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WPCb513 *%'513 h!h!*3%)+.- h1h1 WPCb513 *%'513 h!h!*3%)+.- h1h1 WPCb513 *%'513 h!h!*3%)+.- h1h1 WPCb513 *%'513 h!h!*3%)+.- h1h1 WPCb513 *%'513 h!h!*3%)+.- h1h1 WPCb513 *%'513 h!h!*3%)+.- h1h1 359=AEIMQ2........)Hairline d($     Table_Ahttp://www.multi-med.com/pdi/litlinks3#37=CIQYag1.a.i.(1)(a)(i)1)a)i)2* ;ng(S3|xU !USUS.,  _SS SAXXXX#XXXAXh#AXXXX#XXXAX#AXXXX#XXXAX#AXXXX#XXXAX.#AXXXX#XXXAXp#AXXXX#XXXAX#AXXXX#XXXAX#AXXXX#XXXAX6#AXXXX&    A(XAX#(A(x#A((PeritonealDialysisInternational,Vol.20,pp.610624 S  #AXXA(##XXXAX#AXXXX) A(XAX  Sqn)  PrintedinCanada.Allrightsreserved.' )4݌ q Ќ AXXA(  #XXXAX#AXXXX) A(XAX  Sb  )K  08968608/00$3.00+.00)K݌  Ќ AXXA(  #XXXAX#AXXXX  ) A(XAX  SI  )  Copyright2000InternationalSocietyforPeritonealDialysis)݌ I Ќ AXXA(  #XXXAX#AXXXX     S=  : V  ?Cxhd$~bp@+pddx bE b V9 f V݌̌     S |        ISPDGUIDELINES/RECOMMENDATIONS  ݌   Ќ       Sa  ^   |    ConsensusGuidelinesfortheTreatmentofPeritonitisin | ݌ a  Ќ       SC     {    PediatricPatientsReceivingPeritonealDialysis  { ݌ C  Ќ       S 6       BradleyA._Warady_,FranzSchaefer,1MaggieHolloway,2StevenAlexander,3MarianneKandert,1   BethPiraino,4IsidroSalusky,2AndersTranus,5JoseDivino,6_Masataka_ԀHonda,7  ݌ u  Ќ       SW     SalimMujais,8andEnricoVerrina,9fortheInternationalSocietyfor ݌ W  Ќ       SF     PeritonealDialysis(ISPD)AdvisoryCommitteeon 7݌   Ќ       S+{(     PeritonitisManagementinPediatricPatients (݌ +{  Ќ       S j     TheChildren'sMercyHospital,KansasCity,Missouri,U.S.A.;UniversityChildren'sHospital,1 ݌    Ќ       SOL   $  Heidelberg,Germany;_U.C.L.A._ԀHospital,2LosAngeles,California;StanfordUniversity $`݌ O Ќ       S1     MedicalCenter,3Stanford,California;UniversityofPittsburgh,4Pittsburgh, ݌ 1 Ќ       Ss p     Pennsylvania,U.S.A.;BaxterLimited,Japan,5Tokyo,Japan;BaxterSA,6Brussels,Belgium; "݌ s Ќ       SU   S  TokyoMetropolitanChildren'sHospital,7Tokyo,Japan;RenalDivision,8 S݌ U Ќ       SD     BaxterHealthcareCorporation,Deerfield,Illinois,U.S.A.; ݌  Ќ       S)!y &     G._Gaslini_ԀChildren'sHospital,9Genoa,Italy ݌ )!y Ќ       S" h"   ?Exhd$~bp@+pddx bEW#b V9 #f 9݌̌  & E % As XAX  SM$#J%E  Guideline1:DiagnosisofPeritonitisӀ%E݌ M$ Ќ AXX As  #XXXAX#AXXXX   SS&!&P!   ?Kxhd$~bp@+pddx bE&b V9&f'E#) ݌̌  " ,?+ ` hp x X?  S'5#'""  Anempiricdiagnosisofperitonitisshouldbemadeiftheperitonealeffluentiscloudy,the '5# effluentwhitebloodcell(WBC)countisgreaterthan100/mm3,andatleast50%ofthe (!$ _WBCs_Ԁare_polymorphonuclear_Ԁleukocytes.Thediagnostic_workup_Ԁshouldbeperformedusing ) %  astandardizedprocedure(Table1)."y ݌ *% Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  SS  "Z#  IMVFBx \lp9-@XEll S  INVFBx \p.@XE0#"Z##݌  Ќ ,! XX!  &    ?+ ` hp x X?& A]` XAX  SDA ,?+ ` hp x X?&(&  Rationale&(&&݌ D Ќ AXX A]`  #XXXAXz#AXXXX ,B+ ` hp x XB   SN '  ?Pxhd$~bp@+pddx bEb V9Of'% '=(݌̌  " ,?+ ` hp x X?  S = "P)  Althoughthediagnosticcriteriaforperitonitishavenotbeenvalidatedinclinicalstudies,   theyrepresentaninternationalconsensusamongadultandpediatric_nephrologists_Ԁ(411). |! Abdominalpainandfeveraregenerallyfeaturesthataretoononspecificinchildrentopredict h" peritonitisintheabsenceofanelevateddialysateleukocytecount.Iftheeffluentiscloudy, T# theinitialsampleisoptimalforevaluation,irrespectiveofthelengthoftheexchangedwell @$ time.Inequivocalcases,orinpatientson_cycler_Ԁdialysiswithshortexchangedwelltimesand ,%|  withsystemicorabdominalsymptoms,andinwhomtheeffluentappearstobeclear,a &h!  secondexchangeisperformedwithadwelltimeofatleast1hourandtheappearanceofthe 'T"  effluentisreevaluated.Itisnoteworthythat6%ofadultswithculturepositiveperitonitis '@#  presentwithclearfluidandabdominalpain(10).(Onlytwothirdsofthesepatients (,$  subsequentlydevelopcloudyeffluent.)Dialysatecultureresultsaretypicallynotavailable )% before24hoursand,albeitconfirmingthediagnosisinretrospect,arenothelpfulininitial *& clinicaldecisionmaking.Anegativeculturedoesnotexcludebacterialperitonitis.Inupto +&  20%ofpediatricperitonitisepisodes,cultureresultsarenegative(4,1114)."P))݌ ,' Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  SS"F1  Eosinophilicperitonitis(diagnosedwhen_eosinophils_Ԁrepresentmorethan10%ofthetotal S  dialysate_polymorphonuclear_Ԁleukocytecount)iscommonlyassociatedwiththedevelopment ? ofcloudyeffluentinanasymptomaticpatientnewtodialysis.Itislikelysecondarytoalocal + allergicreactiontocomponentsofthedialysisfluidorsubstancesreleasedfromthedialysis  equipment.Itistypicallyselflimited(4,10)."F11݌  Ќ ,! XX!  & E ?+ ` hp x X?% As XAX  SE  B ,?+ ` hp x X?%5  Guideline2:EmpiricTherapyofPeritonitisӀ%55݌ E  Ќ AXX As  #XXXAX~'#AXXXX ,B+ ` hp x XB   SK  H  7  ?Rxhd$~bp@+pddx bE b V9 f'E 4  7I7݌̌  " ,?+ ` hp x X?  S - "\8  Inpatientswithcloudyeffluent,withoutfeverand/orsevereabdominalpain,andnorisk  -  factorsforsevereinfection(listedbelow),thecombined_intraperitoneal_Ԁadministrationofa   firstgenerationcephalosporinand_ceftazidime_Ԁisrecommended(Figure1).Inpatientswith   feverand/orsevereabdominalpain,ahistoryof_methicillin_ԄresistantStaphylococcusaureus   (_MRSA_)infection,arecenthistoryorcurrentevidenceofanexitsite/tunnelinfectionor   nasal/exitsitecolonizationwithS.aureus,andinpatientsyoungerthan2years,a y  _glycopeptide_Ԁ(_vancomycin_Ԁor_teicoplanin_)combinedwith_ceftazidime_Ԁshouldbe e  administrated_intraperitoneally_Ԁ(Figure1)._Aminoglycosides_Ԁshouldnotbeusedasinitial Q treatmentinchildren."