Long-term incidence of peritonitis in CAPD patients treated by the Y set technique: experience in a single center

Our experience of peritonitis in 156 patients over an 8-year period represents 186 episodes of peritonitis and 4,964 patient-months of CAPD. The incidence of peritonitis was significantly greater (1 episode every 8.6 patient-months) when the Oreopoulos technique was used and dropped to 1 episode every 43.3 patient-months when the Y set system was used. Of the 109 patients using the Y set system, 88 (80.7%) never had episodes of peritonitis, whereas only 7 (16.7%) of the 42 patients using the Oreopoulos technique were free of peritonitis. For 23 patients shifted from the Oreopoulos to the Y set technique, the incidence of peritonitis dropped from 1/9.8 to 1/35.2 episodes/patient-months.     

Peritonitis in continuous ambulatory peritoneal dialysis: impact of a compulsory switch from a standard to a Y-connector system in a single North American Center.

One hundred one continuous ambulatory peritoneal dialysis (CAPD) patients from a single North American center were analyzed in a retrospective and cross-over study for peritonitis rates using a standard system (Travenol System II) or a Y-shaped disconnect-disinfectant system (Travenol O-set). Twenty-one of 34 patients using the standard set (group I) had 53 episodes of peritonitis in 508 patient-months or one episode per 9.6 patient-months. Nine of 17 patients switching from the standard to the disconnect-disinfectant system (group II) experienced 22 episodes of peritonitis in 275 patient-months or one episode per 12.5 patient-months on the standard set, while six patients had 10 episodes of peritonitis in 275 patient-months or one episode per 27.5 patient-months on the disconnect-disinfectant system (P less than 0.04). Twenty-eight of 67 new CAPD patients starting on the disconnect-disinfectant system (group III) had 37 episodes of peritonitis in 1,086 patient-months or one episode per 29.4 patient-months (P less than 0.01 v group I). Exit-site infections (ESI) occurred in 35.3% of patients using the standard set versus 34.3% of those using the O-set. The presence of an ESI was not associated with a higher risk of peritonitis, but modified the bacteriological profile of subsequent peritonitis episodes in patients using the O-set, favoring the organisms isolated from the exit site. Decreases in peritonitis rates with the O-set were due to a reduction of peritonitis episodes secondary to most bacterial agents and not only to skin organisms. Diabetics using intraperitoneal insulin had similar peritonitis and ESI rates as nondiabetics.(ABSTRACT TRUNCATED AT 250 WORDS)     

Use of pure bicarbonate-buffered peritoneal dialysis fluid reduces the incidence of CAPD peritonitis.

BACKGROUND: Advances in bag connection technology have reduced the incidence of peritonitis in CAPD patients but there is little information on the effect of the new peritoneal dialysis fluids. METHODS: We studied the incidence of CAPD peritonitis for about 3 years in 100 incident patients--50 patients dialysed with lactate-buffered solution, pH 5.5 and containing glucose degradation products (GDP) (lactate group), and 50 patients with pure bicarbonate-buffered solution, pH 7.4 and low GDP (bicarbonate group). Patients in both groups were similar in age, sex, length of time on CAPD, connection technology and handling of dialysis. RESULTS: In the lactate group, 74 episodes of peritonitis were recorded compared with 43 in the bicarbonate group, i.e. one episode per 21 patient-months with the lactate dialysis fluid and one episode per 36 patient-months with the bicarbonate dialysis fluid (OR 0.58, 95% CI 0.37-0.91, P = 0.017). A total of 3369 exchanges per episode of peritonitis were recorded for bicarbonate compared with 2004 exchanges per episode of peritonitis in the lactate group. The majority of organisms isolated in both groups were Gram-positive bacteria, with a predominance of the oropharyngeal and cutaneous endogenous flora. Three episodes of fungal peritonitis occurred in the lactate group and none in the bicarbonate group. CONCLUSIONS: Our results suggest that the pure bicarbonate-buffered peritoneal dialysis fluid appears to reduce the frequency of peritonitis in CAPD patients possibly in relation to greater biocompatibility and maintenance of peritoneal membrane structural integrity. Similar results can probably relate to all low-GDP solutions.     

