Management of bacterial peritonitis and exit‐site infections in continuous ambulatory peritoneal dialysis*

SUMMARY: Peritonitis and exit‐site infections remain the most important limitations to the delivery of continuous ambulatory peritoneal dialysis (CAPD). Contamination of the peritoneum, from endogenous or exogenous sources, is responsible for most peritonitis episodes. Patients usually present with a cloudy bag, although other causes should be distinguished. Clinical suspicion of peritonitis should be followed rapidly by microbiological examination and empirical treatment. Microbiological confirmation allows for subsequent treatment based on sensitivities. Other interventions such as catheter removal may be appropriate in some patients. Exit‐site infections should also be identified and treated early. Peritonitis may be further prevented by adequate exit‐site care, hygienic methods, and techniques to minimise early contamination of the exit site. Mupirocin may also have a role in preventing infections caused by Staphylococcus aureus.     

An analysis of ten-year trends in infections in adults on continuous ambulatory peritoneal dialysis (CAPD)

Infectious complications are the Achilles heel of CAPD. To determine trends in these events, we analyzed the CAPD related infections of 303 adults on CAPD at a single university center between 1979 and 1989. During this decade the percentage of insulin-dependent diabetics increased from 14% to 39% (p less than 0.005). Peritonitis rates fell from 2.4 episodes/y in 1979 to 0.8 episodes/y in 1989. The proportion of patients with multiple episodes of peritonitis decreased (40% of the patients in 1979-1982 vs 15% in 1983-1989, p = 0.0001) while the proportion of patients with no episodes of peritonitis increased during the same periods (29% vs 49%, p = 0.005). The proportion of peritonitis episodes due to S. aureus rose over the 10-year period (p = 0.005), while those due to S. epidermidis decreased (p less than 0.10). The overall incidence of S. aureus peritonitis remained unchanged. Catheter infection rates initially increased and then fell during the decade; S. aureus remained the predominant cause. The proportion of peritonitis episodes associated with catheter infection rose (13% in 1982 vs 24% in 1989, p = 0.025), and in 1989, 80% of these episodes were caused by S. aureus. Catheter loss was also primarily due to S. aureus infections in 1989 (80%). Infections due to P. aeruginosa were a persistent problem. The proportion of patients transferring to hemodialysis each year paralleled catheter loss rates, which in turn appeared to be more related to catheter infection rates than to peritonitis rates. We conclude that control of S. aureus and P. aeruginosa will be the key to future reductions in the infectious complications of CAPD patients.     

Adult and pediatric peritonitis rates in a home dialysis program: comparison of continuous ambulatory and continuous cycling peritoneal dialysis

We reviewed our 115-month experience with continuous ambulatory peritoneal dialysis (CAPD) and continuous cycling peritoneal dialysis (CCPD) in adult and pediatric patients to determine whether there is a difference in the incidence of peritonitis between patients performing CAPD or CCPD. Peritonitis rates were similar in patients performing CAPD or CCPD in both the adult and pediatric age groups. The overall CAPD peritonitis rate was significantly lower in adult patients when compared with pediatric patients. There was no difference in peritonitis rates for CCPD between adult and pediatric patients. When the data are divided into 3-year subgroups, the incidence of peritonitis is significantly lower in adult patients undergoing either CAPD or CCPD when compared with pediatric patients during the years 1986 to 1988. There is significant improvement over time in the incidence of peritonitis in both adult and pediatric patients performing CCPD; similarly, there is a trend toward improvement in patients performing CAPD. Staphylococcus species organisms remain the most common bacterial cause of peritonitis, except in pediatric patients under the age of 2 years or with nephrostomies, where gram-negative rod infections were more common. Peritonitis resulted in discontinuation of peritoneal dialysis in a greater number of adult patients. These results suggest that the number of catheter manipulations is not important in determining the incidence of peritonitis. Pediatric patients are more likely than adult patients to develop peritonitis with either CAPD or CCPD. Adult patients are more likely than pediatric patients to discontinue peritoneal dialysis secondary to peritonitis.     

