Perit Dial Int-2016-Li-481-508
Perit Dial Int-2016-Li-481-508
Perit Dial Int-2016-Li-481-508
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www.PDIConnect.com Copyright © 2016 International Society for Peritoneal Dialysis
ISPD GUIDELINES/RECOMMENDATIONS
Philip Kam-Tao Li,1 Cheuk Chun Szeto,1 Beth Piraino,2 Javier de Arteaga,3 Stanley Fan,4 Ana E. Figueiredo,5
Douglas N. Fish,6 Eric Goffin,7 Yong-Lim Kim,8 William Salzer,9 Dirk G. Struijk,10
Isaac Teitelbaum,11 and David W. Johnson12
PERITONITIS RATE N.B. Relapsing peritonitis (see Table 6 for the definition) should be
counted as a single episode.
• We recommend that every program should monitor, at least
on a yearly basis, the incidence of peritonitis (1C). in a linear scale. Some centers also monitor the incidence of
• We recommend that the parameters monitored should death associated with peritonitis, which is typically defined as
include the overall peritonitis rate, peritonitis rates of death with active peritonitis or within 4 weeks of a peritonitis
specific organisms, the percentage of patients per year who episode, or any death during hospitalization for a peritonitis
are peritonitis-free, and the antimicrobial susceptibilities episode (6,12,30).
Besides prophylactic antibiotics, various techniques of of peritonitis with double bag compared with the standard Y
catheter placement have been tested. Four randomized tri- systems (82). On the other hand, 2 updated systematic reviews
als have compared laparoscopic or peritoneoscopic catheter did not find any difference (42,81). It was suggested that the
placement with standard laparotomy (38–41). One study use of conservative statistical techniques might have partly
showed that peritoneoscopic insertion led to significantly less accounted for the lack of difference observed (42).
early peritonitis (38), but the other 3 were negative (39–41). Published studies that compared the peritonitis rate of
A systematic review concluded that there is no significant machine-assisted automated PD (APD) and CAPD showed con-
difference in peritonitis rate between these techniques (42). flicting results (83–91). However, most of these studies were
Two studies compared midline with lateral incision (43,44), observational rather than randomized trials, and the analysis
but neither found any difference in peritonitis rate. Several of these studies is handicapped by failure to report on the
studies examined the technique of burying the PD catheter connection type in the cyclers used. At present, the choice of
in subcutaneous tissue for 4 to 6 weeks after implantation APD versus CAPD should not be based on the risk of peritonitis.
(45–47). The first prospective study with historic control
found a decrease in rate of peritonitis (45). In the 2 sub- TRAINING PROGRAMS
sequent randomized studies, one showed a decrease in
peritonitis rate with a buried catheter (46), while the other • We recommend that the latest ISPD recommendations for
showed no difference (47). One retrospective study found teaching PD patients and their caregivers be followed (92).
no difference in peritonitis rate between pre-sternal and • We recommend that PD training be conducted by nursing staff
with the appropriate qualifications and experience (1C).
on re-training and the results are pending (112). The indica- TABLE 2
tion, optimal time, and content of retraining have not been Indications for PD Re-Training
well defined. Home visits by PD nurses may be a good way to
determine which patients require re-training (98). Other indi- • Following prolonged hospitalization
cations for re-training are listed in Table 2 (14,92). Certainly, • Following peritonitis and/or catheter infection
all patients must be re-trained whenever the equipment to • Following change in dexterity, vision, or mental acuity
perform PD is changed. • Following change to another supplier or a different type of
connection
• Following other interruption in PD (e.g. period of time on
DIALYSIS SOLUTION
hemodialysis)
Early data suggested that the choice of PD solution may study showed that intranasal mupirocin reduced S. aureus ESI
affect peritonitis rates, although the results of published trials but not peritonitis (134), but this study has been criticized
are conflicting (113–120). The largest and methodologically for excluding patients at highest risk for S. aureus PD-related
most robust randomized trial of neutral-pH, low-glucose- infections. Intranasal mupirocin treatment is also less well
degradation-product (GDP) PD solutions demonstrated that accepted by patients (135). A recent study in pediatric patients
suggested that the addition of sodium hypochlorite solution
simple soap and water cleansing only (147). Two randomized follow hysteroscopy with biopsy (170) as well as in women
studies comparing oral rifampicin with no treatment both with vaginal fistula and leakage (171–174). One retro-
demonstrated significant reductions in peritonitis risk with spective study of 13 gynecological procedures reported a
rifampicin treatment (148,149). In another study, cyclic oral non-significant reduction in peritonitis rates associated
rifampicin and daily topical mupirocin to the exit site were with antibiotic prophylaxis (0/4 vs 5/9, p = 0.10) but had
equally effective in reducing the rate of S. aureus peritonitis inadequate statistical power (161). Transient bacteremia
(125). However, adverse effects of rifampicin were more com- is common after dental procedures and may lead to peri-
mon than those of topical mupirocin (124). Moreover, drug tonitis (175,176). Prophylactic antibiotics (e.g. single oral
interactions involving rifampicin were a real concern, and rifam- dose of amoxicillin) before extensive dental procedures may
picin resistance developed in up to 18% of cases with repeated be reasonable.
