The diagnostic value of Gram stain for initial identification of the etiologic agent of peritonitis in CAPD patients

Objective: To evaluate the effectiveness of the Gram stain in the initial diagnosis of the etiologic agent of peritonitis in continuous ambulatory peritoneal dialysis (CAPD). Design: Retrospective study analyzing the sensitivity (S), specificity (SS), positive predictive value (+PV), and negative predictive value (-PV) of the Gram stain relating to the results of cultures in 149 episodes of peritonitis in CAPD. The data were analyzed in two studies. In the first, only the cases with detection of a single agent by Gram stain were taken (Study 1). In the second, only the cases with two agents in Gram stain were evaluated (Study 2). Setting: Dialysis Unit and Laboratory of Microbiology of a tertiary medical center. Patients: Sixty-three patients on regular CAPD who presented one or more episodes of peritonitis from May 1992 to May 1995. Results: The positivity of Gram stain was 93.2% and the sensitivity was 95.7%. The values of S, SS, +PV, and -PV were respectively: 94.9%, 53.5%, 68.3%, and 90.9% for gram-positive cocci and 83.3%, 98.8%, 95.2%, and 95.6% for gram-negative bacilli. The association of gram-positive cocci plus gram-negative bacilli were predictive of growth of both in 6.8%, growth of gram-positive cocci in 13.7%, and growth of gram-negative bacilli in 72.5%. Conclusions: The Gram stain is a method of great value in the initial diagnosis of the etiologic agent of peritonitis in CAPD, especially for gram-negative bacilli.

Spatial and temporal profiles for anti-inflammatory gene expression in leukocytes during a resolving model of peritonitis

The recent appreciation of the role played by endogenous counterregulatory mechanisms in controlling the outcome of the host inflammatory response requires specific analysis of their spatial and temporal profiles. In this study, we have focused on the glucocorticoid-regulated anti-inflammatory mediator annexin 1. Induction of peritonitis in wild-type mice rapidly (4 h) produced the expected signs of inflammation, including marked activation of resident cells (e.g., mast cells), migration of blood-borne leukocytes, mirrored by blood neutrophilia. These changes subsided after 48-96 h. In annexin 1null mice, the peritonitis response was exaggerated (∼40% at 4 h), with increased granulocyte migration and cytokine production. In blood leukocytes, annexin 1 gene expression was activated at 4, but not 24, h postzymosan, whereas protein levels were increased ai both time points. Locally, endothelial and mast cell annexin 1 gene expression was not detectable in basal conditions, whereas it was switched on during the inflammatory response. The significance of annexin 1 system plasticity in the anti-inflammatory properties of dexamethasone was assessed. Clear induction of annexin 1 gene in response to dexamethasone treatment was evident in the circulating and migrated leukocytes, and in connective tissue mast cells; this was associated with the steroid failure to inhibit leukocyte trafficking, cytokine synthesis, and mast cell degranulation in the annexin 1null mouse. In conclusion, understanding how inflammation is brought under control will help clarify the complex interplay between pro- and anti-inflammatory pathways operating during the host response to injury and infection. Copyright © 2006 by The American Association of Immunologists, Inc.

Risk of peritonitis during peritoneal dialysis in carriers of Staphylococcus aureus and coagulase-negative staphylococci

The presence of Staphylococcus aureus in the nasal cavities and pericatheter skin of peritoneal dialysis patients put them at high risk of developing peritonitis. However, it is not clear whether the presence of coagulase-negative staphylococci (CNS) in the nasal passages and skin of patients is related to subsequent occurrence of peritoneal infection. The aim of the present study was to verify the relationship between endogenous sources of S. aureus and CNS and occurrence of peritonitis in patients undergoing peritoneal dialysis. Thirty-two patients on peritoneal hemodialysis were observed for 18 months. Staphylococcus species present in their nasal passage, pericatheter skin and peritoneal effluent were identified and compared based on drug susceptibility tests and dendrograms, which were drawn to better visualize the similarity among strains from extraperitoneal sites as well as their involvement in the causes of infection. Out of 288 Staphylococcus strains isolated, 155 (53.8%) were detected in the nasal cavity, 122 (42.4%) on the skin, and 11 (3.8%) in the peritoneal effluent of patients who developed peritonitis during the study. The most frequent Staphylococcus species were CNS (78.1%), compared with S. aureus (21.9%). Among CNS, S. epidermidis was predominant (64.4%), followed by S. warneri (15.1%), S. haemolyticus (10.7%), and other species (9.8%). Seven (64%) out of 11 cases of peritonitis analyzed presented similar strains. The same strain was isolated from different sites in two (66%) out of three S. aureus infection cases. In the six cases of S. epidermidis peritonitis, the species that caused infection was also found in the normal flora. From these, two cases (33%) presented highly similar strains and in three cases (50%), it was difficult to group strains as to similarity. Patients colonized with multidrug-resistant S. epidermidis strains were more predisposed to infection. Results demonstrated that an endogenous source of S. epidermidis could cause peritonitis in peritoneal dialysis patients, similarly to what has been observed with S. aureus.

