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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2010  |  Volume : 21  |  Issue : 1  |  Page : 168-173
Microbial spectrum and outcome of peritoneal dialysis related peritonitis in Qatar


Nephrology Division, Department of Medicine, Hamad Medical Corporation, Doha, Qatar

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Date of Web Publication8-Jan-2010
 

   Abstract 

Peritoneal dialysis therapy rapidly expanded in Qatar during the last decade. Peritoneal dialysis related peritonitis remains the leading cause of morbidity and technique failure. The objec­tive of this study was to determine the incidence of peritoneal dialysis related peritonitis in Qatar, during a five year study period. The records of all patients on maintenance peritoneal dialysis from January 1, 2003 to December 31, 2007 were reviewed. Episodes of peritonitis, microbial profile, cli­nical course and outcome were analyzed. A total of 241 patients were included, males represented 74%, the mean age was 53 ± 13 years, and 48% of patients were diabetics. During the study period 118 episode of peritonitis were observed, with a mean incidence of 0.24 ± 0.1 episodes per patient year. Gram-positive organisms were isolated in 40% of episodes, with Staphylococcus epidermidis and Staphylococcus hemolyticus being the commonest organisms, isolated in 21% and 9% of infec­tions, respectively. Escherichia coli was the commonest Gram-negative organism and was isolated in 9% of peritonitis episodes, whereas culture-negative peritonitis represented 28% of all diagnosed infections. Seventy nine percent of peritonitis episodes completely resolved with the use of intra­peritoneal antimicrobial therapy. Peritoneal dialysis catheters were removed in 19% of episodes. Peritonitis related mortality rate was 3%, and it was due to Candida spp. and Pseudomonas aerugi­nosa. Despite its low incidence, peritonitis remained the leading cause of patient dropout. Prompt diagnosis and prudent management as well as psychological support to the patients remained essential to reduce the incidence of technique failure following peritonitis episodes.

How to cite this article:
Shigidi MM, Fituri OM, Chandy SK, Asim M, Al Malki HA, Rashed AH. Microbial spectrum and outcome of peritoneal dialysis related peritonitis in Qatar. Saudi J Kidney Dis Transpl 2010;21:168-73

How to cite this URL:
Shigidi MM, Fituri OM, Chandy SK, Asim M, Al Malki HA, Rashed AH. Microbial spectrum and outcome of peritoneal dialysis related peritonitis in Qatar. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2019 Jul 23];21:168-73. Available from: http://www.sjkdt.org/text.asp?2010/21/1/168/58799

   Introduction Top


In long-term peritoneal dialysis (PD) patients, peritonitis remains the leading cause of morbi­dity and dropouts of patients from therapy. Des­pite the reduction in the rates of peritonitis in the last few years, [1],[2] it still accounts for 30% to 40% of all patient transfers from PD to hemodia-lysis (HD). [3]

During the past decade, great developments and precautions were considered in the various PD centers to protect against peritonitis. These include the use of advanced connecting devices, double-bag systems, aseptic precautions, vigi­lant management of exit site infection, and rou­tine application of antibiotics at exit sites. These precautions reduced the rate of peritonitis sig­nificantly, but did not eliminate it. [4]

The outcome of peritonitis usually depends on the isolated organisms. [5] Direct mortality from peritonitis is usually not high, but recurrent or persistent infection can lead to peritoneal mem­brane malfunction, which may result in techni­que failure. [6],[7]

The aim of our study is to determine incidence and microbial pathogens of peritonitis and out­come of the patients in our country.


   Materials and Methods Top


All patients who were on PD in Qatar, during the period from January 1, 2003 to December 31, 2007 were included in the study. We used double bag system, "flush before fill", dialysate line-bags with luer-lock connections, and standard silicon Tenckhoff double cuff catheter. We also applied topical Mupirocin for the care of the exit site. We educate our patients about proper hand wa­shing techniques and aseptic technique of bag exchange during a two weeks training period.

All the patients who developed peritonitis du­ring the study period were identified. The diag­nosis of peritonitis was established by the pre­sence of two of the following criteria: (i) an ab­dominal pain or a cloudy dialysate effluent, (ii) presence of a white cell count of more than 100 white blood cells/΅L, with a differential count of more than 50% polymorphonuclear cells in PD effluent, (iii) a positive Gram stain or cul­ture from peritoneal effluent. [5] Episodes of peri­tonitis and culture reports were carefully noted; re-infections with the same organism occurring within four weeks of discontinuation of therapy were excluded as these were considered as re­lapsing episodes. [8] Tuberculosis was checked for in all patients who had culture negative perito­nitis, a minimum of three specimens of peritoneal fluid were examined for acid-fast-bacilli smears and for mycobacterium culture. Tuberculosis was diagnosed on the basis of positive microscopy or culture of Mycobacterium tuberculosis.