usage (150). The use of oral rifampicin for prophylactic purpose Prophylactic antibiotics are usually recommended after
is therefore not routinely advocated. Other oral antibiotics, such wet contamination, i.e. if the dialysis solution is infused
as trimethoprim/sulfamethoxazole, cephalexin, and ofloxacin after contamination, or if the catheter administration set was
were not effective in reducing peritonitis rates (151–153). open for an extended period (14). Most nephrologists give a
There is a strong association between ESI and subsequent 2-day course of oral antibiotics after contamination in which
peritonitis (31,154,155). Early detection of ESI and prompt dialysis has been infused, but there is no widely accepted
management with appropriate antibiotics are logical steps to standard regimen.
minimize the risk of subsequent peritonitis (31,154). A number of other potentially modifiable risk factors for
CONTINUOUS QUALITY IMPROVEMENT urokinase therapy (203). When PD effluent clears up after
antibiotic treatment, catheter removal and re-insertion can
• We recommend each PD center have a continuous quality be performed as a single procedure without the need for tem-
improvement (CQI) program in place to reduce peritonitis porary hemodialysis (202,204,205).
rates (1C).
• We suggest that multidisciplinary teams running CQI INITIAL PRESENTATION AND MANAGEMENT OF PERITONITIS
programs in PD centers meet and review their units’ per-
formance metrics regularly (2C). The algorithm of initial management for PD patients pre-
senting with a clinical diagnosis is summarized in Figure 1.
A team approach for CQI is the key to a successful PD pro-
gram (19). The CQI team generally includes nephrologists, Clinical Presentation and Diagnosis of Peritonitis
nurses, social workers, and dietitians. Regular meetings of
the team should be held to examine all PD-related infections • We recommend that peritonitis always be diagnosed when
and identify the root cause of each episode. The CQI team at least 2 of the following are present: (1) clinical features
identifies problems, develops solutions, and evaluates results consistent with peritonitis, i.e. abdominal pain and/or
in an iterative fashion. In essence, if a pattern of infections cloudy dialysis effluent; (2) dialysis effluent white cell
develops, the team needs to investigate and plan interven- count > 100/μL or > 0.1 x 109/L (after a dwell time of at
tions such as retraining, changing equipment, applying new least 2 hours), with > 50% polymorphonuclear; and (3)
protocols for exit-site care, or managing contamination. positive dialysis effluent culture (1C).
TABLE 4 the home setting. Such an approach requires that the patients
Differential Diagnosis of Cloudy Effluent be trained in this technique and that antibiotics be kept at
home. Whenever possible, cultures should be obtained either
• Culture-positive infectious peritonitis at a local facility or by having blood culture bottles kept at
• Infectious peritonitis with sterile cultures home for use. However, it is important that no one accesses
• Chemical peritonitis the PD catheter without the appropriate training or equipment,
• Calcium channel blockers which is often the case in smaller emergency departments. In
• Eosinophilia of the effluent
this case the patient can drain his/her abdomen and provide
• Hemoperitoneum
• Malignancy (rare)
the cloudy effluent for culture. Alternatively, the patient may
• Chylous effluent (rare) place the cloudy effluent bag in the refrigerator until they
• Specimen taken from “dry” abdomen can bring the sample to their PD center. The benefit of self-
initiated treatment, however, should be carefully balanced
against the potential problems of over-diagnosis and habitual
diarrhea. In addition, the patient should be questioned about misuse of antibiotics.
past history of peritonitis and ESI.
On physical examination, abdominal tenderness is typi- Identification of Causative Organism
cally generalized and is occasionally associated with rebound.
