Do topical antibiotics reduce exit site infection rates and peritonitis episodes in peritoneal dialysis patients? The Pan Thames Renal Audit

Background and objectives: Peritonitis is the major cause of peritoneal dialysis (PD) technique failure. Prophylactic topical antibiotics have been reported to reduce peritoneal dialysis catheter exit site infections (ESI) and peritonitis rates. Methods: We audited the effect of different exit site practices in the 12 Pan Thames and South East England PD centres, on ESIs and peritonitis between 2005 and 2008. Results: PD patients used prophylactic mupirocin (n=1,270), gentamicin (n=502) and no prophylactic antibiotics (n=1,203); annualised ESI rates were reduced with mupirocin (median 0.18, interquartile range [IQR] 0.13-0.23, patient episodes per year, vs. median 0.32, IQR 0.24-0.69, for no antibiotic prophylaxis, p<0.01). Gentamicin treatment was not significantly lower (median 0.29, IQR 0.21-0.47). Staphylococcal ESIs accounted for 39.6% in the no antibiotic group and fell to 25.7% with mupirocin and 28.2% with gentamicin. Despite the reduction in ESIs, there was no significant reduction in peritonitis rates (no antibiotics: median 0.56, IQR 0.5-0.65; mupirocin: median 0.55, IQR 0.53-0.75; and gentamicin: median 0.47, IQR 0.32-0.65). In particular, mupirocin did not reduce Staphylococcus aureus peritonitis rates. Conclusions: Topical antibiotics have been reported to reduce both ESI and peritonitis rates in controlled trials, and although in this audit of routine clinical practice, topical mupirocin did reduce overall ESI rates and both mupirocin and gentamicin reduced S. aureus ESIs, neither reduced overall peritonitis rates.     

Catheter revision for the treatment of intractable exit site infection/tunnel infection in peritoneal dialysis patients: A single centre experience

Aim: Catheter‐related infection is a major cause of catheter loss in peritoneal dialysis (PD). We evaluated the effect of catheter revision on the treatment of intractable exit site infection (ESI)/tunnel infection (TI) in PD patients who required catheter removal. Methods: We reviewed the medical records of 764 continuous ambulatory peritoneal dialysis (CAPD) patients from May 1995 to April 2011 at our hospital. One hundred and twenty six patients had more than one occurrence of ESI. Catheter revision was performed to treat intractable ESI/TI. Incidence of ESI, causative organisms and the outcomes of catheter revision were analyzed. Results: The total PD duration of all patients was 32 581 months. Three hundred and twelve ESI episodes occurred in 126 patients and the incidence of ESI was 1/104 patient‐months (0.12/patient‐year). The most common causative organism was methicillin‐sensitive Staphylococcus aureus (MSSA) (98 episodes), followed by Pseudomonas aeruginosa (63 episodes) and methicillin‐resistant S. aureus (MRSA) (28 episodes). Among these, catheter revision was required due to intractable ESI/TI in 36 patients. The most common causative organism was MSSA (14 episodes) followed by P. aeruginosa (10 episodes) and MRSA (six episodes) in catheter revision cases. The outcomes of catheter revision were as follows: ESI relapsed in 11 patients (30.6%) after catheter revision. Among them, five patients were treated with antibiotic treatment, two patients required secondary catheter revision, four patients required catheter removal due to ESI/TI accompanying peritonitis. The catheter survival rate after catheter revision was 89.7% in one year. There were no statistical differences in the rates of ESI relapse after catheter revision between ESI caused by P. aeruginosa (5/10, 50%) and ESI caused by S. aureus (6/21, 28.6%). Conclusion: Catheter revision may be an alternative treatment option to treat intractable ESI/TI before catheter removal is considered in PD patients.     

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     

Current epidemiology and practice patterns in prevention and treatment of PD-related infections in Poland

Background

Peritoneal dialysis (PD) related infections are associated with technique failure and mortality. The aim of this multicentre study was to examine epidemiology, treatment and outcomes of PD-related infections in Poland as well as practice patterns for prevention of these complications in the context of current ISPD recommendations.

