Treatment for peritoneal dialysis‐associated peritonitis

TLDR: IP administration of antibiotics was superior to IV administration for treating PD-associated peritonitis and glycopeptide regimens appear optimal for complete cure ofperitonitis, although evidence for this finding was assessed as low quality.

Abstract: Background Peritonitis is a common complication of peritoneal dialysis (PD) that is associated with significant morbidity including death, hospitalisation, and need to change from PD to haemodialysis. Treatment is aimed to reduce morbidity and recurrence. This is an update of a review first published in 2008. Objectives To evaluate the benefits and harms of treatments for PD-associated peritonitis. Search methods For this review update we searched the Cochrane Renal Group's Specialised Register to March 2014 through contact with the Trials Search Co-ordinator using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE and EMBASE, and handsearching conference proceedings. Selection criteria We included randomised controlled trials (RCTs) and quasi-RCTs assessing the treatment of peritonitis in PD patients (adults and children). We included any study that evaluated: administration of an antibiotic by different routes (e.g. oral, intraperitoneal (IP), intravenous (IV)); dose of an antibiotic agent; different schedules of administration of antimicrobial agents; comparisons of different regimens of antimicrobial agents; any other intervention including fibrinolytic agents, peritoneal lavage and early catheter removal. Data collection and analysis Multiple authors independently extracted data on study risk of bias and outcomes. Statistical analyses were performed using the random effects model. We expressed summarised treatment estimates as a risk ratio (RR) with 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) with 95% CI for continuous outcomes. Main results We identified 42 eligible studies in 2433 participants: antimicrobial agents (36 studies); urokinase (4 studies), peritoneal lavage (1 study), and IP immunoglobulin (1 study). We did not identify any optimal antibiotic agent or combination of agents. IP glycopeptides (vancomycin or teicoplanin) had uncertain effects on primary treatment response, relapse rates, and need for catheter removal compared to first generation cephalosporins, although glycopeptide regimens were more likely to achieve a complete cure (3 studies, 370 episodes: RR 1.66, 95% CI 1.01 to 2.72). For relapsing or persistent peritonitis, simultaneous catheter removal and replacement was better than urokinase at reducing treatment failure rates (RR 2.35, 95% CI 1.13 to 4.91) although evidence was limited to a single small study. Continuous and intermittent IP antibiotic dosing schedules had similar treatment failure and relapse rates. IP antibiotics were superior to IV antibiotics in reducing treatment failure in one small study (RR 3.52, 95% CI 1.26 to 9.81). Longer duration treatment (21 days of IV vancomycin and IP gentamicin) had uncertain effects on risk of treatment relapse compared with 10 days treatment (1 study, 49 patients: RR 1.56, 95% CI 0.60 to 3.95) although may have increased ototoxicity. In general, review conclusions were based on a small number of studies with few events in which risk of bias was generally high; interventions were heterogeneous, and outcome definitions were often inconsistent. There were no RCTs evaluating optimal timing of catheter removal and data for automated PD were absent. Authors' conclusions Many of the studies evaluating treatment of PD-related peritonitis are small, out-dated, of poor quality, and had inconsistent definitions and dosing regimens. IP administration of antibiotics was superior to IV administration for treating PD-associated peritonitis and glycopeptides appear optimal for complete cure of peritonitis, although evidence for this finding was assessed as low quality. PD catheter removal may be the best treatment for relapsing or persistent peritonitis. Evidence was insufficient to identify the optimal agent, route or duration of antibiotics to treat peritonitis. No specific antibiotic appears to have superior efficacy for preventing treatment failure or relapse of peritonitis, but evidence is limited to few trials. The role of routine peritoneal lavage or urokinase is uncertain.

