PDI
septEMBER 2014 – Vol. 34, No. 6
Short Reports
Our 12-month catheter survival of 79.2% was similar to that reported in the literature (7,12). More than 90% of all PD catheters in our unit are inserted by a nephrologist. CONCLUSIONS
DISCLOSURES
The authors have no competing financial interests to declare. Yeoungjee Cho Richard Baer John P. Killen Murty Mantha* Renal Unit Cairns Base Hospital Cairns, Australia *email: [email protected] REFERENCES 1. Lim WH, Boudville N, McDonald SP, Gorham G, Johnson DW, Jose M. Remote indigenous peritoneal dialysis patients have higher risk of peritonitis, technique failure, all-cause and peritonitis-related mortality. Nephrol Dial Transplant 2011; 26:3366–72. 2. Australian Bureau of Statistics (ABS). National Regional Profile 2007–2011 [Web resource]. Far North Queensland. Canberra, Australia: ABS; 2013. [Available at: http://www.ausstats.abs.gov.au/ausstats/nrpmaps.nsf/ NEW+GmapPages/national+regional+profile?opendocument (search for “Far north (SA3) [31501] (QLD)”); accessed 22 October 2013] 3. Asif A, Byers P, Gadalean F, Roth D. Peritoneal dialysis underutilization: the impact of an interventional nephrology peritoneal dialysis access program. Semin Dial 2003; 16:266–71. 4. Ash SR. Chronic peritoneal dialysis catheters: procedure for placement, maintenance and removal. Semin Nephrol 2002; 22:221–36. 5. Asif A, Tawakol J, Khan T, Vieira CF, Byers P, Gadalean F,
doi: 10.3747/pdi.2011.00261
Gastroscopy-Related Peritonitis in Peritoneal Dialysis Patients Peritonitis is associated with an increased risk of technique failure and mortality among peritoneal dialysis (PD) patients (1–3). Along with improved connectology and training methods, antibiotic prophylaxis given before high-risk procedures has probably contributed to an overall decline in peritonitis rates since the early 1990s. As recommended by the International Society of Peritoneal Dialysis (ISPD), most peritoneal dialysis units use prophylactic antibiotics for PD patients undergoing colonoscopy and dental procedures (4). In a retrospective
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667
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In indigenous patients with ESKD, a close-knit model of PD delivery, with components including nephrologistinserted catheters and integral involvement of PD nurses, can facilitate the provision of timely, safe, and efficient PD access, despite limitations of geographic remoteness. The incorporation of local health practitioners, indigenous allied health workers, and regular home visits by PD staff can also help to maintain therapy and prevent social dislocation.
et al. Modification of the peritoneoscopic technique of peritoneal dialysis catheter insertion: experience of an interventional nephrology program. Semin Dial 2004; 17:171–3. 6. Figueiredo A, Goh BL, Jenkins S, Johnson DW, Mactier R, Ramalakshmi S, et al. Clinical practice guidelines for peritoneal access. Perit Dial Int 2010; 30:424–9. 7. Li PK, Chow KM. Importance of peritoneal dialysis catheter insertion by nephrologists: practice makes perfect. Nephrol Dial Transplant 2009; 24:3274–6. 8. Henderson S, Brown E, Levy J. Safety and efficacy of percutaneous insertion of peritoneal dialysis catheter under sedation and local anesthesia. Nephrol Dial Transplant 2009; 24:3499–504. 9. Moon JY, Song S, Jung KH, Park M, Lee SH, Ihm CG, et al. Fluoroscopically guided peritoneal dialysis catheter placement: long-term results from a single center. Perit Dial Int 2008; 28:163–9. 10. Ash SR, Wolf GC, Block R. Placement of Tenckhoff peritoneal dialysis catheter under peritoneoscopic visualization. Dial Transplant 1981; 10:382–6. 11. Kelly J, McNamara K, May S. Peritoneoscopic peritoneal dialysis catheter insertion. Nephrology (Carlton) 2003; 8:315–17. 12. Gadallah MF, Pervez A, el-Shahawy MA, Sorrells D, Zibari G, McDonald J, et al. Peritoneoscopic versus surgical placement of peritoneal dialysis catheters: a prospective randomized study on outcome. Am J Kidney Dis 1999; 33:118–22. 13. Crabtree JH, Burchette RJ, Siddiqi NA. Optimal peritoneal dialysis catheter type and exit site location: an anthropometric analysis. ASAIO J 2005; 51:743–7. 14. Anderson K, Devitt J, Cunningham J, Preece C, Cass A. “All they said was my kidneys were dead”: indigenous Australian patients’ understanding of their chronic kidney disease. Med J Aust 2008; 189:499–503. 15. Wilson R, Krefting L, Sutcliffe P, Van Bussel L. Native Canadians relocating for renal dialysis. Psychosocial and cultural issues. Can Fam Physician 1994; 40:1934–41.
