Once-daily intraperitoneal gentamicin is effective therapy for gram-negative CAPD peritonitis.

OBJECTIVE: To report our 3-year experience with the use of once-daily intraperitoneal (IP) gentamicin in the treatment of gram-negative continuous ambulatory peritoneal dialysis (CAPD) peritonitis. DESIGN: A prospective cohort study in prevalent CAPD patients. SETTING: A tertiary care institution. PATIENTS: All CAPD patients who presented with new episodes of peritonitis were studied. At presentation with peritonitis, IP vancomycin and gentamicin were administered as empirical therapy. IP gentamicin was given at a single daily dose of 40 mg/2 L in the overnight bag. The antimicrobial agents were reviewed when the culture results became available. Intraperitoneal ceftazidime was added for the treatment of pseudomonas peritonitis. MAIN OUTCOME MEASURES: Results of microbiological cultures and clinical outcomes of peritonitis were analyzed. RESULTS: Over a 36-month period, 190 episodes of peritonitis were recorded, of which 62/190 episodes (32.6%) isolated gram-negative organisms. The gram-negative organisms isolated were Escherichia coli, 15/62 episodes (24.1%); Pseudomonas aeruginosa, 12/62 episodes (19.4%); Acinetobacter spp, 12/62 episodes (19.4%); Klebsiella spp, 10/62 episodes (16.1%); and others, 13/62 episodes (21.0%). The overall treatment success rate was 66.1%. The treatment success rates were 74.0% if pseudomonas infections were excluded, 76.1% if gentamicin-resistant pathogens were excluded, and 80.5% if both pseudomonas infections and gentamicin-resistant pathogens were excluded. CONCLUSIONS: Once-daily IP gentamicin appears to be effective in the treatment of gram-negative CAPD peritonitis.

Psychosocial and psychiatric morbidity in patients on CAPD.

Continuous ambulatory peritoneal dialysis (CAPD) is an important mode of therapy for patients with end-stage renal disease. Although techniques and patient survival rates have improved, the psychosocial rehabilitation of Asian CAPD patients has not been studied. The aim of this study is to measure the extent of psychosocial and psychiatric morbidity in a sample of Asian CAPD patients. Patients from the outpatient CAPD facility affiliated with a tertiary care hospital were randomly selected and enrolled in the study. Demographic and clinical data were collected. Psychosocial and psychiatric assessments using the Hospital Anxiety and Depression Scale and coping style questionnaires were performed by a trained psychiatrist. The patients' most bother-some symptoms and specific worries were noted. Thirty of 105 stable CAPD patients (mean age 54.2 +/- 14.1 years, M:F 1:2, mean duration on CAPD 22.3 +/- 8.3 months) were studied. Twenty-one patients were married. Twenty-two patients were uneducated, 19 were unemployed, and 9 were homemakers. Based on the Hospital Anxiety and Depression scales, 50% of the patients were identified as cases of anxiety and 13% as depression. Although 93% of the patients accepted their illness, 46% of the patients were in a state of despair and hopelessness. Pruritus was the most frequent complaint (40%), followed by dietary restrictions (23%). The main worries were financial in 83% of patients, sexual dysfunction in 73%, and unemployment in 67%. In conclusion, Asian CAPD patients have a high degree of undetected psychosocial and psychiatric morbidity. These issues need to be addressed to provide adequate psychosocial rehabilitation.

Quantitative gait analysis in patients with vascular parkinsonism.

Until now the clinical criteria for the diagnosis of vascular parkinsonism (VP) have been disputed. The purpose of the present study is to investigate whether quantitative gait analysis can differentiate between the gait pattern of patients with VP and the gait pattern of patients with idiopathic Parkinson's disease (PD). Twelve patients with VP, 12 patients with PD, and 10 neurologically nondiseased controls were examined by quantitative gait analysis. Patients with VP, having a similar gait velocity and stride length, showed relatively preserved arm swing with markedly more anteflexion in the shoulder on the forward sway of the arm swing than patients with PD. Patients with VP also showed less flexion dystonic posture of the elbow, hip, knee, and trunk than did patients with PD. There was no significant difference in the excursions and coordination of arm swing in the patients with VP compared with the control group. Both patient groups showed reduced leg movements, reduced hip extension, and reduced knee flexion and extension as compared with the controls.

