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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2021  |  Volume : 32  |  Issue : 1  |  Page : 69-83
Factors Contributing to Peritonitis in Peritoneal Dialysis: Comparing Triple Cuff Saudi Catheter to Double Cuff Tenckhoff Catheter: A 12-Year Observational Study

1 Department of Internal Medicine, Division of Nephrology, King Fahd Hospital of the University, Alkhobar, Saudi Arabia
2 Department of Computer Science, AFDA, Cape town, South Africa
3 Department of Internal Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia

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Date of Web Publication16-Jun-2021


Very few detailed descriptive studies focusing on peritonitis in patients on peritoneal dialysis (PD) have been published. Most of the current information is available through from either study with the limited number of patients or isolated case reports. We conducted an observational study of our PD-peritonitis database over the past 12 years to study the clinical profile and the outcomes of peritonitis episodes in our PD center. A total of 1123 patients (male: 59.5%) with 319 episodes of peritonitis were identified. Of the patients, 130 (11.6%) were considered immunocompromised (steroid use, failed renal transplant, systemic lupus erythematosus, malignancy) and 468 (41.7%) had diabetes mellitus. The total number of bacterial peritonitis episodes was 319; of these 226 (70.8%) were seen with double cuff Tenckhoff PD catheter and 93 (29.2%) occurred with triple-cuff Saudi PD catheter (P = 0.0001). Of all peritonitis episodes 170 (53.3%) episodes were caused by a single Gram-positive organism, 124 (38.9%) episodes by a single Gram-negative organism, and 25 (7.8%) were polymicrobial. Coagulase-negative staphylococci were responsible for most cases of Gram-positive peritonitis (n = 110, 64.7%), while Escherichia coli was the causative organism in 67 (54.0%) of the single Gram-negative episodes. Peritonitis episodes due to Gram-positive organisms had a better outcome than those caused by Gram-negative bacteria. Fifteen (4.7%) of the 319 episodes resulted in death in 13 patients. In 79 (24.8%) episodes, the patients had to be transferred to hemodialysis because of unresolved peritonitis. Resolution rate was 75.2% (240 episodes) which was influenced by PD catheter type, PD duration and the number of days peritoneal fluid effluent remained above 100 cells/μL. Other modifiable and non-modifiable factors had no effect on the resolution rate. Peritonitis episodes due to Gram-positive organisms had a better outcome than those with Gram-negative or polymicrobial etiology. Peritonitis resolution rates were worse with Staphylococcus aureus and Pseudomonas aeruginosa infections. Diabetes, current steroid use, and exit-site/tunnel infections seemed to have limited influence on the peritonitis outcome. Type of PD catheter (double Tenckhoff vs triple-cuff Saudi catheter), duration of PD and the number of days peritoneal fluid effluent remained >100 cells/μL were the only factors with significant effects on the outcome.

How to cite this article:
Al-Hwiesh AK, Abdul-Rahman IS, Al-Hwiesh A, Taha A, Amir R, Al-Audah N, Abdel Galil MM, Nasr El-Din MA, Alhwiesh B, Alotaibi K, Fiore JR. Factors Contributing to Peritonitis in Peritoneal Dialysis: Comparing Triple Cuff Saudi Catheter to Double Cuff Tenckhoff Catheter: A 12-Year Observational Study. Saudi J Kidney Dis Transpl 2021;32:69-83

How to cite this URL:
Al-Hwiesh AK, Abdul-Rahman IS, Al-Hwiesh A, Taha A, Amir R, Al-Audah N, Abdel Galil MM, Nasr El-Din MA, Alhwiesh B, Alotaibi K, Fiore JR. Factors Contributing to Peritonitis in Peritoneal Dialysis: Comparing Triple Cuff Saudi Catheter to Double Cuff Tenckhoff Catheter: A 12-Year Observational Study. Saudi J Kidney Dis Transpl [serial online] 2021 [cited 2021 Nov 30];32:69-83. Available from: https://www.sjkdt.org/text.asp?2021/32/1/69/318550

