Abstract:

The aim of our study was to look at the overall risk of peritonitis post colonoscopy in end stage renal disease patients on automated peritoneal dialysis and to evaluate the use of prophylactic antibiotic in those patients when given prior to colonoscopy.

A total of 93 patients out of 134 patients on automated peritoneal dialysis (APD) undergoing diagnostic colonoscopy were enrolled in a prospective randomized study. The study extended from January 2016 throughout May 2018 Patients were randomized into two age and sex matched groups; group 1 (46 patients) who had prophylaxis ceftazidime prior to colonoscopy and group 2 (47 patients) who had colonoscopy without prophylactic antibiotics. The following parameters: age, gender, duration on dialysis, duration on APD, diabetic status, use of antibiotics before the procedure, and indications for and findings of colonoscopy were studied. Prophylactic antibiotics were given for prevention of peritonitis if needed according to the 2010 ISPD guidelines.

Results: Post-colonoscopy peritonitis was documented in 2 (4.3%) and 3 (6.4%) patients in groups A and B respectively (p > 0.05). The most common causative agents were gram negative bacteria and there were no other complications.

Conclusion: There was no strong correlation between prophylactic antibiotic use and risk of peritonitis in peritoneal dialysis patients and it seems that the overall risk of developing peritonitis after colonoscopy is low. Only old age, diabetes mellitus and low serum albumin appear to be of significance. Polypectomy; partial or complete did not increase peritonitis episodes in our study population.

Keywords: APD, ESRD, diabetes, colonoscopy, polypectomy, antibiotic prophylaxis, peritonitis.

References:

[1].Allison MC, Sandoe JA, Tighe R, Simpson IA, Hall RJ, Elliott TS; Endoscopy Committee of the British Society of Gastroenterology: Antibiotic prophylaxis in gastrointestinal endoscopy. Gut 2009; 58: 869-80.

[2].ASGE Standards of Practice Committee, Banerjee S, Shen B, Baron TH, Nelson DB, Anderson MA, Cash BD, Dominitz JA, Gan SI, Harrison ME, Ikenberry SO, Jagannath SB, Lichtenstein D, Fanelli RD, Lee K, van Guilder T, Stewart LE: Antibiotic prophylaxis for GI endoscopy. ASGE guidelines. Gastrointest Endosc 2008; 67: 791-98.

[3].Bac DJ, van Blankenstein M, de Marie S, Fieren MW. Peritonitis following endoscopic polypectomy in a peritoneal dialysis patient: the need for antibiotic prophylaxis. Infection 1994; 22:220–1.

[4].Bayston R, Andrews M, Rigg K, Shelton A. Recurrent infection and catheter loss in patients on continuous ambulatory peritoneal dialysis. Perit Dial Int 1999; 19:550–55.

[5].Bunke CM, Brier ME, Golper TA. Outcomes of single organism peritonitis in peritoneal dialysis: gram-negatives versus gram-positives in the Network 9 Peritonitis Study. Kidney Int 1997; 52:524–29.

[6].Choi P, Nemati E, Banerjee A, Preston E, Levy J, Brown E. Peritoneal dialysis catheter removal for acute peritonitis: a retrospective analysis of factors associated with catheter removal and prolonged postoperative hospitalization. Am J Kidney Dis 2004; 43:103–11.

[7].Coward RA, Gokal R, Wise M, Mallick NP, Warrell D. Peritonitis associated with vaginal leakage of dialysis fluid in continuous ambulatory peritoneal dialysis. Br Med J 1982; 284:1529.

[8].Edlund C, Nord CE. 1999b. Effect of quinolones on intestinal ecology. Drugs, 58(Suppl 2):65–70.

[9].Fatemeh Rafii, John B Sutherl and, Carl E Cerniglia. Effects of treatment with antimicrobial agents on the human colonic microflora. Therapeutics and Clinical Risk Management 2008:4(6) 1343–57.

[10]. Fried L, Bernardini J, Piraino B. Iatrogenic peritonitis: the need for prophylaxis. Perit Dial Int 2000; 20: 343-345.

[11]. Johnson DW, Dent H, Hawley CM, McDonald SP, Rosman JB, Brown FG, et al. Associations of dialysis modality and infectious mortality in incident dialysis patients in Australia and New Zealand. Am J Kidney Dis 2009; 53:290–97.

[12]. Katsanos KH, Tsianos EV. Bacterial peritonitis following multiple endoscopic polypectomy in a peritoneal dialysis patient despite antibiotics prophylaxis. Annals of Gastroenterology 2010; 23: 211-212.

[13]. Kumar S, Abcarian H, Prasad L, et al. Bacteremia as sociated with lower gastrointestinal endoscopy, fact or fiction? Dis Colon Rectum. 1982; 25:131-134.

