Topical mupirocin/sodium hypochlorite reduces peritonitis and exit-site infection rates in children

Peritoneal Dialysis Guidelines 2019 Part 1 (Position paper of the Japanese Society for Dialysis Therapy)

Approximately 10 years have passed since the Peritoneal Dialysis Guidelines were formulated in 2009. Much evidence has been reported during the succeeding years, which were not taken into consideration in the previous guidelines, e.g., the next peritoneal dialysis PD trial of encapsulating peritoneal sclerosis (EPS) in Japan, the significance of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), the effects of icodextrin solution, new developments in peritoneal pathology, and a new international recommendation on a proposal for exit-site management. It is essential to incorporate these new developments into the new clinical practice guidelines. Meanwhile, the process of creating such guidelines has changed dramatically worldwide and differs from the process of creating what were “clinical practice guides.” For this revision, we not only conducted systematic reviews using global standard methods but also decided to adopt a two-part structure to create a reference tool, which could be used widely by the society’s members attending a variety of patients. Through a working group consensus, it was decided that Part 1 would present conventional descriptions and Part 2 would pose clinical questions (CQs) in a systematic review format. Thus, Part 1 vastly covers PD that would satisfy the requirements of the members of the Japanese Society for Dialysis Therapy (JSDT). This article is the duplicated publication from the Japanese version of the guidelines and has been reproduced with permission from the JSDT.

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 on Chronic Peritoneal Dialysis: The Experience of a Large National Pediatric Cohort

BACKGROUND

We performed this study to evaluate the incidence, risk factors, microbiology, treatment, and outcome of peritonitis in pediatric Peritoneal dialysis (PD) patients at a nationwide prospective study.

METHODOLOGY

Patients younger than 18 years recruited in the BRAZPD II study from 2004 to 2011, who presented their first peritonitis episode, were included in the study.

RESULTS

We found 125 first episodes of peritonitis in 491 children PD patients (0.43 episodes/patient-year). Patients free of peritonitis episode constituted 75.6% in 1 year. Culture-negative episodes were very high (59.2%) and gram-positive (GP) bacteria were the most commonly found organisms (58.8%). First-generation cephalosporin was the initial choice to cover GP (40.5%) and aminoglycosides was the most prescribed antibiotics used for gram-negative agents (27.5%). Treatment failure was 26.4%. Technique failure (TF) occurred in 12.1% and peritonitis was the main cause (65.1%). Pseudomonas (p = 0.04) and negative cultures (p < 0.001) were identified as predictors of TF.

CONCLUSION

Peritonitis remains a common complication of PD in children and negative cultures and pseudomonas had a negative impact on TF.

Peritoneal dialysis-related infections recommendations: 2016 update. What is new?

In 2016, the International Society of Peritoneal Dialysis (ISPD) published guidelines that focus on the importance of both prevention and treatment of peritonitis. For once more, the need for annual reporting of peritonitis rates and recording of peritonitis and exit-site infections, isolated microorganism and antimicrobial susceptibilities as a central component of a quality improvement program is highlighted. Data on new antibiotic regimens, techniques for microorganism isolation and peritoneal dialysis solutions are included. Training of both peritoneal dialysis nurses and patients seems to be crucial, while the modifiable risk factors for peritonitis seem to be of great interest. In this article, we record the changes in the last ISPD (2016) guidelines compared to the previous ones published in 2010.

Comparing the Effect of Dressing Versus No-dressing on Exit Site Infection and Peritonitis in Chronic Ambulatory Peritoneal Dialysis Patients

Bachground:

Peritonitis and exit site (ES) infection are two main complications of peritoneal dialysis. There are some controversies regard to preventive strategies for ES care. In this study we compared peritonitis and ES infection rates in patients with and without dressing.

Materials and Methods:

This historical cohort study carried out on 72 patients under continuous ambulatory peritoneal dialysis treatment, 54 with dressing versus 18 patients without dressing, followed from October 1, 2010 to March 31, 2011 for peritonitis and ES infection.

Results:

A total of 17 episodes of ES infection occurred in 12 patients in dressing group, but no case was seen in no-dressing group (P = 0.02). Twenty-one episodes of peritonitis occurred in 15 patients in both groups (one episode every 20.6 patient-months). In no-dressing group two episodes occurred in only one patient (one episode every 54 patient-months), and in dressing group, 19 episode in 14 patients (one episode every 17.1 patient-months) (P = 0.03). Peritonitis was significantly more frequent in male versus female in overall patients (38% vs. 14%, P = 0.025) and in dressing group (52% vs. 15%, P = 0.003). In dressing group, peritonitis was more frequent in diabetics versus non-diabetics (48% vs. 11%, P = 0.01). Odds ratio for developing peritonitis was 9.4 in dressing group (95% confidence interval [CI] =1.05 − 84.4; P = 0.045), and 4.4 in men (95% CI = 1.26 − 15.19; P = 0.02).

