A 12-month review of peritoneal dialysis-related peritonitis in Western Australia: is empiric vancomycin still indicated for some patients?
BACKGROUND
The International Society for Peritoneal Dialysis (ISPD) guidelines recommend empiric therapy with cefazolin and ceftazidime for peritoneal dialysis (PD)-related peritonitis. Empiric cefazolin therapy may have diminishing efficacy because of emerging methicillin resistance in gram-positive bacteria (GPB). Western Australia also has large numbers of Aboriginal and isolated regional patients, where giving these antimicrobials can be impractical.


OBJECTIVE
To evaluate, based on local antimicrobial resistance patterns, the feasibility of following ISPD guidelines in Western Australia and to identify any subgroups of PD peritonitis patients that may benefit from alternative empiric intraperitoneal antibiotics (e.g., vancomycin).


METHODS
Retrospective study of all PD peritonitis episodes in Western Australia from 1 February 2000 to 31 January 2001.


METHODS
Three adult tertiary referral university hospitals and their PD patients in metropolitan Perth and regional Western Australia.


METHODS
All adults on PD in Western Australia.


METHODS
Isolates and antibiograms were analyzed versus patient characteristics, including race and patient demographics.


RESULTS
293 patients (28% Aborigines, 32% regional patients) received PD. 145 episodes of PD peritonitis occurred during the study. The overall PD peritonitis rate was 1 episode/16 patient months, with Aborigines having 1 episode/10.5 patient months versus non-Aborigines having 1 episode/17 patient months (p < 0.001). 36% of isolates from PD peritonitis episodes were resistant to cefazolin or ceftazidime. 22% were methicillin-resistant GPB (MR-GPB) [18% coagulase-negative staphylococci (CoNS), 1.6% MR Staphylococcus aureus]; 2.5% were multidrug-resistant gram-negative bacteria (MDR-GNB); 5.7% were polymicrobial (MR-GPB and/or MDR-GNB); and 5.7% were fungal. 63% of CoNS were methicillin resistant. Non-Aboriginal patients yielded MR-GPB in 22% of isolates versus 23% in Aborigines (p = 0.9). Six of seven cases of fungal peritonitis occurred in Aboriginal patients (p < 0.001).


CONCLUSIONS
In our study population the ISPD guidelines were appropriate for 64% of patients with PD peritonitis. We could not identify specific patient subgroups where empiric cefazolin use could be more effective. High proportions of MR-GPB PD peritonitis episodes, along with local factors, make empiric cefazolin unsuitable for many regional PD patients in Western Australia.
Kan
George W
GW
Department of Nephrology, Royal Perth Hospital, Perth, Western Australia, Australia. georgekan@ausdoctors.net
Thomas
Mark A B
MA
Heath
Christopher H
CH
D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D019983:Guideline Adherence; D006801:Humans; D010530:Peritoneal Dialysis / Q000009:adverse effects*; D010538:Peritonitis / Q000188:drug therapy* / Q000453:epidemiology / Q000382:microbiology*; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome; D014640:Vancomycin / Q000627:therapeutic use*; D014904:Western Australia / Q000453:epidemiology
D000900:Anti-Bacterial Agents; D014640:Vancomycin