Prevention of infectious complications in peritoneal dialysis: best demonstrated practices

Peritoneal dialysis (PD) related infections continue to be a serious complication for PD patients. Peritonitis can be associated with pain, hospitalization and catheter loss as well as a risk of death. Peritonitis risk is not evenly spread across the PD population or programs. Very low rates of peritonitis in a program are possible if close attention is paid to the causes of peritonitis and protocols implemented to reduce the risk of infection. Protocols to decrease infection risk in PD patients include proper catheter placement, exit-site care that includes Staphylococcus aureus prophylaxis, careful training of patients with periodic retraining, treatment of contamination, and prevention of procedure-related and fungal peritonitis. Extensive data have been published on the use of antibiotic prophylaxis to prevent exit site infections. There are fewer data on training methods of patients to prevent infection risk. Quality improvement programs with continuous monitoring of infections, both of the catheter exit site and peritonitis, are important to decrease the PD related infections in PD programs. Continuous review of every episode of infection to determine the root cause of the event should be routine in PD programs. Further research is needed examining approaches to decrease infection risk.     

Pseudomonas exit site infections in continuous ambulatory peritoneal dialysis patients.

The purpose of this study is to examine the natural history of Pseudomonas aeruginosa exit site infections in continuous ambulatory peritoneal dialysis (CAPD) patients treated with oral ciprofloxacin and local exit site care. A retrospective view was undertaken of 18 episodes of P. aeruginosa exit site infections developing in 17 patients maintained on CAPD during 1989 and 1990. Standardized therapy for the exit site infection consisted of oral ciprofloxacin (500 mg twice daily) and local exit site care with antiseptic agents. Fifteen (83%) of 18 of the pseudomonas exit site infections resolved with therapy. Three episodes (17%) required catheter removal to successfully eradicate the infection. Four of the 15 patients whose exit site infections resolved developed P. aeruginosa peritonitis 2 to 9 months after the clinical resolution of the exit site infection. The majority of pseudomonas exit site infections in CAPD patients can be successfully treated with oral ciprofloxacin and local care. Approximately 17% of the patients in this study required catheter removal to successfully eradicate the infection and an additional 22% of the patients developed pseudomonas peritonitis several months after the resolution of the exit site infection.     

Peritoneal infections

Peritoneal dialysis related infections include infection of the catheter exit site, subcutaneous pathway, or effluent. Exit-site infections, predominately owing to Staphylococcus aureus, are defined as purulent drainage at the exit site, although erythema may be a less serious type of exit-site infection. Tunnel infections are underdiagnosed clinically, and sonography of the tunnel is useful to delineate the extent of the infection and to evaluate response to antibiotic therapy. S aureus infections occur more frequently in S aureus carriers and immunosuppressed patients and can be reduced by mupirocin prophylaxis either intranasally or at the exit site. Patients with peritonitis present with cloudy effluent and usually pain, although 6% of patients may initially have pain without cloudy effluent. A white blood cell count of 100 or greater per microL, 50% of which are polymorphonuclear cells, has long been the hallmark of peritonitis. Empiric therapy is controversial, with some recommending cefazolin and others vancomycin (with cefatazidime for Gram-negative coverage). The choice should depend on the center's antibiotic sensitivity profile; those centers with a high rate of Enterococcus- or methicillin resistant organisms should use vancomcycin. Peritonitis episodes occurring in association with a tunnel infection with the same organism seldom resolve with antibiotics and require catheter removal. Other indications for catheter removal are refractory peritonitis, relapsing peritonitis, tunnel infection with inner-cuff involvement that does not respond to antibiotic therapy (based on ultrasound criteria), fungal peritonitis, and enteric peritonitis owing to intra abdominal pathology. Centers can reduce dialysis related infections to very low levels by proper catheter selection and insertion, careful selection and training of patients, avoidance of spiking techniques, and use of antibiotic prophylaxis against S. aureus. Further research is required to identify methods to reduce the risk of enteric peritonitis.     

