Fontán Miguel Pérez, Cambre Helena Díaz, Rodríguez-Carmona Ana, Muñiz Andrés López, Falcón Teresa García
Division of Nephrology, University Hospital Juan Canalejo, A Coruña, Spain.
Perit Dial Int. 2009 May-Jun;29(3):310-8.
There is controversy about the preferred initial antibiotic therapy for peritoneal dialysis (PD)-related peritonitis. Quinolones have been used extensively in this setting, yet their long-term effectiveness is unknown.
To analyze the results of a protocol of treatment of PD-related peritonitis with ciprofloxacin, maintained over two decades.
We analyzed the clinical outcome of 682 episodes of bacterial peritonitis treated with intraperitoneal ciprofloxacin monotherapy, and the time course of bacterial susceptibility to this antimicrobial, in a historical cohort of 641 PD patients (1988-2007). Main outcome variables included changes to initial therapy and rates of hospital admission, catheter removal, relapse, reinfection, PD dropout, and mortality. For comparisons we divided the study period into phases A (1988-1994), B (1995-2000), and C (2001-2007).
The incidence of Staphylococcus aureus peritonitis decreased, while the incidences of polymicrobial and negative-culture peritonitis increased after phase A. In vitro susceptibility to ciprofloxacin decreased significantly only among coagulase-negative staphylococci (87.0% susceptible strains in phase A vs 70.0% in B and 70.1% in C, p = 0.006). Overall success rates (catheter not removed and ongoing PD after the episode) remained stable, at over 85%. However, the proportion of patients treated solely with ciprofloxacin declined from 75.7% (A) to 47.3% (B) to 32.4% (C) (p < 0.0005) and admission rates increased from 12.7% to 16.8% to 24.9% respectively (p = 0.001). These changes affected all the etiologic groups except culture-negative peritonitis. In vitro resistance to ciprofloxacin was a marker of multiresistance and correlated strongly with clinical outcome of peritonitis. Among isolates susceptible to ciprofloxacin, changing initial therapy for any reason also predicted a poor outcome.
Following satisfactory early results, the effectiveness of ciprofloxacin as monotherapy for PD-related peritonitis has declined markedly in the long term. This decline cannot be explained solely by a decrease of in vitro susceptibility to this antimicrobial, which was significant only among coagulase-negative staphylococci. Resistance to ciprofloxacin is a strong marker of in vitro multiresistance and poor clinical outcome of peritonitis.
对于腹膜透析（PD）相关腹膜炎的首选初始抗生素治疗存在争议。喹诺酮类药物已在这种情况下广泛使用，但其长期有效性尚不清楚。
分析用环丙沙星治疗PD相关腹膜炎方案持续二十多年的结果。
我们分析了641例PD患者（1988 - 2007年）的历史队列中682例接受腹腔内环丙沙星单一疗法治疗的细菌性腹膜炎的临床结果，以及细菌对这种抗菌药物的敏感性随时间的变化情况。主要结局变量包括初始治疗的改变、住院率、导管拔除率、复发率、再感染率、PD退出率和死亡率。为了进行比较，我们将研究期分为A期（1988 - 1994年）、B期（1995 - 2000年）和C期（2001 - 2007年）。
A期后，金黄色葡萄球菌腹膜炎的发病率下降，而多微生物和培养阴性腹膜炎的发病率增加。仅凝固酶阴性葡萄球菌对环丙沙星的体外敏感性显著下降（A期87.0%的敏感菌株，B期为70.0%，C期为70.1%，p = 0.006）。总体成功率（发作后导管未拔除且PD仍在进行）保持稳定，超过85%。然而，仅用环丙沙星治疗的患者比例从75.7%（A期）降至47.3%（B期）再降至32.4%（C期）（p < 0.0005），住院率分别从12.7%升至16.8%再升至24.9%（p = 0.001）。这些变化影响了除培养阴性腹膜炎之外的所有病因组。对环丙沙星的体外耐药性是多重耐药的标志，与腹膜炎的临床结果密切相关。在对环丙沙星敏感的分离株中，因任何原因改变初始治疗也预示着不良结局。
在取得令人满意的早期结果后，环丙沙星作为PD相关腹膜炎单一疗法的有效性在长期内已显著下降。这种下降不能仅通过对这种抗菌药物的体外敏感性降低来解释，这种降低仅在凝固酶阴性葡萄球菌中显著。对环丙沙星的耐药性是体外多重耐药和腹膜炎不良临床结果的强烈标志。
