Intraperitoneal Vancomycin/Oral Pefloxacin versus Intraperitoneal Vancomycin/Gentamicin in the Treatment of Continuous Ambulatory Peritoneal Dialysis Peritonitis
Abstract:Sixty patients were enrolled In a prospective, randomized study to evaluate the efficacy of two different regl mens for the empirical treatment of continuous ambulatory peritoneal dialysis (CAPD) peritonitis. At presentation, Group I received Intraperitoneal vancomycin (1 g) and oral pefioxacin (400 mg b.l.d.), and Group II Intraperitoneal vancomycin (1 g) and gentamicin (80 mg loading dose, followed by 15 mg/2 L). Treatment duration was 14 days. Despite randomization, Group I had significantly more patients w… Show more
“…This resolution rate was significant higher than initial treatment with a first generation cephalosporin plus aminoglycosides (pooled proportion of 66%, 95% CI 0.57–0.75) from 14 included studies [ 57 , 61 , 64 – 75 ] with 1,438 total episodes (Figure 3 ). Initial treatment with ceftazidime plus a glycopeptide also showed a higher resolution rate than a glycopeptide plus aminoglycosides (pooled proportion of 75%, 95% CI 0.69–0.80) that were used in 16 included studies [ 55 , 66 – 68 , 75 – 86 ] with 574 episodes (Figure 4 ). Figure 3 Combined resolution rate with 95% CIs of studies of initial treatment with ceftazidime plus a glycopeptide versus a first generation cephalosporin plus an aminoglycoside.…”
Section: Resultsmentioning
confidence: 99%
“…For treatment of episodes due to Gram-positive rods, the pooled resolution rate from 13 studies [ 54 , 55 , 62 , 76 , 84 , 85 , 87 – 93 ] with 917 episodes was 78% (95% CI 0.66–0.88) for a glycopeptide, while from five studies [ 57 , 74 , 88 , 93 , 94 ] with 532 episodes for a first generation cephalosporin it was 73% (95% CI 0.55–0.88). There was no significant difference between the schemes.…”
Section: Resultsmentioning
confidence: 99%
“…The pooled proportion resolution rate from nine studies [ 55 , 76 , 85 , 92 , 95 – 98 ] with 138 episodes was 68% (95% CI 0.50–0.85) for a quinolone (Figure 5 ). For ceftazidime, the resolution rate was 61% (95% CI 0.53–0.70) from three studies [ 68 , 56 , 98 ] with 117 episodes (Figure 6 ), and for aminoglycosides it was 65% (95% CI 0.51–0.77) from nine studies [ 55 , 57 , 62 , 68 , 76 , 85 , 90 , 97 , 98 ] with 211 episodes (Figure 7 ). There were no significant differences among the three drugs because their CIs overlapped.…”
BackgroundThe choice of antimicrobials for initial treatment of peritoneal dialysis (PD)-related peritonitis is crucial for a favorable outcome. There is no consensus about the best therapy; few prospective controlled studies have been published, and the only published systematic reviews did not report superiority of any class of antimicrobials. The objective of this review was to analyze the results of PD peritonitis treatment in adult patients by employing a new methodology, the proportional meta-analysis.MethodsA review of the literature was conducted. There was no language restriction. Studies were obtained from MEDLINE, EMBASE, and LILACS. The inclusion criteria were: (a) case series and RCTs with the number of reported patients in each study greater than five, (b) use of any antibiotic therapy for initial treatment (e.g., cefazolin plus gentamicin or vancomycin plus gentamicin), for Gram-positive (e.g., vancomycin or a first generation cephalosporin), or for Gram-negative rods (e.g., gentamicin, ceftazidime, and fluoroquinolone), (c) patients with PD-related peritonitis, and (d) studies specifying the rates of resolution. A proportional meta-analysis was performed on outcomes using a random-effects model, and the pooled resolution rates were calculated.ResultsA total of 64 studies (32 for initial treatment and negative culture, 28 reporting treatment for Gram-positive rods and 24 reporting treatment for Gram-negative rods) and 21 RCTs met all inclusion criteria (14 for initial treatment and negative culture, 8 reporting treatment for Gram-positive rods and 8 reporting treatment for Gram-negative rods). The pooled resolution rate of ceftazidime plus glycopeptide as initial treatment (pooled proportion = 86% [95% CI 0.82–0.89]) was significantly higher than first generation cephalosporin plus aminoglycosides (pooled proportion = 66% [95% CI 0.57–0.75]) and significantly higher than glycopeptides plus aminoglycosides (pooled proportion = 75% [95% CI 0.69–0.80]. Other comparisons of regimens used for either initial treatment, treatment for Gram-positive rods or Gram-negative rods did not show statistically significant differences.ConclusionWe showed that the association of a glycopeptide plus ceftazidime is superior to other regimens for initial treatment of PD peritonitis. This result should be carefully analyzed and does not exclude the necessity of monitoring the local microbiologic profile in each dialysis center to choice the initial therapeutic protocol.Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2334-14-445) contains supplementary material, which is available to authorized users.