   Introduction Top

Peritoneal dialysis (PD) associated infections both exit-site and peritonitis rates should be monitored and reported for every clinical dialysis program annually. Peritonitis is a common and serious complication of PD. Although less than 5% of peritonitis episodes result in death, peritonitis is the direct or major contributing cause of death in around 16% of PD patients.[1],[2],[3],[4],[5],[6] In addition, severe or prolonged peritonitis leads to structural and functional alterations of the peritoneal membrane, eventually leading to membrane failure. The overall peritonitis rate should not exceed 0.5 episodes per year at risk. In some outstanding centers, reported peritonitis rates are as low as 0.18 to 0.20 episodes per year.[7] In addition, the PD team comprised physicians and nurses, should review the presumed etiology, causative organisms, and antibiotic sensitivity of each infection. When infection rates are increasing or undesirably high, interventions should be employed. The three main methods of reporting infections due to PD include using rates, percentages, and median rates for each program each year. The updated 2016 guidelines recommend that every program should monitor and record peritonitis incidence, the overall rate of peritonitis, rates of specific organisms, percentage of patients who are peritonitis free, and susceptibilities yearly. The guidelines suggest using a standard number of episodes per patient-year for reporting and alsothat absolute rates should be reported as part of a continuous quality improvement (CQI) program.[7] The purpose of data documentation is to evaluate the program’s treatment regimen and to facilitate the best possible outcomes for patients. Most of peritonitis episodes are catheter related and hence, the primary goal of exit-site care is to prevent infections in PD. Catheter-related infection is one of the most common PD-related complications and can lead to peritonitis and permanent loss of peritoneal catheter (20%), and transfer to hemodialysis (HD) (15%–20%).[1] Therefore, the primary goal of exit-site care is to prevent infections in PD.[7] Peritonitis episodes caused by certain pathogens such as pseudomonas and fungi are associated with increased catheter loss and transfer to HD,[8],[9],[10],[11],[12],[13] while peritonitis due to peritonitis caused by coagulase-negative staphylococci (CoNS) has a higher resolution rate than peritonitis caused by other pathogens.[14],[15],[16] Polymicrobial peritonitis is thought to originate from a bowel leak.[17],[18],[19] Thus, one would expect a worse outcome from a bowel leak etiology rather than from an infection caused by touch contamination. The source of Gram-negative organisms in PD-associated peritonitis has been speculated to be either a gastrointestinal or skin source.[20] There are no convincing data regarding the effect of PD catheter design and configuration on peritonitis risk. Eight randomized trials have compared straight and coiled Tenckhoff PD catheters[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32] and found no difference in peritonitis rate. Several retrospective studies suggested that double-cuffed Tenckhoff catheters are associated with a lower peritonitis rate than single-cuffed ones. However, the only randomized trial on this topic showed no difference in peritonitis risk between the two catheter types.[31],[32] Our PD center used the double cuff Tenckhoff PD catheter which was replaced later with the previously described 3-cuff low-entry Saudi catheter[33] for sake of comparison. The current study aimed at determining the magnitude of the infection problem, identifying possible risk factors for PD-associated peritonitis, and comparing the outcomes with these two PD catheter modalities as well as the outcomes with different pathogens.

