Seasonal variations of enteric peritonitis in Belgium and France : RDPLF data

Summary Little information is available on the seasonal ecology of germs responsible for peritoneal dialysis peritonitis. We performed a retrospective study based on RDPLF data covering the last 20 years and 20411 episodes of peritonitis. We show that the percentage of enteric peritonitis is highest in summer, lowest in winter and identical in spring and autumn. This higher proportion of organisms of enteric origin in summer has itself tended to increase in recent years. We postulate that a food contamination by enteric germs associated with an increased bacterial translocation at the level of the digestive tract itself favoured by constipation, as well as changes of the food nature could be responsible for this phenomenon. These seasonal variations may suggest that probabilistic initial antibiotic therapy should be adapted in cases of suspected peritonitis before the results of bacteriological analysis.  

Association between the use of exchange devices for peritoneal dialysis fluids and peritonitis incidence: A nationwide cohort study

BACKGROUND

The use of exchange devices for peritoneal dialysis (PD) fluids is a common practice in Japan. Evidence on the effectiveness of exchange devices in preventing PD-related peritonitis is scarce. We evaluated the association between the use of exchange devices for PD fluids and peritonitis incidence.

METHODS

We retrospectively enrolled 3845 patients, aged ≥20 years, receiving PD for ≥3 months, with available data on the exchange procedure for PD fluids and peritonitis incidence that was obtained from the Japan Renal Data Registry, a nationwide annual survey. The patients were grouped according to whether the manual or device PD fluid exchange method was used. The onset of peritonitis was defined as a leukocyte count of >100/µL (neutrophils ≥50%) in PD effluents. We applied quasi-Poisson regression analyses to estimate the incidence rate ratio (IRR). Age, sex, PD vintage, body mass index, automated PD use, residual kidney function, comorbidities, haemoglobin and serum albumin were adjusted as potential confounders.

RESULTS

Older age, automated PD use, diabetes as comorbidity and lower haemoglobin levels were associated with the use of exchange devices for PD fluids. Patients using devices for PD fluid exchange (69.2%) had an increased risk of peritonitis of 37% (IRR: 1.37, 95% confidence interval (CI): 1.07-1.75) and 28% (IRR: 1.28, 95% CI: 1.00-1.63) in the crude and multivariate adjustment models, respectively.

CONCLUSIONS

The use of exchange devices for PD fluids and peritonitis incidence showed no favourable association. There may remain possible residual confounding by indication.

Changes before and after COVID-19 pandemic on the personal hygiene behaviors and incidence of peritonitis in peritoneal-dialysis patients: a multi-center retrospective study

Background

The impact of Coronavirus disease (COVID-19) pandemic and its influence on personal hygiene behaviors and peritonitis rate in peritoneal-dialysis patients is unknown.

Methods

A multi-center retrospective study was conducted. We reviewed all the cases of peritoneal-dialysis (PD) patients from four major PD centers in Wuhan before and after COVID-19. There were 567 patients enrolled in total. Information was collected on personal hygiene behaviors, basic clinical characteristics, lab results, peritonitis details. We used Chi-square analysis to compare the personal hygiene behaviors, and used Chi-square goodness-of-fit analysis to compare the peritonitis rates before and after COVID-19. Multivariate logistic regression analysis was used to analyze the risk factors for peritonitis rate.

Results

There were no significant differences on peritonitis rates in six-month period before and after COVID-19 (p = 0.0756, Fig. 2 and Table 3). But Gram-positive infections decreased dramatically (p = 0.0041, Table 4). Personal hygiene behaviors such as length of time for washing hands when performing PD treatment, the frequency of washing hands before PD treatment and six general behaviors had significant differences (P < 0.05 Table 2). The multivariate logistic regression analysis showed never washing hands before PD treatment and serum albumin level were the risk factors of peritonitis during COVID-19 (OR 14.408, 95%CI 3.930 –52.821, P = 0.0002; OR 4.681, 95% CI 1.755 –12.485, P = 0.002, Table 5).

Conclusions

The COVID-19 pandemic had a significant positive influence on personal hygiene behaviors. Peritonitis rate did not significantly decrease but Gram-positive infections dramatically decreased. Never hand washing before PD treatment and serum albumin were the risk factors for peritonitis. We should emphasize hand washing before PD treatment in training and re-training program.

The influence of seasonal factors on the incidence of peritoneal dialysis-associated peritonitis

OBJECTIVES

To investigate the effects of climatic variables on peritoneal dialysis-associated peritonitis (PDAP) among patients receiving PD, such as seasonal variations in temperature and humidity.

METHODS

A retrospective analysis was performed on PD patients, from 1 January 2011, to 31 December 2019. We evaluated the influence of seasonal factors on peritonitis rates and outcomes.

RESULTS

Over the 9-year study period, 667 peritonitis episodes occurred, in 401 PD patients. Diarrhea-associated peritonitis occurred more frequently in summer compared with other seasons. Eating raw and cold food was identified as the primary cause of peritonitis in the summer. More peritonitis episodes occurred during summer. The peritonitis rate associated with gram-negative bacteria (p = 0.050) during summer was higher than those in all other seasons. The gram-negative bacterial peritonitis rate was positively correlated with monthly mean temperature (r = 0.504, p < 0.01) and humidity (r = 0.561, p < 0.01). A similar trend was observed for Enterobacterial peritonitis (temperature: r = 0.518, p < 0.01; humidity: r = 0.456, p = 0.001). Logistic regression analysis showed that summer was a risk factor for peritonitis (p = 0.041). Peritonitis prognosis during summer was significantly worse than those for all other seasons (p = 0.037).

CONCLUSIONS

Seasonal variations exist in the incidence of dialysis-associated peritonitis, with peak incidents caused by gram-negative bacteria in the summer. High average temperature and humidity are associated with significant increases in the gram-negative bacteria and Enterobacterial peritonitis rates. Peritonitis prognosis during summer is worse.

