Peritonitis rates vary by country, facility for patients on PD
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For patients on peritoneal dialysis, the risk of developing peritonitis varies based on country and facility-related factors, according to recently published findings.
Jeffrey Perl, MD, SM, FRCP(C), of Arbor Research Collaborative for Health in Michigan and St. Michael’s Hospital in Toronto, and colleagues argued that PD-related peritonitis is the leading cause of transition to hemodialysis and is associated with adverse patient outcomes. Therefore, “better understanding regarding the incidence and prevalence of PD peritonitis episodes ... is needed to develop and evaluate peritonitis prevention strategies,” they wrote.
Perl and colleagues used data from the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) related to 7,051 patients on PD in 209 facilities across Australia, New Zealand, Canada, Japan, Thailand, United Kingdom and United States. Peritonitis rate (by country, overall and variation across facilities) and facility characteristics (census count, facility age, nurse to patient ratio and use of automated PD) were considered.
Researchers identified 2,272 peritonitis episodes, which showed a crude incidence rate of 0.28 episodes per patient per year. Researchers noted facility peritonitis rates were variable within each country and exceeded 0.50 episodes per patient per year in 10% of facilities.
By country, researchers determined peritonitis rates to be 0.40 episodes per patient per year in Thailand, 0.38 in the United Kingdom, 0.35 in Australia/New Zealand, 0.29 in Canada, 0.27 in Japan and 0.26 in the United States. More than two-thirds of peritonitis episodes were associated with hospitalization
As for facility characteristics, size was positively associated with peritonitis risk in Japan (rate ratio per 10 patients = 1.07), while lower risk was observed in facilities that had higher automated PD use, in centers that used antibiotics at catheter insertion and at facilities with PD training duration of 6 or more days.
When examining the microbiology of peritonitis, researchers found that while it was similar across most countries, gram-negative infections and culture-negative peritonitis were more common in Thailand.
“We have identified important regional differences in the risk for peritonitis and potentially modifiable practices that may reduce these risks,” they wrote. “ ... This study sets the stage for future PDOPPS studies of other practices related to peritonitis prevention; for example, highlighting differences in patient training strategies and novel technologies such as remote patient monitoring. In addition, PDOPPS has identified important gaps in translating best practices across facilities, including selected [International Society of Peritoneal Dialysis] ISPD guideline recommendations that may affect the risk for peritonitis.” – by Melissa J. Webb
Disclosures: Perl reports consulting fees from Baxter Healthcare and DaVita, and speaker honoraria from Baxter International, DaVita, Dialysis Clinic Inc. and Fresenius Medical Care. Please see study for all other authors’ relevant financial disclosures.
Perspective
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Vesh Srivatana, MD
For those of us who take care of patients on PD, these latest results from PDOPPS are highly anticipated. This article details the rates and risk factors for PD-related infection in a large cohort with prospectively collected data from seven countries.
Peritonitis is the most dreaded complication of PD and yet, somehow, misinformation likely outpaces the facts among patients and professionals alike. These data represent the most modern and comprehensive study of peritonitis and PD facility practices to date.
The peritonitis rate of 0.28 episodes/patient-year detailed by Perl and colleagues provides a reasonable overall reference point. This finding alone shows peritonitis is far from inevitable and, more importantly, preventable. In addition, this rate is below the International Society of Peritoneal Dialysis (ISPD) recommendation of 0.5 episodes/patient-year. PDOPPS data excludes PD units with fewer than 20 patients, so the authors concede this may represent the experience of higher volume and higher performing PD units that choose to participate in PDOPPS.
Lower peritonitis risk was observed in facilities that had higher automated PD use, facilities that used antibiotics at catheter insertion and facilities with PD training duration of 6 days or more.
The broad international cohort represented in these data is fascinating given the heterogeneity in resources, practice patterns and government policies between countries. This serves as proof of concept that PD programs can find success despite fewer resources. Perhaps peritonitis risk can be further minimized in higher resource countries.
There are potential interventions for all types of PD programs to decrease the rate of peritonitis. The finding of lower peritonitis risk in facilities with higher automated PD (APD) use should further dispel any myth that there is a difference in peritonitis rates between PD modalities. Perhaps there is an advantage to using APD.
There is no established standard length of patient training, but better trained patients can lead by extension to lower rates of peritonitis. Additionally, uniform adherence to established ISPD recommendations like antibiotic use at catheter insertion and topical exit site antibiotic prophylaxis may further improve peritonitis rates. Overall these findings provide a foundation for the future to find practical solutions for peritonitis prevention.
The Rogosin Institute
New York
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