Use of pulsed-field gel electrophoresis in the analysis of recurrent Staphylococcus aureus infections in patients on continuous ambulatory peritoneal dialysis

BACKGROUND/AIM: The purpose of this study was to evaluate pulsed-field gel electrophoresis (PFGE) for distinguishing between relapse and reinfection of Staphylococcus aureus infections in patients on continuous ambulatory peritoneal dialysis (CAPD). METHODS: Between July 1993 and May 1997, 4 patients with recurrent CAPD-associated infections caused by S. aureus we enrolled in this study. There were nine episodes of peritonitis, one episode of temporary double lumen catheter infection, and one episode of Hickman catheter infection. A total of eleven S. aureus isolates were collected from peritoneal fluid (n = 9) and blood (n = 2). PFGE typing was applied. RESULTS: In our study, from PFGE typing, the 11 S. aureus isolates were classified into seven patterns. Antibiogram profiling classified only four patterns. Patient A had a reinfection by another strain of S. aureus, and patient B had three episodes of peritonitis caused by the same strain of S. aureus due to exit site infections. Patient C had two episodes of CAPD peritonitis caused by two different strains, respectively. Patient D had four episodes of S. aureus infection (three CAPD peritonitis and one bacteremia); the first two episodes of peritonitis were caused by an identical strain of S. aureus, whereas the subsequent two infections were caused by other organisms. CONCLUSION: PFGE has a high discriminatory power and can be an assistant method to antibiogram profiling for distinguishing relapse from reinfection in CAPD-associated peritonitis.     

Frequent involvement of the internal cuff segment in CAPD peritonitis and exit-site infection--an ultrasound study

BACKGROUND.: The extent of involvement of the subcutaneous Tenckhoff cathetertract in CAPD peritonitis and catheter-related infections isof major therapeutic importance. By definition, both peritonitisand exit-site infections do not involve the catheter tract.However, diagnosis of these infections as well as the more sinistertunnel infection is based mainly on clinical signs. METHODS.: We examined the usefulness of ultrasound examination (US) ofthe catheter tract in delineating catheter-related (exit-siteand tunnel) infections, and their relationship to each otherand to peritonitis. CAPD patients with no evidence of peritonitisor catheter-related infections for 6 months prior to examinationserved as controls. US were performed by one of two experiencedradiologists using the Acuson 128XP/10 scanner with a 7-MHzlinear transducer. A positive US was defined as an area of hypoechogenicity(indicative of fluid collection) >2 mm in width along anyportion of the catheter tract. Findings were localized intosegments (S) as follows: S1, limited to external cuff; S2, intercuffsegment adjacent to the external cuff; S3, intercuff segmentadjacent to the internal cuff; S4, limited to the internal cuff;and S5, involvement extending throughout the catheter tract. RESULTS.: Between March 1993 and January 1995, 39 CAPD patients, all witha double-cuff straight Tenckhoff catheter with the exit sitesituated above the point of entry into the peritoneum were studied.A total of 56 US were performed divided among 26 episodes ofperitonitis, four tunnel infections, 13 exit-site infections,and 13 controls. There were 30 positive US distributed among16 peritonitis, four tunnel, eight exit site infections andtwo control patients. The two positive controls went on to develop peritonitis within1 month of the US. The majority of the US findings (13/16 inepisodes of peritonitis and 5/8 exit site infections) were localizedto segment 4, that is, to the internal cuff region. Apart from a significant increase in width in all infected segmentsversus a normal tunnel, no differences in size were seen betweenperitonitis, exit-site, or tunnel infections, nor were thereany differences in size and localization in these infectionswhen comparing the offending organism (Gram-positive, negative,or culture negative). CONCLUSIONS.: We conclude that peritonitis and exit-site infections are frequentlyaccompanied by involvement of the catheter tract. The localizationof infection to the internal cuff region in cases of exit-siteinfection probably occurred as a result of downward migrationalong the catheter tract. This supports the notion that ideallythe exit site should be pointing caudally or that the peritonealcatheter have a swan-neck configuration. With regard to peritonitis,infection within the peritoneal cavity appears to extend andinvolve the internal cuff region. Thus both the internal andexternal cuffs do not seem to pose an effective barrier againstthe spread of infection. Based on our data, we recommend thatUS be performed as a routine investigation in all cases of exit-siteinfection and in cases of refractory or relapsing peritonitis.     

