Zapalenie otrzewnej – Zapobieganie i profilaktyka

Zapalenie otrzewnej
Zapobieganie i profilaktyka

Zapalenie otrzewnej (peritonitis) stanowi istotne powikłanie u pacjentów dializowanych otrzewnowo oraz u osób z marskością wątroby i wodobrzuszem, wiążąc się z wysoką śmiertelnością i chorobowością. Wytyczne ISPD zalecają monitorowanie częstości zapalenia otrzewnej, z celem utrzymania wskaźnika poniżej 0,40 epizodów na rok ryzyka oraz ponad 80% pacjentów bez epizodów rocznie. Profilaktyka obejmuje techniki aseptyczne, właściwe szkolenie pacjentów i personelu, pielęgnację miejsca ujścia cewnika, szybkie leczenie zakażeń oraz stosowanie antybiotyków profilaktycznych w określonych sytuacjach, takich jak przed wprowadzeniem cewnika (wankomycyna 1 g lub cefazolina 1 g dożylnie, zalecenie klasy 1A), przed kolonoskopią i zabiegami ginekologicznymi (schemat ampicylina z aminoglikozydem ± metronidazol, zalecenia klasy 2C/D). Profilaktyka przeciwgrzybicza (np. nystatyna lub flukonazol doustnie) jest rekomendowana podczas antybiotykoterapii (zalecenie klasy 1B), co zmniejsza ryzyko grzybiczego zapalenia otrzewnej (RR 0,28, 95% CI 0,12–0,63).

Profilaktyka zapalenia otrzewnej (Peritonitis Prevention, Prophylaxis)

Profilaktyka zapalenia otrzewnej związanego z dializą otrzewnową
Profilaktyka spontanicznego bakteryjnego zapalenia otrzewnej
Profilaktyka zapalenia otrzewnej w chirurgii
Profilaktyka zapalenia otrzewnej u pacjentów z innymi schorzeniami

Ocena skuteczności strategii profilaktycznych
Podsumowanie i przyszłe kierunki

Kolejne rozdziały

Profilaktyka zapalenia otrzewnej (Peritonitis Prevention, Prophylaxis)

Zapalenie otrzewnej (peritonitis) stanowi poważne powikłanie, szczególnie u pacjentów poddawanych dializie otrzewnowej oraz u osób z marskością wątroby i wodobrzuszem. Ze względu na wysoką śmiertelność i chorobowość związaną z tym schorzeniem, opracowano różne strategie profilaktyczne mające na celu zmniejszenie ryzyka jego wystąpienia. Międzynarodowe Towarzystwo Dializy Otrzewnowej (International Society for Peritoneal Dialysis, ISPD) oraz Amerykańskie Towarzystwo Badań nad Chorobami Wątroby (American Association for the Study of Liver Diseases, AASLD) opracowały wytyczne dotyczące profilaktyki zapalenia otrzewnej.¹²³

Profilaktyka zapalenia otrzewnej związanego z dializą otrzewnową

Zapalenie otrzewnej jest głównym powikłaniem dializy otrzewnowej (PD) i wiodącą przyczyną przejścia na hemodializę. ISPD zaleca, aby każdy ośrodek dializy otrzewnowej monitorował częstość występowania zapalenia otrzewnej przynajmniej raz w roku. Wskaźnik zapalenia otrzewnej powinien być raportowany jako liczba epizodów na pacjenta rocznie, a nie jako jeden epizod na liczbę miesięcy leczenia pacjenta, co było powszechnie stosowane w przeszłości.⁴⁵ Według zaktualizowanych w 2022 roku wytycznych ISPD, roczny wskaźnik zapalenia otrzewnej nie powinien przekraczać 0,40 epizodów na rok ryzyka, a odsetek pacjentów bez zapalenia otrzewnej powinien wynosić ponad 80% rocznie.⁶

Strategie zapobiegania zapaleniu otrzewnej związanemu z dializą otrzewnową obejmują:⁷⁸⁹

Właściwe szkolenie i sprzęt¹⁰
Technika aseptyczna¹¹
Pielęgnacja miejsca ujścia cewnika¹²
Zarządzanie po naruszeniu techniki¹³
Szybkie leczenie zakażeń cewnika¹⁴
Postępowanie przed zabiegami¹⁵
Opróżnianie jamy brzusznej¹⁶
Antybiotyki przed wybranymi zabiegami¹⁷
Postępowanie podczas zakażenia lub stanu zapalnego wewnątrz jamy brzusznej¹⁸
Wycieki z miejsca ujścia cewnika¹⁹
Profilaktyka przeciwgrzybicza podczas antybiotykoterapii²⁰

Antybiotykoterapia profilaktyczna

ISPD zaleca podawanie ogólnoustrojowych antybiotyków profilaktycznych w następujących sytuacjach:²¹²²²³

Przed wprowadzeniem cewnika do dializy otrzewnowej – jedyna profilaktyka o udowodnionej skuteczności w randomizowanych badaniach klinicznych (zalecenie klasy 1A). Stosowanie dożylnej wankomycyny (1 g) lub cefazoliny (1 g) przed zabiegiem zmniejsza ryzyko wczesnego zapalenia otrzewnej.²⁴²⁵²⁶
Przed kolonoskopią – ISPD zaleca profilaktykę antybiotykową (zalecenie klasy 2C). Najczęściej stosowany schemat to pojedyncza dawka dożylnej ampicyliny z aminoglikozydem, z metronidazolem lub bez niego.²⁷²⁸
Przed inwazyjnymi zabiegami ginekologicznymi – zalecany jest ten sam schemat antybiotykowy co w przypadku kolonoskopii (zalecenie klasy 2D).²⁹
Po skażeniu systemu dializy otrzewnowej – ISPD sugeruje profilaktyczne stosowanie antybiotyków po mokrym skażeniu systemu PD (zalecenie klasy 2D).³⁰

Badania wykazały, że przedoperacyjna dożylna wankomycyna w porównaniu z brakiem leczenia może zmniejszyć ryzyko wczesnego zapalenia otrzewnej (1 badanie, 177 pacjentów, dowody niskiej jakości: RR 0,08, 95% CI 0,01 do 0,61), ale ma niepewny wpływ na ryzyko zakażenia ujścia/tunelu cewnika.³¹

Profilaktyka zapalenia otrzewnej związanego z grzybami

ISPD zdecydowanie zaleca stosowanie profilaktyki przeciwgrzybiczej podczas każdego kursu antybiotykoterapii, niezależnie od wskazania do jego stosowania (zalecenie klasy 1B).³² Profilaktyka przeciwgrzybicza za pomocą doustnej nystatyny/flukonazolu w porównaniu z placebo/brakiem leczenia może zmniejszyć ryzyko grzybiczego zapalenia otrzewnej występującego po antybiotykoterapii (2 badania, 817 pacjentów, dowody niskiej jakości: RR 0,28, 95% CI 0,12 do 0,63).³³

Higiena i szkolenie

Właściwe szkolenie pacjentów i ich opiekunów jest kluczowe dla zapobiegania zapaleniu otrzewnej. ISPD podkreśla znaczenie przestrzegania najnowszych zaleceń dotyczących nauczania pacjentów dializowanych otrzewnowo i ich opiekunów. Szkolenie powinno być prowadzone przez personel pielęgniarski z odpowiednimi kwalifikacjami i doświadczeniem.³⁴

Zalecenia dotyczące higieny dla pacjentów stosujących dializę otrzewnową obejmują:³⁵³⁶³⁷

Dokładne mycie rąk przed dotknięciem cewnika – szorowanie pod paznokciami i między palcami
Codzienne czyszczenie skóry wokół cewnika środkiem antyseptycznym
Przechowywanie sprzętu w czystym miejscu
Noszenie maski chirurgicznej podczas wymiany płynu dializacyjnego
Utrzymywanie krótkich paznokci
Używanie środka dezynfekującego na bazie alkoholu przed procedurą dializy
Unikanie dotykania łącznika
Właściwe usuwanie ścieków z dializy
Regularnie otrzymywanie informacji zwrotnych na temat techniki dializy
Brak roślin w pomieszczeniu używanym do dializy (bakterie, pleśń, pyłki mogą zwiększać ryzyko infekcji)
Brak zwierząt domowych w pomieszczeniu używanym do dializy

Badania wykazały, że programy regularnego szkolenia uzupełniającego (retraining) znacząco zmniejszają częstość zapalenia otrzewnej, szczególnie wywołanego przez bakterie Gram-dodatnie. Wskaźniki zapalenia otrzewnej są znacznie niższe w ośrodkach z aktywnymi programami szkoleń uzupełniających w porównaniu z tymi, które ich nie prowadzą.³⁸³⁹

Profilaktyka spontanicznego bakteryjnego zapalenia otrzewnej

Spontaniczne bakteryjne zapalenie otrzewnej (SBP) jest poważnym powikłaniem u pacjentów z marskością wątroby i wodobrzuszem. SBP wiąże się z wysoką śmiertelnością wewnątrzszpitalną (20-40%), dlatego konieczne są środki profilaktyczne w celu zapobiegania tej infekcji.⁴⁰⁴¹

