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    "textoCompleto" => "<p class="elsevierStylePara">According to recent treatment guidelines for peritonitis in patients undergoing peritoneal dialysis &#40;PD&#41;&#44; peritonitis accounts for approximately 18&#37; of the infections associated with mortality in PD patients&#46; Although less than 4&#37; of peritonitis cases result in death&#44; peritonitis is a factor contributing to exitus in 16&#37; of all patients who die while on PD&#46; Severe and long-lasting episodes of peritonitis may lead to peritoneal membrane failure&#46; These episodes are one of the most common reasons for PD failure and one of the most common causes of discontinuing PD and starting haemodialysis&#46; With these reasons in mind&#44; prevention and treatment of PD-related peritonitis is crucial to the overall care of these patients&#46; Episodes must be resolved as effectively as possible in order to preserve peritoneal membrane function and by extension the PD technique as well&#46; Treatment should be initiated as quickly as possible&#44; and must include gram-positive coverage with vancomycin or cephalosporins and gram-negative coverage with third-generation cephalosporins or aminoglycosides&#46;<span class="elsevierStyleSup">1</span></p><p class="elsevierStylePara">Delivering antibiotics by the intraperitoneal &#40;IP&#41; route is more effective for treating PD-related peritonitis than administration by the intravenous &#40;IV&#41; route&#46;</p><p class="elsevierStylePara">At present&#44; the constant emergence of multidrug-resistant bacteria also affects this type of infection and results in new challenges in the treatment of this disease&#46; Daptomycin may be a valid option for the treatment of infections caused by gram-positive bacteria with resistance to methicillin and intermediate sensitivity to vancomycin&#46;</p><p class="elsevierStylePara">Daptomycin&#44; discovered in the early 1980s&#44; is a 13 amino acid lipopeptide antibiotic&#46; Clinical development of the drug was halted at that time due to its lack of efficacy against endocarditis and its high toxicity&#44; particularly to skeletal muscle&#46; In recent years&#44; the constant appearance of multidrug-resistant pathogens has led to renewed interest in this antibiotic&#44; which was approved by the Food and Drug Administration &#40;FDA&#41; in 2003 for treating gram-positive infections&#46;<span class="elsevierStyleSup">2</span> Its 3 phase mechanism of action differentiates it from other antibiotics and&#44; so far&#44; has prevented bacteria from developing resistances&#46;</p><p class="elsevierStylePara">In Spain&#44; the drug has been officially approved for the treatment of complicated skin and soft tissue infections&#44; right-sided endocarditis caused by <span class="elsevierStyleItalic">Staphylococcus aureus</span>&#44; <span class="elsevierStyleItalic">Staphylococcus aureus</span> bacteraemia associated with right-sided endocarditis&#44; and skin and soft tissue infections by the IV route only&#46;</p><p class="elsevierStylePara">Dosage for the approved indications is 4-6mg&#47;kg IV every 24 hours&#46; In the presence of decreased renal function or creatinine clearance &#60;30ml&#47;min&#44; it must be administered every 48 hours&#46;</p><p class="elsevierStylePara">It only acts on gram-positive bacteria and it is not physically or chemically compatible with glucose&#44; so it has to be diluted in saline in order to be administered by the IV route&#46; Its activity is pH-independent&#46; All of these properties&#44; which will be discussed later&#44; are very important in the context of PD-related peritonitis&#46;</p><p class="elsevierStylePara">Very little evidence is currently available regarding use of daptomycin in the treatment of PD-related peritonitis&#46;<span class="elsevierStyleSup">2&#44;3</span> Burklein D&#46; et al<span class="elsevierStyleSup">4</span> described the case of a patient with an intestinal perforation that led to peritonitis and sepsis that caused renal failure&#46; Microbial testing revealed a strain of <span class="elsevierStyleItalic">Enterococcus faecium</span> that is only sensitive to vancomycin&#46; Given the patient&#8217;s renal function&#44; IV daptomycin was administered in doses of 4mg&#47;kg every 48 hours during the first 6 days&#46; After recovering renal function&#44; daptomycin was administered in the same quantities every 24 hours until completion of 14 days of treatment&#46; IP and plasma daptomycin