Methods

A survey on PD practices in relation to infectious complications was conducted in 11 large Polish PD centres. Epidemiology of peritonitis and exit-site infections (ESI) was examined in all patients treated in these units over a 2 year period.

Results

The study included data on 559 PD patients with 62.4% on CAPD. Practice patterns for prevention of infectious complications are presented. The rate of peritonitis was 0.29 episodes per year at risk, with Gram positive microorganisms responsible for more than 50% of infections and 85.8% effectively treated. Diagnosis and treatment followed ISPD guidelines however most units did not provide an anti-fungal prophylaxis. Although neither of the centres reported routine topical mupirocin on catheter exit-site, the rate of ESI was low (0.1 episodes per year at risk), with Staphylococcus aureus as most common pathogen and full recovery in 78.3% of cases.

Conclusion

The study shows rewarding outcomes in prevention and treatment of PD-associated infections, mainly due to a thorough compliance with the current ISPD guidelines, although some deviations from the recommendations in terms of practice patterns have been observed. More studies are needed in large numbers of patients to differentiate the importance of specific recommendations and further support the guidelines.

     

A survey of peritonitis and exit-site and/or tunnel infections in Japanese children on PD

To obtain data on peritonitis and exit-site and/or tunnel infections (ESI/TI) in Japanese children undergoing peritoneal dialysis (PD) from January 1999 through June 2003, we surveyed 22 members of the Japanese Study Group of Pediatric Peritoneal Dialysis (JSPPD) by questionnaire. One hundred and thirty patients were eligible. Seventy episodes of bacterial peritonitis occurred in 45 patients (0.17 episodes/patient-year), and 123 ESI/TI occurred in 60 patients (0.29 episodes/patient-year). S. aureus and MRSA were found to be the causative organisms in 39% and 13% of the peritonitis episodes, and in 59% and 20% of the ESI/TI, respectively. Tunnel infection was found in 55% of the MRSA peritonitis episodes. Eleven percent of the peritonitis episodes relapsed, and 19% needed hemodialysis. One patient died due to MRSA peritonitis. The PD catheter was removed in all fungal and 78% of MRSA peritonitis. However, the type of organism did not influence the need for catheter-related surgery for ESI/TI. Neither peritonitis nor ESI/TI was prevented by the use of a swan-neck catheter, a downward-pointing exit site, povidone iodine exit-site care, bathing instruments, or nasal mupirocin. In conclusion, MRSA peritonitis was not uncommon in children in Japan, was frequently associated with tunnel infections, and had a poor outcome. No association was found between the occurrence of infection and preventive measures previously reported as effective. Alternative approaches are needed in children, especially for MRSA.Members of the Japanese Study Group of Pediatric Peritoneal Dialysis (JSPPD) that participated in this survey: Yuko Akioka (Chiba), Kazumoto Iijima (Tokyo), Masahiro Ikeda (Tokyo), Masaaki Ikoma (Kawasaki), Yuhei Ito (Kurume), Osamu Uemura (Ohbu), Yoshiyuki Ohtomo (Iwatsuki), Yoshitsugu Kaku (Fukuoka), Takashi Sakano (Hiroshima), Kenichi Satomura (Osaka), Junzo Suzuki (Fukushima), Eihiko Takahashi (Yokohama), Masafumi Taki (Okayama), Motoshi Hattori (Tokyo), Hitoshi Nakazato (Kumamoto), Shinya Nakamura (Sagamihara), Kandai Nozu (Kobe), Toshio Yanagihara (Niigata), Hiroshi Yoshimura (Uruma)     

Decrease in infections with the introduction of mupirocin cream at the peritoneal dialysis catheter exit site