Wskazania do profilaktyki antybiotykowej SBP obejmują:⁴²⁴³⁴⁴⁴⁵

Profilaktyka pierwotna:
- Pacjenci z niskim stężeniem białka w płynie puchlinowym (<1,5 g/dl) ORAZ upośledzeniem czynności wątroby (skala Child-Pugh ≥9 punktów ze stężeniem bilirubiny ≥3 mg/dl) lub dysfunkcją nerek (kreatynina ≥1,2 mg/dl, azot mocznikowy ≥25 mg/dl lub sód w surowicy ≤130 mEq/l)
Profilaktyka wtórna:
- Wszyscy pacjenci z przebytym epizodem SBP (ryzyko nawrotu w ciągu roku wynosi około 70% bez profilaktyki, a zastosowanie antybiotyków zmniejsza to ryzyko do około 20%)
Krótkoterminowa profilaktyka:
- Pacjenci z marskością wątroby i krwawieniem z górnego odcinka przewodu pokarmowego (zalecana przez 7 dni)

Zalecane schematy antybiotykowe

Według aktualnych wytycznych, zalecane schematy antybiotykowe w profilaktyce SBP obejmują:⁴⁶⁴⁷⁴⁸

Profilaktyka pierwotna i wtórna:
- Ciprofloksacyna 500 mg PO raz dziennie
- Trimetoprim/sulfametoksazol (jedna tabletka o podwójnej mocy) raz dziennie
- Norfloksacyna 400 mg PO raz dziennie (stosowana głównie poza USA)
Profilaktyka po krwawieniu z górnego odcinka przewodu pokarmowego:
- Ceftriakson 1 g IV co 24 godziny przez 7 dni

Preferowane jest codzienne dawkowanie w porównaniu z dawkowaniem przerywanym ze względu na zwiększone ryzyko rozwoju oporności na środki przeciwdrobnoustrojowe przy dawkowaniu przerywanym.⁴⁹

Obawy związane z długotrwałą profilaktyką antybiotykową

Chociaż profilaktyka antybiotykowa jest skuteczna w zapobieganiu SBP, istnieją obawy związane z długotrwałym stosowaniem antybiotyków:⁵⁰⁵¹⁵²

Rozwój oporności bakterii – długotrwała profilaktyka z fluorochinolonami prowadzi do selektywnej dekontaminacji jelit i wysokiego poziomu oporności na fluorochinolony
Wzrost zakażeń wywołanych przez organizmy wielolekooporne
Zwiększone ryzyko zakażenia Clostridium difficile
Zmiany we florze patogennej jelit

Badania wskazują, że profilaktyka SBP z użyciem kotrimoksazolu (trimetoprim/sulfametoksazol) może być równie skuteczna jak schematy oparte na chinolonach, ale ma przewagę w postaci drastycznego zmniejszenia zakażeń C. difficile.⁵³

Co ciekawe, rifaksymina wykazuje obiecujące wyniki jako alternatywa dla norfloksacyny w profilaktyce SBP, szczególnie w profilaktyce wtórnej, gdzie wykazuje silniejsze działanie profilaktyczne niż norfloksacyna przy lepszym profilu bezpieczeństwa.⁵⁴⁵⁵

Profilaktyka zapalenia otrzewnej w chirurgii

W przypadku zapalenia otrzewnej pooperacyjnej, kluczowe znaczenie mają odpowiednie podejścia chirurgiczne.⁵⁶ Fundamentalne znaczenie w zapobieganiu rozwoju zapalenia otrzewnej pooperacyjnej mają:

Terminowe wykonanie i adekwatna objętość operacji
Maksymalna ewakuacja patologicznej zawartości z następowym płukaniem jamy brzusznej
Ostrożne obchodzenie się z narządami jamy brzusznej (zszywanie wątpliwych obszarów i uszkodzeń jelita)
Staranny hemostaza
Aktywno-pasywny drenaż nie tylko luźnych obszarów jamy brzusznej, ale także zespoleń i jam ropni

Profilaktyka zapalenia otrzewnej u pacjentów z innymi schorzeniami

Zapalenie otrzewnej może być związane z różnymi innymi schorzeniami. Profilaktyka obejmuje:⁵⁷

Szukanie pomocy w przypadku zaburzeń związanych z alkoholem, jeśli istnieje obawa o spożycie alkoholu lub ryzyko marskości wątroby
Stosowanie prezerwatyw lub innych metod barierowych w celu uniknięcia zakażeń przenoszonych drogą płciową (STI), które mogą prowadzić do choroby zapalnej miednicy (PID)
Ograniczenie stosowania niesteroidowych leków przeciwzapalnych (NLPZ), które są związane z wrzodami żołądka
Szybkie leczenie w przypadku objawów zapalenia wyrostka robaczkowego lub zdiagnozowanego zapalenia wyrostka robaczkowego

Ocena skuteczności strategii profilaktycznych

Mimo licznych strategii profilaktycznych, dowody na ich skuteczność są zróżnicowane i często oparte na niewielkiej liczbie randomizowanych badań klinicznych. W przypadku profilaktyki SBP, najnowsza metaanaliza obejmująca 29 randomizowanych badań klinicznych (łącznie 3896 uczestników) analizujących dziewięć różnych schematów antybiotykowych nie wykazała różnic między którymkolwiek z antybiotyków a brakiem interwencji pod względem śmiertelności lub poważnych zdarzeń niepożądanych, chociaż pewność dowodów była bardzo niska.⁵⁸

W przypadku dializy otrzewnowej, stosowanie doustnego lub miejscowego antybiotyku w porównaniu z placebo/brakiem leczenia miało niepewny wpływ na ryzyko zakażenia ujścia/tunelu cewnika (3 badania, 191 pacjentów, dowody niskiej jakości: RR 0,45, 95% CI 0,19 do 1,04) i ryzyko zapalenia otrzewnej (5 badań, 395 pacjentów, dowody niskiej jakości: RR 0,82, 95% CI 0,57 do 1,19).⁵⁹

Biorąc pod uwagę dużą liczbę pacjentów na dializie otrzewnowej i znaczenie zapalenia otrzewnej, brak odpowiednio zaprojektowanych i wysokiej jakości randomizowanych badań klinicznych, które mogłyby informować o podejmowaniu decyzji dotyczących strategii zapobiegania zapaleniu otrzewnej, jest uderzający.⁶⁰

Podsumowanie i przyszłe kierunki

Profilaktyka zapalenia otrzewnej wymaga wielopłaszczyznowego podejścia obejmującego procedury aseptyczne, odpowiednie szkolenia, monitorowanie i selektywne stosowanie antybiotyków w grupach wysokiego ryzyka. W przypadku dializy otrzewnowej, kluczowe znaczenie ma właściwe szkolenie pacjentów, regularne szkolenia uzupełniające oraz ścisłe przestrzeganie protokołów higieny.⁶¹⁶²

W przypadku SBP, chociaż profilaktyka antybiotykowa jest skuteczna, należy ją stosować rozważnie u pacjentów z wysokim ryzykiem rozwoju SBP, biorąc pod uwagę rosnący problem oporności na antybiotyki. Potrzebne są dalsze badania nad alternatywnymi antybiotykami i strategiami zapobiegawczymi.⁶³⁶⁴

Optymalizacja zapobiegania zapaleniu otrzewnej wymaga standaryzacji definicji zapalenia otrzewnej, kluczowych elementów danych i wyników w celu ułatwienia ogólnokrajowej sprawozdawczości. Standaryzowane raportowanie może również pomóc opisać zmienność wskaźników zapalenia otrzewnej i wyników w różnych placówkach w celu identyfikacji potencjalnych strategii zapobiegania zapaleniu otrzewnej i zaangażowania interesariuszy w opracowanie strategii ich wdrażania.⁶⁵

Przyszłe badania powinny koncentrować się na opracowaniu optymalnych schematów antybiotykowych, identyfikacji pacjentów, którzy mogą odnieść największe korzyści z profilaktyki antybiotykowej, oraz na strategiach zmniejszających ryzyko rozwoju oporności na antybiotyki.⁶⁶

Kolejne rozdziały

Zapraszamy do dalszego czytania naszego leksykonu.

Wybierz kolejny rozdział z menu poniżej, aby otworzyć nową podstronę kompedium wiedzy i uzyskać szczegółowe informację o leku, substancji lub chorobie.