NOVEL PREDICTORS OF PERITONITIS-RELATED OUTCOMES IN THE BRAZPD COHORT

Introduction: Peritonitis remains the main cause of peritoneal dialysis (PD) technique failure worldwide, despite significant reductions in infection rates observed over the past decades. Several studies have described risk factors for peritonitis, technique failure and mortality. However, there are scarce data regarding predictors of complications during and after a peritonitis episode. The aim of our study was to analyze predictors of peritonitis-related outcome in the Brazilian Peritoneal Dialysis study (BRAZPD) cohort.Methods: All adult incident patients recruited in the BRAZPD Study between December 2004 and October 2007, who remained at least 90 days on PD and presented their first peritonitis episode (n = 474 patients) were included in the study. The endpoints analyzed were non-resolution, death due to a peritonitis episode and long-term technique survival after a peritonitis episode.Results: In the multivariable regression, non-resolution was independently associated with older age (odds ratio (OR) 1.02; p < 0.01), collagenosis as the primary renal disease (OR 4.6; p < 0.05) and Pseudomonas spp as etiological agent (OR 2.9; p < 0.05). Patients who were transferred from APD to CAPD during peritonitis therapy presented a higher risk of non-response (OR 2.5; p < 0.05). The only factor associated with death during a peritonitis episode was older age (OR 1.04; p < 0.05). Exposure to vancomycin and male gender were the independent predictors of long-term technique failure (OR 2.2; p < 0.01).Conclusion: Apart from confirming previous observations of the negative impact of older age and Pseudomonas spp peritonitis on outcomes, we observed that collagenosis may negatively impact response to treatment and exposure to vancomycin may possibly reduce long-term technique survival. It is important to emphasize that the association of vancomycin with technique failure does not prove causality. These findings shed light on new factors predicting outcome when peritonitis is diagnosed.

Peritoneal Dialysis-Related Peritonitis due to Coagulase-Negative Staphylococcus: A Review of 115 Cases in a Brazilian Center

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Efficacy of antibiotic therapy for peritoneal dialysis-associated peritonitis: a proportional meta-analysis

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Impact of patient training patterns on peritonitis rates in a large national cohort study

Background. Ideal training methods that could ensure best peritoneal dialysis (PD) outcome have not been defined in previous reports. The aim of the present study was to evaluate the impact of training characteristics on peritonitis rates in a large Brazilian cohort.Methods. Incident patients with valid data on training recruited in the Brazilian Peritoneal Dialysis Multicenter Study (BRAZPD II) from January 2008 to January 2011 were included. Peritonitis was diagnosed according to International Society for Peritoneal Dialysis guidelines; incidence rate of peritonitis (episodes/patient-months) and time to the first peritonitis were used as end points.Results. Two thousand two hundred and forty-three adult patients were included in the analysis: 59 +/- 16 years old, 51.8% female, 64.7% with <= 4 years of education. The median training time was 15 h (IQI 10-20 h). Patients were followed for a median of 11.2 months (range 3-36.5). The overall peritonitis rate was 0.29 per year at risk (1 episode/41 patient-months). The mean number of hours of training per day was 1.8 +/- 2.4. Less than 1 h of training/day was associated with higher incidence rate when compared with the intervals of 1-2 h/day (P = 0.03) and > 2 h/day (P = 0.02). Patients who received a cumulative training of > 15 h had significantly lower incidence of peritonitis compared with < 15 h (0.26 per year at risk versus 0.32 per year at risk, P = 0.01). The presence of a caregiver and the number of people trained were not significantly associated with peritonitis incidence rate. Training in the immediate 10 days after implantation of the catheter was associated with the highest peritonitis rate (0.32 per year), compared with training prior to catheter implantation (0.28 per year) or > 10 days after implantation (0.23 per year). More experienced centers had a lower risk for the first peritonitis (P = 0.003).Conclusions. This is the first study to analyze the association between training characteristics and outcomes in a large cohort of PD patients. Low training time (particularly < 15 h), smaller center size and the timing of training in relation to catheter implantation were associated with a higher incidence of peritonitis. These results support the recommendation of a minimum amount of training hours to reduce peritonitis incidence regardless of the number of hours trained per day.