\88݌ = Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  S|  " ?  ITVFBx \xp[&@XExx  IUVFBx \p.@XE%%0#" ??݌ % ! Ќ ,! XX!  &    ?+ ` hp x X?& A]` XAX  Sf+&+c& ,  ?+ ` hp x X?&A  Rationale&AxB݌ f+& Ќ AXX A]`  #XXXAX6#AXXXX ,  B+ ` hp x XB   S -p(,( C  ?Wxhd$~bp@+pddx bE-b V9q-f '+fA CC݌  -p( Ќ  " ,?+ ` hp x X?  SS"!E  Childrenwithendstagerenalfailuremaybedependentuponafunctionalperitoneumfora S prolongedperiodoftime(15,16).Moreover,childrenareatahighcumulativeriskof ? experiencingsevereadverseeffectsofvariousdrugs,including_ototoxicity_Ԁand_nephrotoxicity_ + (1719).Thelatterisparticularlyimportantinviewoftheconsiderableresidualrenal  functionthatcommonlyispreservedinchildrenwith_hypoplastic_Ԁkidneydisorders.Hence,  antibiotictherapyofperitonitisinchildrenshouldaimtoprovidethehighestefficacyand   lowestpotentialforsideeffects."!EE݌   Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  S m "I  Antibiotictreatmentshouldbeinitiatedassoonasthediagnosisofperitonitisismade.While  m itisadvisabletoperformandreviewtheresultsofadialysatecellcountandGramstainprior  Y totheinitiationoftreatment(andpossiblyobtainabloodcultureduringinfancy),treatment  E  shouldbestartedimmediatelyuponrecognitionofeffluentcloudinessifsignsofsevere 1  infection,suchaspainandfever,arepresent.Insuchcases,dialysatesamplesshouldbe   collectedforsubsequentcytologicalanalysis,Gramstain,andculturepriortoinitiating   treatment.Theinitialantibioticregimenshouldbeselectedaccordingtosymptomseverity,   peritonitishistory,andthepatient'sriskfactorprofile."I;J݌   Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  S#s "N  Thecombinedadministrationofa_glycopeptide_Ԁ(e.g.,_vancomycin_Ԁor_teicoplanin_)andathird #s generationcephalosporin(e.g.,_ceftazidime_)hasbeenfoundtobesuperiortootherantibiotic _ combinationsbymetaanalysisinadults,andtheexcellentefficacyandsafetyprofileofthis K regimenhasbeendemonstratedinchildren(2022).Intermittentperitonealtreatmentwitha 7 _glycopeptide_Ԁ(e.g.,2loadingdosesof_vancomycin_Ԁor_teicoplanin_Ԁ5Ӏ7daysapart)isequally # effectiveasandmoreconvenientandeconomicalthancontinuoustreatment(20).Intermittent  therapywith_ceftazidime_Ԁ(e.g.,antibioticaddedtoasingleexchangedaily)mayalsobeas  effectiveascontinuoustherapyinchildren,inamannersimilartoothercephalosporinsin  adults(2325).Ontheotherhand,thepossiblespreadof_vancomycin_Ԅresistant_enterococci_  andthepotentialemergenceof_glycopeptide_Ԅresistantstaphylococci,ingeneral,mandatethe o restricteduseof_glycopeptides_Ԁinallendstagerenalfailurepatients(2630).Therefore,the [ useofa_glycopeptide_/_ceftazidime_Ԁcombinationisrecommendedonlyforchildrenatriskfora G severeclinicalcourseand/oraninfectionwitha_methicillin_Ԅresistantcausativeorganism, 3 whereasafirstgenerationcephalosporin(e.g.,_cefazolin_Ԁor_cephalothin_)insteadofa  o _glycopeptide_Ԁshouldbeprescribedinasymptomaticpatientswithcloudyeffluentandwithout  ![ suchriskfactors._Aminoglycosides_Ԁshouldnotbeapartofempiricperitonitistherapyin !G childrenduetotheir_oto_ԄӀand_nephrotoxic_Ԁpotential."NO݌ "3 Ќ ,! XX!  &  ?+ ` hp x X?% As XAX  Su$"$r ,?+ ` hp x X?%U[  Guideline3:ModificationofAPDRegimenforTreatment u$  ofPeritonitisӀ%U[[݌ %%!! Ќ AXX As  #XXXAX/C#AXXXX ,B+ ` hp x XB   S'+#'" ]  ?Yxhd$~bp@+pddx bEw(b V9,(f '"$Z ]]݌̌  " ,?+ ` hp x X?  Sm)$)j$"^  Inpatientswhoreceivenocturnalautomatedperitonealdialysis(APD)withshortdwelltimes m)$# forroutinetherapy,theinitial(24Ӏ48hours)treatmentofperitonitisshouldincludea Y*%$ prolongationofthedialysatedwelltimeto3Ӏ6hours,untilthereisclearingoftheperitoneal E+&% effluent.Thisdoesnotapplytoasymptomaticpatientsinwhomtheroutineprescriptioncan 1,'& becontinued,ortopatientswith_ultrafiltration_Ԁneedsrequiringmorefrequentexchanges. -m(' Patientsreceivingcontinuousambulatoryperitonealdialysis(CAPD)donotrequireany  changeintheirexchangefrequency."^Z_݌  Ќ ,! XX!  &  ?+ ` hp x X?& A]` XAX  S.~+ ,?+ ` hp x X?&ac  Rationale&acd݌ .~ Ќ AXX A]`  #XXXAX ]#AXXXX ,B+ ` hp x XB   S8 6e  ?[xhd$~bp@+pddx bE b V99 f 'c 6eve݌̌  " ,?+ ` hp x X?  Sz ' w"f  ManychildrenwhoreceiveAPDcharacteristicallyreceivedialysisexchangeswithshort(   z  2hours)dwelltimesinordertoenhancesoluteandfluidremoval.However,thecellular f  componentsoflocalhostdefensemechanismsaredepletedbyfrequentexchanges,andthe R  _cytotoxicity_Ԁoffreshconventionaldialysissolutionscompromisesthefunctionofperitoneal >  _macrophages_Ԁ(31,32).Accordingly,prolongationofthedwelltimeallowsforatleastpartial *z  normalizationoftheperitoneal"milieu,"whichhopefullyenhancesbacterialkilling.