Chronic peritoneal dialysis: mechanical and infectious complications

The present report summarizes the mechanical and infectious complications attributable to the devices and procedures used for chronic peritoneal dialysis (PD), comparing the type and frequency of such complications in contemporaneous groups of patients undergoing continuous ambulatory PD (CAPD) or intermittent PD (IPD). Mechanical complications related directly to the catheter and its placement proved to be equally frequent during CAPD and IPD. On the other hand, mechanical complications related to increased intraperitoneal pressure were more frequent during CAPD. In most instances mechanical complication can be managed without permanent interruption of chronic PD. Peritonitis occurs more frequently during CAPD (1.6 episodes per patient-year) than during IPD (0.4 episodes per patient-year), with a tendency to more frequent peritonitis among diabetics, children, patients with white blood cell abnormalities, patients with catheter cuff or tunnel inflammation, and during the 1st month of treatment. Medical therapy eradicates peritonitis and allows continuation of chronic PD with retention of the catheter in more than 90% of episodes, although special problems may be encountered with fungal, pseudomonal, and some coagulase-positive staphylococcal infections.     

Peritoneal dialysis catheter infections and peritonitis in children: a report of the North American Pediatric Renal Transplant Cooperative Study

Peritonitis and catheter-related infections remain the two most-common causes of peritoneal dialysis (PD) treatment failure. To define the frequency and risks associated with exit site/tunnel infections (ESI/TI), as well as peritonitis, in pediatric patients on PD, we undertook a retrospective cohort study of patients initiated on PD in the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS). We examined demographic data and PD catheter characteristics of 1,258 patients, aged <21 years, initiated on PD from 1992 to 1997. We examined the frequency and complications of ESI/TI occurring within 30 days, 6 months, and 1 year of follow-up. For peritonitis episodes, we examined patient risk factors for peritonitis. Almost 11% of patients had an ESI/TI at 30 days, 26% between 30 days and 6 months, and 30% between 6 months and 1 year of follow-up. There was no increased risk of ESI/TI associated with patient age, race, or catheter characteristics. Peritonitis occurred in dialysis patients at a rate of 1 episode per 13.2 patient months. Proportional hazards regression analysis demonstrated that black race, single-cuffed catheters, and upward pointing exit sites were independent risk factors for peritonitis in the pediatric PD population. Patients with ESI/TI had twice the risk of those without these infections of developing peritonitis or needing access revision, and an almost threefold increased risk of hospitalization for access complications/malfunction. ESI/TI occurs commonly in pediatric PD patients. These infections cause significant morbidity, through risk of peritonitis, access revision, and hospitalization for catheter complications. Further study of potentially modifiable risk factors for ESI/TI in pediatric end-stage renal disease patients is warranted. Received: 22 November 1999 / Revised: 7 June 2000 / Accepted: 9 June 2000     

Ultrasound Evaluation of Peritoneal Catheter Tunnel in Catheter Related Infections in CAPD

In cases of peritonitis and exit site infections it is important to determine the extent of involvement of the subcutaneous catheter tract. The assessment of such involvement by physical examination alone appears to be inadequate and insensitive. We examined the usefulness of ultrasound (US) examination of the catheter tract in delineating catheter related infections, and their relationship to each other and to peritonitis. Patients were examined during clinically defined states of exit-site infection (ESI), clinically defined tunnel infection (TI), peritonitis and in the normal condition. US examinations of the catheter tunnel were performed in 44 CAPD patients. A total of 47 US examinations (examination was repeated in three patients) were performed, divided among 13 episodes of peritonitis, four ESI, and 30 controls. In 12 of 47 US examinations, US-defined TI was demonstrated as a sonolucent pericatheteric fluid collection. These 12 positive US were distributed among seven patients with peritonitis, three with exit-site infections and two control patients. We conclude that peritonitis and ESIs are frequently accompanied by involvement of the catheter tract. It seems that both the internal and external cuffs do not constitute an effective barrier against the spread of infection.     

