Prevalence and risk factors of exit-site infection in incident peritoneal dialysis patients

BACKGROUND

Exit-site infection (ESI) is a common complication in peritoneal dialysis (PD) patients. Clearly understanding the risk factors may be useful for the prevention of ESI. This study was to explore the prevalence and risk factors of ESI in incident PD patients.

METHODS

We evaluated ESI in incident PD patients who had catheter insertion in our center between 1 January 2009 and 31 December 2013, with follow-up for 1 year. We collected data on demographics, clinical features, and nursing care methods of the exit site (ES).

RESULTS

We recruited 1133 incident PD patients (687 male (60.6%); mean age 47.0 ± 15.1 years), and 245 (21.6%) had diabetes. Median follow-up was 12.0 months. One hundred and thirty-one patients had 139 episodes of ESI with a rate of 92.8 patient-months per episode (0.13 episodes per year). Coagulase-negative staphylococcus was the main pathogen, accounting for 33.8% of the ESIs. Gram-positive rods, Staphylococcus aureus, Pseudomonas, fungi, and other organisms accounted for 23.0%, 15.8%, 1.4%, 1.4%, and 2.9%, respectively. No bacterial growth was found in 15.1%. There were no differences in demographic and laboratory data (age, gender, primary kidney disease, hemoglobin, white blood cell, serum albumin, blood urea nitrogen, serum creatinine, and C-reactive protein) between the ESI and non-ESI groups. Poor competency of ES care, poor catheter immobilization, history of catheter-pulling injury, and mechanical stress on the ES were significantly associated with increased risk of ESI.

CONCLUSIONS

The prevalence of ESI was 0.13 episodes per year. Poor competency of ES care, catheter mobilization, history of catheter-pulling injury, and mechanical stress by waist belt or the protective bag of PD on ES were risk factors for ESI.

Peritonitis in children with automated peritoneal dialysis: a single-center study of a 10-year experience

Peritoneal dialysis (PD) constitutes the preferred dialysis modality for children requiring renal replacement therapy with peritonitis being one of the most common complications of PD. This study was performed to evaluate the epidemiology, microbiology, and outcomes of PD-associated peritonitis in Greek children for a 10-year period. A total of 27 patients (16 males) with a mean age 121.8 ± 57.2 months were retrospective analyzed. Patients were on PD therapy for a mean duration of 45.2 ± 26.1 months. We found 23 episodes of PD-associated peritonitis occurred in 9 out of 27 patients (0.23 episodes/patient-year), with four patients experienced two or more peritonitis episodes. Gram-positive bacteria were responsible for 15 (65.2%) peritonitis episodes, with Staphylococcus aureus being the predominant specie isolated in 30.4% of cases. A total of seven episodes of exit-site infections (ESIs) were identified in five patients (0.069 episodes/patient-year) with the most common bacteria isolated being S. aureus (57.4%). Initial antibiotic treatment included intraperitoneal vancomycin plus ceftazidime in the majority of cases (82.6%). At the end of study, 12 (44.4%) patients remained on PD, 11 (41.8%) underwent renal transplantation, 2 (7.4%) shifted to hemodialysis and unfortunately, two patients (7.4%) died. Conclusively, our study revealed a noticeable low peritonitis and ESIs rate as compared to international data and represents the first evaluation of the characteristics and outcomes of peritonitis in the Greek pediatric PD population.

[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.

Outcomes of peritonitis in children on peritoneal dialysis: a 25-year experience at Severance Hospital

PURPOSE

Relatively little is known on the microbiology, risk factors and outcomes of peritoneal dialysis (PD)-associated peritonitis in Korean children. We performed this study in order to evaluate the incidence, treatment and clinical outcomes of peritonitis in pediatric PD patients at Severance Hospital.

MATERIALS AND METHODS

We analyzed data from 57 PD patients younger than 18 years during the period between June 1, 1986 and December 31, 2011. The collected data included gender, age at commencement of PD, age at peritonitis, incidence of peritonitis, underlying causes of end stage renal disease, microbiology of peritonitis episodes, antibiotics sensitivity, modality and outcomes of PD.

RESULTS

We found 56 episodes of peritonitis in 23 of the 57 PD patients (0.43 episodes/patient-year). Gram-positive bacteria were the most commonly isolated organisms (40 episodes, 71.4%). Peritonitis developed in 17 patients during the first 6 months following initiation of PD (73.9%). Peritonitis episodes rarely resulted in relapse or the need for permanent hemodialysis and no patient deaths were directly attributable to peritonitis. Antibiotic regimens included cefazolin+tobramycin from the years of 1986 to 2000 and cefazolin+ ceftazidime from the years of 2001 to 2011. While antibiotic therapy was successful in 48 episodes (85.7%), the treatment was ineffective in 8 episodes (14.3%). The rate of continuous ambulatory PD (CAPD) peritonitis was statistically higher than that of automated PD (APD) (p=0.025).

