Vancomycin and Ciprofloxacin: Systemic Antibiotic Administration for Peritoneal Dialysis-Associated Peritonitis

Abstract

Objectives Peritonitis due to peritoneal dialysis (PD) is best treated empirically while waiting for the results of the dialysate culture. Thus, antibiotic therapy must cover both gram-positive and gram-negative micro-organisms. First, over a period of 9 years in a multicenter study we evaluated the efficiency of a vancomycin and ciprofloxacin combination given as the first-line treatment protocol for PD peritonitis. Second, we evaluated whether a systemic route of administration of the antibiotics could be an interesting alternative to the usual cumbersome intraperitoneal drug administration. Methods Vancomycin 15 mg/kg body weight, intravenous, and oral ciprofloxacin 250 mg two times per day (500 mg twice per day if residual creatinine clearance was above 3 mL/minute) were prescribed at diagnosis of peritonitis. Vancomycin injections were repeated (when blood trough level was expected to be below 12 μg/mL) in cases of gram-positive organisms for a total duration of 3 weeks. Ciprofloxacin was given for a total of 3 weeks in cases of gram-negative and a total of 10 days for susceptible gram-positive infections. Results A total of 129 episodes of peritonitis occurred; 28 of them were not included in the study because of protocol violation ( n = 15) or fungal ( n = 7) or fecal ( n = 6) peritonitis, leaving 101 peritonitis episodes for analysis. 52 (51.5%) gram-positive and 28 (27.7%) gram-negative organisms were grown; 38 gram-positive organisms were coagulase-negative staphylococci. No organism was identified in 8 peritonitis episodes, whereas 13 peritonitis episodes were caused by more than 1 organism. 35% of the coagulase-negative staphylococci were resistant to first-generation cephalosporin and methicillin, whereas all were susceptible to vancomycin. For gram-negative bacilli, the susceptibility rate was 96% and 95% for ciprofloxacin and ceftazidime respectively. The overall treatment success rate was 77.2% (78 of the 101 peritonitis episodes): 61.4% at first intention and 15.8% after optimization of the antibiotic therapy (second intention). The protocol failed in 22.8% of the peritonitis episodes. Hospitalization was required in 52% of the peritonitis episodes; average hospitalization was 11 (range 1 – 45) days. Conclusion Systemic vancomycin and ciprofloxacin administration is a simple and efficient first-line protocol antibiotic therapy for PD peritonitis. In our opinion, vancomycin should still be used for gram-positive infections because of its high susceptibility rate compared with first-generation cephalosporins, providing a close monitoring of the local epidemiology. Oral ciprofloxacin provides satisfactory results in gram-negative infections, comparable to those obtained with intraperitoneal ceftazidime or aminoglycosides.

ISPD Peritonitis Recommendations: 2016 Update on Prevention and Treatment

“…Moreover, IP dosing avoids venipuncture and could be done by the patient at home after appropriate training. Although IV vancomycin is reasonably successful as empirical gram-positive coverage ( 237 ), previous studies have shown that IV vancomycin resulted in a significantly higher rate of primary treatment failure than IP administration ( 203 , 305 ). Intraperitoneal antibiotics should be added using sterile technique, such as placing povidone iodine, rubbing with alcohol 70% strip, or chlorhexidine on the medication port for 5 minutes prior to insertion of the needle through the port.…”

Efficacy of antibiotic therapy for peritoneal dialysis-associated peritonitis: a proportional meta-analysis

“…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 ).…”

Procedimientos en cirugía: Colocación percutánea del catéter de diálisis peritoneal

“…Se debe tener cuidado al examinar el líquido de drenaje por el catéter, el cual podrá ser turbio o incluso purulento, pero nunca intestinal. Se puede administrar una terapia empírica con vancomicina y ciprofloxacino [26], sin embargo idealmente se administrara una antibiótico-terapia dirigida mediante el cultivo [27], dicho tratamiento podrá administrarse IV o intraperitoneal [28], cabe recordar que el antibiótico intraperitoneal podrá causar una reacción inflamatoria en la capa mesotelial subdiafragmática condicionando un pobre funcionamiento si se considera la recolocación del catéter.…”