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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 1998  |  Volume : 9  |  Issue : 1  |  Page : 12-17
Peritonitis in Patients on CAPD at King Khalid University Hospital: Less Infection-rate with More Center-experience


1 Nephrology Division, Department of Medicine, King Khalid University Hospital, Riyadh, Saudi Arabia
2 College of Medicine and Research center, King Khalid University Hospital, Riyadh, Saudi Arabia

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   Abstract 

Continuous ambulatory peritoneal dialysis (CAPD) was started at the King Khalid University Hospital in 1986. Peritonitis remains the most significant complication of the procedure. Earlier rates of peritonitis were high, but after gaining sufficient experience, the rates are declining. To evaluate the change in peritonitis trend, 55 new patients who were recruited to our CAPD program between the periods October 1993-October 1996 were analyzed for the development of peritonitis on annual basis. There were 37 (67%) males and 18 (33%) females with a mean age of 43.3 years (range 12-72 years). A total of 34 episodes of peritonitis were recorded with a rate of 1.5 episode/patients year in 1993, 0.5 episode/patient year in 1994 and 0.8 in 1995. only 40% of episodes showed positive cultures whereas 60% remained culture-negative despite use of recommended modified culture techniques. Organisms causing peritonitis included staphylococcus eipdermides (6.7%), E. coli (3.3%), Streptococcus fecalis (3.3%) and pseudomonas (6.7%). Out of 34 episodes of peritonitis, 29 (85.3%) showed response to treatment and five episodes could only be treated after removal of catheter. Of the 29 episodes that responded to treatment, three relapsed and one had recurrent infection . However, all were successfully treated though one responded only after removal of catheter. Thus, a total of six catheters (20%) necessitated removal and replacement. In spite of high diabetic patients population in our series (27.2%) only one died of peritonitis related sepsis and another died of myocardial infarction after clearing the infection. Thus mortality remains low in spite of potential risk. Although we still use straight system CAPD rather than Y system peritonitis rates have declined considerable and we hope that the procedure will gain more acceptability amongst patients with ESRD in Saudi Arabia.

Keywords: CAPD, Peritonitis, Saudi Arabia

How to cite this article:
Al Wakeel J, Abu-Aisha H, Mitwalli AH, Huraib SO, Memon N, Marzouk AS. Peritonitis in Patients on CAPD at King Khalid University Hospital: Less Infection-rate with More Center-experience. Saudi J Kidney Dis Transpl 1998;9:12-7

How to cite this URL:
Al Wakeel J, Abu-Aisha H, Mitwalli AH, Huraib SO, Memon N, Marzouk AS. Peritonitis in Patients on CAPD at King Khalid University Hospital: Less Infection-rate with More Center-experience. Saudi J Kidney Dis Transpl [serial online] 1998 [cited 2019 Dec 7];9:12-7. Available from: http://www.sjkdt.org/text.asp?1998/9/1/12/39295

   Introduction Top


Continuous ambulatory peritoneal dialysis (CAPD) has gained popularity in recent years due to overall improvement in patient well being, technique survival and decline in peritonitis rates [1] . These factors have made CAPD and increasingly acceptable modality of renal replacement therapy throughout the world [1],[2],[3] . With all the said improvements, peritonitis still remains a major and potentially serious complication causing morbidity and occasional mortality [4],[5],[6] .

The incidence of peritonitis has declined after the introduction of the Y set and disconnect system. With the Y system, the reported incidence of peritonitis is one eposide/24-36 patient's months and this low incidence is attributed to the "flush before fill" technique [7],[8],[9],[10],[11] .

CAPD was started at the King Khalid University Hospital, Riyadh in 1986. our earlier experience and peritonitis rates have been reported and published earlier [12] . Although we are still using the straight giving-set system, the peritonitis rates seem to be decreasing with time this could be due to our center's longer experience with the technique, careful patients-education systems as well as good grasp of the expertise in CAPD training by the nursing staff. This study was performed to objectively evaluate the current status of peritonitis in our centre.