Short Reports
septEMBER 2014 – Vol. 34, No. 6
CASE 1
Our first patient was a 28-year-old man with chronic obstructive uropathy on continuous ambulatory PD for 9 years. One month after starting PD, he developed an episode of Citrobacter braakii peritonitis and was treated with intraperitoneal tobramycin and oral ciprofloxacin. The patient’s PD history was peritonitis-free for the subsequent 9 years, until an elective gastroscopy because of symptoms suggestive of gastroesophageal reflux. The gastroscopy showed high-grade esophagitis (Los Angeles class D), with esophageal ulcers. The following day, the patient reported abdominal pain, and the day after that, he presented to the hospital with cloudy effluent, nausea, and vomiting. An effluent white blood cell (WBC) count showed 1850 cells/mm3, with 86% neutrophils. The patient was started on vancomycin and tobramycin. An effluent culture was positive for Bacteroides fragilis. Despite antibiotic therapy and the addition of metronidazole, the effluent culture stayed positive for more than a week. No visceral or intestinal perforations were seen on abdominal computed tomography imaging. The patient remained highly symptomatic and had a complicated hospitalization. Peritoneal effluent cultures subsequently showed multiple bacteria, including Klebsiella pneumoniae, Morganella morganii, B. fragilis, Prevotella species, Clostridium clostridioforme, Cit. koseri, and Enterococcus faecium. The peritoneal catheter was removed, but the peritonitis persisted despite aggressive treatment. The patient died of ongoing complications 4 months after the gastroscopy. CASE 2
Our second patient was a 73-year-old man with a 3-year history of continuous ambulatory PD for chronic 668
glomerulopathy. He had experienced only 1 previous episode of culture-negative peritonitis treated with cefazolin 2 years after PD initiation. The patient was admitted for uremic encephalopathy secondary to nonadherence to dialysis therapy. Extended blood work and cultures, including effluent cultures at admission, all came back negative. Uremic symptoms improved with re-commencement of PD. However, 10 days after his admission, the patient developed upper gastrointestinal bleeding. He underwent a gastroscopy that revealed active bleeding from a large duodenal ulcer. Epinephrine was injected, and clips were placed. A second gastroscopy performed 2 days later observed no active bleeding. That day, the patient reported abdominal pain and cloudy effluent. An effluent WBC count was elevated at 2930 cells/ mm3, with 93% neutrophils, and an effluent culture was positive for Escherichia coli. The WBC count remained elevated for 6 days. The patient was treated empirically with tobramycin and cefazolin until receipt of the definitive culture results; the antibiotic course was completed with ciprofloxacin treatment for a total of 21 days. The patient was discharged home a few days after his peritonitis without any further complications. DISCUSSION
Our two cases of gastroscopy-related peritonitis occurred in patients who each had previously experienced only 1 peritonitis episode in PD durations of 9 and 4 years. Within 2 days of the gastroscopy, both presented with classical symptoms of bacterial peritonitis, an elevated WBC count, and a positive peritoneal effluent culture. The short delay between the procedure and the complication—together with the low previous peritonitis rate—suggests, but does not confirm, causality. In the gastroscopy literature, cirrhotic patients with active bleeding are known to be at higher risk of infection (mostly bacteremia and spontaneous bacterial peritonitis). Antibiotic prophylaxis given in this group before gastroscopy has been associated with a lower risk of subsequent infection (11,12). Although gastroscopy is usually a low-risk intervention, PD patients could be vulnerable to the same peritonitis risk as cirrhotic patients because of the presence of fluid in the peritoneal cavity in both conditions. Higher rates of infection have also been associated with specific endoscopic interventions, including treatment of esophageal varices, endoscopic retrograde cholangiopancreatography, and percutaneous endoscopic gastrostomy (13,14). Bacterial translocation with transient bacteremia and mucosal microperforation with bacterial migration
This single copy is for your personal, non-commercial use only. For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact Multimed Inc. at [email protected]
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study by Yip et al., PD patients undergoing a colonoscopy without any antibiotic prophylaxis had a 6.3% risk of developing peritonitis subsequent to the procedure; no episodes of peritonitis occurred in the group receiving antibiotic prophylaxis (5). Many case reports also highlight the added peritonitis risk for PD patients under going colonoscopy (6–8). Although prophylaxis is widely accepted before colonoscopy, little is known about the gastroscopyinduced peritonitis risk in patients on PD. No recommendation has been made by the ISPD, and to our knowledge, only 2 cases have previously been reported in the literature (9,10). In this report, we describe another 2 gastroscopy-related cases and discuss further the implications of this complication.
