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Chapter 17 : Infections Related to Hemodialysis and Peritoneal Dialysis

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Infections Related to Hemodialysis and Peritoneal Dialysis, Page 1 of 2

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Abstract:

Hemodialysis and peritoneal dialysis provide life-sustaining therapy for patients with end-stage renal disease (ESRD). Peritoneal dialysis requires the regular exchange of dialysate within the peritoneum. The dialysate contains high concentrations of glucose, which create an osmotic force to move fluid into the peritoneal cavity. Immunosuppression can also be a direct result of the dialysis process. During peritoneal dialysis, the regular exchange of dialysate causes the dilution and removal of white cells, along with factors such as cytokines, immunoglobulins, and opsonins. The standard material for the construction of bridge grafts is polytetrafluoroethylene (PTFE). PTFE is hydrophobic, inert, and thought to resist infection. Central venous catheters (CVCs) play a vital role in the maintenance of vascular access for many patients. Tunneling and dacron cuffs are designed to prevent infection of hemodialysis CVCs. Empiric treatment of catheter-related bloodstream infection (CR-BSI) should cover gram-positive (e.g., vancomycin, cefazolin, cloxacillin) and gram-negative (e.g., gentamicin) organisms while awaiting culture results. Vancomycin should be used if the prevalence of methicillin-resistant staphylococci is high. Blood cultures should be repeated periodically during and immediately after completion of therapy to monitor effectiveness. Infections related to peritoneal dialysis are broadly classified as peritonitis or exit-site/ tunnel infection. Peritonitis caused by pseudomonal or xanthomonal organisms is generally more serious than that caused by other gram-negative bacteria. Catheter loss has been reported to complicate 16.3% of episodes of peritonitis and 21% of exit-site and tunnel infections.

Citation: Oliver M, Schwab S. 2000. Infections Related to Hemodialysis and Peritoneal Dialysis, p 345-372. In Waldvogel F, Bisno A (ed), Infections Associated with Indwelling Medical Devices, Third Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818067.ch17

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Coronary Artery Disease
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Urinary Tract Infections
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Catheter-Related Bloodstream Infections
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Figures

Image of Figure 1
Figure 1

Location of exit-site infection and tunnel infection in typical hemodialysis central venous catheter. Tunnel infection can be defined as signs of infection extending beyond a 2-cm radius of the exit site or, alternatively, signs of infection that extend proximal to the Dacron cuff.

Citation: Oliver M, Schwab S. 2000. Infections Related to Hemodialysis and Peritoneal Dialysis, p 345-372. In Waldvogel F, Bisno A (ed), Infections Associated with Indwelling Medical Devices, Third Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818067.ch17
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Image of Figure 2
Figure 2

Location of exit site, tunnel infection, and peritonitis in a typical peritoneal dialysis catheter. Tunnel infection occurs when infection extends beyond the superficial cuff. Peritonitis occurs when infection enters into the peritoneal cavity.

Citation: Oliver M, Schwab S. 2000. Infections Related to Hemodialysis and Peritoneal Dialysis, p 345-372. In Waldvogel F, Bisno A (ed), Infections Associated with Indwelling Medical Devices, Third Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818067.ch17
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Image of Figure 3
Figure 3

Randomized studies of carriage eradication to prevent peritoneal exit-site infection. For intranasal mupirocin. the treatment was mupirocin twice daily to the nose for 5 consecutive days every 4 weeks. For first oral rifampin study (third column from left), the treatment was 300 mg twice daily for 5 days of each 12-wcek interval. For the second oral rifampin study (fifth and sixth columns from the left), the rifampin was given as 600 mg daily for 5 days every 3 months, and the mupirocin ointment was applied to the exit site daily.

Citation: Oliver M, Schwab S. 2000. Infections Related to Hemodialysis and Peritoneal Dialysis, p 345-372. In Waldvogel F, Bisno A (ed), Infections Associated with Indwelling Medical Devices, Third Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818067.ch17
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Image of Figure 4
Figure 4

The Y-conncct system for peritoneal dialysis. The patient connects the peritoneal dialysis catheter to the Y connector. One arm of the Y connects to the fresh bag of dialysis solution while the other arm is connected to the previously used dialysis bag. The first step after the spike is to flush a small amount of the new dialysis solution into the old dialysis bag. The remainder is instilled into the peritoneal cavity. This “flush before fill” technique significantly reduced peritonitis rates. An additional modification is to have a separate drainage bag pre-attached to the Y connector, rather than to the previously used bag. to minimize the number of connections performed by the patient. The solid triangle (▲) represent a clamped dialysis line and the arrows represent the direction of dialysis flow. Adapted with permission from reference . Copyright 1999 UpToDate. Inc.