   Material and Methods Top


A total of 55 new patients were started on CAPD during the period between October 1993 and October 1996. The etiology of end-stage renal disease (ESRD) comprised of diabetes mellitus, hypertension, glomerulonephritis and unknown etiology in the majority of our patients accounting for 27.2%, 12.7%, 16.6% and 20% respectively. Renal transplantation rejection, sickle cell disease, bilateral renal artery stenosis and congestive heart failure each accounted for 1.8%. The remaining patients (16.3%) had interstitial nephritis. All the patients chose CAPD on their own with after the procedure has been fully explained with the aid of video tapes. Those patients who accepted CAPD were admitted to the peritoneal dialysis (PD) unit for peritoneal access and training.

Tenckhoff's catheter was inserted by a consultant surgeon under general aesthesia. Immediately after catheter insertion 3-4 exchanges in and out were given till the returning fluid became clear. Following this, the catheter was capped and dry period of a week was given till healing occurred to minimize the para­catheter leak. Thereafter, PD was started with small volume exchanges of 2550 mls hourly at daytime only,. Then increments of 250 mls on alternate days were allowed if no leakage was observed. This was continued till target-volume of 2 liters was achieved. Once 2 liters exchanged was achieved without leakage, proper CAPD was started along with simultaneous patient training. On completion of the training, patients were discharged from the hospital to be followed up in CAPD outpatient clinic. Patients were instructed to report any abdominal pain or cloudiness of the dialysate to the PD unit where the facility of assessment regarding peritonitis and direct admission and investigations exists bypassing the hospital emergency department. On admission, the following data were recorded in the peritonitis register especially designed for this purpose:

a) symptoms and signs,

b) PD effluent cell count, gram stain and culture sensitivity,

c) Initial antibiotic cover and subsequent modification after receiving culture and sensitivity results,

d) Dialysate inflow and outflow (drainage) problems if any,

e) Complications of peritonitis and

f) Outcome or ultimate fate of the peritonitis episode.

Diagnosis of peritonitis was made on any one of following criteria:

a) PD effluent cell count more than 100 cells/ml with neutrohphils more than 50%.

b) Positive gram stain.

c) Positive culture.

Peritonitis was also diagnosed if patients had suggestive symptoms and signs or cloudiness of the dialysate plus any one of the above mentioned criteria.

The PD fluid collection protocol

The PD fluid samples were sent for cell count, gram stained and culture and sensitivity. The sampling and culture techniques have been standardized and the nurses in the unit were instructed about the following collection protocol. After shaking the PD effluent bag well, 20 ml of the fluid is aspirated with a sterile syringe and 10 ml is injected into each aerobic and anaerobic bacterial blood culture bottles. Another 14 ml of the fluid is injected into a universal bottle for cell count and gram staining and cultures. All samples thus obtained are sent along with the whole PD fluid bag to the microbiology laboratory. In the microbiology laboratory, sample is taken from universal bottle for cell count, gram staining and for culture in blood agar CO 2 , MacConkey agar AO2 and Robertson cooked meat medium. In the PD effluent bag, 50 ml of 10 x BHI (Brain and Heart) both is injected and incubated at 37 degrees centigrade for seven days. The bag is examined for turbidity everyday. If turbidity is observed, sub-culture is done on appropriate media; otherwise routine sub-culture is done on the third and seventh day.

After sending the above investigations, combination of antibiotics in the form of cefazolin and gentamicin were started intra­peritoneally in accordance with standard protocol [13] . If a patient looked ill and had fever and chills, the above antibiotics were used intravenously for the first 48 hours. Once the culture and sensitivity results were available, the antibiotics were modified accordingly. If no improvement was observed after 72 hours, gram stain and culture were repeated and antibiotics were changed; also occult intra-abdominal pathology such as diverticulosis or abscess were looked for. If no improvement was seen in 10 days, the catheter was removed. The terms relapse, recurrence and re-infection are not well defined in CAPD. For the purpose of this study, "relapse" means a) re-appearances of symptoms after initial improvement, or b) if the culture was initially was negative and has subsequently become positive, or c) increasing neutrophils in the PD fluid after declining to normal "Recurrence" means re-appearance of symptoms of infection within four weeks of apparent cure after stopping antibiotics "Re-infection" means new episode of peritonitis beyond four weeks of apparent cure.