PDI
PDI
septEMBER 2014 – Vol. 34, No. 6
CONCLUSIONS
Although no definitive conclusions can be drawn from these few cases of gastroscopy-related peritonitis, they highlight the need to reassess the infectious risk associated with gastroscopy in PD patients. Knowing the significant adverse outcomes associated with a peritonitis episode in these patients, antibiotic prophylaxis should be contemplated in PD patients undergoing upper endoscopy. It might also be prudent for the patient to be drained of dialysis fluid. The next generation of infection prevention and management guidelines from
bodies such as the ISPD should consider expanding their recommendations for antibiotic prophylaxis to include gastroscopy. ACKNOWLEDGMENT ACNF holds a UHN–Baxter Home Dialysis Fellowship. DISCLOSURES
ACNF has no disclosures. JMB has been a consultant for Amgen and Baxter Healthcare, and is in the speakers’ bureau for Amgen and DaVita Healthcare Partners. Annie-Claire Nadeau–Fredette Joanne M. Bargman* Division of Nephrology University Health Network Toronto, Ontario, Canada *email: [email protected] REFERENCES 1. Fried LF, Bernardini J, Johnston JR, Piraino B. Peritonitis influences mortality in peritoneal dialysis patients. J Am Soc Nephrol 1996; 7:2176–82. 2. Boudville N, Kemp A, Clayton P, Lim W, Badve SV, Hawley CM, et al. Recent peritonitis associates with mortality among patients treated with peritoneal dialysis. J Am Soc Nephrol 2012; 23:1398–405. 3. Perl J, Wald R, Bargman JM, Na Y, Jassal SV, Jain AK, et al. Changes in patient and technique survival over time among incident peritoneal dialysis patients in Canada. Clin J Am Soc Nephrol 2012; 7:1145–54. 4. Piraino B, Bernardini J, Brown E, Figueiredo A, Johnson DW, Lye WC, et al. ISPD position statement on reducing the risks of peritoneal dialysis–related infections. Perit Dial Int 2011; 31:614–30. 5. Yip T, Tse KC, Lam MF, Cheng SW, Lui SL, Tang S, et al. Risks and outcomes of peritonitis after flexible colonoscopy in CAPD patients. Perit Dial Int 2007; 27:560–4. 6. Poortvliet W, Selten HP, Raasveld MH, Klemt–Kropp M. CAPD peritonitis after colonoscopy: follow the guidelines. Neth J Med 2010; 68:377–8. 7. Ray SM, Piraino B, Holley J. Peritonitis following colonoscopy in a peritoneal dialysis patient. Perit Dial Int 1990; 10:97–8. 8. Lin YC, Lin WP, Huang JY, Lee SY. Polymicrobial peritonitis following colonoscopic polypectomy in a peritoneal dialysis patient. Intern Med 2012; 51:1841–3. 9. Machuca E, Ortiz AM, Rabagliati R. Streptococcus viridans– associated peritonitis after gastroscopy. Adv Perit Dial 2005; 21:60–2.
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can both lead to peritonitis. Specific interventions aimed at controlling active bleeding could also increase the risk of peritonitis in dialysis patients. One of our patients underwent an endoscopic intervention with epinephrine injection and clip insertion during his first gastroscopy. An intervention was also performed for one of the two cases of gastroscopy-related peritonitis in the literature. As reported by Machuca et al. (9), a 69-year-old patient on automated PD underwent an emergency gastroscopy for occult gastrointestinal bleeding associated with syncope. Epinephrine injection and heat-probe coagulation were performed to control an actively bleeding duodenal ulcer, and a Streptococcus viridans peritonitis became clinically apparent on the subsequent day. On the other hand, no specific intervention was performed during the endoscopic procedure in our first patient. Another patient reported by Morimoto et al. (10) also underwent a simple gastroscopy without any intervention. This 49-year-old woman on PD had an episode of Ent. faecalis peritonitis 7 days after a gastroscopy. Her case differs from those of our two patients and the other reported case, because the woman was known to have repetitive peritonitis episodes related to gynecologic examinations. The 7-day peritonitis delay after that gastroscopy is also longer than the delay in the other cases. Interestingly, considering our two cases and the two previously reported ones, gram-positive and gramnegative organisms have both been associated with upper endoscopy. Our first patient initially presented with B. fragilis, an obligatory anaerobic bacteria more specific to gut; the patient reported by Machuca et al. developed a S. viridans peritonitis, a bacterium frequently associated with mouth flora. If antibiotic prophylaxis were to be given to PD patients before gastroscopy, it should probably resemble the protocols used with colonoscopy as recommended by ISPD guidelines: ampicillin, plus a single dose of aminoglycoside, with or without metronidazole (4). Ampicillin would be effective prophylaxis for both oral and enteric bacteria.