[14]. Macrae F, Tan K, Williams C. Towards safer colonoscopy: A report on the complications of 5000 diagnostic or therapeutic colonoscopies. Gut. 1983; 24:376-383.

[15]. Oreopoulos DG. Prevention of peritonitis in patients undergoing CAPD. Perit Dial Bull. 1986; 6:2-3.

[16]. Petersen JH, Weesner RE, Giannella RA. Escherichia coli peritonitis after left-sided colonoscopy in a patient on continuous ambulatory peritoneal dialysis. Am J Gastroenterol 1987; 82:171–2.

[17]. Philip Kam-Tao Li, Cheuk Chun Szeto, Beth Piraino, Judith Bernardini, Ana E. Figueiredo, Amit Gupta, David W. Johnson, Ed J. Kuijper, Wai-Choong Lye, William Salzer, Franz Schaefer, and Dirk G. Struijk10. Peritoneal dialysis-related infections recommendations: 2010 update. Perit Dial Int, 30: 393–423.

[18]. Philip Kam-Tao Li, Cheuk Chun Szeto, Beth Piraino, Javier de Arteaga, Stanley Fan, Ana E. Figueiredo, Douglas N. Fish, Eric Goffin, Yong-Lim Kim, William Salzer, Dirk G. Struijk, Isaac Teitelbaum, and David W. Johnson. ISPD peritonitis recommendations: 2016 update on prevention and treatment. Perit Dial Int, in Press www.PDIConnect.com

[19]. Piraino B, Bernardini J, Sorkin M. The influence of peritoneal catheter exit-site infections on peritonitis, tunnel infections, and catheter loss in patients on continuous ambulatory peritoneal dialysis. Am J Kidney Dis 1986; 8:436–40.

[20]. Piraino B, Bernardini J, Sorkin M. Catheter infections as a factor in the transfer of continuous ambulatory peritoneal dialysis patients to hemodialysis. Am J Kidney Dis 1989; 13:365–69.

[21]. Piraino B, Bernardini J, Brown E, et al. ISPD position statement on reducing the risks of peritoneal dialysis–related infections. Perit Dial Int 2011; 31:614-30.

[22]. Poortvliet W, Selten HP, Raasveld MH, et al. CAPD peritonitis after colonoscopy: follow the guidelines. Neth J Med 2010; 68:377-78.

[23]. Sipahi S, Gungor O, Kircelli F, Aydin B, Ulker EA, Tamer A. Peritonitis after colonoscopy in a peritoneal dialysis patient. Turk Nephrol Dial Transpl 2012; 21 (1): 105-106.

[24]. Sullivan A, Edlund C, Nord CE. 2001a. Effect of antimicrobial agents on the ecological balance of human microfl ora. Lancet Infect Dis, 1:101–14.

[25]. Sullivan A, Edlund C, Svenungsson B, et al. 2001b. Effect of perorally administered pivmecillinam on the normal oropharyngeal, intestinal and skin microfl ora. J Chemother, 13:299–308.

[26]. Szeto CC, Chow KM, Wong TY, Leung CB, Li PK. Conservative management of polymicrobial peritonitis complicating peritoneal dialysis—a series of 140 consecutive cases. Am J Med 2002; 113:728–33.

[27]. Terence Yip, Kai Chung Tse, Man Fai Lam, Suk Wai Cheng, Sing Leung Lui, Sydney Tang, Matthew Ng, Tak Mao Chan, Kar Neng Lai, and Wai Kei Lo. Risks and outcomes of peritonitis after flexible colonoscopy in CAPD patients. Perit Dial Int 2007; 27:560–564.

[28]. Verger C, Danne O, Vuillemin F. Colonoscopy and continuous ambulatory peritoneal dialysis. Gastrointest Endosc 1987; 33:334–5.

[29]. Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes

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Abstract:

Cardiac dysrhythmia is a term for any of large heterogeneous group of conditions in which there is abnormal electrical activity in the heart. Dysrhythmias may be life threatening medical emergencies that can result in cardiac arrest and sudden death; it may predispose the patient to potentially life threatening stroke and embolism.

The pathogenesis of cardiac dysrhythmia involves crossing of electrolytes through different ions channels on the cellular level that may be dysrhythmogenic.

In this study, ischemic-reperfusion dysrhythmia were performed in experimental animals, ischemia of the myocardium results in release of ischemic metabolites and slowing impulse propagation while reperfusion results in increase late inward Na current (INaL) which amplifies Na⁺ influx and intracellular Na⁺ concentration leading finally to calcium overload. The enhancement of Na⁺ and Ca2⁺ concentration causes electrophysiological instability, formation of free oxygen radicle and liberation of platelet activating factor.