Simple descriptive statistical analysis was used to analyze variables of sample data.


   Results Top


A total of 55 patients were admitted for CAPD during the period between 1993 and 1996 in our center giving us 413 patient's months experience. There were 37 (67%) males and 18 (33%) females. The mean age of the patients was 43.3 years with a range of 12-72 years. A total of 34 episodes of peritonitis were recorded, giving a rate of 1.5 episode/patients year in 1993, 0.5 episode/patient year in 1994 and 0.8 episode/patient year in 1995.

The white cell cont in the PD fluid ranged between 72-11000 cells/ml with a mean of 2270 ± 2716. On differential count, neutrophil leukocytes ranged between 20% - 100% with mean of 75% ± 25. Red blood cells in the PD fluid ranged between 4-6000 cells/ml with a mean of 117 ± 171 cells/ml.

Positive cultures were found in only 40% of the episodes while culture negative peritonitis accounted for 18 cases (60%). The organisms causing peritonitis were as follows: Staphylococccus epidermidis 6 (20%), Staphylococcus aureus Scientific Name Search  2 (6.7%), E. Coli 1 (3.3%), Streptococcus fecalis 1 (3.3%) and P seudomonas 2 (6.7%).

Out of the total 34 episodes of peritonitis, five episodes (14.7%) has persistent peritonitis and resolved only after catheter removal. All these episodes were culture negative and in four of them, we observed faulty catheter implantation technique. The remaining 29 (85.3%) episodes were apparently cured initially but three of them relapsed and one developed recurrent infection. Out of these four episodes two were due to Pseudomonas, one of whom needed catheter removal and the other improved, one was due to Streptococcus fecalis and one due to Staphylococcus epidermidis, both of whom improved after the use of appropriate antibiotics.

Two patients died during the episodes of peritonitis, one with peritonitis related sepsis and the other due to acute myocardial infarction which occurred one week after discharging him from the hospital.


   Discussion Top


Peritonitis still remains the major complication of CAPD, decreasing the overall acceptance of this valuable procedure and leading to unacceptable high rates of dropout from CAPD and changing over to hemodialysis [2],[3],[4] .

At the start of CAPD, the rates of peritonitis were very high at 5.2 -7.5 episodes/patients year [2],[6],[14] . After the advent of Tenchkhoff's catheter, infection rates have declined and different centers have reported variable rates of peritonitis between 1.2-6.3 episodes/patients year [15] . With improvement in peritoneal dialysate delivery system and connections, the rates have further decreased. With the "Y Set" or disconnect system peritonitis-rate reported is one episode per 24-36 patient months. This 'flush before fill' method has now become more popular in comparison to standard connection systems [9],[10] . Although we use the straight giving set system, peritonitis rate is low in our patient population i.e. 0.93 episode per patient year. This probably is related to our strict selection criteria and prolonged training period. Adequately motivated patients are trained to do CAPD themselves and in elderly patients, their young offspring's or hired nurses are trained to do the exchanges. The minimum training period was tow weeks. This again has been shown to have an impact on decreasing peritonitis rate (16). At present only 2% of patients with ESRD in Saudi Arabia are accepted for CAPD, but the number of patients is ever increasing and future studies with large number of patients may give us different insight [17] . But in our opinion both of the above factors have definitely contributed to decrease the peritonitis rates.