(This f  may,however,beprecededbyseveralrapidflushesofdialysissolutionatdiagnosistohelp R  reduceabdominalpain.)Thepatientcanbedisconnectedfromthe_cycler_Ԁduringthe >  prolongeddialysatedwelltimes,ifsymptomspermit.Whentheeffluentdemonstrates *  clearing,whichtypicallyoccurswithintheinitial48hoursoftreatment,thepatientmay   returntoamorestandardAPDregimen.However,thedaytimedwellthatcontainsantibiotics  shouldbeafullexchange(approximately1100_mL_/_m2_bodysurfacearea)aslongas  antibiotictreatmentiscontinued.If,ontheotherhand,theperitonealvolumeisslightly(e.g.,  <25%)decreasedduringtheinitial24Ӏ48hoursoftherapybecauseofabdominalpain v (Guideline11),theconcentrationofantibioticsmustbeincreasedtoensuretheinfusionof b  thesamemassofantibioticsthatwouldbeprovidedinafulldwellvolume(Table2)."fg݌ N Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  SS  "o  I]V FBx \!p}-Z;@XE!!!  S  I^VFBx \p.@XE&&0# "oip݌ &! Ќ ,! XX!  _&     ?+ ` hp x X?% As XAX  SS ,?+ ` hp x X?%r  Guideline4:ModificationofTherapyforGramPositive S PeritonitisӀ%rWs݌ c Ќ AXX As  #XXXAXd#AXXXX ,B+ ` hp x XB   Sif t  ?`xhd$~bp@+pddx bE b V9f'Gr t:u݌̌  " ,?+ ` hp x X?  S K "Mv  Ifagrampositiveorganismiscultured,theempiricuseof_ceftazidime_Ԁshouldbe  K discontinued.Afirstgenerationcephalosporinshouldbecontinuedfornon_methicillin_Ԅ  7 resistantstaphylococci;_vancomycin_,_clindamycin_,or_teicoplanin_Ԁfor_methicillin_Ԅresistant  # staphylococci;andampicillinfor_enterococci_Ԁandstreptococci(Figure2).Treatmentduration   shouldbe2weeksforallorganismsexceptS.aureus,whichshouldbetreatedfor3weeks."Mvv݌   Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  S= :   "{  IbVFBx \ p(@@XE=  -.  =  IcVFBx \p.@XE0#"{{݌    Ќ ,! XX!  &    ?+ ` hp x X?& A]` XAX  Sfc ,?+ ` hp x X?&}  Rationale&}g~݌ f  Ќ AXX A]`  #XXXAX{t#AXXXX ,B+ ` hp x XB   S !p    ?exhd$~b p@+pddx bE!b V9q!f'a} ݌̌  " ,?+ ` hp x X?  S"_""  Grampositiveorganismsarethecauseofperitonitisinmorethan50%ofpediatriccases "  (7,9,1114,33,34).Peritonitissecondarytocoagulasenegativestaphylococciistypicallythe #  resultoftouchcontamination,whileinfectionssecondarytoS.aureusarecommonly $ associatedwithacathetertunnel/exitsiteinfectionwith/withoutS.aureusnasalcarriage."m݌ v%  Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  S'X"&""  Inpatientswhoseperitonealcultureispositivefor_methillicin_ԄsensitiveS.aureusor 'X" coagulasenegativestaphylococci,whoareclinicallyimproved,andwhoseempirictherapy 'D# includedtheuseofafirstgenerationcephalosporin,thecephalosporinshouldbecontinuedto (0$ completetherapy.Inpatientswhoreceivedaglycopeptideaspartofempirictherapy, )% substitutionofthisantibioticwithafirstgenerationcephalosporinshouldbeconsidered.In *& somecases,thecoagulasenegativestaphylococcisusceptibilityprofilewillsuggest +& "resistance"tothefirstgenerationcephalosporinwhentheorganismisactuallysusceptiblein ,' vivobecauseofthehighintraperitonealdruglevelsthatareobtained.Rifampinmayalsobe |-( addedtothecephalosporiniftheclinicalresponseislessthanoptimal."݌  Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  SB?"  InthesettingofmethicillinresistantS.aureusorcoagulasenegativestaphylococci,theuse B ofclindamycin,vancomycin,orteicoplaninwith/withouttheadditionofrifampinis .~ recommended.Thechoiceofantibioticsshouldtakeintoconsiderationtheclinicalsymptoms j ofthepatientandtheconcernsinrelationtoemergingresistancetoglycopeptides."݌  V Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  S E "  Ifthecultureispositiveforenterococcus,thefirstgenerationcephalosporinorglycopeptide   andceftazidimeshouldbediscontinuedandreplacedwithampicillin.Onoccasion,asecond   antibiotic,suchasanaminoglycoside,maybeaddedbasedonsensitivityresultsandpatient p  response.Vancomycinorclindamycinshouldbeusedinthesettingofampicillinresistance."`݌ \  Ќ ,! XX!  &  ?+ ` hp x X?% As XAX  S>   ,?+ ` hp x X?%  Guideline5:ModificationofTherapyforGramNegative >  PeritonitisӀ%݌ N  Ќ AXX As  #XXXAX#AXXXX ,B+ ` hp x XB   ST Q  T  ?gxhd$~b p@+pddx bEb V9f' T݌̌  " ,?+ ` hp x X?  S6"  Ifasingleceftazidimesensitivegramnegativeorganism(e.g.,Escherichiacoli,Klebsiella, 6  orProteusspecies)iscultured,theempiricuseofceftazidimeshouldbecontinuedandthe "  firstgenerationcephalosporinorglycopeptideshouldbediscontinued.Ifthesingleorganism  isapseudomonad(e.g.,Pseudomonasaeruginosa),ceftazidimeshouldbecontinuedanda  secondantibioticwithactivityagainsttheisolatedorganismshouldbeadded.Ifanaerobic  bacteriaormultiplegramnegativeorganismsareisolated,intraabdominalpathologyshould  beconsideredandtreatmentshouldincludetheuseofmetronidazole(Figure3).Treatment n durationshouldbe2weeksforasinglegramnegativeorganismotherthan Z Pseudomonas/Stenotrophomonasspecies.Treatmentdurationshouldbe3weeksfor F Pseudomonas/Stenotrophomonasspecies,multipleorganisms,and/oranaerobes."$݌ 2 Ќ ,! XX!  _?+ ` hp x X?" ,?+ ` hp x X?  Sq  "ě  IiVFBx \.H pn,@XE.H .H Nh    IjVFBx \p.@XE ('0#"ě]݌  (\# Ќ ,! XX!  &     ?+ ` hp x X?& A]` XAX  SS ,?+ ` hp x X?&  Rationale&;݌ S Ќ AXX A]`  #XXXAXՒ#AXXXX ,B+ ` hp x XB   S j q  ?lxhd$~b p@+pddx bEYb V9f'+ q݌̌  " ,?+ ` hp x X?  