Regional variation in the treatment and prevention of peritoneal dialysis-related infections in the Peritoneal Dialysis Outcomes and Practice Patterns Study

Boudville, Neil; Johnson, David W.; Zhao, Junhui; Bieber, Brian; Pisoni, Ronald L.; Piraino, Beth; Bernardini, Judith; Nessim, Sharon J.; Ito, Yasuhiko; Woodrow, Graham; Brown, Fiona G.; Collins, John; Kanjanabuch, Talerngsak; Szeto, Cheuk Chun; Perl, Jeffrey

doi:10.1093/ndt/gfy204

Cited by 67 publications

(77 citation statements)

References 39 publications

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“…It has also been demonstrated that in many countries it is very common not to follow these ISPD recommendations. 15 The fact that many patients discontinued the study, mainly due to kidney transplantation, transfer to hemodialysis, and death, could have altered the probability of a first peritonitis episode over the course of the study. We therefore used the Fine and Gray analysis to take these competing risks into account, as has been recommended for survival analysis in PD research.…”

Section: Discussionmentioning

confidence: 99%

Retraining for prevention of peritonitis in peritoneal dialysis patients: A randomized controlled trial

et al. 2020

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Background: Peritonitis is more common in peritoneal dialysis (PD) patients nonadherent to the PD exchange protocol procedures than in compliant patients. We therefore investigated whether regular testing of PD knowledge with focus on infection prophylaxis could increase the time to first peritonitis (primary outcome) and reduce the peritonitis rate in new PD patients. Methods: This physician-initiated, open-label, parallel group trial took place at 57 centers in Sweden, Denmark, Norway, Finland, Estonia, Latvia, the Netherlands, and the United Kingdom from 2010 to 2015. New peritonitis-free PD patients were randomized using computer-generated numbers 1 month after the start of PD either to a control group ( n = 331) treated according to center routines or to a retraining group ( n = 340), which underwent testing of PD knowledge and skills at 1, 3, 6, 12, 18, 24, 30, and 36 months after PD start, followed by retraining if the goals were not achieved. Results: In all, 74% of the controls and 80% of the retraining patients discontinued the study. The groups did not differ significantly regarding cumulative incidence of first peritonitis adjusted for competing risks (kidney transplantation, transfer to hemodialysis and death; hazard ratio 0.84; 95% confidence interval (CI) 0.65–1.09) nor regarding peritonitis rate per patient year (relative risk 0.93; 95% CI 0.75–1.16). Conclusions: In this randomized controlled trial, we were unable to demonstrate that regular, targeted testing and retraining of new PD patients increased the time to first peritonitis or reduced the rate of peritonitis, as the study comprised patients with a low risk of peritonitis, was underpowered, open to type 1 statistical error, and contamination between groups.

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Section: Discussionmentioning

confidence: 99%

Retraining for prevention of peritonitis in peritoneal dialysis patients: A randomized controlled trial

et al. 2020

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“…Although the recommendations state that the overall peritonitis rate should be below 0.5 episodes per patient-year, there is a wide variation in the peritonitis rates reported by different countries, as well as by different centers within the same country (8). A recent study shows highly variable rates of adopting the ISPD recommendations across different centers, and such variations probably account for the difference in infection risk between PD centers (9).…”

Section: Reporting Of Peritonitis Ratementioning

confidence: 99%

Peritoneal Dialysis–Associated Peritonitis

Szeto¹,

Li²

2019

CJASN

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Peritonitis is a common and severe complication in peritoneal dialysis (PD). Detailed recommendations on the prevention and treatment of PD-associated peritonitis have been published by the International Society for Peritoneal Dialysis (ISPD), but there is a substantial variation in clinical practice among dialysis units. Prophylactic antibiotics administered before PD catheter insertion, colonoscopy, or invasive gynecologic procedures, daily topical application of antibiotic cream or ointment to the catheter exit site, and prompt treatment of exit site or catheter infection are key measures to prevent PD-associated peritonitis. When a patient on PD presents with clinical features compatible with PD-associated peritonitis, empirical antibiotic therapy, with coverage of both Gram-positive and Gram-negative organisms (including Pseudomonas species), should be started once the appropriate microbiologic specimens have been obtained. Intraperitoneal is the preferred route of administration. Antifungal prophylaxis, preferably oral nystatin, should be added to prevent secondary fungal peritonitis. Once the PD effluent Gram stain or culture and sensitivity results are available, antibiotic therapy can be adjusted accordingly. A detailed description on the dosage of individual antibiotic can be found in the latest recommendations by the ISPD. The duration of antibiotics is usually 2–3 weeks, depending on the specific organisms identified. Catheter removal and temporary hemodialysis support is recommended for refractory, relapsing, or fungal peritonitis. In some patients, a new PD catheter could be inserted after complete resolution of the peritonitis. PD catheter removal should also be considered for refractory exit site or tunnel infections. After the improvement in clinical practice, there is a worldwide trend of reduction in PD-associated peritonitis rate, supporting the use of PD as a first-line dialysis modality.

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“…In Australia and New Zealand, for instance, 89% of the centers used antifungal prophylaxis compared with 54% in the United States and only 8% in Japan. 6 Of note, consideration for fungal prophylaxis practice needs to be taken in the context of individual countries and centers because the utility of this approach might be lower in centers with low rates of fungal peritonitis. The preferred agent in our opinion is nystatin, given the low cost and safety profile with a dose of 500,000 units orally 4 times per day for the entire duration of antibiotic therapy plus 1 week.…”

Section: We Do Not Consider Antifungal Prophylaxismentioning

confidence: 99%

Peritoneal Dialysis–Associated Peritonitis: Suggestions for Management and Mistakes to Avoid

2020

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Peritonitis is a common complication of peritoneal dialysis that is associated with substantial morbidity and mortality. Peritonitis increases treatment costs and hospitalization events and is the most common reason for transfer to hemodialysis. Although there is much focus on preventing peritoneal dialysis–associated peritonitis, equally as important is appropriate management to minimize the morbidity of a peritonitis episode when it has occurred. Despite the presence of international guidelines on peritonitis treatment, the evidence base to support optimal peritonitis treatment practices is lacking, leaving the practitioner to rely on clinical experience and extrapolate from across other infection treatment practices. This article reviews common mistakes and misconceptions that we have observed in the management of peritonitis that may compromise treatment success. It also provides suggestions on common controversial aspects of peritonitis management based on the best available literature. Although the use of the word mistakes is somewhat controversial and subjective, we acknowledge that evidence is lacking and have based many of our suggestions on clinical judgment, experience, and available data.

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Regional variation in the treatment and prevention of peritoneal dialysis-related infections in the Peritoneal Dialysis Outcomes and Practice Patterns Study

Cited by 67 publications

References 39 publications

Retraining for prevention of peritonitis in peritoneal dialysis patients: A randomized controlled trial

Retraining for prevention of peritonitis in peritoneal dialysis patients: A randomized controlled trial

Peritoneal Dialysis–Associated Peritonitis

Peritoneal Dialysis–Associated Peritonitis: Suggestions for Management and Mistakes to Avoid

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