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SS S   MXXAMM!=  ISPDGuidelines/Recommendations#AXXAM##XXXAX#AXXXXԀ!=݌ S Ќ  !    Sqn   AeXAX#eAec#Aee!  ADULTPERITONEALDIALYSISRELATED q PERITONITISTREATMENTRECOMMENDATIONS: ! 2000Update #AXXAe*##XXXAXl#AXXXXԀ!݌ 1  Ќ  !    S7  4  !  0  WilliamF.Keane,1GeorgeR.Bailie,2ElizabethBoeschoten,3RamGokal,4ThomasA.Golper,5 7  CliffordJ.Holmes,6YoshindoKawaguchi,7BethPiraino,8MiguelRiella,9StephenVas10!?݌ # s Ќ  !    |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@FXS  b   !7  DepartmentofMedicine,1HennepinCountyMedicalCenter,UniversityofMinnesotaMedical    School,Minneapolis,Minnesota;AlbanyCollegeofPharmacy,2Albany,NewYork,U.S.A.;   DepartmentofPeritonealDialysis,3AcademicMedicalCenter,Amsterdam,TheNetherlands;   ManchesterRoyalInfirmary,4Manchester,UnitedKingdom;VanderbiltUniversityMedical y  Center,5Nashville,Tennessee;BaxterHealthcareCorporation,6McGawPark,Illinois,U.S.A.; e  RenalDivision,7JikeikaiUniversity,SchoolofMedicine,Tokyo,Japan;UniversityofPittsburgh Q  MedicalCenter,8Pittsburgh,Pennsylvania,U.S.A.;RenalDivision,9DepartmentofMedicine, =  EvangelicSchoolofMedicine,CuritibaParana,Brazil;UniversityofToronto,10Toronto )y  Hospital,Toronto,Ontario,Canada!72݌ e Ќ  !    ST@Cxhd$~bp@+pddx bECb V9f! ݌̌  !  S96% G !݌̌  !  Sx  AeXAX#eAe#Aee!\  TableofContents!\݌  Ќ  #AXXAe##XXXAX#!  AXXXX  S!~%G*!݌̌   D(83N!  Sc` #XXXAX#HX/W XXX#XX XHX/Wz#AXXXX!  0    CLINICALPRESENTATION!݌ c Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((SE#XXXAX#HX/W XXX#XX XHX/W#AXXXX!  0    INITIATIONOFTHERAPY!0݌ E Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((S 4 #XXXAX#HX/W XXX#XX XHX/W!#AXXXX!  0    INITIALEMPIRICANTIBIOTICSELECTION!݌   Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((S"i!#XXXAXc#HX/W XXX#XX XHX/W#AXXXX![  0    MODIFICATIONOFTREATMENTREGIMENONCECULTUREANDSENSITIVITY "i RESULTSAREKNOWN![݌ #U Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((S$D$#XXXAX#HX/W XXX#XX XHX/W##AXXXX!  0    TREATMENTOFPERITONITISINAPDPATIENTS!݌ $ Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((S)&y!%&!#XXXAXe#HX/W XXX#XX XHX/W#AXXXX!a  0    ASSESSMENTOFPATIENTSWHOFAILTODEMONSTRATECLINICAL )&y! IMPROVEMENT!a݌ 'e" Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((S(#T(##XXXAX#HX/W XXX#XX XHX/W!#AXXXX!  0    DURATIONOFANTIBIOTICTHERAPY!}!݌ (# Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((S9*%)6%#XXXAX^!#HX/W XXX#XX XHX/Ww##AXXXX!P"  0    TUBERCULOUSPERITONITIS!P"#݌ 9*% Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((S+'x+&#XXXAX##HX/W XXX#XX XHX/W%#AXXXX!$  0    PROPHYLACTICANTIBIOTICUSE!$,&݌ +' Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((S]-( -Z(#XXXAX &#HX/W XXX#XX XHX/W#(#AXXXX!&  0    TREATMENTOFEXITSITEINFECTIONS!&(݌ ]-( Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((SS#XXXAXe(#HX/W XXX#XX XHX/W*#AXXXX!j)  0    RELAPSINGPERITONITIS!j)*݌ S Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((SB#XXXAX*#HX/W XXX#XX XHX/W,#AXXXX!+  0    CATHETERINSERTIONAFTERREMOVALFORCAPDPERITONITIS!+D-݌  Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((S'w$#XXXAX%-#HX/W XXX#XX XHX/WU/#AXXXX!..  