SOL"ġ  Gramnegativeperitonitisisparticularlytroublesomebecauseitisfrequentlyunresponsiveto O antibiotictherapyalone,andbecauseitcanhavelongtermadverseconsequenceson ;  peritonealmembranefunctionandleadtoinabilitytoconductperitonealdialysis(_PD_). ' w Studiesinchildrenhavedemonstratedchronicalterationsofperitonealmembranetransport  c capacityfollowingthedevelopmentofperitonitis(3537).Thereisevidencethatthechanges  O aremostdramaticinchildrenwithahistoryofgramnegativeperitonitis,acomplicationthat  ; mayleadtoperitonealmembranefailure.Inmanysituations,theunsuccessfultreatmentof  '  gramnegativeperitonitisresultsintheneedforcatheterremoval(Guideline12)."ġA݌   Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  SU R "  Athirdgenerationcephalosporinsuchas_ceftazidime_Ԁisgenerallyrecommendedfortreatment U  ofperitonitissecondarytoagramnegativeorganism(otherthan A  Pseudomonas/_Stenotrophomonas_speciesoranaerobes)incontrasttoan_aminoglycoside_ -}  becauseoftherisksof_ototoxicity_Ԁandthelossofresidualrenalfunctionassociatedwiththe i  latterantibiotic(18,19).Onoccasion,however,theuseofafirstgenerationcephalosporin, U whichislessexpensivethan_ceftazidime_,maysufficefortreatmentofE.coliperitonitis A basedonantibioticsusceptibilitytesting.Whereasmostclinicalexperiencewith_ceftazidime_ - treatmenthasbeenwithcontinuoustherapy(e.g.,presenceofantibioticineachbagof  dialysate),asinglepediatricstudyevaluatedtheuseofintermittent_ceftazidime_Ԁtherapy(e.g.,  antibioticadministeredduring1cycle/day)(20).Theintermittenttherapywaslesssuccessful  thancontinuoustreatmentaccordingtoclinicaljudgment,butnotwhenratedbya  standardizeddiseaseseverityscore."q݌ y Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  S ["Ӯ  InfectionssecondarytoPseudomonas/_Stenotrophomonas_speciesaredifficulttotreatbecause  [ oftheorganisms'capacitytogeneratea_biofilm_Ԁthatdecreasesthelikelihoodofsuccessful G treatmentwithoutcatheterremoval.Whilecombinationtherapywith_ceftazidime_Ԁandan 3 additionalagent(e.g.,_piperacillin_,_ciprofloxacin_,_aminoglycoside_,_aztreonam_)towhichthe  _organismissusceptibleisindicated,theuseofciprofloxacinshouldberestrictedtopatients   olderthan12years,unlesstheantibioticsusceptibilitypattern,severityofillness,or   mitigatingcircumstancessuggestotherwise.Theuseofintermittentintraperitonealdosingof ! aminoglycosidesandcephalosporinswithCAPD,andintermittentintravenousdosingof " tobramycinandcefazolinwithAPD,hasbeendemonstratedtobeefficaciousinadults,but k# notyetinchildren(2325,38)."ӮP݌ W$ Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  S%9!% "  Finally,theintraperitonealcombinationofanaminoglycosideandpiperacillinmaybe %9!  incompatibleandmandatestheprovisionofpiperacillinbytheintravenousroutewhen &%"! prescribedinthissetting."݌ '#" Ќ ,! XX!  &  ?+ ` hp x X?% As XAX  SS)$)P$ ,?+ ` hp x X?%  Guideline6:ModificationofTherapyforCulture S)$# NegativePeritonitisӀ%݌ *&$ Ќ AXX As  #XXXAX#AXXXX ,B+ ` hp x XB   S, (f,' /  ?nxhd$~b p@+pddx bEU-b V9 -f') /o݌ , (% Ќ  " ,?+ ` hp x X?  SS"  Iftheinitialculturesremainsterileat72hoursandsignsandsymptomsofperitonitisare S improved,thecombinedempiricantibiotictherapyprescribedtocoverthegrampositiveand ? gramnegativespectrashouldbecontinuedfor2weeks."݌ + Ќ ,! XX!  &  ?+ ` hp x X?& A]` XAX  Smj ,?+ ` hp x X?&=  Rationale&=ܾ݌ m Ќ AXX A]`  #XXXAX#AXXXX ,B+ ` hp x XB   S' w $   ?pxhd$~b p@+pddx bE b V9x f' R݌̌  " ,?+ ` hp x X?  S f "e  Intheabsenceofoutcomedataconcerningtheearlyterminationofantibiotictherapywith   sterileperitonitis,itappearssafetoapplyfullantibioticcoverageforacompletetreatment   coursetodecreasetheriskofrecurrentinfection.Incenterswhereculturenegativeperitonitis   representsmorethan20%ofperitonitisepisodes,appliedsamplingandculturetechniques }  (Table1)shouldbereviewedwiththedialysisstaffandtherespectivelaboratory."e݌ i  Ќ ,! XX!  &  ?+ ` hp x X?% As XAX  SK   ,?+ ` hp x X?%  Guideline7:ModificationofTherapyforFungal K  PeritonitisӀ%݌ [  Ќ AXX As  #XXXAX#AXXXX ,B+ ` hp x XB   Sa^ *  ?rxhd$~bp@+pddx bEb V9f' *j݌̌  " ,?+ ` hp x X?  SC"}  IffungiareidentifiedbyGramstainorculture,treatmentshouldbeinitiatedwitheither C  intravenousamphotericinBoracombinationofanimidazole/triazole(e.g.,intraperitonealor / oralfluconazole)andflucytosine.Ineachcase,itisrecommendedthattreatmentshouldbe  associatedwithearlycatheterremoval.Inpatientsinwhomthecatheterisnotremoved  initially,immediatecatheterremovalshouldtakeplaceifimprovementdoesnotoccurwithin  3daysoftreatmentinitiation.Treatmentdurationfollowingcatheterremovalforallpatients  shouldbe2weeksorlongerfollowingcompleteresolutionoftheclinicalsymptomsof { infection.Treatmentdurationwithoutcatheterremovalshouldbe4Ӏ6weeks."}݌ g Ќ ,! XX!  &  ?+ ` hp x X?& A]` XAX  SI ,?+ ` hp x X?&}  Rationale&}݌ I Ќ AXX A]`  #XXXAX#AXXXX ,B+ ` hp x XB   S` R  ?txhd$~bp@+pddx bEO b V9 f'" R݌̌  " ,?+ ` hp x X?  SE! B"  FungalperitonitisisaninfrequentbutpotentiallyseriouscomplicationofPD.Inpediatrics, E! thisinfectionrepresentslessthan2%ofallperitonitisepisodes(4,1214,39,40).Historically, 1" thedevelopmentoffungalperitonitishasresultedinthefrequentconversionofpatientsto #m hemodialysis.Arecentstudyof51pediatricpatientssuggeststhatsuccessfultherapycan  $Y frequentlyresultinpreservationoftheperitonealmembraneandcontinuedPD(40).""