A prospective, randomized trial of two antibiotic regimens in the treatment of peritonitis in CAPD patients: teicoplanin plus tobramycin versus cephalothin plus tobramycin
Abstract:A multicentre, comparative, randomized study was performed to compare the efficacy and tolerability of two antibiotic regimens in the treatment of peritonitis in continuous ambulatory peritoneal dialysis (CAPD) patients: teicoplanin plus tobramycin versus cephalothin plus tobramycin. After informed consent had been obtained, 68 patients were randomized prospectively to receive either teicoplanin plus tobramycin or cephalothin plus tobramycin. Patients were followed throughout the study and for up to 4 weeks af… Show more
“…This resolution rate was significant higher than initial treatment with a first generation cephalosporin plus aminoglycosides (pooled proportion of 66%, 95% CI 0.57–0.75) from 14 included studies [ 57 , 61 , 64 – 75 ] with 1,438 total episodes (Figure 3 ). Initial treatment with ceftazidime plus a glycopeptide also showed a higher resolution rate than a glycopeptide plus aminoglycosides (pooled proportion of 75%, 95% CI 0.69–0.80) that were used in 16 included studies [ 55 , 66 – 68 , 75 – 86 ] with 574 episodes (Figure 4 ). Figure 3 Combined resolution rate with 95% CIs of studies of initial treatment with ceftazidime plus a glycopeptide versus a first generation cephalosporin plus an aminoglycoside.…”
BackgroundThe choice of antimicrobials for initial treatment of peritoneal dialysis (PD)-related peritonitis is crucial for a favorable outcome. There is no consensus about the best therapy; few prospective controlled studies have been published, and the only published systematic reviews did not report superiority of any class of antimicrobials. The objective of this review was to analyze the results of PD peritonitis treatment in adult patients by employing a new methodology, the proportional meta-analysis.MethodsA review of the literature was conducted. There was no language restriction. Studies were obtained from MEDLINE, EMBASE, and LILACS. The inclusion criteria were: (a) case series and RCTs with the number of reported patients in each study greater than five, (b) use of any antibiotic therapy for initial treatment (e.g., cefazolin plus gentamicin or vancomycin plus gentamicin), for Gram-positive (e.g., vancomycin or a first generation cephalosporin), or for Gram-negative rods (e.g., gentamicin, ceftazidime, and fluoroquinolone), (c) patients with PD-related peritonitis, and (d) studies specifying the rates of resolution. A proportional meta-analysis was performed on outcomes using a random-effects model, and the pooled resolution rates were calculated.ResultsA total of 64 studies (32 for initial treatment and negative culture, 28 reporting treatment for Gram-positive rods and 24 reporting treatment for Gram-negative rods) and 21 RCTs met all inclusion criteria (14 for initial treatment and negative culture, 8 reporting treatment for Gram-positive rods and 8 reporting treatment for Gram-negative rods). The pooled resolution rate of ceftazidime plus glycopeptide as initial treatment (pooled proportion = 86% [95% CI 0.82–0.89]) was significantly higher than first generation cephalosporin plus aminoglycosides (pooled proportion = 66% [95% CI 0.57–0.75]) and significantly higher than glycopeptides plus aminoglycosides (pooled proportion = 75% [95% CI 0.69–0.80]. Other comparisons of regimens used for either initial treatment, treatment for Gram-positive rods or Gram-negative rods did not show statistically significant differences.ConclusionWe showed that the association of a glycopeptide plus ceftazidime is superior to other regimens for initial treatment of PD peritonitis. This result should be carefully analyzed and does not exclude the necessity of monitoring the local microbiologic profile in each dialysis center to choice the initial therapeutic protocol.Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2334-14-445) contains supplementary material, which is available to authorized users.