Seasonality of peritoneal dialysis-related peritonitis in Japan: a single-center, 10-year study

BACKGROUND

Peritonitis is one of the major complications of peritoneal dialysis (PD). Although several reports have indicated seasonality of peritonitis, the observation periods were short, and there were no reports from Japan. Therefore, the purpose of this study was to investigate the long-term seasonality of peritonitis in a single institution in Japan.

METHODS

Of 126 patients who started PD in our hospital between January 1, 2009, and December 31, 2018, 25 patients (15 men, 10 patients with diabetes) developed peritonitis with a total of 42 episodes. The median age at onset was 63 years, and the median duration from the start of PD to the onset of peritonitis was 22 months.

RESULTS

The 10-year incidence of peritonitis was 0.12 episodes per patient-year. Compared with the reference season of winter (December-February), the incidence rate ratios (95% confidence interval) for spring (March-May), summer (June-August), and autumn (September-November) were 1.75 (0.65-4.75), 1.56 (0.57-4.31), and 2.42 (0.94-6.23), respectively. In addition, no seasonality of Gram-positive and Gram-negative organisms was observed.

CONCLUSION

No seasonality was evident in the incidence of PD-related peritonitis in our hospital over a 10-year period. These findings suggest that the development of peritonitis in Japanese PD patients is not affected by seasonality.

Take Care in how you Store Your PD Fluids: Actual Temperature Determines the Balance between Reactive and Non-Reactive GDPs

Objective

During heat sterilization and during prolonged storage, glucose in peritoneal dialysis fluids (PDF) degrades to carbonyl compounds commonly known as glucose degradation products (GDPs). Of these, 3,4-dideoxyglucosone-3-ene (3,4-DGE) is the most cytotoxic. It is an intermediate in degradation between 3-deoxyglucosone (3-DG) and 5-hydroxymethyl-2-furaldehyde (5-HMF). We have earlier reported that there seems to be equilibrium between these GDPs in PDF. The aim of the present study was to investigate details of this equilibrium.

Methods

Aqueous solutions of pure 3-DG, 3,4-DGE, and 5-HMF were incubated at 40°C for 40 days. Conventional and low-GDP fluids were incubated at various temperatures for up to 3 weeks. Formaldehyde, acetaldehyde, glyoxal, methylglyoxal, 3-DG, 3,4-DGE, and 5-HMF were analyzed using high performance liquid chromatography.

Results

Incubation of 100 μmol/L 3,4-DGE resulted in the production of 36 μmol/L 3-DG, 4 μmol/L 5-HMF, and 40 μmol/L unidentified substances. With the same incubation, 200 μmol/L 3-DG was converted to 9 μmol/L 3,4-DGE, 6 μmol/L 5-HMF, and 14 μmol/L unidentified substances. By contrast, 100 μmol/L 5-HMF was uninfluenced by incubation. In a conventional PDF incubated at 60°C for 1 day, the 3,4-DGE concentration increased from 14 to a maximum of 49 μmol/L. When the fluids were returned to room temperature, the concentration decreased but did not reach original values until after 40 days. In a low GDP fluid, 3,4-DGE increased and decreased in the same manner as in the conventional fluid but reached a maximum of only 0.8 μmol/L.

Conclusions

Considerable amounts of 3,4-DGE may be recruited by increases in temperature in conventional PDFs. Lowering the temperature will again reduce the concentration but much more time will be needed. Precursors for 3,4-DGE recruitment are most probably 3-DG and the enol 3-deoxyaldose-2-ene, but not 5-HMF. Considering the ease at which 3,4-DGE is recruited from its pool of precursors and the difficulty of getting rid of it again, one should be extremely careful with the temperatures conventional PDFs are exposed to.

A Risk Analysis of Continuous Ambulatory Peritoneal Dialysis-Related Peritonitis

Objective

We studied the clinical characteristics that influence the risk of dialysis-related peritonitis complication in incident Chinese patients undergoing continuous ambulatory peritoneal dialysis (CAPD).

Methods

A single center, retrospective, observational cohort study was carried out to examine the risk factors of developing a first episode of dialysis-related peritonitis.

Results

Between 1995 and 2004, 246 incident CAPD patients were recruited for analysis. During the study period of 897.1 patient-years, 85 initial episodes of peritonitis were recorded. The median peritonitis-free time for diabetic subjects was significantly worse than for nondiabetic subjects (49.0 ± 10.5 vs 82.3 ± 12.6 months, p = 0.0019). The difference was due mainly to a higher likelihood of developing peritonitis with gram-negative organisms in patients with diabetes mellitus ( p = 0.038). Low serum albumin concentration was also associated with worse peritonitis-free survival. There was a nonsignificant trend toward an increased risk for peritonitis in the group of patients with cerebrovascular disease. According to multivariate Cox proportional hazards model for the analysis of time to first peritonitis episode, the two independent risk factors were presence of diabetes mellitus and initial serum albumin concentration. In particular, diabetes mellitus was associated with a hazard ratio of 1.50 and a 95% confidence interval of 1.05 – 2.40 ( p = 0.030) to develop an initial peritonitis. Lower serum albumin level at the start of CAPD was a significant predictor of peritonitis, with hazard ratio of 1.67 for every decrease of 10 g/L, and 95% confidence interval 1.08 – 2.60 ( p = 0.021).

Conclusions

Our results confirm the susceptibility of diabetic CAPD and hypoalbuminemic patients to peritonitis, and highlight the role of further studies in reducing this complication.

Treatment of Refractory Pseudomonas Aeruginosa Exit-Site Infection by Simultaneous Removal and Reinsertion of Peritoneal Dialysis Catheter

Background

Patients on continuous ambulatory peritoneal dialysis (CAPD) with Pseudomonas aeruginosa exit-site infection (ESI) refractory to antibiotic treatment often require replacement of their peritoneal dialysis catheter (PDC). The optimal interval between removal and reinsertion of the PDC is not known. There are relatively few data on the feasibility of simultaneous removal and reinsertion of dialysis catheters for the treatment of P. aeruginosa ESI.

