CAPD has established itself as an alternative therapeutic modality to hemodialysis in the treatment of patients with end-stage renal disease. Peritonitis in CAPD patients, despite a continuing decrease in its frequency, remains as a major complication and the leading cause of CAPD failure.
Peritonitis can be diagnosed in any patient who has at least two of the following:
1) abdominal pain or tendeness; 2) cloudy effluent containing greater than 100 WBC/cmm; 3) the presence of microorganisms either in Gram stain or in culture.
The main routes of bacterial invasion into the peritoneal cavity are through the lumen of the catheter and across the abdominal wall, through the tunnel around the catheter.
Of the organisms isolated from patients with peritonitis, Gram positive cocci predominate and account for 50--60io, most of which are due to S. epidermidis or S. aureus.About 20?40% are Gram negative bacilli.
A widely accepted therapeutic regimen includes three or four initial rapid in-and-out dialysate exchanges followed by exchanges every 4-´6 hours with dialysate containing heparin, cephalothin, and tobramycin. The choice of antibiotic(s) may have to be modified later, according to the in vitro sensitivity of the isolated organisms and the total length of antibiotic treatment is usually 10~15 days.
Catheter removal may be indicated in cases of fungal peritonitis, fecal peritonitis, tuberculous peritonitis, recurrent peritonitis, recurrent peritonitis with same organisms over a short period, and peritonitis not responding to adequate therapy for 5?7 days. Catheter also should be removed from patients who suffer persistent skin exit site or tunnel infections which lead to peritonitis.
In conclusion, the future of CAPD as a long-term therapeutic modality depends on the incidence cf peritonitis and, at present, the early diagosis and the prompt therapy allow us to keep peritonitis from being a life-threatening complication in patients being treated with CAPD.
|