“…This resolution rate was significant higher than initial treatment with a first generation cephalosporin plus aminoglycosides (pooled proportion of 66%, 95% CI 0.57–0.75) from 14 included studies [ 57 , 61 , 64 – 75 ] with 1,438 total episodes (Figure 3 ). Initial treatment with ceftazidime plus a glycopeptide also showed a higher resolution rate than a glycopeptide plus aminoglycosides (pooled proportion of 75%, 95% CI 0.69–0.80) that were used in 16 included studies [ 55 , 66 – 68 , 75 – 86 ] with 574 episodes (Figure 4 ). Figure 3 Combined resolution rate with 95% CIs of studies of initial treatment with ceftazidime plus a glycopeptide versus a first generation cephalosporin plus an aminoglycoside.…”
Section: Resultsmentioning
confidence: 99%
“…For treatment of episodes due to Gram-positive rods, the pooled resolution rate from 13 studies [ 54 , 55 , 62 , 76 , 84 , 85 , 87 – 93 ] with 917 episodes was 78% (95% CI 0.66–0.88) for a glycopeptide, while from five studies [ 57 , 74 , 88 , 93 , 94 ] with 532 episodes for a first generation cephalosporin it was 73% (95% CI 0.55–0.88). There was no significant difference between the schemes.…”
Section: Resultsmentioning
confidence: 99%
“…The pooled proportion resolution rate from nine studies [ 55 , 76 , 85 , 92 , 95 – 98 ] with 138 episodes was 68% (95% CI 0.50–0.85) for a quinolone (Figure 5 ). For ceftazidime, the resolution rate was 61% (95% CI 0.53–0.70) from three studies [ 68 , 56 , 98 ] with 117 episodes (Figure 6 ), and for aminoglycosides it was 65% (95% CI 0.51–0.77) from nine studies [ 55 , 57 , 62 , 68 , 76 , 85 , 90 , 97 , 98 ] with 211 episodes (Figure 7 ). There were no significant differences among the three drugs because their CIs overlapped.…”
BackgroundThe choice of antimicrobials for initial treatment of peritoneal dialysis (PD)-related peritonitis is crucial for a favorable outcome. There is no consensus about the best therapy; few prospective controlled studies have been published, and the only published systematic reviews did not report superiority of any class of antimicrobials. The objective of this review was to analyze the results of PD peritonitis treatment in adult patients by employing a new methodology, the proportional meta-analysis.MethodsA review of the literature was conducted. There was no language restriction. Studies were obtained from MEDLINE, EMBASE, and LILACS. The inclusion criteria were: (a) case series and RCTs with the number of reported patients in each study greater than five, (b) use of any antibiotic therapy for initial treatment (e.g., cefazolin plus gentamicin or vancomycin plus gentamicin), for Gram-positive (e.g., vancomycin or a first generation cephalosporin), or for Gram-negative rods (e.g., gentamicin, ceftazidime, and fluoroquinolone), (c) patients with PD-related peritonitis, and (d) studies specifying the rates of resolution. A proportional meta-analysis was performed on outcomes using a random-effects model, and the pooled resolution rates were calculated.ResultsA total of 64 studies (32 for initial treatment and negative culture, 28 reporting treatment for Gram-positive rods and 24 reporting treatment for Gram-negative rods) and 21 RCTs met all inclusion criteria (14 for initial treatment and negative culture, 8 reporting treatment for Gram-positive rods and 8 reporting treatment for Gram-negative rods). The pooled resolution rate of ceftazidime plus glycopeptide as initial treatment (pooled proportion = 86% [95% CI 0.82–0.89]) was significantly higher than first generation cephalosporin plus aminoglycosides (pooled proportion = 66% [95% CI 0.57–0.75]) and significantly higher than glycopeptides plus aminoglycosides (pooled proportion = 75% [95% CI 0.69–0.80]. Other comparisons of regimens used for either initial treatment, treatment for Gram-positive rods or Gram-negative rods did not show statistically significant differences.ConclusionWe showed that the association of a glycopeptide plus ceftazidime is superior to other regimens for initial treatment of PD peritonitis. This result should be carefully analyzed and does not exclude the necessity of monitoring the local microbiologic profile in each dialysis center to choice the initial therapeutic protocol.Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2334-14-445) contains supplementary material, which is available to authorized users.
“…There is now ample experience in the use of quinolones for the treatment of PD-related peritonitis. Ciprofloxacin has been reported on most frequently (9-14,18,20-25) but other related drugs, including ofloxacin, levofloxacin, and pefloxacin, have also been used in this setting (15-17). Quinolones have been used alone and in association with other antimicrobials, and both oral and IP routes have been employed successfully.…”
Background There is controversy about the preferred initial antibiotic therapy for peritoneal dialysis (PD)-related peritonitis. Quinolones have been used extensively in this setting, yet their long-term effectiveness is unknown. Aim To analyze the results of a protocol of treatment of PD-related peritonitis with ciprofloxacin, maintained over two decades. Method We analyzed the clinical outcome of 682 episodes of bacterial peritonitis treated with intraperitoneal ciprofloxacin monotherapy, and the time course of bacterial susceptibility to this antimicrobial, in a historical cohort of 641 PD patients (1988-2007). Main outcome variables included changes to initial therapy and rates of hospital admission, catheter removal, relapse, reinfection, PD dropout, and mortality. For comparisons we divided the study period into phases A (1988-1994), B (1995-2000), and C (2001-2007). Results The incidence of Staphylococcus aureus peritonitis decreased, while the incidences of polymicrobial and negative-culture peritonitis increased after phase A. In vitro susceptibility to ciprofloxacin decreased significantly only among coagulase-negative staphylococci (87.0% susceptible strains in phase A vs 70.0% in B and 70.1% in C, p = 0.006). Overall success rates (catheter not removed and ongoing PD after the episode) remained stable, at over 85%. However, the proportion of patients treated solely with ciprofloxacin declined from 75.7% (A) to 47.3% (B) to 32.4% (C) ( p < 0.0005) and admission rates increased from 12.7% to 16.8% to 24.9% respectively ( p = 0.001). These changes affected all the etiologic groups except culture-negative peritonitis. In vitro resistance to ciprofloxacin was a marker of multiresistance and correlated strongly with clinical outcome of peritonitis. Among isolates susceptible to ciprofloxacin, changing initial therapy for any reason also predicted a poor outcome. Conclusions Following satisfactory early results, the effectiveness of ciprofloxacin as monotherapy for PD-related peritonitis has declined markedly in the long term. This decline cannot be explained solely by a decrease of in vitro susceptibility to this antimicrobial, which was significant only among coagulase-negative staphylococci. Resistance to ciprofloxacin is a strong marker of in vitro multiresistance and poor clinical outcome of peritonitis.
“…Lye et al . compared different dosing regimens of gentamicin with vancomycin and found similar outcomes in six culture negative patients (4/6 primary cures) 6 . Merchant et al .…”
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