title: Assessment of current practice and barriers to antimicrobial prophylaxis in peritoneal dialysis patients.
abstract: Existing Australasian and international guidelines outline antibiotic and antifungal measures to prevent the development of treatment-related infection in peritoneal dialysis (PD) patients. Practice patterns and rates of PD-related infection vary widely across renal units in Australia and New Zealand and are known to vary significantly from guideline recommendations, resulting in PD technique survival rates that are lower than those achieved in many other countries. The aim of this study was to determine if there is an association between current practice and PD-related infection outcomes and to identify the barriers and enablers to good clinical practice.
  
  
  
  This is a multicentre network study involving eight PD units in Australia and New Zealand, with a focus on adherence to guideline recommendations on antimicrobial prophylaxis in PD patients. Current practice was established by asking the PD unit heads to respond to a short survey about practice/protocols/policies and a 'process map' was constructed following a face-to-face interview with the primary PD nurse at each unit. The perceived barriers/enablers to adherence to the relevant guideline recommendations were obtained from the completion of 'cause and effect' diagrams by the nephrologist and PD nurse at each unit. Data on PD-related infections were obtained for the period 1 January 2011 to 31 December 2011.
  
  
  
  Perceived barriers that may result in reduced adherence to guideline recommendations included lack of knowledge, procedural lapses, lack of a centralized patient database, patients with non-English speaking background, professional concern about antibiotic resistance, medication cost and the inability of nephrologists and infectious diseases staff to reach consensus on unit protocols. The definitions of PD-related infections used by some units varied from those recommended by the International Society for Peritoneal Dialysis, particularly with exit-site infection (ESI). Wide variations were observed in the rates of ESI (0.06-0.53 episodes per patient-year) and peritonitis (0.31-0.86 episodes per patient-year).
  
  
  
  Despite the existence of strongly evidence-based guideline recommendations, there was wide variation in adherence to these recommendations between PD units which might contribute to PD-related infection rates, which varied widely between units. Although individual patient characteristics may account for some of this variability, inconsistencies in the processes of care to prevent infection in PD patients also play a role.
authors.affiliation: Centre for Kidney Research, Sydney Children's Hospital Network (Westmead), Westmead, NSW, Australia School of Public Health, University of Sydney, Sydney, NSW, Australia.
authors.forename: Denise J
authors.initials: DJ
authors.lastname: Campbell
authors.affiliation: Monash University, Clayton, VIC, Australia.
authors.forename: Fiona G
authors.initials: FG
authors.lastname: Brown
authors.affiliation: Centre for Kidney Research, Sydney Children's Hospital Network (Westmead), Westmead, NSW, Australia School of Public Health, University of Sydney, Sydney, NSW, Australia.
authors.forename: Jonathan C
authors.initials: JC
authors.lastname: Craig
authors.affiliation: University of Sydney and George Institute for Global Health, Sydney, NSW, Australia.
authors.forename: Martin P
authors.initials: MP
authors.lastname: Gallagher
authors.affiliation: University of Queensland at Princess Alexandra Hospital, Brisbane, QLD, Australia.
authors.forename: David W
authors.initials: DW
authors.lastname: Johnson
authors.affiliation: Royal Hobart Hospital, Hobart, TAS, Australia.
authors.forename: Geoffrey S
authors.initials: GS
authors.lastname: Kirkland
authors.affiliation: Gosford Hospital, Gosford, NSW, Australia.
authors.forename: Subramanian K
authors.initials: SK
authors.lastname: Kumar
authors.affiliation: Sir Charles Gairdner Hospital, Perth, WA, Australia.
authors.forename: Wai H
authors.initials: WH
authors.lastname: Lim
authors.affiliation: Royal Brisbane and Women's Hospital, Herston, QLD, Australia.
authors.forename: Dwarakanathan
authors.initials: D
authors.lastname: Ranganathan
authors.affiliation: Whangarei Hospital, Northland District Health Board, Whangarei, New Zealand University of Auckland, Auckland, New Zealand.
authors.forename: Walaa
authors.initials: W
authors.lastname: Saweirs
authors.affiliation: Nepean Clinical School, University of Sydney, Sydney, NSW, Australia Westmead and Nepean Hospitals, NSW, Australia.
authors.forename: Kamal
authors.initials: K
authors.lastname: Sud
authors.affiliation: Western Health, Footscray, VIC, Australia The Royal Melbourne Hospital, Parkville, VIC, Australia.
authors.forename: Nigel D
authors.initials: ND
authors.lastname: Toussaint
authors.affiliation: The Royal Melbourne Hospital, Parkville, VIC, Australia The Alfred Hospital, Prahran, VIC, Australia.
authors.forename: Rowan G
authors.initials: RG
authors.lastname: Walker
authors.affiliation: Royal Brisbane and Women's Hospital, Herston, QLD, Australia.
authors.forename: Lesley A
authors.initials: LA
authors.lastname: Williams
authors.affiliation: Auckland City Hospital, Auckland, New Zealand.
authors.forename: Maha
authors.initials: M
authors.lastname: Yehia
authors.affiliation: University of Queensland at Princess Alexandra Hospital, Brisbane, QLD, Australia.
authors.forename: David W
authors.initials: DW
authors.lastname: Mudge
mesh_terms: D000368:Aged; D000890:Anti-Infective Agents / Q000627:therapeutic use*; D019072:Antibiotic Prophylaxis / Q000379:methods*; D002408:Catheters, Indwelling / Q000009:adverse effects*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010530:Peritoneal Dialysis / Q000009:adverse effects*; D010538:Peritonitis / Q000209:etiology / Q000517:prevention & control*; D010818:Practice Patterns, Physicians'; D011446:Prospective Studies
chemical_list: D000890:Anti-Infective Agents
keywords: antibiotic; antifungal agents; catheters indwelling; peritoneal dialysis; peritonitis