Figures

Figure 1. Results of a literature review performed to identify RCTs of all treatments for peritoneal dialysisassociated peritonitis

Full text

Treatment for peritoneal dialysis-associated peritonitis
(Review)
Wiggins KJ, Craig JC, Johnson DW, Strippoli GFM
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2008, Issue 1
http://www.thecochranelibrary.com
Treatment for peritoneal dialysis-associated peritonitis (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

T A B L E O F C O N T E N T S
1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
7DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
16CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
65DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.1. Comparison 1 Intravenous (IV) versus intraperitoneal (IP) antibiotics, Outcome 1 Primary treatment
failure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Analysis 1.2. Comparison 1 Intravenous (IV) versus intraperitoneal (IP) antibiotics, Outcome 2 Adverse events. . . 72
Analysis 1.3. Comparison 1 Intravenous (IV) versus intraperitoneal (IP) antibiotics, Outcome 3 Infusion pain. . . 73
Analysis 2.1. Comparison 2 Oral (drug A) versus intraperitoneal (drug A) antibiotics (same antibiotic), Outcome 1 Failure
to achieve complete cure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Analysis 2.2. Comparison 2 Oral (drug A) versus intraperitoneal (drug A) antibiotics (same antibiotic), Outcome 2 Primary
treatment failure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Analysis 2.3. Comparison 2 Oral (drug A) versus intraperitoneal (drug A) antibiotics (same antibiotic), Outcome 3
Relapse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Analysis 2.4. Comparison 2 Oral (drug A) versus intraperitoneal (drug A) antibiotics (same antibiotic), O utcome 4 Catheter
removal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Analysis 2.5. Comparison 2 Oral (drug A) versus intraperitoneal (drug A) antibiotics (same antibiotic), Outcome 5
Hospitalisation rate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Analysis 2.6. Comparison 2 Oral (drug A) versus intraperitoneal (drug A) antibiotics (same antibiotic), Outcome 6 Adverse
events. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Analysis 3.1. Comparison 3 Oral (regimen A) versus intraperitoneal (regimen B) antibiotics (different antibiotic/s),
Outcome 1 Failure to achieve complete cure. . . . . . . . . . . . . . . . . . . . . . . . 76
Analysis 3.2. Comparison 3 Oral (regimen A) versus intraperitoneal (regimen B) antibiotics (different antibiotic/s),
Outcome 2 Primary treatment failure. . . . . . . . . . . . . . . . . . . . . . . . . . 78
Analysis 3.3. Comparison 3 Oral (regimen A) versus intraperitoneal (regimen B) antibiotics (different antibiotic/s),
Outcome 3 Relapse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Analysis 3.4. Comparison 3 Oral (regimen A) versus intraperitoneal (regimen B) antibiotics (different antibiotic/s),
Outcome 4 Catheter removal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Analysis 3.5. Comparison 3 Oral (regimen A) versus intraperitoneal (regimen B) antibiotics (different antibiotic/s),
Outcome 5 Hospitalisation rate. . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Analysis 3.6. Comparison 3 Oral (regimen A) versus intraperitoneal (regimen B) antibiotics (different antibiotic/s),
Outcome 6 All-cause mortality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Analysis 3.7. Comparison 3 Oral (regimen A) versus intraperitoneal (regimen B) antibiotics (different antibiotic/s),
Outcome 7 Microbiological eradication. . . . . . . . . . . . . . . . . . . . . . . . . . 81
Analysis 3.8. Comparison 3 Oral (regimen A) versus intraperitoneal (regimen B) antibiotics (different antibiotic/s),
Outcome 8 Adverse e vents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Analysis 4.1. Comparison 4 Low dose versus high dose antibiotic, Outcome 1 Failure to achieve complete cure. . . 83
Analysis 4.2. Comparison 4 Low dose versus high dose antibiotic, Outcome 2 Relapse. . . . . . . . . . . . 83
Analysis 4.3. Comparison 4 Low dose versus high dose antibiotic, Outcome 3 Seizures. . . . . . . . . . . . 84
Analysis 5.1. Comparison 5 Intermittent versus continuous antibiotics, Outcome 1 Failure to achieve complete cure. 84
Analysis 5.2. Comparison 5 Intermittent versus continuous antibiotics, Outcome 2 Primary treatment failure. . . . 86
iTreatment for peritoneal dialysis-associated peritoniti s (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Analysis 5.3. Comparison 5 Intermittent versus continuous antibiotics, Outcome 3 Relapse. . . . . . . . . . 87
Analysis 5.4. Comparison 5 Intermittent versus continuous antibiotics, Outcome 4 Rash. . . . . . . . . . . 88
Analysis 6.1. Comparison 6 First generation cephalosporin versus glycopeptide-based IP antibiotic regimen, Outcome 1