Methods

We retrospectively reviewed the short- and long-term outcomes of all CAPD patients who had undergone simultaneous removal and reinsertion of their PDC for the treatment of refractory P. aeruginosa ESI in our hospital between January 1994 and December 2003. During the operation, the old catheter was removed first and a new catheter was inserted into the opposite side of the abdomen. All patients received 7 days of antibiotic therapy postoperatively. CAPD was resumed after 2 weeks of intermittent peritoneal dialysis.

Results

Over a 10-year period, 37 CAPD patients underwent the operation. Mean age of the patients was 59.5 ± 10.9 years. The interval between the diagnosis of ESI and the operation was 16.7 ± 6.9 weeks. The patients received 7.6 ± 2.5 weeks of antibiotic treatment before the procedure. Early postoperative complications were uncommon. None of the patients developed ESI within 4 weeks after the operation. At 1 year after the operation, 3 patients (8%) had developed recurrence of P. aeruginosa ESI 24 – 40 weeks postoperatively. Peritonitis due to P. aeruginosa was not observed.

Conclusions

We conclude that simultaneous removal and reinsertion of the PDC is feasible in eradicating refractory ESI due to P. aeruginosa. This procedure alleviates the need for temporary hemodialysis and allows continuation of peritoneal dialysis.

Peritonitis in Latin America

Peritoneal dialysis has a high acceptance rate in Latin America, thus the knowledge concerning complication patterns is of great relevance. This work reviews Latin American data on peritonitis, the most serious complication of peritoneal dialysis.

The incidence of peritonitis has been reduced over time, concomitantly with the incorporation of safer exchange systems and the use of prophylactic measurements. Today, rates lower than 1 episode per 24 patient-months are commonly reported. Furthermore, changes in causative organisms have been observed, with predominance of Staphylococcus aureus up through the mid-1990s, as well as increases in coagulase-negative staphylococcus and participation of gram negatives. However, the prevalence of S. aureus is still high, due possibly to climatic conditions and the elevated prevalence of carriers. Resolution rate varies from 55% to 78%, transfer to hemodialysis from 10.9% to 15.4%, and death in 3% to 9.9% of cases. Outcome is worse in S. aureus episodes compared to those with coagulase-negative staphylococcus, despite the higher percentage of oxacillin-resistant strains among the former. In general, despite socioeconomic or climatic conditions, our results are similar to those in developed countries, perhaps as a consequence of technological improvements and/or center expertise.

Seasonal Variation in the Peritoneal Dialysis-Related Infections: A Single Center Experience in the Mediterranean

Seasonal variation in the incidence of peritoneal dialysis-related infections (PDRI) has been sparingly investigated, especially in the Mediterranean. Our aim was to explore this association in Malta. All PDRI occurring between Jan-2008 and Dec-2012 were retrospectively studied.A total of 137 patients were followed-up for a median time of 32.5 months (range: 2-81). During this time, 19% never had PDRI, 11.7% transferred permanently to hemodialysis and 6.6% received a kidney transplant. A total of 279 PDRI were identified, equating to 145 catheter-related infections (CRI) and 144 peritonitis episodes (including 10 catheter related peritonitis). A spring peak in the overall gram positive PDRI (0.61 vs. 0.34/patient-year-at-risk, P=0.05), together with a peak in gram negative peritonitis in the warm period (0.13 vs. 0.07/patient-year at risk, P=0.04) was identified. The incidence rate ratios (Confidence Interval) involving the overall gram positive PDRI, gram positive peritonitis, coagulase-negative Streptococci (CoNS) and Streptococci were 1.82 (1.18-2.82, P=0.007), 2.20 (1.16-4.16, P=0.02), 2.65 (1.17-6.02, P=0.02] and 3.18 (1.03-9.98, P=0.04) in spring when compared to winter. No significant difference in the overall PDRI, peritonitis or CRI rates between seasons or warm/cold period was identified.To our knowledge, this is the first study which examines the effect of seasons on the incidence of PDRI in the Mediterranean basin. Findings suggest that spring confers a higher risk for gram positive PDRIs, gram positive peritonitis, CoNS and Streptococcus, whilst the warm period was associated with a peak in the gram negative peritonitis.

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

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%), gram-negative (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 dialysis-associated peritonitis.

[Peritonitis in pediatric patients receiving peritoneal dialysis]

BACKGROUND

Peritonitis on catheter of dialysis represents the most frequent complication of the peritoneal dialysis (PD) in the pediatric population. It remains a significant cause of morbidity and mortality. In this study, we investigated the risk factors for peritonitis in children.

METHODS

In this study, we retrospectively collected the records of 85 patients who were treated with PD within the past ten years in the service of pediatrics of the University Hospital Charles-Nicolle of Tunis.

RESULTS

Peritonitis rate was 0.75 episode per patient-year. Notably, peritonitis caused by Gram-positive organisms were more common. Analysis of infection risk revealed three significant independent factors: the poor weight (P=0.0045), the non-automated PD (P=0.02) and the short delay from catheter insertion to starting PD (P=0.02). The early onset peritonitis was significantly associated with frequent peritonitis episodes (P=0.0008). The mean duration between the first and second episode of peritonitis was significantly shorter than between PD commencement and the first episode of peritonitis. We revealed a significant association between Gram-negative peritonitis and the presence of ureterostomy (0.018) and between Gram-positive peritonitis and the presence of exit-site and tunnel infections (0.02). Transition to permanent hemodialysis was needed in many children but no death occurred in patients with peritonitis.

CONCLUSION

Considering the important incidence of peritonitis in our patients, it is imperative to establish a targeted primary prevention. Nutritional care must be provided to children to avoid poor weight. The automated dialysis has to be the modality of choice.

