The Incidence Of Peritonitis In Patients Essay

This chapter will analyse and discuss the findings related to the PICO guided question. The incidence of peritonitis and findings reported from the research retrieved are discussed in this chapter. These findings are also discussed in relation to the foreign and local health care policies together with further achievement of Evidence Based Practice (EBP). Any gaps in literature that might influence findings will also be taken into account to prevent any influence on the discussion.

4.2- Incidence of Peritonitis
The incidence of peritonitis, which is the outcome of the PICO question, is discussed in this section. The Incidence Of Peritonitis In Patients Essay. In addition, findings of other factors such as catheter connection technique and diabetes which contribute to affect the incidence of peritonitis and were reported by the literature retrieved, are also discussed (Than, Roberts, & Collins, 2005).

4.2.1- Definition of Peritonitis and Diagnosis of Peritonitis in the Studies Retrieved
Peritonitis is defined as an acute inflammation of the peritoneum, the thin tissue that lines the inner wall of the abdomen. Peritonitis results from bacterial infection, which this is caused by Gram positive and Gram negative bacteria (Johnson, Baldessarre, & Levison, 2007).

In all of the ten studies that were retrieved for this study they all have the same definition of peritonitis which is acute inflammation of the peritoneum. In these studies the incidence of peritonitis is objective measurement (involve an impartial measurement) that is without bias or prejudice (Rothstein, 1989).

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In the literature reviewed, the incidence of peritonitis was assessed by various tools and tests. The tools that were used were the SF-36 questionnaire of quality of life, other include abdominal signs and symptoms which this is a subjective measurement because the patient provides the information when experiencing pain. The tolerance of pain is different from each patient and this cannot be the only diagnosis done on patients who are receiving treatment for peritoneal dialysis. Other diagnosis includes blood cultures tests and dialysate cultures which these rule out the bacteria that is causing the peritonitis.

The following studies have used the tests that have been mentioned in the previous paragraph. Five of the studies retrieved (Fijter, et al., 1991; Fijter C.W., et al, 1994; Huang, Hung, Yen, Wu & Tsai, 2001; Rodriguez Carmona, Fontan, Falcon, Rivera & Valdes, 1999 and Balasaubramanian, McKitty, & Fan, 2001) have based their diagnosis of peritonitis on three aspects. These are; abdominal signs or symptoms, dialysate leukocyte greater than or equal to 108/L, 50% or more granulocyte in the differentiation or both and the presence of microorganism using Gram stain or dialysate culture. Two of the studies (Yishak, Bernardini, Fried, & Piraino, 2001 and Sanchez, Madonia & Rascon-Pacheco, 2008), have based their diagnosis of peritonitis on cloudy dialysate containing more than 100 leukocyte per micro litre, with more than 50% being polymorphonuclear and presence of bacteria in the dialysate effluent.

In the study carried out by Than, Roberts & Collins in 2005 the authors have evaluated the incidence of peritonitis first during the 6 month entry period by gaining data from the United States Renal Data System, about hospital days, comorbid condition and peritonitis episodes. The Incidence Of Peritonitis In Patients Essay.

Bro et al.,(1999) have used the SF-36 questionnaire which is a multi dimensional index that measures physical, mental social and general health of the patient. This measure was used to measure the influence of dialysis modality selection on ESRD related symptoms and on patient satisfaction with the treatment. Also biochemical data such as blood tests were used to analyse the incidence of peritonitis.

Yu et al., (2010) did not provide any information on how the incidence of peritonitis was diagnosed but still showed results on the incidence of peritonitis in patient using automated peritoneal dialysis (APD) and continuous ambulatory peritoneal dialysis (CAPD) as their treatment.

4.3- Analysis of the Results Found
There are six factors when interpreting results and one has to take into consideration when interpreting these results. These factors include on how accurate and credible the results are, presentation of the estimation of the effect, the effect size and the results importance, the meaning and generaslisabilty of the results, implication of results for practice and research within further development (Schunemann, et al., 2008).

