Update on the challenging role of biofilms in peritoneal dialysis

Figures & data

Figure 1 PD technique. (a) A patient is shown during an exchange. The patient is connected to the tubing set and the spent dialysate is drained out. Then, the peritoneal cavity is filled with fresh dialysate and the tubing set is disconnected. After a dwell, the process is repeated. (b) A schematic diagram indicating the relationship between the PD catheter and the adjacent tissues. The potential pathways of peritoneal cavity contamination are indicated: 1-intraluminal, 2-periluminal, and 3-transmural/hematogenous/transvaginal (adapted from Spencer (1988)).

Table 1. Summary of studies carried out on PD catheters supporting the presence of a microbial biofilm.

Clinical situation (n)	Catheter analyses		Evidence for biofilm (number positive/number total samples)	Reference
	Segment(s)	Methodology
Peritonitis^† (2)	External, ns^‡	Intraluminal culture, SEM	Fungus isolation (2/2) and morphological evidences of biofilm (1/1)	McNeely et al. (1981)
ESI (3), peritonitis (4), ESI and peritonitis (1), no infection (2)	Tunneled and ip	Extraluminal and cuff culture, SEM, TEM	Gram-positive and -negative bacteria and fungus isolation (9/10), morphological evidences of biofilm (8/10)	Marrie et al. (1983)
No infection^† (1)	External	Intraluminal culture, SEM	Fungus isolation and morphological evidences of biofilm (1/1)	Locci et al. (1984)
ESI (4), Peritonitis (6), ESI and peritonitis (5), no infection (5)	External, tunneled, and ip	Intra- and extra luminal culture, SEM, TEM	Isolation of Gram-positive and -negative bacteria (15/20), morphological evidences of biofilm (ns)	Dasgupta et al. (1986)
Peritonitis (13), no infection (12)	External, tunneled, and intraperitoneal	Intra- and extraluminal culture, SEM, TEM	Isolation of Gram-positive and -negative bacteria (20/25), morphological evidences of biofilm (25/25)	Dasgupta et al. (1987)
Peritonitis (7), no infection (17)	Transfer set, external, tunneled, and ip	Intraluminal culture, SEM, LM	No culturable microorganism isolated (0/17), morphological evidences of biofilm in the external segment (3/10)	Verger et al. (1987)
No infection^† (1)	ns^‡	Intraluminal culture, LM	Fungus isolation and morphological evidences of fungal elements (1/1)	Wegmann et al. (1988)
No infection^† (1)	ns^‡	Intra-luminal culture, SEM	Fungus isolation and morphological evidences of fungal elements (1/1)	Sekkarie et al. (1991)
Peritonitis, no infection (6)	ip	Intra- and extraluminal culture, SEM, CLSM	Isolation of Gram-positive bacteria (6/6), morphological evidences of biofilm (6/6)	Gorman et al. (1993)
Peritonitis (4), no infection (28)	Tunneled and ip	Intra- and extraluminal culture, SEM, TEM, CLSM	Isolation of Gram-positive and -negative bacteria (26/32), morphological evidences of biofilm (29/32)	Gorman et al. (1994)
ESI (11), peritonitis (7), ESI and peritonitis (8), No infection (19)	Tunneled and ip	Intraluminal fluid and cuff culture, SEM	Gram-positive and -negative bacteria and fungus isolation from catheter and/or cuff (22/45), morphological evidence of biofilm in the cuff (ns)	Bayston et al. (1999)
No infection^† (1)	ns	LM	Morphological evidences of fungal elements (1/1)	Ortiz et al. (1999)
ESI (29), peritonitis (36), no infection (22)	Tunneled and ip	ns	Gram-positive and -negative bacteria and fungus isolation from catheter and/or cuff (ns)	Rodriguez-Carmona et al. (2000)
No infection^† (1)	ns^‡	LM	Morphological evidences of fungal elements (1/1)	Huang et al. (2000)
No infection^† (1)	External	SEM, LM	Fungus isolation and morphological evidences of fungal elements (1/1)	Guerra e Silva et al. (2006)
Peritonitis (30), no infection (33)	ns^‡	SEM	Morphological evidences of biofilm (30/63)	Nodaira et al. (2008)
Peritonitis (5), no infection (6)	ns^‡	SEM, LM	Morphological evidences of biofilm (5/11)	Guerra e Silva et al. (2011)
ESI (1), peritonitis (1), no infection (15)	Tunneled and ip	Intra- and extraluminal culture, CLSM	Isolation of Gram-positive and -negative bacteria (11/17), morphological evidences of biofilm (9/17)	Pihl et al. (2013)

Notes: ^†, Case report; ip, intraperitoneal; ns, non-specified; ns^‡, non-specified but the catheter was removed; CLSM, confocal laser scanning microscopy; ESI, exit-site infection; LM, light microscopy; SEM, scanning electron microscopy; and TEM, transmission electron microscopy.