Localized pain or tenderness should raise the suspicion of an • We recommend that the blood-culture bottle be the pre-
ferred technique for bacterial culture of PD effluent (1C).
only facilitate microbial identification, but also reduce the time ceftazidime was considered to be superior to other regimens
needed for a positive culture. In over 75% of cases, microbio- in a proportional meta-analysis (227).
logic diagnosis can be established in less than 3 days. When For gram-positive coverage, several studies compared a
the causative microorganism has been identified, subsequent first-generation cephalosporin with a glycopeptide-based regi-
cultures for monitoring may be performed by only inoculating men (228–231). When analyzed as a whole, glycopeptide-based
the effluent in blood-culture bottles. regimens result in a higher complete cure rate, but there is no
When cultures remain negative after 3 – 5 days of incubation, difference in the rate of primary treatment failure, relapse, or
PD effluent should be sent for repeat cell count, differen- catheter removal (203). A systematic review noted that the
tial count, fungal, and mycobacterial culture. In addition, result was largely influenced by 1 study, in which the dosage
subculture on media with aerobic, anaerobic, and microaero- of cefazolin was substantially lower than current recommenda-
philic incubation conditions for a further 3 – 4 days may help tions (228). Other studies found no difference in cure rates for
to identify slow-growing fastidious bacteria and yeasts that are vancomycin and cefazolin when an appropriate cephalosporin
undetectable in some automated culture systems. dose was used (228,230,231). Nonetheless, some PD units have
a high rate of methicillin-resistant organisms and vancomycin
Other Novel Diagnostic Techniques may be preferable for empirical gram-positive coverage (232),
although it remains controversial what threshold prevalence
• We suggest that there is insufficient evidence to currently of methicillin resistance would justify the routine empirical
support the use of novel techniques for the diagnosis of use of vancomycin as gram-positive coverage.
peritonitis (2D).
• We suggest that IP aminoglycoside be administered as daily previously that for patients with substantial residual renal
intermittent dosing (2B). function, the dose of antibiotics that have renal excretion
• We recommend that prolonged courses of IP aminoglycoside needs to be adjusted (12,13). However, recent studies suggest
be avoided (1C). that such adjustments are not necessary (284,304).
• We suggest that IP vancomycin be administered intermit- In general, IP dosing results in high IP drug levels and is
tently and the serum vancomycin level be kept above 15 μg/ preferable to IV administration. Moreover, IP dosing avoids
mL (2C). venipuncture and could be done by the patient at home after
• We suggest that IP cephalosporin be administered either appropriate training. Although IV vancomycin is reasonably
continuously (in each exchange) or on a daily intermittent successful as empirical gram-positive coverage (237), pre-
basis (2C). vious studies have shown that IV vancomycin resulted in a
significantly higher rate of primary treatment failure than IP
The recommended dosage of antibiotics for the treatment administration (203,305). Intraperitoneal antibiotics should
of PD-related peritonitis is summarized in Tables 5 and 6 (236– be added using sterile technique, such as placing povidone
239,252–303). However, the recommended dosages of many iodine, rubbing with alcohol 70% strip, or chlorhexidine on
antibiotics are based on published clinical experience rather the medication port for 5 minutes prior to insertion of the
than formal pharmacokinetic studies. It was recommended needle through the port.