Staphylococcus aureus associated peritonitis and catheter exit site infections (ESI) are an important cause of hospitalization and catheter loss in the patients undergoing chronic peritoneal dialysis (PD). We aimed to determine the potential effectiveness of the application of mupirocin cream at the catheter exit site in preventing exit site infection and peritonitis. METHODS: This prospective historically controlled study was done in a total of 86 patients who entered our PD program from April 1999 to January 2001. They were instructed to apply Mupirocin cream 2% to the exit site daily or on alternate days. The patients were not screened to determine whether they were staphylococcus aureus carriers. One hundred and thirteen patients on PD prior to April 1999 acted as historical controls. Both groups were followed prospectively for a period of 22 months. RESULTS: In the study group application of mupirocin lead to a significant reduction in the incidence rate of both exit site infections overall (0.43 vs. 0.09; p<0.0001) and ESI due staphylococcus aureus (0.14 vs. 0.02; p=0.004) amounting to a relative reduction of 79% and 85% respectively. Although the overall incidence of peritonitis did not change (0.28 vs. 0.26; p=0.7) there was a significant reduction in peritonitis caused by staphylococcus aureus (0.07 vs. 0; p=0.01) Although only one catheter required removal in the mupirocin group as against 5 in the control group, this was not statistically significant. CONCLUSIONS: Mupirocin application at the exit site significantly lowers the incidence of ESI and peritonitis caused by staphylococcus aureus without any significant side effects.     

Nontuberculous mycobacterial peritonitis in peritoneal dialysis patients

While nontuberculous mycobacterial peritonitis is uncommon among peritoneal dialysis (PD) patients, these infections have serious consequences. They present a significant diagnostic and therapeutic challenge for clinicians. Diagnosis can be delayed due to the slow growth rate of some mycobacterial species. These organisms can also be overlooked when adequate culture media are not used in the microbiological evaluation process. The choice of antimicrobial therapy depends upon isolation and speciation of the infecting Mycobacterium species, and prompt catheter removal is essential. Because serious intra-abdominal complications may follow infection, identifying patient risk factors for nontuberculous mycobacterial peritonitis and initiating prompt diagnosis and treatment are essential. We report three cases of peritonitis associated with Mycobacterium chelonae and Mycobacterium gordonae, each with a unique presentation, and discuss the appropriate diagnosis and treatment strategies for the management of PD-associated mycobacterial infections.     

Clearing the clouds: Case‐report and review of the literature

In peritoneal dialysis (PD), a cloudy dialysate is an alarming finding. Bacterial peritonitis is the most common cause, however, atypical infections and non‐infectious causes must be considered. A 46‐year‐old man presented with asthenia, paraesthesia, foamy urine and hypertension. Laboratory testing revealed severe azotaemia, anaemia, hyperkalaemia and nephrotic‐range proteinuria. Haemodialysis was started through a central venous catheter. Later, due to patient preference, a Tenckhoff catheter was inserted. Conversion to PD occurred 3 weeks later, during hospitalization for a presumed central line infection. A month later, the patient was hospitalized for neutropenic fever. He was diagnosed an acute parvovirus infection and was discharged under isoniazid for latent tuberculosis. Four months later, the patient presented with fever and a cloudy effluent. Peritoneal fluid (PF) cytology was suggestive of infectious peritonitis, but the symptoms persisted despite antibiotic therapy. Bacterial and mycological cultures were negative. No neoplastic cells were detected. Mycobacterium tuberculosis eventually grew in PF cultures, despite previous negative molecular tests. Directed therapy was then initiated with excellent response. Thus, facing a cloudy effluent, one must consider multiple aetiologies. Diagnosis of peritoneal tuberculosis is hampered by the lack of highly sensitive and specific exams. Here, diagnosis was only possible due to positive mycobacterial cultures.     

