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Warady BA, Same R, Borzych-Duzalka D, Neu AM, El Mikati I, Mustafa RA, Begin B, Nourse P, Bakkaloglu SA, Chadha V, Cano F, Yap HK, Shen Q, Newland J, Verrina E, Wirtz AL, Smith V, Schaefer F. Clinical practice guideline for the prevention and management of peritoneal dialysis associated infections in children: 2024 update. Perit Dial Int 2024; 44:303-364. [PMID: 39313225 DOI: 10.1177/08968608241274096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/25/2024] Open
Abstract
Infection-related complications remain the most significant cause for morbidity and technique failure in infants, children and adolescents who receive maintenance peritoneal dialysis (PD). The 2024 update of the Clinical Practice Guideline for the Prevention and Management of Peritoneal Dialysis Associated Infection in Children builds upon previous such guidelines published in 2000 and 2012 and provides comprehensive treatment guidance as recommended by an international group of pediatric PD experts based upon a review of published literature and pediatric PD registry data. The workgroup prioritized updating key clinical issues contained in the 2012 guidelines, in addition to addressing additional questions developed using the PICO format. A variety of new guideline statements, highlighted by those pertaining to antibiotic therapy of peritonitis as a result of the evolution of antibiotic susceptibilities, antibiotic stewardship and clinical registry data, as well as new clinical benchmarks, are included. Recommendations for future research designed to fill important knowledge gaps are also provided.
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Affiliation(s)
- Bradley A Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Rebecca Same
- Department of Pediatrics, Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Dagmara Borzych-Duzalka
- Department of Pediatrics, Nephrology and Hypertension, Medical University of Gdańsk, Gdańsk, Poland
| | - Alicia M Neu
- Division of Pediatric Nephrology, Johns Hopkins Children's Hospital, Baltimore, Maryland, USA
| | - Ibrahim El Mikati
- Division of Nephrology and Hypertension, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Reem A Mustafa
- Division of Nephrology and Hypertension, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Brandy Begin
- Doernbecher Children's Hospital at Oregon Health & Science University, Portland, Oregon, USA
| | - Peter Nourse
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | | | - Vimal Chadha
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Francisco Cano
- Luis Calvo Mackenna Children's Hospital, Santiago, Chile
| | - Hui Kim Yap
- Division of Pediatric Nephrology, National University Hospital, Singapore, Singapore
| | - Qian Shen
- Children's Hospital of Fudan University, Shanghai, China
| | - Jason Newland
- Division of Pediatric Infectious Diseases, St. Louis Children's Hospital, St Louis, Missouri, USA
| | - Enrico Verrina
- Nephrology, Dialysis and Transplantation Unit, IRCCS Istituto Giannina Gaslini Children's, Genoa, Italy
| | - Ann L Wirtz
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Valerie Smith
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Franz Schaefer
- Heidelberg University Center for Pediatrics and Adolescent Medicine, Heidelberg, Germany
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Borzych-Dużałka D, Same R, Neu A, Yap HK, Verrina E, Bakkaloglu SA, Cano F, Patel H, Szczepańska M, Obrycki Ł, Spizzirri AP, Sartz L, Vondrak K, Rebori A, Milosevski-Lomic G, Chan EYH, Basu B, Pezo AL, Zaloszyc A, Chadha V, Schaefer F, Warady BA. Best Practice of Peritoneal Dialysis-Associated Gram-Negative Peritonitis in Children: Insights From the International Pediatric Peritoneal Dialysis Network Registry. Kidney Int Rep 2024; 9:1654-1663. [PMID: 38899186 PMCID: PMC11184244 DOI: 10.1016/j.ekir.2024.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/19/2024] [Accepted: 03/25/2024] [Indexed: 06/21/2024] Open
Abstract