“…This resolution rate was significant higher than initial treatment with a first generation cephalosporin plus aminoglycosides (pooled proportion of 66%, 95% CI 0.57–0.75) from 14 included studies [ 57 , 61 , 64 – 75 ] with 1,438 total episodes (Figure 3 ). Initial treatment with ceftazidime plus a glycopeptide also showed a higher resolution rate than a glycopeptide plus aminoglycosides (pooled proportion of 75%, 95% CI 0.69–0.80) that were used in 16 included studies [ 55 , 66 – 68 , 75 – 86 ] with 574 episodes (Figure 4 ). Figure 3 Combined resolution rate with 95% CIs of studies of initial treatment with ceftazidime plus a glycopeptide versus a first generation cephalosporin plus an aminoglycoside.…”
BackgroundThe choice of antimicrobials for initial treatment of peritoneal dialysis (PD)-related peritonitis is crucial for a favorable outcome. There is no consensus about the best therapy; few prospective controlled studies have been published, and the only published systematic reviews did not report superiority of any class of antimicrobials. The objective of this review was to analyze the results of PD peritonitis treatment in adult patients by employing a new methodology, the proportional meta-analysis.MethodsA review of the literature was conducted. There was no language restriction. Studies were obtained from MEDLINE, EMBASE, and LILACS. The inclusion criteria were: (a) case series and RCTs with the number of reported patients in each study greater than five, (b) use of any antibiotic therapy for initial treatment (e.g., cefazolin plus gentamicin or vancomycin plus gentamicin), for Gram-positive (e.g., vancomycin or a first generation cephalosporin), or for Gram-negative rods (e.g., gentamicin, ceftazidime, and fluoroquinolone), (c) patients with PD-related peritonitis, and (d) studies specifying the rates of resolution. A proportional meta-analysis was performed on outcomes using a random-effects model, and the pooled resolution rates were calculated.ResultsA total of 64 studies (32 for initial treatment and negative culture, 28 reporting treatment for Gram-positive rods and 24 reporting treatment for Gram-negative rods) and 21 RCTs met all inclusion criteria (14 for initial treatment and negative culture, 8 reporting treatment for Gram-positive rods and 8 reporting treatment for Gram-negative rods). The pooled resolution rate of ceftazidime plus glycopeptide as initial treatment (pooled proportion = 86% [95% CI 0.82–0.89]) was significantly higher than first generation cephalosporin plus aminoglycosides (pooled proportion = 66% [95% CI 0.57–0.75]) and significantly higher than glycopeptides plus aminoglycosides (pooled proportion = 75% [95% CI 0.69–0.80]. Other comparisons of regimens used for either initial treatment, treatment for Gram-positive rods or Gram-negative rods did not show statistically significant differences.ConclusionWe showed that the association of a glycopeptide plus ceftazidime is superior to other regimens for initial treatment of PD peritonitis. This result should be carefully analyzed and does not exclude the necessity of monitoring the local microbiologic profile in each dialysis center to choice the initial therapeutic protocol.Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2334-14-445) contains supplementary material, which is available to authorized users.
We have found several inconsistencies within and between the recently published ISPD Peritonitis Recommendations: 2016 Update on Prevention and Treatment by Li et al. (1) and the ISPD Catheter-Related Infection Recommendations: 2017 Update by Szeto et al. (2) as detailed below (references cited from the International Society for Peritoneal Dialysis [ISPD] papers in question correspond to references from the original papers and they are noted in square brackets). 2016 PERITONITIS RECOMMENDATIONS RESIDUAL RENAL FUNCTION (RRF)-NO NEED TO INCREASE DOSE OF ANTIBIOTIC The ISPD Recommendations for 2016 state, "It was recommended previously that for patients with substantial residual renal function, the dose of antibiotics that have renal excretion needs to be adjusted [12,13]. However, recent studies suggest that such adjustments are not necessary [284,304]." This statement appears to be a direct contradiction to the references cited.
“…Some previous clinical studies have demonstrated that empirical therapy with first‐generation cephalosporin and gentamicin has a similar efficacy to regimens using second‐line antibiotics (22,23); however, some studies did not have such favorable results (14,24). In this study the efficacy of an empirical regimen with intermittent intraperitoneal first‐generation cephalosporin and gentamicin was poor.…”
Empirical antibiotic treatment with a first-generation cephalosporin plus gentamicin for peritoneal dialysis (PD)-associated peritonitis before culture results are available is still wildly used due to concerns regarding the economic burden and antibiotic-resistant bacterial infections. The aim of this study is to define the factors that predict the outcome of empirical antibiotic therapy for PD peritonitis. This is a retrospective study of patients with PD peritonitis over the last 10 years. Patients who had been treated empirically with intermittent intraperitoneal first-generation cephalosporin and gentamicin were enrolled. Eighty-three patients had 192 episodes of PD peritonitis. In total, 159 peritonitis episodes were treated with intraperitoneal antibiotics combined with first-generation cephalosporin and gentamicin empirically. Twenty-five peritonitis episodes had no pathogens identified by dialysate culture. In total, 122 (122/159, 76.7%) PD peritonitis episodes were caused by bacteria, 9 (9/159, 5.7%) were fungal, and 3 (3/159, 1.9%) were Mycobacterium tuberculosis peritonitis. Sixty-four (64/159, 40.3%) peritonitis episodes were successfully cured by empirical intraperitoneal antibiotic therapy. Empirical antibiotic treatment failed in 95 episodes (95/159, 59.7%). The positive rates of dialysate Gram stain in the empirical treatment success and failure groups were 15.6% and 40.0%, respectively (P = 0.001). The odds ratio of empirical treatment failure with a positive bacteria Gram stain was 3.60 (95% CI: 1.65-7.82). The dialysate Gram staining result was a significant predictor of empirical antibiotics treatment outcome for PD-associated peritonitis. Therefore, using an empirical antibiotic regimen for patients with an initial positive bacterial Gram stain of the dialysate should be introduced cautiously.
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