The commonest organisms causing peritonitis in our previous study and in other studies [5],[6],[14] was staphylococcus epidermidis seen in over 50% of episodes; culture negative episodes did not exceed 10­-20% [5],[6],[12] . Staphylococcus epidermidis is part of the normal skin flora and has the capability of adhering to and colonizing smooth surfaces such as PD catheter and connection lines. Thus, infection caused by this organism is usually through the PD catheter lumen [13],[18] . However, our present study showed that 6.7% of episodes were caused by Staphylococcus epidermises and culture negative peritonitis was responsible for 60% episodes in spite of using recommended culture methods. This high rate of culture negative peritonitis was extensively discussed with the microbiologists and culture techniques and recommended methods were checked and observed more carefully. It is likely that the high rate of culture negative peritonitis in our group is related low grade infection, factitious organisms or at least in some patient's prior usage of antibiotics.

Abdominal pain was observed in 88% of our patients and fever in 50% of cases and both the symptoms improved within 1-3 days of institution of antibiotics. Cloudiness of the PD effluent was observed in 88% of episodes and cleared within 48-72 hours particularly in patients who showed response to antibiotics. In only one patient, cloudiness persisted beyond three days. The frequency of cloudiness of dialysate observed in our study was lesser than quoted in the literature [4],[5],[6] .

We also noticed more hypotensive episodes on the second day of peritonitis in spite of good response to antibiotics. This was probably related to increased ultrafiltration during peritonitis because of increased permeability of he peritoneal membrane as well as decreased oral intake due to abdominal pain and vomiting.

In our group, only six patients needed catheter removal (17.6%). Five of these catheters were removed because of lack of response to antibiotics and it was thought that there was colonization of the catheters by the organisms. Prior to catheter removal, all these patients received a trial of vancomycin and ceflazidime with or without addition of ciprofloxacin despite which adequate response was not seen. Rifampicin was not tried as tuberculosis is highly prevalent in Saudi Arabia and this drug is reserved for tuberculosis as far as possible. One catheter needed replacement because of recurrence of infection and responded only after catheter removal.

Although 27.2% of our patients were diabetics, mortality was observed in only two of them. One died of peritonitis related sepsis and other of myocardial infarction. The mortality rates quoted in literature varies between 2.5 - 12% [19],[20] . The low mortality rate observed in our patients might be related to the relatively younger age or the patients in our series, also other risk factors like intra-abdominal abscess formation, multiple organisms, fungal infection and bowel perforation did not occur in our patients [4],[18],[21] .

In conclusion, peritonitis has declined to low rtes even with the use of straight giving set technique, probably due to improved medical experience. The commonest organs, responsible for peritonitis used to be Staphylococcus epidermidis in our center, but more recently, there is an increase in occurrence of culture-negative peritonitis. Therefore, pending culture results, adequate gram positive and gram negative cover should be given to effectively treat peritonitis and appropriate modifications made after obtaining culture results.


   Acknowledgment Top


I take this opportunity to express my heartfelt appreciation to Ms. Farida Al Gayyar (Ward 33-B Head Nurse) and Mr. Mahjoub for their assistance and cooperation, who in one way have excelled their efforts in gathering data which made the publication of this manuscript possible.