Seeking for novel antidysrhythmogenic agents having ions channels inhibiting properties, this work aims to investigate the effects of vernakalant, antidysrhythmic drug with atrial selective and multi-channel blocking effect on ischemia-reperfusion dysrhythmia in experimental animals in comparison with amiodarone as a standard antidysrhythmic medication.

Keywords: Ischemic-Reperfusion Dysrhythmia, Vernakalnt & Amiodarone.

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Abstract:

The biggest burden in peritoneal dialysis is still peritonitis which increases the rate of mortality and hospitalization. The aim of our research was to address one of the ISPD (international society of peritoneal dialysis) guidelines 2016 which advocate the use of prophylactic antibiotic in peritoneal dialysis patients before going to colonoscopy, but this recommendation is class C which means a weak one. Our aim was to look at the effect of giving intraperitoneal ceftazidime before the procedure of colonoscopy in reducing the possible risk of peritonitis.

Patients and methods: Over a period of 2 years and 6 months, from January 2016 we managed to enroll 120 patients out of 163 whom we performed 120 colonscopies. Patients were randomized for Ceftazidime use by 1:1 method, ending up with 60 patients in group A who received the drug and 60 patients in group B who did not receive the drug.

Results: peritonitis occurred within 48 hours following the procedure. It was documented in 4 (6.7%) and 5 (8.3%) patients in groups 1 and 2 respectively (p =0.3243); the causative organisms were mainly gram-negative bacteria.

Conclusion: It appeared that giving intraperitoneal Ceftazidime prior to colonoscopy did not offer greater benefits in reducing the risk of peritonitis when compared with the group who did not receive it.

Keywords: Peritoneal dialysis, peritonitis, colonoscopy, ESRD, colon cancer, ceftazidime.

References:

[1].  Allison MC, Sandoe JA, Tighe R, Simpson IA, Hall RJ, Elliott TS; Endoscopy Committee of the British Society of Gastroenterology: Antibiotic prophylaxis in gastrointestinal endoscopy. Gut 2009; 58: 869-80.

[2].    ASGE Standards of Practice Committee, Banerjee S, Shen B, Baron TH, Nelson DB, Anderson MA, Cash BD, Dominitz JA, Gan SI, Harrison ME, Ikenberry SO, Jagannath SB, Lichtenstein D, Fanelli RD, Lee K, van Guilder T, Stewart LE: Antibiotic prophylaxis for GI endoscopy. ASGE guidelines. Gastrointest Endosc 2008; 67: 791-98.

[3].    Association of CKD and Cancer Risk in Older People, Germaine Wong, JASN June 2009 vol. 20 no. 61341-135.

[4].   Bac DJ, van Blankenstein M, de Marie S, Fieren MW. Peritonitis following endoscopic polypectomy in a peritoneal dialysis patient: the need for antibiotic prophylaxis. Infection 1994; 22:220–1.

[5].   Bayston R, Andrews M, Rigg K, Shelton A. Recurrent infection and catheter loss in patients on continuous ambulatory peritoneal dialysis. Perit Dial Int 1999; 19:550–55.

[6].   Bunke CM, Brier ME, Golper TA. Outcomes of single organism peritonitis in peritoneal dialysis: gram-negatives versus gram-positives in the Network 9 Peritonitis Study. Kidney Int 1997; 52:524–29.

[7].   Choi P, Nemati E, Banerjee A, Preston E, Levy J, Brown E. Peritoneal dialysis catheter removal for acute peritonitis: a retrospective analysis of factors associated with catheter removal and prolonged postoperative hospitalization. Am J Kidney Dis 2004; 43:103–11.

[8].   Coward RA, Gokal R, Wise M, Mallick NP, Warrell D. Peritonitis associated with vaginal leakage of dialysis fluid in continuous ambulatory peritoneal dialysis. Br Med J 1982; 284:1529.

[9].   Elwell RJ, Frye RF, Bailie GR. Pharmacokinetics of intraperitoneal cefepime in

[10]. automated peritoneal dialysis. Perit Dial Int 2006;25: 380-86.

[11]. Fatemeh Rafii, John B Sutherl and, Carl E Cerniglia. Effects of treatment with antimicrobial agents on the human colonic microflora. Therapeutics and Clinical Risk Management 2008:4(6) 1343–57.

[12]. Fried L, Bernardini J, Piraino B. Iatrogenic peritonitis: the need for prophylaxis. Perit Dial Int 2000; 20: 343-345.

[13]. Johnson DW, Dent H, Hawley CM, McDonald SP, Rosman JB, Brown FG, et al. Associations of dialysis modality and infectious mortality in incident dialysis patients in Australia and New Zealand. Am J Kidney Dis 2009; 53:290–97.

[14]. Katsanos KH, Tsianos EV. Bacterial peritonitis following multiple endoscopic polypectomy in a peritoneal dialysis patient despite antibiotics prophylaxis. Annals of Gastroenterology 2010; 23: 211-212.

