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PROPHYLACTIC ANTIBIOTIC USE

Extended Use of Prophylactic Antibiotics: Prophylactic use of antibiotics does not prevent peritonitis. This has been shown for penicillins and the sulfamethoxazole trimethoprim combinations. In patients with chronic exit-site infections, there are no data to show whether long-term antibiotic therapy for chronic exit-site infections decreases peritonitis risk. However, the regular use of intranasal mupirocin for nasal carriage has a definitive advantage in decreasing S. aureus exit-site infections. Recently, it has been suggested that use of oral prophylaxis with nystatin (500 U ƒ 3) during antibiotic therapy for various infections reduced the incidence of subsequent fungal peritonitis (see Záruba et al., 1991). Additional studies of this approach will be of great interest.

Short-Term Antibiotic Prophylaxis: Invasive procedures associated with transient bacteremia have not been frequently reported to cause peritonitis in PD patients. In some patients undergoing colonoscopy polypectomy, ampicillin plus aminoglycoside with or without metronidazole prescribed as a three-dose antibiotic course (three exchanges) started immediately prior to the procedure may be of potential benefit. However, a randomized prospective study in PD patients has not been performed.

Prophylactic Antibiotics and Catheter Placement: There is some evidence now that prophylactic antibiotics before catheter placement will prevent subsequent infection. The experience in general surgical practice indicates that perioperative antibiotics, especially in the presence of a foreign body, diminish the incidence of wound infection. A first-generation cephalosporin has been most frequently used in this context. In this setting routine use of vancomycin should be avoided.

Use of Prophylactic Antibiotics after a Technique Break: There are no data to support or refute the suggestion that the use of prophylactic antibiotics after a break in sterile technique is effective in preventing peritonitis. Thus, no specific recommendation for antibiotic use can be made in this setting, although many nephrologists give a short three- to five-day course of antibiotics after a break in sterile technique. Exit-Site Infections and Prophylactic Antibiotics: S. aureus nasal carriage is associated with an increased risk of S. aureus exit-site/tunnel infections and peritonitis (see Luzar et al., 1990). Prophylaxis with intranasal mupirocin, exit-site mupirocin, or oral rifampin is effective in reducing S. aureus exit-site infection in adults (see Zimmerman et al., 1991; Bernardini et al., 1996; and Coles et al., 1994). Rifampin, 300 mg b.i.d. for five days every 12 weeks, effectively reduced the incidence of S. aureus exit-site infections to one third of the rate in the controls, but 12% of the patients could not tolerate the drug (see Figure 6). Mupirocin applied daily to the exit site after routine exit-site care was as effective as oral rifampin in reducing exit-site infection rates. The use of mupirocin at the exit site, however, should be avoided in patients with polyurethane catheters (Cruz catheter), as structural damage to the catheter has been reported. Intranasal mupirocin b.i.d. for five days every four weeks to S. aureus carriers was also effective in reducing S. aureus exit-site infections to 0.12 episodes/year compared to 0.43 episodes/year in the placebo group. Patients with three negative nose cultures are at minimal risk for S. aureus infections. Therefore, in this group of patients prophylaxis is unnecessary.

FIGURE 6

Figure 6


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