Evidence-based medicine: an update on treatments for peritoneal dialysis-related peritonitis

Peritonitis continues to be a major complication of peritoneal dialysis (PD), and adequate treatment is crucial for a favorable outcome. There is no consensus regarding the optimal therapeutic regimen, and few prospective controlled studies have been published. The objective of this manuscript is to review the results of PD peritonitis treatment reported in narrative reviews, systematic reviews, and proportional meta-analyses. Two narrative reviews, the only existing systematic review and its update published between 1991 and 2014 were included. In addition, we reported the results of a proportional meta-analysis published by our group. Results from systematic reviews of randomized control trials (RCT) and quasi-RCT were not able to identify any optimal antimicrobial treatment, but glycopeptide regimens were more likely to achieve a complete cure than a first generation cephalosporin. Compared to urokinase, simultaneous catheter removal and replacement resulted in better outcomes. Continuous and intermittent IP antibiotic use had similar outcomes. Intraperitoneal antibiotics were superior to intravenous antibiotics in reducing treatment failure. In the proportional meta-analysis of RCTs and the case series, the resolution rate (86%) of ceftazidime plus glycopeptide as initial treatment was significantly higher than first generation cephalosporin plus aminoglycosides (66%) and glycopeptides plus aminoglycosides (75%). Other comparisons of regimens used for either initial treatment or treatment of gram-positive rods or gram-negative rods did not show statistically significant differences. The superiority of a combination of a glycopeptide and a third generation cephalosporin was also reported by a narrative review study published in 1991, which reported an 88% resolution rate.

Características celulares e bioquímicas do líquido peritoneal de equinos submetidos à obstrução experimental do duodeno, íleo e cólon maior

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Synthesis, Characterization and Pharmacological Evaluation of 1-(2-Chloro-6-Fluorophenyl)-5-Methylindolin-2-One: A New Anti-Inflammatory Compound with Reduced Gastric Ulceration Properties

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Effect of indomethacin on the pregnant rat

O objetivo deste trabalho foi avaliar a performance reprodutiva, estudo morfológico do fígado e característicapost mortem de ratas Wistar prenhes tratadas com indometacina, um inibidor geral de COX. Indometacina foi administrada oralmente, nas doses de 0 (controle), 0,32, 1,68 e 8,40 mg/kg/dia (n=10/grupo), nos dias 3 e 4 de prenhez (dia 0 = primeiro dia de prenhez = esperma positivo). Os animais foram eutanasiados sob anestesia no 11º dia de prenhez, e foram realizadas necropsia e cultura de microorganismos. Os resultados mostraram que as doses de 0,32 e 1,68 mg/kg de peso corpóreo (dose terapêutica para humanos) de indometacina não causaram efeitos embriotóxicos ou letais. A maior dose (8,40 mg/kg) de indometacina prejudicou o processo de implantação e, portanto, interferiu no desenvolvimento fetal. A peritonite foi detectada na necropsia e nos estudos bacteriológicos dos animais tratados com 8,4 mg/kg e considerada a causa-morte destes animais. Portanto, este estudo analisou um agente farmacológico na prenhez de roedores e evidenciou que a indometacina apresentou efeitos embriotóxicos e letais na maior dose empregada, mas foi segura na dose terapêutica usada pelo homem.

Parasitic infection of the appendix as a cause of acute appendicitis

The association between parasitic infection of the appendix and acute appendicitis has been widely investigated. The aim of this retrospective study was to evaluate the prevalence of parasitic infection of the appendix in a tropical area at southeast Brazil and to assess its possible relation to acute appendicitis in surgically removed appendices. of the 1,600 appendectomies performed during a 10-year period, 24 (1.5%) were found to have helminths within the appendix. Enterobius vermicularis was observed in 23 of the 24 specimens (95.8%), and Taenia sp. was detected in only one case. Sixteen patients (66.7%) were less than 10 years old; 15 patients were male and nine female; 21 patients were white, and three were nonwhites. Pathologic analysis disclosed acute neutrophilic inflammation in the appendix wall in 12 of the 24 specimens and lymphoid hyperplasia in 10 of the 24 appendices. Gangrenous appendicitis was diagnosed in three cases, and peritonitis was found in 11 of the 24 infected appendices. The results of the present study indicate that E. vermicularis is the commonest worm found in the appendix and that its presence can cause pathologic changes ranging from lymphoid hyperplasia to acute phlegmonous inflammation with life-threatening complications like gangrene and peritonitis.