Short Reports
Short Reports
septEMBER 2014 – Vol. 34, No. 6
doi: 10.3747/pdi.2012.00340
A Preliminary Report on the Effectiveness of Nanotechnology Anti-Microbial Spray Dressing in Preventing Tenckhoff Catheter Exit-Site Infection For most patients receiving peritoneal dialysis (PD), there is evidence showing that their satisfaction and quality of life have been increasing (1). However, the Tenckhoff catheter (TC) can become a potential source of infection and peritonitis. If exit-site infection (ESI) is not well managed it can lead to peritonitis or require removal of the TC (2). Peritonitis is a well-known cause of mortality in PD patients (3). Consequently, suspending treatment due to access failure may affect patients’ overall health status. The purpose of routine care of the exit site is to prevent ESI. There is a large volume of information focused on the prevention of ESI, with different approaches being proposed. The practice guidelines and protocols from institutions are varied and have not been adequately evaluated, although large volumes of data have been published on the prevention of ESI (4). Several recent trial studies show that the application of JUC Physical Antimicrobial Spray Dressing (NMS Technologies Company Limited, Nanjing, Jiangsu Province, China), has proven to be effective in the prevention of lower urinary tract infection where the spray was applied on the surface of the catheter and the urethral orifice (5,6), treatment of post-operative infection for oral cancer (7), open wound treatment in 670
emergency clinics (8), and managing radiation-induced acute skin reactions (9). It is also an alternative to antibiotic treatment on wound management for patients with methicillin-resistant Staphylococcus aureus (MRSA) infection (10). JUC spray dressing was developed in China in 2002 and registered as a dressing product by the United States Food and Drug Administration in 2006. The spray consists of 2% organosilicon quaternary ammonium salt and 98% distilled water, and is safe for application, even for contact with eyes and mucous membranes. It is composed using nano-manufacture technology, yet the antibacterial mechanism is not fully understood. Some proposed mechanisms relate to the physical structure of the nanoparticles while others relate to the enhanced release of antibacterial metal ions from nanoparticle surfaces which interact with and penetrate into the bacteria (11). Proper exit-site care is of paramount importance in reducing TC-associated infection and subsequent catheter loss. In current practice, patients who have a TC are usually advised to use the traditional antiseptic 0.05% chlorhexidine in exit-site care. Previous studies suggest that 0.05% chlorhexidine is able to reduce the bacterial load in the wound and promotes cell growth (12). In this study, JUC spray was applied to the TC exit site to compare the incidence of ESI with the usual standard care. In addition to ESI, the existence of skin allergy, catheter damage, and time spent on exit-site dressing were examined. METHODS
The study was carried out through a randomized controlled trial. Patients were recruited from the renal unit of a 1,700-bed acute-care, general regional hospital in Hong Kong. Those patients who did not receive oral or external antibiotics and who had a TC in place for at least 3 months were recruited sequentially. Patients presenting with signs and symptoms of exit-site infection and poor healing of exit site were excluded. There were 121 patients assessed for eligibility and 47 subjects were excluded. The reasons for exclusion were patients not meeting the inclusion criteria or refusing to participate. To compute the sample size, we referred to Li et al. (10) on the effectiveness of JUC spray to prevent ventilatorassociated pneumonia. To have 80% power, α = 0.05, to detect a 27.9% reduction in the incidence of bacterial colonization in the pharyngeal cavity in the experimental group compared with the control group, a sample size of 35 subjects for each group was required. The catheter was inserted surgically by open surgical incision. It was well secured with a dressing and PD was started 4 weeks
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10. Morimoto S, Kido E, Higashi M, Sumitani N, Takagishi H, Kakimoto S, et al. Peritonitis after gynecological and gastroscopic examinations in a peritoneal dialysis patient. Clin Nephrol 2010; 74:491–2. 11. Fernandez J, Navasa M, Gomez J, Colmenero J, Vila J, Arroyo V, et al. Bacterial infections in cirrhosis: epidemiological changes with invasive procedures and norfloxacin prophylaxis. Hepatology 2002; 35:140–8. 12. Bernard B, Grange JD, Khac EN, Amiot X, Opolon P, Poynard T. Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: a meta-analysis. Hepatology 1999; 29:1655–61. 13. Banerjee S, Shen B, Baron TH, Nelson DB, Anderson MA, Cash BD, et al. on behalf of the ASGE Standards of Practice Committee. Antibiotic prophylaxis for GI endoscopy. Gastrointest Endosc 2008; 67:791–8. 14. von Schnakenburg C, Feneberg R, Plank C, Zimmering M, Arbeiter K, Bald M, et al. Percutaneous endoscopic gastrostomy in children on peritoneal dialysis. Perit Dial Int 2006; 26:69–77.