   Patients and Methods Top

This observational study was carried out at the PD Unit of King Fahd Hospital of the University, Al-Khobar, Saudi Arabia. We included all episodes of peritonitis occurring between October 2006 and November 2018. We obtained our data by reviewing case records of all patients with bacterial peritonitis. Diagnosis of peritonitis was made based on the presence of a positive bacterial culture of the PD effluent if it was associated with an effluent white cell count of >100/mL, with >50% polymorphonuclear leucocytes or symptoms and signs of peritoneal inflammation. We considered an episode of peritonitis that recurred within four weeks after the treatment of a previous episode to be a relapse. Repeat peritonitis was considered as infection by the same organism after four weeks of treatment. The data recorded included age at the time of peritonitis, age at the start of PD, gender, presence of diabetes mellitus (DM), cause of the end-stage renal disease (ESRD), type of PD catheter, PD effluent cell count, and duration of PD before the onset of the peritonitis episode. A patient receiving cortico-steroids at the time of peritonitis, or with an autoimmune disease, or having previous renal transplantation or with evidence of malignancy was considered immunocompromised. During the period of review, we used two types of peritoneal catheters placed either by surgeons or nephrologists. Catheters placed since October 2013 were the three-cuff Saudi catheter,[33] whereas the catheters placed earlier were the conventional double-lumen Tenckhoff PD catheters and both types had a coiled intra-abdominal segment. For each episode of peritonitis, data were collected on the symptoms of peritonitis, the condition of the exit site/tunnel, the initial PD effluent cell count, the initial effluent neutrophil count, the systemic white blood cell (WBC) count, the species of microorganism causing peritonitis, and the type and duration of antibiotic treatment. A record was made of the number of days the PD fluid cell count was >100 cells/μL and if the cell count was not available, we considered the number of days until the PD effluent was recorded as clear. From previous reports,[1],[34] the term “clear fluid” has always corresponded with an effluent cell count of <100 cells/μL. Peritonitis that was slow to resolve, or refractory peritonitis, was defined as the presence of PD fluid cell count >100 cells/μL after five days of antibiotic therapy.[35] Serum albumin prior to each episode of peritonitis was recorded as a measure of patients’ nutritional and inflammatory status. Furthermore, we recorded the date of catheter removal, death or transfer to HD. “Nonresolution” was defined as either death of the patient due to peritonitis, catheter removal, or temporary or permanent transfer to HD secondary to unresolved peritonitis. All these factors were analyzed in relation to the outcome of peritonitis episodes. During our study period, we used one empirical antibiotic regimen; ceftazidime and vancomycin for peritonitis treatment following the International Society of Peritoneal Dialysis (ISPD) recommendations.[7] Antibiotics were then modified according to the culture and sensitivity results of the PD effluent. All our patients used automated PD (APD), and for exit-site care all of them used povidone-iodine on a daily or every-other-day basis. Less frequently, chlorhexidine or soap and water were used on an intermittent basis. In all cases, mupirocin ointment or gentamicin cream was applied locally at the exit site on regular basis.

Technique of the 3-cuff PD Saudi catheter insertion

The triple-cuff catheter was inserted while the patient was placed in the supine position under general anesthesia using aseptic precautions. A Veress needle was used to create pneumoperitoneum at pressure of 10–12 mm Hg. A 5-mm port was inserted in right hypochondriac region at the midclavicular line, 2 cm below the costal margin for laparoscopic camera (30°). A diagnostic laparoscopy was then performed to rule out adhesions or herniations, and to help in assessing the size of omentum. The operating table was then placed in about 30° Trendelenburg position. A small incision (about 1 cm) was made at the lateral aspect of the rectus muscle in the suprapubic area through which the trocar with the pull-away sheath was introduced at an oblique angle. The peritoneum was then entered followed by removal of the trocar leaving the pull-away sheath in place. Dilatation of the oblique passage was performed by a small dilator followed by a larger one. The three-cuff PD catheter was then introduced caudally and obliquely through the pull-away sheath over a 90-cm stylet into the peritoneal cavity. The tip of the PD catheter was placed in the pouch of Douglas or the rectovesical pouch in females and males, respectively. The PD catheter was advanced to a level that allows the external cuff to be in position at the anterior surface of the rectus muscle; the stylet was then removed and the external cuff was secured with purse string suture on the fascia anterior to the rectus muscle. Then, a subcutaneous tunnel was created for the catheter with selection of a midway point at the umblicocrestal line to be the output of the catheter so that the catheter passage would be oblique. The end of the catheter attached to a stylet was advanced into the tunnel and pulled out from the above-mentioned point; the second cuff is about 10 cm from the distal one and the proximal cuff is 2 cm from the exit site. Antibiotic prophylaxis was given with a first-generation cephalosporin administered intravenously before the procedure. APD was generally instituted 14 days after PD catheter insertion. Patient training was performed during this period with low volume exchanges.

   Statistical Analysis Top

Univariate analyses were first conducted to identify potential risk factors for complicated episodes. The association between two categorical variables was evaluated by Chi-square test or Fisher’s exact test as appropriate. For continuous variables, the Student’s t-test (for normally distributed variables) or the nonparametric Mann–Whitney test was used to compare the difference in mean values in the two groups. Variables showing a statistically significant association with the complicated course, with a P <0.05, were considered candidate variables for inclusion in the multivariate model in order to determine which variables were independent predictors of a complicated outcome. Stepwise multivariate logistic regression was performed including the potential candidate variables. All analyses were conducted using the IBM SPSS Statistics version 20.0 (IBM Corp., Armonk, NY, USA). All statistical tests performed were two-tailed; P <0.05 was considered statistically significant.

