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.     

New insights on preventing and managing peritonitis

Methods to prevent peritonitis are an essential component of any successful peritoneal dialysis (PD) program. Careful attention to training of the parents and child on the proper technique of PD and avoidance of manual spiking by using an assist device for the cycler, or use of the double-bag system for continuous ambulatory PD, should decrease risk of peritonitis from touch contamination. Secondly, reduction of peritonitis can be achieved through reduction of exit site infections by use of mupirocin antibiotic cream at the exit site of the PD catheter as part of routine care. If an exit site infection develops and is refractory to therapy, then the PD catheter can be successfully replaced as a single procedure, to reduce the risk of peritonitis. The third step in reducing the risk of peritonitis is to avoid repetitive episodes with the same organism. This may again involve replacing the catheter; as long as the effluent can be cleared, this again can be performed as a single procedure, thus allowing the child to avoid the trauma of hemodialysis. The focus in pediatric PD programs must always be on preserving the peritoneal membrane, and not on preservation of the catheter. With careful attention, peritonitis can become an uncommon event.     

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.     

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.     

A five-year study of the microbiologic results of exit site infections and peritonitis in continuous ambulatory peritoneal dialysis

We studied the culture results from 321 continuous ambulatory peritoneal dialysis (CAPD) related infections (exit site, tunnel infections, and peritonitis) in 137 patients over a 5-year period to determine the contribution of exit site and tunnel infections to peritonitis and catheter loss. Seventeen percent of peritonitis episodes were associated temporally and by microbiologic results with exit site or tunnel infections. Twenty-one percent of exit site and tunnel infections and 20% of peritonitis episodes resulted in catheter loss. Peritonitis due to Staphylococcus aureus was more likely to be associated with an exit site or tunnel infection and was more likely to result in loss of the catheter than peritonitis due to Staphylococcus epidermidis. Peritonitis and exit site infections due to Pseudomonas sp also frequently resulted in catheter removal. We found that exit site infections cause significant morbidity in CAPD patients. Further studies in this area are needed.     

Prevention of peritoneal dialysis-related infections

Despite substantial advances in peritoneal dialysis (PD) as a renal replacement modality, PD-related infection remains an important cause of morbidity, technique failure, and mortality. This review describes the microbiology and outcomes of PD peritonitis and catheter infection, followed by a discussion of several strategies that may reduce the risk of PD-related infections. Strategies that are reviewed include use of antibiotics at the time of PD catheter insertion, selection of PD catheter design and insertion technique, patient training, PD connectology, exit site prophylaxis, periprocedural prophylaxis, fungal prophylaxis, and choice of PD solutions.     

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     

Complications of gastrostomy feeding in children receiving peritoneal dialysis

 Gastrostomy tube (g-tube) feeding is recognized to improve the nutritional delivery to children with end-stage renal disease. A retrospective study was undertaken assessing the complications of g-tube feeding in children receiving peritoneal dialysis (PD). Twenty-three patients, mean age 3.8±3.2 years received PD and g-tube feeding for 758 patient-months, with 127 patients receiving PD for 1,969 patient-months used as controls. Peritonitis occurred every 18.4 patient-months in controls and 7.8 patient-months in those with a g-tube. Peritonitis occurred every 6.0 patient-months before and 8.1 patient-months after g-tube insertion in those undergoing g-tube insertion on PD. PD catheter exit site infection (PDESI) occurred every 18.7 patient-months in controls and 16.8 patient-months in those with a g-tube. PDESI occurred every 126 patient-months before and 16.2 patient-months following g-tube insertion. PD catheter replacement secondary to infection occurred every 109.4 patient-months in controls and 39.9 patient-months in those with a g-tube. It did not occur before g-tube insertion and occurred every 32.5 patient-months following insertion. Thirty-four episodes of g-tube exit site infection occurred, in 10 the same organism caused concurrent peritonitis. G-tube replacement occurred on 37 occasions. Hemodynamically significant gastrointestinal bleeding occurred in 3 patients, being terminal in 1. We conclude that, although not without risk, g-tube feeding in patients receiving PD is not contraindicated. Received: 15 May 1998 / Revised: 8 September 1998 / Accepted: 9 September 1998     

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.     

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.     

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.     

Moncrief-Popovich catheter and implantation technique: the AV fistula of peritoneal dialysis

Despite the decrease in peritonitis rate from touch contamination caused by the use of disconnect systems, technique failure in peritoneal dialysis (PD) from pericatheter and exit-site infections in PD remains unchanged. This indicates a failure of current PD catheters to prevent bacterial transfer from exit site to the peritoneal cavity. In 1991, Moncrief and Popovich introduced a new catheter design and implantation technique to address this problem. The catheter is made of silastic, has a coiled tip with 2 cuffs, and an arcuate bend between the cuffs. This would prevent catheter malfunction and leakage of PD fluid. The implantation technique involves embedding of the external segment of the catheter in the subcutaneous tunnel at insertion. The catheter segment is kept embedded for 4 to 6 weeks before externalization. This procedure will allow time for tissue ingrowth on into the external cuff and catheter surfaces between the 2 cuffs, preventing bacterial colonization of the catheter surfaces from the exit wound and thereby reducing pericatheter infections. Thus, the new technique will establish a more effective bacteriologic barrier between the exit wound and the peritoneal cavity than the conventional catheters. Ten years after validation of the catheter design and implantation technique by Moncrief and Popovich, various clinical studies confirm that this new technique of catheter implantation increases catheter life expectancy and reduces pericatheter infections in PD. Like the arteriovenous fistula of haemodialysis, this new catheter remains embedded in subcutaneous tunnel, is exteriorized electively when patient needs to be started on dialysis, and reduces pericatheter and exit-site infections in PD. The new technique, therefore, is widely accepted as a simple, safe, and cost-effective procedure for quality care of PD patients around the world.     

