The Effect of Continuing Nursing Intervention on Peritoneal Dialysis Patients and the Occurrence of Peritonitis: A Meta-Analysis.

Background: Chronic kidney disease, affecting millions globally, has emerged as a significant health concern alongside tumors, diabetes, and cardiovascular diseases. Peritoneal dialysis is a widely used therapeutic intervention, but its effectiveness can be compromised by complications such as peritonitis. Methods: We conducted a comprehensive search across eight international databases to obtain controlled trials evaluating the impact of continuous nursing on peritonitis occurrence in peritoneal dialysis patients. Following stringent quality assessment, data analysis was performed using RevMan 5.3 software. Results: Our meta-analysis included 15 controlled trials. Of these, 13 reported peritonitis rates in both intervention and control groups. Continuous nursing was associated with a significant reduction in peritonitis incidence (OR: 0.32; 95% CI: 0.23,0.44) and complications (SMD: 3.21; 95% CI: 1.17,5.25; P = .01), as well as a decrease in serum creatinine levels (SMD: -130.06; 95% CI: -195.46,-64). Conclusion: The findings of this study support the possibility that ongoing nursing is beneficial for the complications and creatinine for peritoneal dialysis patients.

Comparative effectiveness of prophylactic hyperthermic intraperitoneal chemotherapy (HIPEC) for resected low-grade appendiceal mucinous neoplasm (LAMN): A protocol for systematic review and network meta-analysis.

BACKGROUND: Whether prophylactic hyperthermic intraperitoneal chemotherapy (HIPEC) offers long-term survival benefit to patients with low-grade appendiceal mucinous neoplasms (LAMNs) after resection surgery is still under heated debate. The aim of the present meta-analysis is to investigate the comparative effectiveness and safety of prophylactic HIPEC regimens in LAMNs METHODS:: A systematic search of MEDLINE, EMBASE, PubMed, Web of Science, the Cochrane Central Register of Controlled Trials, International Clinical Trials Registry Platform (ICTRP), clinicaltrials.gov and controlledtrials.com will be performed. All published RCTs and quasi-RCTs through July 20, 2020 with language restricted in English will be included in this review study. Two reviewers will independently conduct the procedures of study identification, data collection, and methodological quality assessment. The primary outcomes are overall survival (OS) and disease-free survival (DFS). The secondary outcomes consist of peritonitis and sepsis, colonic fistula, chemotherapy-associated adverse events, and adhesive intestinal obstruction. The pooled odds ratios (ORs) or hazard ratios (HRs) and relative 95% confident intervals (CIs) of each outcome measurement will be calculated. EndNote X9 software will be applied to manage all citations. The Stata software version 14.0 and R x64 software version 3.5.1 will be employed for main statistical analyses. DISCUSSION: This study will employ a network meta-analysis to summarize direct and indirect evidence in the specific area to provide detailed individualized guidance on surgical management for LAMNs. REGISTRATION: This protocol was registered with the International Platform of Registered Systematic Review and Meta-Analysis Protocols (INPLASY) on 25 July 2020 (registration number INPLASY202070112).

Prevalence and Predictors of Third-Generation Cephalosporin Resistance in the Empirical Treatment of Spontaneous Bacterial Peritonitis.

OBJECTIVE: To better characterize the changing patterns of spontaneous bacterial peritonitis (SBP) in a tertiary academic center in the United States by identifying the prevalence of gram-positive organisms and cephalosporin resistance along with predictors of mortality and antibiotic drug resistance. PATIENTS AND METHODS: We reviewed 481 consecutive patients with SBP at Mayo Clinic in Rochester, Minnesota, from January 1, 2005, through December 31, 2016. Data on comorbid conditions, etiology of cirrhosis, factors predisposing to infection, and antimicrobial and antibiotic drug use were collected. RESULTS: We identified 96 patients (20%) with culture-positive SBP requiring treatment (median age, 60 years; age range, 22-87 years; 44% men). Gram-positive organisms account for more than half of the cases. Overall resistance to third-generation cephalosporins was 10% (n=10). Risk factors for third-generation cephalosporin resistance include nosocomial acquisition, recent antibiotic drug use, and hepatocellular carcinoma. The negative predictive value for antibiotic drug resistance in the present model was 96% (70 of 73). Overall mortality at 30 and 90 days was 23% and 37%, respectively. CONCLUSION: These findings support the recent observation of a rising prevalence of gram-positive organisms in SBP. Despite the changing pattern, third-generation cephalosporins seem to provide adequate empirical treatment in patients with community-acquired and health care-associated SBP without hepatocellular carcinoma.