   Results Top

The demographic characteristics of patients are presented in [Table 1]. We recorded 363 peritonitis episodes during the study period. Episodes of fungal (n = 12; 3.3%), tuberculous (11; 3.0%), or culture-negative (n = 20; 5.5%) peritonitis were excluded from the study. A total of 319 episodes of nontuberculous bacterial peritonitis were recorded in 1123 patients on PD between October 2006 and November 2018. Abdominal pain was the most common symptom of peritonitis present in 288 (90.3%) episodes, positive rebound in 173 (54.2%) episodes, nausea and vomiting in 98 (30.7%), fever in 79 (24.8%), and diarrhea in 50 (15.7%). Cloudy PD effluent was present in all, but 11 episodes. PD fluid cell count was not available in four episodes at presentation and were found to be <100 in nine (2.8%) of the remaining episodes. These patients were diagnosed based on two out of the three cardinal symptoms of peritonitis. PD effluent fluid cell count varied from 80 to 22000 (median: 5324). Elevated blood leucocyte count was present in 223(69.9%) episodes. Two-hundred and six episodes (64.6%) needed 7 ± 5.4 days of hospitalization. The total number of bacterial peritonitis episodes was 319; of these 226 (70.8%) were seen in the early phase with double cuff PD catheter and 93 (29.2%) occurred with triple-cuff PD catheter (late phase of the study) (P = 0.0001). Exit site infection (ESI) was found in 55 out of 226 (24.3%) and 23 out of 93 (24.7%) episodes in the early and the late phases of the study, respectively (P = 0.3316). Peritoneal leak and co-existent peritonitis were found in 9.7% and 8.6% episodes with double and triple-cuff, respectively (P = 0.2021) [Figure 1]. Twelve episodes were acquired in the hospital, with PD being performed by the trained nursing staff. No definite precipitating cause could be found in the remaining episodes.
Figure 1: Consort diagram for the outcome of peritonitis episodes.
ES/TI: Exit-site/tunnel infection, P. leak: Peritoneal leak, Gm +ve: Gram-positive, Gm -ve: Gram-negative, CoNS: Coagulase negative staphylococci, HD: Hemodialysis.

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Table 1: Demographic characteristics of 1063 peritoneal dialysis patients.

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The mean age of all 1123 patients was 55.7 ± 13.6 years; 53.8 ± 14.1 for patients with double-cuff PD catheter and 56.2 ± 12.1 for patients with triple-cuff PD catheter. There were 668 (59.5%) males and 455 (40.5%) females, all patients were Saudi. Diabetic nephropathy was the main cause of ESRD (n = 468; 41.7%), followed by chronic glomerulo-nephritis (n = 290; 25.8%) and hypertension (n= 172; 15.3%). Thirty-three (2.9%) had some form of malignancy, 27 (2.4%) patients had undergone renal transplantation in the past, and 72 (6.4%) patients were receiving steroids at the time of peritonitis as a part of postrenal transplant maintenance or for suppression of vasculitis or lupus activity. All patients used APD during the study period. For exit site care, almost all patients used povidone-iodine on a daily or every-other-day basis. Less frequently, chlorhexidine or soap and water were used on an intermittent basis. In all cases, mupirocin ointment or gentamicin cream was applied postcleaning.