Citation: Oliver M, Schwab S. 2000. Infections Related to Hemodialysis and Peritoneal Dialysis, p 345-372. In Waldvogel F, Bisno A (ed), Infections Associated with Indwelling Medical Devices, Third Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818067.ch17
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Image of Figure 5
Figure 5

Recommended care path for the diagnosis and treatment of peritoneal dialysis-related peritonitis. The diagram is a general recommendation for diagnoses and treating peritonitis. Management should be reassessed based on actual sensitivities and the clinical status of the patient. Catheter removal may be required to resolve infection. For antibiotic dosages see Table 11 . Adapted and redrawn with permission ( ).

Citation: Oliver M, Schwab S. 2000. Infections Related to Hemodialysis and Peritoneal Dialysis, p 345-372. In Waldvogel F, Bisno A (ed), Infections Associated with Indwelling Medical Devices, Third Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818067.ch17
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Tables

Generic image for table
Table 1

Classification of infections in dialysis patients

Citation: Oliver M, Schwab S. 2000. Infections Related to Hemodialysis and Peritoneal Dialysis, p 345-372. In Waldvogel F, Bisno A (ed), Infections Associated with Indwelling Medical Devices, Third Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818067.ch17
Generic image for table
Table 2

Predisposing factors for infection in dialysis population

Citation: Oliver M, Schwab S. 2000. Infections Related to Hemodialysis and Peritoneal Dialysis, p 345-372. In Waldvogel F, Bisno A (ed), Infections Associated with Indwelling Medical Devices, Third Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818067.ch17
Generic image for table
Table 3

Risk factors for infection in dialysis patients

Citation: Oliver M, Schwab S. 2000. Infections Related to Hemodialysis and Peritoneal Dialysis, p 345-372. In Waldvogel F, Bisno A (ed), Infections Associated with Indwelling Medical Devices, Third Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818067.ch17
Generic image for table
Table 4

Incidence of infectious complications from cuffed, tunneled hemodialysis CVCs

Citation: Oliver M, Schwab S. 2000. Infections Related to Hemodialysis and Peritoneal Dialysis, p 345-372. In Waldvogel F, Bisno A (ed), Infections Associated with Indwelling Medical Devices, Third Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818067.ch17
Generic image for table
Table 5

Catheter-related bacteremia rates according to CVC type

Citation: Oliver M, Schwab S. 2000. Infections Related to Hemodialysis and Peritoneal Dialysis, p 345-372. In Waldvogel F, Bisno A (ed), Infections Associated with Indwelling Medical Devices, Third Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818067.ch17
Generic image for table
Table 6

Management options for catheter-related bacteremia

Citation: Oliver M, Schwab S. 2000. Infections Related to Hemodialysis and Peritoneal Dialysis, p 345-372. In Waldvogel F, Bisno A (ed), Infections Associated with Indwelling Medical Devices, Third Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818067.ch17
Generic image for table
Table 7

Clinical characteristics of exit site based on appearance category

Citation: Oliver M, Schwab S. 2000. Infections Related to Hemodialysis and Peritoneal Dialysis, p 345-372. In Waldvogel F, Bisno A (ed), Infections Associated with Indwelling Medical Devices, Third Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818067.ch17
Generic image for table
Table 8

Pathogenesis of peritonitis

Citation: Oliver M, Schwab S. 2000. Infections Related to Hemodialysis and Peritoneal Dialysis, p 345-372. In Waldvogel F, Bisno A (ed), Infections Associated with Indwelling Medical Devices, Third Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818067.ch17
Generic image for table
Table 9

Common organisms causing peritonitis since introduction of the Y-set connector

Citation: Oliver M, Schwab S. 2000. Infections Related to Hemodialysis and Peritoneal Dialysis, p 345-372. In Waldvogel F, Bisno A (ed), Infections Associated with Indwelling Medical Devices, Third Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818067.ch17
Generic image for table
Table 10

Summary of evaluation and treatment of exit-site and cuff/tunnel infection related to peritoneal dialysis

Citation: Oliver M, Schwab S. 2000. Infections Related to Hemodialysis and Peritoneal Dialysis, p 345-372. In Waldvogel F, Bisno A (ed), Infections Associated with Indwelling Medical Devices, Third Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818067.ch17
Generic image for table
Table 11

Dosage regimens for antibiotics commonly used to treat peritonitis

Citation: Oliver M, Schwab S. 2000. Infections Related to Hemodialysis and Peritoneal Dialysis, p 345-372. In Waldvogel F, Bisno A (ed), Infections Associated with Indwelling Medical Devices, Third Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818067.ch17
Generic image for table
Table 12

Peritonitis complications according to infecting organism

Citation: Oliver M, Schwab S. 2000. Infections Related to Hemodialysis and Peritoneal Dialysis, p 345-372. In Waldvogel F, Bisno A (ed), Infections Associated with Indwelling Medical Devices, Third Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818067.ch17

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