levels were measured&#44; showing a maximum antibiotic concentration of 17mg&#47;l and a minimum concentration of 5mg&#47;l&#44; which was sufficient considering that 4 mg&#47;l is the minimum inhibitory concentration &#40;MIC&#41; of daptomycin against most enterococci&#46;<span class="elsevierStyleSup">2&#44;3</span> In this case&#44; peritonitis resolved successfully&#46;</p><p class="elsevierStylePara">Dmyto K el al<span class="elsevierStyleSup">5</span> published a case in which a patient on PD with recurrent peritonitis and suspected <span class="elsevierStyleItalic">Staphylococcus capitis</span> biofilm was administered IV daptomycin at doses of 5mg&#47;kg every 48 hours&#46; Mean concentrations of daptomycin in PD solution rapidly exceeded 1mg&#47;l&#59; again&#44; these levels were higher than the MIC of daptomycin against most staphylococci&#46;<span class="elsevierStyleSup">2&#44;3</span></p><p class="elsevierStylePara">Huen SC et al<span class="elsevierStyleSup">6</span> published the first cases of successful treatment with IP daptomycin in 2 patients with vancomycin-resistant <span class="elsevierStyleItalic">Enterococcus faecium </span>peritonitis<span class="elsevierStyleItalic">&#46;</span> Doses of 200mg of daptomycin were administered diluted in PD solution &#40;2l&#41; followed by 20mg of daptomycin per litre of replacement fluid<span class="elsevierStyleBold"> </span>&#40;every 4 hours&#41; during 14 days&#46; The purpose was to raise IP levels to more than 5 times higher than the MIC of daptomycin against enterococci &#40;4mg&#47;l&#41;&#46; Once again&#44; infection was resolved in these cases without adverse effects or complications arising from IP administration of the drug&#46; These authors argue that its physical and chemical incompatibility with glucose appears not to compromise either its clinical efficacy or its antimicrobial potency&#44; at least at low levels of glucose such as those in the PD solution in which this drug was diluted before administration&#46;</p><p class="elsevierStylePara">Another case that deserves mention was published by Bahte SK et al<span class="elsevierStyleSup">7</span> regarding a patient who had been on kidney replacement therapy with PD for 7 years and whose central catheter for total parenteral nutrition had to be removed on multiple occasions due to <span class="elsevierStyleItalic">Staphylococcus aureus</span> infections&#46; The patient suffered an episode of sepsis related to the central catheter and was treated with IV daptomycin&#46; After 5 weeks he was admitted with peritonitis judged to be a relapse of the prior septic process&#46; Once the central catheter had been removed&#44; doctors chose treatment with daptomycin for the peritoneal infection&#46; Daptomycin dosed at 7mg&#47;kg body weight &#40;280mg total&#41; was administered at the end of an Automated Peritoneal Dialysis &#40;APD&#41; session and the solution remained in the peritoneum for the next 12 hours&#46; Blood samples were extracted at 0&#46;5&#44; 3&#46;5 and 25 hours and a pharmacokinetic study of daptomycin was completed&#46; Doctors observed that after IP administration of daptomycin&#44; plasma drug levels rose above 10mg&#47;l&#59; once again exceeding the MIC of daptomycin against most bacterial strains&#46; These authors call for more studies in order to determine whether or not IP administration of daptomycin might be useful in treating systemic infections in PD patients&#44; especially those with difficult vascular accesses&#46;</p><p class="elsevierStylePara">Two other cases of daptomycin treatment for peritonitis were recently published in this journal&#46; The first case<span class="elsevierStyleSup">8</span> describes a patient treated by our working group who received IP daptomycin&#46; After 14 days of treatment the catheter was locked with 350mg of daptomycin in 7ml saline during 12 hours once weekly&#44; coinciding with the PD dry day&#44; for 1 month&#46; In the second case&#44;<span class="elsevierStyleSup">9</span> the patient received IV daptomycin&#46; Treatment was successful in both cases&#46;</p><p class="elsevierStylePara">Peritonitis episodes in patients on PD often become recurrent infections because of biofilm formation&#46; Biofilm formation is a complex process that begins when a bacterium adheres irreversibly to an abiotic surface&#44; a tissue or a liquid-air interface&#46; Once the bacteria adhere&#44; they begin to divide and form a microcolony&#46; The bacteria making up this microcolony begin