Once diagnosed, peritonitis was treated initia­lly with empirical intraperitoneal cefazoline and ceftazidime, or vancomycin and gentamicin in those hypersensitive to betalactam antibiotics. Subsequent therapy was tailored as per culture and sensitivity reports. For those with culture­negative peritonitis treatment was continued with intraperitoneal cefazoline for a total of two weeks.

Peritoneal dialysis catheters were removed at the discretion of the treating nephrologist for one of the following reasons: non-resolving, recurrent, fungal, or tuberculous peritonitis. Non-resolving peritonitis was defined as lack of resolution of the abdominal pain, clearing of dialysate, or a significant drop in PD effluent white cell count after 72 hours from initiation of the-rapy.

Once a PD catheter was removed, the patients were switched for temporary HD. Catheter re­insertion was usually performed after four to six weeks.


   Statistical Analysis Top


Data obtained during this study was extracted from the hospital and PD medical records, and entered into a specially designed questionnaire. Infection rates were calculated as the number of infections in each year, divided by the number of patient-years on PD. We analyzed the inci­dence and etiology of peritonitis, outcome, and need for catheter removal to control infection and mortality.

Statistical analysis was performed using Win­dows Excel program. Data was expressed as the mean ± standard deviation for continuous data, and frequencies and percentages for categorical data. Chi-square test was applied for differences in proportions, and the statistical significance of data was defined as a P value of less than 0.05.


   Results Top


During the five years study period, there were 241 patients on PD therapy, 74% were males, mean age was 53 ± 13 years and 48% were dia­betics. The mean incidence of peritonitis was 0.24 ± 0.1 episodes per patient year; though the incidence of peritonitis increased with time, the adjusted incidence for the expanding PD popu­lation pool disclosed no statistically significant change, [Figure 1].

A total of 118 episodes of peritonitis were re­corded during the study period, with Gram­positive organisms being isolated in 47 (40%) episodes, Gram-negative in 29 (24%) episodes, fungi and acid-fast-bacilli in 9(8%) episodes, whereas culture-negative peritonitis was repor­ted in 33 (28%) episodes. Polymicrobial gram­negative infections were observed in two epi­sodes. A statistically significant rise in the over­all incidence of gram-positive infections with time was observed during the study period, P < 0.001, [Figure 2].

Examining the culture-positive peritonitis de­tails,  Staphylococcus epidermidis Scientific Name Search and Staphylo­coccus hemolyticus were the commonest Gram­positive organisms isolated in 21% and 9% of infections, respectively; whereas  Escherichia More Details coli was the commonest gram-negative orga­nism isolated in 9% of the culture-positive peri­tonitis episodes.

In 79% of the episodes of peritonitis, complete resolution of infection occurred using intraperi­toneal antibiotics without the need for PD ca­theter removal. PD catheters were removed in 23 patients, 19% of episodes, to allow for cure; among these, two patients died despite catheter removal, one patient underwent catheter rein­sertion and returned back to PD after 6 weeks, whereas all the remaining 20 patients (87%) con­tinued permanently on HD. Fungal peritonitis,  Pseudomonas aeruginosa Scientific Name Search i>infection and culture­negative peritonitis were the main reasons for catheter removal, [Table 1].

Our mortality rate was 3% (4 patients); Candida spp. and Pseudomonas aeruginosa were isolated equally from these patients before their demise.