The trials retrieved in this dissertation all gave a logical explanation of the results expected and the results obtained indicating that the findings were credible. From all the articles used the results are estimated through statistical analysis which this is necessary to determine that the null hypothesis which was formed by the author is false (Davies & Cromble, 2009). In statistical analysis a p-value is only indicative whether a results was due to chance (normally > 0.05) or not due to chance (normally give at <0.05) (Davies & Cromble, 2009).

To determine whether the results are statistically significant, one must take into consideration its effect size and its clinical importance. The Incidence Of Peritonitis In Patients Essay. The effect size is the measurement of the relationship between the variables being tested (Polit & Beck, 2008). From then ten articles in this study only one done by Bro, et al.(1999) have tried to used power analysis to determine the effect size and the sample needed to produce credible result and statistical difference between the two groups. The statistical difference in the results achieved does not necessarily mean that the results are important and meaningful to the clients (Polit & Beck, 2008). To interpret the importance of the results found one has to assess the numeric values and effect sizes. Every author in this study has supported his results by other studies and literatures and gave also information on what importance the outcome measurement could be done.

4.3.1- Results Found In the Studies
In the following Table 6 all the results retrieved from the ten articles consisting of 3 randomized control trials, 3 prospective cohort studies and 4 retrospective cohort studies are tabulated and explained clearly.

Table 6- Explanation of the results found in the ten studies
Type of Study
Title
Author / Year
Results
Randomized Control Study

A Prospective, Randomized Study Comparing the Peritonitis Incidence of CAPD and Y-Connector (CAPD Y) with Continuous Cyclic Peritoneal Dialysis (CCPD)

Fijter, et al, 1991

Number of Episodes of Peritonitis per patient

Patients Using CAPD-Y

Patients Using CCPD

0

16

21

1

3

6

2

2

2

3

5

1

Table- 6.1- Distribution of the number of peritonitis episodes per patient (Fijter C. d., et al., 1991)

CAPD- Y- 1 episode of peritonitis every 13.3 patient months or 0.9 episode of peritonitis a year

CCPD- 1 episode of peritonitis every 25.9 patient months or 0.46 episode of peritonitis a year

Clinical Efficacy and Morbidity Associated with Continuous Cyclic Compared with Continuous Ambulatory Peritoneal Dialysis. The Incidence Of Peritonitis In Patients Essay.

Fijter C.W., et al, 1994

APD- 19/41  0.51 episode of peritonitis/ patient / year

CAPD- 25/41  0.94 episode of peritonitis /patient/year

A prospective randomized multi centre study comparing APD and CAPD treatment

Bro, et al., 1999

CAPD- 2/13  0.31 episode of peritonitis/ patient / year

APD- 1/13  0.17 episode of peritonitis/ patient / year

A comparative analysis on the incidence of peritonitis and exit site infection in CAPD and Automated peritoneal dialysis

Rodriguez Carmona, Fontan, Falcon, Rivera & Valdes, 1999

Group 1 – CAPD- 213 patients  over the 10 year period 261 episodes of peritonitis were recorded. This means 1 episode/ 18.7 patient-month or 0.64 episode of peritonitis/ patient / year

Group 2 – APD- 115 patients  over the 10 year period 53 episodes of peritonitis were recorded. This means 1 episode/ 38.4 patient-month or 0.31 episode of peritonitis/ patient / year

The outcome of peritonitis in patients on automated peritoneal dialysis.

Yishak, Bernardini, Fried, & Piraino, 2001

APD- 0.57 episode of peritonitis/ patient / year

CAPD- 0.55 episode of peritonitis/ patient / year

Comparison of infectious complications in peritoneal dialysis patients using either a twin-bag system or automated peritoneal dialysis

Huang, Hung, Yen, Wu & Tsai, 2001

APD- 0.9 episode / 100 patient month

CAPD- 2.2 episode / 100 patient month

Comparing automated peritoneal dialysis with continuous ambulatory peritoneal dialysis: survival and quality of life difference? The Incidence Of Peritonitis In Patients Essay.