Predictors for and impact of high peritonitis rate in Taiwanese continuous ambulatory peritoneal dialysis patients

AIM

The influence of high peritonitis rate (HPR) on clinical outcomes of continuous ambulatory peritoneal dialysis (CAPD) patients has been far less studied in the Chinese population than in those of the USA, Australia and Europe. Furthermore, concerning the peritonitis risk, most studies primarily examined the risk of developing the first peritonitis episode, rather than a HPR.

METHODS

A single-center, retrospective, observational study was carried out over 10 years in Taiwan. A total of 124 patients with at least one peritonitis episode were the study subjects. The Cox proportional hazard model was used to assess the impact of HPR on clinical outcomes. Multivariate logistic regression was conducted to determine the independent factors associated with a HPR.

RESULTS

In the multivariate Cox regression model, HPR was still a significant predictor for technique failure, patient mortality and dropout from peritoneal dialysis (PD). Factors independently associated with a HPR were peritonitis occurrence during the first year after the start of CAPD and the first peritonitis infected with streptococcus species.

CONCLUSION

Peritonitis during the first year after PD commencement and the first peritonitis infected by streptococcus species were significantly associated with an increased risk of a HPR. Our data also indicate that HPR was correlated with technique failure, patient mortality and dropout from PD, thus highlighting the need and role of future studies to reduce this complication.

Treatment for peritoneal dialysis-associated peritonitis

BACKGROUND

Peritonitis is a common complication of peritoneal dialysis (PD) that is associated with significant morbidity including death, hospitalisation, and need to change from PD to haemodialysis. Treatment is aimed to reduce morbidity and recurrence. This is an update of a review first published in 2008.

OBJECTIVES

To evaluate the benefits and harms of treatments for PD-associated peritonitis.

SEARCH METHODS

For this review update we searched the Cochrane Renal Group's Specialised Register to March 2014 through contact with the Trials Search Co-ordinator using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE and EMBASE, and handsearching conference proceedings.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs assessing the treatment of peritonitis in PD patients (adults and children). We included any study that evaluated: administration of an antibiotic by different routes (e.g. oral, intraperitoneal (IP), intravenous (IV)); dose of an antibiotic agent; different schedules of administration of antimicrobial agents; comparisons of different regimens of antimicrobial agents; any other intervention including fibrinolytic agents, peritoneal lavage and early catheter removal.

DATA COLLECTION AND ANALYSIS

Multiple authors independently extracted data on study risk of bias and outcomes. Statistical analyses were performed using the random effects model. We expressed summarised treatment estimates as a risk ratio (RR) with 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) with 95% CI for continuous outcomes.

MAIN RESULTS

We identified 42 eligible studies in 2433 participants: antimicrobial agents (36 studies); urokinase (4 studies), peritoneal lavage (1 study), and IP immunoglobulin (1 study). We did not identify any optimal antibiotic agent or combination of agents. IP glycopeptides (vancomycin or teicoplanin) had uncertain effects on primary treatment response, relapse rates, and need for catheter removal compared to first generation cephalosporins, although glycopeptide regimens were more likely to achieve a complete cure (3 studies, 370 episodes: RR 1.66, 95% CI 1.01 to 2.72). For relapsing or persistent peritonitis, simultaneous catheter removal and replacement was better than urokinase at reducing treatment failure rates (RR 2.35, 95% CI 1.13 to 4.91) although evidence was limited to a single small study. Continuous and intermittent IP antibiotic dosing schedules had similar treatment failure and relapse rates. IP antibiotics were superior to IV antibiotics in reducing treatment failure in one small study (RR 3.52, 95% CI 1.26 to 9.81). Longer duration treatment (21 days of IV vancomycin and IP gentamicin) had uncertain effects on risk of treatment relapse compared with 10 days treatment (1 study, 49 patients: RR 1.56, 95% CI 0.60 to 3.95) although may have increased ototoxicity.In general, review conclusions were based on a small number of studies with few events in which risk of bias was generally high; interventions were heterogeneous, and outcome definitions were often inconsistent. There were no RCTs evaluating optimal timing of catheter removal and data for automated PD were absent.

AUTHORS' CONCLUSIONS

Many of the studies evaluating treatment of PD-related peritonitis are small, out-dated, of poor quality, and had inconsistent definitions and dosing regimens. IP administration of antibiotics was superior to IV administration for treating PD-associated peritonitis and glycopeptides appear optimal for complete cure of peritonitis, although evidence for this finding was assessed as low quality. PD catheter removal may be the best treatment for relapsing or persistent peritonitis.Evidence was insufficient to identify the optimal agent, route or duration of antibiotics to treat peritonitis. No specific antibiotic appears to have superior efficacy for preventing treatment failure or relapse of peritonitis, but evidence is limited to few trials. The role of routine peritoneal lavage or urokinase is uncertain.

Catheter-related infection and septicemia: impact of seasonality and modifiable practices from the DOPPS

Hemodialysis (HD) catheter-related infection (CRI) and septicemia contribute to adverse outcomes. The impact of seasonality and prophylactic dialysis practices during high-risk periods remain unexplored. This multicenter study analyzed DOPPS data from 12,122 HD patients (from 442 facilities) to determine the association between seasonally related climatic variables and CRI and septicemia. Climatic variables were determined by linkage to National Climatic Data Center of National Oceanic and Atmospheric Administration data. Catheter care protocols were examined to determine if they could mitigate infection risk during high-risk seasons. Survival models were used to estimate the adjusted hazard ratio (AHR) of septicemia by season and by facility catheter dressing protocol. The overall catheter-related septicemia rate was 0.47 per 1000 catheter days. It varied by season, with an AHR for summer of 1.46 (95% CI: 1.19-1.80) compared with winter. Septicemia was associated with temperature (AHR = 1.07; 95% CI: 1.02-1.13; p < 0.001). Dressing protocols using chlorhexidine (AHR of septicemia = 0.55; 95% CI: 0.39-0.78) were associated with fewest episodes of CRI or septicemia. Higher catheter-related septicemia in summer may be due to seasonal conditions (e.g., heat, perspiration) that facilitate bacterial growth and compromise protective measures. Extra vigilance and use of chlorhexidine-based dressing protocols may provide prophylaxis against CRI and septicemia.

