HDCN Article Review/Hyperlink

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)