Treatment for peritoneal dialysis-associated peritonitis.
BACKGROUND
Peritonitis is a common complication of peritoneal dialysis (PD) that is associated with significant morbidity including death, hospitalisation, and need to change from PD to haemodialysis. Treatment is aimed to reduce morbidity and recurrence. This is an update of a review first published in 2008.


OBJECTIVE
To evaluate the benefits and harms of treatments for PD-associated peritonitis.


METHODS
For this review update we searched the Cochrane Renal Group's Specialised Register to March 2014 through contact with the Trials Search Co-ordinator using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE and EMBASE, and handsearching conference proceedings.


METHODS
We included randomised controlled trials (RCTs) and quasi-RCTs assessing the treatment of peritonitis in PD patients (adults and children). We included any study that evaluated: administration of an antibiotic by different routes (e.g. oral, intraperitoneal (IP), intravenous (IV)); dose of an antibiotic agent; different schedules of administration of antimicrobial agents; comparisons of different regimens of antimicrobial agents; any other intervention including fibrinolytic agents, peritoneal lavage and early catheter removal.


METHODS
Multiple authors independently extracted data on study risk of bias and outcomes. Statistical analyses were performed using the random effects model. We expressed summarised treatment estimates as a risk ratio (RR) with 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) with 95% CI for continuous outcomes.


RESULTS
We identified 42 eligible studies in 2433 participants: antimicrobial agents (36 studies); urokinase (4 studies), peritoneal lavage (1 study), and IP immunoglobulin (1 study). We did not identify any optimal antibiotic agent or combination of agents. IP glycopeptides (vancomycin or teicoplanin) had uncertain effects on primary treatment response, relapse rates, and need for catheter removal compared to first generation cephalosporins, although glycopeptide regimens were more likely to achieve a complete cure (3 studies, 370 episodes: RR 1.66, 95% CI 1.01 to 2.72). For relapsing or persistent peritonitis, simultaneous catheter removal and replacement was better than urokinase at reducing treatment failure rates (RR 2.35, 95% CI 1.13 to 4.91) although evidence was limited to a single small study. Continuous and intermittent IP antibiotic dosing schedules had similar treatment failure and relapse rates. IP antibiotics were superior to IV antibiotics in reducing treatment failure in one small study (RR 3.52, 95% CI 1.26 to 9.81). Longer duration treatment (21 days of IV vancomycin and IP gentamicin) had uncertain effects on risk of treatment relapse compared with 10 days treatment (1 study, 49 patients: RR 1.56, 95% CI 0.60 to 3.95) although may have increased ototoxicity.In general, review conclusions were based on a small number of studies with few events in which risk of bias was generally high; interventions were heterogeneous, and outcome definitions were often inconsistent. There were no RCTs evaluating optimal timing of catheter removal and data for automated PD were absent.


CONCLUSIONS
Many of the studies evaluating treatment of PD-related peritonitis are small, out-dated, of poor quality, and had inconsistent definitions and dosing regimens. IP administration of antibiotics was superior to IV administration for treating PD-associated peritonitis and glycopeptides appear optimal for complete cure of peritonitis, although evidence for this finding was assessed as low quality. PD catheter removal may be the best treatment for relapsing or persistent peritonitis.Evidence was insufficient to identify the optimal agent, route or duration of antibiotics to treat peritonitis. No specific antibiotic appears to have superior efficacy for preventing treatment failure or relapse of peritonitis, but evidence is limited to few trials. The role of routine peritoneal lavage or urokinase is uncertain.
Department of Medicine, University of Otago Christchurch, 2 Riccarton Ave, Christchurch, New Zealand, 8041.
Angela E
AE
Ballinger
Suetonia C
SC
Palmer
Kathryn J
KJ
Wiggins
Jonathan C
JC
Craig
David W
DW
Johnson
Nicholas B
NB
Cross
Giovanni F M
GF
Strippoli
D000284:Administration, Oral; D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D004333:Drug Administration Routes; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006801:Humans; D007136:Immunoglobulins / Q000627:therapeutic use; D007263:Infusions, Parenteral; D007275:Injections, Intravenous; D010530:Peritoneal Dialysis / Q000009:adverse effects*; D010533:Peritoneal Lavage; D010538:Peritonitis / Q000188:drug therapy / Q000209:etiology / Q000628:therapy*; D016032:Randomized Controlled Trials as Topic; D014568:Urokinase-Type Plasminogen Activator / Q000627:therapeutic use
D000900:Anti-Bacterial Agents; D005343:Fibrinolytic Agents; D007136:Immunoglobulins; D014568:Urokinase-Type Plasminogen Activator