Prevention of Peritonitis in Peritoneal Dialysis

Reducing the frequency of peritonitis for patients undergoing peritoneal dialysis (PD) continues to be a challenge. This review focuses on recent updates in catheter care and other patient factors that influence infection rates. An experienced nursing staff plays an important role in teaching proper PD technique to new patients, but nursing staff must be cognizant of each patient's unique educational needs. Over time, many patients become less adherent to proper dialysis technique, such as washing hands or wearing a mask. This behavior is associated with higher risk of peritonitis and is modifiable with re‐training. Prophylactic antibiotics before PD catheter placement can decrease the infection risk immediately after catheter placement. In addition, some studies suggest that prophylaxis against fungal superinfection after antibiotic exposure is effective in reducing fungal peritonitis, although larger randomized studies are needed before this practice can be recommended for all patients. Over time, exit site and nasal colonization with pathogenic organisms can lead to exit‐site infections and peritonitis. For patients with Staphylococcus aureus colonization, exit‐site prophylaxis with either mupirocin or gentamicin cream reduces clinical infection with this organism. Although there are limited data for support, antibiotic prophylaxis before gastrointestinal, gynecologic, or dental procedures may also help reduce the risk of peritonitis.     

Mycobacterial peritonitis in pediatric peritoneal dialysis patients

Peritonitis is the most common complication and the leading cause of death in pediatric peritoneal dialysis (PD) patients. According to the most recent data available from the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS), approximately 25% of pediatric PD patients who die succumb to infection. There are no reported cases of Mycobacterium tuberculosis (MTB) or Mycobacterium avium-intracellulare peritonitis in the NAPRTCS registry. With an increasing incidence of MTB worldwide and the impairment of cellular immunity in chronic renal failure patients, it is not surprising that mycobacterium peritonitis can occur in PD patients. We report two pediatric PD patients with mycobacterial peritoneal infection diagnosed over an 11-year period at our institution. One patient presented with a malfunctioning Tenckhoff catheter and again 3 years later with hyponatremia and ascites. The other presented with recurrent culture-negative peritonitis. These cases illustrate the importance of more extensive evaluation of PD complications, to include evaluation for mycobacterium with special media or peritoneal biopsy, in the above clinical settings if the routine work-up is unrevealing.     

The changing trends of peritoneal dialysis related peritonitis and novel risk factors

Abstract

Aim: Continuous ambulatory peritoneal dialysis (PD) has become a treatment modality for end stage renal disease with a peak of its use in 1990s. The aim of this study was to examine the peritonitis rates, causative organisms and the risk factors of peritonitis in a large group of patients in our center. Methods: The study was conducted in the Nephrology Department of a University Hospital in Turkey. Patients in the PD programme between January 2000 and January 2006 were included. Cohort-specific and subject specific peritonitis incidence, and peritonitis-free survival were calculated. Causative organisms and risk factors were evaluated. Results: Totally 620 episodes of peritonitis occurred in 440 patients over the six years period. Peritonitis rates showed a decreasing trend through the years (0.79 episodes/patient-year 2000–2003 and 0.46 episodes/patient-year 2003–2006). Cohort-specific peritonitis incidence was 0.62 episodes/patient-years and median subject-specific peritonitis incidence was 0.44 episodes/patient-years. The median peritonitis-free survival was 15.25 months (%95 CI, 9.45–21.06 months). The proportion of gram-negative organisms has increased from 9.8% to 17.3%. There was a significant difference in the percentage of culture negative peritonitis between the first three and the last three years (53.1% vs. 43.2%, respectively). Peritonitis incidence was higher in patients who had been transferred from HD, who had catheter related infection and who had HCV infection without cirrhosis. Conclusions: Our study showed significant trends in the peritonitis rates, causative organisms and antibiotic resistance. Prior HD therapy, catheter related infections and HCV infection were found to be risk factors for peritonitis.     

Non-tuberculous mycobacterial PD peritonitis in Australia

Purpose

Peritonitis can be a severe complication of peritoneal dialysis (PD) due to associated morbidity and mortality. Non-tuberculous mycobacteria (NTM) are a rare cause of PD peritonitis, with high rates of catheter removal and conversion to haemodialysis, and a reported mortality as high as 40 %. The incidence, culprit NTM species, and outcomes associated with PD peritonitis have not been described in many countries, including Australia.

Methods

We examined the Australia and New Zealand Dialysis and Transplant Registry from 1 October 2003 to 31 December 2009 for all prevalent peritoneal dialysis patients. Patient characteristics, organisms, treatment and outcome for all NTM PD peritonitis episodes were obtained.

