[How to diagnose and treat peritoneal infections in patients with terminal chronic renal insufficiency treated by peritoneal dialysis]. / Comment diagnostiquer et traiter les infections péritonéales chez les malades en insuffisance rénale chronique terminale traités par dialyse péritonéale?

There have been improvements in the technique of peritoneal dialysis (PD) over the last ten years. However, peritoneal infections remain the major complication associated with this treatment, and the risk of infection cannot be accurately predicted. Nevertheless, it is widely accepted that simple connections should be replaced by improved systems of connection, and that patient training is important. Peritoneal infection should be suspected when the dialysate is turbid, whether or not associated with peritoneal irritation. None of the various techniques used for the culture of dialysates has been shown to be either more sensitive or more specific than any of the others. Thus, collaboration between the physicians supervising the dialysis and microbiologists is necessary to choose the culture techniques best adapted. The sensitivity should be at least 85 to 90%. If the sensitivity is lower, the techniques used should be reconsidered. There have been several hundred publications assessing treatments of peritoneal infections associated with PD. However, no particular antibiotic treatment has been demonstrated to be systematically superior. The use of associated antibiotics seems to be preferable initially, until the causative agent has been identified. For example, vancomycin with a third generation cephalosporin seems to be the association of choice, because of its efficacy, tolerance and ease of use. The optimal duration of treatment has not been established by randomised study, but 10 days is commonly used for Gram-positive infections, and longer for Gram-negative. Whatever the treatment used, the success rate should be at least 80 to 90%. Randomised trials with sufficiently large numbers of patients are required to determine the indications and delay before withdrawal of the DP catheter in cases of peritonitis which do not respond to antibiotics.

Fungal peritonitis in patients on peritoneal dialysis.

Fungal peritonitis (FP) is a serious complication of peritoneal dialysis, both in terms of morbidity and mortality. Available data on the effectiveness of fluconazole in eradicating FP without catheter removal are still controversial. We reviewed 20 FP cases that occurred among 325 patients who underwent peritoneal dialysis in our center between January 1984 and January 1992, in order to establish whether a profile of patients at risk of developing FP could be identified and to evaluate the effectiveness of fluconazole in treating FP (7 cases). Age, sex, a particular cause of end-stage renal disease, and the presence of diabetes did not correlate significantly with the development of FP. The risk of FP increased in patients on immunosuppressive treatment. Sixteen of our 20 patients had bacterial peritonitis during the month before they developed FP. Nineteen were treated with antibiotics. Neither the type of bacterial organism isolated during the bacterial peritonitis preceding FP nor modality and duration of antibiotic treatment correlated significantly with the development of FP. Patients who subsequently developed FP were more frequently treated with antibiotics while in hospital (p < 0.001). Candida species accounted for 15 of our 20 FP cases (75%), with Candida albicans being by far the most common isolate. Treatment strategies varied among the 20 patients. The combination of intravenous or intraperitoneal administration of 5-fluorocytosine and oral administration of fluconazole was used in 7 cases: only 1 patient was cured without catheter removal, 1 patient died within the first 4 days of treatment, removal of peritoneal catheter was necessary in the other 5 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Didanosine pharmacokinetics in patients with normal and impaired renal function: influence of hemodialysis.

The pharmacokinetics of didanosine were investigated following oral administration of a single 375-mg dose to eight human immunodeficiency virus-seropositive patients with normal renal function and eight human immunodeficiency virus-seropositive uremic patients. In uremic patients, the plasma half-life was longer than that in control patients (respectively, 4.5 +/- 2.2 and 1.6 +/- 0.4 h). The ratio of total plasma clearance to absolute bioavailability was four- to fivefold lower in uremic patients than in patients with normal renal function (respectively, 491 +/- 181 and 2,277 +/- 738 ml/min). Because of the decrease in elimination, concentrations in plasma were higher for uremic patients than for control patients; the maximum concentrations of drug in plasma were, respectively, 3,978 +/- 1,607 and 1,948 +/- 994 ng/ml; the areas under the concentration-time curve were, respectively, 14,050 +/- 4,262 and 3,000 +/- 956 ng.h/ml. Didanosine was removed by hemodialysis with an extraction ratio of 53% +/- 8%, a hemodialysis clearance value of 107 +/- 21 ml/min, and a fractional drug removal during a 4-h dialysis of 20% +/- 8% of the dose. Dosage adjustments are necessary in uremic patients.

Synthesis and antiviral evaluation of 6-p-ethylphenyl-5H-pyrrolo [3,4-b]pyridine-5,7-dione.

The synthesis of 6-(p-ethylphenyl)-5H-pyrrolo [3,4-b]pyridine-5,7-dione is described. The compound has been studied for its in vitro activity on RNA-containing influenza viruses types A and B. The preliminary results indicate that the compound has a significant antiviral activity against influenza viruses types A and B at concentrations at which no cytotoxic effects on MRC-5 cells in tissue culture are present.