Materiały źródłowe

#1 The new ISPD peritonitis guideline | Renal Replacement Therapy | Full Text
https://rrtjournal.biomedcentral.com/articles/10.1186/s41100-018-0150-2
Peritonitis is a common and serious complication of peritoneal dialysis (PD). Recommendations for the treatment and prevention of PD-related peritonitis, and latter those for catheter-related infections, under the auspices of the International Society for Peritoneal Dialysis (ISPD) were first published in 1987 and revised in 1989, 1993, 1996, 2000, 2005, and 2010. In the latest version, a single set of recommendations was provided for the treatment and prevention of PD-related peritonitis, and another for catheter-related infections. In this article, we will focus on the new changes and key messages of the new ISPD guideline on the treatment and prevention of peritonitis. […] The latest ISPD recommendation states that every PD center should monitor, at least on a yearly basis, the incidence of peritonitis. Notably, peritonitis rate should be reported as number of episodes per patient-year rather than as one episode per number of patient-month of treatment, which used to be commonly used.
#2 Periprocedural Peritonitis Prophylaxis: A Summary of the Microbiology and the Role of Systemic Antimicrobials
https://pmc.ncbi.nlm.nih.gov/articles/PMC8010226/
Peritonitis is a leading complication of peritoneal dialysis (PD). One strategy that the International Society for Peritoneal Dialysis (ISPD) has used to help mitigate the morbidity and mortality associated with peritonitis is through prevention, including antibiotic prophylaxis utilization in high-risk situations. […] The ISPD currently recommends intravenous antibiotics prior to PD catheter insertion, colonoscopies, and invasive gynecologic procedures, though prophylaxis has only demonstrated benefit in a prospective, randomized control setting for PD catheter insertion. […] Antibiotic prophylaxis is a potential strategy that the ISPD utilizes to prevent these infections. However, further research needs to be done to determine the optimal antibiotic regimen. […] The ISPD currently recommends multiple strategies to prevent ESI, especially during the catheter insertion, with the hope that preventing ESIs will decrease the risk of peritonitis. Of particular interest to this review is the grade 1A recommendation from the 2016 ISPD guidelines to administer systemic antibiotics prior to catheter insertion, though a specific antibiotic regimen is not listed.
#3 Antibiotic prophylaxis to prevent spontaneous bacterial peritonitis may not be effective – The Hospitalist
https://www.the-hospitalist.org/hospitalist/article/243339/infectious-diseases/antibiotic-prophylaxis-prevent-spontaneous-bacterial/
Antibiotic prophylaxis to prevent spontaneous bacterial peritonitis may not be effective. […] Antibiotic prophylaxis is the mainstay preventive treatment, but there is concern about development of drug resistance and other adverse events. […] Across 29 randomized clinical trials (total of 3,896 participants) looking at nine different antibiotic regimens for prophylaxis of spontaneous bacterial peritonitis, there was no evidence of differences between any of the antibiotics and no intervention in terms of mortality or serious adverse events, though there was very low certainty of evidence. […] The authors felt only two small studies were conducted without flaws. […] There was no difference between any of the antibiotics and no intervention in the proportion of people who developed spontaneous bacterial peritonitis. […] Whether antibiotics are effective prophylaxis to prevent spontaneous bacterial peritonitis and which antibiotics should be used is still uncertain; future well-designed studies are needed.
#4 The new ISPD peritonitis guideline | Renal Replacement Therapy | Full Text
https://rrtjournal.biomedcentral.com/articles/10.1186/s41100-018-0150-2
Peritonitis is a common and serious complication of peritoneal dialysis (PD). Recommendations for the treatment and prevention of PD-related peritonitis, and latter those for catheter-related infections, under the auspices of the International Society for Peritoneal Dialysis (ISPD) were first published in 1987 and revised in 1989, 1993, 1996, 2000, 2005, and 2010. In the latest version, a single set of recommendations was provided for the treatment and prevention of PD-related peritonitis, and another for catheter-related infections. In this article, we will focus on the new changes and key messages of the new ISPD guideline on the treatment and prevention of peritonitis. […] The latest ISPD recommendation states that every PD center should monitor, at least on a yearly basis, the incidence of peritonitis. Notably, peritonitis rate should be reported as number of episodes per patient-year rather than as one episode per number of patient-month of treatment, which used to be commonly used.
#5 The new ISPD peritonitis guideline | Renal Replacement Therapy | Full Text
https://rrtjournal.biomedcentral.com/articles/10.1186/s41100-018-0150-2
As emphasized repeatedly in recent three versions of the guideline, empirical antibiotic therapy should be initiated as soon as possible after appropriate microbiological specimens have been obtained. The recommended empirical antibiotic regimens have not changed in the latest version and should be center-specific and cover both Gram-positive and Gram-negative organisms. […] The latest guideline highlights the importance of performing a root cause analysis for each peritonitis episode to determine the etiology of the episode, and, whenever possible, further intervention should be directed against any reversible risk factor to prevent another episode. […] The latest guideline makes a few specific recommendations on evidence-based strategies for the prevention of peritonitis. First, systemic prophylactic antibiotics should be administered immediately prior to catheter insertion, which is highly effective in reducing the incidence of early peritonitis after catheter insertion, although the evidence for the prevention of catheter-related infections (i.e., exit site or tunnel infections) is less solid.
#6 Peritonitis Prevention Strategies – Klarity Health Library
https://my.klarity.health/peritonitis-prevention-strategies/
Peritonitis is an inflammation of the abdomen’s inner lining, also known as the peritoneum, and causes significant abdominal pain. […] This article will focus on strategies to prevent the occurrence of peritonitis. […] Thus, it takes a collaborative approach of key stakeholders, including clinicians, researchers and policymakers to implement ways to prevent peritonitis. […] The International Society of Peritoneal Dialysis (ISPD) peritonitis guideline recommendations have been updated in 2022. They recommended that the yearly rate of peritonitis should be no more than 0.40 episodes per year at risk, and the percentage of peritonitis-free patients should be targeted at more than 80% per year. […] Additionally, below are some recommendations from the ISPD on how to minimise the risk of developing PD-associated peritonitis: Administration of prophylactic antibiotics (antibiotics administered to prevent infection) before proper catheter placement to reduce the risk of exit-site infection where the catheter contacts the patients skin.
#7 Risk factors and prevention of peritonitis in peritoneal dialysis – UpToDate
https://www.uptodate.com/contents/risk-factors-and-prevention-of-peritonitis-in-peritoneal-dialysis
Risk factors and prevention of peritonitis in peritoneal dialysis […] PREVENTION […] Proper training and equipment […] Aseptic technique […] Exit site care […] Transfer set […] Management after breaks in technique […] Prompt treatment of catheter infections […] Management before procedures […] Draining the abdomen […] Antibiotics before select procedures […] Management during intraabdominal infection or inflammation […] Catheter exit-site leaks […] Antifungal prophylaxis during antibiotic therapy.
#8 Preventing and Treating Peritonitis – AAKP
https://aakp.org/preventing-and-treating-peritonitis/
When the outside world comes in contact with the internal world of our body we are at risk for developing an infection. […] To avoid infection the PD patient needs to make sure technique is perfect. […] Fortunately peritonitis caused by PD technique error is nearly completely preventable and is controllable by the patient! […] Probably the most important part of preventing infections is perfect hand washing. […] We also believe that wearing a mask prevents infection too. […] Preventing catheter related infections starts with surgical insertion. […] Patients clean the exit site daily and then apply a small dab of antibiotic cream to the exit site. […] Nevertheless, every episode of peritonitis can have a long lasting bad impact on patient health and should be prevented. […] Peritonitis is a preventable event and the patient should involve the dialysis team to help but ultimately the patient has control and should make sure it doesnt occur!
#9 Peritonitis – Symptoms and causes – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/peritonitis/symptoms-causes/syc-20376247
Peritonitis that’s linked with peritoneal dialysis is often caused by germs around the catheter. If you use peritoneal dialysis, take these steps to prevent peritonitis: Wash your hands before you touch the catheter. Scrub under your fingernails and between your fingers. Clean the skin around the catheter with an antiseptic every day. Store your supplies in a clean place. Wear a surgical mask during your dialysis fluid exchanges. Talk with your dialysis care team about the correct care for your peritoneal dialysis catheter. […] Your health care provider may prescribe antibiotics to prevent peritonitis, especially if you’ve had peritonitis before. Antibiotics also might be prescribed if you have a buildup of peritoneal fluid due to a medical condition such as liver cirrhosis. If you take medicine called a proton pump inhibitor, you may be asked to stop taking it.
#10 The new ISPD peritonitis guideline | Renal Replacement Therapy | Full Text
https://rrtjournal.biomedcentral.com/articles/10.1186/s41100-018-0150-2
The latest guideline also emphasizes the adherence of the latest ISPD recommendations for teaching PD patients and their caregivers. PD training should be conducted by nursing staff with the appropriate qualifications and experience. […] In essence, the latest guideline summarizes a number of measures with proved efficacy for the prevention of peritonitis: antibiotic prophylaxis before catheter insertion, the application of disconnect PD system, and regular use of antibiotic cream or ointment for exit site care.