Clinical course of peritonitis due to Pseudomonas species complicating peritoneal dialysis: a review of 104 cases

BACKGROUND: Peritonitis due to Pseudomonas species is a serious complication in continuous ambulatory peritoneal dialysis (CAPD) patients. The clinical course of peritonitis due to Pseudomonas complicating CAPD remains unclear. METHODS: All of the Pseudomonas species episodes of peritonitis in our dialysis unit were studied from 1995 to 1999. During this period, there were 859 episodes of peritonitis recorded, 113 of which were caused by the Pseudomonas species. Nine episodes were excluded because they were mixed growth. The remaining 104 episodes in 68 patients were reviewed. RESULTS: The underlying renal diagnosis and prevalence of comorbid conditions of the 68 patients were similar to those found in our entire dialysis population. There was a history of antibiotic therapy within 30 days of the onset of peritonitis due to the Pseudomonas species in 69 episodes (66.3%). In 47 episodes (45.2%) there was a concomitant exit site infection. The overall primary response rate was 60.6% and the complete cure rate was 22.1%. The presence of exit site infection was associated with a lower primary response rate (22 in 47 vs. 41 in 57 episodes, P < 0.01) and a lower complete cure rate (5 in 47 vs. 18 in 57 episodes, P < 0.02). The episodes that had received recent antibiotic therapy had a significantly lower complete cure rate than the de novo cases (8 in 69 vs. 15 in 35 episodes, P < 0.001). Episodes receiving third-generation cephalosporin as part of the initial antibiotic regimen had a significantly higher primary response rate than the ones that initially received aminoglycoside (54 in 81 episodes vs. 8 in 22 episodes, P < 0.05), but their complete cure rates were similar. Twenty-four cases failed to respond to antibiotics and the Tenckhoff catheter was removed. The chance of returning to CAPD was higher when the Tenckhoff catheter was removed on day 10 than on day 15 (9 in 14 cases vs. 5 in 10 cases), although the result was not statistically significant. The Tenckhoff catheter was removed and replaced at another site simultaneously in another 14 cases after the effluent cleared up. None of these patients had a relapse of peritonitis within three months. CONCLUSIONS: Recent antibiotic therapy is the major risk factor for peritonitis due to the Pseudomonas species. Exit site infection and recent antibiotic therapy are associated with poor therapeutic response to antibiotics. When the therapeutic response is suboptimal, early Tenckhoff catheter removal may help preserve the peritoneum for further peritoneal dialysis. Elective Tenckhoff catheter exchange after clearing up the peritoneal dialysis effluent may also reduce the likelihood of relapse. It is desirable to use third-generation cephalosporin in the initial antibiotic regimen for peritonitis treatment in localities with a high incidence of peritonitis due to the Pseudomonas species.     

Randomized, double-blind trial of antibiotic exit site cream for prevention of exit site infection in peritoneal dialysis patients

Infection is the Achilles heel of peritoneal dialysis. Exit site mupirocin prevents Staphylococcus aureus peritoneal dialysis (PD) infections but does not reduce Pseudomonas aeruginosa or other Gram-negative infections, which are associated with considerable morbidity and sometimes death. Patients from three centers (53% incident to PD and 47% prevalent) were randomized in a double-blinded manner to daily mupirocin or gentamicin cream to the catheter exit site. Infections were tracked prospectively by organism and expressed as episodes per dialysis-year at risk. A total of 133 patients were randomized, 67 to gentamicin and 66 to mupirocin cream. Catheter infection rates were 0.23/yr with gentamicin cream versus 0.54/yr with mupirocin (P = 0.005). Time to first catheter infection was longer using gentamicin (P = 0.03). There were no P. aeruginosa catheter infections using gentamicin compared with 0.11/yr using mupirocin (P < 0.003). S. aureus exit site infections were infrequent in both groups (0.06 and 0.08/yr; P = 0.44). Peritonitis rates were 0.34/yr versus 0.52/yr (P = 0.03), with a striking decrease in Gram-negative peritonitis (0.02/yr versus 0.15/yr; P = 0.003) using gentamicin compared with mupirocin cream, respectively. Gentamicin use was a significant predictor of lower peritonitis rates (relative risk, 0.52; 95% confidence interval, 0.29 to 0.93; P < 0.03), controlling for center and incident versus prevalent patients. Gentamicin cream applied daily to the peritoneal catheter exit site reduced P. aeruginosa and other Gram-negative catheter infections and reduced peritonitis by 35%, particularly Gram-negative organisms. Gentamicin cream was as effective as mupirocin in preventing S. aureus infections. Daily gentamicin cream at the exit site should be the prophylaxis of choice for PD patients.     