Prevention of peritoneal dialysis catheter infections in Saudi peritoneal dialysis patients: the emergence of high-level mupirocin resistance

PURPOSE

Exit-site infection (ESI) and peritonitis remain the major causes of morbidity and mortality in peritoneal dialysis (PD) patients. This study compared the effectiveness of local mupirocin ointment and gentamicin cream in preventing both gram-positive and gram-negative bacterial infections in PD patients.

METHODS

Patients from two centers (n = 203) were assigned to daily mupirocin ointment or gentamicin cream application. Infections were tracked prospectively by organisms and expressed as episodes per patient-year for both ESI and peritonitis.

RESULTS

The rate of gram-positive ESI was 0.31/episode/patient-year and 0.22 episodes/patient-year (p<0.05), whereas the rate of gram-negative ESI was 0.28 episode/patient-year and 0.11 episode/patient-year (p<0.01) in the mupirocin group and gentamicin group, respectively. Gram-positive ESI occurred in 17.1% vs 10.2% of patients (p<0.05), whereas 20% of and 5.1% of patients (p<0.001) had gram-negative ESI in the 2 groups respectively. S.aureus was cultured at exit-site in the mupirocin group in 27.8% patients, 60% (16.7% of the total Gram-positive isolates) of them being with high-level mupirocin-resistance. Pseudomonas aeruginosa was cultured in 21.8% of ESI in the mupirocin group, and in only 6.7% in the gentamicin group (p<0.01). Peritonitis rates were lower using gentamicin cream, 0.17 episode/patient-year compared with mupirocin, 0.39 episode/patient-year (p<0.01). With multivariate analysis, only gentamicin exit-site use was a significant predictor for lower catheter infection rate.

CONCLUSION

Prolonged use of mupirocin for ESI-prophylaxis is associated with the emergence of mupirocin-resistant S. aureus. Gentamicin cream is superior to mupirocin ointment in the prevention of PD catheter infections.

Seasonality of staphylococcal infections

Characterization of seasonal variation of Staphylococcus aureus is important in understanding the epidemiology of, and designing preventive strategies against this highly virulent and ever-evolving pathogen. In this review, we summarize the findings of epidemiological studies that have evaluated seasonality in S. aureus colonization and infection. Although most studies published to date are methodologically weak, some seasonal variation in the occurrence of S. aureus infection appears to exist, particularly an association of warm-weather months with S. aureus skin and soft-tissue infections. We highlight the limitations of the published literature, and provide suggestions for future studies on this topic.

Effects of climatic region on peritonitis risk, microbiology, treatment, and outcomes: a multicenter registry study

BACKGROUND

The impact of climatic variations on peritoneal dialysis (PD)-related peritonitis has not been studied in detail. The aim of the current study was to determine whether various climatic zones influenced the probability of occurrence or the clinical outcomes of peritonitis.

METHODS

Using ANZDATA registry data, the study included all Australian patients receiving PD between 1 October 2003 and 31 December 2008. Climatic regions were defined according to the Köppen classification.

RESULTS

The overall peritonitis rate was 0.59 episodes per patient-year. Most of the patients lived in Temperate regions (65%), with others residing in Subtropical (26%), Tropical (6%), and Other climatic regions (Desert, 0.6%; Grassland, 2.3%). Compared with patients in Temperate regions, those in Tropical regions demonstrated significantly higher overall peritonitis rates and a shorter time to a first peritonitis episode [adjusted hazard ratio: 1.15; 95% confidence interval (CI): 1.01 to 1.31]. Culture-negative peritonitis was significantly less likely in Tropical regions [adjusted odds ratio (OR): 0.42; 95% CI: 0.25 to 0.73]; its occurrence in Subtropical and Other regions was comparable to that in Temperate regions. Fungal peritonitis was independently associated with Tropical regions (OR: 2.18; 95% CI: 1.22 to 3.90) and Other regions (OR: 3.46; 95% CI: 1.73 to 6.91), where rates of antifungal prophylaxis were also lower. Outcomes after first peritonitis episodes were comparable in all groups.

CONCLUSIONS

Tropical regions were associated with a higher overall peritonitis rate (including fungal peritonitis) and a shorter time to a first peritonitis episode. Augmented peritonitis prophylactic measures such as antifungal therapy and exit-site care should be considered in PD patients residing in Tropical climates.

Non-compliance to the continuous ambulatory peritoneal dialysis procedure increases the risk of peritonitis

BACKGROUND

Peritonitis in patients on continuous ambulatory peritoneal dialysis (CAPD) is the leading cause of technique failure. Information on the impact of non-compliance in performing CAPD exchange on peritonitis is limited. We aimed to find the prevalence of non-compliance to the CAPD procedure and its influence on the incidence of peritonitis.

METHODS

This observational study included 30 adult patients undergoing CAPD. The CAPD exchange procedure was observed at home and assessed as per the structured checklist and categorized into poor, average and good compliance. The compliance was correlated with the episodes of peritonitis in previous 1 year.

RESULTS

The patients' mean age was 52 ± 13 years and the mean duration of CAPD was 2.1 ± 0.9 years. Only 16.5% of patients were good performers, while 67% were average performers, and 16.5% were poor performers. The technique skill was similar across all the steps of the procedure. The most common improperly performed steps were: not putting on a face mask in 68%, not flushing the tubing system in 60%, and not washing hands in 24%. Poor adherence to procedure was independent of age, gender, education and duration of dialysis. Ten episodes of peritonitis occurred in 5 patients over 1-year period. Peritonitis occurred in 60% of poor performers, whereas fully compliant patients had no peritonitis. Also 40% of the poorly compliant patients had multiple episodes of peritonitis.

