Variability in Culture-Negative Peritonitis Rates in Pediatric Peritoneal Dialysis Programs in the United States

Abstract

Background and objectivesInternational guidelines suggest a target culture-negative peritonitis rate of <15% among patients receiving long-term peritoneal dialysis. Through a pediatric multicenter dialysis collaborative, we identified variable rates of culture-negative peritonitis among participating centers. We sought to evaluate whether specific practices are associated with the variability in culture-negative rates between low– and high–culture-negative rate centers.Design, setting, participants, & measurementsThirty-two pediatric dialysis centers within the Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) collaborative contributed prospective peritonitis data between October 1, 2011 and March 30, 2017. Clinical practice and patient characteristics were compared between centers with a ≤20% rate of culture-negative peritonitis (low-rate centers) and centers with a rate >20% (high-rate centers). In addition, centers completed a survey focused on center-specific peritoneal dialysis effluent culture techniques.ResultsDuring the 5.5 years of observation, 1113 patients had 1301 catheters placed, totaling 19,025 patient months. There were 620 episodes of peritonitis in 378 patients with 411 catheters; cultures were negative in 165 (27%) peritonitis episodes from 125 (33%) patients and 128 (31%) catheters. Low-rate centers more frequently placed catheters with a downward-facing exit site and two cuffs (P<0.001), whereas high-rate centers had more patients perform dialysis themselves without the assistance of an adult care provider (P<0.001). The survey demonstrated that peritoneal dialysis effluent culture techniques were highly variable across centers. No consistent practice or technique helped to differentiate low- and high-rate centers.ConclusionsCulture-negative peritonitis is a frequent complication of maintenance peritoneal dialysis in children. Despite published recommendations for dialysis effluent collection and culture methods, great variability in culture techniques and procedures exists among individual dialysis programs and respective laboratory processes.

An initiative to improve effluent culture detection among pediatric patients undergoing peritoneal dialysis through process improvement

“…Improvement science has been used successfully in decreasing peritonitis rates among children by standardizing protocols and reducing practice variation [ 2 ], and it is thus not surprising that similar methods may be used for reducing culture-negative peritonitis rates. While Davis et al reported high culture-negative peritonitis rates among surveyed centers, an association with peritoneal effluent collection and/or laboratory processing methods was not reported [ 9 ]. Based on published evidence, we hypothesized that process measures were responsible for our high rate of culture-negative peritonitis.…”

“…There is limited data regarding risk factors for culture-negative peritonitis, although those identified—such as culture methodology [ 6 ], dialysate culture volume [ 6 ], antibiotic use with 30 days, and collection by staff without dialysis specialty training [ 7 ]—are related to processes rather than intrinsic patient factors. The Standardizing Care to Improve Outcomes in Pediatric End Stage Kidney Disease (SCOPE) Collaborative, a collaborative of 51 North American institutions whose goal is to prevent dialysis-associated infections among pediatric chronic PD patients [ 8 ], reported an overall culture-negative peritonitis rate of 26.6%, with significant variability in culture-negative peritonitis rates and peritoneal effluent collection methods and processes among 32 surveyed centers, with our institution falling among the higher rates [ 9 ]. In order to reduce culture-negative peritonitis rates among participating centers, the SCOPE Collaborative proposed a standardized culture method process (or “bundle”) aimed to reduce culture-negative peritonitis rates [ 8 ].…”

PD effluent specimen collection: Your questions answered

“…1 hour) are associated with more culture-negative samples and low WBC counts compared to those collected after a longer dwell time (e.g. at least 2 hours, as recommended in the ISPD Peritonitis guidelines) (1,22,23). Treatment and management of a patient with culture-negative peritonitis (no causative organism identified) is problematic and may result in the use of unnecessary or inappropriate antibiotics.…”

“…at least 2 h, as recommended in the ISPD Peritonitis Guidelines). 1,22,23 Treatment and management of a patient with culture-negative peritonitis (no causative organism identified) is problematic and may result in the use of unnecessary or inappropriate antibiotics. Above all, standardisation of collection of PD effluent samples for culture and WBC count (following ISPD Peritonitis Guidelines) should result in the causative organism with sensitivities being identified more often (culture-positive peritonitis), as well as facilitating interpretation of WBC counts, thus improving management of a patient on PD with peritonitis.…”

Opportunities for Improvement in Quality of Care of PD-Related Peritonitis in Children

“…In this issue of CJASN, Davis et al (7) analyzed the topic of culture-negative peritonitis in 32 pediatric dialysis centers across the United States, within the framework of the SCOPE Collaborative. The study period ranged from the start of the quality initiative (October 2011) to March 2017.…”