to secrete substances such as polysaccharides and other macromolecules that form a three-dimensional structure&#46; Micropores can be seen in this structure which bacteria use to exchange substances &#8212;both nutrients and waste products&#8212; with the medium&#46; When the biofilm formation process is finished&#44; some of the bacteria may leave this structure&#44; adhere to another site on the surface and begin a new biofilm formation process&#46;</p><p class="elsevierStylePara">When bacteria form part of a biofilm&#44; their sensitivity to antimicrobial agents is different due to several reasons&#46; The physical and chemical diffusion barrier formed by the exopolysaccharide matrix prevents antimicrobial agents from penetrating&#46; In addition&#44; growth of bacteria in the biofilm is slowed down due to nutrients being limited&#46; There may be microenvironments that antagonise the antibiotic action&#46; They activate stress responses that lead to changes in bacterial physiology and cause the appearance of a specific biofilm phenotype that actively combats the inhibitory effects of the antimicrobial substances&#46;<span class="elsevierStyleSup">10 </span></p><p class="elsevierStylePara">In light of the above&#44; we must consider whether using MIC is the right strategy for evaluating antibiotic sensitivity in confirmed or suspected cases of biofilm-associated infections&#46; A published study on this subject evaluated the sensitivity of 21 methicillin-sensitive strains of <span class="elsevierStyleItalic">Staphylococcus aureus</span> from PD patients with peritonitis using the MIC and the minimal biofilm eradication concentration &#40;MBEC&#41;&#46;<span class="elsevierStyleSup">11</span> Antibiograms revealed that when MIC was used to determine bacterial sensitivity&#44; all strains tested sensitive to all the antibiotics &#44; but when the MBEC was used&#44; all of the bacteria tested resistant or moderately sensitive to the same antibiotics&#46; The only antibiotic to which strains were not resistant was the combination of vancomycin and rifampicin &#40;1&#58;1&#41;&#46; Most of the strains were either sensitive or moderately sensitive<span class="elsevierStyleBold"> </span>to this treatment&#46;</p><p class="elsevierStylePara">The disadvantage of using rifampicin in this type of patient is that it is physically and chemically incompatible with basic pH solutions&#46; Most of the solutions used in PD are mildly basic liquids &#40;pH &#61; 7&#46;4&#41;&#46; In addition&#44; this instability or incompatibility causes antimicrobial inefficiency&#44; as demonstrated by Richards GK et al<span class="elsevierStyleSup">12</span> in a study that showed that the pH of PD solutions was a determining factor in the response of <span class="elsevierStyleItalic">Staphylococcus epidermidis</span> biofilm to rifampicin&#46; An acidic medium increased rifampicin&#39;s antimicrobial power&#44; while basic and even neutral media &#40;pH&#61;7&#41; inhibited its antibiotic activity&#46;</p><p class="elsevierStylePara">Other antibiotics&#44; such as linezolid&#44; can be used in this type of infection due to their antibiotic spectrum&#44; and in fact&#44; there are several published cases of peritonitis<span class="elsevierStyleSup">13&#44;14</span> treated with linezolid&#44; even orally&#44; due to the drug&#8217;s high bioavailability &#40;100&#37;&#41;&#46; Recommendations for the treatment of PD-related peritonitis include the option of oral linezolid&#46;<span class="elsevierStyleSup">1</span> It can be administered by the IP route since its stability in PD solution has been tested&#46;<span class="elsevierStyleSup">15</span> However&#44; it is also physically and chemically stable in solutions that are used less frequently at present &#40;those with an acidic pH&#41;&#46; So far&#44; no cases of peritonitis treated with IP linezolid have been published in medical literature&#46;</p><p class="elsevierStylePara">Another reason for discouraging use of linezolid in patients with recurrent peritonitis and suspected biofilm is that the drug is less active against biofilm&#46; The <span class="elsevierStyleItalic">in vitro</span> study published by Raad I et al<span class="elsevierStyleSup">16</span> showed daptomycin as the best option for eradicating methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> &#40;MRSA&#41; embedded in biofilm three days after exposure to the antibiotic&#44; compared to minocycline&#44; tigecycline&#44; linezolid&#44; rifampicin and