PERITONITIS IN CAPD Signs and Symptoms Cloudy fluid
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PERITONITIS IN CAPD
������ Signs and Symptoms Cloudy fluid Abdominal pain Abdominal tenderness (Rebound) Fever Chills Nausea Vomiting Diarrhoea Percentage 98 – 100 67 – 97 62 – 79 (35 – 62) 34 – 36 18 – 23 30 – 35 25 – 30 7 – 15
������� “��� 1. 2. 3. 4. 5. 6. 7. Infectious peritonitis (culture positive or negative) Eosinophilic peritonitis Sclerosing peritonitis Chylous ascites Malignant ascites Pancreatitis (Amylase > 100 without bowel perforation) Chemical peritonitis
������� 1 (��� ( �� 47 �� ��������� ��CAPD ������ � 1 ������� generalized mild tenderness of abdomen exit site and tunnel PDF : �� white cells 320 ��� /��. ���� PMN 89%, Mononuclear cell 9% Eosinophil 2% Gram stain : no organism found PDF, centrifuged, aerobic bacterial culture : pending
����� Organisms Percentage Coag. –ve Staph. 30 – 40 S. aureus 20 Streptococcus spp. 10 – 15 Neiseria spp. 1– 2 Diphtheroid spp. 1– 2 Enterococcus 3– 6 Anaerobes 2– 5 Organisms Percentage E. coli 5 – 10 Pseudomonas spp. 5 – 10 Klebsiella spp. 1– 3 Proteus spp. 3– 6 Acinetobacter spp. 2– 5 Fungus 2 – 10 Other (Mycobacteria etc. ) 2– 5 Culture negative 0 – 30 % Keane WF, et al. The Textbook of PD 1994: 475.
����� Hematogenous (Blood) Transmural (Bowel, KUB) Transluminal Periluminal (Catheter) (Skin, Tunnel) Ascending (Female Genital) Multiple routes
���������� Transluminal S. epidermidis, Acinetobacter 30 – 40 Periluminal S. epidermidis, S. aureus 20 - 30 Pseudomonas, Yeast Transmural Enteric gram negative, Anaerobes 25 - 30 Hematogenous Streptococcus, M. tuberculosis 5 - 10 Ascending Yeast, Lactobacillus 2– 5 Keane WF, et al. The Textbook of PD 1994: 475.
������ Number of Micro-organism and their virulence Host Defense Mechanisms Peritonitis No peritonitis
������ Number of Micro-organism and their virulence Host Defense Mechanisms Peritonitis No peritonitis
������� Humoral factors �������� immunoglobulins, complem ��� opsonin Cellular factors ���� Mesothelial cells & Mononuclear cells ���� Polymorphonuclear cells ����� ? Lymphocytes ? ������ ? Eosinophils ? �������
������ 1. Inflammatory mediators : opsonins ��� complement ��������� - chemotactic factors ����� - vasodilators ���� histamine, serotonin ��� ����������� 2. Fibrin and fibronectin - �� fibrinogen ����� fibrinolysis ��� - �� fibronectin �������������� ���
������ 3. Cellular response ��������� mesothelial cells ��� macr ���� PMN, lymphocytes ��� eosinophils �����������
������� 1 (��� ( ��� 47 �� ������� spike system ��������� 1 ��� �� ����� generalized mild tenderness of abdomen normal exit site and tunnel PDF white cells 320 (PMN 89%, M 9%, Eo 2%) Organism not yet known ��������������
������ ma Staphylococcus spp. S. aureus ทไมดอยา methicillin S. aureus ทดอยา Staph ชนดอนทไมดอยา methicillin Staph ชนดอนทดอยา methicillin ยาทแนะนำ Cephalothin/Cefazolin รวมกบ Rifampin 600 มก. /วน รบประทาน methicillin Vancomycin/Clindamycin Cephalothin/Cefazolin Vancomycin/Clindamycin