݌ $E  Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  S&!4&!"5  Severalfactorsappeartopredisposepatientstothedevelopmentoffungalperitonitis,the &! mostcommonofwhichistheprioruseofantibioticstotreatbacterialperitonitisora s'" catheterrelatedinfection.However,Waradyetal.foundthat,innearly50%ofchildrenwho _(# developedfungalperitonitis,therewasnohistoryofapriorperitonealinfection.Despitea K)$ previoussuggestiontothecontrary,itisalsolikelythatthepresenceofagastrostomydoes 7*%  notpredisposetothedevelopmentoffungalperitonitis(4042).Theroleofantifungal #+s&! prophylaxis(e.g.,nystatin,fluconazole)inthesettingofantibiotictherapyremains ,_'" controversial,butisgenerallyadvocated(Guideline11)(4345)."5݌ ,K(# Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  SS"`  WhereasamphotericinBhasgenerallybeenrecommendedastreatmentforfungalperitonitis S inpatientsreceivingPD,datacollectedinchildrenandadultsprovideevidencethatthe ? peritonealpenetrationofamphotericinBwithsystemicadministrationispoor.Inaddition, + theintraperitonealadministrationofamphotericinBischaracteristicallyirritatingtothe  peritoneumandmayresultinsevereabdominalpain.Ontheotherhand,fluconazoleis  characterizedbyexcellentbioavailabilityandperitonealpenetration,andiscurrentlythedrug   ofchoiceformostCandidaspeciesotherthanC.kruseiandsomeisolatesofC.glabrata(46   53).Sinceoralabsorptionisessentiallycomplete,therecommendeddoseoffluconazoleis w  thesamefororal,intraperitoneal,andintravenousadministration.Ideally,fungal c  susceptibilitiesshouldbeobtainedtohelpdirecttherapy.Thereliabilityofsusceptibility O   resultshasrecentlyimprovedfollowingthedevelopmentofstandardizedtechniquesfor ;  yeast,butnotmolds(54,55)."`݌ 'w  Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  S f   "%  Therecommendationthatthedurationofantifungaltreatmentfollowingcatheterremovalbe2   weeksorlongerfollowingcompleteresolutionoftheclinicalsymptomsofinfection(or4Ӏ6   weekswithoutcatheterremoval)takesintoconsiderationtheinabilitytocreateanevidence   basedrecommendationbecauseofthelackofpediatricoradultdataintheliterature,andthe } treatmentgoaloflongtermperitonealmembranefunctioninchildren(5)."%݌ i Ќ ,! XX!    ?+ ` hp x X?" ,?+ ` hp x X?  SK"  Theinclusionoftherecommendationforcatheterremovalfollowingthediagnosisoffungal K peritonitisisduetothepropensityoffungitocolonizethePDcatheterandprevent 7 eradicationoftheinfectiondespitedrugtherapy(Guideline12).Theoptimaltimingof # catheterremoval,intermsofnumberofdaysposttreatmentinitiation,hasnotbeen  determined."_݌  Ќ ,! XX!  & E ?+ ` hp x X?% As XAX  S=: ,?+ ` hp x X?%   Guideline8:EvaluationofPrimaryTreatmentResponseӀ% ݌ = Ќ AXX As  #XXXAX#AXXXX ,B+ ` hp x XB   SC@   ?vxhd$~bp@+pddx bEb V9f'E \݌̌  " ,?+ ` hp x X?  S%"o  Theresponsetotheinitialantibiotictreatmentshouldbeevaluateddailyaftertreatment % initiation.Treatmentcanbeconsideredsuccessfulifanimprovementinclinicalstatus(e.g.,  cessationofabdominalpainandfever,reductionofeffluentcloudiness)hasbeenachievedby   72hoursoftherapy.AreductionofthedialysateWBCcountbymorethan50%isadditional ! evidenceofsuccessfultherapy."o݌ " Ќ ,! XX!  &  ?+ ` hp x X?& A]` XAX  S$g# ,?+ ` hp x X?&  Rationale&݌ $g Ќ AXX A]`  #XXXAX#AXXXX ,B+ ` hp x XB   S%!!~%    ?xxhd$~bp@+pddx bEm&b V9"&f'# ݌̌  " ,?+ ` hp x X?  Sc'"'`""  Theearlyassessmentoftreatmentefficacycharacteristicallyconsistsofanevaluationofthe c'" patient'ssymptomsandtheappearanceoftheperitonealeffluent.Improvementinpatient O(#  symptoms(e.g.,decreaseofpainandfever)andclearingofeffluentcloudinessat72hoursis, ;)$! inmostcases,evidenceofsuccessfultherapy."݌ '*w%" Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  S+ 'f+&"  Insomecases,theuseofobjective,standardizedresponsecriteriacanbehelpfultoavoid + '# unnecessaryprematurechangesoftreatmentanddelayedrecognitionofaninsufficient ,'$ treatmentresponse.Thisapproachwasappliedinapediatricprospectivetrial,withexcellent -(% agreementbetweenaninitialresponseratingandthefinaloutcome(20).Adecreaseinthe  effluentWBCcount3daysafterinitiationoftreatmentwasahelpfuldiagnosticindicatorof  treatmentresponse.Arelativeshiftfrompolymorphonucleartomononuclearcellsshould  alsostartatthistime,butoccurswithmuchgreatertemporalvariabilitythantheabsolute t decreaseinthenumberofWBCs."݌ ` Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  S B "  Incompleteeradicationofmicroorganismsfromtheperitonealcavityafter3daysof  B antibiotictherapyshouldnotbeconsideredtreatmentfailure.Inaprospectiveevaluation,  . Schaeferetal.foundpersistentbacterialgrowthin20%ofperitonitisepisodes60hoursafter   treatmentinitiation(20).After7daysofcontinuedtherapy,theeradicationratewas95%;   eradicationbytreatmentdays3or7didnotpredicttheriskforperitonitisrelapse."&݌    Ќ ,! XX!  &  ?+ ` hp x X?% As XAX  S4 1  ,?+ ` hp x X?%b  Guideline9:ApproachtoPatientsWhoFailto 4  DemonstrateClinicalImprovementӀ%b݌   Ќ AXX As  #XXXAX=#AXXXX ,B+ ` hp x XB   S G    ?zxhd$~bp@+pddx bE6b V9f' ݌̌  " ,?+ ` hp x X?  