[15]. Kumar S, Abcarian H, Prasad L, et al. Bacteremia as sociated with lower gastrointestinal endoscopy, fact or fiction? Dis Colon Rectum. 1982; 25:131-134.

[16]. Low CL, Gopalakrishna K, Lye WC. Pharmacokinetics of once daily intraperitoneal cefazolin in continuous ambulatory peritoneal dialysis. J Am Soc Nephrol 2000; 11:1777-21.

[17]. Macrae F, Tan K, Williams C. Towards safer colonoscopy: A report on the complications of 5000 diagnostic or therapeutic colonoscopies. Gut. 1983; 24:376-383.

[18]. Oreopoulos DG. Prevention of peritonitis in patients undergoing CAPD. Perit Dial Bull. 1986; 6:2-3.

[19]. Petersen JH, Weesner RE, Giannella RA. Escherichia coli peritonitis after left-sided colonoscopy in a patient on continuous ambulatory peritoneal dialysis. Am J Gastroenterol 1987; 82:171–2.

[20]. Philip Kam-Tao Li, Cheuk Chun Szeto, Beth Piraino, Judith Bernardini, Ana E. Figueiredo, Amit Gupta, David W. Johnson, Ed J. Kuijper, Wai-Choong Lye, William Salzer, Franz Schaefer, and Dirk G. Struijk10. Peritoneal dialysis-related infections recommendations: 2010 update. Perit Dial Int, 30: 393–423.

[21]. Philip Kam-Tao Li, Cheuk Chun Szeto, Beth Piraino, Javier de Arteaga, Stanley Fan, Ana E. Figueiredo, Douglas N. Fish, Eric Goffin, Yong-Lim Kim, William Salzer, Dirk G. Struijk, Isaac Teitelbaum, and David W. Johnson. ISPD peritonitis recommendations: 2016 update on prevention and treatment. Perit Dial Int, in Press www.PDIConnect.com

[22]. Piraino B, Bernardini J, Sorkin M. The influence of peritoneal catheter exit-site infections on peritonitis, tunnel infections, and catheter loss in patients on continuous ambulatory peritoneal dialysis. Am J Kidney Dis 1986; 8:436–40.

[23]. Piraino B, Bernardini J, Sorkin M. Catheter infections as a factor in the transfer of continuous ambulatory peritoneal dialysis patients to hemodialysis. Am J Kidney Dis 1989; 13:365–69.

[24]. Piraino B, Bernardini J, Brown E, et al. ISPD position statement on reducing the risks of peritoneal dialysis–related infections. Perit Dial Int 2011; 31:614-30.

[25]. Poortvliet W, Selten HP, Raasveld MH, et al. CAPD peritonitis after colonoscopy: follow the guidelines. Neth J Med 2010; 68:377-78.

[26]. Predictive Value of a Positive Fecal Occult Blood Test Increases as the Severity of CKD Worsens. Edmund J. Bini. American journal of kidney diseases, volume 48, Issue 4 October 2006, Pages 580-586.

[27]. Sipahi S, Gungor O, Kircelli F, Aydin B, Ulker EA, Tamer A. Peritonitis after colonoscopy in a peritoneal dialysis patient. Turk Nephrol Dial Transpl 2012; 21 (1): 105-106.

[28]. Sullivan A, Edlund C, Nord CE. 2001a. Effect of antimicrobial agents on the ecological balance of human microfl ora. Lancet Infect Dis, 1:101–14.

[29]. Sullivan A, Edlund C, Svenungsson B, et al. 2001b. Effect of perorally administered pivmecillinam on the normal oropharyngeal, intestinal and skin microfl ora. J Chemother, 13:299–308.

[30]. Szeto CC, Chow KM, Wong TY, Leung CB, Li PK. Conservative management of polymicrobial peritonitis complicating peritoneal dialysis—a series of 140 consecutive cases. Am J Med 2002; 113:728–33.

[31]. Terence Yip, Kai Chung Tse, Man Fai Lam, Suk Wai Cheng, Sing Leung Lui, Sydney Tang, Matthew Ng, Tak Mao Chan, Kar Neng Lai, and Wai Kei Lo. Risks and outcomes of peritonitis after flexible colonoscopy in CAPD patients. Perit Dial Int 2007; 27:560–564.

[32]. Tobudic S, Matzneller P, Stoiser B, Wenisch MJ, Zeitlinger M, Vychytil A, et al. Pharmacokinetics of intraperitoneal and intravenous fosfomycin in automated peritoneal dialysis patients without peritonitis. Antimicrobia Agents and Chemotherapy 2012; 3992-95.

[33]. Verger C, Danne O, Vuillemin F. Colonoscopy and continuous ambulatory peritoneal dialysis. Gastrointest Endosc 1987; 33:334–5.

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