#11 Peritonitis – Symptoms and causes – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/peritonitis/symptoms-causes/syc-20376247
Peritonitis that’s linked with peritoneal dialysis is often caused by germs around the catheter. If you use peritoneal dialysis, take these steps to prevent peritonitis: Wash your hands before you touch the catheter. Scrub under your fingernails and between your fingers. Clean the skin around the catheter with an antiseptic every day. Store your supplies in a clean place. Wear a surgical mask during your dialysis fluid exchanges. Talk with your dialysis care team about the correct care for your peritoneal dialysis catheter. […] Your health care provider may prescribe antibiotics to prevent peritonitis, especially if you’ve had peritonitis before. Antibiotics also might be prescribed if you have a buildup of peritoneal fluid due to a medical condition such as liver cirrhosis. If you take medicine called a proton pump inhibitor, you may be asked to stop taking it.
#12 Risk factors and prevention of peritonitis in peritoneal dialysis – UpToDate
https://www.uptodate.com/contents/risk-factors-and-prevention-of-peritonitis-in-peritoneal-dialysis
Risk factors and prevention of peritonitis in peritoneal dialysis […] PREVENTION […] Proper training and equipment […] Aseptic technique […] Exit site care […] Transfer set […] Management after breaks in technique […] Prompt treatment of catheter infections […] Management before procedures […] Draining the abdomen […] Antibiotics before select procedures […] Management during intraabdominal infection or inflammation […] Catheter exit-site leaks […] Antifungal prophylaxis during antibiotic therapy.
#13 Risk factors and prevention of peritonitis in peritoneal dialysis – UpToDate
https://www.uptodate.com/contents/risk-factors-and-prevention-of-peritonitis-in-peritoneal-dialysis
Risk factors and prevention of peritonitis in peritoneal dialysis […] PREVENTION […] Proper training and equipment […] Aseptic technique […] Exit site care […] Transfer set […] Management after breaks in technique […] Prompt treatment of catheter infections […] Management before procedures […] Draining the abdomen […] Antibiotics before select procedures […] Management during intraabdominal infection or inflammation […] Catheter exit-site leaks […] Antifungal prophylaxis during antibiotic therapy.
#14 Risk factors and prevention of peritonitis in peritoneal dialysis – UpToDate
https://www.uptodate.com/contents/risk-factors-and-prevention-of-peritonitis-in-peritoneal-dialysis
Risk factors and prevention of peritonitis in peritoneal dialysis […] PREVENTION […] Proper training and equipment […] Aseptic technique […] Exit site care […] Transfer set […] Management after breaks in technique […] Prompt treatment of catheter infections […] Management before procedures […] Draining the abdomen […] Antibiotics before select procedures […] Management during intraabdominal infection or inflammation […] Catheter exit-site leaks […] Antifungal prophylaxis during antibiotic therapy.
#15 Risk factors and prevention of peritonitis in peritoneal dialysis – UpToDate
https://www.uptodate.com/contents/risk-factors-and-prevention-of-peritonitis-in-peritoneal-dialysis
Risk factors and prevention of peritonitis in peritoneal dialysis […] PREVENTION […] Proper training and equipment […] Aseptic technique […] Exit site care […] Transfer set […] Management after breaks in technique […] Prompt treatment of catheter infections […] Management before procedures […] Draining the abdomen […] Antibiotics before select procedures […] Management during intraabdominal infection or inflammation […] Catheter exit-site leaks […] Antifungal prophylaxis during antibiotic therapy.
#16 Risk factors and prevention of peritonitis in peritoneal dialysis – UpToDate
https://www.uptodate.com/contents/risk-factors-and-prevention-of-peritonitis-in-peritoneal-dialysis
Risk factors and prevention of peritonitis in peritoneal dialysis […] PREVENTION […] Proper training and equipment […] Aseptic technique […] Exit site care […] Transfer set […] Management after breaks in technique […] Prompt treatment of catheter infections […] Management before procedures […] Draining the abdomen […] Antibiotics before select procedures […] Management during intraabdominal infection or inflammation […] Catheter exit-site leaks […] Antifungal prophylaxis during antibiotic therapy.
#17 Risk factors and prevention of peritonitis in peritoneal dialysis – UpToDate
https://www.uptodate.com/contents/risk-factors-and-prevention-of-peritonitis-in-peritoneal-dialysis
Risk factors and prevention of peritonitis in peritoneal dialysis […] PREVENTION […] Proper training and equipment […] Aseptic technique […] Exit site care […] Transfer set […] Management after breaks in technique […] Prompt treatment of catheter infections […] Management before procedures […] Draining the abdomen […] Antibiotics before select procedures […] Management during intraabdominal infection or inflammation […] Catheter exit-site leaks […] Antifungal prophylaxis during antibiotic therapy.
#18 Risk factors and prevention of peritonitis in peritoneal dialysis – UpToDate
https://www.uptodate.com/contents/risk-factors-and-prevention-of-peritonitis-in-peritoneal-dialysis
Risk factors and prevention of peritonitis in peritoneal dialysis […] PREVENTION […] Proper training and equipment […] Aseptic technique […] Exit site care […] Transfer set […] Management after breaks in technique […] Prompt treatment of catheter infections […] Management before procedures […] Draining the abdomen […] Antibiotics before select procedures […] Management during intraabdominal infection or inflammation […] Catheter exit-site leaks […] Antifungal prophylaxis during antibiotic therapy.
#19 Risk factors and prevention of peritonitis in peritoneal dialysis – UpToDate
https://www.uptodate.com/contents/risk-factors-and-prevention-of-peritonitis-in-peritoneal-dialysis
Risk factors and prevention of peritonitis in peritoneal dialysis […] PREVENTION […] Proper training and equipment […] Aseptic technique […] Exit site care […] Transfer set […] Management after breaks in technique […] Prompt treatment of catheter infections […] Management before procedures […] Draining the abdomen […] Antibiotics before select procedures […] Management during intraabdominal infection or inflammation […] Catheter exit-site leaks […] Antifungal prophylaxis during antibiotic therapy.
#20 Risk factors and prevention of peritonitis in peritoneal dialysis – UpToDate
https://www.uptodate.com/contents/risk-factors-and-prevention-of-peritonitis-in-peritoneal-dialysis
Risk factors and prevention of peritonitis in peritoneal dialysis […] PREVENTION […] Proper training and equipment […] Aseptic technique […] Exit site care […] Transfer set […] Management after breaks in technique […] Prompt treatment of catheter infections […] Management before procedures […] Draining the abdomen […] Antibiotics before select procedures […] Management during intraabdominal infection or inflammation […] Catheter exit-site leaks […] Antifungal prophylaxis during antibiotic therapy.
#21 Periprocedural Peritonitis Prophylaxis: A Summary of the Microbiology and the Role of Systemic Antimicrobials
https://pmc.ncbi.nlm.nih.gov/articles/PMC8010226/
Peritonitis is a leading complication of peritoneal dialysis (PD). One strategy that the International Society for Peritoneal Dialysis (ISPD) has used to help mitigate the morbidity and mortality associated with peritonitis is through prevention, including antibiotic prophylaxis utilization in high-risk situations. […] The ISPD currently recommends intravenous antibiotics prior to PD catheter insertion, colonoscopies, and invasive gynecologic procedures, though prophylaxis has only demonstrated benefit in a prospective, randomized control setting for PD catheter insertion. […] Antibiotic prophylaxis is a potential strategy that the ISPD utilizes to prevent these infections. However, further research needs to be done to determine the optimal antibiotic regimen. […] The ISPD currently recommends multiple strategies to prevent ESI, especially during the catheter insertion, with the hope that preventing ESIs will decrease the risk of peritonitis. Of particular interest to this review is the grade 1A recommendation from the 2016 ISPD guidelines to administer systemic antibiotics prior to catheter insertion, though a specific antibiotic regimen is not listed.
#22 Periprocedural Peritonitis Prophylaxis: A Summary of the Microbiology and the Role of Systemic Antimicrobials
https://pmc.ncbi.nlm.nih.gov/articles/PMC8010226/
Due to the concern for peritonitis, the ISPD 2016 guidelines recommend antibiotic prophylaxis in all patients undergoing invasive gynecologic procedures. They suggest the same antibiotic regimen as that for colonoscopies: a single dose of IV ampicillin plus an aminoglycoside, with or without metronidazole. […] The role of antibiotics in PD catheter insertion has been studied prospectively, but only small retrospective studies have looked at the benefits of antibiotic prophylaxis in other routine procedures.
#23 ISPD Peritonitis Update 2022 — NephJC
http://www.nephjc.com/news/ispd2022peritonitis
We recommend that peritonitis should be diagnosed when at least two of the following are present (1C): clinical features consistent with peritonitis: abdominal pain and/or cloudy dialysis effluent; dialysis effluent white blood cell (WBC) count 100/L or 0.1×109/L (after a dwell time of at least 2 h), with 50% polymorphonuclear leukocytes (PMN); positive dialysis effluent culture. […] In the guideline, there is only one 1A recommendation, which can be found both in the 2016 and 2022 ISPD guidelines: that systemic prophylactic antibiotics be administered prior to catheter placement. […] We suggest prophylactic antibiotics after wet contamination of the PD system to prevent peritonitis (2D). […] We suggest antibiotic prophylaxis prior to colonoscopy (2C) and invasive gynecological procedure (2D).
#24 Periprocedural Peritonitis Prophylaxis: A Summary of the Microbiology and the Role of Systemic Antimicrobials
https://pmc.ncbi.nlm.nih.gov/articles/PMC8010226/