0    USEOFADJUNCTIVETHERAPYINTREATMENTOFAPDPERITONITIS!../݌ 'w Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((S f #XXXAX/#HX/W XXX#XX XHX/W1#AXXXX!0  0    TECHNIQUESFORSAMPLINGANDCULTURINGPDEFFLUENT!0,2݌   Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((SK  H#XXXAX 2#HX/W XXX#XX XHX/W94#AXXXX!3  0    FUTUREDIRECTIONS!34݌ K  Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((S - #XXXAX{4#HX/W XXX#XX XHX/W6#AXXXX!`5  0    ACKNOWLEDGMENTS!`56݌  - Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((So l #XXXAX6#HX/W XXX#XX XHX/W8#AXXXX!7  0    SELECTEDREADINGS!749݌ o  Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((SQ  @Ixhd$~bp@+pddx bEb V9Rf!9݌ Q  Ќ  !  S @ AeXAX#eAe9#Aee!;  P#AXXAe3<##XXXAXu<#AXXXXeritonitisisacommonclinicalproblemthatoccursinpatientswithendstagerenaldiseasetreated   byperitonealdialysis(PD).Althoughtheincidenceofperitonitisvariesfromcentertocenter, C  sincethe1980sithasprogressivelydeclined,andduringthepastdecadeapproximately1episode /  every24patienttreatmentmonthswasroutinelyobserved.Insomecenters,1episodeevery60   patienttreatmentmonthshasbeenachieved,inlargepartbecauseofexceptionalpatient   education,aswellasnewconnectorandcathetertechnologies.Themorerecentintroductionof   automatedperitonealdialysis(APD)hasalsocontributedtothegrowthofPD,butthistechnique  isalsocomplicatedbyepisodesofperitonitis.!;<݌ { Ќ  !  S ] ! A  Thedevelopmentofdisconnectsystemshashadanimportanteffectonoverallreductionofthe  ] incidenceofperitonitisepisodes,particularlythoseduetoskinorganisms.Avarietyofmicro I organismsmaycausePDperitonitis.Grampositiveorganisms,particularlyStaphylococcus 5 aureusandS.epidermidis,havebeenthemostfrequentpathogens.However,inpatientsutilizing ! thedisconnectsystems,withthereductionintheincidenceofgrampositivestaphylococcus   peritonitis,therelativeincidenceofgramnegativeinfectionhasincreased.! A\A݌  Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((S; 8!D  ManydifferentantimicrobialagentshavebeenusedtotreatPDperitonitis.Asinthepast,thecurrent ;  Committeereviewedexperiencesreportedintheliteratureandformulatedrecommendations '!w basedupontheseassessments.Overtheyears,avarietyofdifferentregimenshavebeenproposed "c basedupontheseexperiences.Antibioticshavebeenadministeredintraperitoneally(IP),or "O intravenously(IV),ororally,andanumberofdifferentdosingregimenshavebeenutilized. #; Unfortunately,nosingleregimenhasbeenshowninappropriateclinicaltrialstobemost $'  efficacious.!DE݌ %! Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((SU'"'R"!H  AdiagnosticandtherapeuticapproachtothepatientwithpresumptivePDperitonitiswaspublished U'" in1987andrevisedin1989,1993,and1996.Theselatterrecommendationscontainedanumber A(# ofnewrecommendationsbaseduponintermittentdosing.Inaddition,therecentemergenceof -)}$ vancomycinresistancehascreatedatherapeuticdilemmaofinternationalproportions(see *i%  RecommendationsforPreventingtheSpreadofVancomycinResistance,inSuggestedReading). +U&! Asaresult,majormodificationstoourrecommendationswereproposedin1996.Asalways, +A'" individualclinicalsituationsandvariabilityinpatientpopulationsmaynecessitatemodification ,-(# oftheserecommendations.Importantly,itisrecognizedthatthereareclinicalsituationsinwhich -)$ vancomycinistheappropriateantibiotictobeused;however,thecommitteestillrecommends  thatroutineandprophylacticuseofthisantimicrobialagentbeavoided.!HI݌  Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((S.