The Relationship Between Presentation and the Time of Initial Administration of Antibiotics With Outcomes of Peritonitis in Peritoneal Dialysis Patients: The PROMPT Study

Abstract

IntroductionThe impact of time to treatment on clinical outcome is an established precept in infectious disease but is not established in peritoneal dialysis–related peritonitis (PDRP).MethodsIn a prospective multicenter study of PDRP, symptom-to-contact time (SC), contact-to-treatment time (CT), defined as the time from health care presentation to initial antibiotic, and symptom-to-treatment time (ST) were determined.ResultsOne hundred sixteen patients had 159 episodes of PDRP. Median SC for all episodes was 5.0 hours (first to third quartile [Q1–Q3]: 1.3–13.9); CT, 2.3 hours (Q1–Q3: 1.2–4.0); and ST, 9.0 hours (Q1–Q3: 4.7–25.3). Thirty-eight (23.9%) patient episodes (28 catheter removals and 10 deaths) met the primary composite outcome of PD failure at 30 days (PD-fail). The risk of PD-fail increased by 5.5% for each hour of delay of administration of antibiotics (odds ratio [OR] for CT: 1.055; 95% confidence interval [CI]: 1.005–1.109; P = 0.032). Neither SC (OR: 1.00; 95% CI: 0.99–1.01; P = 0.74) nor ST (OR: 1.00; 95% CI: 0.99–1.01; P = 0.48) was associated with PD-fail. In a multivariable analysis, only CT for presentation to a hospital-based facility compared with a community facility (OR: 1.068; 95% CI: 1.013–1.126; P = 0.015) and female sex (OR: 2.4; 95% CI: 1.1–5.4; P = 0.027) were independently associated with PD-fail. Each hour of delay in administering antibacterial therapy from the time of presentation to a hospital facility increased the risk of PD failure or death by 6.8%.DiscussionStrategies targeted to expedited antibiotic treatment should be implemented to improve outcomes from PDRP.

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

“…However, such a practice may increase the risk of culture-negative peritonitis due to potential antibiotic treatment prior to proper PD effluent sampling. A recent study from Australia demonstrated the benefit of earlier administration of antibiotics in suspected peritonitis with respect to achieving successful treatment [37]. Taken together, further study is necessary to evaluate the impact of initial administration of antibiotics at home by patients for suspected peritonitis.…”

Peritoneal Dialysis–Associated Peritonitis

“…Intraperitoneal administration of antibiotics is the preferred route unless there are features of systemic sepsis (6). When there is a foreseeable delay in administering intraperitoneal antibiotics, however, the systemic route should be used as a temporary measure so as to ensure a prompt treatment (35). Vancomycin, aminoglycosides, and cephalosporin can be mixed in the same dialysis solution bag (36).…”

Measurement of innate immune response biomarkers in peritoneal dialysis effluent using a rapid diagnostic point-of-care device as a diagnostic indicator of peritonitis

“…A simple POC test that can quickly support or refute the diagnosis of PD peritonitis and avoid delay in initiating antibiotic treatment could improve patient outcomes. 3 Tests used to diagnose serious conditions such as peritonitis must have favorable test characteristics. We found a sensitivity of 97.6% and specificity of 87.7%, with a diagnostic accuracy of 92%.…”

“…2 When PD peritonitis is suspected, making the correct diagnosis quickly is important to permit rapid initiation of appropriate antibiotic treatment and improve outcomes. 3 Some patients present with clinically obvious features, such as cloudy effluent dialysate and abdominal pain, 4 but the diagnosis of infection is not always immediately clear. Some patients present with a cloudy bag and minimal symptoms, and there are causes other than infection for hazy fluid.…”