Peritoneal Dialysis?Related Infection Rates and Outcomes: Results From the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS)
Peritoneal Dialysis?Related Infection Rates and Outcomes: Results From the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS)
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DOI：
10.1053/j.ajkd.2019.09.016
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发表时间：
2020-07-01
影响因子：
13.2
通讯作者：
Johnson, David W.
中科院分区：
文献类型：
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作者：
Perl, Jeffrey;Fuller, Douglas S.;Johnson, David W.
理由与目的腹膜透析（PD）相关性腹膜炎在PD患者中发病率较高。了解腹膜炎的特点和危险因素可以指导区域预防策略的制定。我们描述了参与腹膜透析结果和实践模式研究（PDOPPS）的国家的腹膜炎发病率和选定的设施实践与腹膜炎风险的关联。研究设计观察性前瞻性队列研究。环境与参与者：来自7个国家（澳大利亚、新西兰、加拿大、日本、泰国、英国、美国）的209家机构的7051名成年PD患者。暴露设施特征（人口普查计数，设施年龄，护士与病人比例）和选定的设施实践（使用自动化PD，使用icodextrin或生物相容性PD溶液，抗生素预防策略，PD培训持续时间）。结果：腹膜炎发生率（按国家、总体和各设施的差异）、微生物学模式。分析方法泊松率估计，比例率模型调整选定的患者病例混合变量。结果7051例患者共发生2272次腹膜炎（粗率0.28次/患者-年）。每个国家的设施腹膜炎发生率各不相同，在10%的设施中超过0.50/患者年。总腹膜炎发生率，以每患者年为例，泰国为0.40 (95% CI, 0.36-0.46)，英国为0.38 (95% CI, 0.32-0.46)，澳大利亚/新西兰为0.35 (95% CI, 0.30-0.40)，加拿大为0.29 (95% CI, 0.26-0.32)，日本为0.27 (95% CI, 0.25-0.30)，美国为0.26 （95% CI, 0.24-0.27）。各国腹膜炎的微生物学相似，但泰国除外，那里革兰氏阴性感染和培养阴性腹膜炎更为常见。在日本，设施规模与腹膜炎风险正相关（每10名患者的比率[RR]为1.07；95% CI为1.04-1.09）。在自动化PD使用较高的设施（RR每增加10个百分点，0.95;95% CI, 0.91-1.00），在导管插入时使用抗生素的设施（RR, 0.83; 95% CI, 0.69-0.99），以及PD培训时间为6天或更长（vs <6）天的设施（RR, 0.81; 95% CI, 0.68-0.96）中观察到较低的腹膜炎风险。使用外用莫匹罗星或氨基糖苷软膏的医院的腹膜炎风险较低，但这种关联没有达到常规水平的统计学显著性（RR, 0.79; 95% CI, 0.62-1.01）。局限性：抽样变异、选择偏差（率估计）和残留混淆（关联）。结论不同的治疗方法可能导致腹膜炎的风险存在显著的国际差异。这些发现可能为未来制定更低的最大可接受腹膜炎率提供指导。
Rationale & ObjectivePeritoneal dialysis (PD)-related peritonitis carries high morbidity for PD patients. Understanding the characteristics and risk factors for peritonitis can guide regional development of prevention strategies. We describe peritonitis rates and the associations of selected facility practices with peritonitis risk among countries participating in the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS).Study DesignObservational prospective cohort study.Setting & Participants7,051 adult PD patients in 209 facilities across 7 countries (Australia, New Zealand, Canada, Japan, Thailand, United Kingdom, United States).ExposuresFacility characteristics (census count, facility age, nurse to patient ratio) and selected facility practices (use of automated PD, use of icodextrin or biocompatible PD solutions, antibiotic prophylaxis strategies, duration of PD training).OutcomesPeritonitis rate (by country, overall and variation across facilities), microbiology patterns.Analytical ApproachPoisson rate estimation, proportional rate models adjusted for selected patient case-mix variables.Results2,272 peritonitis episodes were identified in 7,051 patients (crude rate, 0.28 episodes/patient-year). Facility peritonitis rates were variable within each country and exceeded 0.50/patient-year in 10% of facilities. Overall peritonitis rates, in episodes per patient-year, were 0.40 (95% CI, 0.36-0.46) in Thailand, 0.38 (95% CI, 0.32-0.46) in the United Kingdom, 0.35 (95% CI, 0.30-0.40) in Australia/New Zealand, 0.29 (95% CI, 0.26-0.32) in Canada, 0.27 (95% CI, 0.25-0.30) in Japan, and 0.26 (95% CI, 0.24-0.27) in the United States. The microbiology of peritonitis was similar across countries, except in Thailand, where Gram-negative infections and culture-negative peritonitis were more common. Facility size was positively associated with risk for peritonitis in Japan (rate ratio [RR] per 10 patients, 1.07; 95% CI, 1.04-1.09). Lower peritonitis risk was observed in facilities that had higher automated PD use (RR per 10 percentage points greater, 0.95; 95% CI, 0.91-1.00), facilities that used antibiotics at catheter insertion (RR, 0.83; 95% CI, 0.69-0.99), and facilities with PD training duration of 6 or more (vs <6) days (RR, 0.81; 95% CI, 0.68-0.96). Lower peritonitis risk was seen in facilities that used topical exit-site mupirocin or aminoglycoside ointment, but this association did not achieve conventional levels of statistical significance (RR, 0.79; 95% CI, 0.62-1.01).LimitationsSampling variation, selection bias (rate estimates), and residual confounding (associations).ConclusionsImportant international differences exist in the risk for peritonitis that may result from varied and potentially modifiable treatment practices. These findings may inform future guidelines in potentially setting lower maximally acceptable peritonitis rates.