The influence of peritoneal catheter exit-site infections on peritonitis, tunnel infections, and catheter loss in patients on continuous ambulatory peritoneal dialysis

The importance of exit-site infections (ESIs) as a source of peritonitis and catheter loss in continuous ambulatory peritoneal dialysis (CAPD) patients is unknown. We collected data on 137 CAPD patients over a 5-year period (2,052 cumulative patient months). Patients with a history of ESIs were more likely to have peritonitis and tunnel infections than patients without a history of ESIs. A larger percentage of patients with a history of ESIs lost catheters and transferred to hemodialysis than those without such a history, independent of the effect of peritonitis. These data confirm the importance of reducing the incidence of ESIs. More information is needed to determine the nature of the relationship between ESIs and peritonitis.     

Renal histology for the diagnosis of primary hyperoxaluria in patients with end-stage renal disease

In patients utilizing continuous ambulatory peritoneal dialysis (CAPD), Staphylococcus epidermidis is the most prevalent organism isolated from peritoneal and exit site infections [1] although clinically significant systemic infection is unusual. We report 2 patients undergoing CAPD who developed generalized lymphadenopathy following peritonitis and exit site infection with S. epidermidis isolated from the excised lymph nodes. We conclude that catheter-related S. epidermidis infection may result in generalized lymphadenopathy due to dissemination of the infective focus.     

Polymicrobial peritonitis in patients on continuous peritoneal dialysis.

Little data are available about the characteristics, outcome, and risk factors for polymicrobial peritonitis in patients on continuous peritoneal dialysis. We therefore reviewed the 43 episodes of polymicrobial peritonitis that occurred in 39 of our patients over the 11.5 years of our program. Polymicrobial peritonitis represented 9% (43/492) of all peritonitis episodes. Only three episodes of polymicrobial peritonitis were associated with an enteric source. Sixteen percent (7/43) of the polymicrobial peritonitis episodes were associated with catheter infections. Staphylococcus aureus was one of the cultured organisms in 33% of the polymicrobial peritonitis episodes. Patients with polymicrobial peritonitis had higher rates of tunnel infection (0.28/yr v 0.18/yr) and overall peritonitis (1.23/yr v 0.81/yr) than patients with single-organism peritonitis. Black patients were more likely to have polymicrobial peritonitis (12/56 v 27/338 whites, chi 2 = 9.8, P less than 0.005). Patient age, gender, time on peritoneal dialysis, insulin dependence, and cause of end-stage renal disease had no influence on polymicrobial peritonitis. Significantly more catheters were removed for polymicrobial peritonitis than for single-organism peritonitis (17/42 v 89/420, chi 2 = 7.05, P less than 0.01), but in 60% of the episodes, the polymicrobial peritonitis was successfully treated without catheter removal. Polymicrobial peritonitis often occurs without gram-negative organisms and extension of catheter infection may be involved in some cases. For unclear reasons, black patients are at higher risk of polymicrobial peritonitis.     

