How to avoid Peritonitis?

[kristina]

I have two questions about Peritonitis.

1 What are the ways of getting Peritonitis in home-Dialysis.
   Does it only come from unclean hands or are there other things we have to watch out for (I have read
   it (only) comes from touching the connection between the bag of fluid and the catheter) ?

2 Again, this is about home-Dialysis. As I understand it, there are several different types of home-Dialysis,
   is one better than another to avoid getting Peritonitis?

Thanks from Kristina.

[*kana*]

You get peritonitis from not washing your hands, touching areas that are sterile, not wearing your mask, leaving a fan on or window open.  Having animals in the room when you do an exchange.  Poor exit site care(exit site infection).  Defect in the tubing or exchange set.  Solution that has expired or is cloudy due to a small leak.  Warming PD solution in a sink of water. You can even get it from the bowels from constipation. 
There are a lot more ways to get it other than touching the connector.   I just recently had it for the first time in 2 years and I have no idea what I did. 

If you do manuals all day you are at increase risk because you are opening your cath 5-6 times a day.  If you run on the machine all night you only have to make 1 sterile connection in the same time frame. 

[peleroja]

Couldn't have said it better myself!

[monrein]

Another point perhaps is that peritonitis is a risk for peritoneal dialysis patients rather than hemo patients. 

[RightSide]

Another point perhaps is that peritonitis is a risk for peritoneal dialysis patients rather than hemo patients.

Yeah, for hemo patients with catheters, the big risk is bacterial endocarditis (which is worse than peritonitis, IMO).

[monrein]

Absolutely RS, I'm certainly not suggesting that HD is without risks, merely pointing out that peritonitis isn't one of them.   I will also add that I'm a big fan of The AV fistula despite the issue of needles (and yes fistulas too are no piece of cake) precisely because tunneled catheters may seem convenient but can also be very dangerous.

[KICKSTART]

Kristina do you mind me asking why you are asking about Peritonitis ? Are you considering starting PD? Does that mean you have finally found a neph? . All i can say is poor hygiene is the most likely cause , keep everything as sterile as possible. Im proud to say that in 6 years of PD i never got peritonitis or any other infection and i did manuals for 5 years and 6 months ! Oh and we dont wear masks over here for exchanges either.

[Riki]

Bad PD nurses can cause peritonitis too..

I wass getting my tubing changed, which by policy here is done every 6 months.  In case you're wondering, it's just the external tubing, with the end that connects to the bags, and older tubings also had a roller clamp.  The tubing that she used was faulty, and came apart just after she put it on.  She just reconnected it.  Policy said that she should have started over, cleaning the end and putting on a new tubing.  It loosened once after that, and me not knowing any better, just closed it up again.  Then, one night it fell off completely.  I battled bouts of peritonitis for 6 months after that, finally getting a fungal infection, caused by all the bacterial infections and was forced to go to HD

[kristina]

Thanks for all your kind replies.

kana, this sounds like really great advice. Can you please elaborate on one particular point.
Not a nice subject but I have never heard this before and would like to understand how it happens,
I refer to your point that Perintonitis can be caused by constipation. Could you explain how this happens?

peleroja, from someone who has a great deal of experience, your reassuring comment is important to this discussion,
thanks for the input.

monrein, thanks, I have taken all the points, thanks again.

RightSide, gosh! What is bacterial endocarditis, how does it affect Dialysis patients
and what makes it worse than Perindonitis? Thanks again.

KICKSTART, no, I am not on Dialysis yet, I am merely preparing and acquiring all the information
on the issues which surround all the various methods.
 
I have not yet resolved the issue of a nephrologist and/or rheumatologist,
specialists, who appreciate both my 10-12% GFR and effects of my Lupus/MCTD-involvement.

It sounds as though you have been very successful in avoiding infection.
Would you mind my asking. Did you use any special cleansing agent?

Riki, I am so sorry to hear of your experience. It sounds dreadful.
I gather from this we have to keep a sharp eye on anyone
who does anything with the equipment
and we have to be absolutely consequent
about rules and regulations in order to survive.
Thanks for the tip.