Introduction Gram-negative peritonitis (GNP) is associated with significant morbidity in children receiving long-term peritoneal dialysis (PD) and current treatment recommendations are based on limited data. Methods Analysis of 379 GNP episodes in 308 children (median age 6.9 years, interquartile range [IQR]: 3.0-13.6) from 45 centers in 28 countries reported to the International Pediatric Peritoneal Dialysis Network registry between 2011 and 2023. Results Overall, 74% of episodes responded well to empiric therapy and full functional recovery (FFR) was achieved in 82% of cases. In vitro bacterial susceptibility to empiric antibiotics and lack of severe abdominal pain at onset were associated with a good initial response. Risk factors for failure to achieve FFR included severe abdominal pain at onset and at 60 to 72 hours from treatment initiation (odds ratio [OR]: 3.81, 95% confidence interval [CI]: 2.01-7.2 and OR: 3.94, 95% CI: 1.06-14.67, respectively), Pseudomonas spp. etiology (OR: 1.73, 95% CI: 1.71-4.21]) and in vitro bacterial resistance to empiric antibiotics (OR: 2.40, 95% CI: 1.21-4.79); the risk was lower with the use of monotherapy as definitive treatment (OR: 0.40, 95% CI: 0.21-0.77). Multivariate analysis showed no benefit of dual antibiotic therapy for treatment of Pseudomonas peritonitis after adjustment for age, presenting symptomatology, 60 to 72-hour treatment response, and treatment duration. Monotherapy with cefazolin in susceptible Enterobacterales peritonitis resulted in a similar FFR rate (91% vs. 93%) as treatment with ceftazidime or cefepime monotherapy. Conclusion Detailed microbiological assessment, consisting of patient-specific and center-specific antimicrobial susceptibility data, should guide empiric treatment. Treatment "deescalation" with the use of monotherapy and narrow spectrum antibiotics according to susceptibility data is not associated with inferior outcomes and should be advocated in the context of emerging bacterial resistance.
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Affiliation(s)
- Dagmara Borzych-Dużałka
- Department for Pediatrics, Nephrology and Hypertension, Medical University of Gdańsk, Gdańsk, Poland
- University Center for Pediatrics and Adolescent Medicine, Heidelberg, Germany
| | - Rebeca Same
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Alicia Neu
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Hui Kim Yap
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | | | - Francisco Cano
- Division of Pediatric Nephrology, Hospital Dr. Luis Calvo Mackenna, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Hiren Patel
- Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Maria Szczepańska
- Department of Pediatrics, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | | | - Ana Paula Spizzirri
- Division of Pediatric Nephrology, Hospital for Maria Ludovica, La Plata, Argentina
| | - Lisa Sartz
- Department of Pediatrics, Clinical Sciences Lund, Lund University, Lund, Sweden
| | | | | | | | - Eugene Yu-hin Chan
- Pediatric Nephrology Centre, Hong Kong Children’s Hospital, Kowloon Bay, Hong Kong SAR
| | | | | | - Ariane Zaloszyc
- Pediatric Nephrology, Pédiatrie 1, Centre Hospitalier Universitaire de Strasbourg, France
| | - Vimal Chadha
- Children’s Mercy Kansas City, Kansas City, Missouri, USA
| | - Franz Schaefer
- University Center for Pediatrics and Adolescent Medicine, Heidelberg, Germany
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Chow KM, Li PKT, Cho Y, Abu-Alfa A, Bavanandan S, Brown EA, Cullis B, Edwards D, Ethier I, Hurst H, Ito Y, de Moraes TP, Morelle J, Runnegar N, Saxena A, So SWY, Tian N, Johnson DW. ISPD Catheter-related Infection Recommendations: 2023 Update. Perit Dial Int 2023; 43:201-219. [PMID: 37232412 DOI: 10.1177/08968608231172740] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
Peritoneal dialysis (PD) catheter-related infections are important risk factors for catheter loss and peritonitis. The 2023 updated recommendations have revised and clarified definitions and classifications of exit site infection and tunnel infection. A new target for the overall exit site infection rate should be no more than 0.40 episodes per year at risk. The recommendation about topical antibiotic cream or ointment to catheter exit site has been downgraded. New recommendations include clarified suggestion of exit site dressing cover and updated antibiotic treatment duration with emphasis on early clinical monitoring to ascertain duration of therapy. In addition to catheter removal and reinsertion, other catheter interventions including external cuff removal or shaving, and exit site relocation are suggested.