[Table 2] lists the causative organisms of the 319 episodes of bacterial peritonitis. One hundred and seventy (53.3%) episodes were caused by a single Gram-positive organism, 124 (38.9%) episodes by a single Gram-negative organism. the remaining 25 (7.8%) episodes were polymicrobial. CoNS were responsible for most cases of Gram-positive peritonitis (n = 110; 64.7%), whereas Staphylococcus aureus was the etiologic agent in 40 episodes (23.5%) of Gram-positive episodes. Enterococcus comprised only 11.8% (n = 20) of the episodes caused by a Gram-positive organism. Escherichia coli was the causative organism in 67 (54.0%) of the single Gram-negative episodes, whereas Pseudomonas aeruginosa accounted for 22.6% (n = 28) of episodes due to Gram-negative organisms. Fifteen (4.7%) of the 319 episodes resulted in death, four of these episodes occurred in two patients [Figure 1]. All 13 patients were diabetic and above 65 years; their characteristics are shown in [Table 3]. Their initial PD effluent cell count was above 3000/μL, and the cell count remained above 100 cells/μL for an average of 7.9 ± 2.7 days and median duration of PD was 7.3 (interquartile range: 6.7–8.8) years. In 79 (24.8%) of episodes, the patients had to be transferred to HD because of unresolved peritonitis. PD catheter had to be removed and reinserted later in 27 (8.5%) episodes post-treatment of S. aureus or Pseudomonas peritonitis and in 10 (37.0%) episodes out of 27 there was no tissue infection (ESI/TI). The remaining 240 episodes (75.2%) had a successful outcome. Because of the small number of episodes resulting in death, these were combined with those ending in transfer to HD and, for sake of further analysis, were considered as episodes with no resolution (treatment failure). The outcomes of all episodes for each type of microorganism are listed in [Table 2]. The outcomes of episodes of single Gram-negative peritonitis and those due to polymicrobial peritonitis were significantly worse than episodes due to a single Gram-positive organism. The resolution rate for single Gram-positive peritonitis episodes was 86.5%, compared to 63.7% and 56.0% for single Gram-negative peritonitis episodes and poly-microbial peritonitis episodes, respectively (P = 0.001). Among episodes due to Gram-positive peritonitis, those due to S. aureus resulted in significantly lower resolution rates than other Gram-positive episodes (62.5% for S. aureus vs. 93.8% for other Gram-positive organisms, P = 0.0001). Seventeen (85%) of the 20 episodes of enterococcal peritonitis recovered but, when compared with other Gram-positive infection, there was no significant difference in the resolution rates (85.0% resolution rate for Enterococcus vs. 86.7% for other Gram-positive infections, P = 0.235). Among Gram-negative episodes, those due to E. coli had the highest resolution rate while those caused by P. aeruginosa had the lowest (83.6% vs.25.0%, respectively; P = 0.0001). Nonpseudomonas Gram-negative peritonitis episodes had a significantly higher resolution rate (55.2%) than P. aeruginosa peritonitis (P = 0.001). Peritonitis rates varied significantly between the two types of PD catheter used; it was 0.11-patient-year in the three-cuff PD Saudi catheter (late phase of the study) and 0.16 patient-year for episodes with the double-cuff conventional Tenckhoff catheter (early phase) (P = 0.001). History of steroid use, previous renal transplantation, and presence of some form of malignancy, serum uric acid level, and KT/V had no effect on the outcome of peritonitis. Conversely, the presence of diabetes, catheter type (2-cuff vs. 3-cuff) and the presence of a purulent exit site were associated with a significantly higher non-resolution rate. Diabetes was present in 44 out of 79 (55.7%) unresolved peritonitis episodes, 49 (62%) and 30 (38%) episodes were associated with the double-cuff and the three-cuff PD catheters respectively (P = 0.026). Fifty-four out of 79 non-resolution episodes (68.4%) was associated with purulent exit site versus 25 out of 79 episodes (31.6%) without purulent exit site, P = 0.016 [Table 4]. However, regression analysis showed that with exception of catheter type, none of these factors independently affected the outcome. After multivariate regression analysis of the continuous variables, catheter type (double-cuff vs. triple-cuff), the duration of PD and the number of days the effluent cell count was >100 cells/μL were the only factors that had a significant effect on outcome [Table 5]. Patients that had a successful outcome had been on PD for a significantly shorter time than patients that had nonresolution (4.6 ± 1.8 years for patients that had resolution vs. 6.8 ± 2.4 years for patients with nonresolution, P = 0.005). Further analysis (nonparametric) showed that the difference in outcome becomes significant at a cut-off of five years [Figure 2]. The nonresolution rate for patients that had been on PD for >5 years was 23.9%, compared to 15.8% for patients that had been on PD for <5 years (P = 0.038). The number of days the PD effluent cell count remained >100 cells/μL also had a significant effect on outcome. For the episodes that did not resolve, the mean number of days in which the cell count was >100/μL was 7.4 ± 1.4, compared to 4.8 ± 3.3 days for the episodes that had a successful outcome (P <0.001). Triple-cuff PD catheter was associated with significantly better resolution rate than the conventional Tenckhoff catheter (P = 0.022). Neither age at the onset of peritonitis nor patient age at the start of PD had any independent effect on the outcome. The other variables, including serum albumin concentration, total leukocyte count, and initial effluent WBC count, did not have any significant effect on the outcome of an episode of peritonitis.
Figure 2: Relation between unresolved peritonitis rate and duration of PD. Rate significantly increases after 5 years, P = 0.005.
PD: Peritoneal dialysis.