~+!N  Wedonotsuggestthattherecommendationsoutlinedinthisreportrepresenttheonlyacceptable .~ waystomanagePDpatientswithperitonitis.Nonetheless,thepurposeofthisdocumentisto j presentasystematicapproachreflectingachangingmicrobialenvironmentandtheemergenceof  V newantibiotics.!NO݌  B Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((S 1 !oQ  Inadditiontothesetherapeuticrecommendations,animportantclinicalmanagementtoolhasbeen   thedevelopmentandutilizationoftechniquesineachcenterformonitoringtheincidenceof p  peritonitis,exitsiteinfections(ESI),andtunnelinfectionsinthePDpopulation.This \  epidemiologicalapproachshouldallowprogramdirectorstoassesswhetherachangeinthe H  frequencyandincidenceofperitonitishasoccurredintheirpatientpopulation,andthusto 4  provideanindexofqualityofcare.Attentiontochangingmicrobialbiogramswithinacenteris  p  alsoofmajorimportanceinthesettingofincreasingprevalenceofvancomycinresistant  \  staphylococcusandenterococcusorganisms.Finally,thisyear2000Updateisfocusedonthe H  adultpopulation;separatepediatricrecommendationswillbepublishedlaterthisyear.!oQsR݌ 4 Ќ  !  &  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((Sv#s ,|T)(T)PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((% J !V  CLINICALPRESENTATION%JXӀ!VX݌ v Ќ  #XXXAX =#!  AXXXX ,|(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@FT)T)PP(((( (( #((((((((SX@\xhd$~bp@+pddx bEb V9Yf'#V!WY݌ X Ќ  !  SG![  DiagnosisofPeritonitisinContinuousAmbulatoryPD(CAPD)Patients:Inpatientswithcloudy  fluidand/orabdominalpainand/orfever,asampleoftheappropriate(i.e.,>4hours'dwelltime)  dialysateeffluentshouldbeobtainedforlaboratoryevaluationincludingacellcountwith r differential,Gramstain,andculture(Table1).Anelevateddialysatecountofwhitebloodcells ^ (WBC)ofmorethan100/mm3,ofwhichatleast50%arepolymorphonuclearneutrophils(PMN), J issupportiveofthediagnosisofmicrobialinducedperitonitis,andcallsforimmediateinitiation 6 ofantimicrobialtherapy.Inasymptomaticpatientswithonlycloudyfluid,itisreasonableto "r delayinitiationoftherapyuntiltheresultsofthecellcount,differential,andGramstainare ^ available,aslongasthesestudiescanbeperformedexpeditiously(i.e.,within2_3hours).If J thereisnoincreaseintheperitonealWBCcount,thedifferentialdoesnotshowapredominance 6 ofPMN,andnobacteriaareseenonGramstain,immediatetherapyisnotindicated.Similarly,if  " morethan10%ofperitonealleukocytesareeosinophilsandtheGramstainisnegative, ! immediateantimicrobialtherapyisusuallyunnecessary.![[݌ " Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((S<$#9!b  Patientswithcloudyfluidaccompaniedbyabdominalpainand/orfeverrequirepromptinitiationof <$ empirictherapy(Table2).NeitherthedifferentialnorthemagnitudeoftheWBCelevationhas (%x  beenshowntobehelpfulinpredictingthecausativeorganism.Thereissomeevidencethat &d!  peritonitiscausedbyS.aureusorgramnegativebacillimaybeaccompaniedbymoresevere 'P"! symptomsthananinfectioncausedbycoagulasenegativestaphylococci.However,alteringthe '<#" empirictherapybasedontheseverityofsymptomsorthedialysatecellcountisnot (($# recommended.AGramstainispositivein9%_40%ofperitonitisepisodesand,whenpositive, )%$ ispredictiveofeventualcultureresultsinapproximately85%ofcases.AGramstainis *&% particularlyusefulintheearlyrecognitionoffungalperitonitis.Cultureofdialysateeffluent +&& shouldalwaysbeperformedpriortoinitiationofantibiotictherapy,buttreatmentshouldnotbe ,'' delayedwhilewaitingforcultureresults.!bc݌ t-(( Ќ  SS*KL ddd Xdd Xdd X(#(#,<+  1'SS 1!  