TABLE 5
Aminoglycosides
Amikacin 2 mg/kg daily (252) LD 25 mg/L, MD 12 mg/L (253)
Gentamicin 0.6 mg/kg daily (254) LD 8 mg/L, MD 4 mg/L (255,256)
Netilmicin 0.6 mg/kg daily (233) MD 10 mg/L (257)
Tobramycin 0.6 mg/kg daily (253) LD 3 mg/kg, MD 0.3 mg/kg (258,259)
Cephalosporins
Cefazolin 15–20 mg/kg daily (260,261) LD 500 mg/L, MD 125 mg/L (254)
Cefepime 1,000 mg daily (262,263) LD 250–500 mg/L, MD 100–125 mg/L (262,263)
Cefoperazone no data LD 500 mg/L, MD 62.5–125 mg/L (264,265)
Cefotaxime 500–1,000 mg daily (266) no data
Ceftazidime 1,000–1,500 mg daily (267,268) LD 500 mg/L, MD 125 mg/L (236)
Ceftriaxone 1,000 mg daily (269) no data
Penicillins
Penicillin G no data LD 50,000 unit/L, MD 25,000 unit/L (270)
Amoxicillin no data MD 150 mg/L (271)
Ampicillin no data MD 125 mg/L (272,273)
Ampicillin/Sulbactam 2 gm/1 gm every 12 hours (274) LD 750–100 mg/L, MD 100 mg/L (253)
Piperacillin/Tazobactam no data LD 4 gm/0.5 gm, MD 1 gm/0.125 gm (275)
Others
Aztreonam 2 gm daily (242) LD 1,000 mg/L, MD 250 mg/L (243,244)
Ciprofloxacin no data MD 50 mg/L (276)
Clindamycin no data MD 600 mg/bag (277)
Daptomycin no data LD 100 mg/L, MD 20 mg/L (278)
Imipenem/Cilastatin 500 mg in alternate exchange (244) LD 250 mg/L, MD 50 mg/L (236)
Ofloxacin no data LD 200 mg, MD 25 mg/L (279)
Polymyxin B no data MD 300,000 unit (30 mg)/bag (280)
Quinupristin/Dalfopristin 25 mg/L in alternate exchangea (281) no data
Meropenem 1 gm daily (282) no data
Teicoplanin 15 mg/kg every 5 days (283) LD 400 mg/bag, MD 20 mg/bag (229)
Vancomycin 15–30 mg/kg every 5–7 daysb (284) LD 30 mg/kg, MD 1.5 mg/kg/bag (285)
Antifungals
Fluconazole IP 200 mg every 24 to 48 hours (286) no data
Voriconazole IP 2.5 mg/kg daily (287) no data
LD = loading dose in mg; MD = maintenance dose in mg; IP = intraperitoneal; APD = automated peritoneal dialysis.
a Given in conjunction with 500 mg intravenous twice daily (281).
b Supplemental doses may be needed for APD patients.
must be used for adding the antibiotics. Although vancomycin showed that intermittent dosing of vancomycin was as effec-
and ceftazidime are compatible when added to dialysis solu- tive as continuous dosing in children receiving APD (311).
tions (1 L total volume or greater), they are incompatible if Vancomycin can probably be given intermittently for APD
combined in the same syringe or added to an empty dialysis patients. Oral ciprofloxacin can also achieve adequate levels
solution bag for reinfusion into the patient. within the peritoneum in APD patients (323). In a retrospec-
Antibiotics are stable for variable times after being added tive, single-center observational cohort study of 508 episodes
to the PD solution (327). Vancomycin is stable for 28 days in of PD-associated peritonitis in 208 patients, no differences in
dialysis solutions stored at room temperature, although higher relapse rates, mortality, or the combined end-point of mortal-
ambient temperatures will reduce the duration of stability. ity and catheter removal were observed between APD and CAPD
Gentamicin is stable for 14 days both at room temperature and patients continuing their own PD modality during continuous
under refrigeration, but the duration of stability is reduced by IP antibiotic treatment in each PD exchange, although elevated
admixture with heparin. Cefazolin is stable for 8 days at room dialysis effluent leukocyte counts and antibiotic treatment
temperature or for 14 days if refrigerated; addition of heparin durations were longer in the former (90).
has no adverse influence. Ceftazidime is stable for 4 days at
room temperature or 7 days if refrigerated. Cefepime is stable Adjunctive Treatments
for 14 days if the solution is refrigerated (328).
Data on the stability of various new antibiotics and PD solu- Some patients with PD-related peritonitis could be managed
tions are limited and often fragmented (329–332). Clinicians on an outpatient basis. The decision to hospitalize a patient
removal. Temporary use of icodextrin solution may prevent addition, monitoring of WBC count in PD effluent may predict
fluid overload in PD patients with acute peritonitis (342). treatment response. A retrospective study showed that dialysis
Because of rapid glucose absorption, glycemic control may effluent WBC count ≥ 1,090/mm3 on day 3 was an independent
worsen in diabetic patients. Blood glucose monitoring with prognostic marker for treatment failure (343).
appropriate adjustments of insulin dosage may be needed.
Protein loss during peritonitis is also increased. Screening for Refractory Peritonitis
malnutrition should be undertaken in patients with prolonged
peritoneal inflammation. • We recommend that the PD catheter be removed promptly in
refractory peritonitis episodes, defined as failure of the PD
SUBSEQUENT MANAGEMENT OF PERITONITIS effluent to clear up after 5 days of appropriate antibiotics
(1C).