Staphylococcus aureus skin carriage and development of peritonitis in patients on continuous ambulatory peritoneal dialysis

We conducted a 15-month prospective study to investigate the skin carriage of Staphylococcus aureus and the development of peritonitis in 43 patients undergoing continuous ambulatory peritoneal dialysis (CAPD). Sixteen of 43 patients (37%) were chronic carriers of S. aureus in the anterior nares and/or in the exit-site of the catheter; 12 patients (28%) were intermittent carriers, and 15 (35%) were noncarriers. Fifty episodes of peritonitis occurred during a total of 422 patient-months of observation. S. aureus was responsible for 16 episodes of peritonitis diagnosed in 15 patients. All episodes of S. aureus peritonitis occurred in chronic and intermittent carriers. Phage typing was performed on isolates from 8 patients with S. aureus peritonitis, and they were found to have the same phage type as that previously carried in the skin. We conclude that CAPD patients who are chronic or intermittent carriers of S. aureus are at higher risk of development of peritonitis than noncarriers.     

Analysis of the causative pathogens in uncomplicated CAPD-associated peritonitis: duration of therapy, relapses, and prognosis

We analyzed the frequency with which certain bacteria caused uncomplicated peritonitis in an adult continuous ambulatory peritoneal dialysis (CAPD) program that continued patients on this modality of therapy despite frequent infections. All infections were treated with a commonly employed 10- to 14-day course of narrow spectrum intraperitoneal antibiotics. Although the distribution of bacterial pathogens was similar to previous reports (coagulase-negative staphylococci, 43%; Staphylococcus aureus, 13%), we observed no episodes of fungal peritonitis. Twenty percent of our infections were associated with either "no specimens obtained" or "no growth," a finding similar to the CAPD registry. When the data were available, two thirds of all infections were caused by the same pathogen (genus and species) as in the most immediately preceding infection. Twenty-two of 96 episodes of uncomplicated peritonitis occurred within three weeks of a preceding infection. In all 11 cases where organisms were isolated from both paired episodes, the infecting agent was the same as in the preceding infection and was a staphylococcus. This high rate of apparent relapse and the absence of fungal infections may relate to our treatment protocol and possible explanations are discussed. Lastly, the occurrence of coagulase-negative staphylococcal peritonitis is a harbinger of future episodes of peritonitis caused by a variety of organisms.     

The characteristic of causative organisms and outcomes of peritonitis in younger and elderly peritoneal dialysis patients

Objective To provide guide for prevention and cure of peritonitis in peritoneal dialysis(PD) by comparing the causative organisms and clinical outcome of PD related peritonitis in younger and elderly patients in our center. Methods All patients who developed PD related peritonitis between January 2006 and December 2013 in Wuhan NO.1 hospital were included. According to their age, episodes were divided into younger patients group (＜65 years) and elderly patients group (≥65 years). The microbiology and clinical outcome of PD related peritonitis were compared, and the related risk factors of the treatment failure were analyzed. Results Three hundred and sixty - six episodes of peritonitis occurred in 258 patients during the study period. The overall rate of peritonitis was 1 episode in 76.8 patient-months. Elderly patients had higher incidence of peritonitis (1 episode every 56.4 months vs 1 episode every 88.7 months, P=0.001), higher incidence of fungus infection (9.6% vs 3.9%, P=0.026) and higher mortality ( 46.2% vs 14.0%, P=0.001) than that in younger patients. Cox regression analysis showed that longer duration of PD treatment and fungal peritonitis were both risk factors of the treatment failure. Conclusion Elderly patients had higher incidence of peritonitis, higher incidence of fungus infection and higher PD - related mortality than younger patients.     

Treatment of fungal peritonitis complicating continuous ambulatory peritoneal dialysis with oral fluconazole: a series of 21 patients

Twenty-one episodes of fungal peritonitis occurred over 35 monthsamong 290 patients on CAPD, accounting for 6.3% of all peritonitisepisodes. Patients with more frequent bacterial peritonitiswere at higher risk of developing fungal peritonitis, and 28.6%of cases followed antimicrobial therapy. Candida species accountedfor 85.7% of cases. Oral fiuconazole was used as initial therapyin all patients, which was followed by catheter removal if peritonitisfailed to improve. The cure rate with fluconazole therapy alonewithout catheter removal was 9.5%. Fluconazole plus catheterremoval, the latter necessitated in 85.7% of cases, resultedin a cure rate of 66.7%. The remaining 3 (14.3%) patients respondedto intravenous amphotericin given as salvage therapy. Disease-relatedmortality was 14.3%. Reinsertion of dialysis catheter was attemptedin 15 patients and CAPD was successfully resumed in 13 (86.7%).We conclude that oral fluconazole can be safely used as initialtherapy in patients with fungal peritonitis complicating CAPD.Although catheter removal was necessary in the majority of patients,this sequential approach resulted in a relatively low prevalenceof peritoneal adhesions and subsequent CAPD failure.     

