Introduction:
A significant risk of infection of the peritoneum, subcutaneous tunnel, and catheter exit site is linked to peritoneal dialysis (PD). The reported total rate of PD-associated infection is 0.24-1.66 episodes per patient per year, despite quality guidelines requiring an infection rate of not more than 0.67 episodes per patient per year on dialysis. According to estimates, the risk of death rises by 4 percent or every 0.5 percent increase in peritonitis rates annually. Of these incidents, 3.5 percent ended in death, and 18 percent required the removal of the PD catheter.
Due to patients' weakened immune systems and the increased risk of microbiological contamination associated with dialysis procedures, there is a certain risk of infection associated with all dialysis treatments. Peritoneal dialysis (PD) carries a significant risk of infection of the peritoneum, subcutaneous tunnel, and catheter exit site, especially with continuous ambulatory PD (CAPD). While exit site infection (ESI) and tunnel infection (TI) do not provide significant hazards in and of themselves, they must be closely monitored because of the potential for PD peritonitis. PD peritonitis is thought to occur in 12 percent of instances of ESI and TI. Up to 15 to 50 percent of ERF patients are receiving PD; nonetheless, chronic or recurrent peritonitis might lead to PD technique failure.
The bulk of catheter-related issues are caused by infections, with peritonitis accounting for 61 percent of cases, ESI and TI for 23 percent, and catheter blockage, dislocation, and leakage accounting for the remaining cases. Peritonitis is a major problem for persons with Parkinson's disease (PD) since it can cause excruciating pain that can result in hospitalization, catheter loss, and even death. Although PD peritonitis typically resolves in a matter of days and has a good prognosis, it can occasionally result in the much-feared sclerosing encapsulated peritonitis (SEP).
Although peritonitis has been far less common since the late 1980s, the infection is still a serious side effect of long-term Parkinson's disease. If the causes and treatments of peritonitis are closely monitored, very low rates of peritonitis can occur in a program.
What Are the Infectious Complications of Peritoneal Dialysis?
1. Infections Connected to Catheters: Tunnel infection (TI) and Exit-Site Infection (ESI):
The annual rate of end-stage renal disease (ESI) was 0.25 per dialysis year, and the median duration to acquire ESI was 392 days, according to the Standardising Care to Improve Outcomes in Paediatric End-Stage Renal Disease (SCOPE) research. Furthermore, 6 % of individuals had peritonitis, and children under the age of two had the lowest incidence of ESI. The exit-site score system, which is composed of five parameters—exit-site edema, crust, redness, pain on pressure, and secretion is advised for assessing the condition of the PD catheter exit site.
2. Peritonitis:
The North American Paediatric Renal Trials and Collaborative Studies (NAPRTCS) data show that children's annualized rate of peritonitis was 0.68 (one episode every 17.8 months), and age (less than one year, 0.86; more than 12 years, 0.61), was inversely correlated with it). The PD modality also had an impact on the incidence of peritonitis, with patients on automated PD showing somewhat better rates than those on continuous ambulatory PD). The most frequent causes of peritonitis in kids with Parkinson's disease (PD) are Gram-positive bacteria, just like in adults. Gram-positive bacteria account for about 50–60 % of peritonitis episodes, while Gram-negative bacteria account for 20–30 percent, with cultures remaining negative (<20 percent).
The most common etiological agents of PD-associated peritonitis globally are Gram-positive cocci, including Staphylococcus aureus (S. aureus), various CoNS, and Staphylococcus epidermidis (S. epidermidis). Both the range of organisms linked to PD peritonitis and the frequency of culture-negative events differ geographically]. For instance, in the CAPD population in India, Gram-negative PD peritonitis is more common than Gram-positive peritonitis and is linked to worse outcomes.
What Are the Diagnosis for Infectious Complications of Peritoneal Dialysis?
