FP597IMPROVED OUTCOME OF ENTERIC PERITONITIS IN PERITONEAL DIALYSIS (PD) PATIENTS WITH TEMPORARY DISCONTINUATION OF PD AND INTRAVENOUS MEROPENEM

Abstract

Introduction and Aims: The outcome of PD‐related peritonitis caused by enteric micro‐organisms (EM) is poor. To improve this, the University Medical Center Utrecht (UMCU) has adapted its peritonitis protocol since January 1998.We assumed that 1) EM peritonitis cannot be distinguished clinically from non‐EM peritonitis at presentation; 2) EM peritonitis is often related to microperforations of colonic diverticulae; 3) interruption of PD without catheter removal allows sealing of these perforations; 4) broad initial coverage of the intestinal flora facilitates cure. The protocol was applied pre‐emptively in all PD patients of 50 years or older considered to be at risk of EM peritonitis because diverticulosis is more prevalent in this age category. The protocol implies: 1) temporary discontinuation of PD without removing the PD catheter, 2) intravenous meropenem and 3) meropenem intracatheter as lock. If cultures show EM, this treatment is continued for 1 week. After 1 week, PD is resumed and meropenem is administrated intraperitoneally (IP) for another week. In cases of non‐EM, PD is resumed with IP antibiotics adapted to culture results. Aim of this study was to evaluate the efficacy of this protocol. Methods: We analysed all peritonitis episodes in PD patients of 50 years or older in the UMCU between 1998‐2008. Results were compared with those in a comparable contemporary cohort of patients of 50 years or older in the VU University medical center (VUmc), which applies a standard IP gentamicin‐rifampicin‐based protocol with continuation of PD and adjustment of antibiotics based on culture results. The efficacy of the protocols was assessed for all episodes of EM peritonitis (definition: culture of < 1 micro‐organisms likely to be derived from the gut) and for all non‐EM peritonitis episodes. The primary outcomes were primary cure rate, technique survival and patient survival. Adjusted odds ratios (OR) were calculated by logistic generalized‐estimating‐equations models. Results: 420 episodes were available for analysis (203 vs 217). The UMCU protocol was actually applied in 80.3%, the standard VUmc‐protocol in 73.7%. 50 episodes in the UMCU were classified as EM peritonitis and treated according to the UMCU protocol and were compared with 49 EM peritonitis episodes in the VUmc treated with gentamicin‐rifampicin. The UMCU protocol was associated with a significantly higher primary cure rate (90.0% vs 65.3%, adjusted OR 4.54, 95%CI 1.46‐14.15) and better technique survival (90.0% vs 69.4%, adjusted OR 3.41, 95%CI 1.07‐10.87). Patient survival did not differ significantly from the VUmc protocol (92.0% vs 81.6%). In 113 episodes in the UMCU, cultures proved to be non‐EM peritonitis (vs 111 in VUmc). In these cases, PD was resumed with IP antibiotics adjusted to culture results. Both primary cure rate (95.6% vs 84.7%, adjusted OR 3.92, 95%CI 1.37‐11.19) and technique survival (95.6% vs 85.6%, adjusted OR 3.60, 95%CI 1.25‐10.32) differed significantly between the two centers, while patient survival did not (96.5% vs 91.0%). Conclusions: In patients of 50 years or older judged to be at risk for EM peritonitis, pre‐emptive use of a peritonitis treatment protocol involving temporary discontinuation of PD without removing the PD catheter and intravenous meropenem resulted in a primary cure rate and technique survival of 90% in actual cases of EM peritonitis. Interestingly, the adapted protocol also resulted in excellent outcome in cases of non‐EM peritonitis (95.6%) suggesting that one or more of the elements of the new protocol may be beneficial in peritonitis in general.