Thank you all very much for your kind replies, Kristina.

[calypso]

If/when you do go on PD you will be trained how to avoid infection. Just follow the proper procedure strictly and you will be fine. Don't take shortcuts, don't get lazy, don't get complacent. Keep everything clean and use sterile technique, and you will be fine....for a while.

What do I mean by for a while? Dialysis is not a long term solution. No dialysis is. If you're young it might not last you your whole life. This is why many have gone through PD, transplant and hemo throughout their lives. Not necessarily in that order. No modality will last for more than say about 20 years. Probably more like 10 on average. Be prepared to one day have to switch from whatever modality you're now doing to another for a myriad of reasons. Even if you never get an infection, your peritoneal membrane may no longer function adequately.

[Zach]

No modality will last for more than say about 20 years. Probably more like 10 on average.

I beg to differ when it comes to hemodialysis.

[billybags]

Well I don't know what to say, I agree with what kana says to a point. We have been doing APD  for a year now with no problems till Friday tea-time. Manual tea-time bag was cloudy, Shit. Visit to hospital straight away for antibiotics, Hubby will have to go every day for about a week. luckily he is not feeling unwell. . We are really spot on with cleanliness after getting an e-coli bug in Greece a year ago. We do not cut corners because peritonitis is a killer. My question is where did we pick up the bug. When we see our own nurse to-morrow she will say it is down to hygiene. No one seems to know the answer. Apparently there has been a spat of infections being reported at our clinic just lately.  Another question I will be asking her is " how safe are the dialysis fluid bags.do people ever question that. It seems funny how you get a spat of infections in an area when you are doing it at home.

[KICKSTART]

BB hope Al is doing ok ?
Kristina ..dont worry about using the right fluid/sterile items as everything is supplied in the UK. You get a 3-5 day training course before you start doing home exchanges as well. PD would probably suit you if you are ok with being in control , it would also keep you away from a hospital enviroment and those horrid lights. However with your other complications it might not be considered the best option for you ? The one thing you will need though is plenty of room for storage. I used a spare bedroom both for my supplies and to do my exchanges in. Only i went in there and only used it for my exchanges, so keeping it reasonably sterile i suppose?

[calypso]

No modality will last for more than say about 20 years. Probably more like 10 on average.

I beg to differ when it comes to hemodialysis.

Point well taken. What I said applies to PD more than hemo. Now watch the PDers come in that have been on for 30 yrs lol.

[Riki]

No modality will last for more than say about 20 years. Probably more like 10 on average.

I beg to differ when it comes to hemodialysis.

Hemo will work forever.. the problem will be in running out of access sites..

A friend of mine, who is probably about 30 now, has been on hemo his entire life.  PD didn't work for him, and even though he's had several transplants, they never "took" for him.  He'd had several fistulas by the time he was 10,when I met him, and was using a line at that point.  He told me then that they had run out of place to put them.  I haven't seen him in a while, but my guess is that he's still using lines, because he has no other choice.

[Jie]

No modality will last for more than say about 20 years. Probably more like 10 on average.

I beg to differ when it comes to hemodialysis.

Point well taken. What I said applies to PD more than hemo. Now watch the PDers come in that have been on for 30 yrs lol.

One patient of my clinic has done PD for close to 18 years. This statement may not be true for some extreme PD patients too.

My "bible" says Peritonitis occurs once for average about 24 months for manual exchange patients and 48 months for cycler patients.

[KICKSTART]

I did well then all those years and nothing .. so you cant trust your 'bible ! '

[kristina]

Thanks calypso for your honest reply. A lot to take in here, thanks again for the bigger picture.

Thanks Zach, could it be you are the exception, and the average is about ten years?

Sorry about this bb, it is quite interesting what you say about a spat of infection,
I have several times come across in the news reports about localized infection
which expert opinion says was just a coincidence.
One never knows if this has a political swing to it or some other swing
because to us it looks like there is a local spread of infection.
I suppose there is no definitive answer to this infection business.
It would appear that infections can come from many different directions
and all we can do as individuals is to pre-empt possible sources of infection
and try to prepare ourselves, and use strategies, to avoid as best we can getting contaminated.