Peritoneal dialysis in older adults: Evaluation of clinical, nutritional, metabolic outcomes, and quality of life.

The number of older adults requiring dialysis is increasing worldwide, whereas the use of peritoneal dialysis (PD) in this population is lower with respect to younger patients, despite the theoretical advantages of PD respect to hemodialysis. This is most likely due to the concern that older patients may not be able to correctly and safely manage PD.We aimed to prospectively compare clinical, nutritional and metabolic outcomes and measures of quality of life between younger (<65 years old) and older (≥65 years old) patients on PD.PD patients were enrolled and divided into 2 groups according to age (Group A < 65 years, Group B ≥ 65 years). Clinical and instrumental parameters, and quality of life were evaluated at baseline (start of PD) (T0) and at 24 months (T1). Technique survival, mortality, total number of hospitalizations, and the index of peritonitis (episodes of peritonitis/month) were also evaluated.Fifty-one patients starting PD were enrolled. Group A included 22 patients (48.7 ±â€Š8.3 years), and Group B consisted of 29 patients (74.1 ±â€Š6.4 years). At baseline, the 2 groups showed no differences in cognitive status, whereas Group A showed higher total cholesterol (P = .03), LDL (P = .03), and triglycerides (P = .03) levels and lower body mass index (P = .02) and carotid intima media thickness (P < .0001) with respect to Group B. At T1 Group B showed, compared to baseline, a significant reduction in albumin (P < .0001) and phosphorus (P = .045) levels, while no significant differences on body composition, technique survival, total number of hospitalizations, index of peritonitis, and quality of life indices were observed.Our data do not show clinically relevant barriers to use PD in older adult patients, supporting its use in this population. Nutritional and metabolic parameters should be carefully monitored in older PD patients.

Risk of Catastrophic Health Expenditure in Rwandan Surgical Patients with Peritonitis.

BACKGROUND: Surgical procedures are cost-effective compared with various medical and public health interventions. While peritonitis often requires surgery, little is known regarding the associated costs, particularly in low- and middle-income countries. The aim of this study was to determine in-hospital charges for patients with peritonitis and if patients are at risk of catastrophic health expenditure. METHODS: As part of a larger study examining the epidemiology and outcomes of patients with peritonitis at a referral hospital in Rwanda, patients undergoing operation for peritonitis were enrolled and hospital charges were examined. The primary outcome was the percentage of patients at risk for catastrophic health expenditure. Logistic regression was used to determine the association of various factors with risk for catastrophic health expenditure. RESULTS: Over a 6-month period, 280 patients underwent operation for peritonitis. In-hospital charges were available for 245 patients. A total of 240 (98%) patients had health insurance. Median total hospital charges were 308.1 USD, and the median amount paid by patients was 26.9 USD. Thirty-three (14%) patients were at risk of catastrophic health expenditure based on direct medical expenses. Estimating out-of-pocket non-medical expenses, 68 (28%) patients were at risk of catastrophic health expenditure. Unplanned reoperation was associated with increased risk of catastrophic health expenditure (p < 0.001), whereas patients with community-based health insurance had decreased risk of catastrophic health expenditure (p < 0.001). CONCLUSIONS: The median hospital charges paid out-of-pocket by patients with health insurance were small in relation to total charges. A significant number of patients with peritonitis are at risk of catastrophic health expenditure.

Efficacy and safety of metronidazole injection for the treatment of infectious peritonitis, abdominal abscess and pelvic inflammatory diseases in Japan.