The appearance of purulent discharge at the catheter-skin interface, along with or without skin erythema, is indicative of an exit-site infection. When a catheter is recently inserted or has been damaged, per catheter, erythema without purulent discharge may be a sign of an infection, but it can also be a straightforward skin reaction.
Ultrasound studies have demonstrated that TI is frequently clinically hidden, but it can manifest as erythema, edema, or discomfort across the subcutaneous pathway. TI rarely happens on its own; it typically happens in conjunction with an ESI. Staphylococcus aureus and Pseudomonas aeruginosa ESI are the most common causes of catheter infection-related peritonitis and are frequently linked to concurrent TI.
Along with a peritoneal dialysate culture, any purulent discharge from the exit site needs to be swabbed for Gram stain and culture. In managing PD peritonitis, the degree of involvement of the subcutaneous PD catheter tract is critical. Clinical symptoms are the primary means of diagnosing both these illnesses and the more serious TI. The utility of ultrasonography (US) of the catheter tract in identifying catheter-related infections (tunnel and exit site) and their connections to peritonitis was investigated by Korzets et al. If an area of hypoechogenicity (a sign of fluid collection) of more than two millimeters in width was found anywhere along the catheter tract, the results were considered positive.
Peritonitis in Peritonitis Dialysis:
When Parkinson's disease (PD) patients exhibit hazy wastewater, it is recommended to assume they have peritonitis and confirm with tests such as effluent cell count less than 100 per milliliter, differential count, culture, and Gram stain staining. Even in cases where the effluent is clear, peritonitis should always be considered a possibility in the differential diagnosis of any patient with Parkinson's disease who presents with abdominal pain, as this is not the case for most patients. The PD patient with abdominal pain and clear fluid should also have other explanations such as constipation, renal or biliary colic, peptic ulcer disease, pancreatitis, and acute intestinal perforation looked into. The level of pain can help a doctor decide whether to admit or treat a patient as an outpatient because it is fairly organism-specific (for example, it is usually higher with streptococcus, Gram negative rods, and S. aureus, and less with CoNS).
What Are the Treatment Plan For Infectious Complications of Peritoneal Dialysis?
Both non-antiseptic and antiseptic cleaning chemicals have been applied at exit sites. A perfect cleaning agent would be low in germs, safe for the body's defenses, and not impede the healing of wounds. Antimicrobial soap is advised for cleaning a healed exit site; nevertheless, biocompatible solutions are indicated for postoperative, infected, or traumatized exit sites. There is still a dearth of in vivo research on the efficacy of some cleansing agents, therefore exit-site cleansing needs to be clinically studied to identify the best agents for the job.
Proper management of the exit site can prevent catheter loss and avoid changing dialysis modes unnecessarily. It has been reported from Italy that systemic and local antibiotic therapy, along with sodium hypochlorite packs, are effective treatments for ESI caused by Pseudomonas. Based on the positive outcomes of treating Pseudomonas infections, the same regimen was applied to treat ESI brought on by other, more challenging-to-get-rid-of pathogens. By forming a shield at the exit site, sodium hypochlorite (50 percent packs) has a broad antibacterial range and a quick start of action.
The antibiotic course needs to be followed until the exit site looks completely normal. The minimum treatment duration is two weeks; a three-week course of treatment is likely required for ESI brought on by P. aeruginosa.
Conclusion:
The isolation of Gram negative bacteria or fungus is a reliable indicator of poor clinical results. Delays in PD catheter removal of more than one week following the onset of polymicrobial peritonitis are strongly linked to higher morbidity and a change in dialysis modality, whereas pure Gram-positive peritonitis is associated with the best clinical results. A worse prognosis is associated with the isolation of Gram negative bacteria (with or without Gram-positive bacteria) or fungi, which is often addressed with early catheter removal and the right antimicrobial medication. Following recurrent bouts of PD peritonitis, close observation of PD function and monitoring for potential consequences such as SEP are necessary. Achieving infection-free Parkinson's disease requires extensive patient education. To prevent PD fluid contamination, all patients need to receive aseptic technique training.