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Affiliation(s)
- Kai Ming Chow
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Philip Kam-Tao Li
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Yeoungjee Cho
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Ali Abu-Alfa
- Division of Nephrology and Hypertension, American University of Beirut, Lebanon
- Section of Nephrology, Yale School of Medicine, New Haven, CT, USA
| | | | - Edwina A Brown
- Imperial College Renal and Transplant Centre, Imperial College NHS Trust, London, UK
| | - Brett Cullis
- Department of Nephrology and Child Health, University of Cape Town, South Africa
| | - Dawn Edwards
- National Forum of ESRD Networks, Kidney Patient Advisory Council (KPAC), USA
| | - Isabelle Ethier
- Division of Nephrology, Centre hospitalier de l'Université de Montréal, Canada
- Health Innovation and Evaluation Hub, Centre de recherche du Centre hospitalier de l'Université de Montréal, Canada
| | - Helen Hurst
- School of Health and Society, University of Salford, Salford Royal, Northern Care Alliance Trust, UK
| | - Yasuhiko Ito
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Thyago Proença de Moraes
- Programa de Pós-Graduação em Ciências da Saúde, Pontifícia Universidade Católica do Paraná, Curitiba, Brazil
| | - Johann Morelle
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Naomi Runnegar
- Infectious Management Services, Princess Alexandra Hospital, University of Queensland, Brisbane, Australia
| | - Anjali Saxena
- Department of Medicine, Division of Nephrology, Stanford University, CA, USA
- Department of Medicine, Division of Nephrology, Santa Clara Valley Medical Center, San Jose, CA, USA
| | - Simon Wai-Yin So
- Department of Pharmacy, Alice Ho Miu Ling Nethersole Hospital, Tai Po, Hong Kong
| | - Na Tian
- Department of Nephrology, General Hospital of NingXia Medical University, Yinchuan, China
| | - David W Johnson
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
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Sachar M, Shah A. Epidemiology, management, and prevention of exit site infections in peritoneal dialysis patients. Ther Apher Dial 2021; 26:275-287. [PMID: 34435734 DOI: 10.1111/1744-9987.13726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 08/04/2021] [Accepted: 08/22/2021] [Indexed: 11/29/2022]
Abstract
Exit site infection (ESI) is a leading complication of peritoneal dialysis (PD), at an incidence of 0.6 episodes per year in the United States, and a major risk factor for catheter removal and peritonitis. An estimated 20% of all peritonitis cases are preceded by an ESI, with up to 50% of Staphylococcus aureus peritonitis associated with ESI. Gram-negative ESIs are less associated with succeeding peritonitis than their gram-positive counterparts, though when present, are associated with a lower peritonitis cure rate. The rate of catheter removal for refractory ESI is relatively highest in ESI due to mycobacteria (up to 40%), S. aureus (35%), Pseudomonas aeruginosa (28%), followed by Corynebacterium, Serratia, and fungi. In review of relevant literature, we found no prophylactic benefit of dressings over nondressings, specific antiseptics over normal saline, or topical honey over topical antibiotic prophylaxis, and thus recommend individualized exit site hygiene. We found topical gentamicin effective for prevention of most ESIs, including gram-negative ESIs, and thus recommend consideration of prophylactic topical gentamicin in areas of high gram-negative peritonitis incidence. With long-term use, observational studies detect up to 25% of gram-positive and 14% of gram-negative ESIs may be mupirocin and gentamicin resistant, respectively. We review empiric and targeted ESI management, including indications for ultrasound, anti-VMRSA, anti-Pseudomonal, and anti-mycobacterial antibiotic use, and catheter removal. We recommend further investigation into the earlier use of second-line treatment agents and the utility of treating post-infectious exit site colonization as avenues to decrease refractory and repeat ESI.
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Affiliation(s)
- Moniyka Sachar
- Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Ankur Shah
- Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Division of Nephrology, Rhode Island Hospital, Providence, Rhode Island, USA.,Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
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