vancomycin&#46; The difference was statistically significant &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41;&#46; Daptomycin&#8217;s superior activity against biofilm was highlighted once again in the study by Smith K et al<span class="elsevierStyleSup">17</span> in which the mean survival rate of MRSA cells in biofilm was 4&#37; with daptomycin&#44; compared to 62&#37; with clindamycin&#44; 45&#37; with linezolid&#44; 43&#37; with tigecycline and 19&#37; with vancomycin&#46;</p><p class="elsevierStylePara">It is therefore interesting that&#44; in light of currently available scientific evidence&#44; daptomycin is a very effective option in the treatment of PD-related peritonitis in patients with suspected biofilm&#46;</p><p class="elsevierStylePara">Within this panorama&#44; daptomycin&#39;s true physical and chemical stability in PD solutions must be determined using validated laboratory tests&#46; In addition&#44; the drug&#8217;s effectiveness in these patients must be assessed using randomised clinical trials comparing daptomycin with available alternatives in order to determine its placement within the treatment options for PD-related peritonitis&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">The authors affirm that they have no conflicts of interest related to the content of this article&#46;</p>"
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Intraperitoneal administration of daptomycin in recurrent peritonitis with suspected biofilm
Administración intraperitoneal de daptomicina en peritonitis recurrente con sospecha de biofilm
Laura García-Lópeza, M. José Fernández-Reyes Luisb, M. Teresa Criado-Illanac, Leonor Gómez-Sayagoa, Manuel Heras-Benitob
a Servicio de Farmacia Hospitalaria, Hospital General de Segovia, Segovia,
b Servicio de Nefrología, Hospital General de Segovia, Segovia,
c Farmacéutica especialista en Farmacia Hospitalaria. Jefa de Servicio de Farmacia, Hospital General de Segovia, Segovia,
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    "textoCompleto" => "<p class="elsevierStylePara">According to recent treatment guidelines for peritonitis in patients undergoing peritoneal dialysis &#40;PD&#41;&#44; peritonitis accounts for approximately 18&#37; of the infections associated with mortality in PD patients&#46; Although less than 4&#37; of peritonitis cases result in death&#44; peritonitis is a factor contributing to exitus in 16&#37; of all patients who die while on PD&#46; Severe and long-lasting episodes of peritonitis may lead to peritoneal membrane failure&#46; These episodes are one of the most common reasons for PD failure and one of the most common causes of discontinuing PD and starting haemodialysis&#46; With these reasons in mind&#44; prevention and treatment of PD-related peritonitis is crucial to the overall care of these patients&#46; Episodes must be resolved as effectively as possible in order to preserve peritoneal membrane function and by extension the PD technique as well&#46; Treatment should be initiated as quickly as possible&#44; and must include gram-positive coverage with vancomycin or cephalosporins and gram-negative coverage with third-generation cephalosporins or aminoglycosides&#46;<span class="elsevierStyleSup">1</span></p><p class="elsevierStylePara">Delivering antibiotics by the intraperitoneal &#40;IP&#41; route is more effective for treating PD-related peritonitis than administration by the intravenous &#40;IV&#41; route&#46;</p><p class="elsevierStylePara">At present&#44; the constant emergence of multidrug-resistant bacteria also affects this type of infection and results in new challenges in the treatment of this disease&#46; Daptomycin may be a valid option for the treatment of infections caused by gram-positive bacteria with resistance to methicillin and intermediate sensitivity to vancomycin&#46;</p><p class="elsevierStylePara">Daptomycin&#44; discovered in the early 1980s&#44; is a 13 amino acid lipopeptide antibiotic&#46; Clinical development of the drug was halted at that time due to its lack of efficacy against endocarditis and its high toxicity&#44; particularly to skeletal muscle&#46; In recent years&#44; the constant appearance of multidrug-resistant pathogens has led to renewed interest in this antibiotic&#44; which was approved by the Food and Drug Administration &#40;FDA&#41; in 2003 for treating gram-positive infections&#46;<span class="elsevierStyleSup">2</span> Its 3 phase mechanism of action differentiates it from other antibiotics and&#44; so far&#44; has prevented