Peritonitis is a leading complication of peritoneal dialysis (PD). One strategy that the International Society for Peritoneal Dialysis (ISPD) has used to help mitigate the morbidity and mortality associated with peritonitis is through prevention, including antibiotic prophylaxis utilization in high-risk situations. […] The ISPD currently recommends intravenous antibiotics prior to PD catheter insertion, colonoscopies, and invasive gynecologic procedures, though prophylaxis has only demonstrated benefit in a prospective, randomized control setting for PD catheter insertion. […] Antibiotic prophylaxis is a potential strategy that the ISPD utilizes to prevent these infections. However, further research needs to be done to determine the optimal antibiotic regimen. […] The ISPD currently recommends multiple strategies to prevent ESI, especially during the catheter insertion, with the hope that preventing ESIs will decrease the risk of peritonitis. Of particular interest to this review is the grade 1A recommendation from the 2016 ISPD guidelines to administer systemic antibiotics prior to catheter insertion, though a specific antibiotic regimen is not listed.
#25 Acute Bacterial Peritonitis in Adults
https://www.uspharmacist.com/article/acute-bacterial-peritonitis-in-adults
Certain patient populations should be considered for prophylaxis of bacterial peritonitis. Primary bacterial peritonitis can be prevented using antibiotics if there is a known risk factor. For example, a single IV dose of vancomycin 1 g given at the time of catheter placement in patients undergoing peritoneal dialysis can help prevent bacterial peritonitis. […] An alternate to vancomycin is a single dose of cefazolin 1 g IV. […] Secondary bacterial peritonitis prophylaxis should be considered in patients with cirrhosis who are admitted for upper GI hemorrhage. […] In the past, norfloxacin 400 mg daily had been the drug of choice in the setting of upper GI hemorrhage; however, alternative antimicrobials have since been considered due to epidemiological changes of bacterial infections in cirrhosis. […] Ceftriaxone 1 g IV has been proven to be an effective alternative.
#26 The new ISPD peritonitis guideline | Renal Replacement Therapy | Full Text
https://rrtjournal.biomedcentral.com/articles/10.1186/s41100-018-0150-2
As emphasized repeatedly in recent three versions of the guideline, empirical antibiotic therapy should be initiated as soon as possible after appropriate microbiological specimens have been obtained. The recommended empirical antibiotic regimens have not changed in the latest version and should be center-specific and cover both Gram-positive and Gram-negative organisms. […] The latest guideline highlights the importance of performing a root cause analysis for each peritonitis episode to determine the etiology of the episode, and, whenever possible, further intervention should be directed against any reversible risk factor to prevent another episode. […] The latest guideline makes a few specific recommendations on evidence-based strategies for the prevention of peritonitis. First, systemic prophylactic antibiotics should be administered immediately prior to catheter insertion, which is highly effective in reducing the incidence of early peritonitis after catheter insertion, although the evidence for the prevention of catheter-related infections (i.e., exit site or tunnel infections) is less solid.
#27 Periprocedural Peritonitis Prophylaxis: A Summary of the Microbiology and the Role of Systemic Antimicrobials
https://pmc.ncbi.nlm.nih.gov/articles/PMC8010226/
Given the high risk for infection, leaks should be avoided, and if present, antibiotics should probably be given prophylactically while an infectious workup is completed to rule out peritonitis or ESI. […] Patients with high risk for endocarditis, like those with prosthetic heart valves or unrepaired congenital cyanotic diseases, are well known to require antibiotic prophylaxis prior to dental procedures. […] In fact, in a survey completed in 2004 with nephrologists in Australia and New Zealand, only 41% of respondents recommended antibiotic prophylaxis for dental procedures. […] The most frequent culprit organisms cultured from the peritoneal fluid are from the Enterobacteriaceae family, especially E. coli. […] The ISPD recommends prophylactic antibiotics for any PD patient prior to undergoing a colonoscopy.
#28 Periprocedural Peritonitis Prophylaxis: A Summary of the Microbiology and the Role of Systemic Antimicrobials
https://pmc.ncbi.nlm.nih.gov/articles/PMC8010226/
Due to the concern for peritonitis, the ISPD 2016 guidelines recommend antibiotic prophylaxis in all patients undergoing invasive gynecologic procedures. They suggest the same antibiotic regimen as that for colonoscopies: a single dose of IV ampicillin plus an aminoglycoside, with or without metronidazole. […] The role of antibiotics in PD catheter insertion has been studied prospectively, but only small retrospective studies have looked at the benefits of antibiotic prophylaxis in other routine procedures.
#29 Periprocedural Peritonitis Prophylaxis: A Summary of the Microbiology and the Role of Systemic Antimicrobials
https://pmc.ncbi.nlm.nih.gov/articles/PMC8010226/
Due to the concern for peritonitis, the ISPD 2016 guidelines recommend antibiotic prophylaxis in all patients undergoing invasive gynecologic procedures. They suggest the same antibiotic regimen as that for colonoscopies: a single dose of IV ampicillin plus an aminoglycoside, with or without metronidazole. […] The role of antibiotics in PD catheter insertion has been studied prospectively, but only small retrospective studies have looked at the benefits of antibiotic prophylaxis in other routine procedures.
#30 ISPD Peritonitis Update 2022 — NephJC
http://www.nephjc.com/news/ispd2022peritonitis
We recommend that peritonitis should be diagnosed when at least two of the following are present (1C): clinical features consistent with peritonitis: abdominal pain and/or cloudy dialysis effluent; dialysis effluent white blood cell (WBC) count 100/L or 0.1×109/L (after a dwell time of at least 2 h), with 50% polymorphonuclear leukocytes (PMN); positive dialysis effluent culture. […] In the guideline, there is only one 1A recommendation, which can be found both in the 2016 and 2022 ISPD guidelines: that systemic prophylactic antibiotics be administered prior to catheter placement. […] We suggest prophylactic antibiotics after wet contamination of the PD system to prevent peritonitis (2D). […] We suggest antibiotic prophylaxis prior to colonoscopy (2C) and invasive gynecological procedure (2D).
#31 Antimicrobial agents for preventing peritonitis in peritoneal dialysis patients
https://pmc.ncbi.nlm.nih.gov/articles/PMC6478113/
Pre/perioperative intravenous vancomycin compared with no treatment may reduce the risk of early peritonitis (1 study, 177 patients, low quality evidence: RR 0.08, 95% CI 0.01 to 0.61) but has an uncertain effect on the risk of exitsite/tunnel infection (1 study, 177 patients, low quality evidence: RR 0.36, 95% CI 0.10 to 1.32). […] Antifungal prophylaxis with oral nystatin/fluconazole compared with placebo/no treatment may reduce the risk of fungal peritonitis occurring after a patient has had an antibiotic course (2 studies, 817 patients, low quality evidence: RR 0.28, 95% CI 0.12 to 0.63). […] In this update, we identified limited data from RCTs and quasiRCTs which evaluated strategies to prevent peritonitis and exitsite/tunnel infections. This review demonstrates that pre/perioperative intravenous vancomycin may reduce the risk of early peritonitis and that antifungal prophylaxis with oral nystatin or fluconazole reduces the risk of fungal peritonitis following an antibiotic course. However, no other antimicrobial interventions have proven efficacy. […] Given the large number of patients on PD and the importance of peritonitis, the lack of adequately powered and high quality RCTs to inform decision making about strategies to prevent peritonitis is striking.
#32 ISPD Peritonitis Update 2022 — NephJC
http://www.nephjc.com/news/ispd2022peritonitis
We recommend PD patients take extra precautions to prevent peritonitis if domestic pets are kept (1C). […] We suggest that avoidance and treatment of hypokalemia may reduce the risk of peritonitis (2C). […] To prevent fungal peritonitis, we recommend that anti-fungal prophylaxis be co-prescribed whenever PD patients receive an antibiotic course, regardless of the indication for that antibiotic course (1B).
#33 Antimicrobial agents for preventing peritonitis in peritoneal dialysis patients
https://pmc.ncbi.nlm.nih.gov/articles/PMC6478113/
Pre/perioperative intravenous vancomycin compared with no treatment may reduce the risk of early peritonitis (1 study, 177 patients, low quality evidence: RR 0.08, 95% CI 0.01 to 0.61) but has an uncertain effect on the risk of exitsite/tunnel infection (1 study, 177 patients, low quality evidence: RR 0.36, 95% CI 0.10 to 1.32). […] Antifungal prophylaxis with oral nystatin/fluconazole compared with placebo/no treatment may reduce the risk of fungal peritonitis occurring after a patient has had an antibiotic course (2 studies, 817 patients, low quality evidence: RR 0.28, 95% CI 0.12 to 0.63). […] In this update, we identified limited data from RCTs and quasiRCTs which evaluated strategies to prevent peritonitis and exitsite/tunnel infections. This review demonstrates that pre/perioperative intravenous vancomycin may reduce the risk of early peritonitis and that antifungal prophylaxis with oral nystatin or fluconazole reduces the risk of fungal peritonitis following an antibiotic course. However, no other antimicrobial interventions have proven efficacy. […] Given the large number of patients on PD and the importance of peritonitis, the lack of adequately powered and high quality RCTs to inform decision making about strategies to prevent peritonitis is striking.
#34 The new ISPD peritonitis guideline | Renal Replacement Therapy | Full Text
https://rrtjournal.biomedcentral.com/articles/10.1186/s41100-018-0150-2
The latest guideline also emphasizes the adherence of the latest ISPD recommendations for teaching PD patients and their caregivers. PD training should be conducted by nursing staff with the appropriate qualifications and experience. […] In essence, the latest guideline summarizes a number of measures with proved efficacy for the prevention of peritonitis: antibiotic prophylaxis before catheter insertion, the application of disconnect PD system, and regular use of antibiotic cream or ointment for exit site care.
#35 Peritonitis – Symptoms and causes – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/peritonitis/symptoms-causes/syc-20376247
