Monday, November 25, 2013

Clinical Case 77 Answers and Summary

A 56 y old on PD presents with PD peritonitis and bacteremia as well likely related to the peritonial infection. How would you treat?

The role of IV antibiotics in PD peritonitis has always been questions. A recent Cochrane review was done on this topic. They identified 36 studies (2089 patients): antimicrobial agents (30); urokinase (4), peritoneal lavage (1) intraperitoneal (IP) immunoglobulin (1). No superior antibiotic agent or combination of agents were identified. Primary response and relapse rates did not differ between IP glycopeptide-based regimens compared to first generation cephalosporin regimens, although glycopeptide regimens were more likely to achieve a complete cure (3 studies, 370 episodes: RR 1.66, 95% CI 1.01 to 3.58). IP antibiotics were superior to IV antibiotics in reducing treatment failure (1 study, 75 patients: RR 3.52, 95% CI 1.26 to 9.81). Based on one study, IP administration of antibiotics is superior to IV dosing for treating PD peritonitis. Intermittent and continuous dosing of antibiotics are equally efficacious.
What about bacteremia in addition to the PD peritonitis?  This is a hard question that hasn’t been looked at. A study did analyze the incidence rates and risks of bacteremia and HD and PD. Placement of a permanent access (fistula, graft, or PD catheter) prior to initiation of dialysis, smoking cessation, and better nutritional status (i.e. higher serum albumin) were associated with a reduced risk of bacteremia in dialysis patients. Higher serum albumin was also associated with a reduced bacteremia-associated mortality.
Two cases reports have looked at treating cases of peritonitis and bacteremia. Most used IP only but some had combo treatment. The jury is still out.

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