bacteria from developing resistances&#46;</p><p class="elsevierStylePara">In Spain&#44; the drug has been officially approved for the treatment of complicated skin and soft tissue infections&#44; right-sided endocarditis caused by <span class="elsevierStyleItalic">Staphylococcus aureus</span>&#44; <span class="elsevierStyleItalic">Staphylococcus aureus</span> bacteraemia associated with right-sided endocarditis&#44; and skin and soft tissue infections by the IV route only&#46;</p><p class="elsevierStylePara">Dosage for the approved indications is 4-6mg&#47;kg IV every 24 hours&#46; In the presence of decreased renal function or creatinine clearance &#60;30ml&#47;min&#44; it must be administered every 48 hours&#46;</p><p class="elsevierStylePara">It only acts on gram-positive bacteria and it is not physically or chemically compatible with glucose&#44; so it has to be diluted in saline in order to be administered by the IV route&#46; Its activity is pH-independent&#46; All of these properties&#44; which will be discussed later&#44; are very important in the context of PD-related peritonitis&#46;</p><p class="elsevierStylePara">Very little evidence is currently available regarding use of daptomycin in the treatment of PD-related peritonitis&#46;<span class="elsevierStyleSup">2&#44;3</span> Burklein D&#46; et al<span class="elsevierStyleSup">4</span> described the case of a patient with an intestinal perforation that led to peritonitis and sepsis that caused renal failure&#46; Microbial testing revealed a strain of <span class="elsevierStyleItalic">Enterococcus faecium</span> that is only sensitive to vancomycin&#46; Given the patient&#8217;s renal function&#44; IV daptomycin was administered in doses of 4mg&#47;kg every 48 hours during the first 6 days&#46; After recovering renal function&#44; daptomycin was administered in the same quantities every 24 hours until completion of 14 days of treatment&#46; IP and plasma daptomycin levels were measured&#44; showing a maximum antibiotic concentration of 17mg&#47;l and a minimum concentration of 5mg&#47;l&#44; which was sufficient considering that 4 mg&#47;l is the minimum inhibitory concentration &#40;MIC&#41; of daptomycin against most enterococci&#46;<span class="elsevierStyleSup">2&#44;3</span> In this case&#44; peritonitis resolved successfully&#46;</p><p class="elsevierStylePara">Dmyto K el al<span class="elsevierStyleSup">5</span> published a case in which a patient on PD with recurrent peritonitis and suspected <span class="elsevierStyleItalic">Staphylococcus capitis</span> biofilm was administered IV daptomycin at doses of 5mg&#47;kg every 48 hours&#46; Mean concentrations of daptomycin in PD solution rapidly exceeded 1mg&#47;l&#59; again&#44; these levels were higher than the MIC of daptomycin against most staphylococci&#46;<span class="elsevierStyleSup">2&#44;3</span></p><p class="elsevierStylePara">Huen SC et al<span class="elsevierStyleSup">6</span> published the first cases of successful treatment with IP daptomycin in 2 patients with vancomycin-resistant <span class="elsevierStyleItalic">Enterococcus faecium </span>peritonitis<span class="elsevierStyleItalic">&#46;</span> Doses of 200mg of daptomycin were administered diluted in PD solution &#40;2l&#41; followed by 20mg of daptomycin per litre of replacement fluid<span class="elsevierStyleBold"> </span>&#40;every 4 hours&#41; during 14 days&#46; The purpose was to raise IP levels to more than 5 times higher than the MIC of daptomycin against enterococci &#40;4mg&#47;l&#41;&#46; Once again&#44; infection was resolved in these cases without adverse effects or complications arising from IP administration of the drug&#46; These authors argue that its physical and chemical incompatibility with glucose appears not to compromise either its clinical efficacy or its antimicrobial potency&#44; at least at low levels of glucose such as those in the PD solution in which this drug was diluted before administration&#46;</p><p class="elsevierStylePara">Another case that deserves mention was published by Bahte SK et al<span class="elsevierStyleSup">7</span> regarding a patient who had been on kidney replacement therapy with PD for 7 years and whose central catheter for total parenteral nutrition had to be removed on multiple occasions due to <span class="elsevierStyleItalic">Staphylococcus aureus</span> infections&#46; The patient suffered an episode of sepsis related to the central catheter and was treated with IV daptomycin&#46; After 5 weeks he was admitted with