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Table 2: Causative organisms and outcome of 266 episodes of bacterial peritonitis.

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Table 3: Characteristics of patients who died with peritonitis during the study.

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Table 4: Significant predictors of outcome (univariate analysis).

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Table 5: Predictors of unresolved peritonitis (multivariate analysis).

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   Discussion Top

PD is associated with a high risk of infection of the peritoneum, subcutaneous tunnel, and catheter exit site.[6] ESI and tunnel infection (TI) per se pose little risks but the possibility of developing PD peritonitis demands careful attendance to these problems. As many as 15%–50% of ESRD patients are on PD, but recurrent or prolonged peritonitis may cause technique failure. The majority of PD catheter-related problems are of an infection nature -mainly represented by peritonitis (61%); ESI and TI (23%); catheter obstruction, dislocation, and leakage making up the rest.[36],[37] Peritonitis can be associated with severe pain leading to hospitalization, catheter loss, and risk of death; and it, therefore, continues to be a serious complication for PD patients.[38],[39],[40],[41] PD peritonitis usually has an excellent prognosis with resolution within days but it can lead occasionally to the much dreaded sclerosing encapsulated peritonitis or death. Peritonitis risk is not evenly spread across the PD population or programs. During a median follow-up of 1.9 years, about 50% a large cohort of 7401 PD patients aged 65–100 years had at least one infection-related hospitalization.[41] In another series, catheter-related peritonitis occurred in about 20% of patients and ESI was responsible for catheter removal in more than one-fifth of cases.[42] The infection may be caused by the surgical procedure to insert a PD catheter or the conduct of PD. The UK Renal Association standard for peritonitis is one episode per 18 months in adults (0.67 episodes per patient-year).[43] Although, the overall rate of PD-associated peritonitis is between 0.24 and 1.66 episodes per patient years on dialysis,[44],[45],[46] our center reported rates of as low as 0.11–0.16 episodes per patient-year, thanks to our strict aseptic precautions and limitation of the number of expert operators. Very low rates of peritonitis in a program like ours were possible due to close attention is paid to the causes of peritonitis and protocols implemented to reduce the risk of infection. Action to decrease the risk of PD-peritonitis should start in the pre-catheter insertion phase. To obtain a reduction of the complications, achieve prolonged catheter duration and a better quality of life for PD patients, the surgical technique requires strict adherence to a standardized procedure and a dedicated team.[37],[47] Improved diagnosis, increased awareness of causative agents in addition to other measures will facilitate prompt management of PD-associated infections and salvage of PD modality.

