title: Aseptic peritonitis due to peptidoglycan contamination of pharmacopoeia standard dialysis solution.
abstract: BACKGROUND
  Manufacturers of parenteral solutions adhere to European and US Pharmacopoeia standards to define safety and sterility. In response to excess cases of aseptic peritonitis in peritoneal dialysis patients using icodextrin-containing dialysate that met all pharmacopoeia standards, a global recall was issued in May, 2002. We aimed to establish the cause of aseptic peritonitis.
  
  
  METHODS
  We analysed 186 reports of aseptic peritonitis between September, 2001, and January, 2003. Extensive physical, chemical, and microbiological investigations of recalled dialysate were done. We calculated dose-response curves for peptidoglycan-induced interleukin 6 elaboration in peripheral blood mononuclear cells (PBMCs) from healthy donors and for sterile peritonitis in rats.
  
  
  RESULTS
  Although its chemical constituents and concentrations of endotoxin were within pharmacopoeia specifications, the dialysis solution elicited an interlukin 6 response in vivo and in vitro. We identified peptidoglycan from thermophilic acidophilic bacteria (Alicyclobacillus acidocaldarius) as the contaminating proinflammatory substance. In the PBMC assay, strong dose-response relations were noted between peptidoglycan concentrations and interleukin 6. In rats injected with peptidoglycan, dose-dependent increases of intraperitoneal neutrophils and pyrogenic cytokines were recorded. We measured a positive relation between peptidoglycan concentrations in recalled dialysate and reports of aseptic peritonitis. After implementation of corrective actions, the rate of peritonitis returned to baseline.
  
  
  CONCLUSIONS
  Excess cases of aseptic peritonitis in peritoneal dialysis patients were due to peptidoglycan contamination of dialysate by Alicyclobacillus. This outbreak serves as an example of how contemporary parenteral products with microbial contaminants can be considered safe under current pharmacopoeia tests, but provoke adverse clinical effects.
authors.affiliation: Baxter Healthcare, McGraw Park, IL, USA.
authors.forename: Leo
authors.initials: L
authors.lastname: Martis
authors.forename: Mehul
authors.initials: M
authors.lastname: Patel
authors.forename: Joe
authors.initials: J
authors.lastname: Giertych
authors.forename: Jim
authors.initials: J
authors.lastname: Mongoven
authors.forename: Michel
authors.initials: M
authors.lastname: Taminne
authors.forename: Michele A
authors.initials: MA
authors.lastname: Perrier
authors.forename: Omar
authors.initials: O
authors.lastname: Mendoza
authors.forename: Niranjan
authors.initials: N
authors.lastname: Goud
authors.forename: Aidan
authors.initials: A
authors.lastname: Costigan
authors.forename: Nicole
authors.initials: N
authors.lastname: Denjoy
authors.forename: Christian
authors.initials: C
authors.lastname: Verger
authors.forename: William F
authors.initials: WF
authors.lastname: Owen
mesh_terms: D000818:Animals; D001202:Ascitic Fluid / Q000737:chemistry; D001407:Bacillus / Q000378:metabolism; D001681:Biological Assay; D015314:Dialysis Solutions / Q000009:adverse effects* / Q000737:chemistry; D004305:Dose-Response Relationship, Drug; D004340:Drug Contamination; D004731:Endotoxins / Q000032:analysis; D005936:Glucans / Q000009:adverse effects*; D005947:Glucose / Q000009:adverse effects*; D006801:Humans; D000077607:Icodextrin; D015850:Interleukin-6 / Q000032:analysis; D007963:Leukocytes, Mononuclear / Q000378:metabolism; D008033:Limulus Test; D008297:Male; D010457:Peptidoglycan / Q000378:metabolism / Q000494:pharmacology; D010530:Peritoneal Dialysis / Q000009:adverse effects*; D010538:Peritonitis / Q000209:etiology*; D011817:Rabbits; D051381:Rats; D017207:Rats, Sprague-Dawley
chemical_list: D015314:Dialysis Solutions; D004731:Endotoxins; D005936:Glucans; D015850:Interleukin-6; D010457:Peptidoglycan; D000077607:Icodextrin; D005947:Glucose