CONCLUSION

Peritonitis was an important complication of PD therapy and we observed a higher incidence of PD peritonitis in patients with CAPD when compared to APD.

The association between exit site infection and subsequent peritonitis among peritoneal dialysis patients

BACKGROUND AND OBJECTIVES

Peritonitis is the most common infectious complication seen in peritoneal dialysis (PD). Traditionally, exit site infection (ESI) has been thought to predispose PD patients to peritonitis, although the risks have not been quantified. This study aimed to quantify the risk of PD peritonitis after ESI.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Data from 203 clinically stable PD patients >18 years of age who were followed as part of a randomized controlled trial over 18 months were used to estimate the risk of developing peritonitis within 30 days of an ESI compared with individuals who did not have a recent ESI. Sensitivity analyses were performed at 15, 45, and 60 days.

RESULTS

Patients were mostly male (64.5%) and Caucasian, with a mean age of 60.5 ± 14.4 years. There were 44 ESIs and 87 peritonitis episodes during the 18-month study. Seven patients had an ESI followed by peritonitis within 30 days. Using a frailty model, patients who had an ESI had a significantly higher risk of developing peritonitis within 30 days, even if the ESI was appropriately treated. This risk was maximal early on and diminished with time, with hazard ratios (95% confidence interval) of 11.1 at 15 days (HR=11.1, 95% CI=4.9-25.1), 5.3 at 45 days (2.5-11.3), and 4.9 at 60 days (2.4-9.9). In 2.3% of patients, subsequent peritonitis was caused by the same organism as the previous ESI.

CONCLUSIONS

A strong association between a treated ESI and subsequent PD peritonitis was present up to 60 days after initial diagnosis.

Epidemiology and outcomes of peritonitis in children on peritoneal dialysis in Australasia

Peritonitis is a common complication and major cause of morbidity in children on peritoneal dialysis. In this retrospective longitudinal study, we analysed data retrieved from the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA) on 167 patients aged less than 18 years of age who were treated with peritoneal dialysis during the period from October 2003 to December 2007. During this period there were 100 episodes of peritonitis in 57 patients (0.71 episodes/patient-year), with Gram-positive organisms most commonly isolated (44%). Peritonitis occurred frequently in the first 6 months after starting dialysis, with survival analysis showing peritonitis-free survival rates of 72%, 56% and 36% at 6 months, 1 year and 2 years respectively. Age was a weak predictor of peritonitis on univariate analysis, but previous peritonitis was the only significant predictor in a multivariate Cox proportional hazards model (adjusted hazard ratio 2.02; 95% CI: 1.20 to 3.40, p = 0.008). Peritonitis episodes infrequently resulted in relapse (5%), recurrence (7%) or the need for either temporary or permanent haemodialysis (5% and 7% respectively) and there were no patient deaths directly attributable to peritonitis. Compared with single organism peritonitis, polymicrobial peritonitis was not associated with any statistically significant differences in outcome. Further prospective studies are required to determine the most appropriate prophylactic measures and antibiotic regimens for use in pediatric patients.

Conservative surgical management of catheter infections in children on peritoneal dialysis

INTRODUCTION

Major indications for peritoneal dialysis catheter removal include chronic exit-site infection (ESI) or tunnel infection (TI). No consensus on the optimal treatment of these infections in children exists.

PATIENTS

During the last 10 years, 13 patients (7 females, mean age 56 months) on peritoneal dialysis were treated for recurrent ESI (N: 4) or TI (N: 9). Staphylococcus aureus (12 patients) and Pseudomonas aeruginosa (1 patient) were isolated. All patients had a double-cuff straight Tenchkoff catheter and underwent the shaving of the external cuff, with a new tunnel tightly adherent to the catheter, and an exit-site in the opposite abdominal region. A mean follow-up of 31 months/catheter demonstrated no recurrence of ESI and TI.

DISCUSSION

Little pediatric experience with cuff shaving exists: reported catheter salvage rates are 48-100%. In our experience, good results were obtained by shaving off the external cuff and re-creating a new tunnel, with a different course, strictly adherent to the catheter. This measure seems to guarantee an effective barrier against infections, while obviating the need of the external cuff.

CONCLUSIONS

Sometimes, in case of recurrent ESI or TI, the external cuff may facilitate the persistence of bacteria. A conservative surgical treatment offers good results in children.