Piraino B
Renal Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
Adv Ren Replace Ther. 2000 Oct;7(4):280-8. doi: 10.1053/jarr.2000.18035.
Peritoneal dialysis related infections include infection of the catheter exit site, subcutaneous pathway, or effluent. Exit-site infections, predominately owing to Staphylococcus aureus, are defined as purulent drainage at the exit site, although erythema may be a less serious type of exit-site infection. Tunnel infections are underdiagnosed clinically, and sonography of the tunnel is useful to delineate the extent of the infection and to evaluate response to antibiotic therapy. S aureus infections occur more frequently in S aureus carriers and immunosuppressed patients and can be reduced by mupirocin prophylaxis either intranasally or at the exit site. Patients with peritonitis present with cloudy effluent and usually pain, although 6% of patients may initially have pain without cloudy effluent. A white blood cell count of 100 or greater per microL, 50% of which are polymorphonuclear cells, has long been the hallmark of peritonitis. Empiric therapy is controversial, with some recommending cefazolin and others vancomycin (with cefatazidime for Gram-negative coverage). The choice should depend on the center's antibiotic sensitivity profile; those centers with a high rate of Enterococcus- or methicillin resistant organisms should use vancomcycin. Peritonitis episodes occurring in association with a tunnel infection with the same organism seldom resolve with antibiotics and require catheter removal. Other indications for catheter removal are refractory peritonitis, relapsing peritonitis, tunnel infection with inner-cuff involvement that does not respond to antibiotic therapy (based on ultrasound criteria), fungal peritonitis, and enteric peritonitis owing to intra abdominal pathology. Centers can reduce dialysis related infections to very low levels by proper catheter selection and insertion, careful selection and training of patients, avoidance of spiking techniques, and use of antibiotic prophylaxis against S. aureus. Further research is required to identify methods to reduce the risk of enteric peritonitis.
腹膜透析相关感染包括导管出口处、皮下通道或流出液的感染。出口处感染主要由金黄色葡萄球菌引起，表现为出口处有脓性引流物，尽管红斑可能是较轻类型的出口处感染。隧道感染在临床上易被漏诊，隧道超声检查有助于明确感染范围并评估对抗生素治疗的反应。金黄色葡萄球菌感染在金黄色葡萄球菌携带者和免疫抑制患者中更常见，可通过鼻内或出口处使用莫匹罗星预防。腹膜炎患者表现为流出液浑浊，通常伴有疼痛，尽管6%的患者最初可能有疼痛但流出液不浑浊。每微升白细胞计数100或更高，其中50%为多形核细胞，长期以来一直是腹膜炎的标志。经验性治疗存在争议，一些人推荐头孢唑林，另一些人推荐万古霉素（联合头孢他啶覆盖革兰阴性菌）。选择应取决于中心的抗生素敏感性谱；肠球菌或耐甲氧西林菌发生率高的中心应使用万古霉素。与同一病原体引起的隧道感染相关的腹膜炎发作很少通过抗生素治愈，需要拔除导管。拔除导管的其他指征包括难治性腹膜炎、复发性腹膜炎、对抗生素治疗无反应（根据超声标准）的累及内袖套的隧道感染、真菌性腹膜炎以及由腹腔内病变引起的肠道性腹膜炎。通过正确选择和插入导管、仔细选择和培训患者、避免加样技术以及使用针对金黄色葡萄球菌的抗生素预防措施，各中心可将透析相关感染降低到非常低的水平。需要进一步研究以确定降低肠道性腹膜炎风险的方法。