peritonitis judged to be a relapse of the prior septic process&#46; Once the central catheter had been removed&#44; doctors chose treatment with daptomycin for the peritoneal infection&#46; Daptomycin dosed at 7mg&#47;kg body weight &#40;280mg total&#41; was administered at the end of an Automated Peritoneal Dialysis &#40;APD&#41; session and the solution remained in the peritoneum for the next 12 hours&#46; Blood samples were extracted at 0&#46;5&#44; 3&#46;5 and 25 hours and a pharmacokinetic study of daptomycin was completed&#46; Doctors observed that after IP administration of daptomycin&#44; plasma drug levels rose above 10mg&#47;l&#59; once again exceeding the MIC of daptomycin against most bacterial strains&#46; These authors call for more studies in order to determine whether or not IP administration of daptomycin might be useful in treating systemic infections in PD patients&#44; especially those with difficult vascular accesses&#46;</p><p class="elsevierStylePara">Two other cases of daptomycin treatment for peritonitis were recently published in this journal&#46; The first case<span class="elsevierStyleSup">8</span> describes a patient treated by our working group who received IP daptomycin&#46; After 14 days of treatment the catheter was locked with 350mg of daptomycin in 7ml saline during 12 hours once weekly&#44; coinciding with the PD dry day&#44; for 1 month&#46; In the second case&#44;<span class="elsevierStyleSup">9</span> the patient received IV daptomycin&#46; Treatment was successful in both cases&#46;</p><p class="elsevierStylePara">Peritonitis episodes in patients on PD often become recurrent infections because of biofilm formation&#46; Biofilm formation is a complex process that begins when a bacterium adheres irreversibly to an abiotic surface&#44; a tissue or a liquid-air interface&#46; Once the bacteria adhere&#44; they begin to divide and form a microcolony&#46; The bacteria making up this microcolony begin to secrete substances such as polysaccharides and other macromolecules that form a three-dimensional structure&#46; Micropores can be seen in this structure which bacteria use to exchange substances &#8212;both nutrients and waste products&#8212; with the medium&#46; When the biofilm formation process is finished&#44; some of the bacteria may leave this structure&#44; adhere to another site on the surface and begin a new biofilm formation process&#46;</p><p class="elsevierStylePara">When bacteria form part of a biofilm&#44; their sensitivity to antimicrobial agents is different due to several reasons&#46; The physical and chemical diffusion barrier formed by the exopolysaccharide matrix prevents antimicrobial agents from penetrating&#46; In addition&#44; growth of bacteria in the biofilm is slowed down due to nutrients being limited&#46; There may be microenvironments that antagonise the antibiotic action&#46; They activate stress responses that lead to changes in bacterial physiology and cause the appearance of a specific biofilm phenotype that actively combats the inhibitory effects of the antimicrobial substances&#46;<span class="elsevierStyleSup">10 </span></p><p class="elsevierStylePara">In light of the above&#44; we must consider whether using MIC is the right strategy for evaluating antibiotic sensitivity in confirmed or suspected cases of biofilm-associated infections&#46; A published study on this subject evaluated the sensitivity of 21 methicillin-sensitive strains of <span class="elsevierStyleItalic">Staphylococcus aureus</span> from PD patients with peritonitis using the MIC and the minimal biofilm eradication concentration &#40;MBEC&#41;&#46;<span class="elsevierStyleSup">11</span> Antibiograms revealed that when MIC was used to determine bacterial sensitivity&#44; all strains tested sensitive to all the antibiotics &#44; but when the MBEC was used&#44; all of the bacteria tested resistant or moderately sensitive to the same antibiotics&#46; The only antibiotic to which strains were not resistant was the combination of vancomycin and rifampicin &#40;1&#58;1&#41;&#46; Most of the strains were either sensitive or moderately sensitive<span class="elsevierStyleBold"> </span>to this treatment&#46;</p><p class="elsevierStylePara">The disadvantage of using rifampicin in this type of patient is that it is physically and chemically incompatible with basic pH solutions&#46; Most of the solutions used in PD are mildly basic liquids &#40;pH &#61; 7&#46;4&#41;&#46; In addition&#44; this instability or incompatibility causes antimicrobial