Conclusion:

In this study, chronic ES care without dressing was associated with lower risk of peritonitis and ES infection.

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.

Readmission within 30 days of hospital discharge among children receiving chronic dialysis

BACKGROUND AND OBJECTIVES

The hospital admission rate for children receiving chronic dialysis has been increasing over the last decade. Approximately one third of patients with ESRD age 0-19 years are readmitted to the hospital within 30 days of discharge. The objective of this study was to examine hospital readmissions among a cohort of children receiving chronic dialysis to identify factors associated with higher rates of 30-day readmission.

DESIGN, SETTINGS, PARTICIPANTS, & MEASUREMENTS

A retrospective cohort of index admissions was developed among chronic dialysis patients age 3 months to 17 years at free-standing children's hospitals reporting information to the Pediatric Hospital Information System between January 2006 and November 30, 2010, and followed until December 31, 2010. The primary outcome was any-cause 30-day readmission, and the secondary outcome was 30-day readmission for a cause similar to that of the index hospitalization.

RESULTS

In this cohort, 25% of hospital admissions were followed by a readmission within 30 days. Children older than 2 years of age had a lower odds of readmission (odds ratio [OR], 0.6; 95% confidence interval [95% CI], 0.5 to 0.8). Those receiving hemodialysis had a higher risk of readmission (OR, 1.2; 95% CI, 1.0 to 1.4), and admissions >14 days were also more likely to be followed by a readmission (OR, 1.5; 95% CI, 1.1 to 2.0). Approximately 50% of the readmissions were for a similar diagnosis as the index admission; however, the specific admitting diagnosis was not associated with readmission.

CONCLUSIONS

A significant number of admissions among children receiving long-term dialysis are followed by readmission within 30 days. Further investigation is required to reduce the high rate of readmissions in these children.

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.

A randomized controlled trial comparing mupirocin and polysporin triple ointments in peritoneal dialysis patients: the MP3 Study

BACKGROUND AND OBJECTIVES

Infectious complications remain a significant cause of peritoneal dialysis (PD) technique failure. Topical ointments seem to reduce peritonitis; however, concerns over resistance have led to a quest for alternative agents. This study examined the effectiveness of applying topical Polysporin Triple ointment (P(3)) against mupirocin in a multi-centered, double-blind, randomized controlled trial.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

PD patients routinely applied either P(3) or mupirocin ointment to their exit site. Patients were followed for 18 months or until death or catheter removal. The primary study outcome was a composite endpoint of exit-site infection (ESI), tunnel infection, or peritonitis.

RESULTS

Seventy-five of 201 randomized patients experienced a primary outcome event (51 peritonitis episodes, 24 ESIs). No difference was seen in the time to first event for P(3) (13.2 months; 95% confidence interval, 11.9-14.5) and mupirocin (14.0 months; 95% confidence interval, 12.7-15.4) (P=0.41). Twice as many patients reported redness at the exit site in the P(3) group (14 versus 6, P=0.10). Over the complete study period, a higher rate per year of fungal ESIs was seen in patients using P(3) (0.07 versus 0.01; P=0.02) with a corresponding increase in fungal peritonitis (0.04 versus 0.00, respectively; P<0.05).

CONCLUSIONS

This study shows that P(3) is not superior to mupirocin in the prophylaxis of PD-related infections. Colonization of the exit site with fungal organisms is of concern and warrants further study. As such, the use of P(3) over mupirocin is not advocated in the prophylaxis of PD-related infections.

Peritoneal dialysis in children with end-stage renal disease

Peritoneal dialysis is the preferred chronic dialysis modality for most children owing to its almost universal applicability and superior compatibility with lifestyle over other modalities. Although technological advances and increasing clinical experience have impacted favorably on patient and technique survival, clinical research in pediatric peritoneal dialysis has been hampered by the low incidence of end-stage renal disease (ESRD) in the pediatric population. To overcome this limitation, several international registries have emerged in the past few years to complement other long-standing registries, which together have provided useful information regarding technique-specific complications and comorbidities associated with ESRD in children undergoing chronic peritoneal dialysis. In this Review, we summarize the most relevant findings from these studies, highlighting the substantial variation in patient conditions, peritoneal dialysis practices and management of comorbidities encountered in different parts of the world.

Advances in pediatric renal replacement therapy

Advances in the understanding and clinical application of hemodialysis, peritoneal dialysis, and continuous renal replacement therapy have resulted in strategies designed to further improve their safety and efficacy. These advances have been particularly important to children, in whom a variety of clinical and technical issues must be taken into consideration for optimum dialysis across a broad spectrum of patient size and need. This manuscript reviews recent data pertaining to the use of renal replacement therapy, with an emphasis on those aspects of dialysis management that are especially pertinent to pediatric ESRD and acute kidney injury care.

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.