Kliger AS, Gorban-Brennan N, Fikrig M, Golden M, Finkelstein
Nine episodes of CPD-associated peritonitis with vancomycin
(Oct) 50:1368-1372 1996
Vancomycin resistant enterococci have been found with increasing
frequency in hospitalized patients. They have been associated with
severe infections, although peritonitis with VRE has to-date been
uncommon. In dialysis patients, it is difficult to avoid the use of
vancomycin for two reasons (1) reimbursement problems in the United
States make daily home therapy with cephalosporin addition to the
dialysate difficult if not impossible, (2) in many places, > 50% of
the local S. epidermidis population is resistant to
In this report from Yale University in
Connecticut, nine episodes of dialysis-related peritonities due to VRE
are described. In 5 patients the infection was acquired nosocomially,
whereas in the remaining 4 it may have been community acquired,
although all patients had been in hospital during the preceding 12
months, and all had received vancomycin during the 6 months prior to
onset of VRE peritonitis. In 8/9 patients, vancomycin had been given
within 3 months of acquiring VRE peritonitis. Seven of the nine
patients had also been exposed to cephalosporins in the past 6 months,
and it is theorized that cephalosporin use may predispose to bowel
overgrowth of resistant enterococcal organisms. Fecal cultures were
done in 4/9 and were positive for 2 patients prior to VRE
peritonitis. Treatment results were dismal, with 5/9 patients dying.
Only 2/4 survivors remained on PD. The catheter was ultimately
removed in 6/9.
Comment: The new Ad Hoc Committee Recommendations on
Peritonitis Treatment should be released very soon now (October 1996);
keep checking the ISPD
site. What they will say is: use less vancomycin and more
cephalosporins when possible to treat peritonitis. Unfortunately, for
reasons described at the outset of this review, this will be
difficult. See also the May 1996 NEPHROL thread
on this subject. (John T. Daugirdas, M.D., University of
Illinois at Chicago)
Additional comments by Dr. Stephen Vas:
This is some proof for our collegues who pooh-poohed the recommendations
on the restricted use of vancomycin in peritoneal dialysis.
The patients developing VRE peritonitis had a higher rate of previous
peritonitis (6.3 patient months v. 12.5 patient months) thus were more
often exposed to vancomycin, the routine primary antibiotic used in the
unit. All patients in the group had exposure to vancomycin in the six
months prior to the development of VRE peritonitis. No other predisposing
factors could be identified in this small group of patients.
The outcome of peritonitis was dismal in this small group of patients.
Only two patients remained on PD, two transferred to hemodialysis and 5
expired. No other observations emerged from this retrospective analysis on
diagnostic signs or a consensus on therapy.
Comment: While the experience of this small group, with
a high rate of comorbid conditions may not be typical, it certainly
calls attention for the need of further studies, and the
need to consider restrictions on the use of vancomycin.
(Stephen Vas, M.D., University of Toronto, Canada)