1. Complications of PD Peter Rutherford Medical Director Senior Lecturer in Nephrology

2. Complications Non-infectious –Catheter issues –Leakage Infectious –Exit site infection –Peritonitis

3. Access problems Prevention better than cure –Repair hernias –Timely access insertion –Insertion technique and management Double cuff Lateral para median, “staggering path” Exit site – avoid skin folds and belt lines, face downwards Intra-op – vancomycin 1gram IV

4. Leaks Route –Hernia –Processus vaginalis –Peri-catheter leak –Diagnosis – AXR and CT scan Presentation – clinical and/or low UF Management – low volumes, APD, rest and repair

5. Obstruction Fibrin –Can be a problem and recurrent –Instill urokinase +/- heparin Catheter migration –Laxatives and re-site Omental blockage –One way problem –Diathermy, surgery

8. Exit site care Epithelialisation around cuff Correct regimes for cleaning and hand hygiene Check for nasal Staph aureus carriage – treat 5 days/month with nasal mupirocin Review regularly Redness, pain, pus, tunnel involvement Can be colonised

9. Exit site infection May need local treatment and/or oral drugs If outer cuff – shave If tunnel – likely to spread and cause peritonitis – investigate and remove

10. Peritonitis Variable clinical course Impact –Pain and hospitalisation –Loss of UF –Malnutrition –Technique failure – acute or chronic –Cost –Death

11. Peritonitis - presentation Three features; –Cloudy fluid –Abdominal pain –Fever Educate the patients and staff Remember time course – 48 hours APD patients may be an issue (why?)

12. Numbers of patients Finkelstein AJKD 2002; 39; 1278 1/3 of patients had 2 or more episodes Mean in these 198 patients was 5 (2-17) Most had multiple infections with same organisms

13. Route of infection (Harwell PDI 1997) Touch – 41% Catheter related – 23% Enteric – 11% Insertion – 6% UTI/Diarrhoea – 4% Sepsis – 1% Unknown – 14% ****

14. PD Fluid – how to sample First cloudy bag if possible CAPD – from > 4 hr dwell APD – possibly a problem but think of children oIf fluid turbid – use it, even the overnight fluid oIf fluid clear – use dwell of > 2hours if patient has symptoms oIf concerns – repeat samples Send to laboratory for urgent Gram stain, culture and white cell count Tell the microbiology laboratory if patient is on antibiotics

15. PD fluid sample Send for gram stain and culture and differential white cell count (haematology) Looking for; o >100 white cells/mm3 o > 50% polymorphs Number of white cells/polymorphs is not predictive of organism or outcome Initiate empirical therapy based on these results

16. PD Fluid sample (2) Take PD fluid sample into sterile containers and into a full blood count tube White cell count – how will it be done? Talk to haematology so they know what you are looking for and why

17. PD Fluid sample (3) Gram stain –Strong indication but still preliminary –Gram negative – think Pseudomonas –Fungal –Gram +ve cocci and Gram –ve rods – perforation

18. PD Fluid culture Must get it right to avoid culture negatives ISPD Guidelines give good guidance – discuss with your microbiology dept Key messages oCulture the first cloudy specimen oUse large volumes of fluid oConcentrate – filtration or centrifugation oBlood culture techniques

19. PD Fluid culture (2) 50 mls PD fluid at 3000g for 15 mins Resuspend in 3-5 mls sterile saline Inoculate into blood culture medium – aerobic and anaerobic Antibiotic neutralisation Rapid techniques Subculture the blood culture if required Talk to your microbiologist

20. Cloudy effluent Culture positive Infectious peritonitis with sterile culture Sample from “dry” abdomen Chemical Eosinophilia Haemoperitoneum Malignancy Chylous

21. Organisms Common things are common All sorts of unusual organisms in literature Consider if there is no response to therapy or unusual features First principle approach

22. Trends in organisms Zelenitsky AJKD 2000 36 (5), 1009 546 episodes from 1991-98 Rate declined - 1.37/pt year to 0.55 Gram positive rate fell – 0.75 to 0.28 Gram negative rate – 0.16 to 0.16 –Pseud. = 7.1% –E Coli = 6.8% –Kleb = 5.2%

23. Trends in Gram positives Type of Staph –Epi = 27.8% –Aureus = 19.3% Resistance increasing –Epi – resistance to cipro – 5.4% to 47.5% –MRSA – 18.9% to 73.9% Will depend on your area

24. Utility of gram stain Bezeura PDI 17 (3), 1997 149 peritonitis episodes, Gram stain +ve 93.2% Gram +veGram-ve Sensitivity94.983.3 Specificity53.598.8 +ve Pred Value68.395.2 -ve Pred Value90.995.6 NB – use in fungal infections

25. MRSA – do you have a problem?

26. Pseudomonas resistance

27. Peritonitis management Recent ISPD guidelines (2005) Commence treatment with a combination of ip antibiotics to cover gram +ve and gram –ve organisms Monitor isolates and base choices on local resistance patterns and epidemiology Vanc/1 st ceph and 3 rd ceph/aglyc/quin

28. Management

29. Antibiotics IP route Doses now know for APD and CAPD Continuous for ceph Intermittent for vanc/a glyc Transfer to CAPD? Treat –2 weeks –3 weeks (pseudomonas) –4 weeks (fungal) Consider fungal prophylaxis

30. Organisms Coag neg staph Staph aureus Enterococcus Pseudomonas Multiple enteric Fungal

31. Catheter removal for infection Catheter infection –Associated peritonitis –Inner cuff infection –Chronic infection Peritonitis –Catheter related –Refractory (no response after 4-5 days) –Severe –Relapsing (< 4 weeks) –fungal

32. Relapsing-recurrent peritonitis Same organism within 4 weeks of completed course Likely to be Staph Consider biofilm or catheter infection Catheter change – same day?

33. PD Complications Avoid rather than wait to happen Access insertion Access care Patient education Prompt treatment of problems