Treatment of peritonitis complicating continuous ambulatory peritoneal dialysis: an Asian perspective

Summary: Geographically, socially, economically and culturally, Asia differs from the United States of America and Europe. These differences may affect the delivery of different continuous ambulatory peritoneal dialysis (CAPD) systems, the incidence and nature of CAPD peritonitis and its treatment. From a recent survey, it has been shown that the use of more expensive disconnect systems has yet to gain popularity in many Asian countries due to its increased cost, but may now be justified in the light of recent cost-effective studies done in the region. In order to compare the incidence, microbiological profile and treatment strategy of CAPD peritonitis among Asian–Pacific countries, a survey was conducted among renal units of the Asian–Pacific Society members collecting retrospective data from 1 July, 1994 to 30 June, 1995. In this ‘cross country’ analysis, no correlation was found between peritonitis rate and the percentage use of disconnect systems. This observation highlights the difficulties in extrapolating data from one unit (e.g. in the United States of America) to another (e.g. in Asia) in order to decide if one CAPD system is more cost-effective than the other. Also observed was a relatively high incidence of culture negativity and gram negative culture positivity rates among some Asian–Pacific countries. These findings imply that primary treatment for CAPD peritonitis in these countries should involve the use of a single broad spectrum antibiotic or two antibiotics with gram positive and negative coverage. the median pseudomonas peritonitis rate of 12% means that antibiotics with anti-pseudomonas activity should also be used. the use of oral vs intraperitoneal (i.p.) drug treatment for established CAPD peritonitis has considerable attraction in Asia because of its reduced cost and ease of administration especially in countries with poor transport arrangement between home and the treatment centre and inadequate home social support. the fluoroquinolones have been extensively studied most in the region and achieve cure rates comparable to conventional i.p. regimens. However, with long-term use, progressive development of bacterial resistance has been observed and this would ultimately limit their effectiveness. the introduction of oral fluconazole has not reduced the chance of catheter removal but is recommended for the treatment of fungal (especially candida) peritonitis in Asia as it is relatively safe, cheap and simple to use. Oral nystatin given with each antibiotic prescription is also effective in reducing the incidence of candida peritonitis and is inexpensive. Peritonitis secondary to Mycobacterium tuberculosis is more often observed in Asia because the latter is endemic in the region. In contrast to previous recommendations, we have shown from a much larger experience that catheter removal is not mandatory for the cure of this condition and this approach is compatible with long-term preservation of peritoneal function.