HDCN Article Review/Hyperlink

Kliger AS, Gorban-Brennan N, Fikrig M, Golden M, Finkelstein FO

Nine episodes of CPD-associated peritonitis with vancomycin resistant enterococci

Kidney Int (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 cephalosporins.

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 early 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)