CONCLUSIONS

Poor compliance in performing the CAPD procedure is a modifiable risk factor for peritonitis. Adherence to recommended aseptic technique is the cornerstone of peritonitis prevention.

Seasonal variation in peritoneal dialysis-associated peritonitis: a multi-centre registry study

BACKGROUND

The role of seasonal variation in peritoneal dialysis (PD)-related peritonitis has been limited to a few small single-centre studies.

METHODS

Using all 6610 Australian patients receiving PD between 1 October 2003 and 31 December 2008, we evaluated the influence of seasons on peritonitis rates (Poisson regression) and outcomes (multivariable logistic regression).

RESULTS

The overall rate of peritonitis was 0.59 episodes per patient-year of treatment. Using winter as the reference season, the peritonitis incidence rate ratios (95% confidence interval) for summer, autumn and spring were 1.02 (0.95-1.09), 1.01 (0.94-1.08) and 0.99 (0.92-1.06), respectively. Significant seasonal variations were observed in the rates of peritonitis caused by coagulase-negative Staphylococci (spring and summer peaks), corynebacteria (winter peak) and Gram-negative organisms (summer and autumn peaks). There were trends to seasonal variations in fungal peritonitis (summer and autumn peaks) and pseudomonas peritonitis (summer peak). No significant seasonal variations were observed for other organisms. Peritonitis outcomes did not significantly vary according to season.

CONCLUSIONS

Seasonal variation has no appreciable influence on overall PD peritonitis rates or clinical outcomes. Nevertheless, significant seasonal variations were observed in the rates of peritonitis due to specific microorganisms, which may allow institutions to more precisely target infection control strategies prior to higher risk seasons.

Continuous ambulatory peritoneal dialysis in Egypt: progression despite handicaps

BACKGROUND

Despite the well-known advantages of continuous ambulatory peritoneal dialysis (CAPD), it continues to be grossly underutilized in many developing countries. However, some developing countries, such as Mexico, use the modality very effectively. In view of this, we started the first CAPD program in Egypt.

METHODS

Since its start in 1997, our program has treated 33 patients. Straight double-cuffed Tenckhoff catheters were surgically placed in all patients. Twin-bag systems were used. All patients underwent monthly clinical and biochemical assessment and measurement of Kt/V urea. Peritonitis and exit-site infection rates were monitored.

RESULTS

Most treated patients were adult and female. Mean age was 31.7 years and mean follow-up duration was 18 months. Peritonitis rate was 1 episode /21.3 months and was easily managed in most patients. Staphylococcus aureus was the most commonly isolated organism (24%) but 49% of cases were culture negative. There were no exit-site infections. Mean weekly Kt/V urea was 1.78 +/- 0.23.

CONCLUSION

We report the successful development of a small CAPD program in Egypt, made possible by well-established financial support, a motivated team of doctors and nurses, and good patient selection and training.

Geographic and educational factors and risk of the first peritonitis episode in Brazilian Peritoneal Dialysis study (BRAZPD) patients

BACKGROUND AND OBJECTIVES

Peritonitis remains as the most frequent cause of peritoneal dialysis (PD) failure, impairing patient's outcome. No large multicenter study has addressed socioeconomic, educational, and geographic issues as peritonitis risk factors in countries with a large geographic area and diverse socioeconomic conditions, such as Brazil.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Incident PD patients recruited from 114 dialysis centers and reporting to BRAZPD, a multicenter observational study, from December 2004 through October 2007 were included. Clinical, dialysis-related, demographic, and socioeconomic variables were analyzed. Patients were followed up until their first peritonitis. Cox proportional model was used to determine independent factors associated with peritonitis.

RESULTS

In a cumulative follow-up of 2032 patients during 22.026 patient-months, 474 (23.3%) presented a first peritonitis episode. In contrast to earlier findings, PD modality, previous hemodialysis, diabetes, gender, age, and family income were not risk predictors. Factors independently associated with increased hazard risk were lower educational level, non-white race, region where patients live, shorter distance from dialysis center, and lower number of patients per center.

CONCLUSIONS

Educational level and geographic factors as well as race and center size are associated with risk for the first peritonitis, independent of socioeconomic status, PD modality, and comorbidities.

Fungal peritonitis among the peritoneal dialysis patients of four Turkish centres

This study evaluates the clinical findings and treatment of continuous ambulatory peritoneal dialysis (CAPD) patients with fungal peritonitis in Istanbul from 2000 to 2010. The clinical records of 15 patients with fungal peritonitis among the total 795 patients were reviewed for the clinical and laboratory data. The mean duration of dialysis from the initiation of treatment until the development of fungal peritonitis was 41.14 months. Fungal peritonitis was the primary episode of infection in eight patients. In five other patients previous intensive antibiotherapy was documented. The isolated mircoboes were Candida albicans in six, non-C. albicans in eight and Aspergillus fumigatus in one patient. Tenckoff catheters were removed in all cases and antifungal treatment was given for a minimum of three weeks. Two patients died in the hospital due to the fungal infection whereas others were transferred to haemodialysis. This study highlights the importance of removing the catheter and initiating antifungal therapy as soon as possible in cases of fungal peritonitis because it is responsible for high morbidity and mortality.

Dialysis-associated peritonitis in children

Peritonitis remains a frequent complication of peritoneal dialysis in children and is the most common reason for technique failure. The microbiology is characterized by a predominance of Gram-positive organisms, with fungi responsible for less than 5% of episodes. Data collected by the International Pediatric Peritonitis Registry have revealed a worldwide variation in the bacterial etiology of peritonitis, as well as in the rate of culture-negative peritonitis. Risk factors for infection include young age, the absence of prophylactic antibiotics at catheter placement, spiking of dialysis bags, and the presence of a catheter exit-site or tunnel infection. Clinical symptoms at presentation are somewhat organism specific and can be objectively assessed with a Disease Severity Score. Whereas recommendations for empiric antibiotic therapy in children have been published by the International Society of Peritoneal Dialysis, epidemiologic data and antibiotic susceptibility data suggest that it may be desirable to take the patient- and center-specific history of microorganisms and their sensitivity patterns into account when prescribing initial therapy. The vast majority of patients are treated successfully and continue peritoneal dialysis, with the poorest outcome noted in patients with peritonitis secondary to Gram-negative organisms or fungi and in those with a relapsing infection.