Although metronidazole (MNZ) has been used worldwide for more than 4 decades as a standard therapy for trichomoniasis, anaerobic and amebic infections, resistance to MNZ is still low. MNZ is available as oral, intravenous, and vaginal formulations, but the intravenous formulation of MNZ has not been approved in Japan. We conducted a phase 3 study to evaluate the efficacy and safety of intravenous MNZ combined with ceftriaxone (CTRX) in Japanese subjects with infectious peritonitis, abdominal abscess or pelvic inflammatory diseases (PIDs) to obtain regulatory approval. A combination of MNZ/CTRX at doses of 500 mg 3 or 4 times a day/1 or 2 g twice a day was administered intravenously to a total of 38 hospitalized subjects. MNZ/CTRX was well tolerated and exhibited excellent clinical and bacteriological efficacy with clinical efficacy rates of 100% (20/20) in infectious peritonitis or abdominal abscess subjects and 90.0% (9/10) in PID subjects, and the eradication rates in infectious peritonitis or abdominal abscess subjects and PID subjects were 100% (16/16) and 100% (4/4), respectively, at the test of cure. MNZ/CTRX was effective in 1 subject in whom a metallo-ß-lactamase-producing Bacteroides fragilis strain (MIC of MNZ, 2 µg/ml) was identified. The most common treatment-related adverse event was diarrhea (23.7%), followed by nausea (5.3%). No new safety signals were identified. MNZ/CTRX demonstrated excellent efficacy and was well tolerated in Japanese infectious peritonitis, abdominal abscess and PID subjects. This treatment regimen can be useful for anaerobic infections. Clinical registration number: NCT01473836.

Evolving epidemiology and antimicrobial resistance in spontaneous bacterial peritonitis: a two-year observational study.

BACKGROUND: Current recommendations for empirical antimicrobial therapy in spontaneous bacterial peritonitis (SBP) are based on quite old trials. Since microbial epidemiology and the management of patients have changed, whether these recommendations are still appropriate must be confirmed. METHODS: An observational study that exhaustively collected the clinical and biological data associated with positive ascitic fluid cultures was conducted in four French university hospitals in 2010-2011. RESULTS: Two hundred and sixty-eight documented positive cultures were observed in 190 cirrhotic patients (median age 61.5 years, 58.5% Child score C). Of these, 57 were classified as confirmed SBP and 140 as confirmed bacterascites. The predominant flora was Gram-positive cocci, whatever the situation (SBP, bacterascites, nosocomial/health-care related or not). Enteroccocci (27.7% E. faecium) were isolated in 24% of the episodes, and in 48% from patients receiving quinolone prophylaxis. E. coli were susceptible to amoxicillin-clavulanate and to third-generation cephalosporins in 62.5% and 89.5% of cases, respectively. No single antibiotic allowed antimicrobial coverage of more than 60%. Only combinations such as amoxicillin + third-generation cephalosporin or cotrimoxazole allowed coverage close to 75-80% in non-nosocomial episodes. Combinations based on broader spectrum antibiotics should be considered for empirical therapy of nosocomial infections. CONCLUSIONS: Our study confirmed the changing spectrum of pathogens in SBP and bacterascites, and the need for more complex antibiotic strategies than those previously recommended. Our findings also underline the need for new clinical trials conducted in the current epidemiological context.

Susceptibility to antibiotics of aerobic bacteria isolated from community acquired secondary peritonitis in children: therapeutic guidelines might not always fit with and everyday experience.

Appendicitis is a frequent clinical condition in normal children that may be complicated by community-acquired secondary peritonitis (CASP). We evaluated the potential efficacy of different drugs for initial treatment of this condition, as recommended by recent Consensus Conference and Guidelines for paediatric patients. Susceptibility to ampicillin-sulbactam, ertapenem, gentamycin, piperacillin, piperacillin-tazobactam, vancomycin, and teicoplanin was evaluated according to EUCST 2012 recommendations in aerobic bacteria isolated from peritoneal fluid in CASP diagnosed from 2005 to 2011 at 'Istituto Giannina Gaslini', Genoa, Italy. A total of 114 strains were analysed: 83 E. coli, 15 P. aeruginosa, 6 Enterococci, and 10 other Gram-negatives. Resistance to ampicillin-sulbactam was detected in 37% of strains, while ertapenem showed a potential resistance of 13% (all P. aeruginosa strains). However, the combination of these drugs with gentamicin would have been increased the efficacy of the treatment to 99 and 100%, respectively. Resistance to piperacillin-tazobactam was 3%, while no strain was resistant to meropenem. Our data suggest that monotherapy with ampicillin-sulbactam or ertapenem for community-acquired secondary peritonitis would present a non-negligible rate of failure, but the addition of gentamycin to these drugs could reset to zero this risk. On the contrary, monotherapy with piperacillin-tazobactam or meropenem is highly effective.