Oral treatment of peritonitis complicating continuous ambulatory peritoneal dialysis

The efficacy of oral treatment with cephradine in peritonitis associated with continuous ambulatory peritoneal dialysis (CAPD) was compared with that of intraperitoneal cefuroxime over one year. There were 29 episodes of peritonitis in each group and a primary cure was achieved in 66% of the patients treated with cephradine compared with 55% of the patients treated with cefuroxime, suggesting that oral cephradine is as effective as a treatment with intraperitoneal cefuroxime. Nineteen of the 29 episodes in each treatment group were considered suitable for out-patient management and there was no difference in the success rate of either antibiotic regimen. The results suggest that out-patient treatment with oral cephradine is an efficient way of treating CAPD peritonitis.     

The role of continuous ambulatory peritoneal dialysis in end-stage renal failure due to multiple myeloma

A study in 10 patients (eight male, two female; mean age 61.9 +/- 10.7 years) suffering from multiple myeloma (MM) and end-stage renal failure (ESRF) is detailed. Continuous ambulatory peritoneal dialysis (CAPD) was the preferred mode of chronic dialysis in all the patients. Survival after diagnosis was 32.2 +/- 23.9 months. Survival after starting dialysis was 24.6 +/- 20.6 months. All patients on CAPD were adequately dialyzed and in good fluid control. Peritonitis was the main problem on CAPD (one episode per 5.6 patient-months). The majority of peritonitis episodes responded to intraperitoneal antibiotic therapy. One patient with Staphylococcus aureus peritonitis, septicemia, and neutropenia secondary to chemotherapy, died. Recommendations for prophylaxis and treatment of peritonitis are given. Three patients were transferred to hemodialysis. The use of subclavian vein catheters during hemodialysis was associated with a high incidence of gram-positive septicemia. Alkylating agent-based chemotherapy resulted in hematological responses in five patients. Survival after diagnosis in those responders was 47.4 +/- 25.6 months, compared with 17.0 +/- 7.2 months in the nonresponders (P less than 0.05). All responders subsequently relapsed. Four patients died with progressive myeloma. Bone marrow suppression resulted in a high blood transfusion requirement, neutropenia, and thrombocytopenia associated with bleeding into the gastrointestinal tract and central nervous system. Uremic myeloma patients can be adequately dialyzed using CAPD. Those patients who do not have an initial hematological response have a poor prognosis.     

Ambulatory peritoneal dialysis. Exploratory laparotomy for peritonitis

We present our experience with performing an exploratory laparotomy for peritonitis in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). Six of 134 patients undergoing CAPD during the study period underwent surgical intervention because of abdominal sepsis. Two patients had bacterial peritonitis without abscess formation or evidence of visceral perforation and they recovered readily and, in retrospect, may not have required an operation. Of the three patients with fungal abscesses, two died of subsequent bacterial sepsis, while one patient survived, albeit after drainage of a recurrent pelvic abscess. One patient died because of extensive intestinal gangrene that was misdiagnosed as CAPD-related peritonitis initially. Our experience with these cases suggests that fungal peritonitis is a life-threatening complication that may result in both formation of an abscess and death. Therefore, it warrants aggressive antifungal chemotherapy and surgical intervention should an abscess be discovered. In contrast, bacterial peritonitis should be treated with appropriate antibiotic regimens until adequate evidence indicating the presence of a surgical condition is obtained.     