A Prospective Randomized Study Comparing Tenckhoff Catheters Inserted using the Triple Incision Method with Standard Swan Neck Catheters

Background and Objective

The downward directed exit of the swan neck catheter may decrease the risk of exit-site infection (ESI). The percentage of migrations of the swan neck catheter seems to be less than the conventional Tenckhoff catheter and the swan neck catheter is more expensive and cannot be manipulated by guidewire technique if tip migration occurs. In this study, the conventional Tenckhoff catheter was used. The straight tunnel was converted to an arcuate one using the triple incision method, resulting in a downward directed exit. The arcuate tunnel was created by passing the catheter through an additional incision located between the paramedian incision and the exit site. We compared the infective and mechanical complications of the Tenckhoff catheter with a downward exit, implanted using the triple incision method, with the swan neck catheter.

Patients and Methods

101 new peritoneal dialysis patients were prospectively randomized to receive either the Tenckhoff catheter with a downward exit, implanted using the triple incision method, or the swan neck catheter. Each patient was followed up for 24 months. 50 patients were in the triple incision method group (TIMG) and 51 were in the swan neck catheter group (SNCG).

Results

Over a mean period of 18.9 ± 8.0 months of follow-up, ESI occurred in 35 patients (70%) in TIMG and 37 patients (72.5%) in SNCG ( p = 0.83). The ESI rates were 0.71 and 1.0 episodes/catheter-year in TIMG and SNCG respectively ( p = 0.21). The peritonitis rates were similar in the 2 groups (0.64 episodes/year in TIMG and 0.68 episodes/year in SNCG, p = 0.47). More patients in TIMG had tip migration [15 patients (30%) in TIMG vs 10 patients (19.6%) in SNCG] but the difference was not statistically significant. Repositioning of the catheter by guidewire manipulation was successful in patients in TIMG but not in SNCG. Overall catheter survival at 12 and 24 months was 95% and 83% in TIMG and 93% and 79% in SNCG respectively ( p = 0.72).

Conclusion

By using the conventional Tenckhoff catheter with a downward exit created using the triple incision method, high catheter survival rates with infective and mechanical complication rates similar to those of the swan neck catheter can be achieved. The triple incision method has the additional advantages of lower cost and the catheter can be manipulated by guidewire technique if tip migration occurs.

Streptococcal peritonitis in Australian peritoneal dialysis patients: predictors, treatment and outcomes in 287 cases

BACKGROUND

There has not been a comprehensive, multi-centre study of streptococcal peritonitis in patients on peritoneal dialysis (PD) to date.

METHODS

The predictors, treatment and clinical outcomes of streptococcal peritonitis were examined by binary logistic regression and multilevel, multivariate poisson regression in all Australian PD patients involving 66 centres between 2003 and 2006.

RESULTS

Two hundred and eighty-seven episodes of streptococcal peritonitis (4.6% of all peritonitis episodes) occurred in 256 individuals. Its occurrence was independently predicted by Aboriginal or Torres Strait Islander racial origin. Compared with other organisms, streptococcal peritonitis was associated with significantly lower risks of relapse (3% vs 15%), catheter removal (10% vs 23%) and permanent haemodialysis transfer (9% vs 18%), as well as a shorter duration of hospitalisation (5 vs 6 days). Overall, 249 (87%) patients were successfully treated with antibiotics without experiencing relapse, catheter removal or death. The majority of streptococcal peritonitis episodes were treated with either intraperitoneal vancomycin (most common) or first-generation cephalosporins for a median period of 13 days (interquartile range 8-18 days). Initial empiric antibiotic choice did not influence outcomes.

CONCLUSION

Streptococcal peritonitis is a not infrequent complication of PD, which is more common in indigenous patients. When treated with either first-generation cephalosporins or vancomycin for a period of 2 weeks, streptococcal peritonitis is associated with lower risks of relapse, catheter removal and permanent haemodialysis transfer than other forms of PD-associated peritonitis.

Treatment for peritoneal dialysis-associated peritonitis

BACKGROUND

Peritonitis is a common complication of peritoneal dialysis (PD) and is associated with significant morbidity. Adequate treatment is essential to reduce morbidity and recurrence.

OBJECTIVES

To evaluate the benefits and harms of treatments for PD-associated peritonitis.

SEARCH STRATEGY

We searched the Cochrane Renal Group's specialised register, the Cochrane Central Register of Controlled Trials (CENTRAL, in The Cochrane Library), MEDLINE, EMBASE and reference lists without language restriction. Date of search: February 2005

SELECTION CRITERIA

All randomised controlled trials (RCTs) and quasi-RCTs assessing the treatment of peritonitis in peritoneal dialysis patients (adults and children) evaluating: administration of an antibiotic(s) by different routes (e.g. oral, intraperitoneal, intravenous); dose of an antibiotic agent(s); different schedules of administration of antimicrobial agents; comparisons of different regimens of antimicrobial agents; any other intervention including fibrinolytic agents, peritoneal lavage and early catheter removal were included.

DATA COLLECTION AND ANALYSIS

Two authors extracted data on study quality and outcomes. Statistical analyses were performed using the random effects model and the dichotomous results were expressed as relative risk (RR) with 95% confidence intervals (CI) and continuous outcomes as mean difference (WMD) with 95% CI.

