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No antibiotic regimen superior in treatment of peritoneal dialysis-associated peritonitis; urokinase, peritoneal lavage ineffective, research shows

Wednesday, December 12 2007 | Comments
Evidence Grade 1 What's This?
Intermittent and continuous antibiotic dosing are equivalent treatment strategies for peritoneal dialysis-associated peritonitis, and no antimicrobial class appears superior, according to a review of the literature.

Researchers conducted a review of the literature for randomized trials of treatment for patients with peritoneal dialysis-associated peritonitis. Trials included those of antibiotics (comparisons of routes, agents, and dosing regimens), fibrinolytic agents, peritoneal lavage, and intraperitoneal immunoglobulin, and outcomes examined included treatment failure, relapse, catheter removal, microbiological eradication, hospitalization, all-cause mortality, and adverse reactions.

In the final analysis, 36 trials were included, with a total enrollment of 2,089 patients.

Results demonstrated a statistically significant increase in the treatment failure rate for intravenous administration of vancomycin/tobramycin rather than intraperitoneal administration (relative risk [RR], 3.52; 95% CI, 1.26-9.81). In contrast, rates of treatment failure with oral administration of quinolone antibiotics (ciprofloxacin and ofloxacin) were not significantly different from those with IP administration (RR, 1.66; 95% CI, 0.98-2.83); between-group rates of relapse and catheter removal were also similar between oral and IP administration.

Oral and IP antibiotic regimens were also similar with regard to rates of treatment failure, microbiological eradication, and relapse. No significant differences were observed between any antibiotic regimen studied, including oral rifampicin and/or ofloxacin, IP cephalosporins versus glycopeptides, and IP vancomycin versus IP teicoplanin. However, there was a significantly greater risk of nausea and vomiting with oral antibiotics than with IP antibiotics (RR, 9.14; 95% CI, 1.73-48.32).

In 10 head-to-head trials of different combinations of IP antibiotics, the only significant difference observed was a decreased rate of treatment failure with rifampicin/ciprofloxacin compared with cephradine (RR, 0.50; 95% CI, 0.28-0.89).

Rates of treatment failure and relapse were similar when comparing high-dose imipenem with low-dose imipenem, and when comparing intermittent administration of IP antibiotics with continuous administration. There was also no significant increase in rates of treatment failure with a 24-hour period of peritoneal lavage versus no lavage.

Compared with catheter removal/replacement, urokinase was associated with significantly greater rates of treatment failure (RR, 2.35; 95% CI, 1.13-4.91) and relapse (RR, 2.35; 95% CI, 1.13-4.91) and was no better than placebo.

Use of IP immunoglobulin was associated with a significant decrease in the time for the dialysate white blood cell count to decrease to less than 100 cells/mL (-7.30; 95% CI, -8.12 to -6.48).

"At the present time, broad-spectrum antibiotics should be initiated when a diagnosis of peritonitis is made," the authors of the review concluded. "There is no clear role for such adjunctive therapies as urokinase and peritoneal lavage." (Wiggins KJ, et al. Am J Kidney Dis 2007;50:967-988.)

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