Peritonite pós-cobertura em cadela Boxer apresentando síndrome de ovário remanescente (SOR)

The ovarian remnant syndrome (ORS) is defined as the persistence of ovarian activity in surgically spayed females, in which part or the entire ovary remains after the surgical procedure. ORS is characterized as a neo-vascular formation that promotes the organ's functions again, and may occur in cats and dogs. This condition causes the return of all undesirable signs of estrus, like male attraction, vaginal secretion (proestral bleeding), anxiety, pseudocyesis, among other symptoms. The recommended treatment is the surgical removal of the remaining ovary tissue. However, this procedure should be performed at the estrogenic stage of the cycle, when the remaining ovary tissue is enlarged due to the presence of follicles, which facilitates its location. Apparently there are no papers on the consequences of an undesirable breeding. Thus, the objective of this article was to report a case of peritonitis in a bitch with ORS after natural breeding, referred to the Hospital Veterinario da Faculdade de Medicina Veterinaria e Zootecnia da UNESP, campus Botucatu, São Paulo, Brazil.

Identification and antimicrobial susceptibility of Staphylococcus from home-treated peritoneal dialysis patients

Staphylococcus aureus is the main agent of infections during peritoneal dialysis (PD). The presence of S. aureus in the nasal cavity has been extensively studied and suggested as a risk factor of dialysis-related infections, whereas coagulase-negative Staphylococcus (CNS) species are frequently considered part of the normal human microbiota. The aim of this study was to identify Staphylococcus in the nasal cavity, pericatheter skin and peritoneal effluent from PD patients, as well as to evaluate the antimicrobial activity evolution in vitro. Thirty-two chronic PD patients were observed during 12 months and had nasal and pericatheter skin samples collected for culture. When peritonitis was detected, samples were also collected from the peritoneal effluent for culture. The activity of several antimicrobial drugs (penicillin G, oxacillin, cephalothin, ofloxacin, netilmicin and vancomycin) against different Staphylococcus species was measured by using the agar drug diffusion assay (Kirby-Bauer method). Staphylococcus was separated into S. aureus, S. epidermidis and other CNS species in order to determine the in vitro resistance level. S. epidermidis resistance to oxacillin progressively increased during the study period (p < 0.05). Resistance to ofloxacin was inexpressive, whereas resistance to netilmicin and vancomycin was not detected. of the oxacillin-resistant species (n = 74), 83% were S. epidermidis, 13% other CNS and 4% S. aureus (p < 0.05). Regarding multidrug resistant strains (n = 45), 82% were S. epidermidis, 13% other CNS, and 5% S. aureus (p < 0.05). This study shows the relevance of resistance to oxacillin and CNS multi-drug resistance, particularly concerning S. epidermidis, in PD patients.

Annexin 1 localisation in tissue eosinophils as detected by electron microscopy

BACKGROUND: Human and rodent leukocytes express high levels of the glucocorticoid-inducible protein annexin 1 ( ANXA1) ( previously referred to as lipocortin 1). Neutrophils and monocytes have abundant ANXA1 levels.Aim: We have investigated, for the first time, ANXA1 ultrastructural expression in rat eosinophils and compared it with that of extravasated neutrophils. The effect of inflammation ( carrageenin peritonitis) was also monitored.Methods: Electron microscopy was used to define the sub-cellular localisation of ANXA1 in rat eosinophils and neutrophils extravasated in the mesenteric tissue. A pair of antibodies raised against the ANXA1 N-terminus (i.e. able to recognise intact ANXA1, termed LCPS1) or the whole protein ( termed LCS3) was used to perform the ultrastructural analysis.Results: the majority of ANXA1 was localised in the eosinophil cytosol (similar to 60%) and nucleus (30-40%), whereas a small percentage was found on the plasma membrane (< 10%). Within the cytosol, the protein was equally distributed in the matrix and in the granules, including those containing the typical crystalloid. The two anti-ANXA1 antibodies gave similar results, with the exception that LCPS1 gave a lower degree of immunoreactivity in the plasma membrane. Inflammation (i.e. carrageenin injection) produced a modest increase in eosinophil-associated ANXA1 reactivity ( significant only in the cytoplasm compartment). Extravasated neutrophils, used for comparative purposes, displayed a much higher degree of immunoreactivity for the protein.Conclusion: We describe for the first time ANXA1 distribution in rat eosinophil by ultrastructural analysis, and report a different protein mobilisation from extravasated neutrophils, at least in this acute model of peritonitis.