MAIN RESULTS

We identified 36 studies (2089 patients): antimicrobial agents (30); urokinase (4), peritoneal lavage (1) intraperitoneal (IP) immunoglobulin (1). No superior antibiotic agent or combination of agents were identified. Primary response and relapse rates did not differ between IP glycopeptide-based regimens compared to first generation cephalosporin regimens, although glycopeptide regimens were more likely to achieve a complete cure (3 studies, 370 episodes: RR 1.66, 95% CI 1.01 to 3.58). For relapsing or persistent peritonitis, simultaneous catheter removal/replacement was superior to urokinase at reducing treatment failure rates (1 study, 37 patients: RR 2.35, 95% CI 1.13 to 4.91). Continuous IP and intermittent IP antibiotic dosing had similar treatment failure and relapse rates. IP antibiotics were superior to IV antibiotics in reducing treatment failure (1 study, 75 patients: RR 3.52, 95% CI 1.26 to 9.81). The methodological quality of most included studies was suboptimal and outcome definitions were often inconsistent. There were no RCTs regarding duration of antibiotics or timing of catheter removal.

AUTHORS' CONCLUSIONS

Based on one study, IP administration of antibiotics is superior to IV dosing for treating PD peritonitis. Intermittent and continuous dosing of antibiotics are equally efficacious. There is no role shown for routine peritoneal lavage or use of urokinase. No interventions were found to be associated with significant harm.

Treatment of peritoneal dialysis-associated peritonitis: a systematic review of randomized controlled trials

BACKGROUND

Peritonitis frequently complicates peritoneal dialysis. Appropriate treatment is essential to reduce adverse outcomes. Available trial evidence about peritoneal dialysis peritonitis treatment was evaluated.

SELECTION CRITERIA FOR STUDIES

The Cochrane CENTRAL Registry (2005 issue), MEDLINE (1966 to February 2006), EMBASE (1985 to February 2006), and reference lists were searched to identify randomized trials of treatments for patients with peritoneal dialysis peritonitis.

INTERVENTIONS

Trials of antibiotics (comparisons of routes, agents, and dosing regimens), fibrinolytic agents, peritoneal lavage, and intraperitoneal immunoglobulin.

OUTCOMES

Treatment failure, relapse, catheter removal, microbiological eradication, hospitalization, all-cause mortality, and adverse reactions.

RESULTS

36 eligible trials were identified: 30 trials (1,800 patients) of antibiotics; 4 trials (229 patients) of urokinase; 1 trial of peritoneal lavage (36 patients); and 1 trial of intraperitoneal immunoglobulin (24 patients). No superior antimicrobial class was identified. In particular, glycopeptides and first-generation cephalosporins were equivalent (3 trials, 387 patients; relative risk [RR], 1.84; 95% confidence interval [CI], 0.95 to 3.58). Simultaneous catheter removal/replacement was superior to urokinase at decreasing treatment failures (1 trial, 37 patients; RR, 2.35; 95% CI, 1.13 to 4.91). Continuous and intermittent intraperitoneal antibiotic dosing were equivalent regarding treatment failure (4 trials, 338 patients; RR, 0.69; 95% CI, 0.37 to 1.30) and relapse (4 trials, 324 patients; RR, 0.93; 95% CI, 0.63 to 1.39). One trial showed superiority of intraperitoneal antibiotics over intravenous therapy.

LIMITATIONS

The method quality of trials generally was suboptimal and outcome definitions were inconsistent. Small patient numbers led to inadequate power to show an effect. Interventions, such as optimal duration of antibiotic therapy, were not evaluated.

CONCLUSIONS

Trials did not identify superior antibiotic regimens. Intermittent and continuous antibiotic dosing are equivalent treatment strategies.

Factors Contributing to the Differences in Peritonitis Rates between Centers and Regions

Despite improvements in connectology, peritoneal dialysis (PD)–associated peritonitis contributes significantly to morbidity and modality failure in patients maintained on PD therapy. A broad spectrum of organisms—gram-positive, gram-negative, fungal, anaerobic—are involved in this complication. In addition, a significant percentage of episodes involve polymicrobial and culture-negative infection. Technological advances are being developed to minimize the incidence of access-related complications such as peritonitis. Many traditional factors such as exit-site infection and poor technique have been already identified. In the present review, we discuss the geographic, patient selection, and clinical issues that can affect peritonitis rates in different areas of the world and in different centers in the same area.

3,4-di-deoxyglucosone-3-ene promotes leukocyte apoptosis

BACKGROUND

Heat-sterilized, single-chambered, glucose-containing peritoneal dialysis solutions promote neutrophil apoptosis and impair the peritoneal antibacterial response. It has been proposed that glucose degradation products may be responsible for this effect. However, the precise contribution of individual glucose degradation products had not been addressed.

METHODS

The effect of individual glucose degradation products on apoptosis in cultured human neutrophils and peripheral blood mononuclear cells was studied.

RESULTS

Peritoneal dialysis solutions with a high content of both glucose and glucose degradation products accelerated neutrophil and mononuclear cell apoptosis. Among the different glucose degradation products, 3,4-di-deoxyglucosone-3-ene (3,4-DGE) accelerated apoptosis in neutrophils and peripheral blood mononuclear cells at concentrations (25 micromol/L) in the range found in heat-sterilized, single-chambered, 4.25% glucose peritoneal dialysis fluids. Apoptosis induced by 3,4-DGE was caspase-dependent and could be prevented by the broad-spectrum caspase inhibitor benzyloxycarbonyl-Val-Ala-DL-Asp-fluoromethylketone (zVAD-fmk). By contrast, no cytotoxicity was observed following the addition of methylglyoxal, acetaldehyde, formaldehyde, or 3-deoxyglucosone at concentrations found in peritoneal dialysis solutions.

CONCLUSION

3,4-DGE appears to be the main proapoptotic factor in high glucose peritoneal dialysis solutions. 3,4-DGE may impair peritoneal defenses by accelerating leukocyte apoptosis.