Although several organisms are involved in causing PD-associated infections, CoNS appear to be the most common.[13],[14],[15],[16],[45],[47],[48],[49],[50],[51] However, rare forms of PD infection, for example, tuberculous and nontuberculous mycobacterium and fungal infection are associated with catheter loss (80%) and significant mortality (40%).[7],[9],[10],[11],[12],[13] Gram-positive cocci such as Staphylococcus epidermidis, other CoNS, and S. aureus are the most frequent etiological agents of PD-associated peritonitis worldwide.[13],[14],[15],[16],[52],[53] The spectrum of organisms associated with PD peritonitis varies geographically as does the rate of culture-negative episodes.[54] For example, Gram-negative PD peritonitis is more frequent than Gram-positive peritonitis in the continuous ambulatory peritoneal dialysis population in India and is associated with worse outcome.[49] Although a wide spectrum of organisms is responsible for PD-associated infections, it must be borne in mind that a significant proportion of the infections are polymicrobial; the reported incidence ranges between 9% and 16%.[55],[56],[57],[58],[59],[60],[61] In our center, we reported an incidence of 7.8% and as the case with other investigators, we could not identify significant independent predictors of this type of infection.[55],[57] Polymicrobial peritonitis is thought to originate from a bowel leak.[58],[59] Thus, one would expect a worse outcome from a bowel leak etiology rather than from an infection caused by touch contamination. The worst non-resolution rate of peritonitis in our series (44%) was reported in association with polymicrobial peritonitis and three out of 13 (23.1%) deaths were associated with poly-microbial peritonitis. Although we could not demonstrate bowel perforation in any of those who had polymicrobial or Gram-negative peritonitis, yet, significant bowel disease or bowel perforation in PD patients have been reported to result in polymicrobial peritonitis.[58],[59] Despite the unfavorable outcomes and the higher likelihood of bowel disease described before, it should be noted that Kiernan et al[55] and Holley et al[56] have suggested that even in polymicrobial peritonitis, an aggressive search for bowel pathology may not always be warranted. As there is a poly-microbial rate of up to 16% and culture-negative rate of about 20%, it is recommended by the ISPD and the UK Renal Association that appropriate laboratory samples are obtained before the commencement of antibiotics.[7],[43] In our study, Peritonitis due to Gram-positive organisms had a significantly better outcome than peritonitis due to Gram-negative organisms. Burke et al, in a prospective study,[62] and Troidle et al in a retrospective analysis[63] made a similar observation. However, Burke et al compared the outcomes among CoNS, S. aureus, and nonpseudomonal Gram-negative peritonitis;[62] the inclusion of P. aeruginosa as a causative organism probably would have accentuated the differences in outcome. On the other hand, there was a problem in Troidle et al results as they included some cases of polymicrobial peritonitis in their Gram-negative peritonitis group.[63] S. aureus peritonitis, in our study predisposed patients to catheter removal and transfer to HD when compared to infections with other Gram-positive organisms or to CoNS. The better outcomes of CoNS peritonitis when compared to other forms of peritonitis have been noted before.[34],[61],[63],[64],[65],[66],[67] Increased catheter loss was still evident even in the absence of soft ESI or TI. However, there were no differences in outcomes in the S. aureus and CoNS when a soft TI was present. This supports previous observations that a soft TI plays a pivotal role in the outcome of an episode of any type of staphylococcal peritonitis.[68],[69],[70] Among Gram-positive organisms, in our study, enterococcal peritonitis was associated with favorable outcome (resolution in 85%). Our resolution rates for enterococci are more or less similar to those estimated by Krishnan et al[34] who reported 92.9% resolution rates for episodes caused by the same organism. E. coli accounted for most (54%) Gram-negative peritonitis episodes in our study followed by P. aeruginosa (22.6%). Other observers have found P. aeruginosa to be the commonest Gram-negative organism causing peritonitis, followed by E. coli.[71],[72] On the other hand, Troidle et al reported that Klebsiella was the commonest organism causing Gram-negative peritonitis.[63] Fifteen episodes of peritonitis in 13 of our patients resulted in death (fatality rate of about 4.7%). In other series peritonitis has been reported to cause death (fatality rate) in 1%–6% of PD patients.[62],[63],[73],[74],[75],[76] Our current figure is close to what have been reported by those investigators. Although no single causative organism was responsible for most of the deaths in our patients, yet, polymicrobial and Gram-negative bacteria were the most encountered etiology. Seventy-nine episodes of peritonitis resulted in transfer to HD (temporarily or permanently) but the remaining episodes (240; 75.2%) resolved. Our resolution rate is comparable to most of the previous reports.[34],[61],[63]