Asociación entre excreción peritoneal de proteínas, episodios de peritonitis y D/P de fósforo en pacientes en diálisis peritoneal / Association between peritoneal protein excretion, peritonitis and D/P phosphate, in patients on peritoneal dialysis

Introducción: Se ha observado una relación entre el aumento de la transferencia de solutos (aumento del D/P de creatinina) y la disminución de la ultrafiltración, el aumento de la mortalidad y el riesgo de fracaso de la técnica en pacientes en diálisis peritoneal (DP). Las altas tasas de transporte de solutos se asocian con una mayor excreción peritoneal de proteínas (EPP) y esto se ha relacionado con un mayor riesgo de peritonitis. Nuestro objetivo fue evaluar la posible asociación entre la EPP, el número de episodios de peritonitis y el D/P de fósforo. Material y métodos: Se realizó un estudió longitudinal de cohorte prospectivo en pacientes en DP, a los que se les midió el D/P de fósforo, la EPP, el número de episodios de peritonitis, parámetros de adecuación, así como diferentes variables clínicas y bioquímicas. Resultados: Se incluyeron 60 pacientes en programa de DP ambulatoria. Se encontró una correlación significativa positiva (r = 0,369; p = 0,005) entre el D/P de fósforo y la EPP, al igual que entre la EPP y el número de episodios de peritonitis (r = 0,65; p = 0,044). Finalmente, se encontró que a mayor EPP y a mayor D/P de fósforo, menor nivel sérico de albumina (r = -0,50, p = 0,001 y r = -0,621, p = 0,000, respectivamente). Conclusiones: La EPP se asocia significativamente con el número de episodios de peritonitis y el D/P de fósforo (AU)

Introduction: There is a relationship between increased transfer of solutes (increased D/P creatinine) and decreased ultrafiltration, increased mortality and risk of technique failure in peritoneal dialysis patients. High rates of solute transport are associated with increased peritoneal protein excretion (PPE) and this has been associated with an increased risk of peritonitis. Our objective was to evaluate the possible association between the PPE, the number of episodes of peritonitis and the D/P phosphate. Material and methods: A prospective longitudinal cohort study in PD patients. D/P phosphate, PPE, the number of episodes of peritonitis, as well as adequacy parameters and clinical and biochemical variables were measured. Results: We included 60 patients on ambulatory peritoneal dialysis. We found a significant positive correlation (r=.369, P=.005) between the D/P phosphate and PPE, as well as between the PPE and the number of episodes of peritonitis (r=.65, p=.044). Finally, we found that the higher PPE and D/P phosphate, the lower serum albumin was (r=-0.50, p=.001 and r=-0.621, p=.000, respectively). Conclusions: The EPP is significantly associated with the number of episodes of peritonitis and the D/P phosphate (AU)

Intussusception in children: experience with 105 patients in a department of paediatric surgery, Turkey.

AIM: The aim of this study was to present our experience in patients with intussusception (IN). MATERIALS AND METHODS: One hundred and five cases of IN treated between 1991 and 2007 were analysed. Age, gender, symptoms, signs, diagnostic and treatment methods, types of IN including leading point, and postoperative complications were evaluated. RESULTS: The mean age of the patients was 2.5 years (range 1 month - 15 years). Fifty-nine per cent (62/105) were under 1 year of age, and of these 28% were receiving therapy for upper respiratory tract infection. The most common symptom was colicky abdominal pain. Rectal bleeding was present in all patients under 2 years of age. In 23 children (21.9%) leading points were detected. Thirty per cent of the patients were older than 4 years, and 76.6% of these had leading points. Ultrasonography demonstrated the invaginated segment in 93 patients. Hydrostatic reduction was attempted in 71.4% (75) of the patients and was successful in 48% (36), 70% of whom were under 1 year of age. Of the patients with unsuccessful hydrostatic reduction, 11 required intestinal resection and primary anastomosis and 35 manual reduction. Twenty-four patients were diagnosed by means of ultrasonography and were operated on immediately. Ten of these patients had signs of peritonitis on admission and were treated by resection-primary anastomosis. CONCLUSION: In patients with IN under 2 years of age, hydrostatic or pneumatic reduction may be successful. Considering the high incidence of leading points in older children, one should not persist with reduction but should rather design a treatment plan accordingly, i.e. laparotomy with manual reduction or resection.

Streptococcus bovis peritonitis complicating peritoneal dialysis--a review of 10 years' experience.

