Campbell Denise, Mudge David W, Craig Jonathan C, Johnson David W, Tong Allison, Strippoli Giovanni Fm
Centre for Kidney Research, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW, Australia, 2145.
Department of Nephrology, University of Queensland at Princess Alexandra Hospital, Level 2, ARTS Building, Ipswich Rd, Woolloongabba, Queensland, Australia, 4102.
Cochrane Database Syst Rev. 2017 Apr 8;4(4):CD004679. doi: 10.1002/14651858.CD004679.pub3.
Peritoneal dialysis (PD) is an important therapy for patients with end-stage 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 exit-site 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.This is an update of a Cochrane review first published in 2004.
To evaluate the benefits and harms of antimicrobial strategies used to prevent peritonitis in PD patients.
We searched the Cochrane Kidney and Transplant's Specialised Register to 4 October 2016 through contact with the Information Specialist using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE, and EMBASE; handsearching conference proceedings; and searching the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.
RCTs or quasi-RCTs in patients receiving chronic PD, which evaluated any antimicrobial agents used systemically or locally to prevent peritonitis or exit-site/tunnel infection were included.
Two authors independently assessed risk of bias and extracted data. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratio (RR) with 95% confidence intervals (CI).
Thirty-nine studies, randomising 4435 patients, were included. Twenty additional studies have been included in this update. The risk of bias domains were often unclear or high; risk of bias was judged to be low in 19 (49%) studies for random sequence generation, 12 (31%) studies for allocation concealment, 22 (56%) studies for incomplete outcome reporting, and in 12 (31%) studies for selective outcome reporting. Blinding of participants and personnel was considered to be at low risk of bias in 8 (21%) and 10 studies (26%) for blinding of outcome assessors. It should be noted that blinding of participants and personnel was not possible in many of the studies because of the nature of the intervention or control treatment.The use of oral or topical antibiotic compared with placebo/no treatment, had uncertain effects on the risk of exit-site/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).The use of nasal antibiotic compared with placebo/no treatment had uncertain effects on the risk of exit-site/tunnel infection (3 studies, 338 patients, low quality evidence: RR 1.34, 95% CI 0.62 to 2.87) and the risk of peritonitis (3 studies, 338 patients, low quality evidence: RR 0.94, 95% CI 0.67 to 1.31).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 exit-site/tunnel infection (1 study, 177 patients, low quality evidence: RR 0.36, 95% CI 0.10 to 1.32).The use of topical disinfectant compared with standard care or other active treatment (antibiotic or other disinfectant) had uncertain effects on the risk of exit-site/tunnel infection (8 studies, 973 patients, low quality evidence, RR 1.00, 95% CI 0.75 to 1.33) and the risk of peritonitis (6 studies, 853 patients, low quality evidence: RR 0.83, 95% CI 0.65 to 1.06).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).No intervention reduced the risk of catheter removal or replacement. Most of the available studies were small and of suboptimal quality. Only six studies enrolled 200 or more patients.
AUTHORS' CONCLUSIONS: In this update, we identified limited data from RCTs and quasi-RCTs which evaluated strategies to prevent peritonitis and exit-site/tunnel infections. This review demonstrates that pre/peri-operative 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. In particular, the use of nasal antibiotic to eradicate Staphylococcus aureus, had an uncertain effect on the risk of peritonitis and raises questions about the usefulness of this approach. 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.
腹膜透析（PD）是终末期肾病患者的重要治疗方法，全球有超过20万此类患者使用该方法。然而，其价值常常受到腹膜炎、出口处及隧道感染等感染并发症的限制。人们已制定多种策略来降低腹膜炎风险，包括使用抗生素、出口处局部消毒剂及抗真菌药物。然而，这些策略的有效性参差不齐，且基于少数随机对照试验（RCT）。降低腹膜炎发生率的最佳预防策略仍不明确。这是对2004年首次发表的Cochrane综述的更新。
评估用于预防腹膜透析患者腹膜炎的抗菌策略的益处和危害。
我们通过与信息专家联系，使用与本综述相关的检索词，检索至2016年10月4日的Cochrane肾脏和移植专业注册库。专业注册库中的研究通过专门为CENTRAL、MEDLINE和EMBASE设计的检索策略、手工检索会议论文集以及检索国际临床试验注册平台（ICTRP）检索入口和ClinicalTrials.gov来识别。
纳入接受慢性腹膜透析患者的随机对照试验或半随机对照试验，这些试验评估了全身或局部使用的任何抗菌药物预防腹膜炎或出口处/隧道感染的效果。
两位作者独立评估偏倚风险并提取数据。使用随机效应模型获得效应的汇总估计值，结果以风险比（RR）及95%置信区间（CI）表示。
共纳入39项研究，随机分配4435例患者。本次更新纳入了另外20项研究。偏倚风险领域通常不明确或较高；在随机序列生成方面，19项（49%）研究的偏倚风险被判定为低；分配隐藏方面，12项（31%）研究为低；不完整结局报告方面，22项（56%）研究为低；选择性结局报告方面，12项（31%）研究为低。结局评估者的盲法方面，8项（21%）研究中参与者和人员的盲法偏倚风险较低，10项（26%）研究中为低。需要注意的是，由于干预或对照治疗的性质，许多研究中参与者和人员无法实现盲法。与安慰剂/不治疗相比，口服或局部使用抗生素对出口处/隧道感染风险（3项研究，191例患者，低质量证据：RR 0.45，95%CI 0.19至1.04）和腹膜炎风险（5项研究，395例患者，低质量证据：RR 0.82，95%CI 0.57至1.19）的影响不确定。与安慰剂/不治疗相比，鼻腔使用抗生素对出口处/隧道感染风险（3项研究，338例患者，低质量证据：RR 1.34，95%CI 0.62至2.87）和腹膜炎风险（3项研究，338例患者，低质量证据：RR 0.94，95%CI 0.67至1.31）的影响不确定。术前/围手术期静脉使用万古霉素与不治疗相比，可能降低早期腹膜炎风险（1项研究，177例患者；低质量证据：RR 0.08，95%CI 0.01至0.61），但对出口处/隧道感染风险的影响不确定（1项研究，177例患者；低质量证据：RR 0.36，95%CI 0.
