Strippoli Giovanni F M, Tong Allison, Johnson David, Schena Francesco P, Craig Jonathan C
Centre for Kidney Research, National Health & Medical Research Council Centre for Clinical Research Excellence in Renal Medicine, Cochrane Renal Group, Children's Hospital at Westmead, University of Sydney, Sydney, Australia.
Am J Kidney Dis. 2004 Oct;44(4):591-603.
A large proportion (15% to 50%) of the end-stage renal disease population are on peritoneal dialysis (PD). The major limitation is peritonitis, which leads to technique failure, hospitalization, and increased mortality. Oral, nasal, and topical antibiotic prophylaxis; exit-site disinfectants; and other antimicrobial interventions are used to prevent it. This study was conducted to assess what evidence supports these approaches.
The Cochrane CENTRAL Registry, MEDLINE, EMBASE, and reference lists were searched for randomized trials of antimicrobial agents in patients on PD. Two reviewers extracted data on the number of patients with 1 or more episodes and rates of peritonitis and exit-site and tunnel infection, catheter removal and/or replacement, technique failure, antibiotic toxicity, and all-cause mortality. Analysis was by means of a random-effects model, and results are expressed as relative risk (RR) and 95% confidence intervals (CI).
Nineteen eligible trials (1,949 patients) were identified. Nasal mupirocin compared with placebo significantly reduced the exit-site and tunnel infection rate (1 trial; 2,716 patient-months; RR, 0.58; 95% CI, 0.40 to 0.85), but not peritonitis rate (1 trial; 2,716 patient-months; RR, 0.84; 95% CI, 0.44 to 1.60). Perioperative intravenous antibiotic therapy compared with no treatment significantly reduced the risk for early peritonitis (4 trials; 335 patients; RR, 0.35; 95% CI, 0.15 to 0.80), but not exit-site and tunnel infection (3 trials; 114 patients; RR, 0.32; 95% CI, 0.02 to 4.81).
Based on 1 study, nasal mupirocin reduces exit-site and tunnel infection, but not peritonitis. Based on 4 studies, preoperative intravenous prophylaxis reduces early peritonitis, but not exit-site and tunnel infection. No other antimicrobial intervention has proven efficacy. Given the large number of patients on PD therapy and the importance of peritonitis, the lack of adequately powered randomized trials to inform decision making about strategies to prevent peritonitis is striking.
很大一部分（15%至50%）的终末期肾病患者接受腹膜透析（PD）治疗。主要限制因素是腹膜炎，它会导致技术失败、住院治疗以及死亡率增加。口服、鼻腔和局部使用抗生素预防；出口处消毒剂；以及其他抗菌干预措施被用于预防腹膜炎。本研究旨在评估支持这些方法的证据。
检索Cochrane中心对照试验注册库、MEDLINE、EMBASE以及参考文献列表，以查找关于PD患者使用抗菌药物的随机试验。两名评审员提取了关于有1次或更多次发作的患者数量、腹膜炎、出口处和隧道感染发生率、导管拔除和/或更换、技术失败、抗生素毒性以及全因死亡率的数据。采用随机效应模型进行分析，结果以相对风险（RR）和95%置信区间（CI）表示。
共识别出19项符合条件的试验（1949例患者）。与安慰剂相比，鼻腔使用莫匹罗星显著降低了出口处和隧道感染率（1项试验；2716患者-月；RR，0.58；95%CI，0.40至0.85），但未降低腹膜炎发生率（1项试验；2716患者-月；RR，0.84；95%CI，0.44至1.60）。与未治疗相比，围手术期静脉使用抗生素治疗显著降低了早期腹膜炎的风险（4项试验；335例患者；RR，0.35；95%CI，0.15至0.80），但未降低出口处和隧道感染率（3项试验；114例患者；RR，0.32；95%CI，0.02至4.81）。
基于1项研究，鼻腔使用莫匹罗星可降低出口处和隧道感染，但不能降低腹膜炎发生率。基于4项研究，术前静脉预防可降低早期腹膜炎，但不能降低出口处和隧道感染率。没有其他抗菌干预措施已被证明有效。鉴于接受PD治疗的患者数量众多以及腹膜炎的重要性，缺乏足够样本量的随机试验来为预防腹膜炎策略的决策提供依据，这一点令人震惊。
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