Simultaneous catheter replacement and removal in refractory peritoneal dialysis infections

Abstract

The present report describes more than nine years of experience with simultaneous removal and replacement of the chronic peritoneal dialysis (PD) catheter in treating refractory mechanical and infectious complications. Simultaneous catheter replacement and removal not only succeeded in 22 of 23 cases with non-infectious mechanical complications, allowing uninterrupted PD in all but three, but also succeeded in 30 (83%) of 36 additional cases with persisting or recurring infection. Simultaneous procedures failed in six (17%) of 36 infectious cases, due to persistent infection in two cases and to procedure complications in four cases. The clinical characteristics of the 30 successful infectious cases were compared to the characteristics of both the six failures, as well as 29 additional infectious cases in which the peritoneal catheter was removed but was not replaced because of a variety of serious complications (such as pancreatitis, abscess, sepsis, or fluid overload). At the time of simultaneous catheter replacement in successful cases, temporary control of active peritoneal inflammation was achieved more frequently (80% vs. 31%, P < 0.001) with a shorter interval of antibiotic coverage (6.4 ± 0.9 vs. 14.7 ± 1.3 days, P < 0.001). In addition, the successful cases were characterized by significantly more Staphylococcal infections (70% vs. 26%, P < 0.001) and significantly fewer Pseudomonal or fungal infections (6% vs. 59%, P < 0.001), although successful cases included some non-Pseudomonal. non-enteric gram negative infections (23%). In conclusion, simultaneous catheter replacement at the time of catheter removal works well not only for mechanical complications, but also for infectious complications characterized by: (a) persisting or recurring infection with Staphylococcal species or non-Pseudomonal, non-enteric gram negative rods: (b) active peritoneal inflammation controlled within seven days by antibiotic treatment; and (c) absence of serious systemic or intra-abdominal complications. Indeed, the successes reported here imply an important pathogenetic role tor the catheter itself in the persistence or recurrence of infection. Moreover, our experience suggests that simultaneous procedures are feasible for a substantial number of cases in which this procedure has not ordinarily been performed in the past.