Intermittent versus continuous intraperitoneal glycopeptide/ceftazidime treatment in children with peritoneal dialysis-associated peritonitis

Intermittent intraperitoneal antibiotic administration appears as a practic al and economical therapeutic concept in continuous peritoneal dialysis (CP D)-related peritonitis, but the equivalence of this principle with standard continuous treatment awaits confirmation by prospective, randomized clinic al trials. This study evaluates the efficacy, safety, and clinical acceptan ce of an initial combination treatment including a glycopeptide (vancomycin or teicoplanin) and ceftazidime, each applied either intermittently or con tinuously, in a cohort of pediatric patients with CPD-related peritonitis. Patients randomized for continuous treatment received an intraperitoneal lo ading dose of glycopeptide and ceftazidime followed by maintenance doses ad ded to each dialysate bag. In the intermittent treatment groups, the glycop eptide was administered in two loading doses 7 d apart, and ceftazidime dur ing one dialysis cycle per day. Initial treatment response was evaluated af ter 60 h by the change in a Disease Severity Score and by the clinical deci sion to continue initial treatment. Of 152 patients observed for a total of 234 patient years, 90 patients developed 195 episodes of peritonitis (incl uding 27 relapses; within I wk after end of treatment). Dialysate cultures were positive in 83% of the episodes. In Gram-positive peritonitis (79% of culture-positive cases), the primary success (overall 95%) and relapse rate s (21%) were not different between continuous and intermittent, or between vancomycin and teicoplanin treatment. Oversensitivity reactions occurred in three and ototoxicity in one vancomycin-treated patient, whereas no such s ide effects were observed with teicoplanin. Residual renal function decline d during peritonitis episodes regardless of treatment modality. In Gram-neg ative peritonitis (18% of cases), intermittent ceftazidime treatment was le ss successful than continuous treatment according to clinical judgment (3 o f II versus IO of 14, P < 0.05), but not when rated by Disease Severity Sco re (8 of 11 versus 12 of 14). In conclusion, intermittent and continuous in traperitoneal treatment of CPD-related peritonitis with glycopeptides and c eftazidime is equally efficacious and safe when measured by objective clini cal criteria. This contrasts with a strong tendency of clinicians to move f rom intermittent to continuous treatment in severe peritonitis.