Benefits of Low Dose Immunoglobulin in the Treatment of Refractory CAPD Peritonitis and Longevity of Technical Survival on CAPD

In this study we investigated the long term results of intraperitoneal immunoglobulin (Ig) treatment in continuous ambulatory peritoneal dialyses (CAPD) patients with refractory or relapsing peritonitis. Sixteen CAPD patients (4 female, 12 male) with a mean age of 53 ± 11 years (40–80), with a mean CAPD duration of 46.2 ± 4.8 months (17–75) were included in the study. The patients included had a diagnosis of either refractory or relapsing peritonitis unresponsive to appropriate antibiotic therapy. 0.5 g of Ig was added to every exchange bag qid as an adjunctive therapy to the culture based antibiotherapy for 7 days. Intraperitoneal Ig treatment was found to be successful in treating peritonitis in all but one patient. Interestingly, following Ig treatment, long term peritonitis rate decreased significantly compared to the period before treatment (before: 2.2 ± 0.6 episodes/patient/year vs. after: 0.6 ± 0.17 episodes/patient/year; P = 0.019). The mean CAPD duration after Ig treatment was 30.5 ± 5.4 (4–64) months. Out of 16 patients, one patient who was unresponsive, had his catheter removed and was switched to hemodialysis, and four patients with preexisting ultrafiltration failure or inadequate dialysis problems were transferred to hemodialysis after successful treatment of their peritonitis, one patient was transplanted and 10 patients continued on CAPD. We conclude that low dose Ig treatment may be beneficial in the treatment of refractory or relapsing CAPD peritonitis possibly through restoring impaired host defense within peritoneal cavity. This therapy, by preventing further peritonitis attacks, may prolong survival on CAPD.     

Vancomycin and tobramycin in the treatment of CAPD peritonitis

Seventy-five episodes of continuous ambulatory peritoneal dialysis (CAPD) peritonitis were studied during a 1 year period at the Queen Elizabeth Hospital, Birmingham. When two simple culture methods were used in parallel, the causative organisms were identified in 97% of cases. Nearly two thirds of episodes of peritonitis were caused by coagulase-negative staphylococci (C-NS), many of which were multiply antibiotic-resistant. On the basis of detailed antibiotic sensitivities, intraperitoneal vancomycin and tobramycin were chosen for the initial treatment of CAPD peritonitis. With this regime, a cure was achieved in 32 of 38 episodes, compared with 15 of 27 episodes when cefuroxime was used. All but 1 of 24 episodes caused by C-NS were cured by vancomycin.     

Timing and characteristics of multiple peritonitis episodes: a report of the National CAPD Registry

Patterns of recurrent peritonitis episodes were examined in 6,335 new continuous ambulatory peritoneal dialysis (CAPD) patients entered into the National CAPD Registry. Forty-six percent of all peritonitis episodes were initial occurrences, with 8% of the patients reporting four or more episodes. The proportion of gram-positive and gram-negative infections was constant across episodes. In patients with multiple infections, negative organisms were found to have increased risk of recurring as gram-negative infection. A similar observation was made for fungal infections. Of patients with multiple peritonitis episodes, more than 40% of those who transferred to other maintenance renal replacement therapy identified peritonitis as the reason for transfer. A discrete time logistic model was used to estimate peritonitis risk in 4-month follow-up periods. Patients like those on the registry are estimated to have a 22% risk of developing peritonitis during any 4-month period. This risk was increased 4% for patients aged less than 21 years, 7% for nonwhite patients, and 19% in the period following a peritoneal infection.     

A randomized prospective trial of three different regimens of treatment of peritonitis in patients on continuous ambulatory peritoneal dialysis

A randomized prospective study was undertaken in patients on continuous ambulatory peritoneal dialysis (CAPD) to evaluate the efficacy of three different antibiotic regimens for the treatment of peritonitis. There were 39 episodes in each treatment group. Patients were treated with intraperitoneal (IP) cephalothin (250 mg/L) and tobramycin (8 mg/L) in group 1, oral ofloxacin (400 mg loading followed by 300 mg daily) in group 2, and a combination of ofloxacin (400 mg followed by 300 mg daily) and rifampicin (300 mg daily). Treatment duration was 10 days. The average culture-positive rate was 75%. The overall cure rate was 80.6% with IP antibiotics, 78.4% with oral ofloxacin, and 81.1% with ofloxacin and rifampicin. After the exclusion of tunnel infections and episodes of peritonitis due to Pseudomonas and resistant organisms, the corresponding figures were 100%, 90.6%, and 93.7%, respectively. Side effects were minimal with IP treatment and with oral ofloxacin, but severe nausea and vomiting occurred in some cases with the combination of ofloxacin and rifampicin. It was concluded that oral ofloxacin is an acceptable first-line therapy for peritonitis in CAPD patients.     