OBJECTIVE: An association of Streptococcus bovis bacteremia with carcinoma of colon has been reported, but data regarding peritoneal dialysis (PD) peritonitis caused by S. bovis is scarce. In this study, we examined the clinical characteristics, associations, and outcomes of this disease entity. METHODS: The case records of patients with S. bovis PD peritonitis presenting to 2 renal centers between January 2000 and September 2010 were reviewed. Clinical features and outcomes were identified and analyzed. RESULTS: Of cultures from 23 episodes of S. bovis peritonitis in 20 patients (1.28% of all peritonitis episodes at our center), 19 (82.6%) showed S. bovis alone, and 4 (17.4%) showed mixed growth. In 7 episodes, the S. bovis was moderately resistant to penicillin G. Rates of resistance to clindamycin and erythromycin were 43.5% and 47.8% respectively. In 18 episodes (78.3%), a primary response was achieved with a first-generation cephalosporin and an aminoglycoside. In 4 episodes, a secondary response was achieved after a switch from cephalosporin to vancomycin, and in 1 episode with mixed growth, the Tenckhoff catheter had to be removed. Repeat peritonitis occurred in 3 patients at a mean of 50.0 months (range: 24.2 - 83.1 months). Of the 20 patients of S. bovis peritonitis, 10 (50%) underwent either a barium enema or a colonoscopy. One patient had history of colonic carcinoma 2 years before the peritonitis, and a subsequent work-up revealed no recurrence. Three patients had diverticulosis, and one had a concomitant sigmoid polyp. Findings in the other 6 patients were normal. No colorectal malignancy had developed in the remaining 10 patients after a mean follow-up of 76.6 months (range: 0.8 - 125.1 months). CONCLUSIONS: Outcomes in S. bovis PD peritonitis were favorable, and an association with colorectal cancer was not found in our patients. Routine colonoscopy in these patients remains controversial and should be individualized.

Ten-year experience with fungal peritonitis in peritoneal dialysis patients: antifungal susceptibility patterns in a North-American center.

OBJECTIVE: To describe the clinical and microbiological features associated with fungal peritonitis in peritoneal dialysis (PD) patients at Hôpital Maisonneuve-Rosemont, from August 1996 to July 2006. METHODS: Cases were retrieved from the microbiology laboratory culture registry. Antifungal susceptibility was determined by the Clinical and Laboratory Standards Institute M27A3 method. RESULTS: Among 288 PD patients (total follow-up of 7258 patient-months), nine were found with fungal peritonitis. Candida spp were identified in all of them, with a majority of non-albicans Candida species. Resistance to fluconazole, itraconazole, or voriconazole was as frequent as potential resistance to amphotericin B. No isolate was resistant to caspofungin and one was resistant to micafungin. Prior bacterial peritonitis was frequent (67%). All patients had their PD catheter removed and all of them survived. CONCLUSIONS: In our institution, fungal peritonitis in PD patients is rare. All cases were caused by Candida species. Variable susceptibility patterns were observed, which may influence the initial empirical antifungal therapy and underscore the importance of individual speciation and susceptibility testing of invasive Candida isolates.

Colonic diverticulosis as a risk factor for peritonitis in Chinese peritoneal dialysis patients.

OBJECTIVES: The risk of development of enteric peritonitis in Chinese peritoneal dialysis (PD) patients with colonic diverticulosis is not known. There have been no reports on whether colonic diverticulosis may affect peritonitis outcomes. The objectives of this study were to examine whether colonic diverticulosis is a risk factor for the development of enteric peritonitis and to study its influence on the outcome of enteric peritonitis. PATIENTS AND METHODS: All continuous ambulatory PD patients that had barium enema and colonoscopic examinations performed between January 1994 and January 2006 were included. They were divided into 2 groups: patients with diverticulosis and patients without diverticulosis. Their demographic and clinical characteristics, colonic examination findings, and peritonitis data were compared and analyzed. RESULTS: 104 Chinese patients received 110 colonoscopies and 51 barium enema examinations. 25 patients (24.0%) had colonic diverticulosis. Patients with diverticulosis were older (65.4 +/- 14.7 vs 58.4 +/- 14.0 years, p = 0.033). The most common site of involvement of diverticulosis was the ascending colon (56%). 128 episodes of enteric peritonitis were recorded in 49 patients. Compared with patients without enteric peritonitis, more patients in the enteric peritonitis group had diverticulosis (38.8% vs 10.9%, p = 0.001) and diverticulosis most often involved the ascending colon (20.4% vs 7.3%, p = 0.082). Multivariate logistic regression analysis showed that the presence of diverticulosis (hazard ratio 5.17, 95% confidence interval 1.86 - 14.40; p = 0.002) and diverticulosis involving the ascending colon (hazard ratio 6.89, 95% confidence interval 1.43 - 33.32, p = 0.016) were independent risk factors for the development of enteric peritonitis. Enteric peritonitis in patients with diverticulosis had a higher but nonsignificant treatment failure rate (26.9% vs 18.4%, p = 0.282). CONCLUSION: In this selected cohort of PD patients with indications of colonic examinations, diverticulosis, especially involving the ascending colon, may be a risk factor for the development of enteric peritonitis. Colonic diverticulosis does not appear to affect the outcome of enteric peritonitis. Further studies are warranted to determine ways to prevent enteric peritonitis in PD patients with diverticulosis.