Surgical aspects of the Tenckhoff peritoneal dialysis catheter. A 7 year experience

The experience with CAPD using the Tenckhoff catheter in 115 patients over a 7 year period has been reviewed. The general indications for CAPD in the patient with chronic renal failure are the mental and physical ability of the patient or his relatives to perform CAPD. In our series, diabetes mellitus has been a relative indication for CAPD, because diabetic patients often have vascular disease severe enough to make long-term hemodialysis difficult. The general contraindications are abdominal problems such as hernias, abdominal wall infections, inflammatory bowel disease, adhesions, and gastrointestinal stomas. Other contraindications are lumbar disk disease and respiratory insufficiency. The surgical principles of catheter insertion have been described. Complications associated with the Tenckhoff catheter were either mechanical (intraabdominal organ injury, incisional hernia, catheter leakage, catheter occlusion, or catheter dislodgement), or infectious (peritonitis or abdominal wall infection). The single most common organism isolated from effluent dialysate in 65 patients with peritonitis was Staphylococcus epidermidis in six patients (9.2 percent), and in 20 patients (30.8 percent), no organism could be isolated. For those patients who had peritonitis, the average frequency was at 8.9 months of CAPD. There were only three deaths (3 percent) directly related to the Tenckhoff catheter and these were due to peritonitis and sepsis. Only 22 (19 percent) of the 115 patients in this series had to discontinue CAPD because of its ineffectiveness or the patient's or relative's inability to perform CAPD.     

Infectious and catheter-related complications in pediatric patients treated with peritoneal dialysis at a single institution

Continuous ambulatory peritoneal dialysis (CAPD) and continuous cycling peritoneal dialysis (CCPD) are the predominant dialytic modalities for the majority of children while awaiting transplantation. Wide acceptability of peritoneal dialysis is hindered by infectious complications. A retrospective review of 367 pediatric patients treated with CAPD/CCPD for at least 3 months from September 1980 through December 1994 revealed that the peritonitis incidence ranged from 1.7 to 0.78 episodes per patient-year. No differences in peritonitis rates were observed between patients treated with CAPD or CCPD. Gram-positive organisms were responsible for the majority of peritonitis episodes. Age, sex, race, primary renal disease, presence of nephrotic syndrome, and serum albumin level were not associated risk factors. Longer time on treatment and diminished serum IgG level were associated with increased peritonitis incidence. Treatment was successfully completed at home in most cases. Almost half of the catheter losses were caused byStaphylococcus, Pseudomonas, and fungal peritonitis and tunnel/exit-site infections. Infectious complications are still the major causes of morbidity and treatment failure in patients treated with CAPD/CCPD. Thus, controlled studies are needed to assess methods for prevention or improvement of peritonitis rates in this patient population.     

Reduction of peritonitis with the rectus abdominis muscle flap in a CAPD patient

An adolescent maintained on continuous ambulatory peritoneal dialysis (CAPD) for 8 years had relapsing peritonitis involving peritoneal catheter tunnel infections. We attempted catheter removal and replacement simultaneously, with the catheter covered cylindrically by a rectus abdominis muscle flap to prevent recurrent tunnel infections. During 3 years of follow-up, there have been no episodes of peritonitis involving tunnel infection. Our modified insertion technique can eradicate tunnel infection, thus reducing peritonitis. Received: 23 March 1999 / Revised: 24 June 1999 / Accepted: 25 June 1999     

Continuous ambulatory peritoneal dialysis in the United States: a three-year study

This report of the NIH-supported National Continuous Ambulatory Peritoneal Dialysis (CAPD) Registry summarizes data on 7,404 patients treated with CAPD during the three-year period 1981 through 1983, or nearly one-half of patients treated in the USA who were treated with CAPD during this time. While age and diabetes mellitus impact on mortality, they appear to have a limited influence on transfer or infection rate. There were 1.7 episodes of peritonitis, 0.7 exit site/tunnel infections, and 0.3 catheter replacements reported per patient year of observation. Patients averaged 10.2 hospital days per year for CAPD complications and 22.3 hospital days per year for all causes. Comparisons of these data with similar data reported for other therapies are subject to variations in the distribution of population and disease characteristics, as well as the length of the observation period.