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Peritonitis in Children Who Receive Long-Term Peritoneal Dialysis: A Prospective Evaluation of Therapeutic Guidelines

Bradley A. Warady^*, Reinhard Feneberg, Enrico Verrina, Joseph T. Flynn, Dirk E. Müller-Wiefel^||, Nesrin Besbas^¶, Aleksandra Zurowska^**, Nejat Aksu, Michel Fischbach, Ernesto Sojo, Osman Donmez^||||, Lale Sever^¶¶, Aydan Sirin^***, Steven R. Alexander, Franz Schaefer for the International Pediatric Peritonitis Registry (IPPR)

^* Section of Pediatric Nephrology, Children's Mercy Hospital, Kansas City, Missouri; Division of Pediatric Nephrology, University of Heidelberg, Heidelberg, Germany; Division of Pediatric Nephrology, Instituto Gaslini, Genoa, Italy; Pediatric Nephrology, Montefiore Medical Center, Bronx, New York; ^|| University Children's Hospital, Hamburg-Eppendorf, Germany; ^¶ Department of Pediatric Nephrology, Hacettepe University, Ankara, Turkey; ^** Department of Pediatric Nephrology, Medical University of Gdansk, Gdansk, Poland; Department of Pediatric Nephrology, Tepecik Training and Research Hospital, Izmir, Turkey; Children's Unit, University Louis Pasteur, Strasbourg, France; Pediatric Nephrology, R. Garrahan Children's Hospital, Buenos Aires, Argentina; ^|||| Department of Pediatric Nephrology, Uludag University, Bursa, Turkey; ^¶¶ Department of Pediatric Nephrology, Istanbul University, Cerrahpasa Medical Faculty, Cerrahpasa, Turkey; ^*** Department of Pediatric Nephrology, Istanbul University, Istanbul Medical Faculty, Istanbul, Turkey; and Lucile Salter Packard Children's Hospital Stanford University, Palo Alto, California

Correspondence: Dr. Bradley A. Warady, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108. Fax: 816-234-3494; bwarady{at}cmh.edu

Received for publication October 26, 2006. Accepted for publication April 20, 2007.

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.

Copyright © 2008 by the American Society of Nephrology. Online ISSN: 1533-3450 Print ISSN: 1046-6673