Peritonitis that’s linked with peritoneal dialysis is often caused by germs around the catheter. If you use peritoneal dialysis, take these steps to prevent peritonitis: Wash your hands before you touch the catheter. Scrub under your fingernails and between your fingers. Clean the skin around the catheter with an antiseptic every day. Store your supplies in a clean place. Wear a surgical mask during your dialysis fluid exchanges. Talk with your dialysis care team about the correct care for your peritoneal dialysis catheter. […] Your health care provider may prescribe antibiotics to prevent peritonitis, especially if you’ve had peritonitis before. Antibiotics also might be prescribed if you have a buildup of peritoneal fluid due to a medical condition such as liver cirrhosis. If you take medicine called a proton pump inhibitor, you may be asked to stop taking it.
#36 Peritonitis Prevention
https://apac.mykidneyjourney.com/en-hant/peritonitis-prevention
People on peritoneal dialysis can be at risk of an infection called peritonitis. […] The good news is that you can take simple steps to reduce your risk of peritonitis, little by little. […] By learning more what causes peritonitis, you will know how best to avoid it. Small changes can help you stay healthy. Share this information with your loved ones. […] No plants in the room. This is because bacteria, mould or pollen on plants can increase your risk of infection. […] No pets in the room. We love Fluffy, but pets (and their equipment, such as beds, toys, litter boxes and cages) leave bacteria in the room, which increases your risk of infection. […] Keep nails short. Long nails on you (or your pet!) can trap germs, and sometimes leave scratches where germs can get in. Keep nails trimmed.
#37 Peritonitis Prevention
https://apac.mykidneyjourney.com/en-hant/peritonitis-prevention
Use hand rub before PD. […] Use alcohol rub on your hands before connecting. […] Remember not to touch the connector. Any germs on the connector can get into the catheter. Accidentally touching the connector or the cap with your fingers, especially with unwashed hands (not following aseptic, non-touch technique), can cause peritonitis. […] Properly dispose of the dialysis effluent (as instructed by renal centre nurses). […] We recommend that you proactively seek feedback on your dialysis technique. […] People who do this regularly have a lower rate of peritonitis!
#38 A retraining program reduces the rate of peritonitis in peritoneal dialysis | NefrologÃa
https://www.revistanefrologia.com/en-a-retraining-program-reduces-rate-articulo-S2013251422000463
Peritonitis is both a common and serious complication in peritoneal dialysis (PD). It also leads to morbidity and mortality and patients may need to be transferred to haemodialysis. All dialysis programmes should be aware of and monitor the rate of peritonitis they go through. The guidelines of the International Society for Peritoneal Dialysis cite an overall target rate of 0.5 episodes/year. Establishing appropriate protocols is essential to normalize clinical practice and achieve the best possible clinical outcomes. […] In PD, prevention of peritonitis is very important to reduce its rate. It has been suggested that retraining may reduce the risk of peritonitis. Peritonitis rates are significantly reduced in centres with active retraining programmes compared to those that do not; with retraining, peritonitis caused in particular by Gram-positive germs is reduced.
#39 A retraining program reduces the rate of peritonitis in peritoneal dialysis | NefrologÃa
https://www.revistanefrologia.com/en-a-retraining-program-reduces-rate-articulo-S2013251422000463
Despite following the recommendations established by the clinical guidelines, it was not until we established periodic retraining as a quality indicator that we were able to significantly reduce our peritonitis rate and change the spectrum of the causative germs. However, the improvement in the rate could also be due to other factors, as the design of our study means we cannot demonstrate causality. We conclude that continuous quality improvement initiatives based on scheduled retraining and site-specific outcomes could reduce peritonitis rates in PD.
#40
https://link.springer.com/article/10.1007/BF01782702
Spontaneous bacterial peritonitis is associated with a relatively high in-hospital mortality rate (20-40%), prophylactic measures to prevent this infection are required. […] Short-term and long-term selective intestinal decontamination with oral norfloxacin has proved highly effective in preventing bacterial infection and spontaneous bacterial peritonitis in bleeding cirrhotic patients as well as recurrence of spontaneous bacterial peritonitis. […] Prophylactic measures are required due to the high mortality rate (20-40%) of the disease during hospitalization. […] Oral non-absorbable antibiotics prevent infection in cirrhosis with gastrointestinal hemorrhage. […] Norfloxacin prevents bacterial infection in cirrhotics with gastrointestinal hemorrhage. […] Selective intestinal decontamination prevents spontaneous bacterial peritonitis. […] Norfloxacin prevents spontaneous bacterial peritonitis recurrence in cirrhosis: results of a double-blind, placebo-controlled trial.
#41 Spontaneous bacterial peritonitis in patients with cirrhosis: incidenc | HMER
https://www.dovepress.com/spontaneous-bacterial-peritonitis-in-patients-with-cirrhosis-incidence-peer-reviewed-fulltext-article-HMER
Spontaneous bacterial peritonitis is the most frequent bacterial infection in patients with cirrhosis. […] Early antibiotic treatment of spontaneous bacterial peritonitis is crucial. […] Even though antibiotic prophylaxis has proven to be effective to prevent spontaneous bacterial peritonitis, a careful selection of high-risk candidates is crucial to avoid antibiotic overuse. […] Additionally, spontaneous bacterial peritonitis recurrence can be as high as 70% if no prophylaxis is implemented. […] For this reason, as will be discussed later, universal secondary antibiotic prophylaxis is recommended, since it reduces the probability of recurrence to 20% and improves survival. […] The current recommendations of antibiotic prophylaxis are shown in Table 3. […] The 1-year cumulative incidence of spontaneous bacterial peritonitis recurrence after the first episode is as high as 70% if no prophylaxis is indicated.
#42 Why do we use antibiotics for SBP prophylaxis? | AASLD
https://www.aasld.org/liver-fellow-network/core-series/why-series/why-do-we-use-antibiotics-sbp-prophylaxis
You may have noticed that we often start antibiotics for patients with cirrhosis to prevent spontaneous bacterial peritonitis (SBP). […] SBP is common in patients with decompensated cirrhosis and is associated with high morbidity and mortality. […] If you have had SBP once, it is likely to recur. It is estimated that SBP survivors have a 70% risk of recurrence within 1 year! […] Individuals who have had SBP before are at particularly high risk of developing it again. SBP recurs within a year in about 70% of individuals with a prior episode of SBP and is associated with a low survival rate of only 30 to 50%. The identification of prior SBP as a risk factor for future episodes led to randomized control trials of prophylactic antibiotics. […] One of the first randomized control trials published in 1990 from a group in Barcelona, studied the effects of antibiotic prophylaxis with norfloxacin versus placebo in patients who had recently recovered from an episode of SBP.
#43 Why do we use antibiotics for SBP prophylaxis? | AASLD
https://www.aasld.org/liver-fellow-network/core-series/why-series/why-do-we-use-antibiotics-sbp-prophylaxis
This, along with other studies, led to the recommendation to use antibiotics for secondary prophylaxis in patients that have a history of SBP. Long-term secondary prophylaxis is currently recommended until liver transplantation or death. […] Upper gastrointestinal bleeding is the second clinical scenario where antibiotics are used for SBP prophylaxis. […] Antibiotic prophylaxis is currently recommended to be started as early as possible after upper GI bleeding according to the American Association for the Study of Liver Diseases and to continue for 7 days. […] Results from this study helped lead to recommendations from the American Association of Liver Diseases and the European Association for the Study of the Liver to use antibiotic primary prophylaxis in individuals with low-protein ascites less than 1.5 g/dL PLUS impaired liver (Child-Pugh score 9 points with serum bilirubin 3 mg/dL) or renal dysfunction (creatinine 1.2 mg/dL, blood urea nitrogen 25 mg/dL, or serum sodium 130 mEq/L).
#44 VASF Spontaneous Bacterial Peritonitis (SBP) Treatment Guidelines | Infectious Diseases Management Program at UCSF
https://idmp.ucsf.edu/content/vasf-spontaneous-bacterial-peritonitis-sbp-treatment-guidelines
SBP Prophylaxis […] Advanced cirrhosis without prior episode of SBP and Acute upper gastrointestinal hemorrhage […] Preferred: Ceftriaxone 1 gm IV q24h […] Primary Prophylaxis […] Low ascitic protein (1.5 g/dL) AND Renal dysfunction (Cr 1.2 mg/dL, BUN 25 mg/dL, or Serum Na 130 mEq/L) […] Preferred: Ciprofloxacin* 500 mg PO Q24H […] Secondary Prophylaxis […] Prior episode of SBP […] Preferred: Ciprofloxacin* 500 mg PO Q24H.
#45 Spontaneous bacterial peritonitis – Knowledge @ AMBOSS
https://www.amboss.com/us/knowledge/spontaneous-bacterial-peritonitis/
SBP may manifest with fever, abdominal pain, and/or altered mental status, but some patients are asymptomatic at presentation. […] Long-term prophylactic antibiotic therapy is recommended to prevent recurrent infection. […] Additional risk factors in patients with cirrhosis include: Low ascitic fluid protein concentration, Upper gastrointestinal bleeding, Prior episodes of SBP. […] Indications for diagnostic paracentesis in SBP include: Clinical deterioration or hospital admission, Signs of infection (e.g., fever; hypothermia, tachycardia, tachypnea, shock, leukocytosis, acidosis), Gastrointestinal signs or symptoms (e.g., abdominal pain/tenderness, vomiting, diarrhea, ileus, GI bleed), Encephalopathy, Worsening ascites, Worsening liver and/or renal function. […] Indications for prophylaxis for SBP include: Primary prophylaxis: ascitic fluid protein in patients with either impaired renal function or liver failure, Secondary prophylaxis: all patients with a previous episode of SBP, Short-term prophylaxis in patients with cirrhosis and GI bleeding. […] Commonly used agents for prophylaxis include: Ciprofloxacin, Norfloxacin, Trimethoprim/Sulfamethoxazole.
#46 Why do we use antibiotics for SBP prophylaxis? | AASLD
https://www.aasld.org/liver-fellow-network/core-series/why-series/why-do-we-use-antibiotics-sbp-prophylaxis