������ ma Enterococcus ทไมดอยา ampicillin Enterococcus ทดอยา vancomycin ยาทแนะนำ Ampicillin ± Aminoglycoside Vancomycin/Clindamycin Quinupristin/Dalfopristin
������ ma Gram negative bacilli ยาทแนะนำ Aminoglycoside ถาปสสาวะ < 100 มล. /วน หรอ Ceftazidime ถาปสสาวะ Single organism > 100 มล. /วน ให Cefazolin + Ceftazidime Multiple organism anaerobes เพม Metronidazole Ceftazidime รวมกบ ถาปสสาวะ < 100 มล. /วน ให Pseudomonas/ Aminoglycoside Stenotrophomonas ถาปสสาวะ > 100 มล. /วน ให Ciprofloxacin (Xanthomonas multophilia)) หรอ Piperacillin หรอ Cotrimoxazole
������ ma Fungus ยาทแนะนำ Yeast (mild peritonitis) Fluconazole + Flucytosine Yeast (severe peritonitis) Amphotericin B Yeast ทดอตอ fluconazole และ flucytosine Itraconazole/Amphotericin B Filamentous fungi Amphotericin B
������ ma Other Culture negative with rapid response Culture negative with slow response Mycobacterium ยาทแนะนำ หยด Ceftazidime หรอ Aminoglycoside ใหแต first generation cephalosporin ตอไป ให Cephalothin/cefazolin + Ceftazidime หรอ Aminoglycoside ตอไป และตรวจเชอซำ Anti-tuberculous drugs
������ ชนดของเชอ ระยะเวลาใหยาทแนะ นำ S. aureus 21 วน Staph ชนดอน 14วน Enterococcus 14วน Single gram negative bacilli 14 วน Multiple gram negative bacilli anaerobes 21(28) วน Pseudomonas/Stenotrophomonas spp. 21(28) วน
������ ชนดของเชอ Fungus with good response Fungus with catheter removal ระยะเวลาใหยาทแนะน ำ 4 – 6 สปดาห ใหตอไปอยางนอย Culture negative with rapid response 14วน Culture negative with slow response อยางนอย 14 วน (ตดตามอาการ ) Mycobacterium 9 – 12 เดอน 7 วน
������� ชนดของเชอ ระยะเวลาใหยาทแนะ นำ 1993 1996 & 2000 S. aureus 14 วน (3) 21 วน Staph ชนดอน 14วน (3) 14วน Enterococcus 14วน Single gram negative bacilli 21 วน 14 วน 21 (28) วน 21วน 28 วน 21วน Multiple gram negative bacilli anaerobes Pseudomonas/Stenotrophomonas spp.
������ 1. ��������� compartmentation 2. ������ 3. Membrane failure ���� 4. Sclerosing peritonitis
������ 1. Catheter 1. 1 ������� catheter - Double-cuffed catheter - Catheter with parietal peritoneum fixation device ���� Missouri-coiled, Life-Cath - Swan neck catheter 1. 2 �������� catheter - Downward-drained exit - Sinus tract : 1 – 2 ��. ����� - ����� cuff ������� - ��������� (peritoneoscopic
������ 3. Prophylaxis 3. 1 Cyclical rifampin ������� 600 ��. ������ 5 �� 3. 2 Intra-nasal mupirosin - ����� 2 ������ 5 ���� - ����� 2 -3 ������ 5 -7 ��� 3. 3 Exit-site mupirosin 3. 4 Antibiotics prophylaxis before proceduring
Antibiotic prophylaxis before proceduring ����� Amoxycillin 2 ����������� Colonoscopy Tobramycin 120 ��. IP ����� Metronidazole 500 ��. ����� � 12 �������
������ 4. ���� (Connection and Exchange System) 4. 1 Flush-before-fill ± Antiseptics 4. 2 Double-bag 4. 3 Pre-attached bag (Closed system) 4. 4 Disconnection Y-set O-ring Ultra-bag/Twin-bag Stay-safe/Andy-Disc
Y-SET “FLUSH BEFORE FILL” TECHNIQUE Solution bag Peritoneal cavity Catheter Abdominal wall Drainage bag
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