   Discussion Top


During the five years study period our PD po­pulation had increased by 55%. Compared to other centers, our peritonitis rate and despite the increase during the study, was low; probably due to the intensive patient training, advanced connecting devices, together with the routine application of antibiotics at the catheters exit site. [9],[10] However, as noted by others, severe and fre-quent peritonitis episodes remained the main reason for PD technique failure. [11] Staphy­lococcus epidermidis is a common cause of peri­tonitis in many centers, usually denotes touch contamination. [9] Though it usually responds well to antibiotics, Staphylococcus epidermidis has the ability to form biofilms on silastic material more quickly than other organisms. Biofilms are extremely resilient, and form a source of recu­rrent or new infections. [12],[13] They probably ex­plain the high percentage of infections caused by Staphylococcus epidermidis among our patients, making gram-positive organisms the commonest cause of PD related peritonitis in our unit. [4]

Despite our thorough training program and aseptic precautions employed, some patients still contaminate their PD materials because of poor hand washing technique or poor exit site care, which might include repeated contamination by enteric organisms from the bowel. [14] Mupirocin cream was applied routinely to the exit site in our patients, and although it reduces the overall incidence of peritonitis and exit site infections, [15] it may result in an increased incidence of gram­negative infections. [16],[17] These factors collectively were the probable reasons for the emergence of Escherichia coli as one of the commonest orga­nisms causing peritonitis in our patients. [16],[18] It is known that gram-negative bacteria are less influenced by the advances done on connection systems, [19] and it has been suggested that appli­cation of gentamicin cream (0.1%) to exit sites might help reducing the incidence of gram­negative infections significantly. [20]

We did notice that the rate of culture-negative peritonitis was initially high but it appears to begetting less. That probably reflects the impro­vement in our culture techniques and avoidance of antibiotic therapy before PD fluid sampling for culture. [21] Similar to other reports; the high culture-negative rate in our unit did not influence the cure rate. Most (88%) of our culture-negative peritonitis episodes were completely cured using intraperitoneal antibiotics and without PD ca­theter removal, suggesting that the organisms involved responded to the intra-peritoneal cefa­zoline. It is postulated that many cases of cul­ture-negative peritonitis are due to low virulence Gram-positive organisms. [22]

PD catheters were removed early in our infec­ted patients resulting in low peritonitis related mortality. However, despite the early catheter removal and preservation of the peritoneum for further PD therapy, most of our infected pa­tients refrained from PD after clearance of peritonitis, which may reflect the impact of the psychological trauma caused by peritonitis on our PD patients resulting in technique failure. Increased morbidity and mortality associated with infections caused by Pseudomonas aerugi­nosa was observed in our patients, which sup­ports the policy of some centers to remove the PD catheters if Pseudomonas aeruginosa is identified as the cause of peritonitis. [5]

As part of a continuous quality improvement program, all centers should keep a registry for their peritonitis cases including the causative organisms and their sensitivity patterns. Opti­mal antibiotic regimens for the treatment of peritonitis do not exist. The local epidemiology and sensitivity pattern of causative organisms should dictate the ideal therapy. [23] Patients who do not respond promptly to antibiotic therapy should be considered for urgent catheter remo­val, and regularly re-educated about the need for early return to PD after appropriate coun­seling. Overall, to avoid peritonitis, it remains essential to adopt a good connection technique and a clean exchange procedure.


   Acknowledgement Top


We would like to acknowledge Hamad Me­dical Corporation for providing us with all the necessary data and supporting this work.