Figure 2 Example of SEM and EDX analyses performed on the intraluminal surface of transfer sets removed from two patients (a and b). Biofilm overview (i) and specific encrustations (ii) observed by SEM are shown as inserts to the corresponding EDX spectrum illustrating the elemental composition. Au (from sputtering-coating of samples) and Si (from the catheter wall) are not elements originating from the biofilms.

Table 2. Microbiological findings on PD catheters.

Microorganism	Clinical situation
	ESI (references)	Peritonitis (references)	ESI and peritonitis (references)	No infection (references)
Gram-positive
CNS	1/18 (Dasgupta et al. 1986)^a	7/32 (Dasgupta et al. 1986, 1987; Bayston et al. 1999)^a	2/16 (Dasgupta et al. 1986)	14/72 (Marrie et al. 1983; Dasgupta et al. 1986, 1987)^a (Bayston et al. 1999) ^b (Pihl et al. 2013)^a, c, d
Corynebacterium spp.	1/18 (Bayston et al. 1999)	1/32 (Bayston et al. 1999)	–	1/72 (Pihl et al. 2013)
Micrococcus spp.	–	–	–	1/72 (Pihl et al. 2013)
Propionibacterium acnes	–	–	1/16 (Pihl et al. 2013)	3/72 (Pihl et al. 2013)
Rothia mucilaginosa	–	–	–	1/72 (Pihl et al. 2013)
Staphylococcus aureus	10/18 (Marrie et al. 1983; Dasgupta et al. 1986; Bayston et al. 1999)	5/32 (Dasgupta et al. 1987; Bayston et al. 1999)	10/16 (Marrie et al. 1983; Dasgupta et al. 1986; Bayston et al. 1999; Pihl et al. 2013)	2/72 (Dasgupta et al. 1987)
Streptococcus spp.	–	3/32 (Dasgupta et al. 1987; Bayston et al. 1999)	–	2/72 (Dasgupta et al. 1987; Pihl et al. 2013)^e
Gram-negative
Achromobacter xylosoxidans	–	1/32 (Marrie et al. 1983)	–	–
Enterobacteriaceae	–	1/32 (Marrie et al. 1983)	–	1/72 (Dasgupta et al. 1986)
Klebsiella spp.	–	1/32 (Marrie et al. 1983)	–	–
Pseudomonas spp.	5/18 (Bayston et al. 1999)	2/32 (Dasgupta et al. 1987; Bayston et al. 1999)	2/16 (Dasgupta et al. 1986; Bayston et al. 1999)	2/72 (Bayston et al. 1999)
Proteus mirabilis	–	–	–	1/72 (Pihl et al. 2013)
Serratia spp.	1/18 (Marrie et al. 1983)	–	–	–
Fungi
Aspergillus spp.	–	1/32 (Bayston et al. 1999)^f	–	2/72 (Guerra e Silva et al. 2006)^†,g (Wegmann et al. 1988)^†,h
Candida spp.	–	1/32 (Marrie et al. 1983)^i	1/16 (Bayston et al. 1999)	–
Fusarium spp.	–	1/32 (McNeely et al. 1981)^†	–	–
Helminthasparium spp.	–	1/32 (Sekkarie et al. 1991)^†	–	–
Penicillium pinophilum	–	–	–	1/72 (Locci et al. 1984)^†
Other	–	1/32 (Dasgupta et al. 1987)		3/72 (Dasgupta et al. 1987)

Note: Data expressed as the number of cases of each microorganism within a biofilm/total number of patients with a specific clinical situation (ESI/peritonitis/ESI and peritonitis/no infection).^aStaphylococcus epidermidis;^bStaphylococcus simulans;^cS. lugdunensis;^dS. warneri;^eStreptococcus sanguinis;^fAspergillus niger;^gAspergillus terreus;^hAspergillus fumigatus;ⁱCandida albicans;^†Case report;ESI = Exit-site infection;A dash indicates the absence of reported cases.

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