PDI
septEMBER 2014 – Vol. 34, No. 6
Short Reports
Our 12-month catheter survival of 79.2% was similar to that reported in the literature (7,12). More than 90% of all PD catheters in our unit are inserted by a nephrologist. CONCLUSIONS
DISCLOSURES
The authors have no competing financial interests to declare. Yeoungjee Cho Richard Baer John P. Killen Murty Mantha* Renal Unit Cairns Base Hospital Cairns, Australia *email: [email protected] REFERENCES 1. Lim WH, Boudville N, McDonald SP, Gorham G, Johnson DW, Jose M. Remote indigenous peritoneal dialysis patients have higher risk of peritonitis, technique failure, all-cause and peritonitis-related mortality. Nephrol Dial Transplant 2011; 26:3366–72. 2. Australian Bureau of Statistics (ABS). National Regional Profile 2007–2011 [Web resource]. Far North Queensland. Canberra, Australia: ABS; 2013. [Available at: http://www.ausstats.abs.gov.au/ausstats/nrpmaps.nsf/ NEW+GmapPages/national+regional+profile?opendocument (search for “Far north (SA3) [31501] (QLD)”); accessed 22 October 2013] 3. Asif A, Byers P, Gadalean F, Roth D. Peritoneal dialysis underutilization: the impact of an interventional nephrology peritoneal dialysis access program. Semin Dial 2003; 16:266–71. 4. Ash SR. Chronic peritoneal dialysis catheters: procedure for placement, maintenance and removal. Semin Nephrol 2002; 22:221–36. 5. Asif A, Tawakol J, Khan T, Vieira CF, Byers P, Gadalean F,
doi: 10.3747/pdi.2011.00261
Gastroscopy-Related Peritonitis in Peritoneal Dialysis Patients Peritonitis is associated with an increased risk of technique failure and mortality among peritoneal dialysis (PD) patients (1–3). Along with improved connectology and training methods, antibiotic prophylaxis given before high-risk procedures has probably contributed to an overall decline in peritonitis rates since the early 1990s. As recommended by the International Society of Peritoneal Dialysis (ISPD), most peritoneal dialysis units use prophylactic antibiotics for PD patients undergoing colonoscopy and dental procedures (4). In a retrospective
This single copy is for your personal, non-commercial use only. For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact Multimed Inc. at [email protected]
667
Downloaded from http://www.pdiconnect.com/ at Universite Laval on November 25, 2015
In indigenous patients with ESKD, a close-knit model of PD delivery, with components including nephrologistinserted catheters and integral involvement of PD nurses, can facilitate the provision of timely, safe, and efficient PD access, despite limitations of geographic remoteness. The incorporation of local health practitioners, indigenous allied health workers, and regular home visits by PD staff can also help to maintain therapy and prevent social dislocation.
et al. Modification of the peritoneoscopic technique of peritoneal dialysis catheter insertion: experience of an interventional nephrology program. Semin Dial 2004; 17:171–3. 6. Figueiredo A, Goh BL, Jenkins S, Johnson DW, Mactier R, Ramalakshmi S, et al. Clinical practice guidelines for peritoneal access. Perit Dial Int 2010; 30:424–9. 7. Li PK, Chow KM. Importance of peritoneal dialysis catheter insertion by nephrologists: practice makes perfect. Nephrol Dial Transplant 2009; 24:3274–6. 8. Henderson S, Brown E, Levy J. Safety and efficacy of percutaneous insertion of peritoneal dialysis catheter under sedation and local anesthesia. Nephrol Dial Transplant 2009; 24:3499–504. 9. Moon JY, Song S, Jung KH, Park M, Lee SH, Ihm CG, et al. Fluoroscopically guided peritoneal dialysis catheter placement: long-term results from a single center. Perit Dial Int 2008; 28:163–9. 10. Ash SR, Wolf GC, Block R. Placement of Tenckhoff peritoneal dialysis catheter under peritoneoscopic visualization. Dial Transplant 1981; 10:382–6. 11. Kelly J, McNamara K, May S. Peritoneoscopic peritoneal dialysis catheter insertion. Nephrology (Carlton) 2003; 8:315–17. 12. Gadallah MF, Pervez A, el-Shahawy MA, Sorrells D, Zibari G, McDonald J, et al. Peritoneoscopic versus surgical placement of peritoneal dialysis catheters: a prospective randomized study on outcome. Am J Kidney Dis 1999; 33:118–22. 13. Crabtree JH, Burchette RJ, Siddiqi NA. Optimal peritoneal dialysis catheter type and exit site location: an anthropometric analysis. ASAIO J 2005; 51:743–7. 14. Anderson K, Devitt J, Cunningham J, Preece C, Cass A. “All they said was my kidneys were dead”: indigenous Australian patients’ understanding of their chronic kidney disease. Med J Aust 2008; 189:499–503. 15. Wilson R, Krefting L, Sutcliffe P, Van Bussel L. Native Canadians relocating for renal dialysis. Psychosocial and cultural issues. Can Fam Physician 1994; 40:1934–41.