Results

Twelve cases of NTM PD peritonitis were reported, including the first reports of infection due to Mycobacterium hassiacum and Mycobacterium neoaurum. The incidence of NTM PD peritonitis was approximately 1 per 1000 PD patient-years. Recovery occurred in 11 patients, including 3 without removal of their Tenckhoff catheters. A range of antibiotics were utilised. One patient died of sclerosing peritonitis 5 months after diagnosis of PD peritonitis.

Conclusion

Non-tuberculous mycobacteria PD peritonitis is a rare cause of peritonitis, and mortality may be lower than previously reported. Catheter removal occurred in the majority of patients, and adverse outcomes were not observed for those in whom it was retained.     

Fungal peritonitis in children on peritoneal dialysis

Fungal peritonitis is a rare but serious complication in children on peritoneal dialysis (PD). In this study, risk factors were evaluated, and therapeutic measures were reviewed. A retrospective, multi-centre study was performed in 159 Dutch paediatric PD patients, between 1980 and 2005 (3,573 months). All peritonitis episodes were reviewed. Fungal peritonitis episodes were evaluated based on possible risk factors and treatment strategy. A total of 321 episodes of peritonitis occurred, with 9 cases of fungal peritonitis (2.9%). Candida peritonitis occurred most frequently (78%). Seven patients (78%) had used antibiotics in the prior month. Fungal peritonitis patients had a higher previous bacterial peritonitis rate compared to the total study population (0.13 versus 0.09 episodes/patient*month), with twice as many gram negative organisms. In all fungal peritonitis patients, the PD catheter was removed. In four patients restart on PD was possible. Fungal peritonitis is a rare complication of PD in children, but is associated with high technique failure. The most important risk factors are a high bacterial peritonitis rate, prior use of antibiotics, and previous bacterial peritonitis with gram negative organisms. The PD catheter should be removed early, but in children, peritoneal lavage with fluconazole before removal may be useful to prevent technique failure.     

Clinical significance of exit-site infections due to Xanthomonas in CAPD patients: a comparison with Pseudomonas infection

We have assessed the clinical significance of exit-site infectionssecondary to Xanthomonas maltophilia in continuous ambulatoryperitoneal dialysis (CAPD) patients, and compared them withepisodes due to Pseudomonas. The study was a retrospective surveyof all episodes of Xanthomonas and Pseudomonas-related exit-siteinfections (ESI) in all patients treated in our unit between1984 and 1992. Thirteen episodes of Xanthomonas-related ESIwere observed in eight patients and 17 episodes of Pseudomonas-relatedESI were seen in 15 patients. Xanthomonas-related ESI was frequently associated with othermicroorganisms, while Pseudomonas related ESI was not (66% versus5%, P<0.02). Only one episode of Xanthomonas-related ESIresulted in peritonitis and subsequent catheter removal, after15 months of resistant colonization. Another case was consideredto be chronic and indolent, as the Xanthomonas-related ESI continuedafter 23 months of local treatment. The other 11 episodes wereresolved either without treatment or with an antibiotic creamafter 7–120 days. However, all but two episodes of Pseudomonas-relatedESI required intravenous antibiotics (usually ceftazidime);seven patients developed peritonitis, and 11 required surgicalcatheter manipulation (five external cuff extrusion, and sixcatheter removal) (1/13 Xanthomonas-related versus 11/17 Pseudomonas-relatedESI, P<0.03) Most Xanthomonas-related ESI do not lead to peritonitis, andconstitute a mild condition, easily treatable without parenteralantibiotics or catheter replacement. The appearance of otherassociated organisms and the favourable evolution with localtreatment suggest a saprophytic behaviour for Xanthomonas inour CAPD patients. On the contrary, Pseudomonas-related ESIis usually severe, requires parenteral antibiotics, frequentlyleads to peritonitis, and requires catheter replacement.     