Failure to achieve complete cure. . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Analysis 6.2. Comparison 6 First generation cephalosporin versus glycopeptide-based IP antibiotic regimen, Outcome 2
Primary treatment failure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Analysis 6.3. Comparison 6 First generation cephalosporin versus glycopeptide-based IP antibiotic regimen, Outcome 3
Relapse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Analysis 6.4. Comparison 6 First generation cephalosporin versus glycopeptide-based IP antibiotic regimen, Outcome 4
Catheter removal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Analysis 6.5. Comparison 6 First generation cephalosporin versus glycopeptide-based IP antibiotic regimen, Outcome 5
Microbiological eradication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Analysis 7.1. Comparison 7 Teicoplanin versus vancomycin-based IP antibiotic regimen, Outcome 1 Failure to achieve
complete cure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Analysis 7.2. Comparison 7 Teicoplanin versus vancomycin-based IP antibiotic regimen, Outcome 2 Primary treatment
failure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Analysis 7.3. Comparison 7 Teicoplanin versus vancomycin-based IP antibiotic regimen, Outcome 3 Relapse. . . . 93
Analysis 8.1. Comparison 8 Comparison of two oral antibiotic regimens, Outcome 1 Failure to achieve complete cure. 94
Analysis 8.2. Comparison 8 Comparison of two oral antibiotic regimens, Outcome 2 Change in antibiotics following
culture results. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Analysis 8.3. Comparison 8 Comparison of two oral antibiotic regimens, Outcome 3 Catheter removal. . . . . . 95
Analysis 8.4. Comparison 8 Comparison of two oral antibiotic regimens, Outcome 4 Adverse events. . . . . . . 95
Analysis 9.1. Comparison 9 Fibrinolytic agents versus non-urokinase or placebo, Outcome 1 Failure to achieve complete
cure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Analysis 9.2. Comparison 9 Fibrinolytic agents versus non-urokinase or placebo, Outcome 2 Primary treatment failure
(persistent peritonitis). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Analysis 9.3. Comparison 9 Fibrinolytic agents versus non-urokinase or placebo, Outcome 3 Relapse. . . . . . . 97
Analysis 9.4. Comparison 9 Fibrinolytic agents versus non-urokinase or placebo, Outcome 4 Catheter removal. . . 98
Analysis 9.5. Comparison 9 Fibrinolytic agents versus non-urokinase or placebo, Outcome 5 All-cause mortality. . . 99
Analysis 10.1. Comparison 10 Urokinase versus simultaneous catheter removal or replacement, Outcome 1 Recurrence of
peritonitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Analysis 11.1. Comparison 11 Peritoneal lavage, Outcome 1 Failure to achieve complete cure. . . . . . . . . 100
Analysis 11.2. Comparison 11 Peritoneal lavage, Outcome 2 Relapse. . . . . . . . . . . . . . . . . . 100
Analysis 11.3. Comparison 11 Peritoneal lavage, Outcome 3 Technique failure. . . . . . . . . . . . . . 101
Analysis 11.4. Comparison 11 Peritoneal lavage, Outcome 4 Adverse events. . . . . . . . . . . . . . . 101
Analysis 12.1. Comparison 12 Intraperitoneal immunoglobulin, Outcome 1 Number of exchanges for reduction in
dialysate WWC < 100/mL. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Analysis 12.2. Comparison 12 Intraperitoneal immunoglobulin, Outcome 2 Relapse. . . . . . . . . . . . 102
Analysis 13.1. Comparison 13 Intraperitoneal cefepime versus intraperitoneal vancomycin/netilmicin, Outcome 1 Failure
to achieve complete cure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Analysis 13.2. Comparison 13 Intraperitoneal cefepime versus intraperitoneal vancomycin/netilmicin, Outcome 2 Primary
treatment failure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Analysis 13.3. Comparison 13 Intraperitoneal cefepime versus intraperitoneal vancomycin/netilmicin, Outcome 3
Relapse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Analysis 13.4. Comparison 13 Intraperitoneal cefepime versus intraperitoneal vancomycin/netilmicin, Outcome 4 Death
due to peritonitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Analysis 13.5. Comparison 13 Intraperitoneal cefepime versus intraperitoneal vancomycin/netilmicin, Outcome 5
Hospitalisation rate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Analysis 13.6. Comparison 13 Intraperitoneal cefepime versus intraperitoneal vancomycin/netilmicin, Outcome 6 Infusion
pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Analysis 14.1. Comparison 14 Intraperitoneal cefuroxime versus intraperitoneal vancomycin/netilmicin, Outcome 1
Primary treatment failure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