 
   References Top

1.Geerlings W, Tufveson G, ehrich JHH, et al. Report on management of renal failure in Europe, XXII. Nephrol Dial Transplant 1994;9(suppl 1):6-25.  Back to cited text no. 1    
2.Serkes KD, Blagg CR, Nolph KD, Vonesh EF, Shapiro F. Comparison of patient and technique survival in continuous ambulatory peritoneal dialysis, hemodialysis: a multicenter study. Perit Dial Int 1990;10(1):15-9.  Back to cited text no. 2    
3.Maira R, Vonesh EF, Cavalli P, et al. A multicenter, selection adjusted comparison of patient and technique survivals on CAPD and hemodialysis. Perit Dial Int 1991;11:118.  Back to cited text no. 3    
4.Report of a working party of British society for Antimicrobial chemotherapy. Diagnosis and management of peritonitis in continuous ambulatory peritoneal dialysis. Ancet 1987;1:845-8.  Back to cited text no. 4    
5.Verrina E, Perfumo F, Zacchello G, et al. Chronic peritoneal dialysos catheters in pediatric patients: of the Italian Registry of Oediatric Chronic Peitoneal Dialysis. Perit Dial Int 1993;13 (Supl 2):S254-6.  Back to cited text no. 5    
6.Smith WG, TSakiris DJ, Junor BJ, et al. oeritonitis in continuous ambulatory peritoneal dialysis. Scott Med J 1986;31(2):85-9.  Back to cited text no. 6    
7.Churchill DN, Tayor DW, Vas SI, et al. Peritonitis in continuous ambulatory peritoneal dialysis (CAPD): a multicente rrandomized clinical trial comparing the Y-connector disinfectant system to a standard system. Perit Dial Int 1989;9:159-63.  Back to cited text no. 7    
8.Bhoncristaiani U. the Y set with disinfectant is here to stay. Perit Dial Int 1989;9(3):149-50.  Back to cited text no. 8    
9.Cantaluppi A, Scalamogna A, Castelinuova C, Graziani G. Long term efficacy of a Y­-connector and disinvectant to prevent in continuous ambularoty peritoneal dialysis. Adv Perit Dial 1986;2:182-7.  Back to cited text no. 9    
10.Candian CAPD clinical trials group: peritonitis in continuous peritoneal dialysis: a multi-center randomized clinical trial comparing the Y-connector disinfectant system to standard systems. Perit Dial Int 1989;9(3):159-63.  Back to cited text no. 10    
11.Vilino G, co,ombo A, Schalamogna A, et al. Prospective randomized study of two Y­-device in continuous ambulatory peritoneal dialysis. Perit Dial Int 1989;9(3):165-8.  Back to cited text no. 11    
12.Solis GL, Memon N, Abu-Aisha H. Peritonits in chronic peritoneal dialysis: analysis of 4 year experience at King Khaled University Hospital. Annals of Saudi Med 1989;9(1):27-31.  Back to cited text no. 12    
13.Continuous ambulatory peritoneal dialysis (CAPD) peritonitis treatment recommendations: 1989 update. The Ad Hoc Advisory committee on Peritonitis Management.  Back to cited text no. 13    
14.Peterson PK, Matzke G, Keane WF. Current concepts in the management of peritonitis in patients undergoing continuous ambulatory peritoneal dialysis. Rev Infect Dis 1987;9(3):604-12.  Back to cited text no. 14    
15.Orepoulos DG, A simple and safe technique for continuous ambulatory peritoneal dialysis. Trans Am Soc artif Intern Organs 1978;24:484.  Back to cited text no. 15    
16.Ota K, Kawaguchi Y. Peritoneal dialysis in Japan in: current concepts in peritonela dialysis, edited by Ota K et al. Amstedam, Excerpta Medical 1992;849-54.  Back to cited text no. 16    
17.Shaheen FA, Souqiyyeh MZ, Al Swailem A. Saudi Center for Organ Transplantation Activities and Achievements. Saudi J Kidney Dis Transplant 1995;6(1):41-52.  Back to cited text no. 17    
18.Keane WF, Everett ED, Golper TA, et al. Peritoneal dialysis-related peritonitis treatment recommendation 1993 update. Perit Dial Int 1993;13(1):14-28.  Back to cited text no. 18    
19.Gentil MA, Carriazo A, Pavon MI, et al. comparison of survival in continuous ambularoty peritoneal dialysis and hospital hemodilaysis: a multicenter study. Nephrol Dial Transplant 1991;6:444.  Back to cited text no. 19    
20.Maiorca R, cancarini GC, Brunori G, Camerini C, Manili L. Morbidity and mortality of CAPD and hemodialysis. Kidney Int 1993;43(Suppl 40):4-15.  Back to cited text no. 20    
21.Kierman L, Finkelstein FO, Kliger AS, et al. Outcome of polymicrobial peritoneal dialysis patients. Am J Kidney Dis 1995;25(3):461  Back to cited text no. 21    

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Correspondence Address:
Jamal Al Wakeel
Department of Medicine, King Khalid University Hospital, P.O. Box 2925, Riyadh 11461
Saudi Arabia
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    Abstract
    Introduction
    Material and Methods
    Results
    Discussion
    Acknowledgment
    References
 

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