The majority of SBP infections are due to gram negative bacteria like E. Coli and Klebsiella and therefore, antibiotic prophylaxis should have good coverage against gram negative organisms. […] The current antibiotic regimens recommended for primary and secondary SBP prophylaxis in the United States are ciprofloxacin 500 mg/day PO or TMP/SMX double strength PO daily. […] Antibiotics for infection prophylaxis after a GI bleed is typically with intravenous ceftriaxone and only lasts for a total of 7 days. […] There are several major concerns associated with long-term antibiotic use: […] All and all, there is still work that needs to be done to better understand the patient groups that most benefit from SBP prophylaxis.
#47 VASF Spontaneous Bacterial Peritonitis (SBP) Treatment Guidelines | Infectious Diseases Management Program at UCSF
https://idmp.ucsf.edu/content/vasf-spontaneous-bacterial-peritonitis-sbp-treatment-guidelines
SBP Prophylaxis […] Advanced cirrhosis without prior episode of SBP and Acute upper gastrointestinal hemorrhage […] Preferred: Ceftriaxone 1 gm IV q24h […] Primary Prophylaxis […] Low ascitic protein (1.5 g/dL) AND Renal dysfunction (Cr 1.2 mg/dL, BUN 25 mg/dL, or Serum Na 130 mEq/L) […] Preferred: Ciprofloxacin* 500 mg PO Q24H […] Secondary Prophylaxis […] Prior episode of SBP […] Preferred: Ciprofloxacin* 500 mg PO Q24H.
#48 Core Concepts – Recognition and Management of Spontaneous Bacterial Peritonitis – Management of Cirrhosis-Related Complications – Hepatitis C Online
https://www.hepatitisc.uw.edu/go/management-cirrhosis-related-complications/spontaneous-bacterial-peritonitis-recognition-management/core-concept/all
Several studies have shown that oral norfloxacin 400 mg daily prevents SBP in persons with low-protein ascites and those with a previous history of SBP. […] Recommended regimens for primary and secondary SBP prophylaxis consist of oral ciprofloxacin (500 mg daily) or trimethoprim-sulfamethoxazole (one double-strength tablet daily). Daily dosing is preferred over intermittent dosing due to the increased risk of developing antimicrobial resistance with intermittent dosing. […] Oral norfloxacin 400 mg twice daily for 7 days has been shown to prevent infection in persons with cirrhosis following gastrointestinal hemorrhage.
#49 Core Concepts – Recognition and Management of Spontaneous Bacterial Peritonitis – Management of Cirrhosis-Related Complications – Hepatitis C Online
https://www.hepatitisc.uw.edu/go/management-cirrhosis-related-complications/spontaneous-bacterial-peritonitis-recognition-management/core-concept/all
Several studies have shown that oral norfloxacin 400 mg daily prevents SBP in persons with low-protein ascites and those with a previous history of SBP. […] Recommended regimens for primary and secondary SBP prophylaxis consist of oral ciprofloxacin (500 mg daily) or trimethoprim-sulfamethoxazole (one double-strength tablet daily). Daily dosing is preferred over intermittent dosing due to the increased risk of developing antimicrobial resistance with intermittent dosing. […] Oral norfloxacin 400 mg twice daily for 7 days has been shown to prevent infection in persons with cirrhosis following gastrointestinal hemorrhage.
#50 Why do we use antibiotics for SBP prophylaxis? | AASLD
https://www.aasld.org/liver-fellow-network/core-series/why-series/why-do-we-use-antibiotics-sbp-prophylaxis
The majority of SBP infections are due to gram negative bacteria like E. Coli and Klebsiella and therefore, antibiotic prophylaxis should have good coverage against gram negative organisms. […] The current antibiotic regimens recommended for primary and secondary SBP prophylaxis in the United States are ciprofloxacin 500 mg/day PO or TMP/SMX double strength PO daily. […] Antibiotics for infection prophylaxis after a GI bleed is typically with intravenous ceftriaxone and only lasts for a total of 7 days. […] There are several major concerns associated with long-term antibiotic use: […] All and all, there is still work that needs to be done to better understand the patient groups that most benefit from SBP prophylaxis.
#51 Spontaneous Bacterial Peritonitis (SBP) Treatment & Management: Approach Considerations, Inpatient Care, Deterrence/Prevention
https://emedicine.medscape.com/article/789105-treatment
Outpatient prophylaxis, although not recommended routinely, has been shown to prevent spontaneous bacterial peritonitis in the following high-risk groups: […] Suggested outpatient prophylactic regimens include the following: […] A guideline from the American Association for the Study of Liver Diseases recommends that adult cirrhotic patients who have survived an episode of SBP should receive long-term prophylaxis with norfloxacin or trimethoprim-sulfamethoxazole; however, long-term prophylaxis with norfloxacin is a risk factor for infection with a multi-resistant organism. […] Mounting evidence shows that use of PPIs and selective-intestinal decontamination leads to development of increased pathogenic and drug-resistant flora. […] In addition, despite evidence suggesting that primary prophylaxis of spontaneous bacterial peritonitis delays the development of hepatorenal syndrome and improves survival, a prospective study showed that patients with spontaneous bacterial peritonitis on long-term norfloxacin subsequently developed quinolone-resistant spontaneous bacterial peritonitis.
#52 Norfloxacin versus alternative antibiotics for prophylaxis of spontaneous bacteria peritonitis in cirrhosis: a systematic review and meta-analysis | BMC Infectious Diseases | Full Text
https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-023-08557-6
Prophylaxis of nosocomial- and community-acquired SBP is pivotal for cirrhotic patients. […] Currently, antimicrobial prophylaxis has been suggested to prevent SBP in cirrhotic patients. Norfloxacin is the most widely applicated antibiotic in SBP prophylaxis. […] However, the efficacy of norfloxacin is decreasing with the change in the pattern of causative organisms. […] Taking bacterial resistance into consideration, antibiotic prophylaxis must be used judiciously and sparingly in patients with high risks of developing SBP, and antibiotic alternatives to norfloxacin have been explored in SBP prophylaxis. […] Therefore, we performed the present meta-analysis primarily to compare the effects of norfloxacin and other antibiotics in SBP prophylaxis for patients with high risks of developing SBP.
#53 P08âSpontaneous bacterial peritonitis prophylaxis: reducing the incidence of c difficile infection | Gut
https://gut.bmj.com/content/60/Suppl_2/A4.2
Spontaneous bacterial peritonitis is a serious and life-threatening complication of cirrhosis, especially common in hospitalised patients. Antibiotic prophylaxis is effective but can lead to an increased incidence of hospital-acquired infections such as Clostridium difficle. […] This study shows that Co-trimoxazole inpatient prophylaxis against SBP is as effective as quinolone based regimes, but has the advantage of a dramatic reduction in C difficle infection. At the same time the importance of measures like hand hygiene compliance, environmental cleanliness and strict policy of in hospital antibiotic prescribing cannot be underestimated.
#54 Norfloxacin versus alternative antibiotics for prophylaxis of spontaneous bacteria peritonitis in cirrhosis: a systematic review and meta-analysis | BMC Infectious Diseases | Full Text
https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-023-08557-6
Spontaneous bacterial peritonitis (SBP) is a life-threatening complication in patients with advanced cirrhosis. Prophylactic Norfloxacin used to be considered effective in SBP prevention, but in recent years its efficacy has been partially compromised by increasing quinolone-resistant bacteria. […] The goal of this study is to compare the effects of norfloxacin with other antibiotics in SBP prophylaxis for cirrhotic patients. […] Norfloxacin and alternative antibiotics displayed comparable effects in SBP prophylaxis, survival benefit, overall infection prevention, and safety. […] Other antibiotics are a reasonable alternative to norfloxacin in the prophylaxis of SBP. Rifaximin prophylaxis could be an alternative choose of antibiotic for SBP prevention because of its better protective effect and safety.
#55 Norfloxacin versus alternative antibiotics for prophylaxis of spontaneous bacteria peritonitis in cirrhosis: a systematic review and meta-analysis | BMC Infectious Diseases | Full Text
https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-023-08557-6
The results showed the effects of other antibiotics were comparable to norfloxacin for primary SBP prophylaxis and secondary SBP prophylaxis. […] Interestingly, for secondary SBP prevention, rifaximin exhibited more robust prophylactic effects than norfloxacin. […] These findings suggested that rifaximin was a promising and effective alternative to norfloxacin in SBP primary and secondary prevention. […] Overall, our results illuminated comparable incidences of adverse events with other antibiotics and norfloxacin. […] What should be particularly pointed out was that the adverse events in T-S prophylactic patients obviously increased compared to norfloxacin, suggesting more drug safety should be considered when prophylactic T-S is attempted in SBP patients. […] In summary, the present meta-analysis updated and comprehensively demonstrated the effects of norfloxacin vs. other prophylactic antibiotics in SBP prevention. Generally, for cirrhotic patients with high risk, rifaximin prophylaxis for SBP showed greater efficacy and safety.
#56
https://ifnmujournal.com/acm/article/view/acm202229
The aim of the study. To explore the causes and improve methods of prevention of postoperative peritonitis. […] For today approaches to methods of surgical prevention of postoperative peritonitis are quite uninformative, due to the fact that in most cases the main rules of asepsis and antiseptics and appropriate surgical tactics are followed in combination with conservative intensive infusion therapy and antibacterial drugs. […] Complete removal of pathological contents from the abdominal cavity is a mandatory stage of surgery for postoperative peritonitis and one of the key factors in preventing such complications in the postoperative period as septic shock and multiple organ failure. […] Fundamental meaning in the prevention of the development of postoperative peritonitis are the timely execution and adequate volume of the operation, the maximum evacuation of the pathological contents with subsequent lavage of the abdominal cavity by the proposed method, careful handling of the organs of the abdominal cavity (suture of questionable areas and injuries of the intestine), careful hemostasis, active-passive drainage of not only loose areas of the abdominal cavity, but also of anastomosis and abscess cavities.