iiTreatment for peritoneal dialysis-associated peritonit is (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Analysis 14.2. Comparison 14 Intraperitoneal cefuroxime versus intraperitoneal vancomycin/netilmicin, Outcome 2
Catheter removal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Analysis 16.1. Comparison 16 Intraperitoneal vancomycin/cefotaxime versus intraperitoneal vancomycin/tobramycin,
Outcome 1 Failure to achieve complete cure. . . . . . . . . . . . . . . . . . . . . . . . 107
Analysis 16.2. Comparison 16 Intraperitoneal vancomycin/cefotaxime versus intraperitoneal vancomycin/tobramycin,
Outcome 2 Primary treatment failure. . . . . . . . . . . . . . . . . . . . . . . . . . 107
Analysis 16.3. Comparison 16 Intraperitoneal vancomycin/cefotaxime versus intraperitoneal vancomycin/tobramycin,
Outcome 3 Relapse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Analysis 16.4. Comparison 16 Intraperitoneal vancomycin/cefotaxime versus intraperitoneal vancomycin/tobramycin,
Outcome 4 Catheter removal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Analysis 17.1. Comparison 17 Intraperitoneal ciprofloxacin versus intraperitoneal vancomycin/gentamicin, Outcome 1
Failure to achieve complete cure. . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Analysis 17.2. Comparison 17 Intraperitoneal ciprofloxacin versus intraperitoneal vancomycin/gentamicin, Outcome 2
Primary treatment failure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Analysis 17.3. Comparison 17 Intraperitoneal ciprofloxacin versus intraperitoneal vancomycin/gentamicin, Outcome 3
Relapse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
Analysis 17.4. Comparison 17 Intraperitoneal ciprofloxacin versus intraperitoneal vancomycin/gentamicin, Outcome 4
Catheter removal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
Analysis 18.1. Comparison 18 Intraperitoneal cephazolin/netilmicin versus intraperitoneal vancomycin/ceftazidime,
Outcome 1 Primary treatment failure. . . . . . . . . . . . . . . . . . . . . . . . . . 111
Analysis 19.1. Comparison 19 Intraperitoneal cefuroxime versus intraperitoneal teicoplanin/aztreonam, Outcome 1
Primary treatment failure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Analysis 19.2. Comparison 19 Intraperitoneal cefuroxime versus intraperitoneal teicoplanin/aztreonam, Outcome 2
Relapse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
Analysis 19.3. Comparison 19 Intraperitoneal cefuroxime versus intraperitoneal teicoplanin/aztreonam, Outcome 3 All-
cause mortality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
Analysis 20.1. Comparison 20 Intraperitoneal cefazolin/ceftazidime versus intraperitoneal imipenem, Outcome 1 Primary
treatment failure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Analysis 20.2. Comparison 20 Intraperitoneal cefazolin/ceftazidime versus intraperitoneal imipenem, Outcome 2 Catheter
removal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Analysis 21.1. Comparison 21 Intraperitoneal cefazolin/ceftazidime versus intraperitoneal cefazolin/netilmicin, Outcome 1
Failure to achieve complete cure. . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Analysis 21.2. Comparison 21 Intraperitoneal cefazolin/ceftazidime versus intraperitoneal cefazolin/netilmicin, Outcome 2
Relapse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Analysis 21.3. Comparison 21 Intraperitoneal cefazolin/ceftazidime versus intraperitoneal cefazolin/netilmicin, Outcome 3
Catheter removal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Analysis 22.1. Comparison 22 Intraperitoneal ciprofloxacin/rifampicin versus intraperitoneal cephradine, Outcome 1
Primary treatment failure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Analysis 22.2. Comparison 22 Intraperitoneal ciprofloxacin/rifampicin versus intraperitoneal cephradine, Outcome 2
Relapse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
Analysis 22.3. Comparison 22 Intraperitoneal ciprofloxacin/rifampicin versus intraperitoneal cephradine, Outcome 3
Catheter removal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
Analysis 22.4. Comparison 22 Intraperitoneal ciprofloxacin/rifampicin versus intraperitoneal cephradine, Outcome 4
Microbiological eradication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Analysis 22.5. Comparison 22 Intraperitoneal ciprofloxacin/rifampicin versus intraperitoneal cephradine, Outcome 5
Adverse events. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
117APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
118WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
119HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
119CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
119DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
119INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
iiiTreatment for peritoneal dialysis-associated peritonitis (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