S,|)"  Ifnoclinicalimprovementoccurswithin72hoursoftreatmentinitiation,potentialsourcesof ,|  persistentinfectionshouldbeevaluated.Treatmentmodificationsmayincludeanalteration h ofantibiotictherapyand/orcatheterremoval."p݌ T Ќ ,! XX!  &  ?+ ` hp x X?& A]` XAX  SC ,?+ ` hp x X?&u  Rationale&u݌  Ќ AXX A]`  #XXXAX!#AXXXX ,B+ ` hp x XB   SPM J  ?|xhd$~bp@+pddx bEb V9f'C J݌̌  _" ,?+ ` hp x X?  S2"  Mostpediatricpatientsdemonstratepromptclinicalimprovementsoonaftertheinitiationof 2 successfultreatmentforperitonitis.Inonepediatricstudy,Schaeferetal.foundthat74%of  allperitonitisepisodeswerefreeofanyassociatedclinicalsymptomsafter60hoursof   antibiotictreatment(20).Accordingly,itisreasonabletopursuefurtherinvestigationifa  patienthasnotdemonstratedanyimprovementafter3daysoftherapy.Inallcases,there  evaluationshouldincludearepeatassessmentoftheperitonealeffluentcellcount,Gram ~ stain,andeffluentculture.Insomecases(e.g.,tuberculosis,_capnocytophagia_),specialculture j  techniquesmaybenecessary."*݌ V! Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  S"8""   InthesettingofcoagulasenegativestaphylococciandS._epidermidis_treatmentresistant "8 infections,abrief(48Ӏto72hour)trialwiththeadditionoforal_rifampin_Ԁtherapyshouldbe #$ considered.Ifthepatientsarereceivingafirstgenerationcephalosporinandtheorganismis $  _methicillin_Ԅresistant,thecephalosporinshouldbediscontinuedandtherapywitha %  _glycopeptide_Ԁ(e.g.,_vancomycin_Ԁor_teicoplanin_)or_clindamycin_Ԁshouldbeinstituted. &! Continuedtreatmentfailure,especiallywithS.aureus,maybetheresultofaconcomitant '" cathetertunnelinfectionandshouldresultincatheterremoval(Guideline12)(56).Detection p(#  ofatunnelinfectioncanbemadebyacombinationofclinicalevaluationandultrasound \)$! assessmentinthemajorityofcases(57).InfectionssecondarytoPseudomonasspthatare H*%" resistanttocombinationtherapyshouldalsoresultincatheterremovalandsubsequent 4+&# intravenousantibiotictherapy.Inpatientswithtreatmentresistantperitonitissecondaryto  ,p'$ anaerobicbacteriaormultiplegramnegativeorganisms,thepossibilityof_intraperitoneal_  -\(% pathology(e.g.,rupturedappendix)shouldbeconsidered,thecatheterremoved,and  intravenoustherapyprescribed(58).Intherarecaseoftuberculousperitonitisinchildren,  exploratorylaparotomyorlaparoscopywithbiopsyoftheperitoneuminadditiontocultures  maybenecessaryfordiagnosis(4,5,10,59).Therapyconsistsofacombinationof_isoniazid_, t _rifampin_,and_pyrazinamide_." > ݌ ` Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  S B "  Finally,althoughnotrecommended,somepediatricpatientsmaybeprescribedantifungal  B therapywithoutcatheterremovalfortreatmentoffungalperitonitis.Inthesepatients,failure  . todemonstrateclinicalimprovementwithin72hoursshouldresultincatheterremovaland   intravenous/oralantifungaltherapyforaminimumof2ormoreweeksfollowingthe   resolutionofclinicalsymptoms."B݌    Ќ ,! XX!  &  ?+ ` hp x X?% As XAX  S4 1  ,?+ ` hp x X?%   Guideline10:ApproachtothePatientwithRelapsing 4  PeritonitisӀ% ݌   Ќ AXX As  #XXXAX#AXXXX ,B+ ` hp x XB   S G  ;  ?~xhd$~bp@+pddx bE6b V9f' ;{݌̌  " ,?+ ` hp x X?  S,|)"  Relapsingperitonitisisdefinedasarecurrenceofperitonitiswiththesameorganismasinthe ,|  immediatelyprecedingepisode,accordingtoantibioticsusceptibilities,within4weeksof h completionofantibiotictreatment.Sincethecausativeorganismisnotknownatthetimeof T onsetofsymptoms,empirictreatmentshouldbereinitiatedaccordingtoGuideline2.After @ bacteriologicconfirmationofarelapse,treatmentshouldbeorganismspecific(seetreatment , recommendationsbelow)and(exceptforPseudomonas/_Stenotrophomonas_species)treatment  durationshouldbe3weeks(Table3)." ݌  Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  SFC  "   IVFBx \8 p, @XEF8 8 6X* F IVFBx \p.@XEP#@#0# " !݌ P# Ќ ,! XX!  &    ?+ ` hp x X?& A]` XAX  S(I$(# ,?+ ` hp x X?&#  Rationale&#a$݌ (I$ Ќ AXX A]`  #XXXAX#AXXXX ,B+ ` hp x XB   S*&`*% %  ?xhd$~bp@+pddx bEO+b V9+f!'([# %%݌̌  " ,?+ ` hp x X?  SE,'+B'"&  RelapsingperitonitisismostfrequentlyseenwhenS.aureusorcoagulasenegative E,' staphylococciarethecausativeorganisms(60).Becauseofitsimportanttherapeutic 1-( implications,thediagnosisofarelapseshouldnotrelysolelyonthegenus/species,butalso  ontheantibioticsusceptibilitiesoftheculturedorganism.Insophisticatedlaboratorysettings,  strainidentitycanbeconfirmedbyDNAgenotypeanalysis(21)."&g'݌  Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  Sj"}*  Slimeformingcoagulasenegativestaphylococciarebelievedtosurviveantibiotictherapyin j _fibrinous_Ԁadhesionsand_biofilm_Ԁmatrixonthecathetersurface.Catheterdecontaminationby  V localinstallationof_fibrinolytic_Ԁagentsandhighdoseantibioticshasbeenshowntoimprove  B finalcureratesinadultsandchildren(6062)."}**݌  . Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  Sp  m  ".  InrelapsingperitonitiscausedbyS.aureus,anoccult(e.g.,subclinical)tunnelinfectionorintra p  abdominalabscessshouldbesought.Also,screeningfornasalS.aureus_carriership_Ԁshouldbe \  performedinthechildandhis/her_caregivers_."..݌ H  Ќ ,! XX!    ?+ ` hp x X?" ,?+ ` hp x X?  