Peritoneal Dialysis International, Vol. 13, pp 50-54 0896- 8608/93 $300 + 00
Printed in Canada All rights reserved Copyright © 1993 International Society for Peritoneal Dialysis
POOR RESPONSE TO ORAL CIPROFLOXACIN
IN THE TREATMENT OF PERITONITIS IN PA TIENTS ON INTERMITTENT
PERITONEAL DIAL YSIS
Nancy M. Waite, Michael D. Johnson, Nancy R. Webster, and Ignatius W. Fong
St. Michael's Hospital and University of Toronto, Toronto, Ontario, Canada
.Objectives: To assess the clinical value of oral ciprofloxacin in
the treatment of peritonitis in an intermittent peritoneal dialysis
(IPD) population.
.Design: Open nonrandomized prospective study.
.Setting: Nephrology Peritoneal Dialysis Unit in a tertiary care,
teaching hospital of the University of Toronto. .Patients: Subjects
were participants of the IPD pro gram with an acute episode of
peritonitis defined as at least two of the following: 1. signs and
symptoms of peritonitis, 2. cloudy peritoneal fluid with a white
blood cell count of >100!IJl, 3. demonstration of bacteria in
peritoneal effluent by gram stain or culture. Ten patients were
enrolled in the study, but two were withdrawn because of side
effects and growth of a resistant bacteria.
.Interventions: Ciprofloxacin 750 mg po q12h for 2 doses, then
750 mg daily or 500 mg twice daily for 10 days.
.Main Outcome Measures: Efficacy was determined by clinical
and microbiological assessment. Cure was defined as resolution of
signs and symptoms with eradication of the causative organism.
Peritoneal effluent and blood samples were analyzed for
ciprofloxacin concentration.
.Results: Ciprofloxacin was effective in treating only one of ten
episodes of peritonitis. Seven patients were defined as
microbiological failures (persistence or relapse of organisms). The
signs and symptoms of peritonitis improved in 2 patients, but the
remaining 5 failed clinically. Only Gram-positive organisms were
cultured.
.Conclusions: Ciprofloxacin cannot be recommended for the
treatment of intermittent peritoneal dialysisrelated Gram-positive
bacterial peritonitis.
KEY WORDS: Ciprofloxacin; peritonitis; peritoneal dialysis;
fluoroquinolones.
p
eritonitis continues to be an important complica tion of
intermittent (IPD) and continuous ambu
latory peritoneal dialysis (CAPD) (1). Tradit ional treatment
of peritonitis with intraperitoneal aminoglycosides,
vancomycin, or cephalosporins
Correspondence to: I.W. Fong, St. Michael's Hospital,
30 Bond St., Toronto, Ontario, Canada M5B 1 W8.
Received 27 February 1992; accepted 2 July 1992.
often requires hospitalization, incurs an increased patient
risk of drug-related toxicity, and has significant treatment-
associated costs. In addition, persistent infectious episodes
often limit the provision of adequate dialysis and can
ultimately result in the transfer of the patient to
hemodialysis.
The fluoroquinolones have shown promise in the
treatment of this difficult problem. They have the
advantages of oral administration permitting earlier hospital
discharge, a small incidence of side effects, and a broad
spectrum of antimicrobial activity against Gram-negative
bacilli, staphylococci (including methicillin-resistant
strains), and to some extent streptococci. Therapeutic
concentrations are attain able, and effective treatment of
CAPD-associated perit onitis has been demonstrated with
ciprofloxacin and ofloxacin (2-6). However, concern has
been expressed regarding the increasing incidence of
staphylococci resistance to ciprofloxacin (7,8) and the
decreased activity of ciprofloxacin in different bio logi cal
mediums such as the peritoneal dialysis fluid (9,10).
Further, no studies have examined the effectiveness of the
fluoroquinolones in an IPD population.
Results from these studies encouraged us to initi ate an
open trial of ciprofloxacin in the treatment of peritonitis in
an IPD population and to further examine the in vitra
activity of ciprofloxacin in the peritoneal fluid in this group
of patients.
METHODS
Subjects were participants in the IPD program and were
experiencing an acute episode of peritonitis defined as at
least two of the following: 1. signs and symptoms
ofperitonitis; 2. cloudy peritoneal effluent with a white
blood cell count of >100/μL, 3. demon stration of
bacteria in peritoneal effluent by Gram stain and culture.
Patients were excluded if they had persistent nausea and
vomiting, evidence of sepsis (i.e., systolic blood pressure of
<90 mm Hg or fever >39°C), previous participation in the
study, or a quinolone allergy .
Upon entry, the peritoneal effluent was sent for culture
and sens itivity, white cell count, and anaerobic culture.
Two blood cultures were taken. The peritoneal