Vancomycin and ceftazidime in the treatment of CAPD peritonitis

102 episodes of continuous ambulatory peritoneal dialysis (CAPD) peritonitis were studied prospectively during a 288-day period at The Queen Elizabeth Hospital, Birmingham. Organisms were isolated from 76% of the episodes, with coagulase-negative staphylococci, being the most commonly encountered organism (55%). Initial treatment consisted of intraperitoneal vancomycin and ceftazidime with subsequent adjustment on the basis of antibiotic sensitivities. With this regimen, 83% of the positive cultures became negative by 72 h, 9.8% of cases relapsed and removal of the CAPD catheter was necessary in 8 patients (7.8%). Overall, 92% of cases were cured. No adverse drug reactions were seen. This combination of antibiotics appears effective and safe in the treatment of CAPD peritonitis.     

Candida parapsilosis peritonitis complicated with infected pancreatic pseudocysts in a peritoneal dialysis patient: a challenge for nephrologists

In continuous ambulatory peritoneal dialysis (CAPD)-related cases of fungal peritonitis, Candida parapsilosis (C. parapsilosis) has become as common as Candida albicans (C. albicans) in fungal isolates. This report describes a 74-year-old male CAPD patient who received bypass surgery for coronary artery disease, followed by an episode of bacterial peritonitis. The peritonitis was successfully treated with intraperitoneal antibiotics. However, C. parapsilosis peritonitis with concomitant pancreatitis and infected pseudocysts occurred one month later. Despite surgical drainage and intravenous administration of fluconazole, fungal peritonitis persisted. Finally, he died of nosocomial pneumonia. This case demonstrates the poor outcome of C. parapsilosis peritonitis, suggesting a more aggressive treatment in peritoneal dialysis patients.     

Clinical outcomes of systemic lupus erythematosus patients undergoing continuous ambulatory peritoneal dialysis.

OBJECTIVES: The purpose of this study was to evaluate the outcome of systemic lupus erythematosus (SLE) patients on continuous ambulatory peritoneal dialysis (CAPD). METHODS: Eighteen SLE patients who had been undergoing CAPD for at least 3 months in our unit were compared with 36 other age- and gender-matched non-diabetic CAPD patients with an underlying primary chronic glomerulonephritis (CGn). The clinical outcome, infective complications, lupus activities, biochemical parameters, haemoglobin level and the use of erythropoietin were reviewed. RESULTS: The duration of dialysis of the two studied groups was not different, with a mean of 35.4 months for the SLE group and 36.7 months for the CGn group. Before dialysis, SLE patients had a significantly lower albumin level (30.4+/-6.6 vs 35.4+/-5.59 g/dl, P<0.01), while the mean haemoglobin levels of the two groups were similar (8.5+/-1.8 g/dl for SLE vs 9.0+/-1.9 g/dl for the control group). However, the weekly dose of erythropoietin (EPO) used was significantly higher in the SLE group (6000 vs 3818 U/week, P<0.01) to maintain a similar haemoglobin level during dialysis. Regarding the infective complications, the SLE group had a higher peritonitis rate (5.7 episodes/100 patient-months vs 2.4 episodes/100 patient-months, P<0.05), and an increase in the non catheter related infection rate (6.67 episodes/100 patient-months vs 1.1 episodes/100 patient-months, P<0.001). However, no significant difference could be demonstrated in the Tenckhoff catheter exit site infection rate (2 episodes/100 vs 1.7 episode/100 patient-months). The number of patients who received a kidney transplant or required a change of mode to haemodialysis was similar among the two groups. Seven patients died during the follow-up period, and the overall mortality rate was much higher in the SLE group than in the control group (0.83/100 vs 0.15/100 patient-months, P<0.05). CONCLUSIONS: SLE patients on CAPD have a significantly lower pre-dialysis serum albumin level and use a higher dose of Epo to achieve a comparable haemoglobin level than other non-diabetic CGn CAPD patients. They also have a poorer prognosis in terms of infective complications and mortality rate.     

