The effect of radiological imaging on treatment delay and hospitalisation in patients with peritoneal dialysis-related peritonitis: A secondary analysis of the PROMPT study

Abstract

Background: In peritoneal dialysis-related peritonitis (peritonitis), delayed antibiotic therapy is associated with adverse outcomes. Identifying barriers to timely treatment may improve outcomes. Aim: To determine the impact of radiological investigations on treatment delay and predictors of hospitalisation and length of stay (LOS). Methods: Retrospective review of patients with presumed peritonitis in Western Australia. Results: In 153 episodes of peritonitis, 79 (51.6%) resulted in admission with a median LOS of 3 days (Q1, Q3: 1, 6). In a multivariable model, significant predictors of admission were abnormal exit-site (odds ration (OR) 5.7; 95% confidence interval (CI): 1.4, 23.6; p = 0.02), failure to detect a cloudy bag (OR 11.9; 95%CI: 3.2, 44.7; p < 0.001), female sex (OR 3.3; 95% CI: 1.4, 9.7; p = 0.027), radiological imaging within 24 h (OR 8.8; 95% CI: 2.2, 34.8; p = 0.002) and contact with ambulant care facility (OR 0.32, 95% CI: 0.11, 0.98; p = 0.04). Imaging within 24 h of presentation occurred in 41 (27%) episodes of peritonitis, mostly plain X-rays (91%), of which 83% were clinically irrelevant. Imaging performed within 24 h of presentation increased the median time to antibiotic treatment (2.9 h (Q1, Q3: 1.6, 6.4) vs 2.0 h (Q1, Q3: 1, 3.8; p = 0.046)). Imaging performed prior to administering antibiotics significantly increased the median time to treatment (4.7 h (Q1, Q3: 2.9, 25) vs 1.5 h (Q1, Q3: 0.75, 2.5; p < 0.001)) in those where imaging followed antibiotic treatment. Conclusions: Half of all presentations with peritonitis result in hospital admission. Radiological imaging was associated with an increased risk of hospitalisation, potentially contributes to treatment delay, and was mostly clinically unnecessary. When required, imaging should follow antibiotic therapy.

Peritoneal Dialysis–Related Infections

“…57 Secondary analysis of this study demonstrated that radiologic investigation in the first 24 hours was associated with a doubling of odds of antibiotic treatment delay. 59 Similarly, a study in Japan showed a three-fold higher risk of PD catheter removal after a delay of antibiotic treatment by 24 hours or more from the time of recognizing cloudy effluent. 58 Finally, a third study confirmed that antibiotic administration before hospitalization was an independent predictor of peritonitis cure.…”

Realtime Remote Detection of Evolving Peritonitis in Peritoneal Dialysis

“… 3 Investigations that delay antibiotics, such as waiting for the results of radiological investigations, can be deleterious to patient care. 6 …”