Balasaubramanian, McKitty, & Fan 2010

APD  1:36.7 patient-month

CAPD  1:28.8 patient-month

Improved patient/techniques survival and peritonitis rates in patients treated with automated peritoneal dialysis when compared to continuous ambulatory peritoneal dialysis in a Mexican PD center

Sanchez, Madonia & Rascon-Pacheco, 2008

APD  1 episode of peritonitis /34 patient-month

CAPD  1 episode of peritonitis / 16 patient-month

Comparison of clinical characteristics between automated peritoneal dialysis and continuous ambulatory peritoneal dialysis: a 2 year single centre observational study

Su, et al., 2010

APD  10/32 or 21 episodes of peritonitis / 100 patient-month

CAPD  48/140 or 86 episodes of peritonitis / 100 patient month

A comparison of peritonitis rates from United States renal data system: CAPD versus continuous cyclic peritoneal dialysis patients

Than, Roberts & Collins, 2005

CAPD 17.1 months mean number of months until first episode of peritonitis episode after 9 months of starting PD treatment

CCPD  16.1 months mean number of months until first episode of peritonitis episode after 9 months of starting PD treatment

4.4-Discussion of the Results
In most of all the ten articles retrieved the authors seem to agree that APD causes less incidence of peritonitis than CAPD. This is mainly due to the fewer connections involved in performing APD as this type of method is done once daily and CAPD is done 4 to 5 times daily (Rabindranath, Adams, Ali, Daly, & MacLeod, 2007).

The evidence collected with respect to the incidence of peritonitis in patients using the two methods of peritoneal dialysis is somewhat controversial as some studies favour APD (Huang, Hung, Yen, Wu & Tsai, 2001; Fijiter et al., 1991; de Fijter et al., 1994; Rodriguez Carmona, Fontan, Falcon, Rivera & Valdes, 1999; Sanchez, Madonia & Rascon-Paceheco, 2008; Balasubramanian, Mc Kitty & Fan, 2011) ,other find the rate of peritonitis to be similar between the two modalities (Bro et al. 1991 ; Yishak, Bernardini, Fried, & Piraino, 2001; Su, et al., 2010 ) and other favour CAPD (Than, Roberts and Collins, 2005 ) .

Out of the three randomized control studies that are used in this dissertation, two of these studies conducted by de Fijter et al., (1994) (Ranked as the top RCT) and Fijiter et al., (1991) have found out that patients on CCPD produced lower incidence of infection. On the other hand in the study done by Bro et al., (1999) complications rates between APD and CAPD could not be confirmed.

In the study conducted by de Fijieter et al., (1994) out of 82 patients that took part in this ten year study 41 patients which were on APD treatment have developed 19 episodes of peritonitis or 0.51 episode of peritonitis/patient/year and 41 patients on CAPD treatment have developed 25 episode of peritonitis or 0.94 episodes of peritonitis/patient/year.The Incidence Of Peritonitis In Patients Essay.  Thus the observed difference in the average rate of peritonitis/patient/year was 0.43 episode per year (95% confidence interval, 0.1 to 0.8, p=0.03) (Fijter C. W., et al., 1994). The confidence interval for this outcome suggests that there is a difference between APD and CAPD regarding the incidence of peritonitis. Also 53.7% of the patients using CCPD as their treatment have remained peritonitis free during the ten year period of this study. The Kaplan Meier in this study also showed the probability of remaining peritonitis free a median time for the first episode of 11 months for CAPD-Y compared with 18 months for CCPD. In this study patients with diabetes and those without had similar risk of developing peritonitis because the number of peritonitis was small (Fijter C. W., et al., 1994). This study was unique because the patients used were unselected and included all new dialysis patients treated at a single centre.

In the other randomized control trial done by Fijiter et al.,(1999 )also have found that Continuous Cycling Peritoneal Dialysis ( another form of APD) was accompanied with a significant lower incidence of peritonitis than Continuous Ambulatory Peritoneal Dialysis with y connector. With 26 patients having enrolled in the CAPD-y group over the 3 years of the study there were 292 patient follow up of observation. There were 22 episode of peritonitis in the CAPD-Y group, with an incidence of one episode per 13.3 patients month. In the CCPD group 30 patients have enrolled in this study and there were 337 patient follow up of observation (Fijter C. d., et al., 1991). The episodes of peritonitis that were recorded in the 3 year study were 13 episodes which means an incidence of one episode of peritonitis every 25.9 patients months. During this observation study it was noted that 16 patients (61.5%) undergoing CAPD-Y and 21 patients (70%) on CCPD have been free from peritonitis over the 3 year study. The statistical data of remaining peritonitis free showed a significant difference between CAPD-Y and CCPD. The quartile time to first peritonitis for CCPD was 12 months and that of CAPD-Y was 3 months ( p<0.05) (Fijter C. d., et al., 1991).