Intraoperative blood salvage and leukocyte depletion during liver transplantation with bacterial contamination.

BACKGROUND: Bacterial contamination is considered to be a contraindication for intraoperative blood salvage (IBS) during OLT. The aims of this study were to evaluate the efficiency of the autotransfusion device with an additional leukocyte depletion filter (LDF) for eliminating bacterial contaminations, and its clinical outcomes in terms of post-operative infections during OLT. METHODS: Forty-five patients with end-stage liver disease and cirrhotic ascites were enrolled in this study. The blood from the surgical field was collected and processed by an autotransfusion device (Cell Saver 5) and a LDF for bacteriological analysis. Among them, 12 patients with chronic severe hepatitis B received autologous transfusion for analysis of the effect on post-operative infections. RESULTS: Spontaneous bacterial peritonitis (SBP) (p < 0.05, OR = 20.1) and a long duration of operation (p < 0.01, OR = 8.3) were found to be critical risk factors for contamination. Autotransfusion devices with an additional LDF significantly eliminated bacterial contaminants from shed blood (p < 0.05). About 33% (4/12) of the patients who received autologous transfusion with salvaged and filtered erythrocytes got post-operative bacterial infection. CONCLUSIONS: Autotransfusion devices with an additional LDF could significantly eliminate bacterial contaminants of shed blood during OLT. The new mode of IBS might be a good option in reducing post-operative infections, and deserves a large-scale clinical trial.

Peritonitis bacteriana espontánea en pacientes con cirrosis mayores de 65 años / Spontaneous bacterial peritonitis in cirrhotic patients over 65 years

Fundamento y objetivo: Estudiar los episodios de peritonitis bacteriana espontánea (PBE) en pacientes cirróticos mayores de 65 años y comparar sus características y su evolución clínica dentro de una cohorte de pacientes cirróticos con PBE. Material y métodos: Se realizó un estudio observacional y retrospectivo sobre todas las altas hospitalarias con diagnóstico de PBE en el período de enero de 2003 a diciembre de 2005, con un total de 158 episodios. Se valoró el episodio de PBE desde su diagnóstico hasta la muerte o el fin de seguimiento por otras causas del paciente. Se dividió la cohorte en 2 grupos, según edad superior a 65 años (grupo 1: 73 episodios) o edad inferior o igual a 65 años (grupo 2: 86 episodios). Se realizó un estudio descriptivo y comparativo de ambos grupos y posteriormente se realizó un análisis de supervivencia mediante curvas de Kaplan-Meier (comparadas mediante el test log-rank) y valoración de los factores predictivos independientes mediante regresión de Cox en la cohorte global. Resultados: En el grupo 1 el 74% de los pacientes eran varones y la edad media (desviación estándar) fue de 72,8 (5,6) años, y la distribución según la clasificación de Child-Pugh fue del 8,2 (A), del 68,5 (B) y del 23,3% (C). La etiología de la cirrosis fue vírica en el 65,8% de los casos. Comparado con el grupo 2, se observó mayor frecuencia de insuficiencia renal al ingreso, prevalencia de hepatocarcinoma y etiología vírica, mientras que las cifras de bilirrubina eran superiores en el grupo 2. La mortalidad intrahospitalaria fue del 23,3%. Se observó una supervivencia a los 3 y a los 6 meses del 69,5 y del 54,8% y en el grupo 2 del 80,3 y del 78,4%, respectivamente (p=0,001). La edad superior a 65 años, la existencia de hepatocarcinoma y la presión arterial media superior a 75mmHg al ingreso fueron factores predictivos independientes de mortalidad (AU)