[Intervention Review]
Treatment for peritoneal dialysis-associated peritonitis
Kathryn J Wiggins
1
, Jonathan C Craig
2
, David W Johnson
3
, Giovanni FM Strippoli
4
1
Department of Nephrology, St Vincent’s Hospital, Fitzroy, Australia.
2
(a) Cochrane Renal Group, Centre for Kidney Research, The
Children’s Hospital at Westmead, (b) School of Public Health, The University of Sydney, Westmead, Australia.
3
Department of
Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia.
4
a) School of Public Health, University of Sydney, b) Cochrane
Renal Group, c) Diaverum Medical Scientific office, d) Mario Negri Sud Consortium, Italy, Westmead, Australia
Contact address: Kathryn J Wiggins, Department of Nephrology, St Vincent’s Hospital, Level 4, Clinical Sciences Building, Fitzroy,
VIC, 3065, Australia.
kate.wiggins@mh.org.au.
Editorial group: Cochrane Renal Group.
Publication status and date: Edited (no change to conclusions), published in Issue 4, 2010.
Review content assessed as up-to-date: 4 November 2007.
Citation: Wiggins KJ, Craig JC, Johnson DW, Strippoli GFM. Treatment for peritoneal dialysis-associated peritonitis. Cochrane
Database of Systematic Reviews 2008, Issue 1. Art. No.: CD005284. DOI: 10.1002/14651858.CD005284.pub2.
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
A B S T R A C T
Background
Peritonitis is a common complication of peritoneal dialysis (PD) and is associated with significant morbidity. Adequate treatment is
essential to reduce morbidity and recurrence.
Objectives
To evaluate the benefits and harms of treatments for PD-associated peritonitis.
Search methods
We search ed the Cochrane Renal Group’s specialised register, the Cochrane Central Register of Controlled Trials (CENTRAL, in The
Cochrane Library), MEDLINE, EMBASE and reference lists without language restriction.
Selection criteria
All randomised controlled trials (RCTs) and quasi-RCTs assessing the treatment of peritonitis in peritoneal dialysis patients (adults and
children) evaluating: administration of an antibiotic(s) by diff erent routes (e.g. oral, intraperitoneal, intravenous); dose of an antibiotic
agent(s); different schedules of administration of antimicrobial agents; comparisons of different regimens of antimicrobial agents; any
other intervention including fibrinolytic agents, peritoneal lavage and early catheter removal were included.
Data coll ection and analysis
Two authors extracted data on study quality and outcomes. Statistical analyses were performed using the random effects model and the
dichotomous results were expressed as risk ratio (RR) with 95% confidence intervals (CI) and continuous outcomes as mean difference
(MD) with 95% CI.
Main results
We identified 36 studies (2089 patients): antimicrobial agents (30); urokinase (4), peritoneal lavage (1) intraperitoneal (IP) immunoglob-
ulin (1). No superior antibiotic agent or combination of agents were identified. Primary response and relapse rates did not differ
between IP glycopeptide-based regimens compared to first generation cephalosporin regimens, although glycopeptide regimens were
more likely to achieve a complete cure (3 studies, 370 episodes: RR 1.66, 95% CI 1.01 to 3.58). For relapsing or persistent peritonitis,
1Treatment for peritoneal dialysis-associated peritonitis (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Frequently asked questions

