Cefepime versus vancomycin plus netilmicin therapy for continuous ambulatory peritoneal dialysis-associated peritonitis

Cefepime is a cephalosporin with a broad spectrum of activity against most gram-positive and gram-negative pathogens. In this study, we attempted to c ompare the safety and efficacy of cefepime monotherapy against the potentia lly more toxic combination of vancomycin and netilmicin in the treatment of continuous ambulatory peritoneal dialysis (CAPD)-associated bacterial peri tonitis. Eighty-one consecutive CAPD patients who presented with peritoniti s from January 1, 1998, to June 30, 2000, were recruited for study. Patient s were randomized to be administered either intraperitoneal (IP) cefepime, 1 g once daily (group A), or intravenous vancomycin and netilmicin at conve ntional doses (group B) for 10 days. Bacterial growth was obtained in 52 ep isodes (66%), and pathogens identified included gram-positive organisms (30 episodes; 38%), gram-negative organisms (14 episodes; 18%), mixed organism s (2 episodes; 2.5%), and fungus (6 episodes; 8%). Eight patients were excl uded after randomization for various reasons (6 patients, fungal peritoniti s; 2 patients, wrong diagnoses). Because of the relatively low peritonitis rate after the use of a disconnect system, the sample size of this study wa s relatively small, giving a power of 0.45. There were no significant diffe rences in primary response rates and cure rates (no relapse > 28 days after completion of antibiotic therapy) between both groups of patients (group A versus group B, 82% [32 of 39 patients] versus 85% [29 of 34 patients] and 72% [28 of 39 patients] versus 76% [26 of 34 patients], respectively; P = not significant). No significant side effect was encountered in either grou p. Total peritonitisrelated hospitalizations were 84 patient-days (1,7, 8, 11,20, and 37 patient-days) and 115 patient-days (3, 6, 9, 14, 21, 21, and 41 patient-days), whereas total costs per patient cure were estimated to be US $1,039 and US $1,371 in groups A and B, respectively. We conclude that once-daily l-g IP cefepime monotherapy is a simple, safe, and cost-effectiv e alternative to vancomycin and netilmicin therapy in the treatment of CAPD -associated bacterial peritonitis. (C) 2001 by the National Kidney Foundati on, Inc.