Aims: Our aim was to study the episodes of spontaneous bacterial peritonitis (SBP) in cirrhotic patients older than 65 years. Their clinical characteristics were compared with a cohort of cirrhotic patients with SBP. Methods: We conducted a retrospective study on all hospital discharged patients diagnosed with SBP in the period from January 2003 to December 2005, obtaining a total of 158 episodes. Two groups of patients were created: those over 65 (group 1: 73 episodes) and those aged }65 years (group 2: 86 episodes). A descriptive study, an analysis of survival by Kaplan Meier curves (compared with log-rank test) and a Cox regression analysis was conducted comparing the two groups. Results: In Group 1, males were 74%, the average age was 72.4 (SD 4.2) years, and the Child-Pugh distribution was 8.2% (A), 68.5% (B) and 23.3% (C).The most usual etiology of cirrhosis was viral (65.8%). In comparison with group 2, there was a superior frequency of renal impairment at admission, hepatocellular carcinoma and a viral etiology. Yet the bilirubin levels were higher in group 2. In-hospital mortality rate was 23.3%. The survival at 3 and 6 months was of 69.5% and 54.8%, while in group 2 it was 80.3% and 78.4% respectively (p=0001). An age> 65 years, the existence of hepatocellular carcinoma and a Mean Arterial Pressure <75mm Hg at admission, in the overall cohort, were independent predictors of mortality. Conclusion: An age above 65 years is an independent predictor of mortality following the development of an episode of spontaneous bacterial peritonitis in cirrhotic patients (AU)

Treatment of peritoneal dialysis-related peritonitis with ciprofloxacin monotherapy: clinical outcomes and bacterial susceptibility over two decades.

BACKGROUND: There is controversy about the preferred initial antibiotic therapy for peritoneal dialysis (PD)-related peritonitis. Quinolones have been used extensively in this setting, yet their long-term effectiveness is unknown. AIM: To analyze the results of a protocol of treatment of PD-related peritonitis with ciprofloxacin, maintained over two decades. METHOD: We analyzed the clinical outcome of 682 episodes of bacterial peritonitis treated with intraperitoneal ciprofloxacin monotherapy, and the time course of bacterial susceptibility to this antimicrobial, in a historical cohort of 641 PD patients (1988-2007). Main outcome variables included changes to initial therapy and rates of hospital admission, catheter removal, relapse, reinfection, PD dropout, and mortality. For comparisons we divided the study period into phases A (1988-1994), B (1995-2000), and C (2001-2007). RESULTS: The incidence of Staphylococcus aureus peritonitis decreased, while the incidences of polymicrobial and negative-culture peritonitis increased after phase A. In vitro susceptibility to ciprofloxacin decreased significantly only among coagulase-negative staphylococci (87.0% susceptible strains in phase A vs 70.0% in B and 70.1% in C, p = 0.006). Overall success rates (catheter not removed and ongoing PD after the episode) remained stable, at over 85%. However, the proportion of patients treated solely with ciprofloxacin declined from 75.7% (A) to 47.3% (B) to 32.4% (C) (p < 0.0005) and admission rates increased from 12.7% to 16.8% to 24.9% respectively (p = 0.001). These changes affected all the etiologic groups except culture-negative peritonitis. In vitro resistance to ciprofloxacin was a marker of multiresistance and correlated strongly with clinical outcome of peritonitis. Among isolates susceptible to ciprofloxacin, changing initial therapy for any reason also predicted a poor outcome. CONCLUSIONS: Following satisfactory early results, the effectiveness of ciprofloxacin as monotherapy for PD-related peritonitis has declined markedly in the long term. This decline cannot be explained solely by a decrease of in vitro susceptibility to this antimicrobial, which was significant only among coagulase-negative staphylococci. Resistance to ciprofloxacin is a strong marker of in vitro multiresistance and poor clinical outcome of peritonitis.

An outbreak of peritonitis caused by multidrug-resistant Salmonella Typhi in Kinshasa, Democratic Republic of Congo.