Mycobacterium tuberculous peritonitis in CAPD patients: a report of 11 patients and review of literature

Background

The aims of the present report were to document our experience of the prevalence of tuberculous peritonitis in continuous ambulatory peritoneal dialysis (CAPD) patients, mode of presentation, diagnosis and outcome and to discuss the current published data about catheter removal.

Methods

A retrospective study of CAPD patients with tuberculous peritonitis was done. A minimum of three specimens of peritoneal fluid were examined for acid-fast bacilli smears. The BACTEC 9000 Blood Culture Series of instruments were used for the culture of Mycobacterium tuberculosis. After 2005, patients were treated with anti-tuberculous treatment, and catheter retention was started in our patients.

Results

There were eleven patients (2.6 %) with tuberculous peritonitis among 414 CAPD patients. M. tuberculosis accounted for 4.47 % of all peritonitis episodes. The incidence of tuberculous peritonitis was 1/794 months. There were eight males and three females. The mean age was 49 years. Intestinal obstruction was reported in two patients, and two patients were treated for antecedent peritonitis. One of them had a simultaneous fungal peritonitis. One patient each developed a peritoneo-cutaneous fistula and ultrafiltration failure. Three were successfully treated without the removal of catheter.

Conclusion

Based on the analysis of all published reports of tuberculous peritonitis, there was no significant difference in patient survival between patients in whom CAPD catheter was removed or retained. Tuberculous peritonitis should be considered in patients with neutrophilic ‘sterile’ peritonitis with no response to antibacterial medications, predominance of lymphocytic peritonitis and in bacterial peritonitis not responding to antibiotics. After an early diagnosis, with close monitoring, an effort to retain the catheter after 5 days of anti-tuberculous therapy may be attempted.     

Use of inhaled imipenem/cilastatin in pediatric patients with cystic fibrosis: A case series

Mycobacterium abscessus is a rapidly-growing, virulent, non-tuberculous mycobacterium that causes progressive inflammatory lung damage and significant decline in lung functionin patients with cystic fibrosis. M. abscessus complex pulmonary infections are notoriously difficult to treat, and while many antibiotics are approved for children, drug allergies or intolerances can prohibit their use. Intravenous imipenem/cilastatin is among the preferred antibiotics for treatment of M. abscessus, however, its use may result in systemic toxicities including hepatic injury and gastrointestinal effects. Case reports document the successful use of inhaled imipenem/cilastatin in adult cystic fibrosis and non- cystic fibrosis patients with non- M. abscessus pulmonary infections. To our knowledge, similar evidence does not exist for pediatric patients. In this case series, we describe two pediatric patients with cystic fibrosis and previous intolerance or lack of response to standard therapies who received inhaled imipenem/cilastatin for the treatment of chronic M. abscessus infection.     

ASDIN: Antibiotic Prophylaxis: Is it Needed for Dialysis Access Procedures?

Antibiotic prophylaxis has been employed to reduce the risk of infection. Many reports have documented the role of prophylactic antibiotics on the subsequent development of infection in patients undergoing surgical as well as a variety of percutaneous interventions including cardiac, vascular, biliary, genitourinary, and drainage of fluid collections. While prophylactic antibiotics can be critically important for certain procedures, their use can be associated with allergic reactions (including anaphylaxis), development of bacterial resistance, and increased costs of medical care. In this analysis, we report the incidence of clinical infection following minimally invasive interventions for dialysis access procedures. Hemodialysis (HD) and peritoneal dialysis (PD) patients undergoing consecutive percutaneous interventions (n = 3162) for HD and PD access were included in this study. Procedure‐related clinical infection was defined as the presence of fever/chills, tenderness, erythema, swelling within 72 hours postprocedure. The procedures included percutaneous balloon angioplasty (arterial and venous) [n = 2078 (AVF = 1310; AVG = 768)], venography for vascular mapping (n = 110), endovascular stent insertion (n = 26), intravascular coil placement (n = 31), thrombectomy for an arteriovenous fistula (n = 106), thrombectomy for an arteriovenous graft (n = 110), tunneled hemodialysis catheter (TDC) insertion and exchange (n = 283), TDC removal (n = 160), and insertion of accidentally extruded TDC through the same exit site (n = 9). There were 260 peritoneal dialysis catheter insertions and 15 repositioning procedures. Only patients undergoing TDC insertion for accidentally extruded catheter and PD catheter placement received antibiotic prophylaxis within 1–2 hours before the procedure. Extruded TDC received 1 g of cefazolin while PD catheter insertion had 1 g of intravenous vancomycin. Povidone iodine was used for skin antisepsis in all cases. One patient (0.04%) postangioplasty and one patient (0.3%) after tunneled catheter placement developed clinical infection manifested by fever, chills, and malaise within 24 hours of the procedure. Both required hospitalization. Patient with angioplasty was a diabetic with an arteriovenous graft while TDC insertion was performed in a patient with advanced HIV. Percutaneous dialysis access procedure infections are generally low and might not warrant routine administration of antibiotic prophylaxis for all cases except for PD catheters and accidentally extruded TDC.     

