Objectives & Background Definition Rehab Process Outcomes Nephrology Roles Conclusions Objectives S. aureus Fungal Conclusion Mycobacteria “Staph, Fungal & Tuberculous Peritonitis” Long Beach CA, (March 2017) S. Vanita Jassal Professor of Medicine, Univ. of Toronto & Staff Nephrologist, University Health Network
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Objectives & Background Definition Rehab
Process Outcomes Nephrology Roles ConclusionsObjectives S. aureus Fungal ConclusionMycobacteria
“Staph, Fungal & Tuberculous Peritonitis”
Long Beach CA, (March 2017)
S. Vanita JassalProfessor of Medicine, Univ. of Toronto &
Staff Nephrologist, University Health Network
Objectives S. aureus Fungal ConclusionMycobacteria
Disclosures
• Investigator led funding from Fresenius Health Care 2015
• Salary benefits: Ontario Renal Network
Objectives
Objectives S. aureus Fungal ConclusionMycobacteria
Objectives
• To recognize and treat peritonitis caused by – Staphylococcus aureus– Fungal organisms– Mycobacteria
Objectives
Objectives & Background Definition Rehab
Process Outcomes Nephrology Roles Conclusions
STAPHYLOCOCCUS AUREUS
Objectives S. aureus Fungal ConclusionMycobacteria
ISPD Recommendations 2016
• Empiric treatment includes antibiotics that cover S Aureus
• Treatment modified based on cultures • Cefazolin IP• Methicillen resistant organisms Vancomycin IP• Duration of treatment 3 weeks
www.ispd.org
Objectives S. aureus Fungal ConclusionMycobacteria
Process Outcomes Nephrology Roles ConclusionsObjectives S. aureus Fungal ConclusionMycobacteria
Yeast/Fungal Peritonitis: outcomes
• The high mortality rate is related to co-morbidity: some very ill, dying patients will get fungal peritonitis as an agonal event
• In Toronto cohort, 33% of patients were able to return to PD
Nadeau-Fredette and Bargman Perit Dial Int 2013
Objectives S. aureus Fungal ConclusionMycobacteria
Early catheter removal associated with better outcomes
• Retrospective study of 94 episodes of fungal peritonitis– Catheter removal within 24 hours in 42%– Catheter removal 2-9 days later in 45%– Mortality rate significantly higher with delayed
catheter removal (32 vs. 13%)
Chang et al, PDI 2011
Objectives S. aureus Fungal ConclusionMycobacteria
colposcopy, PD catheter manipulation– Regimens for colonoscopy should cover
enterococcus, enteric gram negatives and anaerobes
Objectives S. aureus Fungal ConclusionMycobacteria
Fungal Peritonitis
• Patients should receive fungal prophylaxis with any course of antibiotics
• Can use nystatin or fluconazole• As soon as fungal peritonitis diagnosed,
arrange early catheter removal
Objectives & Background Definition Rehab
Process Outcomes Nephrology Roles Conclusions
MYCOBACTERIAL INFECTIONS
Objectives S. aureus Fungal ConclusionMycobacteria
Mycobacteria
• Slow growing– M. tuberculosis– M. bovis– M. avium complex
• Fast growing– M. chelonae– M. fortuitum
Objectives S. aureus Fungal ConclusionMycobacteria
Consider M. tuberculosis when
• Endemic area• Culture negative, poor response• Culture positive with worsening or poor
response• Systemic illness consistent with TB
Objectives S. aureus Fungal ConclusionMycobacteria
M. tuberculosis is “tricky” to find
• Initial presentation is often with a neutrophil response (not lymphocytic)
• Classic ZN stains may not be sensitive– Centrifuge 50-100mls and then plate– Liquid media – Longer incubation
• DNA PCR studies have high rates of false positives
Objectives S. aureus Fungal ConclusionMycobacteria
Lymphocytic features are not always present
Tamayo-Isla et al, Perit Dial Int 2016; 36(2):218–222
Objectives S. aureus Fungal ConclusionMycobacteria
..nor are cultures always +ve
Tamayo-Isla et al, Perit Dial Int 2016; 36(2):218–222
Objectives S. aureus Fungal ConclusionMycobacteria
Treatment
• Local sensitivity and resistance patterns will influence medications used
• Often 4 drugs in combination: – rifampicin, isoniazid x 12-18 months– pyrazinamide & ofloxacin x 2 months– IP rifampicin if possible
• Pyridoxine 50-100 mg daily (with isoniazid)
www.ispd.org
Objectives S. aureus Fungal ConclusionMycobacteria
Catheter removal
• Controversial– Limpopo series – recommend it strongly– India series – not always needed
• ISPD recommendation uses the word “may” remove the catheter
Objectives S. aureus Fungal ConclusionMycobacteria
Non-tuberculous Mycobacteriae
• Emerging more commonly• Australian series 2013
– 12 cases– 1 in 1000 patient-years (0.6-1.4)– Recovery in 11 cases (3 no cath removal)
• Possible association with gentamicin– Lo et al, PDI 2013 33:267-72
Jiang et al, Int Urol Nephrol 2013 Oct;45(5):1423-8
Objectives S. aureus Fungal ConclusionMycobacteria
TreatmentsJiang et al, Int Urol Nephrol 2013 Oct;45(5):1423-8
Objectives S. aureus Fungal ConclusionMycobacteria
Conclusions
• Difficult to treat infections• All require high vigilance• Prevention is better than cure• Treatment is best with consultation with
local infectious disease specialists and use of ISPD guidelines
Objectives S. aureus Fungal ConclusionMycobacteria
University of Toronto Geriatric Nephrology Fellowship
Areas of specific focus will include one or more of the following areas: dialysis rehabilitation, care for residents in long-term care facilities, non-dialysis care and symptom management. Research
mentorship available includes Clinical Epidemiology or Translational Research