Gram-negative peritonitis in children undergoing long-term peritoneal dialysis.
BACKGROUND
The proportion of gram-negative causative organisms in peritoneal dialysis-associated peritonitis is increasing. Little published information for this complication exists in children. The objective of this study is to evaluate the clinical presentation, early and late response to treatment, and identification of factors influencing the outcome of gram-negative peritonitis (GNP) in children.


METHODS
Case series.


METHODS
104 children (aged 7.9 +/- 5.9 years) with 121 GNP episodes reported to the International Pediatric Peritonitis Registry from October 2001 through December 2004.


METHODS
Patient, clinical, bacteriological, and treatment features.


RESULTS
Initial response to empirical treatment was assessed after approximately 72 hours of therapy. Final outcome was judged according to the occurrence of death, technique failure, relapse, need for catheter exchange, and a composite end point defining full functional recovery.


RESULTS
44% of episodes of GNP occurred in children younger than 5 years. Causative organisms included Pseudomonas species, 21%; Klebsiella species, 18%; Escherichia coli, 17%; and Acinetobacter species, 12%. Thirty-two percent of organisms classified as gram-negative were not identified further. Clinical manifestations were severe and uniform for all causative gram-negative agents. A substantial proportion (20%) of organisms were resistant to ceftazidime, with resulting suboptimal response to empirical therapy. By day 3 of initial empiric treatment, 85% of children with GNP had improved clinically (39%, complete resolution; 46%, improvement in symptoms), 10% showed poor response, and 5% had worsening of symptoms. Multivariate analysis identified severe abdominal pain, use of a single-cuff catheter, and intermittent (versus continuous) intraperitoneal ceftazidime administration as independent predictors of worse initial response to treatment. Full functional recovery was achieved in 86% of episodes. Nineteen patients (16%) required catheter removal, 11 (9%) experienced a relapse, 7 (6%) discontinued peritoneal dialysis therapy permanently, and 3 died. Lack of clinical improvement after 72 hours of therapy (odds ratio, 5.39; P < 0.01) and the presence of an exit-site infection (odds ratio, 7.69; P = 0.01) independently increased the risk of an incomplete functional recovery.


CONCLUSIONS
The study was not designed to assess absolute incidence figures or risk factors for the development of GNP in children.


CONCLUSIONS
GNP is a significant complication of long-term peritoneal dialysis therapy in children, and a substantial proportion of affected children are at risk of permanent sequelae. Because results of empiric treatment with ceftazidime are suboptimal in the setting of this infection, alternative antimicrobial agents should be reconsidered.
Zurowska
Aleksandra
A
Department of Paediatric and Adolescent Nephrology and Hypertension, Medical University of Gdansk, Poland.
Feneberg
Reinhard
R
Warady
Bradley A
BA
Zimmering
Miriam
M
Monteverde
Maria
M
Testa
Sara
S
Calyskan
Salim
S
Drozdz
Dorota
D
Salusky
Isidro
I
Kemper
Markus J
MJ
Ekim
Mesiha
M
Verrina
Enrico
E
Misselwitz
Joachim
J
Schaefer
Franz
F
D000293:Adolescent; D000328:Adult; D017677:Age Distribution; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D019072:Antibiotic Prophylaxis; D002442:Ceftazidime / Q000627:therapeutic use; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D015999:Multivariate Analysis; D010530:Peritoneal Dialysis / Q000009:adverse effects* / Q000379:methods; D010538:Peritonitis / Q000188:drug therapy / Q000453:epidemiology* / Q000382:microbiology; D012307:Risk Factors; D016896:Treatment Outcome
D000900:Anti-Bacterial Agents; D002442:Ceftazidime