SVS!@i  TABLE1!@ipi݌ V Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((S8 ,|T)(T)PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((!i  InitialClinicalEvaluationofPatientwith 8 SuspectedPeritonealDialysisRelated $ Peritonitis#XXXAXrY#AXXXX!iuk݌ ?5  ?Ќ  !  ,|(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@FT)T)PP(((( (( #((((((((S O @`xhd$~bp@+pddx bE b V9P f!l݌ ?5 O  ?Ќ  !  S>  ; |+(+PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((#XXXAX;l#HX/W XXX#XX XHX/Wo#AXXXX!n   4 Symptoms:cloudyfluidand >  abdominalpain!n7p݌ * z Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F++PP(((( (( #((((((((S i |+(+PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((#XXXAXp#HX/W XXX#XX XHX/Wr#AXXXX!p   4 Docellcountanddifferential!pr݌   Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F++PP(((( (( #((((((((SN K |+(+PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((#XXXAXr#HX/W XXX#XX XHX/W7u#AXXXX!ys   4 Gramstainandcultureoninitial N  drainage!ysu݌ :  Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F++PP(((( (( #((((((((S y |+(+PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((#XXXAXyu#HX/W XXX#XX XHX/Ww#AXXXX!:v   4 Initiateempirictherapy!:vYx݌   Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F++PP(((( (( #((((((((S^ [|+(+PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((#XXXAX:x#HX/W XXX#XX XHX/Wz#AXXXX!x   4 Choiceoffinaltherapyshould ^  alwaysbeguidedbyantibiotic J  sensitivities!xz݌ ?56  ?Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F++PP(((( (( #((((((((Su"r@bxhd$~bp@+pddx bEb V9f#XXXAXz#AXXXX!{݌-#!u   -Ќ  !  SW!~  DiagnosisofPeritonitisinAPDPatients:PatientsonvariousformsofAPDrequirea W modifiedapproachtodiagnosisandtreatmentofperitonitis.Thesepatientsreceivea C periodofconsecutive,relativelyshortexchangesduringthenight(nocturnal / exchanges),andmayhaveonlyapartialexchangeoradryabdomenduringtheday  (daytimeexchanges).!~N~݌  Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((SIF!W  Diagnosticcriteriaforperitonitiswereestablishedbasedonclinicalexperiencewith I CAPDpatientswhosedwelltimeswere4_6hoursinduration.Concernshavebeen 5 raisedthattheshorterdwelltimesofAPDpatientswithsuspectedperitonitiscould !q resultinmisleadinglylowdialysatecellcountsandfalselynegativecultures.In  ] pediatricpatients,70%ofwhomaretreatedwithAPD,thishasnotbeenthecase.For  I morethanadecade,CAPDperitonitisdiagnosticandtreatmentcriteriaandmethods !5 havebeensuccessfullyappliedtothemanagementofpediatricpatientsreceiving "! APD,withonlyminormodifications(seeKuizonetal.,1995).Thefollowing #  recommendationsarebasedonthispediatricexperienceandmayproveusefulinthe $ managementofadultsonAPD.Peritonitisdiagnosisandtreatmentdatainadultson %  APDaregraduallyemerging.!W;݌ &! Ќ  !  S!  !݌ '# Ќ  *]de dd<<KL4(#4(#],,,+  5+(# (# 5!  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((S(O$(# S!-  TABLE2!-'݌ (O$! Ќ  !  S*%>*% ,|T)(T)PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((!  EmpiricInitialTherapy,forPeritonealDialysisRelatedPeritonitis,Stratified *%" forResidualUrineVolume#XXXAX}#AXXXX!x݌ F< }+&#   F  !  ,|(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@FT)T)PP(((( (( #((((((((S, (i,'@gxhd$~bp@+pddx bEX-b V9 -f!ʊ݌ B8 , ($   BЌ  !  SS!ь݌ +!S +  !  SSA XAX#  A7#A  !Z  Residualurineoutput#AXX A##XXXAX̍#AXXXX!Z݌ B8 S   BЌ  !  SB?A XAX#  Ad#A  !  Antibiotic#AXX A##XXXAX[#AXXXX!z݌ 'B 'Ќ  !  SB?A XAX#  A#A  !R  <100mL/day#AXX A##XXXAXĐ#AXXXX!R݌ 'B 'Ќ  !  SB?A XAX#  AS#A  !  >100mL/day#AXX A##XXXAX/#AXXXX!N݌ C9B  CЌ  !  SEB@ixhd$~bp@+pddx bEb V9f!D݌ B8 E   BЌ  !  S1A XAX#  A#A  !  Cefazolinorcephalothin#AXX A##XXXAX#AXXXX!݌ ' 'Ќ  !  S1A XAX#  A#A  !  1g/bag,q.d.#AXX A-##XXXAXo#AXXXX!݌ ' 'Ќ  !  S1A XAX#  A#A  !i  20mg/kgBW/bag,q.d.#AXX A##XXXAXۗ#AXXXX!i݌ ?5   ?Ќ  !  S 4 !݌ '   'Ќ  !  S 4 A XAX#  As#A  !p  or#AXX A##XXXAX#AXXXX!p݌ '   'Ќ  !  S 4 !њ݌ ?5    ?Ќ  !  S s !d݌ '   'Ќ  !  S s A XAX#  Ag#A  !ߛ  15mg/kgBW/bag,q.d.#AXX A##XXXAXQ#AXXXX!ߛp݌ '  'Ќ  !  S s !S݌ ?5   ?Ќ  !  S U A XAX#  A#A  !  Ceftazidime#AXX A##XXXAXX#AXXXX!w݌ ' U 'Ќ  !  S U A XAX#  A#A  !P  1g/bag,q.d.#AXX A##XXXAXŸ#AXXXX!P݌ ' U 'Ќ  !  S U A XAX#  AR#A  !  20mg/kgBW/bag,q.d.#AXX A##XXXAX.#AXXXX!M݌ ?5 U  ?Ќ  !  S X A XAX#  Aơ#A  !H  Gentamicin,tobramycin,netilmycin#AXX Ax##XXXAX#AXXXX!H٢݌ ' X 'Ќ  !  S X A XAX#  A_#A  !ɣ  0.6mg/kgBW/bag,q.d.#AXX A##XXXAX;#AXXXX!ɣZ݌ ' X 'Ќ  !  S X A XAX#  AԤ#A  !>  Notrecommended#AXX An##XXXAX#AXXXX!>ϥ݌ ?5 X  ?Ќ  !  S [  A XAX#  AB#A  !Ħ  Amikacin#AXX A##XXXAX6#AXXXX!ĦU݌ ' [  'Ќ  !  S [  A XAX#  A#A  !+  2mg/kgBW/bag,q.d.#AXX A[##XXXAX#AXXXX!+݌ ' [  'Ќ  !  S [  A XAX#  A4#A  !  Notrecommended#AXX AΩ##XXXAX#AXXXX!/݌ C9 [   CЌ  !  S^  @kxhd$~bp@+pddx bEb V9_f!(݌ F< ^    FЌ  !  SM J !n  q.d.=once/day;BW=bodyweight.#XXXAX#AXXXX!n݌0&$M    0Ќ  !  S/    !t  CloudyfluidandabdominalpainremainthehallmarkofperitonitisinAPDtreatedpatients. /  Occasionally,theinitialdrainofthe"residual"fluidthathasbeenpresentintheabdomenallday  inpatientswithonlypartialordrydiurnalexchangeswillappearcloudyintheabsenceof  peritonitis.TheWBCmayexceed100/mm3,butmononuclearcellspredominateandabdominal  painisnotpresent.Moreimportant,intheabsenceofinfectiontheinitiallycloudydialysate  rapidlyclearswithinitiationofAPD.!t݌ { Ќ  !    |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((S ] !n  Ifcloudyfluid,and/orabdominalpain,and/orfeveris/areobservedatanypointinthedailyAPD  ]  treatmentcycle,thepatientshouldnotifythedialysiscenterimmediatelyforfurtherspecific I! instructions,includingclinicalevaluation.Asampleofdialysateeffluentshouldbeobtainedfor 5" cellcount,differential,Gramstain,andculture,aswithCAPDpatients.Ifthefluidisveryturbid, !# theinitialsampleissufficientforstudy,regardlessofthelengthofthedwelltimethatproduced  $ it.Inequivocalcases,orinpatientswithsystemicorabdominalsymptomsinwhomdialysate % appearstobeclear,asecondexchangeisperformedwithadwelltimeofatleast2hours. & Obviously,clinicaljudgmentshouldguideinitiationoftherapy.Usingthistechnique,the ' incidenceofculturenegativeperitonitishasremainedapproximately20%,similartothat m( reportedinCAPDpatients.!n^݌ Y ) Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((S!;!!  ClinicalUtilityoftheGramStain:If,oninitialevaluation,theGramstainrevealsagrampositive !;* organism,therapywithasingleantibioticwithactivityagainstgrampositiveorganismsshould "'+ beinitiated.However,identificationofasinglespeciesbyGramstaindoesnotprecludethe #, presenceofotherspeciespresentinlesserconcentrations.Thus,theGramstainresultsmustbe $- consideredpreliminary.Inrarecases,theGramstainmayindicategramnegativeorganisms,and % . theselectionofanantimicrobialagentwithactivityagainstgramnegativebacteriaisappropriate. &!