Short Reports
septEMBER 2014 – Vol. 34, No. 6
CASE 1
Our first patient was a 28-year-old man with chronic obstructive uropathy on continuous ambulatory PD for 9 years. One month after starting PD, he developed an episode of Citrobacter braakii peritonitis and was treated with intraperitoneal tobramycin and oral ciprofloxacin. The patient’s PD history was peritonitis-free for the subsequent 9 years, until an elective gastroscopy because of symptoms suggestive of gastroesophageal reflux. The gastroscopy showed high-grade esophagitis (Los Angeles class D), with esophageal ulcers. The following day, the patient reported abdominal pain, and the day after that, he presented to the hospital with cloudy effluent, nausea, and vomiting. An effluent white blood cell (WBC) count showed 1850 cells/mm3, with 86% neutrophils. The patient was started on vancomycin and tobramycin. An effluent culture was positive for Bacteroides fragilis. Despite antibiotic therapy and the addition of metronidazole, the effluent culture stayed positive for more than a week. No visceral or intestinal perforations were seen on abdominal computed tomography imaging. The patient remained highly symptomatic and had a complicated hospitalization. Peritoneal effluent cultures subsequently showed multiple bacteria, including Klebsiella pneumoniae, Morganella morganii, B. fragilis, Prevotella species, Clostridium clostridioforme, Cit. koseri, and Enterococcus faecium. The peritoneal catheter was removed, but the peritonitis persisted despite aggressive treatment. The patient died of ongoing complications 4 months after the gastroscopy. CASE 2
Our second patient was a 73-year-old man with a 3-year history of continuous ambulatory PD for chronic 668
glomerulopathy. He had experienced only 1 previous episode of culture-negative peritonitis treated with cefazolin 2 years after PD initiation. The patient was admitted for uremic encephalopathy secondary to nonadherence to dialysis therapy. Extended blood work and cultures, including effluent cultures at admission, all came back negative. Uremic symptoms improved with re-commencement of PD. However, 10 days after his admission, the patient developed upper gastrointestinal bleeding. He underwent a gastroscopy that revealed active bleeding from a large duodenal ulcer. Epinephrine was injected, and clips were placed. A second gastroscopy performed 2 days later observed no active bleeding. That day, the patient reported abdominal pain and cloudy effluent. An effluent WBC count was elevated at 2930 cells/ mm3, with 93% neutrophils, and an effluent culture was positive for Escherichia coli. The WBC count remained elevated for 6 days. The patient was treated empirically with tobramycin and cefazolin until receipt of the definitive culture results; the antibiotic course was completed with ciprofloxacin treatment for a total of 21 days. The patient was discharged home a few days after his peritonitis without any further complications. DISCUSSION
Our two cases of gastroscopy-related peritonitis occurred in patients who each had previously experienced only 1 peritonitis episode in PD durations of 9 and 4 years. Within 2 days of the gastroscopy, both presented with classical symptoms of bacterial peritonitis, an elevated WBC count, and a positive peritoneal effluent culture. The short delay between the procedure and the complication—together with the low previous peritonitis rate—suggests, but does not confirm, causality. In the gastroscopy literature, cirrhotic patients with active bleeding are known to be at higher risk of infection (mostly bacteremia and spontaneous bacterial peritonitis). Antibiotic prophylaxis given in this group before gastroscopy has been associated with a lower risk of subsequent infection (11,12). Although gastroscopy is usually a low-risk intervention, PD patients could be vulnerable to the same peritonitis risk as cirrhotic patients because of the presence of fluid in the peritoneal cavity in both conditions. Higher rates of infection have also been associated with specific endoscopic interventions, including treatment of esophageal varices, endoscopic retrograde cholangiopancreatography, and percutaneous endoscopic gastrostomy (13,14). Bacterial translocation with transient bacteremia and mucosal microperforation with bacterial migration
This single copy is for your personal, non-commercial use only. For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact Multimed Inc. at [email protected]
Downloaded from http://www.pdiconnect.com/ at Universite Laval on November 25, 2015
study by Yip et al., PD patients undergoing a colonoscopy without any antibiotic prophylaxis had a 6.3% risk of developing peritonitis subsequent to the procedure; no episodes of peritonitis occurred in the group receiving antibiotic prophylaxis (5). Many case reports also highlight the added peritonitis risk for PD patients under going colonoscopy (6–8). Although prophylaxis is widely accepted before colonoscopy, little is known about the gastroscopyinduced peritonitis risk in patients on PD. No recommendation has been made by the ISPD, and to our knowledge, only 2 cases have previously been reported in the literature (9,10). In this report, we describe another 2 gastroscopy-related cases and discuss further the implications of this complication.
