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Sir,  Peritonitis remains the major cause of catheter removal in peritoneal dialysis (PD) patients suffering from recurrent attacks, despite appropriate antibiotic therapy. Bacteria such as coagulase-negative staphylococci (CNS) from the exit site of the catheter and contaminated dialysis fluids can grow into microcolonies in biofilms on the surface of the catheter [1,2]. In the preliminary study, we evaluated the outcome of administration of a single-dose intracatheterial vancomycin just after primary response to the treatment of the last peritonitis attack with cefazolin in continuous ambulatory PD patients with recurrent peritonitis.  Among 166 patients who underwent routine PD, six cases with recurrent peritonitis attacks were treated with initial empiric antibiotic therapy consisting of intraperitoneal cefazolin given in each exchange for gram-positive organisms. The characteristics and data regarding peritonitis attacks are given in Table ​Table1.1. Six patients had three to five peritonitis attacks with intervals of ∼1–7 weeks following the completion of a standard 2- or 3-week course of antimicrobial therapy. Four cases out of six had no history of peritonitis, tunnel or exit-site infection before. One patient (fourth case in the table) had exit-site infection. For S. aureus positive culture, the patient received mupirocin pomade and Sodium Fusidate (1 g/day per oral for 7 days). After therapy, exit-site infection completely resolved, and the two cultures taken afterwards were negative. Then, she also had a peritonitis attack with S. aureus on 21 February 2006. The other patient (third case in the table) had a culture-negative peritonitis attack on 1 May 2006. They were treated with cefazolin. The wives of the two male patients (one having diabetic retinopathy) helped during the dialysis exchanges, and the remaining patients were on their own. Six patients and the two assistants (wives) were negative for nasal carriage state. However, prophylactic mupirocin was given to all patients, but the peritonitis attacks recurred. None of the patients had tunnel infection. After complete resolution of peritonitis by cefazolin alone in the last attack, 50 cc peritoneal dialysate was mixed with 2 g vancomycin after drainage of the entire peritoneal fluid and left in the catheter lumen for 8 h. Then, without drainage, a normal dialysis session was carried out. During the mean follow-up of 25 ± 0.8 months, none of the six patients had recurrence peritonitis.    Table 1  Characteristics of peritoneal dialysis patients with recurrent gram-positive peritonitis    Many episodes of peritonitis appear to be unrelated to obvious causes. Bacterial biofilm formation on the dialysis catheter represents a concern for PD patients in terms of our ability to eradicate the infection [2]. However, there is sometimes no clear relationship between biofilms and clinical peritonitis. Indeed, one exception may occur in patients with multiple episodes of peritonitis who were likely to have stable biofilms, positive biofilm cultures and a high incidence of catheter loss. Recently, examination by electron microscopy of catheters of patients who experienced PD peritonitis revealed biofilm formation; however, no biofilm formation was found in PD catheters removed from patients without infection [3]. The risk associated with administering cefazolin continuously (in every PD bag) is that the organisms survive and continue dividing in biofilms. Our current antimicrobial protocols may not permit adequate dosing to penetrate the biofilm and be a reason for recurrent episodes of peritonitis. To evaluate the differences in the antibiotic sensitivity patterns of CNS, minimum inhibitory concentrations (MIC) and minimum biofilm eradication concentration (MBEC) assays were compared in CNS isolates from patients with PD-associated peritonitis in a study [4]. In the PD effluent sample from patients with repeat infection, the rate of first-generation cephalosporin (FGC) or gentamicin or both resistances was higher. MBEC results were higher than those with standard MIC assays. Although no vancomycin resistance was observed with MIC assays, a small number of cases were identified with MBEC assays. There was no resistance when a vancomycin/rifampin 1:1 combination was used. All patients with repeat infections had high degrees of FGC resistance, and infection cycles were terminated when their treatment protocol included vancomycin. In conclusion, we assume that adequate antibiotic levels will be achieved within the catheter-contained biofilm with a single dose of vancomycin of 2 g at the end of the treatment course that will prevent recurrent peritonitis and catheter loss. These results are difficult to compare because patient numbers are small. In our opinion, this observation should be confirmed by other investigators.  Conflict of interest statement. None declared.

A single-dose vancomycin application after standard protocol in peritoneal dialysis patients with recurrent peritonitis