A prospective randomized comparison of the Swan neck, coiled, and straight Tenckhoff catheters in patients on CAPD.

Our objective was to study the impact of peritoneal catheter configuration on continuous ambulatory peritoneal dialysis (CAPD)-related infections, mechanical complications, and patient dropout in a prospective randomized trial. Forty consecutive patients who were commencing CAPD were randomized to receive either a double-cuff, Swan neck coiled catheter or a double-cuff, straight Tenckhoff catheter, implanted by surgical technique. There was no significant difference in the peritonitis rate between the two groups. There was a lower rate of exit-site infection in the Swan neck group compared to the straight catheter group (0.29 vs 0.60 episodes/patient-year, p < 0.05). Catheter-tip migration occurred in 3 patients with the straight catheters compared to one patient with the Swan neck catheter. No patient had to discontinue CAPD because of mechanical complications. The number of CAPD patient dropouts was not significantly different between the two groups. The Swan neck configuration resulted in a significant reduction in the rate of exit-site infections. The coiled component of the catheter may lead to fewer episodes of catheter-tip migration. However, catheter configuration did not influence the number of technique failures.

A prospective randomized comparison of single versus multidose gentamicin in the treatment of CAPD peritonitis.

There is an increasing trend towards the use of aminoglycosides in a once-daily dose administration for the treatment of severe infections in nonrenal failure patients. The use of once-daily dose aminoglycoside therapy may be associated with a reduction in toxicity. We performed a prospective randomized study comparing once-daily versus multiple-dose gentamicin in the treatment of continuous ambulatory peritoneal dialysis (CAPD) peritonitis. Seventy-three patients with 100 new episodes of peritonitis were enrolled in the study. At presentation of peritonitis, the patients were alternately assigned to receive either intraperitoneal gentamicin at a dose of 40 mg/2 L dialysate administered as a once-daily dose or gentamicin at a dose of 10mg/2 L dialysate administered 4 times per day. All patients also received intraperitoneal vancomycin at a dose of 1 g per week. There were no significant differences in the treatment success (88% vs 82%, p = NS) and relapse (18% vs 20%, p = NS) rates between the once-daily dose and multiple-dose groups. The mean trough serum gentamicin level was higher in the once-daily dose group compared to the multiple-dose group (0.75 +/- 0.72 vs 1.50 +/- 1.40 mg/L). In conclusion, gentamicin administered in a once-daily dose is as effective as multiple-dose administration in the treatment of CAPD peritonitis. The lower gentamicin level with once-daily dose administration may be associated with a reduction in aminoglycoside toxicity.

Differences and similarities in electrical muscle activity for the abductor pollicis longus muscle divisions.

The abductor pollicis longus (APL) has to be viewed as an important muscle for moving and stabilizing the human thumb(10). This muscle has two divisions, a distal superficial division and a more proximal deep one. The electromyographic (EMG) signals from these divisions were measured for several motor tasks in order to investigate differences in activation and function. EMG signals were recorded with intramuscular wire electrodes in isometric as well as in dynamic contractions in different directions, both for the thumb and for the hand. The EMG signals of the right hand of eight subjects were scaled relative to the mean EMG value at the maximum voluntary isometric contraction (MVC) in order to compare relative muscle activity in various directions for different subjects. In 18 out of the 22 directions the EMG activity in the two divisions of the APL was modulated differently, indicating a different activation. The differences were most prominent in dorsal and palmar flexion of the hand. The results suggested that the APLdeep is activated to stabilize the carpal joint. The APLdeep is a direct mover of the carpal joint in dorsal flexion of the hand.

Staphylococcus aureus CAPD-related infections are associated with nasal carriage.

