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Risk Factors for and Outcomes of Catheter-Associated Peritonitis in Children: The SCOPE Collaborative
Christine B Sethna1, Kristina Bryant2, Raj Munshi3
1Division of Pediatric Nephrology, Cohen Children's Medical Center of New York, New Hyde Park, New York.
Insights
Improving peritoneal dialysis (PD) catheter care bundles in children with end-stage renal disease (ESRD) can significantly reduce PD-associated infections. Adherence to follow-up care bundles lowers peritonitis risk in pediatric PD patients.
Area of Science:
- Pediatric Nephrology
- Quality Improvement Science
- Infectious Disease Epidemiology
Background:
- Peritoneal dialysis (PD)-associated infections, particularly peritonitis, are a significant concern in pediatric patients with end-stage renal disease (ESRD).
- The Standardizing Care to Improve Outcomes in Pediatric ESRD (SCIOPE) Collaborative aimed to enhance PD care and reduce infection rates.
Purpose of the Study:
- To evaluate the association between provider compliance with PD catheter care bundles and the risk of infection in pediatric PD patients.
- To describe the epidemiology, risk factors, and outcomes of peritonitis within the SCIOPE Collaborative.
Main Methods:
- Prospective data collection on PD characteristics, causative organisms, care bundle compliance, and outcomes from October 2011 to September 2014.
- Statistical analysis using Chi-squared tests, t tests, and generalized linear mixed models to identify risk factors for peritonitis.
Main Results:
- Out of 734 children, 245 experienced 391 peritonitis episodes (rate: 0.46/patient-year), with higher rates in children ≤2 years old.
- Gram-positive infections were most common (37.8%). Compliance with the follow-up bundle was linked to a lower peritonitis rate (RR=0.49).
- Upward catheter exit site orientation (RR=4.2) and touch contamination (RR=2.22) increased peritonitis risk. Most infections (76.6%) resolved with antibiotics.
Conclusions:
- Lower compliance with standardized PD catheter care bundles is associated with an increased risk of peritonitis in pediatric ESRD patients.
- Implementing quality improvement and targeted prevention strategies can effectively reduce PD-associated peritonitis in this vulnerable population.
Background And Objectives:
The Standardizing Care to Improve Outcomes in Pediatric ESRD Collaborative is a quality improvement initiative that aims to reduce peritoneal dialysis-associated infections in pediatric patients on chronic peritoneal dialysis. Our objectives were to determine whether provider compliance with peritoneal dialysis catheter care bundles was associated with lower risk for infection at the individual patient level and describe the epidemiology, risk factors, and outcomes for peritonitis in the Standardizing Care to Improve Outcomes in Pediatric ESRD Collaborative.
Design, Setting, Participants, & Measurements:
We collected peritoneal dialysis characteristics, causative organisms, compliance with care bundles, and outcomes in children with peritonitis between October of 2011 and September of 2014. Chi-squared tests, t tests, and generalized linear mixed models were used to assess risk factors for peritonitis.
Results:
Of 734 children enrolled (54% boys; median age =9 years old; interquartile range, 1-15) from 29 centers, 391 peritonitis episodes occurred among 245 individuals over 10,130 catheter-months. The aggregate annualized peritonitis rate was 0.46 episodes per patient-year. Rates were highest among children ≤2 years old (0.62 episodes per patient-year). Gram-positive peritonitis predominated (37.8%) followed by culture-negative (24.7%), gram-negative (19.5%), and polymicrobial (10.3%) infections; fungal only peritonitis accounted for 7.7% of episodes. Compliance with the follow-up bundle was associated with a lower rate of peritonitis (rate ratio, 0.49; 95% confidence interval, 0.30 to 0.80) in the multivariable model. Upward orientation of the catheter exit site (rate ratio, 4.2; 95% confidence interval, 1.49 to 11.89) and touch contamination (rate ratio, 2.22; 95% confidence interval, 1.44 to 3.34) were also associated with a higher risk of peritonitis. Infection outcomes included resolution with antimicrobial treatment alone in 76.6%, permanent catheter removal in 12.2%, and catheter removal with return to peritoneal dialysis in 6% of episodes.
Conclusions:
Lower compliance with standardized practices for follow-up peritoneal dialysis catheter care in the Standardizing Care to Improve Outcomes in Pediatric ESRD Collaborative was associated with higher risk of peritonitis. Quality improvement and prevention strategies have the potential to reduce peritoneal dialysis-associated peritonitis.