Shemin D, Maaz D
Gram-negative peritonitis in peritoneal dialysis: improved
outcome with intraperitoneal ceftazidime
Perit Dial Int
(Dec) 16:638-640 1996
This mini-study points to the good results using combined antibiotic
therapy in gram-negative peritonitis. In 9 patients treated prior to
1993 (5 with Ps. aeruginosa) with an aminoglycoside, only 2/9
responded to treatment. After 1993, oral ciprofloxacin plus IP
ceftazidime was used in 8 patients (4 with Ps. aeruginosa), and
the response rate was 75%.
The difficulty with Gram -negative peritonitis has been recognized
earlier and the 1993 recommendations of the Peritonitis Treatment
committee (not quoted by authors) have recommended combined treatment
primarily with aminoglycoside and ceftazidime (but also recommending
other combinations). This recommendation is reiterated in the
committee's new recommendations (coincidentally in the same issue of
Perit Dial Int;
(Keane et al, 16:557-573, 1996).
Comment: There are some shortcomngs of this presentation.
Neither the initial antibiotic therapy (until identification is
available) is mentioned nor do we know how soon afterwards the new
combination used. There is no breakdown of the effectivenes of
therapy on Pseudomonas infections (notoriously resistant to
therapy). No information is given re: exit site or tunnel infections;
an important determinant of outcome. The use of ciprofloxacin has been
advocated by many as a single initial therapy or in combination. The
therapeutic results are not particularly impressive. In addition, a
large percentage of Xanthomonas maltophilia (an organism that
is still identified as Pseudomonas by many laboratories) is
notoriously resistant to ciprofloxacin.
The purported risk of ototoxicity and nephrotoxicity (a real factor)
has not been observed in many published studies in the treatment of
CAPD peritonitis. The cost of the ciprofloxacin/ceftazidime
combination therapy is also a factor in many localities.
(Stephen Vas, M.D., University of Toronto, Canada)