Term paper on The Use of Antibiotics in CAPD Peritonitis
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Term paper on The Use of Antibiotics in CAPD Peritonitis
  

Introduction
Continuous Ambulatory Peritoneal Dialysis (CAPD) is a technique that have been very helpful for patients with severe renal failure, or whose renal capacities have been far below normal. The technique offers mobility for patients who would have to be confined to the hospital if being treated under conventional dialysis techniques. In this technique the patient’s peritoneum is made to act as a dialysis membrane, and so does away with the need for other costly equipments. However, there are some serious problems with CAPD that forces many patients to discontinue the treatment after some time. One of the main problems with CAPD is the fact that it makes the patient highly susceptible to infections [GpNotebook, 2004]. Even after adhering to the best levels of personal care, the chances of the patient becoming infected is very high. This calls for the need to administer antibiotics to counter the infection caused through CAPD procedures.

Literature Review
The occurrence of secondary infections in patients undergoing CAPD is quite common and often doctors resort to antibiotic use to curb the symptoms presented in such cases. However, the use of antibiotics is not without its bad aspects. In fact, the extensive use of antibiotics is said to be the major cause of antibiotic resistance of bacteria. Patients and doctors are particularly concerned at the resistance to Vancomycin, a drug that has been effectively used to control CAPD infections. In fact, the resistance of bacteria to Vancomycin had boosted the efforts of the International Society of Peritoneal Dialysis (ISPD) to come out with a definite procedure to administer antibiotics and to counter the deleterious effects of antibiotic resistance. Diaz (2004) mentions in his paper that a first generation antibiotic like Cephalosporin (Cefazolin or Cephalothin) must be used to substitute Vancomycin, and a third generation antibiotic like Cephalosporin (Ceftazidime) or an aminoglycoside must be used to treat Gram negative organisms. The reduction in the use of Vancomycin reduced the occurrence of ototoxicity and nephrotoxicity, which is considered to be a very great advantage.

There has been a great deal of debate on the efficacy of certain compounds in the treatment of CAPD derived peritonitis. For example Korzets Z and Lang R (2001), and Kent JR and Almond MK. (2000) believe that the efficacy of Vancomysin is very important in treating CAPD led peritonitis. Vancomycin was found to be effective against a wide range of bacterial strains and the effect of the treatment was long lasting, which prevented repeated hospitalization expenses. However, many other experts such as Gucek A, Bren AF, Lindic J et. al. (1994) and Alves FR, Dantas RC (1997) have argued that other alternatives to Vancomycin, particularly Cefazolin, seem to show significant if not better cure rates. They also argue that Vancomysin resistant bacteria like Vancomycin Resistant Enterococci have been increasingly posing problems to doctors. Cefazolin in particular, is ineffective against methicillin resistant organisms, which constitute 15-43% of the CAPD infections.

Over the years, third generation Cephalosporins have been accused of increasing infections in the human body and many experts believe that this may due to the indiscriminate use of these drugs. Enterococcal infections for example, have been increasingly resistant to Cephalosporins. In fact Barlett JG, Bradley SF, Herwaldt LA, et al (1999) and Teitelbaum (2001) believe that the increasing incidence of infections is proportional to the increasing use of cephalosporins for treating peritonitis.

Many doctors also believe that an empirical prescription of antibiotics can work significantly against CAPD infections because it will act on a wide range of bacterial strains. This will also help in a way to provide a clue on the possible bacterial strain that has infected the patient. If the bacterial infection cannot be controlled with the initial broad spectrum antibiotic, specific antibiotics may be used to deal with the possible strain that is causing the problem. Doctors advise that the use of specific antibiotics at the first stage itself is not a good form of approaching the infection given the fact that many antibiotics have different kinds of adverse effects on the patients. In addition, the issue of drug resistance is a very important factor that needs to be considered before administering any of the specific antibiotics [McDonald, 2002; Sandoe JA, Gokal R, Struthers JK (1997)]. The use of Vancomycin has long been discouraged by medical scientists because of Vancomycin Resistant Enterococci, which escapes the drug. Newer approaches to treating CAPD peritonitis involve the use of combination medicines that have been giving good results. For example Chadwick DH, Agarwal S, Vora BJ, Hair M, McKewan A, and Gokal R (1999) have proved through their experiments that a combination of Vancomycin combined with Netilmicin has a cure rate of more than eighty percent. This is a very positive finding which will contribute significantly towards the treatment of peritonitis. This study also must be followed up with the study of bacterial resistance patterns to evolve better treatment regimens that can effectively kill a large number of bacterial strains.

It would be important to note that CAPD related infections were not a serious cause of diseases a few years before, as noted by Ng R, Zabetakis PM, Callahan C, Krapf R, Sasak C, Fritzsch S, Pollock A, Balter P, and Michelis MF (1999). However, Sanyal D, Williams AJ, Johnson AP, George RC (1993) notes that peritonitis can be caused in patients because of long term treatment with Intra-peritoneal Vancomycin, which is part of the CAPD procedure. Sanyal et al (1993) warns medical practitioners from administering glycopeptides repeatedly to these patients since that can encourage bacterial resistance. Putting these two observations together it may be seen that there is a chance for the patient to develop peritonitis in the long run from hospital procedures that are part of CAPD procedures. This means that care must be taken by the patients as well as the health workers to be always on the lookout for procedures that may become controversial in the long run.

The alertness of the patients and doctors assumes significance considering the fact that new resistant forms of bacteria have been isolated recently in CAPD patients [Klein G, Zill E, Schindler R, Louwers J, 1998; Neef PA, Polenakovik H, Clarridge JE, Saklayen M, Bogard L, Bernstein JM, 2003] Hence, medical practices must be carefully planned to reduce chances of bacterial resistance as far as possible.

While the debates on the use of medicines go on, doctors have come up with interesting observations of bad diagnosis. Often conditions that are considered to be cases of peritonitis is not so, and may be simply a case of the reaction of the body’s defense mechanisms. Experts like Chan MK, Chow L, Lam SS, and Jones B (1988) have observed that a condition called peritoneal eosinophilia in patients can be caused by non-bacterial agents like allergies, reaction of the body to surgical components, gas formation in the area of the insertion etc. In such cases, administering antibiotics will not lead to a cure [Nankivell BJ, Pacey D, Gordon DL 1991; Sridhar R, Thornley-Brown D, Kant KS, 1990; Dobbie JW, 1993]. Hence, in all cases of CAPD peritonitis infections, it will be wise to ascertain the reason for the disease rather than administering the medicines in haste. Der-Cherng Tarng, Tzen Wen Chen and Chin-Huang Chen (2001) notes that peritonitis in CAPD patients does not always warrant the use of antibiotics. What is needed is a clear diagnosis and confirmation of bacterial infection.
 
 
 
     
 

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