腹膜透析感染途徑及細菌的特性與分類

The Infection Routes and Treatment Specificity and Classifications of Pathogens in Peritoneal Dialysis Patients

腹膜炎及腹膜透析導管相關感染，是腹膜透析治療最主要的併發症。本文主要闡述腹膜透析各種可能感染途徑之相關理論及實務，以及分析細菌或其他致病原的特性與如何治療。目前對於腹膜炎及其他感染症的治療，比以前更務實且標準化，臨床上根據細菌之分類以及對於治療後之反應，而有種種不同因應之道。Staphylococcus epidermidis仍是最常見的致病菌，反覆感染成為重要課題，且和細菌生物膜（biofilms）可能有關連。為了防範更嚴重的S. aureus感染，鼻帶菌者的篩檢及導管出口處之局部預防性治療，均有不錯之成果。而S. aureus感染，一旦起始治療之反應不如預期，便必須考慮加上口服rifampin。對於ORSA（oxacillin-resistant S. aureus）或對於ampicillin 有抗藥性的enterococcus感染（ampicillin- resistant enterococcus; ARE），必須使用vancomycin。而感染enterococcus必須注意是否有腹內其他病灶。腹膜炎若長出革蘭氏陰性單一菌種（如E. coli, klebsiella或proteus），應給予ceftazidime，但若病人殘餘腎功能已經很差，也可使用aminoglycoside而不必考慮腎功能保護。多重細菌感染或厭氧菌感染之病人則必須慎重考慮外科療法，並給予適當之抗生素。Pseudomonas腹膜炎是嚴重的併發症，除了給予ceftazidime外，至少要加上第二種有效藥物併用，才有機會治癒。非細菌性的感染，如黴菌及結核菌感染往往有診斷上的延遲，必須有高度的警覺心，以求早期診斷早期處理。

Peritonitis and catheter-related infections are the most common complications of peritoneal dialysis (PD) treatment. The aim of this review article was to analyze the infection routes in PD patients and the treatment specificity of pathogens. Present treatment recommendations of peritonitis and catheter-related infection have become more accurate and standardized. Staphylococcus epidermidis has been the most frequent pathogen. Relapsing peritonitis is an important issue and it probably has some links with biofilm-related infections. The regular use of intranasal or exit-site mupirocin decreases the risk of S. aureus infection. If the clinical response is less effective than expected, rifampin 600mg/day P.O. can be added to the I.P. antibiotics for S. aureus infection. Vancomycin should be used in infections of ORSA (oxacillin-resistant S.aureus) or ampicillin-resistant enterococcus (ARE). Besides, intra-abdominal pathology must be considered in enterococcus infection. For infection of a single gram-negative organism, such as Escherichia coli, klebsiella, or proteus, utilization of ceftazidime or aminoglycoside must be guided by in vitro sensitivity testing and by patient’s residual renal function. For a infection of multiple gram-negative organisms or anaerobic organisms, it is crucial to consider the possibility of intra-abdominal pathology, necessitating surgical exploration. Peritonitis due to Pseudomonas species is a serious complication in CAPD patients. In treating Pseudomonas, it is necessary to combine aminoglycoside or ciprofloxacin with ceftazidime to have a chance to control this infection. Fungal organisms and tuberculous peritonitis are relatively rare complications of PD. Clinically, these should be considered in patients with peritonitis who are not responding to appropriate antibiotic treatment.