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Due to discrepant definitions of exit-site infections and/or tunnel infections (ESI/TI), as well as to the variety of infection rates, data on ESI/TI are extremely difficult to compare. Twardwski et al. have defined exit site, while Nolph et al. have proposed new monitoring and reporting of ESI/TI. The aim of our prospective study was to try combining both systems. From January 1992 to December 1995 we treated 127 patients, in whom 147 double-cuff peritoneal catheters (PCs) were inserted. Tunnel infection was defined as external-cuff infection (ECI), inter-cuff segment infection (ICSI), and/or internal-cuff infection (ICI). Sixty-four PCs (43.5%) were infected. Thirty-eight (25.8%) had acute PC infection (PCI) from 2.4% to 4.7% of the total patient-months of care per year, and 26 (17.7%) PCs were chronically infected from 2.1 to 11.1% of the time per year. Almost all cases of removed acutely and chronically infected PCs had ECI in combination with ESI. According to our experience, ECI should be classified as TI. The proposed approach to monitoring and reporting is very useful for ESI, but does not include TI. Comparison between different peritoneal dialysis units is only possible when they share a common PC classification system, and when their personnel are well experienced, highly trained, and very accurate.

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In spite of several recommendations, choosing the initial antibiotic to treat continuous ambulatory peritoneal dialysis (CAPD) peritonitis remains difficult. In our prospective randomized study we attempted to evaluate the efficacy and safety of less toxic combinations of cephalosporins with vancomycin or netilmycin. From November 1993 to September 1996 we treated 52 episodes of peritonitis in 34 patients. Peritonitis was diagnosed according to the valid criteria. Patients were treated for 14 - 28 days with a combination of either cefazolin plus netilmycin or vancomycin plus ceftazidime. The most frequent bacteria causing peritonitis in the two groups were comparable. The efficacy of the cefazolin/netilmycin combination was 91.6% (22/24) without yeasts and 84.0% (21/25) in the vancomycin/ceftazidime combination. There were no statistically significant differences between the two otherwise efficient combinations of antibiotics. No side effects were observed. We believe that the frequent use of vancomycin could be avoided thus reducing the risks of resistance and ototoxicity.

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Peritoneal dialysis is the preferred dialysis mode for children with end stage renal disease (1). It avoids problems with vascular access and enables near normal life style. Haemodialysis is the only mode of treatment for a child waiting for renal transplantation when peritoneal dialysis is not possible. Haemofiltration, as a mode of renal replacement therapy, was introduced in 1967 by Lee Henderson (2).

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To analyze peritoneal catheter infections (PCIs), primarily the type (acute or chronic), frequency, and therapeutic outcome, we assessed 113 patients treated between January 1992 and December 1994. The average age was 56.3 +/- 15.3 years, and 38% were diabetics. One hundred and thirty peritoneal catheters (PCs) were placed surgically in the lateral abdominal wall. The peritonitis rate fell from 0.61 episodes/year to 0.33 episodes/year, but the exit-site and/or tunnel infection (ESI/TI) rate increased (from 0.48 episodes/year to 0.61 episodes/year). Seventy-nine cases of PCI were observed; 58 (73.4%) were acute ESI/TI and 21 (26.6%) were exacerbations of chronic ESI/TI. Thirty-one (53.4%) acute PCIs were cured, 17 (29.3%) became persistent, and in 10 (17.2%) cases the PC was removed. In chronic ESI/TI, of the 21 exacerbations registered, in 12 cases (57.1%) conservative treatment was effective, while in 9 cases (42.9%) the PC was removed. We conclude that ESI/TIs are the most frequent type of continuous ambulatory peritoneal dialysis (CAPD) infection and the more frequent cause of PC removal compared to peritonitis (p < 0.001). PC removal is more frequent in chronic than in acute ESI/TI (p < 0.005). The progression of infection towards the external and even the internal cuff is a poor prognostic sign. Staphylococcus aureus and Pseudomonas aeruginosa were the most common causes of infection and the most serious infective agents, causing chronic infection or catheter removal. Clinical evaluation of ESI/TI can be helped significantly by ultrasound examination, which is 100% positive in chronic ESI/TI and not more than 52.1% positive in acute ESI/TI (p < 0.005).

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This prospective randomized study is an evaluation of efficacy of cefazolin and ofloxacin in 23 end-stage renal disease (ESRD) patients treated with continuous ambulatory peritoneal dialysis (CAPD) who experienced 38 episodes of peritonitis (P). Cefazolin was administered intraperitoneally: 1000 mg as loading dose and 250 mg every exchange as maintenance dose for ten days. Ofloxacin was given orally: first 300 mg, followed by ten daily doses of 200 mg. Microbes most frequently isolated from peritoneal effluent were Staphylococci (coagulase-negative in 55.3%, aureus in 7.9%), Acinetobacter (in 5.3%), Klebsiella (in 5.5%), and Micrococcus (in 5.3%). Used as monotherapy, we found the efficacy of both cefazolin and ofloxacin inadequate for treatment of P in CAPD patients (cefazolin 65%, ofloxacin 67%) (NS).

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From 1988 to 1992, 114 patients with end-stage renal failure were treated with continuous ambulatory peritoneal dialysis (CAPD). In 30 patients (18 men, 12 women, age 31-80 years), 40 scanning electron micrographs (SEM) of parietal peritoneal tissue, obtained with biopsy, were performed: in 20 patients at the time of the first catheter implantation, in 14 patients after catheter removal (because of peritonitis in 12 patients and drainage problems in 2 patients), and in 6 patients during catheter reinsertion. In uremic patients two types of mesothelial cells were observed: hexagonal and elongated. In some patients microvilli were abundant and covered the whole surface of mesothelial cells; in other patients microvilli were lacking. Wide openings (stomata) between mesothelial cells were found in some cases, which were wider in patients with peritonitis. During peritonitis, microvilli disappeared, and mesothelial cells were covered with fibrin, leukocytes, and erythrocytes instead. In the majority of patients with peritonitis, mesothelial cells were totally peeled away, or removed, leaving a denuded surface of fibrous tissue. A recovery of the parietal peritoneum was observed in one patient at the time of peritoneal catheter reinsertion: a complete mesothelial regeneration with abundant microvilli appeared. In other patients the surface was denuded, without microvilli or mesothelial cells, covered with fibrin and fibrous tissue. Despite observed changes of the parietal peritoneum with SEM during the course of CAPD and peritonitis, changes may be reversible due to regeneration of mesothelial cells. Prolonged changes after discontinuation of peritoneal dialysis may persist in patients without mesothelial cell regeneration or with a defective process of fibrinolysis.

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The aim of this prospective, randomized, open study was to survey the frequency course and to evaluate the therapy of peritonitis induced by staphylococci in patients on continuous ambulatory peritoneal dialysis (CAPD). From June 1983 to November 1986, 20 patients (9 men, 11 women) aged from 25 to 73 were treated. During 258 months of the CAPD treatment they had 54 episodes of peritonitis. Staphylococcus saprophyticus was the most frequent offender of peritonitis, isolated from peritoneal effluent in 44% of the cases, Staphylococcus epidermidis was isolated in 7% of the cases. Staphylococcus aureus was isolated in 5% of the cases and caused a more severe form of peritonitis. The combination of gentamicin and methicillin was used in 14 cases, in 2 cases this treatment was unsuccessful. A combination of gentamicin and cloxacillin was used in 5 cases and a combination of clindamycin and mezlocillin in 12 cases of peritonitis, giving good results in all cases. The last combination seemed to be the most effective in the treatment of staphylococcus induced peritonitis.

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