Pets‐Related Peritonitis in Peritoneal Dialysis: Companion Animals or Trojan Horses?

Infectious peritonitis is still a major concern in peritoneal dialysis (PD). Standard antibiotic regimens target common causative microorganisms such as Staphylococcus aureus and epidermidis or Pseudomonas aeruginosa. When the infection does not respond, unusual infective agents are to be considered including zoonoses—infections with an animal source. Companion animals or occupations involving animal contact favor the development of zoonoses, especially for immunocompromised patients such as those with end‐stage renal disease. We reviewed the literature for all animals‐related peritonitis in PD and analyzed data from our own PD unit and from the French‐speaking registry for peritoneal dialyis (RDPLF) to assess both the frequency and the potential risk for PD patients in owning a pet or to working with animals. In a literature search, we identified 124 cases of PD peritonitis caused by 12 different zoonotic agents. Animals were involved in 24% of the cases. Overall mortality rate was 13.5% and Tenckhoff catheters had to be removed in 27% of the cases. The results from RDPLF analysis show that zoonotic microorganisms were responsible for 0.54% of the peritonitis episodes (51 out of a total of 9433 during a 9‐year period). In our unit, zoonotic microorganisms were responsible for 0.03% of the peritonitis episodes (four out of a total of 128 during a 9‐year period). Considering those results, some specific treatment recommendations can be made, but the major factor still remains prevention, by insisting on strict hygenic measures when a PD patient owns a pet.     

Candida parapsilosis Peritonitis Has More Complications Than Other Candida Peritonitis in Peritoneal Dialysis Patients

Candida parapsilosis is the most prevalent pathogen of fungal peritonitis in peritoneal dialysis (PD). The difference between C. parapsilosis peritonitis and other C. species for clinical outcomes and treatment responses to fungal peritonitis remains unclear. This retrospective study of fungal peritonitis attempts to answer that question. A total 22 patients with fungal peritonitis in 762 PD patients were enrolled in this study. The mean age of the 22 patients, 9 males and 13 females, was 54.7 ± 12.5 years with a mean PD duration of 39.7 ± 33.4 months. Candida species accounted for 86% (19 cases) of fungal peritonitis and 41% (9 cases) were C. parapsilosis. Thirteen (59%) patients received fluconazole as monotherapy; others received either amphotericin B alone or in combination with fluconazole. Catheters were removed for all patients. The mean duration from peritonitis onset to catheter removal was 5.8 ± 4.1 days. Eleven (50%) patients developed severe complications, with abscess formation or persistent peritonitis after catheter removal. C. parapsilosis peritonitis had a higher complication rate than other Candida species (78% versus 20%, p = 0.012). In patients who received fluconazole as monotherapy, the rate of severe complications of C. parapsilosis peritonitis was statistically higher than those of other Candida species (100% versus 29%, p = 0.013). Because of different severity and prognosis, C. parapsilosis peritonitis in PD patients should be treated more aggressively than other Candida species.