Risk Factors for and Outcomes of Catheter-Associated Peritonitis in Children: The SCOPE Collaborative

Abstract

Background and objectives The Standardizing Care to Improve Outcomes in Pediatric ESRD Collaborative is a quality improvement initiative that aims to reduce peritoneal dialysis-associated infections in pediatric patients on chronic peritoneal dialysis. Our objectives were to determine whether provider compliance with peritoneal dialysis catheter care bundles was associated with lower risk for infection at the individual patient level and describe the epidemiology, risk factors, and outcomes for peritonitis in the Standardizing Care to Improve Outcomes in Pediatric ESRD Collaborative.Design, setting, participants, & measurements We collected peritoneal dialysis characteristics, causative organisms, compliance with care bundles, and outcomes in children with peritonitis between October of 2011 and September of 2014. Chi-squared tests, t tests, and generalized linear mixed models were used to assess risk factors for peritonitis.Results Of 734 children enrolled (54% boys; median age =9 years old; interquartile range, 1-15) from 29 centers, 391 peritonitis episodes occurred among 245 individuals over 10,130 catheter-months. The aggregate annualized peritonitis rate was 0.46 episodes per patient-year. Rates were highest among children #2 years old (0.62 episodes per patient-year). Gram-positive peritonitis predominated (37.8%) followed by culture-negative (24.7%), gramnegative (19.5%), and polymicrobial (10.3%) infections; fungal only peritonitis accounted for 7.7% of episodes. Compliance with the follow-up bundle was associated with a lower rate of peritonitis (rate ratio, 0.49; 95% confidence interval, 0.30 to 0.80) in the multivariable model. Upward orientation of the catheter exit site (rate ratio, 4.2; 95% confidence interval, 1.49 to 11.89) and touch contamination (rate ratio, 2.22; 95% confidence interval, 1.44 to 3.34) were also associated with a higher risk of peritonitis. Infection outcomes included resolution with antimicrobial treatment alone in 76.6%, permanent catheter removal in 12.2%, and catheter removal with return to peritoneal dialysis in 6% of episodes.Conclusions Lower compliance with standardized practices for follow-up peritoneal dialysis catheter care in the Standardizing Care to Improve Outcomes in Pediatric ESRD Collaborative was associated with higher risk of peritonitis. Quality improvement and prevention strategies have the potential to reduce peritoneal dialysisassociated peritonitis.

Peritonitis in Children on Chronic Peritoneal Dialysis: The Experience of a Large National Pediatric Cohort

“…Risk factors for peritonitis include catheter exit site infection, tunnel infection, tube use, lower provide compliance, and touch contamination [8, 9, 13, 16, 22, 23]. However, predictors of peritonitis are not always known.…”

“…According to Standardizing Care to Improve Outcomes in Pediatric end-stage renal disease Collaborative, the global peritonitis incidence rate is 0.46 episodes per patient-year [8], while the North American Pediatric Renal Transplant Cooperative Study found 0.68 peritonitis episodes per patient-year in PD-treated children [9]. …”

Peritoneal dialysis and infants: further insights into a complicated relationship

“…Overall, implementation of three standardized PD catheter-care bundles reduced the monthly annualized peritonitis rate from 0.63 pre-SCOPE Collaborative to 0.42 at 3 years postlaunch [31]. In univariate analysis, the peritonitis group had a significantly higher proportion of patients with gastrostomy tube, incontinence (e.g., in diapers), and report of touch contamination in the month before infection or at last follow-up compared with the group without peritonitis [30].…”

“…The objectives of this qualitytransformation effort were to evaluate whether providing compliance with a series of care practice bundles (encompassing PD catheter insertion, patient and caregiver training, and follow-up care) was associated with lower risk for peritonitis among pediatric patients on PD. In the first 3 years of the SCOPE Collaborative (1 October 2011 to 30 September 2014), 734 children with a median age of 9 years were enrolled; children <2 years represented 32.4% of the cohort [30]. About one third of patients enrolled (n = 245) developed at least one episode of peritonitis, resulting in an annualized peritonitis rate of 0.46 infections per patient-year.…”

“…Comparison of PD catheter characteristics revealed that the peritonitis group had significantly more catheters with upward (rather than downward or lateral) orientation at the exit-site and use of a plastic rather than titanium adapter at the distal end of the catheter [30]. Since its launch, it is estimated that the SCOPE Collaborative has prevented nearly 400 episodes of peritonitis, avoided 240 hospitalizations, and saved more than US$7 million in healthcare costs [32].…”