S*  "]1  Patientswithrelapsinggramnegativeperitonitisshouldbeevaluatedforanintraabdominal *  abscess,andmayrequiresurgicalexplorationandcatheterremoval.Inthecaseof   pseudomonasor_stenotrophomonas_Ԁinfections,thecathetershouldberemovedand   intravenousantibioticsprescribedforaminimumof2Ӏ3weekspriortoconsiderationof   catheterreplacement."]11݌  Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  Sl"4  Finally,ifasecondrelapseoccurssecondarytoanyorganismandnootherpathologyis l identified,thecathetershouldberemoved."4L5݌ X Ќ ,! XX!  & E ?+ ` hp x X?% As XAX  SG ,?+ ` hp x X?%6  Guideline11:AdjunctiveTherapyforPeritonitisӀ%6u7݌  Ќ AXX As  #XXXAX%#AXXXX ,B+ ` hp x XB   SM 8  ?xhd$~bp@+pddx bE<b V9f"'EG{6 8"9݌̌  " ,?+ ` hp x X?  S2/"5:  Inpatientswhoarebeingtreatedforperitonitis,adjunctivetherapyshouldbeconsideredon 2 anindividualbasisandmayincludethefollowing:"5::݌ n Ќ ,! XX!   (03 ?+ ` hp x X?""  X<( ` hp x X<  S]  X?+4 4` hp x X? <2  a  .3  Ԁ  Decreasedperitonealfillvolumeinpatientswithsignificantabdominaldiscomfort;<=݌  Ќ $ X4, X$   ?+ ` hp x X?""  X<( ` hp x X<  SB?  X?+4 4` hp x X?D?2  b  .3  Ԁ  Oralantifungalprophylaxisduringthecourseofantibiotics;D?I@݌ B Ќ $ X4, X$   ?+ ` hp x X?""  X<( ` hp x X<  S $   X?+4 4` hp x X?A2  c  .3  Ԁ  Lowdose_intraperitoneal_Ԁheparinaslongasperitonealeffluentiscloudy;andAB݌  $ Ќ $ X4, X$   ?+ ` hp x X?""  X<( ` hp x X<  Sf""c  X?+4 4` hp x X?YD2  d  .3  Ԁ  Intravenousimmuneglobulin(_IVIG_)inpatientswith_hypogammaglobulinemia_.YD^E݌ f" Ќ $ X4, X$   &  ?+ ` hp x X?& A]` XAX  S#H#  ,?+ ` hp x X?&G  Rationale&GG݌ #H Ќ AXX A]`  #XXXAXc8#AXXXX ,B+ ` hp x XB   S%!_%   H  ?xhd$~bp@+pddx bEN&b V9&f#'#F HMI݌̌  " ,?+ ` hp x X?  SD'"&A""`J  Significantabdominalpainisfrequentlynotedinchildrenwhodevelopperitonitis.Earlyin D'" thecourseoftreatment,thepainmaybeworsenedbythepresenceoftheroutineexchange 0(# volume.Accordingly,theperitonealvolumecanbeslightly(e.g.,<25%)decreasedduring )l$ theinitial24Ӏ48hoursoftherapyuntilclinicalsymptomsimprove.Ifthisoccurs,the *X% concentrationofantibioticsmustbeincreasedduringthisperiodoftimetoensurethe *D& infusionofanappropriatemassofantibiotics(Table2).Theexchangevolumeshould +0'  subsequentlybeincreasedtothenormalprescriptiontopreventaprolongedperiodof ,(! _underdialysis_."`JJ݌ -)" Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  SS""O  Theassociationbetweenantibiotictherapyandfungalperitonitishaspromptedseveraltrials S ofantifungalprophylaxisduringantibiotictreatmentinpatientsreceiving_PD_Ԁ(40,4345). ? Studiesinadultshavebeeninconclusivewithrespecttothebenefitsoforalnystatin.Ina + pediatricstudy,oralnystatin(10000U/kg/day)ororal_ketoconazole_Ԁwasassociatedwitha  significantdecreaseintheriskoffungalperitonitisinpatientsreceivingantibiotics(43).  Whenused,theantifungalagentshouldlikelybecontinuedforseveraldaysfollowing   completionoftheantibiotictherapytoallowforrepopulationofthegastrointestinaltractwith   thenormalbacterialflora.Empirically,theprovisionofLactobacillusmightalsobe w  consideredforthispurpose.""OO݌ c  Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  S E "T  Althoughtheefficacyof_intraperitoneal_Ԁheparinhasnotbeenformallyproven,itsinhibitory  E  effectonfibrinclotformationisbelievedtocontributetocatheter_patency_Ԁincasesofsevere 1  peritonitiswithmassiveproteinexudation(63).Heparinalsohasbacteriostaticandanti   inflammatoryproperties.Therecommendeddoseofheparinis500Ӏ1000U/Ldialysateuntil   theeffluentclears."T:U݌   Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  S74"ZX  Finally,thepresenceoflowserumlevelsof_IgG_Ԁhasrepeatedlybeendemonstratedinpatients 7 receiving_PD_Ԁduringinfancy(64,65).Whiletherearenodatatosupporttheroutineuseof #s prophylacticimmunoglobulininthispopulation,theprovisionof_IVIG_Ԁshouldbeconsidered _ intheinfantwithdocumented_hypogammaglobulinemia_Ԁandperitonitis/sepsis."ZXX݌ K Ќ ,! XX!  __&  ?+ ` hp x X?% As XAX  S: ,?+ ` hp x X?%+\  Guideline12:IndicationsforCatheterRemovaland  ReplacementӀ%+\\݌ = Ќ AXX As  #XXXAXH#AXXXX ,B+ ` hp x XB   SC Y^  ?xhd$~bp@+pddx bEb V9Df$':[ Y^^݌̌  " ,?+ ` hp x X?  S2"_  Peritonealdialysiscatheterremovalshouldoccuraspartoftherecommendedtreatment  courseinsituationsinwhichfailuretodosoisunlikelytoresultinsuccessfulperitonitis q therapy.Thetimingofcatheterreplacementshouldbe2Ӏ3weeksfollowingcatheterremoval ] inmostcases."_)`݌ I Ќ ,! XX!  &  ?+ ` hp x X?& A]` XAX  S +  ,?+ ` hp x X?&b  Rationale&b(c݌  + Ќ AXX A]`  #XXXAX]#AXXXX ,B+ ` hp x XB   S"B" ^d  ?xhd$~bp@+pddx bE1#b V9"f%' .b ^dd݌̌  " ,?+ ` hp x X?  S'$w#$"e  Catheterremovalshouldbeconsideredanimportantcomponentofperitonitistherapy.This '$w approachtotherapyisoftennecessaryinpatientswithtreatmentresistantperitonitisbecause %c  ofconcernsforlongtermdamagetotheperitonealmembrane(16,35).Inmostcases,patients %O! treatedinthismannerreceivehemodialysisforavariableperiodoftimeandarethenableto &;" returnto_PD_.Inpediatricpatients,catheterremovalandsubsequentreplacementshouldbe ''#  stronglyconsideredincertainsituationsasshowninTable4."e.f݌ ($  Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  SS  "i  IV&FBx \pp-@XEpp& S  IVFBx \p.@XE0#'"ikj݌ 3 Ќ ,! XX!    ?+ ` hp x X?" ,?+ ` hp x X?  