In the study conducted by Bro et al. (1991), the difference results of the complication of peritonitis between CAPD and APD could not be identified since the sample size was not large enough to calculate a statistical difference between the two groups. During this study 34 patients have full filled the inclusion criteria and all had agreed to take part in the study. Out of these 34 patients, 25 patients have completed the study, 13 were allocated to CAPD and 12 to APD treatment. The Incidence Of Peritonitis In Patients Essay. The results of this study showed that two cases of peritonitis occurred in the CAPD group ( 0.31 episode/patient/year) and one occurred in the APD group ( 0.17 episode/patient/year) (Bro, et al., 1999). This study showed similar complications rate of peritonitis in PD-related patients as those reported by the other study made by Fijter C.W., et al., 1994. However, since that the number of patients and events were low, no proper statistics could be applied for a comparison between APD and CAPD treatment.

In the prospective cohort studies made by Rodriguez Carmona, Fontan, Falcon, Rivera & Valdes, (1999); Yishak, Bernardini, Fried, & Piraino, (2001); and Huang, Hung, Yen, Wu & Tsai, (2001) also showed that there is a difference in the incidence of peritonitis between APD and CAPD. Two of the studies (Rodriguez Carmona, Fontan, Falcon, Rivera & Valdes, 1999 and Hung, Yen, Wu & Tsai, 2001) have showed that APD is associated with lower rates of incidence of peritonitis. The other study done by Yishak, Bernardini, Fried, & Piraino, (2001) have found out that the incidence of peritonitis between APD and CAPD was similar.

In the ten year study conducted by Rodriguez Carmona, Fontan, Falcon, Rivera & Valdes, 1999, 213 patients on CAPD and 115 patients on APD participated. CAPD patients were allocated in group 1 and over the 10 year period of the study 261 episodes of peritonitis were recorded ( 1 episode /18.7 patient month or 0.64 episode of peritonitis/ patient/ year ) and group 2 which was the APD treatment 53 episode of peritonitis were recorded ( 1 episode / 38.4 patient month or 0.31 episode of peritonitis/ patient/ year) (Rodríguez Carmona, Fontán, Falcón, Rivera, & Valdés, 1999). The impact of diabetes and the source of the patients did not make any difference on the incidence of peritonitis.

In another cohort study done by and Huang, Hung, Yen, Wu & Tsai, 2001, also found peritonitis rates to be lower in patients using APD treatment than Twin-Bag System ( CAPD). In the data collected over the 7 year period, 177 patients were recruited; 95 patients on APD and 117 on Twin Bag system. Out of the 177 patients , 35 patients have used both treatment modalities. Results from this study showed significant difference in the incidence of peritonitis were for APD 0.9/ 100 patient month and for Twin bag system 2.2/100 patient month, p < 0.01 (Haung, Hung, Yen, Wu, & Tsai, 2001). The authors have also used Kaplan Meier survival analysis and Cox proportional hazard, which this showed APD to have longer interval of time for the first instance of peritonitis and relative lower risk for peritonitis incidence (Haung, Hung, Yen, Wu, & Tsai, 2001). The results were 50.9 ± 3.9 months for APD and 35.9± 2.7 months for Twin bag system , p, < 0.079. The Incidence Of Peritonitis In Patients Essay.

The incidence of peritonitis was found to be similar between APD and CAPD in the study done by Yishak, Bernardini, Fried, & Piraino, 2001. Over the 10 year review of the incidence of peritonitis in APD was 0.57 episodes of peritonitis/ patient / year while that for CAPD was 0.55 episodes of peritonitis/ patient/year. The authors have concluded that more research is required to have definite results on which method produces the least incidence of peritonitis.

