Nine episodes of CPD-associated peritonitis with vancomycin resistant enterococci

Abstract

Nine episodes of chronic peritoneal dialysis (CPD)-associated peritonitis with vancomycin resistant enterococci (VRE) were described between November 1993 and February 1996 in our dialysis unit. During the time period, 216 patients were treated for 227 episodes of peritonitis. Of the patients developing peritonitis with VRE the mean age +/- SD was 56.3 +/- 9.7 years. There were 5 females, 4 males, 5 Caucasians and 4 African-Americans. Diabetes mellitus, cardiovascular disease and gastrointestinal disease were present in 7, 8 and 7 of the 9 patients with VRE peritonitis, respectively. Patients were maintained on CPD therapy for an average of 29.9 +/- 19.2 patient months before developing VRE peritonitis. The prior rate of CPD associated peritonitis in the patients developing VRE peritonitis was significantly higher than the rate noted in the CPD patients not developing peritonitis with VRE (1 episode in 6.3 patient months vs. 1 episode in 12.5 patient months, P < 0.05). All 9 patients had used vancomycin in the six months prior to the development of VRE peritonitis and 78% had used a cephalosporin. The antimicrobial therapy used to eradicate peritonitis with VRE varied among the 9 patients with chloramphenicol used in 4 patients. The Tenckhoff catheter was removed in 6 of the 9 patients and was successfully reinserted in one patient. The catheter was not removed in 3 patients and 2 of these patients expired. Five of the 9 patients expired while being treated for VRE, 2 transferred to hemodialysis and 2 continued CPD therapy. VRE peritonitis is a major concern for patients maintained on CPD therapy. Future studies are needed with case controls to determine the significance of prior vancomycin and cephalosporin therapy, fecal VRE carriage and certain demographic data on the acquisition of VRE peritonitis. Furthermore, the optimal therapy and outcome may be better clarified through such a review.

Enterococcal Peritonitis in Peritoneal Dialysis Patients: Last Name Matters

“…Glycopeptides-often as monotherapy-represent a common approach (16), but expansion of E. faecium and patterns of antibiotic resistance are becoming an important issue, undermining the traditional reliability of those agents. Peritonitis by VRE may not have the dismal prognosis observed in older reports (22), but resistant infection unquestionably complicates management and outcome. Linezolid and quinupristin-dalfopristin are the current recommendations to treat peritonitis involving ampicillin-resistant organisms and VRE (21).…”

Dialysis-associated peritonitis in children

“…Enterococcal peritonitis is often severe; the organisms are fecal in origin, which often suggests a transmural route of infection. The emergence of vancomycin-resistant organisms in this species has been associated with an increased risk for patient mortality [42, 43]. …”

“…The decision was also influenced by the superiority of this combination in a meta-analysis of studies performed in adults and it’s safety and efficacy profile in children [29, 89, 99–101]. The recommendation is, however, that glycopeptide usage be restricted to high-risk patients because of the fear of promoting vancomycin-resistant enterococci and the potential emergence of glycopeptide-resistant staphylococci [42, 43, 102–104]. Finally, the choice of ceftazidime over aminoglycosides was influenced by the potential for a high cumulative exposure to the latter, with possible resultant ototoxicity and nephrotoxicity [105].…”

Consensus Guidelines for the Prevention and Treatment of Catheter-Related Infections and Peritonitis in Pediatric Patients Receiving Peritoneal Dialysis: 2012 Update

“…Vancomycin-resistant enterococci have also been isolated in pediatric HD and PD patents (52). Although peritonitis with VRE is uncommon in stable patients receiving continuous ambulatory PD (CAPD), when it occurs, it has characteristically been associated with recent hospitalization and the use of antibiotics, mainly vancomycin, or with nosocomial infection (53)(54)(55). Surgical prophylaxis and routine prophylaxis for patients on chronic PD should therefore be acknowledged as situations in which vancomycin use is to be discouraged (50).…”