Antimicrobial agents for preventing peritonitis in peritoneal dialysis patients.
BACKGROUND
Peritoneal dialysis (PD) is used as substitutive treatment of renal function in a large proportion (15-50%) of the end-stage kidney disease (ESRD) population. The major limitation is peritonitis which leads to technique failure, hospitalisation and increased mortality. Oral, nasal, topical antibiotic prophylaxis, exit-site disinfectants and other antimicrobial interventions are used to prevent peritonitis.


OBJECTIVE
The objective of this systematic review of randomised controlled trials (RCTs) was to evaluate what evidence supports the use of different antimicrobial approaches to prevent peritonitis in PD.


METHODS
The Cochrane CENTRAL Registry (issue 1, 2004), MEDLINE (1966-May 2003), EMBASE (1988-May 2003) and reference lists were searched for RCTs of antimicrobial agents in PD.


METHODS
Trials of the following agents were included: antibiotics by any route (oral, nasal, topical), exit-site disinfectants (chlorhexidine, povidone iodine, soap and water), vaccines, and ultraviolet germicidal devices.


METHODS
Two reviewers extracted data on the number of patients with one or more episodes and rates of peritonitis and exit-site/tunnel infection, catheter removal, catheter replacement, technique failure, toxicity of antibiotic treatments, all-cause mortality. Statistical analyses were performed using the random effects model and the results expressed as relative risk (RR) with 95% confidence intervals (CI).


RESULTS
Nineteen trials, enrolling 1949 patients met our inclusion criteria. Nasal mupirocin compared with placebo significantly reduced the exit-site and tunnel infection rate (one trial, 2716 patient months, RR 0.58, 95% CI 0.40 to 0.85) but not peritonitis rate (one trial, 2716 patient months, RR 0.84, 95% CI 0.44 to 1.60). Perioperative intravenous antibiotics compared with no treatment significantly reduced the risk of early peritonitis (four trials, 335 patients, RR 0.35, 95% CI 0.15 to 0.80) but not exit site and tunnel infection (three trials, 114 patients, RR 0.32, 95% CI 0.02 to 4.81). No intervention reduced the risk of catheter removal or replacement.


CONCLUSIONS
This review demonstrates that nasal mupirocin reduces exit-site/tunnel infection but not peritonitis. Preoperative intravenous prophylaxis reduces early peritonitis but not exit-site/tunnel infection. No other antimicrobial interventions have proven efficacy. Given the large number of patients on PD and the importance of peritonitis, the lack of adequately powered RCTs to inform decision making about strategies to prevent peritonitis is striking.
Strippoli
G F M
GF
Cochrane Renal Group, Centre for Kidney Research, NHMRC Centre for Clinical Research Excellence in Renal Medicine, Children's Hospital at Westmead, Locked Bag 4001, Westmead, 2145, NSW, Australia. gfmstrippoli@katamail.com
Tong
A
A
Johnson
D
D
Schena
F P
FP
Craig
J C
JC
D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D019072:Antibiotic Prophylaxis; D006801:Humans; D016712:Mupirocin / Q000627:therapeutic use; D010530:Peritoneal Dialysis / Q000009:adverse effects*; D010538:Peritonitis / Q000517:prevention & control*; D016032:Randomized Controlled Trials as Topic
D000900:Anti-Bacterial Agents; D016712:Mupirocin