Staphylococcus aureus nasal carriage has been shown to be associated with an increased risk of S. aureus exit-site infections, but its association with peritonitis is less well established. We performed a four-year prospective study to determine the relationship between S. aureus continuous ambulatory peritoneal dialysis (CAPD)-related infections and nasal carriage. All patients who had been started on CAPD from 1989 to 1992 had regular nose cultures. S. aureus nasal carriage was defined as two of three positive nose cultures. A total of 41 carriers and 105 noncarriers were studied. The rates of S. aureus exit-site infection (0.23 vs 0.09 episode/patient/year, p < 0.005), peritonitis (0.33 vs 0.10 episode/patient/year, p < 0.005), and catheter loss (0.12 vs 0.05, p < 0.01) were significantly higher among the carriers. Life-table analysis showed a significant risk of S. aureus exit-site infection and peritonitis for carriers (p < 0.01). Logistic regression analysis showed that S. aureus nasal carriage was the most important predictive factor for S. aureus peritonitis. In conclusion, our study showed that S. aureus nasal carriage is related to an increased incidence of S. aureus CAPD-related infections.

Intraperitoneal vancomycin/oral pefloxacin versus intraperitoneal vancomycin/gentamicin in the treatment of continuous ambulatory peritoneal dialysis peritonitis.

Sixty patients were enrolled in a prospective, randomized study to evaluate the efficacy of two different regimens for the empirical treatment of continuous ambulatory peritoneal dialysis (CAPD) peritonitis. At presentation, Group I received intraperitoneal vancomycin (1 g) and oral pefloxacin (400 mg b.i.d.), and Group II intraperitoneal vancomycin (1 g) and gentamicin (80 mg loading dose, followed by 15 mg/2 L). Treatment duration was 14 days. Despite randomization, Group I had significantly more patients with primary Candida peritonitis. When fungal peritonitis was excluded from analysis, there were no significant differences in the treatment success rate (Group I, 73.3% vs Group II, 80.0%, p = NS), number of relapses (Group I, 0 vs Group II, 1), and Tenckhoff catheter removal rates (Group I, 26.6% vs Group II, 16.6%, p = NS) between the two groups. The patients treated with pefloxacin had an increased incidence of nausea and vomiting. In selected situations oral pefloxacin may be a suitable substitute for intraperitoneal gentamicin as out-patient therapy for CAPD peritonitis.

A prospective study of peritoneal dialysis-related infections in CAPD patients with diabetes mellitus.

Data comparing peritoneal dialysis (PD)-related infection rates between diabetic and nondiabetic patients on chronic peritoneal dialysis are conflicting. We carried out a prospective study comparing PD-related infection rates between diabetic and nondiabetic patients treated with continuous ambulatory peritoneal dialysis (CAPD) in our center. All patients commencing CAPD between January 1989 and June 1992 were enrolled into the study. Patients were followed up until death, CAPD dropout, or until December 1992. Data on diabetes mellitus status, Staphylococcus aureus nasal carriage, and PD-related infections were gathered. Infection rates were analyzed using life tables and the negative binomial test. One hundred and seven diabetic patients and 72 nondiabetic patients were studied. Patients with diabetes mellitus were not at increased risk of being S. aureus nasal carriers. The peritonitis rate was significantly higher in the diabetic group (1.2 vs 0.8 episodes/patient/year, p < 0.05). The exit-site and tunnel infection, catheter loss, and patient dropout rates were not significantly different between the two groups. Life-table analysis did not show a significant difference in the time to first episode of peritonitis and catheter-related infection.

Breaking-in after the insertion of Tenckhoff catheters: a comparison of two techniques.

Breaking-in after catheter implantation may be an important factor in the development of early catheter-related infections in continuous ambulatory peritoneal dialysis (CAPD) patients. We carried out a prospective study comparing two break-in techniques after catheter implantation. All patients entering the CAPD program from March 1991 to December 1992 were enrolled into the study. Data on diabetes mellitus status, Staphylococcus aureus nasal carriage, and peritoneal dialysis-related infections were gathered. After catheter implantation, the patients were assigned to either have their catheter rested until the fourteenth postoperative day (group 1) or immediate use of the catheter for intermittent peritoneal dialysis (group 2). Exit-site care was identical for both groups. A total of 32 patients in group 1 and 74 in group 2 were studied. Age, sex, and S. aureus nasal carriage were not significantly different between the two groups. There were more patients with diabetes mellitus in group 2. Four patients in group 2 dropped out of the CAPD program because of refractory peritonitis. There was no significant difference in the number of exit-site infections between groups 1 and 2. There were more patients who had pericatheter leakage and catheter migration in group 2 compared to group 1, although the difference was not statistically significant.