S9"l  Therearenodatainthepediatricoradultliteraturethatpermitanevidencebased  recommendationwithrespecttothelengthofantibiotictreatmentfollowingcatheterremoval. x Therecommendationof2Ӏ3weekstakesintoconsiderationtheabsenceofdataandthe d treatmentgoaloflongtermperitonealmembranefunctioninchildren.Inallcases, P recommendationsconcerningthedurationofantibiotictherapyandthetimingofcatheter < replacementmayrequiremodificationbaseduponthepatient'sclinicalresponse."lm݌ (x Ќ ,! XX!  & E ?+ ` hp x X?% As XAX  S g ,?+ ` hp x X?%p  Guideline13:ProphylacticAntibioticTherapyӀ%p>q݌   Ќ AXX As  #XXXAXc#AXXXX ,B+ ` hp x XB   S!m! r  ?xhd$~bp@+pddx bE\"b V9"f('EgDp rr݌̌  " ,?+ ` hp x X?  SR#"O"s  ProphylacticantibiotictherapyforS.aureusnasalcarriageisrecommendedtodecreasethe R#  riskofS.aureuscatheterexitsite/tunnelinfections.Prophylacticantibiotictherapyshouldbe >$  givenatthetimeofcatheterplacementintheformofasingledoseofafirstgeneration *%z  cephalosporin.Antibioticprophylaxisshouldalsobeconsideredfollowingaccidental &f!  _intraluminal_Ԁcontamination,priortodentalprocedures,andpriortoproceduresinvolvingthe 'R" gastrointestinalorurinarytract.Prophylacticsystemiclongtermantibiotictreatmentisnot '># indicated."sxt݌ (*$ Ќ ,! XX!  &  ?+ ` hp x X?& A]` XAX  Sl*%*i% ,?+ ` hp x X?&x  Rationale&xSy݌ l*% Ќ AXX A]`  #XXXAX)r#AXXXX ,B+ ` hp x XB   S&,v'+#' z  ?xhd$~bp@+pddx bE,b V9w,f)'*Yx zz݌̌  " ,?+ ` hp x X?  S-)e-("{  Staphylococcusaureusnasalcarriageisassociatedwithahighincidenceof_PD_Ԁcatheter -) relatedinfectionswiththisorganism._Intrafamilial_Ԁtransmissionoftheorganismiscommon.  Intermittent(i.e.,3Ӏ4days/month)_intranasal_Ԁtreatmentofnasalcarrierswith_mupirocin_  eliminatedcarriageandmarkedlyreducedinfectionswithS.aureusinadultCAPDpatients  (66).Similarresultswereobtainedwithcycliclocal_mupirocin_Ԁointmentappliedtotheexit t siteofS.aureusnasalcarriers.Morerecently,Pirainoetal.recommendedthatasmall ` amountof_mupirocin_Ԁointmentbeapplieddailytotheexitsite,usingacottonswab,forall L  _PD_Ԁpatients,eliminatingtheneedfornasalcultures(67).Pediatricdataontheimpactof 8  treatingS.aureusnasalcarriers(patientsandcareproviders)iscurrentlylimited,makingit $ t reasonabletoextrapolatetheadultexperiencetochildren(6870).Whereasthedailyuseof  ` _mupirocin_Ԁinallpatientshasthepotentialforgeneratingantibioticresistance,thishasnot  L  beenasignificantproblemasofthistime."{Y|݌  8  Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  Sz 'w "g  Therecommendationconcerning_perioperative_Ԁandpostcontaminationprophylaxistakesinto z  accountthecurrentstateofknowledgeofintraabdominalsurgery,whereantibiotic f  administrationimmediatelypriortoandwithinthefirst6hoursafterconductingabdominal R  surgeryappearstobeeffectiveinpreventinginfection.Asinglepediatricexperienceonthe >  topicrevealedthatpatientswhoreceivedpreoperativeantibiotictherapypriorto_PD_Ԁcatheter *z placementhadasignificantlydecreasedincidenceofpostoperativeperitonitiswhen f comparedtountreatedpatients(71).Themostappropriateprophylacticagentisafirst R generationcephalosporin(e.g.,_cefazolin_Ԁor_cephalothin_),unlessthepatientisknowntobe > colonizedwitha_methillicin_Ԅresistantorganism.A_glycopeptide_Ԁshouldnotbetheinitial * agentroutinelychosenbecauseoftheemergingbacterialresistanceto_glycopeptides_."g݌  Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  SXU"5  Therearenodatademonstratingthebenefitsofantibioticprophylaxisfollowingabreakin X dialysistechnique.However,theuseofafirstgenerationcephalosporinfor1Ӏ3daysinthis D settingistypicallyrecommendedbyadultandpediatric_nephrologists_.A_glycopeptide_Ԁshould 0 beusedonlyinthesettingofapatientpreviouslyknowntobecolonizedwitha_methicillin_Ԅ l resistantorganism."5݌ X Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  SG"  Prophylacticantibiotictherapyisalsorecommendedinthesettingofdentalprocedures  becauseoftheriskofbacteremiaandsubsequentperitonitis(72,73)._Amoxicillin_Ԁisthe  preferredagentinadosecomparabletowhatisrecommendedbytheAmericanHeart r  Associationforsubacutebacterial_endocarditis_Ԁprophylaxis(Table5)(74).Consideration ^! shouldalsobegiventotheprovisionofprophylactictherapyforchildrenon_PD_Ԁhaving J" gastrointestinal(e.g.,_gastrostomy_Ԁtubeplacement)orgenitourinarysurgerybecauseofthe 6#  likelyincreasedriskofperitonitis.Ampicillinplus_ceftazidime_Ԁarerecommended."݌ "$r  Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  SS  "  IV*FBx \pp-9&@XEpp0* S  IVFBx \p.@XE0#+"݌ c Ќ ,! XX!  & E   ?+ ` hp x X?% As XAX  S" i" ,?+ ` hp x X?%  Guideline14:DiagnosisofCatheterExitSiteInfectionӀ%݌ "  Ќ AXX As  #XXXAX z#AXXXX ,B+ ` hp x XB   S$ o$   ?xhd$~bp@+pddx bE^%b V9%f,'Ei"y C݌̌  " ,?+ ` hp x X?  ST&!&Q!"V  Thediagnosisofacatheterexitsiteinfectionshouldbemadeinthepresenceofapurulent T&! dischargefromthesinustract,ormarked_pericatheter_Ԁswelling,redness,and/ortenderness, @'" withorwithoutapathogenicorganismculturedfromtheexitsite.Infectioussymptoms ,(|#  shouldberatedaccordingtoanobjectivescoringsystem(Table6)."VӚ݌ )h$ Ќ ,! XX!  ?+ ` hp x X?" ,?+ ` hp x X?  SS  "  IV-FBx \Bp9-X @XEBBb- S  IVFBx \p.@XEE 5 0#."݌ E  Ќ ,! XX!  &    ?+ ` hp x X?