KK, sounds like good advice if you have a spare room.
So whether it is hooked-up through the night or one has it several times through the day,
in both cases it does sound reasonable to dedicate a room for this purpose only,
where no one else goes in, but for some people this may require a lot of forward planning.
It is becoming obvious that the only form of Dialysis for me would be home-Dialysis
and any problems which that causes, I would have to find a way of dealing with.
 
Riki, thanks for the information, this sounds like a tough life, I hope your friend continues the best he can.

Jie, thanks for your reply. The trouble with statistics is, we never know whether we are average or not.
I suppose the objective is to beat the average. That gives the statistics a headache...

Thanks again for all your kind replies, they did raise many diverse issues
and they have given me a lot to think about and have been very helpful, Kristina.

[RightSide]

You may want to ask what the average time between bouts of Peritonitis is for PD patients in your area.

I asked at my hospital, and they told me that in their experience, a PD patient has an average of one attack of Peritonitis every two years.  I said "Thank you very much and goodbye"--given all my allergies to various antibiotics, that put the kibosh on the whole thing.

The bane of catheter-based HD is bacterial endocarditis--an infection of the heart caused by the catheter spreading infection right into the superior vena cava.   Even with treatment, it has a 25% mortality rate:

http://en.wikipedia.org/wiki/Infective_endocarditis

That's why I wanted that HD catheter out of me as soon as possible.  It was a Sword of Damocles--not hanging over my head but stuck directly into my heart!

[Lillupie]

Are you serious? You dont wear masks? I cant belive that! What if you are sick? Do you still not wear a mask? I am shocked! WOW.

Lisa

Kristina do you mind me asking why you are asking about Peritonitis ? Are you considering starting PD? Does that mean you have finally found a neph? . All i can say is poor hygiene is the most likely cause , keep everything as sterile as possible. Im proud to say that in 6 years of PD i never got peritonitis or any other infection and i did manuals for 5 years and 6 months ! Oh and we dont wear masks over here for exchanges either.

[kristina]

Thanks Rightside & Lisa,

Rightside: This raises some issues for me as I am totally allergic to Penicillin & should never be given this,
& I also have allergic reactions to many of the other antibiotics.

If I go by the statistics if and when I am on home-dialysis, I am likely to get an infection,
whether it be once a year or once every two years.
 
In my position that’s not something I’d like to have hanging over me.
Therefore I will make the subject of infection the most important on my list
and I shall try to find out every possible way to avoid it.

Thanks for writing about this because I know it must be an unpleasant subject to write upon.

Lisa, with regard to masks I think they are a good idea because even if one sneezes or coughs,
possibly even in a nervous slight way whilst doing the exchange
there could be something falling on the connections,
so a mask would avoid any such possibility. Prevention is better than cure...

Thanks again, Kristina.

[KICKSTART]

Are you serious? You dont wear masks? I cant belive that! What if you are sick? Do you still not wear a mask? I am shocked! WOW.

Lisa

No we dont wear masks for PD and like i said i DIDNT get any sort of infection in 6+ years , so surely that tells you something ! Your hands would be of more concern !

[KICKSTART]

Kristina , when the time comes one way or another you are going to open to infection. I didnt have a single infection when i did PD , so dont presume that you might , but if you are going onto a unit full of patients there is a good chance you are going to pick up something even if its just a cold !

[billybags]

My husband has just gotten over peritonitis, this is the first infection in just over a year on APD. We do not know how it happened, he follows really strict hygiene rules because we have been there before. We do not know how it happened. I don't think a mask would have helped.

[kristina]

Thanks for your kind replies.

KS, thanks, it is heartening to know it is possible to beat the statistics.
 
May I ask you if you think there is anything special that you do which may be a main reason
why you avoided peritonitis?
Did you find, washing your hand thoroughly with soap and water is good enough,
or, is it absolutely vital to use alcohol-based hand-cleanser or the equivalent?
And, is it important to also wear special disposable gloves and if so, what type?

bb,  I am so sorry for your experience.
 
Would you mind if I asked what the first indication is
that makes you think it is peritonitis?

Thanks again from Kristina.