• We recommend that antibiotic therapy be adjusted to
narrow-spectrum agents, as appropriate, once culture After initiation of antibiotic treatment, there is usually clini-
results and sensitivities are known. (1C). cal improvement in 72 hours. Refractory peritonitis is defined
as failure of the PD effluent to clear up after 5 days of appro-
The management algorithms for gram-positive cocci and priate antibiotics (Table 7). Catheter removal is indicated in
gram-negative bacilli identified in dialysis effluent are sum- case of refractory peritonitis, or earlier if the patient’s clinical
marized in Figures 2 and 3, respectively. Within 48 hours of condition is deteriorating, in order to preserve the peritoneum
Assess clinical improvement, repeat dialysis effluent cell count and culture at days 3-5
coagulase-
other
negative S. aureus Enterococci
streptococci
staphylococci
treat for 14 days screen for treat for 21 days treat for 14 days
S. aureus carrier;
treat for 21 days
Assess clinical improvement, repeat dialysis effluent cell count and culture at days 3-5
Pseudomonas or
other gram- mixed gram-negative or gram-
Stenotrophomonas
negative bacilli negative + gram-positive organisms
species
treat for 21-28 days treat for 21 days treat for 21 days
Figure 3 — Management algorithm for gram-negative bacilli or mixed bacterial growth identified in dialysis effluent.
* Trimethoprim/sulfamethoxazole is preferred for Stenotrophomonas species.
• We recommend that timely catheter removal be considered • We suggest that coagulase-negative staphylococci generally
for relapsing, recurrent, or repeat peritonitis episodes (1C). be treated with IP cephalosporins or vancomycin, accord-
ing to antimicrobial susceptibility, for a period of 2 weeks.
The definitions of relapsing, recurrent, and repeat perito- (2C).
nitis are summarized in Table 7. Retrospective studies showed
that relapsing, recurrent, and repeat peritonitis episodes are Coagulase-negative Staphylococcus peritonitis episodes,
caused by different species of bacteria and probably represent especially those caused by S. epidermidis, are mostly due
distinct clinical entities (166,345–347). When compared to to touch contamination. Many patients with S. epidermidis
non-relapsing episodes, relapsing ones are associated with a peritonitis have mild clinical symptoms and respond well to
lower rate of cure, more ultrafiltration problems, and higher treatment as outpatients (351–353). In some centers,
rate of technique failure (166,348). Recurrent peritonitis epi- the prevalence of methicillin resistance is now very high
sodes had a worse prognosis than relapsing ones (166,345). (354,355), and vancomycin may have to be considered as
A recent study suggested that bacterial DNA fragment levels empirical therapy. Even for methicillin-sensitive strains,
in PD effluent are significantly higher 5 days before and on it is important to avoid inadequate IP antibiotic levels,
the date of completion of antibiotics amongst patients who which may lead to relapsing peritonitis. For this reason,
subsequently develop relapsing or recurrent peritonitis (349). continuous dosing of IP first-generation cephalosporins is
Another study suggests that effluent white cell count and leu- preferable to intermittent dosing. Effective antibiotic treat-
kocyte strip test at the time of stopping antibiotics may also ment for 2 weeks is generally sufficient (351–354). The
predict relapse (350). However, further studies are needed to patient’s exchange technique should be reviewed to prevent
validate these results and confirm their clinical utility. another episode.
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LI et al. SEPTEMBER 2016 - VOL. 36, NO. 5 PDI
whenever possible. For patients with concomitant S. aureus If single gram-negative organisms are isolated, the anti-
exit-site or catheter tunnel infection, catheter removal should biotic should be chosen according to sensitivity, safety, and
be considered. convenience. It is important to note that bacteria in biofilm
are considerably less sensitive than that indicated by labora-
Corynebacterium Peritonitis tory testing (378), which may account for the high percentage
of treatment failures, even though the organism appears to
• We suggest that corynebacterial peritonitis be treated with be sensitive to the antibiotic in vitro (379,380). Retrospective
effective antibiotics for 3 weeks (2C). studies have shown that gram-negative peritonitis had higher
risks of catheter loss and death than gram-positive episodes
Corynebacterium species belong to the natural flora of the (379–384). In one study, recent antibiotic therapy was the
skin. Infections due to Corynebacterium have been increasingly major risk factor of antibiotic resistance, while ESI, and possibly
recognized over the past decades, largely due to improved recent antibiotic therapy, were associated with poor therapeutic
recognition and microbiological techniques. In a retrospective response (382). The SPICE organisms (Serratia, Pseudomonas,
study, Corynebacterium peritonitis often resulted in relapse or indole-positive organisms such as Proteus and Providentia,
repeat episodes, catheter removal, permanent hemodialysis Citrobacter, and Enterobacter) have amp-C beta-lactamases,
transfer, and death (373). Another retrospective study found which inactivate cephalosporins, and have a high risk of relapse.