Between October 2004 and January 2005, 144 patients with peritonitis were admitted to the surgical wards of Kinshasa General Hospital and a few private city clinics. 63 patients (44%) underwent surgical intervention because of intestinal perforation consistent with typhoid fever; the case fatality rate was 53%. The majority of patients had received a course of first-line antibiotics such as chloramphenicol, ampicillin or co-trimoxazole before admission. On bacteriological investigation, Salmonella Typhi was isolated from the blood of 11 patients with peritonitis. The isolates were all resistant to ampicillin, chloramphenicol, tetracycline and co-trimoxazole, but sensitive to third-generation cephalosporins, quinolone (nalidixic acid, ciprofloxacine) and amoxicillin-clavulanic acid. Several factors contributed to the poor outcome of this disease including a) the use of inappropriate antibiotics, b) long delay in diagnosis, c) difficult access to health facilities. This is the first documented outbreak of typhoid fever caused by a multidrug-resistant S. Typhi in Kinshasa.

[Etiology, epidemiology and microbiological diagnosis of intra-abdominal infections]. / Eziologia, epidemiologia e diagnostica microbiologica delle infezioni intraddominali.

Intra-abdominal infections (IAIs) are commonly encountered in clinical practice. The etiology of these infections, often polymicrobial in nature, can be variable and usually includes organisms derived from the gut microbiota. In community-acquired IAIs enterobacteria predominate (mostly Escherichia coli) in combination with anaerobes (mostly Bacteroides fragilis). In nosocomial IAIs, which can complicate abdominal surgery, other pathogens can also play a role, such as Pseudomonas aeruginosa, Acinetobacter baumannii, Staphylococcus aureus, Enterococcus spp. e Candida spp. Diagnostic microbiology of IAIs is complex and plays a relevant role especially in some situations (e. g. presence of foreign bodies, potential presence of resistant or uncommon pathogens, nosocomial infections in subjects with risk factors). Antibiotic resistance issues are currently encountered in most pathogenic species causing IAIs. Resistance affects all major classes of antimicrobial agents, often involving multiple classes and resulting in complex resistance phenotypes for which only a very limited number of drugs remain active.

Bimodal dialysis: an integrated approach to renal replacement therapy.

BACKGROUND: Peritoneal dialysis (PD) and hemodialysis (HD) are both widely used as sole therapies for end-stage renal disease (ESRD). There is still controversy over which (if either) is superior in terms of patient outcomes. Peritoneal dialysis offers the advantages of long, slow, continuous ultrafiltration and potentially enhanced protection of residual renal function (RRF). In contrast, HD offers superior solute removal at the cost of undesirable cardiovascular tolerance of high rates of sodium and water removal. The aim of this study was to investigate the clinical feasibility of offering a combined treatment of both modalities [bimodal dialysis (BMD)] to incident patients reaching ESRD. We set out to investigate if it might be possible to utilize the intrinsic advantages of both modalities within a setting of good patient acceptability. METHODS: We prospectively studied 8 patients. They were recruited in the pre-ESRD phase from a specialist low clearance clinic. An arteriovenous fistula was formed and peritoneal catheters were inserted. The BMD consisted of 2, 3-hour, high efficiency, euvolemic HD sessions per week in combination with 2 PD exchanges per day to provide a degree of solute clearance and all of the ultrafiltration. Adequacy was measured independently for each modality. Patients were followed using the standard range of evaluations in addition to RRF (by creatinine clearance and EDTA clearance), echocardiography (left ventricular mass and ventricular performance), treatment outcomes, patient symptoms, and complications. RESULTS: Mean time on BMD was 346 +/- 74.9 (range 245 - 431) days. Peritonitis rate was 21 months per episode (mean 0.6 +/- 0.9, 0 - 2 episodes per patient). Mean peritoneal ultrafiltration volume was 1.58 +/- 0.32 (1.3 - 2.1) L per day. Delivered Kt/V and weekly PD Kt/V did not change significantly. Patients' RRF was maintained over the study period, as were serum albumin and control of serum phosphorus. Blood pressure was controlled with a reduction in the number of antihypertensive agents. Left ventricular mass index reduced over the treatment period, from a mean of 194 +/- 31.2 (161 - 265) to 156 +/- 21.2 (138 - 189) g/m2 (p = 0.05). Ventricular performance remained unchanged over the study [ejection fraction 50.4 +/- 11.1 (38 - 67) % to 48 +/- 8.0 (48 - 67) %]. Mean time during BMD spent on HD alone was 4.2 +/- 6.9 (0 - 16) days, and on PD alone 9.2 +/- 10.6 (0 - 25) days. CONCLUSION: This study suggests that BMD is a feasible treatment for ESRD. It is associated with adequate solute removal and good hemodynamic/volume control, and allows increased treatment flexibility for coping with complications normally requiring recourse to unplanned HD with temporary central venous access.