/ TheGramstainmayalsobeusefulinrevealingthepresenceofyeast,andthusallowforprompt s'"0 initiationofantifungaltherapy.Thefindingofgrampositivecocciandgramnegativerods _(#1 togethersuggeststhepossibilityofaperforatedabdominalviscous,andpromptsurgical K)$2 evaluationiswarranted.!ʶ݌ 7*%3 Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((S+'v+&!P  Unfortunately,onmanyoccasionstheGramstainisunavailable,delayed,ornegativeforanyspecific +'4 organisms.Empirictherapyisindicatedintheseconditions(Tables1and2).Therearesome ,(5 clinicalcluesthatmaybehelpful.Thereisaslightstatisticallikelihoodthatthecausative -(6 pathogenwillbethesameasthemostrecentinfection.Iftheexitsiteisinfectedwith  pseudomonasorS.aureuswhenperitonitispresents,thereisahighprobabilitythattheperitonitis  iscausedbythesameorganism.Ifthepatientishavingfrequentperitonitisepisodes,thenrelapse  orrecurrencewiththesameorganismislikely.!P4݌ t Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((S V!  ItisrecognizedthatmanypatientstreatedwithPDresideinlocationsthatareremotefrommedical  V facilities,andthusmaynotbeseenexpeditiouslyfollowingtheonsetofsymptoms.Inaddition,  B thesePDpatientsmaynothaveimmediatelyavailablemicrobialandlaboratorydiagnostic  . services.Sincemostexpertsagreethatpromptinitiationoftherapyforperitonitisiscritical,itis   necessarythatthepatientreportsymptomatologytothecenterimmediately.Promptinitiationof   therapybythesepatientsremotefromthecenterisofobviousimportanceandrequiresthe    availabilityofantimicrobialsinthepatient'shome.Thisapproachhasbeenbroadlyacceptedby   medicalcareprovidersworldwideandhasdemonstratedefficacy.Instructionsforthereportingof z  symptomatologyandtheutilizationofhomeantimicrobialtherapyshouldbeconsideredpartof f  PDpatienttraining.!d݌ R  Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((S4 !  0  ReturntoMenu!݌ 4 Ќ  !  &  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((Sv#s ,|T)(T)PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((% m !s  INITIATIONOFTHERAPY%m%Ԁ!s2݌ v Ќ  !  #XXXAX#AXXXX ,|(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@FT)T)PP(((( (( #((((((((SX@oxhd$~bp@+pddx bEb V9Yf'#!݌ X Ќ  !  SG!  Inthepastfewyears,theincreasingprevalenceofvancomycinresistantmicroorganismshasbeen  noted.Initially,vancomycinresistancewasconfinedtoenterococciisolatedfrompatientswho  werecriticallyillinintensivecareunits.Ithassubsequentlybeendocumentedthatsimilar r organismscouldbeisolatedfrompatientswhohadchronicillnessestreatedwithmultiple ^ antibioticsandthatfrequentlyhadprolongedhospitalstays.Internationally,theprevalenceof J vancomycinresistantorganismshasdramaticallyincreasedandthisincreasehasbeen 6 particularlyevidentinlargeruniversityhospitalswhereupto14%ofenterococcimaybe "r resistant.Vancomycinresistancehasbeenassociatedwithresistancetootherpenicillinsand ^ aminoglycosides,thuspresentingatreatmentdilemma,sincemanyofthesecondline J antimicrobialagentsthatcouldbeusedhavenotbeenprovenintherapeutictrials.Thischangein 6 vancomycinsensitivityhaspromptedanumberofworldwideagenciestodiscourageroutineuse  " ofvancomycinforprophylaxis,forempirictherapy,orfororaluseforClostridiumdifficile ! enterocolitis.Themajorconcernisthatthevancomycinresistancegeneistransmittedto " staphylococcalstrains,creatinganissueofmajorepidemiologicalimportance.Whileagreatdeal # ofconcernhasbeenraisedaboutvancomycin,itisstillanimportantantimicrobialoption. $ Indeed,itisrecommendedforuseinmethicillinresistantS.aureus(MRSA)infectionsandin n%  treatmentofinfectionsduetobetalactamresistantorganisms,aswellasintreatmentfor Z&!! infectionsinpatientsthathaveseriousgrampositiveinfectionsandthatareallergictoother F'"" agents,andinthetreatmentofC.difficileenterocolitisthatdoesnotrespondtometronidazole.!݌ 2(## Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((S)%q)$!  0  ReturntoMenu!݌ )%$ Ќ  !  &  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((SV+&+S& ,|T)(T)PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((% q !Z  INITIALEMPIRICANTIBIOTICSELECTION%q Ԁ!Z݌ V+&% Ќ  !  #XXXAX#AXXXX ,|(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@FT)T)PP(((( (( #((((((((S,8(,'@sxhd$~b p@+pddx bE-b V99-f '+u!݌ ,8(& Ќ  !  SS!  IftheeffluentsedimentGramstainsuggestsgrampositivebacteria,agramnegativeorganism,oris S unavailable,delayed,ornegativeforanyspecificorganisms,empirictherapyisindicated(Table ? 2).Topreventroutineuseofvancomycinandthuspreventemergenceofresistantorganisms,itis + recommendedthatafirstgenerationcephalosporin,forexample,cefazolinorcephalothin(1g  dailyinthelongdwell),incombinationwithceftazidimebeinitiated.Theseantibioticscanbe  mixedinthesamedialysatebagaseitherloadingormaintenancedoses,withoutsignificantloss   ofbioactivity.Thedoseforceftazidimeis1.0g(Table3).!݌   Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((S m !Z  Asingleantibioticforinitialtreatmentneedstosatisfyseveralcriteria,includinggoodantibacterial  m efficacyforcoagulasenegativestaphylococcus,S.aureus,gramnegativeEnterobacteriaceae,  Y andreasonableefficacyforpseudomonas.Inaddition,itneedstohaveareasonablehalflifefor  E  onceperdaytherapyandclinicallyprovenefficacy.The1996Recommendationsinvolvedthe 1  useofacombinationofafirstgenerationcephalosporinandanaminoglycoside.Theneedto   avoidroutineuseofaminoglycosidearisesfromtheconcerntopreserveresidualrenalfunction,   whichisanindependentpredictorofpatientsurvival.Thereisgoodevidenceshowingamore   rapidlossofresidualrenalfunctioninpatientsreceivingaminoglycosides,evenforshortperiods.   FirstgenerationcephalosporinsdonotadequatelycoverMRSA.!Z>݌ } Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((S_ !  Alternativestoceftazidime(inpatientswitharesidualurinevolumeof<100mL/day)maybe _ cefazolinorcephalothinincombinationwithanaminoglycoside,orclindamycin,orvancomycin K inthatorderofpreference(Table3).!f݌ 7 Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((Sy&v!  Thisstrategyisconsistentwiththedesiretopreservevancomycinfortruemethicillinresistant y organisms.Ceftazidimewasselectedasempirictherapybecauseofitsactivityagainstbothgram e positiveandgramnegativeorganisms.!݌ Q Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((S3!  Newinsightsintothepharmacodynamicprinciplesgoverningtheactivityofceftazidimehaveledto 3 asingledailydoseregimen,whichhastheadvantageofeaseofusebypatientandstaff,bothin  hospitalandathome.!