PDI
PDI
septEMBER 2014 – Vol. 34, No. 6
CONCLUSIONS
Although no definitive conclusions can be drawn from these few cases of gastroscopy-related peritonitis, they highlight the need to reassess the infectious risk associated with gastroscopy in PD patients. Knowing the significant adverse outcomes associated with a peritonitis episode in these patients, antibiotic prophylaxis should be contemplated in PD patients undergoing upper endoscopy. It might also be prudent for the patient to be drained of dialysis fluid. The next generation of infection prevention and management guidelines from
bodies such as the ISPD should consider expanding their recommendations for antibiotic prophylaxis to include gastroscopy. ACKNOWLEDGMENT ACNF holds a UHN–Baxter Home Dialysis Fellowship. DISCLOSURES
ACNF has no disclosures. JMB has been a consultant for Amgen and Baxter Healthcare, and is in the speakers’ bureau for Amgen and DaVita Healthcare Partners. Annie-Claire Nadeau–Fredette Joanne M. Bargman* Division of Nephrology University Health Network Toronto, Ontario, Canada *email: [email protected] REFERENCES 1. Fried LF, Bernardini J, Johnston JR, Piraino B. Peritonitis influences mortality in peritoneal dialysis patients. J Am Soc Nephrol 1996; 7:2176–82. 2. Boudville N, Kemp A, Clayton P, Lim W, Badve SV, Hawley CM, et al. Recent peritonitis associates with mortality among patients treated with peritoneal dialysis. J Am Soc Nephrol 2012; 23:1398–405. 3. Perl J, Wald R, Bargman JM, Na Y, Jassal SV, Jain AK, et al. Changes in patient and technique survival over time among incident peritoneal dialysis patients in Canada. Clin J Am Soc Nephrol 2012; 7:1145–54. 4. Piraino B, Bernardini J, Brown E, Figueiredo A, Johnson DW, Lye WC, et al. ISPD position statement on reducing the risks of peritoneal dialysis–related infections. Perit Dial Int 2011; 31:614–30. 5. Yip T, Tse KC, Lam MF, Cheng SW, Lui SL, Tang S, et al. Risks and outcomes of peritonitis after flexible colonoscopy in CAPD patients. Perit Dial Int 2007; 27:560–4. 6. Poortvliet W, Selten HP, Raasveld MH, Klemt–Kropp M. CAPD peritonitis after colonoscopy: follow the guidelines. Neth J Med 2010; 68:377–8. 7. Ray SM, Piraino B, Holley J. Peritonitis following colonoscopy in a peritoneal dialysis patient. Perit Dial Int 1990; 10:97–8. 8. Lin YC, Lin WP, Huang JY, Lee SY. Polymicrobial peritonitis following colonoscopic polypectomy in a peritoneal dialysis patient. Intern Med 2012; 51:1841–3. 9. Machuca E, Ortiz AM, Rabagliati R. Streptococcus viridans– associated peritonitis after gastroscopy. Adv Perit Dial 2005; 21:60–2.
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can both lead to peritonitis. Specific interventions aimed at controlling active bleeding could also increase the risk of peritonitis in dialysis patients. One of our patients underwent an endoscopic intervention with epinephrine injection and clip insertion during his first gastroscopy. An intervention was also performed for one of the two cases of gastroscopy-related peritonitis in the literature. As reported by Machuca et al. (9), a 69-year-old patient on automated PD underwent an emergency gastroscopy for occult gastrointestinal bleeding associated with syncope. Epinephrine injection and heat-probe coagulation were performed to control an actively bleeding duodenal ulcer, and a Streptococcus viridans peritonitis became clinically apparent on the subsequent day. On the other hand, no specific intervention was performed during the endoscopic procedure in our first patient. Another patient reported by Morimoto et al. (10) also underwent a simple gastroscopy without any intervention. This 49-year-old woman on PD had an episode of Ent. faecalis peritonitis 7 days after a gastroscopy. Her case differs from those of our two patients and the other reported case, because the woman was known to have repetitive peritonitis episodes related to gynecologic examinations. The 7-day peritonitis delay after that gastroscopy is also longer than the delay in the other cases. Interestingly, considering our two cases and the two previously reported ones, gram-positive and gramnegative organisms have both been associated with upper endoscopy. Our first patient initially presented with B. fragilis, an obligatory anaerobic bacteria more specific to gut; the patient reported by Machuca et al. developed a S. viridans peritonitis, a bacterium frequently associated with mouth flora. If antibiotic prophylaxis were to be given to PD patients before gastroscopy, it should probably resemble the protocols used with colonoscopy as recommended by ISPD guidelines: ampicillin, plus a single dose of aminoglycoside, with or without metronidazole (4). Ampicillin would be effective prophylaxis for both oral and enteric bacteria.