Peritoneal nitric oxide is a marker of peritonitis in patients on continuous ambulatory peritoneal dialysis

Nitric oxide plays an important role in mediating the inflammatoryprocess. The aim of this study was to evaluate if nitric oxideproduction was increased during peritonitis in patients receivingcontinuous ambulatory peritoneal dialysis (CAPD), and the associationwith the prognosis. The study population comprised 21 patientswith 22 episodes of peritonitis. Fifteen patients without peritonitiswere controls. Nitrate was measured by HPLC and nitrite by theGriess method, to reflect nitric oxide production. Peritonealdialysate effluent and plasma were collected from six patientsduring peritonitis and 1 week after treatment to study changesin dialysate:plasma ratio. In 15 patients, nitrite was measuredduring peritonitis and every 3 days for 2 weeks or until normalizedfor evolutional changes. The dialysate plasma ratios of nitrateand nitrite during peritonitis were reduced 26% and 41.5%, respectively,after 1 week of treatment, indicating the peritoneal productionof nitric oxide during peritonitis. In the evolutional study,a 5.1-fold increase of peak nitrite levels in bacterial peritonitis(n=13) and a 2.5-fold increase in fungal peritonitis (n=3) wereobserved compared to controls. Nitrite gradually declined tocontrol levels (9.3±7.2 days) after effective antibiotictreatment, but took longer than to normalize leukocyte countin the peritoneal dialysate effluent (3.9±1.9 days).In four patients with refractory peritonitis (Candida infectionin three, Acinetobacter infection in one), the nitrite levelsremained elevated 2-fold despite treatment, and the catheterswere removed. It is concluded that nitrite levels in peritonealdialysate effluent may serve as a marker to assess treatmentefficacy in CAPD patients with peritonitis.     

Vancomycin pharmacokinetics in continuous ambulatory peritoneal dialysis patients with peritonitis

Peritonitis has proven to be the major deterrent to the further growth of continuous ambulatory peritoneal dialysis (CAPD) as a treatment strategy for end-stage renal disease. The correct treatment of peritonitis remains unsettled as evidenced by the presence of advocates for oral, intravenous or intraperitoneal antibiotic administration. This study examines the pharmacokinetic parameters of intravenous vancomycin when employed in the therapy of peritonitis. One gram of intravenous vancomycin was administered during 7 episodes of peritonitis in 5 patients. Plasma and end-of-dwell dialysate levels were maintained above the minimum inhibitory concentration for Staphylococcus aureus and S. epidermidis for 7 days following this single dose of vancomycin. These data establish the existence of sustained intraperitoneal entry of intravenous vancomycin during peritonitis and raise for speculation its use as the sole therapy in most episodes of gram-positive peritonitis.     

A randomized prospective comparison of oral versus intraperitoneal ofloxacin as the primary treatment of CAPD peritonitis

Summary: Oral ofloxacin has been successfully used in our centres for the primary treatment of peritonitis complicating continous ambulatory peritoneal dialysis (CAPD). In view of the progressive rise in the resistance rate to ofloxacin among peritoneal bacterial isolates, a study was conducted to determine if oral ofloxacin remains a viable first line treatment for CAPD peritonitis in our centres and if the result can be improved by changing from an oral to an intraperitoneal (i.p.) route. In patients on three 2 L daily CAPD exchanges, ofloxacin given at the i.p. dosage of 200 mg loading followed by 25 mg/L of peritoneal dialysate achieved overnight trough peritoneal levels which are at least four times the minimal 90% inhibitory concentration (MIC90) of most bacterial pathogens without significant accumulation in the systemic circulation. This i.p. dosage was therefore chosen for the clinical study and the result was compared to that using ofloxacin given in the oral dosage of 400 mg loading followed by 300 mg once daily as maintenance. of all the recruited episodes, 35 were eligible for analysis. the overall primary cure rate including primary failures and relapses was 55.6% (10/18) in the oral treatment group and 70.6% (12/17) in the i.p. treatment group. the corresponding figures for gram positive bacterial (g +) infections were 36.4% and 50%, for gram negative bacterial (g -) infections were 66.7 and 80% and for culture negative infections were 75 and 80%. In culture positive cases, all treatment failures were due to resistant infections which were observed in 42.3% of all bacterial isolates, 47.1% of g + isolates and 33.3% of g - isolates. Due to the high background level of bacterial resistance among our CAPD population, ofloxacin monotherapy given either by the oral or the i.p. route can no longer be recommended for the primary treatment of CAPD peritonitis.