݌   Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((SMJ!S  Ifgentamicin,tobramycin,ornetilmycinareused,theyaredosedat0.6mg/kgbodyweightinonly1 M exchangeperday.Amikacinisdosedat2.0mg/kgbodyweight,alsoinonly1exchangeperday 9  (Table2).!S7݌ %!u Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((S"d"!  GramStainRevealsYeast:IfyeastisseenonGramstain,promptinitiationofantifungaltherapy " shouldbeinitiated.AlthoughthemainstayoftherapyinthepasthasbeenamphotericinB,its # toxicityhasfrequentlyprecludeditseffectiveuse.Experiencewiththenewer $ imidazoles/triazolesandflucytosinesuggestthattheseagentsarewelltoleratedandefficacious.!k݌ {%  Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((S ']"& "!t  0  ReturntoMenu!tX݌  ']"  Ќ  !  &  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((S(#L(# ,|T)(T)PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((% u !  MODIFICATIONOFTREATMENTREGIMENONCECULTUREANDSENSITIVITY (#! RESULTSAREKNOWN%uԀ!݌ )$" Ќ  !  #XXXAX#AXXXX ,|(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@FT)T)PP(((( (( #((((((((S+m&*&@wxhd$~b p@+pddx bE+b V9n+f 'L(!݌ +m&# Ќ  !  S,'\,'!  GramPositiveMicroOrganismsCultured:Within24_48hoursaftertheappropriatecultureof ,'$ dialysatefluid,70%_90%ofthesesamplesyieldaspecificmicroorganism(Table4).Ifthe -(% organismisanenterococcus,thefirstgenerationcephalosporin(cephalothinorcefazolin)and  ceftazidimearereplacedwithampicillin,125mg/Lineachexchange;anotherantibioticsuchas  anaminoglycosidemaybeadded,ifnecessary,basedonsensitivity.Afactortoconsiderin  decidingwhetherornottocontinuetheaminoglycosideistherecognitionthatahighampicillin t levelwillbeachievedatthesiteofinfectionusingthisregimen.!݌ ` Ќ  !  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((S B !;  Aspreviouslydiscussed,weurgerestraintinimmediatelyutilizingvancomycinforenterococci  B withoutconsideringalltheimplications.Sinceenterococciarefrequentlyderivedfromthe  . gastrointestinaltract,intraabdominalpathologymustbeconsidered.Moreover,careshouldbe   exercisedinevaluatingthedialysateculturesinceothermorefastidiousandslowgrowing   organismsfromthebowelmaybepresentinconjunctionwiththeenterococci.!;݌    Ќ  S*xy d dde(#(#,,,,,+  5+1 1  5!  |(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((S4 1  S!  TABLE3!݌ 4  Ќ  !  S s  ,|T)(T)PPxx@Ahi 02XZ #HKps8<`d(-PUx}@F(((((((( (( #((((((((!@  AntibioticDosingRecommendationsforCAPD(Only)PatientsWithand   WithoutResidualRenalFunctiona#XXXAX#AXXXX!@2݌ F<     FЌ  !  ,|(((((PPxx@Ahi 02XZ #HKps8<`d(-PUx}@FT)T)PP(((( (( #((((((((SA @{xhd$~b p@+pddx bEb V9Bf !z݌ B8 A   BЌ  !  S0-!݌ +!0 +Ќ  !  S0-A XAX#  A#A  !  CAPDintermittentdosing(once/day)#AXX A0##XXXAXr#AXXXX!݌ .$0 .Ќ  !  S0-A XAX#  A#A  !  CAPDcontinuousdosing(perliterexchange)#AXX A##XXXAX#AXXXX!݌ B8 0   BЌ  !  SolA XAX#  A#A  !.  Drug#AXX A^##XXXAX#AXXXX!.݌ 'o 'Ќ  !  SolA XAX#  A'#A  !  Anuric#AXX A##XXXAX#AXXXX!"݌ 'o 'Ќ  !  SolA XAX#  A#A  !  Nonanuric#AXX A& ##XXXAXh #AXXXX! ݌ 'o 'Ќ  !  SolA XAX#  A #A  !^   Anuric#AXX A ##XXXAX #AXXXX!^  ݌ 'o 'Ќ  !  SolA XAX#  AY #A  !   Nonanuric#AXX A ##XXXAX5 #AXXXX! T ݌ C9o  CЌ  !  Sro@}xhd$~b p@+pddx bEb V9f !H ݌ B8 r   BЌ  !  S^A XAX#  A #A  !  Aminoglycosides#AXX A##XXXAX#AXXXX!݌ ' 'Ќ  !  S^!݌ ' 'Ќ  !  S^!t݌ ' 'Ќ  !  S^!݌ ' 'Ќ  !  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