Q1. What contributions have the authors mentioned in the paper "Treatment for peritoneal dialysis-associated peritonitis" ?

This review of interventions for PD-associated peritonitis identified 36 studies ( 2089 participants ). The reported incidence of peritonitis episodes varies from 1/9 patientmonths to 1/53 patient-months ( Grunberg 2005 ; Kawaguchi 1999 ). This may be temporary and followed by a return to PD, or permanent resulting in technique failure. To address existing uncertainties, the authors performed a systematic review of randomised controlled trial ( RCT ) evidence examining the effectiveness of different treatment options currently employed for PD-associated peritonitis. Further RCTs within this area are required. 

Q2. What future works have the authors mentioned in the paper "Treatment for peritoneal dialysis-associated peritonitis" ?

This may be a true effect due to inadvertent removal of macrophages and other components of the immune system thereby a reduction of local host defences against infection However, further studies to evaluate this therapy further may be useful. Further studies are required to establish the most effective treatment for PD-associated peritonitis. Future research should be adequately powered to assess outcomes such as catheter removal and mortality, and should include long-term follow-up of parameters such as UFF, loss of RRF and technique failure. Further studies are required to establish the most effective treatment for peritoneal dialysis-associated peritonitis. 

Q3. What is the mainstay of treatment for peritonitis?

The mainstay of peritonitis treatment is timely administration of empirical antimicrobial agents that are likely to eradicate the most common causative agents. 

Q4. What are the main factors that should be considered when choosing antibiotics?

When choosing antibiotics the side-effect profile, local drug resistance patterns and previous antibiotic use and infection history in the individual concerned should be considered. 

Q5. What is the reason for the high rate of complications arising from peritonitis?

The high rate of complications arising from peritonitis despite rapid institution of antibiotic therapy suggests a need exists for adjuvant treatment strategies. 

Q6. What is the effect of a broad spectrum antibiotic on emergence of VRE?

The emergence of vancomycin-resistant enterococcus (VRE) is also associated with use of broad spectrum antibiotics (Carmeli 2002; Oprea 2004). 

Q7. What has been the subject of only one RCT?

It has however been the subject of only one RCT (Ejlersen 1991), in which patients with hypotension and shock, the same group in which lavage has been used in surgical settings, were excluded. 

Q8. How many studies were included in the search?

Analysis of the remaining 67 studies identified 36 studies (2089 patients, 2480 peritonitis episodes) published in 42 articles which were analysed in full-text. 

Q9. what is the cheapest teicoplanin for peritoneal dialysis?

A prospective, randomized trial of two antibiotic regimens in the treatment of peritonitis in CAPD patients: Teicoplanin plus tobramycin versus cephalothin plus tobramycin. 

Q10. What are the main questions about the treatment of PD-associated peritonitis?

several questions about the optimal treatment of PD-associated peritonitis remain unanswered, particularly with respect to choice, route of administration (Passadakis 2001) and duration of antimicrobial therapy. 

Q11. Was there a plan to assess funnel plot asymmetry?

It was also planned that if sufficient RCTs were identified an attempt would be made to assess funnel plot asymmetry due to small study effect, as this may be indicative of publication bias (Egger 1997). 

Q12. What is the effect of ciprofloxacin on the emergence of multiresistant?

the broad spectrum of action of both ciprofloxacin and rifampicin predisposes to emergence of multiresistant organisms thereby reducing their desirability as first line agents. 

Q13. What was the quality of included studies assessed?

The quality of included studies was assessed independently by KW and GFMS without blinding to authorship or journal using the checklist developed by the Cochrane Renal Group.