#57 Peritonitis: Symptoms, Causes, Treatments, and More
https://www.healthline.com/health/peritonitis
In many cases, you may be able to prevent peritonitis by taking steps to prevent the infections or conditions that can lead to it. […] If you’re on dialysis: wash your hands and fingernails before touching your catheter […] clean the skin around the catheter daily […] follow your doctor’s instructions regarding the care and storage of your medical supplies. […] You can also consider: seeking help for alcohol use disorder, if you’re concerned about your alcohol intake or are at risk for cirrhosis […] using condoms or other barrier methods to avoid contracting the sexually transmitted infections (STIs) that can lead to PID […] limiting your use of nonsteroidal anti-inflammatory drugs (NSAIDs), which are associated with stomach ulcers […] getting prompt treatment if you have symptoms of appendicitis or a diagnosed case of appendicitis.
#58 Antibiotic prophylaxis to prevent spontaneous bacterial peritonitis may not be effective – The Hospitalist
https://www.the-hospitalist.org/hospitalist/article/243339/infectious-diseases/antibiotic-prophylaxis-prevent-spontaneous-bacterial/
Antibiotic prophylaxis to prevent spontaneous bacterial peritonitis may not be effective. […] Antibiotic prophylaxis is the mainstay preventive treatment, but there is concern about development of drug resistance and other adverse events. […] Across 29 randomized clinical trials (total of 3,896 participants) looking at nine different antibiotic regimens for prophylaxis of spontaneous bacterial peritonitis, there was no evidence of differences between any of the antibiotics and no intervention in terms of mortality or serious adverse events, though there was very low certainty of evidence. […] The authors felt only two small studies were conducted without flaws. […] There was no difference between any of the antibiotics and no intervention in the proportion of people who developed spontaneous bacterial peritonitis. […] Whether antibiotics are effective prophylaxis to prevent spontaneous bacterial peritonitis and which antibiotics should be used is still uncertain; future well-designed studies are needed.
#59 Antimicrobial agents for preventing peritonitis in peritoneal dialysis patients
https://pmc.ncbi.nlm.nih.gov/articles/PMC6478113/
Peritoneal dialysis (PD) is an important therapy for patients with endstage kidney disease and is used in more than 200,000 such patients globally. However, its value is often limited by the development of infections such as peritonitis and exitsite and tunnel infections. Multiple strategies have been developed to reduce the risk of peritonitis including antibiotics, topical disinfectants to the exit site and antifungal agents. However, the effectiveness of these strategies has been variable and are based on a small number of randomised controlled trials (RCTs). The optimal preventive strategies to reduce the occurrence of peritonitis remain unclear. […] To evaluate the benefits and harms of antimicrobial strategies used to prevent peritonitis in PD patients. […] The use of oral or topical antibiotic compared with placebo/no treatment, had uncertain effects on the risk of exitsite/tunnel infection (3 studies, 191 patients, low quality evidence: RR 0.45, 95% CI 0.19 to 1.04) and the risk of peritonitis (5 studies, 395 patients, low quality evidence: RR 0.82, 95% CI 0.57 to 1.19).
#60 Antimicrobial agents for preventing peritonitis in peritoneal dialysis patients
https://pmc.ncbi.nlm.nih.gov/articles/PMC6478113/
Pre/perioperative intravenous vancomycin compared with no treatment may reduce the risk of early peritonitis (1 study, 177 patients, low quality evidence: RR 0.08, 95% CI 0.01 to 0.61) but has an uncertain effect on the risk of exitsite/tunnel infection (1 study, 177 patients, low quality evidence: RR 0.36, 95% CI 0.10 to 1.32). […] Antifungal prophylaxis with oral nystatin/fluconazole compared with placebo/no treatment may reduce the risk of fungal peritonitis occurring after a patient has had an antibiotic course (2 studies, 817 patients, low quality evidence: RR 0.28, 95% CI 0.12 to 0.63). […] In this update, we identified limited data from RCTs and quasiRCTs which evaluated strategies to prevent peritonitis and exitsite/tunnel infections. This review demonstrates that pre/perioperative intravenous vancomycin may reduce the risk of early peritonitis and that antifungal prophylaxis with oral nystatin or fluconazole reduces the risk of fungal peritonitis following an antibiotic course. However, no other antimicrobial interventions have proven efficacy. […] Given the large number of patients on PD and the importance of peritonitis, the lack of adequately powered and high quality RCTs to inform decision making about strategies to prevent peritonitis is striking.
#61 The new ISPD peritonitis guideline | Renal Replacement Therapy | Full Text
https://rrtjournal.biomedcentral.com/articles/10.1186/s41100-018-0150-2
The latest guideline also emphasizes the adherence of the latest ISPD recommendations for teaching PD patients and their caregivers. PD training should be conducted by nursing staff with the appropriate qualifications and experience. […] In essence, the latest guideline summarizes a number of measures with proved efficacy for the prevention of peritonitis: antibiotic prophylaxis before catheter insertion, the application of disconnect PD system, and regular use of antibiotic cream or ointment for exit site care.
#62 Peritonitis Prevention Strategies – Klarity Health Library
https://my.klarity.health/peritonitis-prevention-strategies/
Peritonitis prevention is crucial so that the viability of the peritoneal membrane can be preserved. […] Most importantly, medical help should be sought if unsure about how to maintain PD and also if there is any contamination of the dialysis fluid or catheter in the dialysis collection bag. […] This is because implementing the recommendations can reduce the risk of peritonitis, which in turn reduces associated pain, numerous hospital visits, as well as treatment costs. […] Peritonitis can be prevented by ensuring patients and medical professionals are trained and retrained regularly on the importance of having a clean environment when using PD, as well as hygiene practices before, during and after the use of PD.
#63 Norfloxacin versus alternative antibiotics for prophylaxis of spontaneous bacteria peritonitis in cirrhosis: a systematic review and meta-analysis | BMC Infectious Diseases | Full Text
https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-023-08557-6
Prophylaxis of nosocomial- and community-acquired SBP is pivotal for cirrhotic patients. […] Currently, antimicrobial prophylaxis has been suggested to prevent SBP in cirrhotic patients. Norfloxacin is the most widely applicated antibiotic in SBP prophylaxis. […] However, the efficacy of norfloxacin is decreasing with the change in the pattern of causative organisms. […] Taking bacterial resistance into consideration, antibiotic prophylaxis must be used judiciously and sparingly in patients with high risks of developing SBP, and antibiotic alternatives to norfloxacin have been explored in SBP prophylaxis. […] Therefore, we performed the present meta-analysis primarily to compare the effects of norfloxacin and other antibiotics in SBP prophylaxis for patients with high risks of developing SBP.
#64 Prophylaxis against spontaneous bacterial peritonitis: Too much or too little? | Antimicrobial Stewardship & Healthcare Epidemiology | Cambridge Core
https://www.cambridge.org/core/journals/antimicrobial-stewardship-and-healthcare-epidemiology/article/prophylaxis-against-spontaneous-bacterial-peritonitis-too-much-or-too-little/B69935A71D56DA28DD02C50327CFF7D3
Underutilization of SBP prophylaxis was observed in 70% of the cohort. […] Receipt of guideline-concordant care was not more common among patients seen by gastroenterology specialists. […] Concordance with published guidelines regarding SBP prophylaxis remains low. Strategies to improve clinicians adherence to these recommendations are needed.
#65
https://journals.lww.com/cjasn/fulltext/2021/01000/optimizing_peritoneal_dialysis_associated.25.aspx
Peritoneal dialysis (PD)associated peritonitis is the leading cause of permanent transition to hemodialysis among patients receiving PD. […] Optimizing the prevention of peritonitis in the United States will first require standardization of peritonitis definitions, key data elements, and outcomes in an effort to facilitate nationwide reporting. […] Standardized reporting can also help describe the variability in peritonitis rates and outcomes across facilities in the United States in an effort to identify potential peritonitis prevention strategies and engage with stakeholders to develop strategies for their implementation. […] We will describe existing peritonitis prevention evidence gaps, highlight successful infection-reporting initiatives among patients receiving in-center hemodialysis or PD, and provide an overview of nationwide quality improvement initiatives, both in the United States and elsewhere, that have translated into a reduction in peritonitis incidence. […] We will discuss opportunities for collaboration and expansion of the Nephrologists Transforming Dialysis Safety (NTDS) initiative to develop knowledge translation pathways that will lead to dissemination of best practices in an effort to reduce peritonitis incidence.
#66 Prophylaxis for Spontaneous Bacterial Peritonitis in Patients With Liver Cirrhosis – Infectious Disease Advisor
https://www.infectiousdiseaseadvisor.com/news/data-is-presently-insufficient-to-support-the-use-of-prophylactic-antibiotics-for-sbp/
There remains considerable uncertainty on whether antibiotic prophylaxis for spontaneous bacterial peritonitis is beneficial in people with liver cirrhosis. […] Based on the findings of the review, there is very low-certainty evidence concerning antibiotic prophylaxis. […] Therefore, they recommended that future work consists of adequately powered randomized clinical trials, employ blinding, avoid postrandomization dropouts, or perform intention-to-treat analysis, and use clinically important outcomes such as mortality, health-related quality of life, and decompensation events. […] Further research is therefore needed to determine factors associated with improved clinical outcomes, such as decreasing the rates of cirrhosis.