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Peritonitis in children who receive long-term peritoneal dialysis: a prospective evaluation of therapeutic guidelines
Bradley A Warady1, Reinhard Feneberg, Enrico Verrina
1Pediatric Nephrology, Children's Mercy Hospital, Kansas City, MO 64108, USA. bwarady@cmh.edu
Insights
Peritonitis in pediatric peritoneal dialysis patients often lacks clear treatment guidelines. New data suggest current empiric antibiotic therapy may need modification, potentially including aminoglycosides, to improve outcomes.
Area of Science:
- Pediatric Nephrology
- Infectious Diseases
- Clinical Trials
Background:
- Peritonitis is a major complication in children undergoing chronic peritoneal dialysis, impacting long-term technique survival.
- Optimal treatment strategies for pediatric peritonitis remain uncertain, necessitating further investigation.
Purpose of the Study:
- To evaluate the efficacy and safety of existing, largely opinion-based peritonitis treatment guidelines in pediatric peritoneal dialysis.
- To establish a basis for new, evidence-based guidelines for managing pediatric peritonitis.
Main Methods:
- An Internet-based International Pediatric Peritonitis Registry was created, collecting data from 47 centers in 14 countries.
- 491 episodes of nonfungal peritonitis were analyzed, with antibiotic sensitivity testing performed.
- Empiric antibiotic therapy was stratified by disease severity according to established guidelines.
Main Results:
- Gram-positive organisms were identified in 44% of cases, Gram-negative in 25%, and 31% had negative cultures.
- In vitro, 69% of Gram-positive and 80% of Gram-negative organisms showed sensitivity to specific cephalosporins.
- Neither guideline-based risk factors nor current empiric therapy predicted treatment response or outcome.
Conclusions:
- Current treatment guidelines for pediatric peritonitis may not be fully effective, as empiric therapy choices did not correlate with outcomes.
- High rates of functional recovery (89%) were observed, but relapses occurred in 9% of cases.
- Modification of empiric antibiotic therapy, possibly incorporating aminoglycosides, should be considered for improved peritonitis management in pediatric peritoneal dialysis.
Abstract:
In children who are on chronic peritoneal dialysis, peritonitis is the primary complication compromising technique survival, and the optimal therapy of peritonitis remains uncertain. An Internet-based International Pediatric Peritonitis Registry was established in 47 pediatric centers from 14 countries to evaluate the efficacy and safety of largely opinion-based peritonitis treatment guidelines in which empiric antibiotic therapy was stratified by disease severity. Among a total of 491 episodes of nonfungal peritonitis entered into the registry, Gram-positive organisms were cultured in 44%, Gram-negative organisms were cultured in 25%, and cultures remained negative in 31% of the episodes. In vitro evaluation revealed 69% sensitivity of Gram-positive organisms to a first-generation cephalosporin and 80% sensitivity of Gram-negative organisms to a third-generation cephalosporin. Neither the risk factors assumed by the guidelines nor the choice of empiric therapy was predictive of either the early treatment response or the final functional outcome of the peritonitis episodes. Overall, 89% of cases achieved full functional recovery, a portion after relapsing peritonitis (9%). These data serve as the basis for new evidence-based guidelines. Modification of empiric therapy to include aminoglycosides should be considered.
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