that relapsing Corynebacterium peritonitis was common after a Although single antibiotic therapy is often effective, 1 retro-
2-week course of antibiotic treatment, but relapsing episodes spective study suggested that treatment with 2 antibiotics may
When multiple enteric organisms are grown from the PD agent be continued for at least 2 weeks after catheter
effluent, there is a possibility of intra-abdominal pathol- removal (2C).
ogy. Presentation with hypotension, sepsis, lactic acidosis,
or elevated dialysis effluent amylase level should also raise Fungal peritonitis is a serious complication with high
the possibility of abdominal catastrophe (390,391). When a rates of hospitalization, catheter removal, transfer to hemo-
surgical cause of peritonitis is suspected, the antibiotics of dialysis, and death (397–400). Initial therapy is traditionally
choice are metronidazole plus vancomycin, in combination with a combination of amphotericin B and flucytosine. However,
ceftazidime or an aminoglycoside. Monotherapy with a car- IP amphotericin causes chemical peritonitis and pain, while
bapenem or piperacillin/tazobactam may also be considered. IV administration has poor peritoneal bioavailability. In
Assessment by a surgeon is needed. Computed tomographic addition, flucytosine is not widely available. If flucytosine is
(CT) scan may help to identify the pathology, but a normal used, regular monitoring of serum concentration is necessary
CT scan does not eliminate that possibility. If laparotomy is to avoid bone marrow toxicity. Peak serum flucytosine levels,
needed, the PD catheter is usually removed and antibiotics measured 1 – 2 hours after an oral dose, should be 25 – 50 mcg/
are continued via IV route. mL (401,402).
In contrast, polymicrobial peritonitis due to multiple gram- Other agents of choice include fluconazole, an echinocandin
positive organisms often has a favorable prognosis (392,393). (e.g. caspofungin, micafungin, or anidulafungin), posacon-
Their clinical behavior is similar to peritonitis episodes caused azole, and voriconazole. Although fluconazole is commonly
by single gram-positive organisms and the etiology may well used, the prevalence of azole resistance is increasing (403).
The treatment protocol should be based on general proto- • We suggest that if re-insertion of a new catheter is attempt-
cols for treatment of tuberculosis but is often started with 4 ed after a PD catheter is removed for refractory, relapsing,
drugs: rifampicin, isoniazid, pyrazinamide, and ofloxacin. A or fungal peritonitis, it be performed at least 2 weeks after
previous study showed that rifampicin levels in PD effluent are catheter removal and complete resolution of peritoneal
often low (407). Intraperitoneal rifampicin treatment has been symptoms (2D).
advocated but is not available in many countries. In general,
pyrazinamide and ofloxacin could be stopped after 2 months, Indications for catheter removal are summarized in Table 8.
while rifampicin and isoniazid should be continued for a total For refractory peritonitis and fungal peritonitis, simultaneous
of 12 to 18 months (407–413). Pyridoxine (50 to 100 mg/day) re-insertion of a new PD catheter is not recommended, and
should be given to avoid isoniazid-induced neurotoxicity. On patients should be put on temporary hemodialysis. Observa-
the other hand, long-term use of pyridoxine at a higher dose tional studies suggest that effective antibiotics should be
(e.g. 200 mg daily) is in itself associated with neuropathy and continued for at least 2 weeks after catheter removal for
should be avoided. Streptomycin, even in reduced doses, may refractory peritonitis (423,424).
cause ototoxicity after prolonged use and should be avoided. After severe episodes of peritonitis, around 50% of patients
Ethambutol is associated with a high risk of optic neuritis could potentially return to PD (423–425). An ANZDATA Registry
in dialysis patients and must be used with appropriate dos- study demonstrated that return to PD after catheter removal
age reduction. Previous reports suggest a dose of 15 mg/kg and temporary hemodialysis for peritonitis was not associated
every 48 hours or thrice weekly for up to 2 months (414). The with inferior patient-level clinical outcomes when compared
gram-negative bacteria and is also active against MRSA and patients with and without residual renal function equivalent for survival
methicillin-resistant coagulase-negative staphylococci. The study? Insight from a retrospective review of the cause of death. Nephrol
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