inefficiency&#44; as demonstrated by Richards GK et al<span class="elsevierStyleSup">12</span> in a study that showed that the pH of PD solutions was a determining factor in the response of <span class="elsevierStyleItalic">Staphylococcus epidermidis</span> biofilm to rifampicin&#46; An acidic medium increased rifampicin&#39;s antimicrobial power&#44; while basic and even neutral media &#40;pH&#61;7&#41; inhibited its antibiotic activity&#46;</p><p class="elsevierStylePara">Other antibiotics&#44; such as linezolid&#44; can be used in this type of infection due to their antibiotic spectrum&#44; and in fact&#44; there are several published cases of peritonitis<span class="elsevierStyleSup">13&#44;14</span> treated with linezolid&#44; even orally&#44; due to the drug&#8217;s high bioavailability &#40;100&#37;&#41;&#46; Recommendations for the treatment of PD-related peritonitis include the option of oral linezolid&#46;<span class="elsevierStyleSup">1</span> It can be administered by the IP route since its stability in PD solution has been tested&#46;<span class="elsevierStyleSup">15</span> However&#44; it is also physically and chemically stable in solutions that are used less frequently at present &#40;those with an acidic pH&#41;&#46; So far&#44; no cases of peritonitis treated with IP linezolid have been published in medical literature&#46;</p><p class="elsevierStylePara">Another reason for discouraging use of linezolid in patients with recurrent peritonitis and suspected biofilm is that the drug is less active against biofilm&#46; The <span class="elsevierStyleItalic">in vitro</span> study published by Raad I et al<span class="elsevierStyleSup">16</span> showed daptomycin as the best option for eradicating methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> &#40;MRSA&#41; embedded in biofilm three days after exposure to the antibiotic&#44; compared to minocycline&#44; tigecycline&#44; linezolid&#44; rifampicin and vancomycin&#46; The difference was statistically significant &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41;&#46; Daptomycin&#8217;s superior activity against biofilm was highlighted once again in the study by Smith K et al<span class="elsevierStyleSup">17</span> in which the mean survival rate of MRSA cells in biofilm was 4&#37; with daptomycin&#44; compared to 62&#37; with clindamycin&#44; 45&#37; with linezolid&#44; 43&#37; with tigecycline and 19&#37; with vancomycin&#46;</p><p class="elsevierStylePara">It is therefore interesting that&#44; in light of currently available scientific evidence&#44; daptomycin is a very effective option in the treatment of PD-related peritonitis in patients with suspected biofilm&#46;</p><p class="elsevierStylePara">Within this panorama&#44; daptomycin&#39;s true physical and chemical stability in PD solutions must be determined using validated laboratory tests&#46; In addition&#44; the drug&#8217;s effectiveness in these patients must be assessed using randomised clinical trials comparing daptomycin with available alternatives in order to determine its placement within the treatment options for PD-related peritonitis&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">The authors affirm that they have no conflicts of interest related to the content of this article&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara">Las peritonitis son las infecciones m&#225;s problem&#225;ticas en los pacientes sometidos a di&#225;lisis peritoneal&#44; puesto que pueden llegar a comprometer la t&#233;cnica&#46; Actualmente el tratamiento incluye tratamiento emp&#237;rico con vancomicina&#44; cefalosporinas y aminogluc&#243;sidos hasta conocer el causante de dicha infecci&#243;n&#46; Pero la realidad microbiol&#243;gica&#44; en cuanto a emergencia de resistencias&#44; hace necesaria la incorporaci&#243;n de nuevos f&#225;rmacos al arsenal terap&#233;utico para tratar las peritonitis complicadas que pueden convertirse en recurrentes y comprometer la eficacia de la membrana&#46; La daptomicina es un antibi&#243;tico lipopept&#237;dico que se utiliza para el tratamiento de infecciones por bacterias grampositivas&#46; No tiene aprobada la indicaci&#243;n en el tratamiento de este tipo de infecciones&#44; pero est&#225; comenzando a utilizarse en este campo debido a su elevada efectividad ante infecciones por bacterias resistentes a meticilina con sensibilidades intermedias a vancomicina&#44; sobre todo cuando se asocian a la presencia de un biofilm&#46;</p>"
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