Short Reports
Short Reports
septEMBER 2014 – Vol. 34, No. 6
doi: 10.3747/pdi.2012.00340
A Preliminary Report on the Effectiveness of Nanotechnology Anti-Microbial Spray Dressing in Preventing Tenckhoff Catheter Exit-Site Infection For most patients receiving peritoneal dialysis (PD), there is evidence showing that their satisfaction and quality of life have been increasing (1). However, the Tenckhoff catheter (TC) can become a potential source of infection and peritonitis. If exit-site infection (ESI) is not well managed it can lead to peritonitis or require removal of the TC (2). Peritonitis is a well-known cause of mortality in PD patients (3). Consequently, suspending treatment due to access failure may affect patients’ overall health status. The purpose of routine care of the exit site is to prevent ESI. There is a large volume of information focused on the prevention of ESI, with different approaches being proposed. The practice guidelines and protocols from institutions are varied and have not been adequately evaluated, although large volumes of data have been published on the prevention of ESI (4). Several recent trial studies show that the application of JUC Physical Antimicrobial Spray Dressing (NMS Technologies Company Limited, Nanjing, Jiangsu Province, China), has proven to be effective in the prevention of lower urinary tract infection where the spray was applied on the surface of the catheter and the urethral orifice (5,6), treatment of post-operative infection for oral cancer (7), open wound treatment in 670
emergency clinics (8), and managing radiation-induced acute skin reactions (9). It is also an alternative to antibiotic treatment on wound management for patients with methicillin-resistant Staphylococcus aureus (MRSA) infection (10). JUC spray dressing was developed in China in 2002 and registered as a dressing product by the United States Food and Drug Administration in 2006. The spray consists of 2% organosilicon quaternary ammonium salt and 98% distilled water, and is safe for application, even for contact with eyes and mucous membranes. It is composed using nano-manufacture technology, yet the antibacterial mechanism is not fully understood. Some proposed mechanisms relate to the physical structure of the nanoparticles while others relate to the enhanced release of antibacterial metal ions from nanoparticle surfaces which interact with and penetrate into the bacteria (11). Proper exit-site care is of paramount importance in reducing TC-associated infection and subsequent catheter loss. In current practice, patients who have a TC are usually advised to use the traditional antiseptic 0.05% chlorhexidine in exit-site care. Previous studies suggest that 0.05% chlorhexidine is able to reduce the bacterial load in the wound and promotes cell growth (12). In this study, JUC spray was applied to the TC exit site to compare the incidence of ESI with the usual standard care. In addition to ESI, the existence of skin allergy, catheter damage, and time spent on exit-site dressing were examined. METHODS
The study was carried out through a randomized controlled trial. Patients were recruited from the renal unit of a 1,700-bed acute-care, general regional hospital in Hong Kong. Those patients who did not receive oral or external antibiotics and who had a TC in place for at least 3 months were recruited sequentially. Patients presenting with signs and symptoms of exit-site infection and poor healing of exit site were excluded. There were 121 patients assessed for eligibility and 47 subjects were excluded. The reasons for exclusion were patients not meeting the inclusion criteria or refusing to participate. To compute the sample size, we referred to Li et al. (10) on the effectiveness of JUC spray to prevent ventilatorassociated pneumonia. To have 80% power, α = 0.05, to detect a 27.9% reduction in the incidence of bacterial colonization in the pharyngeal cavity in the experimental group compared with the control group, a sample size of 35 subjects for each group was required. The catheter was inserted surgically by open surgical incision. It was well secured with a dressing and PD was started 4 weeks
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10. Morimoto S, Kido E, Higashi M, Sumitani N, Takagishi H, Kakimoto S, et al. Peritonitis after gynecological and gastroscopic examinations in a peritoneal dialysis patient. Clin Nephrol 2010; 74:491–2. 11. Fernandez J, Navasa M, Gomez J, Colmenero J, Vila J, Arroyo V, et al. Bacterial infections in cirrhosis: epidemiological changes with invasive procedures and norfloxacin prophylaxis. Hepatology 2002; 35:140–8. 12. Bernard B, Grange JD, Khac EN, Amiot X, Opolon P, Poynard T. Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: a meta-analysis. Hepatology 1999; 29:1655–61. 13. Banerjee S, Shen B, Baron TH, Nelson DB, Anderson MA, Cash BD, et al. on behalf of the ASGE Standards of Practice Committee. Antibiotic prophylaxis for GI endoscopy. Gastrointest Endosc 2008; 67:791–8. 14. von Schnakenburg C, Feneberg R, Plank C, Zimmering M, Arbeiter K, Bald M, et al. Percutaneous endoscopic gastrostomy in children on peritoneal dialysis. Perit Dial Int 2006; 26:69–77.
PDI
