Antimicrobial agents for preventing peritonitis in peritoneal dialysis patients

Abstract

In this update, we identified limited data from RCTs and quasi-RCTs which evaluated strategies to prevent peritonitis and exit-site/tunnel infections. This review demonstrates that pre/peri-operative intravenous vancomycin may reduce the risk of early peritonitis and that antifungal prophylaxis with oral nystatin or fluconazole reduces the risk of fungal peritonitis following an antibiotic course. However, no other antimicrobial interventions have proven efficacy. In particular, the use of nasal antibiotic to eradicate Staphylococcus aureus, had an uncertain effect on the risk of peritonitis and raises questions about the usefulness of this approach. Given the large number of patients on PD and the importance of peritonitis, the lack of adequately powered and high quality RCTs to inform decision making about strategies to prevent peritonitis is striking.

Patient and Caregiver Priorities for Outcomes in Peritoneal Dialysis

“…PD infection, including peritonitis, exit-site, and tunnel infections, was the highest ranked outcome overall, consistent with the frequency with which it is reported in trials (17,25). Patients felt they were constantly required to be extremely vigilant with their hygiene practices to minimize their risk of infection, which may jeopardize PD survival, cause pain, or require hospitalization.…”

Regional variation in the treatment and prevention of peritoneal dialysis-related infections in the Peritoneal Dialysis Outcomes and Practice Patterns Study

“…In this regard, it was disappointing to note that routine monitoring of PD infection rates was not universal across all participating PD facilities. Moreover, four randomized controlled trials (RCTs) and a systematic review have demonstrated the benefit of antibiotic prophylaxis at the time of PD catheter insertion (level 1A ISPD guideline) [9,[14][15][16][17]. While this practice was universally applied in all surveyed facilities in Canada and the UK, only 63% of facilities in the USA reported using prophylactic antibiotics at the time of PD catheter insertion and between 82% and 89% of facilities across other countries.…”

“…Moreover, a significant proportion of fungal peritonitis episodes occur following a course of antibiotics [22]. Based on these observations coupled with the findings of two RCTs and a systematic review, the ISPD guidelines recommend antifungal prophylaxis with either oral nystatin or fluconazole when PD patients receive antibiotic courses (level 1B evidence) [9,14,23]. The particularly high uptake in ANZ may reflect ongoing continuous quality improvement initiatives, including a recent call to action in which the use of antifungal prophylaxis was strongly and locally endorsed [8,24,25].…”

“…ISPD guidelines (level 1B) recommend daily topical application of antibiotic (mupirocin or gentamicin) cream or ointment to the catheter exit site. This guideline was based on several studies demonstrating the beneficial effect of topical mupirocin in reducing the risk of Staphylococcus aureus and overall catheter infections and a reduction in the risk of peritonitis [14,29]. The recommendation for gentamicin was based on a single RCT comparing exit-site mupirocin versus gentamicin [30].…”

Early Onset Peritoneal Dialysis-Related Peritonitis

“…As the exposure duration and timing of peritonitis defined by these studies differ, the role of prophylactic systemic antibiotic administration on preventing EOP remains uncertain. Furthermore a recently published Cochrane Systematic Review of this topic [25] references only a single study out of 39 which provides low quality evidence for intravenous vancomycin in reducing the risk of early peritonitis. Thus, it can be seen that EOP-specific preventative factors have been poorly elucidated.…”