Treatment of Peritoneal Dialysis–Associated Peritonitis: A Systematic Review of Randomized Controlled Trials

Wiggins, Kathryn J.; Johnson, David W.; Craig, Jonathan C.; Strippoli, Giovanni F.M.

doi:10.1053/j.ajkd.2007.08.015

« Previous Next »American Journal of Kidney Diseases
Volume 50, Issue 6 , Pages 967-988, December 2007

Treatment of Peritoneal Dialysis–Associated Peritonitis: A Systematic Review of Randomized Controlled Trials

Kathryn J. Wiggins, MBBS
- Department of Nephrology, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia
- Address correspondence to Kathryn J. Wiggins, MBBS(Hons), Department of Nephrology, St Vincent’s Hospital, PO Box 2900, Fitzroy, Victoria 3065, Australia.
David W. Johnson, PhD, MBBS
- Department of Nephrology, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia
Jonathan C. Craig, PhD, MBChB
- Centre for Kidney Research, NHMRC Centre for Clinical Research Excellence in Renal Medicine, Cochrane Renal Group, Children’s Hospital at Westmead, School of Public Health, University of Sydney, Australia
Giovanni F.M. Strippoli, MD, MPH, MM(Epi)
- Centre for Kidney Research, NHMRC Centre for Clinical Research Excellence in Renal Medicine, Cochrane Renal Group, Children’s Hospital at Westmead, School of Public Health, University of Sydney, Australia
- Mario Negri Sud Consortium, Santa Maria Imbaro (Ch), Italy.

Received 10 April 2007; accepted 23 August 2007.

Background

Peritonitis frequently complicates peritoneal dialysis. Appropriate treatment is essential to reduce adverse outcomes. Available trial evidence about peritoneal dialysis peritonitis treatment was evaluated.

Selection Criteria for Studies

The Cochrane CENTRAL Registry (2005 issue), MEDLINE (1966 to February 2006), EMBASE (1985 to February 2006), and reference lists were searched to identify randomized trials of treatments for patients with peritoneal dialysis peritonitis.

Interventions

Trials of antibiotics (comparisons of routes, agents, and dosing regimens), fibrinolytic agents, peritoneal lavage, and intraperitoneal immunoglobulin.

Outcomes

Treatment failure, relapse, catheter removal, microbiological eradication, hospitalization, all-cause mortality, and adverse reactions.

Results

36 eligible trials were identified: 30 trials (1,800 patients) of antibiotics; 4 trials (229 patients) of urokinase; 1 trial of peritoneal lavage (36 patients); and 1 trial of intraperitoneal immunoglobulin (24 patients). No superior antimicrobial class was identified. In particular, glycopeptides and first-generation cephalosporins were equivalent (3 trials, 387 patients; relative risk [RR], 1.84; 95% confidence interval [CI], 0.95 to 3.58). Simultaneous catheter removal/replacement was superior to urokinase at decreasing treatment failures (1 trial, 37 patients; RR, 2.35; 95% CI, 1.13 to 4.91). Continuous and intermittent intraperitoneal antibiotic dosing were equivalent regarding treatment failure (4 trials, 338 patients; RR, 0.69; 95% CI, 0.37 to 1.30) and relapse (4 trials, 324 patients; RR, 0.93; 95% CI, 0.63 to 1.39). One trial showed superiority of intraperitoneal antibiotics over intravenous therapy.

Limitations

The method quality of trials generally was suboptimal and outcome definitions were inconsistent. Small patient numbers led to inadequate power to show an effect. Interventions, such as optimal duration of antibiotic therapy, were not evaluated.