Narrative Review
Peritoneal Dialysis–Related Peritonitis: Towards Improving Evidence, Practices, and Outcomes

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Peritonitis is a common serious complication of peritoneal dialysis that results in considerable morbidity, mortality, and health care costs. It also significantly limits the use of this important dialysis modality. Despite its importance as a patient safety issue, peritonitis practices and outcomes vary markedly and unacceptably among different centers, regions, and countries. This article reviews peritonitis risk factors, diagnosis, treatment, and prevention, particularly focusing on potential drivers of variable practices and outcomes, controversial or unresolved areas, and promising avenues warranting further research. Potential strategies for augmenting the existing limited evidence base and reducing the gap between evidence-based best practice and actual practice also are discussed.

Section snippets

Epidemiology

There is wide variation in rates of PD peritonitis across different centers and countries. Reported rates range from 0.06-1.66 episodes/patient-year.11 These reports tend to be dominated by single-center studies, which may reflect publication bias because overall peritonitis rates tend to be higher in unselected multicenter studies.12, 13 Even within the same country, peritonitis rates vary substantially among PD units. In a previous analysis of data from the Australian and New Zealand Dialysis

Risk Factors

Reported risk factors for PD peritonitis are listed in Box 1. The majority of these associations originate from outcomes based on observational studies and may relate to factors that increase the risk of infection generally (eg, diabetes mellitus,12, 24 frailty, and comorbid disease burden24, 25, 26) or of peritonitis specifically (eg, positive nasal S aureus carrier status27 and history of exit-site infection28, 29). Furthermore, there are several demographic factors that have been associated

Diagnosis

Another potentially significant source of variability in peritonitis rates among different units relates to coding bias according to the peritonitis definitions. The International Society of PD (ISPD) has attempted to minimize such variability by publishing specific diagnostic criteria for PD peritonitis to calculate peritonitis rates for the purpose of benchmarking across units.54 When a diagnosis of peritonitis is made, empiric antimicrobial therapy covering both Gram-positive and

Treatment

Timely management of peritonitis is associated with improved patient outcomes, including decreased risk of catheter removal.63 However, there remains considerable uncertainty about the optimal treatment strategy for peritonitis. The most recent update of the ISPD Peritonitis Treatment Guidelines recommends empiric antibiotics to cover both Gram-positive and Gram-negative organisms guided by local antimicrobial sensitivities.54 Although this is the best advice that can be offered in an

Prevention

There is systematic review and randomized controlled trial evidence supporting the use of disconnect (twin-bag and Y-set) systems87, 88 and preoperative administration of intravenous antibiotic (typically cephalosporin) prior to PD catheter insertion89, 90 to reduce the risk of peritonitis. However, to date, no beneficial effect has been demonstrated convincingly by randomized controlled trials for any other catheter-related intervention, including catheter insertion technique, catheter

Improving PD Peritonitis Outcomes

Despite the widespread availability and awareness of the ISPD guidelines for the prevention and treatment of PD peritonitis, there is substantial variation in PD peritonitis outcomes among different centers and countries.12, 13, 14, 15 The available evidence suggests that center variation in PD practice contributes substantially to these disparate outcomes. For example, a previous survey of Australian PD units by our group reported relatively low adherence (<50%) to evidence-based policies such

Summary and Future Directions

Peritonitis is a major complication of PD. It acts as a major disincentive to greater uptake of this important dialysis modality and extracts a heavy toll in terms of morbidity, mortality, and health care costs. Despite the importance of peritonitis as a patient safety issue, there is extraordinary and unacceptable variation in PD peritonitis rates and outcomes among different centers, regions, and countries. The reasons for this variation have been poorly studied, but may be related to a

Acknowledgements

Support: None.

Financial Disclosure: Dr Johnson is a consultant for Baxter Healthcare Pty Ltd and has previously received research funds from this company; has also received speakers' honoraria and research grants from Fresenius Medical Care; and is a current recipient of a Queensland Government Health Research Fellowship. Dr Cho declares that she has no relevant financial interests.

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