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.     

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.     

Peritonitis in children on peritoneal dialysis in Cape Town, South Africa: epidemiology and risks

Peritonitis is a frequent complication of peritoneal dialysis (PD) in children as well in adults. Data on PD and peritonitis in pediatric patients are very scarce in developing countries. A retrospective cohort study was performed between 2000 and 2008 with the aim to evaluate PD treatment and peritonitis epidemiology in pediatric patients in South Africa and identify risk factors for peritonitis. Baseline characteristics and potential risk factors of peritonitis were recorded, including housing, socio-economic circumstances, distance to PD center, type of PD, mode of catheter placement, race, presence of gastrostomy tube, weight, and height. Outcome indices for peritonitis were peritonitis rate, time to first peritonitis, and number of peritonitis-free patients. The patient cohort comprised 67 patients who were on PD for a total of 544 months. The total number of peritonitis episodes was 129. Median peritonitis rate was one episode every 4.3 patient months (2.8 episodes/patient-year, range 0–21.2). Median time to first infection was 2.03 months (range 0.1–21.5 months), and 28.4% of patients remained free from peritonitis. Patients with good housing and good socio-economic circumstances had a significantly lower peritonitis rate and a longer time to first peritonitis episode. Peritonitis rate was high in this cohort, compared to numbers reported for the developed world; the characteristics of causative organisms are comparable. The most important risk factors for the development of peritonitis were poor housing and poor socio-economic circumstances. More intensive counseling may be beneficial, but improvement of general socio-economic circumstances will have the greatest influence on PD success.     

Xanthomonas maltophilia infection in chronic peritoneal dialysis patients

Xanthomonas maltophilia infection has only been occasionally reported in patients receiving chronic peritoneal dialysis. We describe four cases of Xanthomonas maltophilia infection associated with chronic peritoneal dialysis. Two patients presented with peritonitis and two with exit site infection. All patients were diabetics, who immediately prior to the study had not received antibiotic therapy. Failure to respond to multiple antibiotic therapy resulted in catheter removal in both patients with peritonitis. In those patients with only exit site infections, dialysis could be continued following antibiotic therapy and catheter replacement in one. Catheter loss in our patients was directly attributed to peritonitis with Xanthomonas maltophilia infection.     

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.     

The clinical course of rapidly growing nontuberculous mycobacterial peritoneal dialysis infections in Asians: A case series and literature review

Introduction: Peritoneal dialysis (PD)‐related infections due to rapidly growing nontuberculous mycobacterium (RGNTM) are rare in Asians and have variable clinical outcomes. Methods: We analysed retrospectively a series of RGNTM infections in a single‐centre multi‐ethnic Asian population over a 5‐year period. Clinical features, treatment, risk factors and outcomes are discussed. Results: Ten infections are described. They constituted 3% of all culture‐positive exit site infection (ESI) and PD peritonitis. Seventy percent were due to Mycobacterium abscessus (three ESI and four peritonitis). There were two Mycobacterim fortuitum and one Mycobacterium chelonei peritonitis. No specific findings differentiated RGNTM infections from those caused by traditional organisms. Six cases had received prior antibiotics, two being topical gentamicin. Initial routine culture and alcohol acid fast bacillus were negative except for one case of M. abscessus. A confirmatory diagnosis was made a median 9 days post culture. No infection responded to routine antibiotics. Antibiotic resistance was variable but M. abscessus was universally sensitive to clarithromycin. Combined antibiotics based on sensitivity profile were successfully used in 70% of the cases. PD catheter loss was 80%. Three‐month mortality was 40% (vs. 8.5% and 12% in non‐RGNTM ESI and peritonitis, respectively). This may be related to the cohort high mean Charlson score of 7.5. Conclusion: RGNTM PD infections are commoner in Asians than previously reported. Their early diagnosis requires a high index of suspicion and appropriate treatment started promptly. They are associated with prior antibiotic use and refractory culture‐negative infections, delayed diagnosis and lead to significant catheter loss and death.     

三种腹膜透析导管相关并发症的比较

目的：比较Tenckhoff卷曲管、Tenckhoff直管、鹅颈直管相关并发症的差异,为临床选择不同腹透管提供依据。方法：回顾性分析2008年3月～2011年7月在我中心行腹膜透析置管术的157例终末期肾病患者资料,按导管形态不同分Tenckhoff卷曲管组（n=53）,Tenckhoff直管组（n=54）和鹅颈直管组（n=50）。观察三组导管功能障碍、出口感染、腹膜透析相关性腹膜炎发生情况及对腹膜透析效率的影响。结果：各组共发生导管功能障碍21例,A组11例（13.21%）,B组8例（16.67%）,C组2例（4%）,各组比较差异有统计学意义（P〈0.05）;共发生出口感染和腹膜透析相关性腹膜炎分别为12例和42例,各组比较差异均无统计学意义（P〉0.05）;三种腹透管对透析效率的影响差异无统计学意义（P〉0.05）。结论：鹅颈直管相对Tenckhoff卷曲管和直管可减少导管功能障碍的发生率,三种导管在出口感染、腹膜透析相关性腹膜炎及对透析效率的影响方面差异无统计学意义。     

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.