayed, or negative for any specific organisms Empiric therapy is indicated in these conditions • There is a slight statistical likelihood that the causative pathogen will be the same as the most recent infection • If the exit site is infected with pseudomonas or S. aureus when peritonitis presents, there is a high probability that the peritonitis is caused by the same organism • If the patient is having frequent peritonitis episodes, then relapse or recurrence with the same organism is likely.
- 11. Empiric Initial Therapy,for Peritoneal Dialysis- Related Peritonitis, Stratified for Residual Urine Volume Antibiotic Residual urine output < 100 mL/day Residual urine output > 100 mL/day Cefazolin or cephalothin 1 g/bag, q.d. 20 mg/kg BW/bag, q.d. or 15 mg/kg BW/bag, q.d. Ceftazidime 1 g/bag, q.d. 20 mg/kg BW/bag, q.d. Gentamicin, tobramycin, netilmycin 0.6 mg/kg BW/bag, q.d. Not recommended Amikacin 2 mg/kg BW/bag, q.d. Not recommended
- 12. ?vancomycin • Internationally, theprevalence of vancomycin- resistant organisms has dramatically increased and this increase has been particularly evident in larger university hospitals where up to 14% of enterococci may be resistant • Vancomycin resistance has been associated with resistance to other penicillins and aminoglycosides, thus presenting a treatment dilemma • This change in vancomycin sensitivity has prompted a number of worldwide agencies to discourage routine use of vancomycin for prophylaxis, for empiric therapy, or for oral use for Clostridium difficile enterocolitis.
- 13. • The majorconcern is that the vancomycin- resistance gene is transmitted to staphylococcal strains, creating an issue of major epidemiological importance • It is recommended for use in methicillin-resistant S. aureus (MRSA) infections and in treatment of infections due to beta-lactam-resistant organisms, as well as in treatment for infections in patients that have serious gram-positive infections and that are allergic to other agents.
- 14. Treatment strategies afteridentifying gram positive organism TABLE 4 Treatment Strategies After Identification of Gram-Positive Organism on Culture Enterococcus Staphylococcus aureus Other gram-positive organism (Coagulase-negative staphylococcus) At 24 to 48 hours Stop cephalosporins Stop ceftazidime or aminoglycoside Stop ceftazidime or aminoglycoside Start ampicillin 125 mg/L/bag Continue cephalosporin Continue cephalosporin Consider adding aminoglycoside Add rifampin 600 mg/day, oral If ampicillin-resistant, start If MRSA, start vancomycin If MRSE and clinically not vancomycin or clindamycin or clindamycin responding, start vancomycin If VRE, consider quinupristin/dalfopristin or clindamycin Duration of therapy 14 days 21 days 14 days
- 15. Treatment Recommendations ifa Gram-Negative Organism Is Identified on Culture at 24 to 48 hours Duration of therapy Single gram-negative organism Adjust antibiotics to sensitivity 14 days < 100 mL urine, aminoglycoside > 100 mL urine, ceftazidime Pseudomonas/stenotrophom onas Continue ceftazidime and add 21 days < 100 mL urine, aminoglycoside (see Empiric Therapy, Table 2) > 100 mL urine, ciprofloxacin 500 mg, p.o. b.i.d. or piperacillin 4 g IV q.12 hours or sulfamethoxazole/trimethopri m 1_2 DS/day or aztreonam load 1 g/L; maintenance dose 250 mg/L IP/bag Multiple gram-negatives and/or anaerobes Continue cefazolin and ceftazidime and add 21 days metronidazole, 500 mg q.8 hours, p.o., IV, or rectally If no change in clinical status, consider surgical intervention
- 16. Treatment Strategies ifPeritoneal Dialysis Fluid Cultures Are Negative at 24 to 48 Hours or Not Performed Continue initial therapy Duration of therapy If clinical improvement Discontinue ceftazidime or aminoglycoside Continue cephalosporin 14 days If no clinical improvement at 96 hours If culture positive, adjust therapy accordingly Repeat cell count, Gram stain, and culture 14 days If culture negative, continue antibiotics, consider infrequent pathogens and/or catheter removal 14 days
- 17. Catheter removal • Shouldbe considered when peritonitis is unlikely to resolve with catheter in situ – Fungal peritonitis – TB peritonitis – Perforated bowel – Persistent exit / tunnel infection – Not responsive to second line antibiotic – Relapsing peritonitis not responding to treatment
- 18. AUDIT: PERITONITIS RATE IN THECAPD UNIT CAPD UNIT HOSPITAL PULAU PINANG
- 19. OBJECTIVES To determine o theincidence of peritonitis o outcome of peritonitis o types of organsims causing peritonitis
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- 21. CHARACTERISTICS of allPD patients Total Number of patients 196 Age Mean : 47 years, SD:20.6 Range : 6 – 87 years Duration on PD Mean : 37.9 months ,SD :34.7 Range : 0.5 – 172 months Male : Female ratio 95 : 101 (48%) (52%) Primary disease causing ESRD Diabetes mellitus HPT GN Unknown Others 80 (41%) 21 (11%) 22 (11%) 22 (11%) 51 (26%)
- 22. PD Peritonitis • 28episodes of peritonitis in 23 patients • Mean age = 52 years (range : 15- 81 yrs) • Male: Female ratio = 7 patients:16 patients (1:2.2) • Self care in 9 patients (39 %) Assisted PD in 14 patients (61%)
- 23. PERITONITIS RATE • 28episodes of peritonitis (EOP) in 23 patients in 1006.6 patient-months i.e. 1 in 36 patient-months KPI peritonitis rate is 1 in 24 patient-months Optimal standard for peritonitis rate is 1 in 42 patient-months
- 24. PERITONITIS CULTURE YIELD Culturepositive yield rate is below recommended international rate of at least 80%
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- 26. CAUSATIVE ORGANISMS Number Gram Negative(67%) E.Coli Pseudomonasaeruginosa Acinetobacter sp Haemophilus Influenza Sphingomonas paucibilis Serratia Marcesceus 3 2 2 1 1 1 Gram Positive (20%) Coagulase Negative Staph Staphylococcus aureus 2 1 Fungus (13%) Candida sp 2 TOTAL 15
- 27. OUTCOME OF PERITONITIS 28episodes 17 resolved 7 T/C removal 4 died (60.7%) (25%) (14.2%) Tenckhoff Removal 1 reinsertion 4 changed modality 2 still awaiting (continued CAPD) reinsertion
- 28. CONCLUSION Peritonitis rateis 1 in 36 patient-months --below the optimal standard (1 in 42 patient-months) 60.7% of patients with CAPD peritonitis resolved with treatment 25% required T/C removal 14.2% died (4) - 1 pt had advanced Ca cervix - 3 pt had concomitant nosocomial sepsis Majority of the organism isolated is Gram negative organism
- 29. Thank you foryour attention !