Pseudomonas peritonitis in Australia: predictors, treatment, and outcomes in 191 cases

Abstract

Background and objectives: Pseudomonas peritonitis is a serious complication of peritoneal dialysis. To date, there as been no comprehensive, multicenter study of this condition.

Design, setting, participants, & measurements: The predictors, treatment, and clinical outcomes of Pseudomonas peritonitis were examined by binary logistic regression and multilevel, multivariate Poisson regression in all Australian PD patients in 66 centers between 2003 and 2006.

Results: A total of 191 episodes of Pseudomonas peritonitis (5.3% of all peritonitis episodes) occurred in 171 individuals. Its occurrence was independently predicted by Maori/Pacific Islander race, Aboriginal/Torres Strait Islander race, and absence of baseline peritoneal equilibration test data. Compared with other organisms, Pseudomonas peritonitis was associated with greater frequencies of hospitalization (96 versus 79%; P = 0.006), catheter removal (44 versus 20%; P < 0.001), and permanent hemodialysis transfer (35 versus 17%; P < 0.001) but comparable death rates (3 versus 2%; P = 0.4). Initial empiric antibiotic choice did not influence outcomes, but subsequent use of dual anti-pseudomonal therapy was associated with a lower risk for permanent hemodialysis transfer (10 versus 38%, respectively; P = 0.03). Catheter removal was associated with a lower risk for death than treatment with antibiotics alone (0 versus 6%; P < 0.05).

Conclusions: Pseudomonas peritonitis is associated with high rates of catheter removal and permanent hemodialysis transfer. Prompt catheter removal and use of two anti-pseudomonal antibiotics are associated with better outcomes.

Figure 1.

(A and B) Histograms demonstrating the temporal occurrence of Pseudomonas peritonitis (A)and non-Pseudomonas peritonitis (B) in relation to a previous episode of treated non-Pseudomonas peritonitis in Australian peritoneal dialysis (PD) patients who had experienced more than one episode of peritonitis during the study period.

Figure 2.

Antimicrobial agents prescribed in initial, second, and third antibiotic regimens for Pseudomonas peritonitis episodes in Australian PD patients, 2003 through 2006. Numbers at arrow origins depict number of peritonitis episodes. Dual-agent anti-pseudomonal therapy comprised, in descending order of frequency, ciprofloxacin + aminoglycoside (usually gentamicin), ticarcillin + aminoglycoside, ceftazidime + aminoglycoside, and piperacillin + aminoglycoside. Single-agent anti-pseudomonal therapy (excluding those who received aminoglycoside in combination with either vancomycin or first-generation cephalosporin) comprised, in descending order of frequency, ciprofloxacin, aminoglycoside (usually gentamicin), ticarcillin, piperacillin, ceftazidime, and cefepime.