There are no convincing data regarding the effect of PD catheter design and configuration on peritonitis risk. And so far, no catheter type has consistently been shown to reduce the peritonitis risk. The association between the number of catheter cuffs and peritonitis was tested using data collected in the multicenter Canadian Baxter Peritonitis Organism Exit-Sites Tunnel Infections project. There were 2555 peritonitis episodes in 4247 incident patients (0.364 per dialysis year at risk) with double-cuff catheter use being associated with a lower peritonitis rate ratio (RR) = 0.90, 95% confidence interval (CI): 0.80-1.01, P = 0.08. This trend was largely due to a decreased S. aureus peritonitis rate in those with a double-cuff catheter (RR = 0.46, 95% CI: 0.33–0.64, P<0.001).[31],[46] With our triple-cuff catheter, the rate of ESI and tunnel infections was comparable to that with the conventional double-cuff Tenckhoff catheter. The rate of peritonitis, however, was significantly lower with the three-cuff catheter and the new insertion technique introduced by Al-Hwiesh in a recent study;[33] two peritonitis incidents were reported over 18 months compared with six (16.2%) incidents with the conventional double-cuff Tenckhoff catheter. The authors attributed that to the presence of three cuffs, which probably functioned as three barriers against infection. In addition, the relatively short portion of the three-cuff PD catheter inside the peritoneal cavity could have played a role in minimizing the rate of peritonitis. Our previous study demonstrated catheter survival that exceeded the ISPD recommendations.[7],[33] The study, however, had a small number of patients, and hence, a solid conclusion could not be obtained. The current study, with a population of >1000 clearly demonstrated significant differences in the peritonitis rates (0.11 and 0.16 episode-patient-year; for triple and double-cuff PD catheters respectively, P <0.001) and in outcomes between the two catheter types. Nevertheless, the incidence of chronic PD-associated peritonitis has decreased largely in our center due to technical advances, use of the new Saudi PD catheter and the identification and control of risk factors such as inadequate education, ESI, poor technique of catheter insertion. Although univariate analysis, in our study, showed that catheter type (2-cuff vs. 3-cuff) and purulent exit site were associated with a significantly higher non-resolution rate (P = 0.023), multivariate analysis confirmed only the significance of the Saudi catheter over the conventional one. Burke et al[62] and Gupta et al[68] also have reported a higher peritonitis resolution rate with concomitant ESI. Of notice; the exit-site culture did not always correlate with the organism causing peritonitis and we do not have an estimate of concomitant tunnel infection, in addition, not all patients had ultrasound of the tunnel. Interestingly, multivariate analysis in our study, showed that these factors did not significantly alter the outcome of peritonitis episodes. Although a number of the reported risk factors, as age, sex, hypo-albuminemia, hypokalemia, and ESI, are modifiable, there currently is no high-level evidence that modifying these risk factors will lead to reduced peritonitis rates or improve peritonitis outcomes, apart from topical exitsite antimicrobial prophylaxis and nasal eradication of S. aureus. Similarly, for patients with nonmodifiable peritonitis risk factors, there also is no high-level clinical evidence that specifically targeting these individuals for closer monitoring, augmented home support, regular retraining, or more intensive infection prophylaxis strategies significantly mitigates their nonresolution peritonitis risk. More collaborative research work is required in this area.[29],[30]

Although factors like current steroid use, malignancy, DM, or previous kidney transplant could be expected to have a negative impact on peritonitis episodes, our study showed that these factors did not adversely affect the outcome of these episodes. Tranaeus et al[67] reported a higher fatality rate from peritonitis among diabetic patients, however in their study, diabetics were malnourished and with more fluid gain than nondiabetics; thus, these factors might have been confounding variables. Conversely, we found that the duration of PD significantly and adversely affected the outcome of peritonitis. Further analysis showed that nonresolution rate for patients that had been on PD for >5 years was significantly higher than those with PD of <5 years. Selgas et al[77] also reported that peritonitis episodes had consequences that were more deleterious if they occurred after 4–5 years on PD. After several years with acidic, hyperosmotic, and high-glucose-content dialysate, the peritoneum is not expected to remain unaltered, nor to preserve the same transport characteristics or its ability to fight infection.[78],[79],[80],[81] The results presented in Selgas et al report suggested that peritoneal-function vulnerability to infectious episodes increases with time and that It is more plausible that at later stages of PD the membrane tolerates less easily than before a given aggression. Meanwhile, we found that the peritonitis nonresolution rate was significantly higher if the PD effluent cell count remained above 100 cells/μL for a mean of 7.4 ± 1.4, compared to 4.8 ± 3.3 days for the episodes that had a successful outcome (P <0.001), this positively coincides with the results previously published by Krishnan et al.[34] Our data could have been more interesting if fungal and tuberculous peritonitis were documented, however, it has the merit of being one of the largest studies discussion epidemiology and outcomes of bacterial peritonitis in PD patients.

   Conclusion Top

Peritonitis episodes due to Gram-positive organisms had a better outcome than those with Gram-negative or polymicrobial etiology. Peritonitis resolution rates were worse with S. aureus and P. aeruginosa infections. Diabetes, current steroid use, and exit-site/tunnel infections seemed to have limited influence on the peritonitis outcome. Type of PD catheter (double vs. triple-cuff), duration of PD and the number of days peritoneal fluid effluent remained >100 cells/μL were the only factors with significant effects on the outcome.

Conflict of interest: None declared.

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Correspondence Address:
Abdullah K Al-Hwiesh
Department of Internal Medicine, Division of Nephrology, King Fahd Hospital of the University, Al-Khobar, 40246
Saudi Arabia
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DOI: 10.4103/1319-2442.318550

PMID: 34145116

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