 
   References Top

1.Fried L, Abidi S, Bernarddini J, Johnston JR, Piraino B. Hospitalization in peritoneal dialysis patients. Am J Kidney Dis 1999;33:927-33.  Back to cited text no. 1      
2.Fried LF, Bernardini J, Johnston JR, Piraino B. Peritonitis influences mortality in peritoneal dialysis patients. J Am Soc Nephrol 1996;7: 2176-82.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]  
3.Abdel-Rahman EM, Wakeen M, Zimmerman SW. Characteristics of long-term peritoneal dia­lysis survivors. Perit Dial Int 1997;17:151-6.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]  
4.Piraino B. Peritonitis as a complication of peri­toneal dialysis. J Am Soc Nephrol 1998;9:1956­-64.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]  
5.Troidle L, Gorban-Brennan N, Klinger LP, Finkelstein FO. Differing outcomes of gram­positive and gram-negative peritonitis. Am J Kidney Dis 1998;32:623-8.  Back to cited text no. 5      
6.Davies SJ, Bryan J, Phillips L, Russell GL. Longitudinal changes in peritoneal kinetics: The effects of peritoneal dialysis and peritonitis. Nephrol Dial Transplant 1996;11:498-506.  Back to cited text no. 6      
7.Maiorca R, Vonesh EF, Cavalli PL, et al. A multicenter, selection-adjusted comparison of patient and technique survivals on CAPD and hemodialysis. Perit Dial Int 1991;11:118-27.  Back to cited text no. 7      
8.Piraino B, Bailie GR, Bernardini J, et al. Peri­toneal dialysis-related infections recommenda­tions: 2005 update. Perit Dial Int 2005;25:107­-31.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]  
9.Li PK, Szeto CC, Law MC, et al. Comparison of double-bag and Y-set disconmect systems in continuous ambulatory peritoneal dialysis: A randomized prospective multicenter study. Am J Kidney 1999;33:535-40.  Back to cited text no. 9      
10.Thodis E, Passadakis P, Vargemezis V, Oreopoulos DG. Prevention of catheter related infections in patients on CAPD. Int J Artif Organs 2001;24:671-82.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]  
11.Nolph K. CAPD as long-term treatment of ESKD (Editorial). Am J Kidney Dis 1991;12(2):154-7.  Back to cited text no. 11      
12.Costerton JW, Stewart PS, Greenberg EP. Bacterial biofilms: A common cause of persis­tent infections. Science 1999;284:1318-22.  Back to cited text no. 12  [PUBMED]  [FULLTEXT]  
13.Finkelstein ES, Jekel J, Troidle L, Gorban­Brennan N, Finkelstein FO, Bia FJ. Patterns of infection in patients maintained on long-term peritoneal dialysis therapy with multiple episodes of peritonitis. Am J Kidney Dis 2002;39(6): 1278-86.  Back to cited text no. 13      
14.Bernardini J, Piraino B, Holley J. A randomized trial of Staphylococcus aureus prophylaxis in peritoneal dialysis patients: Mupirocin calcium ointment 2% applied to exit site versus cyclic oral rifampin. Am J Kidney Dis 1991;18:225-­31.  Back to cited text no. 14      
15.Casey M, Taylor J, Clinard P, et al. Application of mupirocin cream at the catheter exit site reduces exit-site infections and peritonitis in peritoneal dialysis patients. Perit Dial Int 2000; 20:566-8.  Back to cited text no. 15  [PUBMED]  [FULLTEXT]  
16.Piraino B, Bernardini J, Florio T, Fried L. Sta­phylococcus aureus prophylaxis and trends in gram-negative infections in peritoneal dialysis patients. Perit Dial Int 2003;23:456-9.  Back to cited text no. 16  [PUBMED]  [FULLTEXT]  
17.Zelenitsky S, Barns L, Findlay I, et al. Analysis of microbiological trends in peritoneal dialysis­related peritonitis from 1991 to 1998. Am J Kidney Dis 2000;36:1009-13.  Back to cited text no. 17  [PUBMED]  [FULLTEXT]  
18.Keithi-Reddy SR, Gupta KL, Jha V, et al. Spec­trum and sensitivity pattern of gram-negative organisms causing CAPD peritonitis in India. Perit Dial Int 2007;27:205-7.  Back to cited text no. 18  [PUBMED]  [FULLTEXT]  
19.Bunke CM, Brier ME, Golper TA. Outcomes of single organism peritonitis in peritoneal dialy­sis: Gram negatives versus gram positives in the Network 9 Peritonitis Study. Kidney Int 1997; 52:524-9.  Back to cited text no. 19  [PUBMED]  [FULLTEXT]  
20.Bernardini J, Bender F, Florio T, et al. Rando­mized double-blind trial of antibiotic exit site cream for prevention of exit site infection in peritoneal dialysis patients. J Am Soc Nephrol 2005;16:539-45.  Back to cited text no. 20  [PUBMED]  [FULLTEXT]  
21.Szeto CC, Wong TY, Chow KM, Leung CB, Li PK-T. The clinical course of culture-negative peritonitis complicating peritoneal dialysis. Am J Kidney Dis 2003;42:567-74.  Back to cited text no. 21      
22.Kent JR, Almond K. A survey of CAPD perito­nitis management and outcomes in north and south Thames NHS regions (UK): Support for the ISPD guidelines. Perit Dial Int 2000;20:301­-5.  Back to cited text no. 22      
23.Van Biesen W, Veys N, Vanholder R, Lameire N. Peritoneal-dialysis-related peritonitis: The art of rope-dancing. Nephrol Dial Transplant 2002; 17:1878-82.  Back to cited text no. 23  [PUBMED]  [FULLTEXT]  

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Correspondence Address:
Omar M Fituri
Department of Medicine, Nephrology Division, Hamad Medical Corporation, P.O. Box 3050, Doha
Qatar
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PMID: 20061719

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