Out of the four retrospective cohort studies two of the studies found that APD was lower in the incidence of peritonitis (Sanchez, Madonia & Rascon-Paceheco, 2008;

Balasubramanian, Mc Kitty & Fan, 2011), Su, et al (2010) found that there is no difference in the incidence of peritonitis between APD and CAPD and the other study done by Than, Roberts and Collins (2005) found that CAPD was associated with lower rates of infection.

Results provided by Sanchez, Madonia & Rascon-Paceheco (2008) showed that in the two year study 28 episode of peritonitis were recorded in 98 patients who were receiving APD treatment. In CAPD 102 episodes of peritonitis were recorded in 139 patients who were on this treatment. Peritonitis rates were 1 episode per 34 patient months on APD and 1 episode per 16 patient months for CAPD treatment (Sanchez, Madonia, & Rascon-Pacheco, 2008) . This study also provided results for the possibility of a first peritonitis event during the first year for both groups, which were 21 % for APD and 47 % for CAPD ( p< 0.001). The results provided in this study analysis demonstrate that the main factor associated with the difference in occurrence of peritonitis is the modality used, in favour of APD, other factors such as age, frequency of exit site infection or the presence of diabetes did not have a significant impact on the results produced (Sanchez, Madonia, & Rascon-Pacheco, 2008). The peritonitis rate in this study favour APD when compared to CAPD.

From the single centre retrospective study conducted by Balasubramanian, Mc Kitty & Fan, 2011 over the 5 year study 372 patients were included in this study. 194 patients have chosen APD out of which 145 episode of peritonitis were recorded and 165 episode of peritonitis in 178 patients receiving treatment of CAPD. The overall peritonitis rate for both groups was 1:32.5 patient-month. The Incidence Of Peritonitis In Patients Essay.For patient receiving APD, the peritonitis rates was 1 : 36.7 and for CAPD was 1: 28.8 patient months providing an odds ratio of 0.78 ( 95 % confidence interval 0.63-0.98) in favour of APD (Balasubramanian, McKitty, & Fan, 2011). When the result of the study were analyses with Kaplan Meier which provides results for peritonitis free period it did not reach a statistical difference although there was a trend in favour of APD.

No significant difference was achieved between the incidence of APD and CAPD in the study done by Su, et al. (2010). Over the 10 year period 32 patient which were on APD treatment formed 10 episode of peritonitis or 1.42/ 100 patient months and 140 patients on CAPD formed 48 episodes of peritonitis or 1.23/ 100 patient months. The mean intervals for the first episode of peritonitis to occur for the CAPD group were 79.1±5.3 months and for APD were 76.0±13.6 months but this difference was not significant because the follow up period after two years start of this study showed no difference between the two modalities (Su, et al., 2010).

The only study that favoured CAPD to have a lower incidence of peritonitis was done by Than, Roberts and Collins, (2005). From the data collected from the United States Renal Data System, CCPD patients have experienced a first peritonitis episode one month earlier than CAPD. CAPD had 17.1 months mean number of months until first episode of peritonitis episode after 9 months of starting PD treatment and CCPD had 16.1 respectively. Also patients on CCPD than CAPD had more peritonitis incidence during the entry period ( 25 .0% CCPD and 22.4 % CAPD). This study was limited to report only whether a patient had at least one entry period episode of peritonitis because no counts on multiple peritonitis episodes during follow up was done. This meant that patients who were on CAPD treatment formed the first episode of peritonitis at an earlier time than those patients who used CCPD as their treatment.

4.4.1- Conclusion of the Results
The difference in the incidence of periotnits in CAPD and APD depends on the techniques used by the patients (Fijter C. W., et al., 1994).The Incidence Of Peritonitis In Patients Essay.  The Flush before the fill technique (that is, the initial event after each connection is dialysate outflow, and the inflow line is also flushed before dialysate inflow), has been shown to be efficient in preventing peritonitis (Rabindranath, Adams, Ali, Daly, & MacLeod, 2007). In addition the prolonged diurnal cycle of APD preceding the (dis)connection procedure might provide better immune defence, as the prolonged dwell time allows the peritoneal macrophage to function better (Fijter C. d., et al., 1991). Also APD requires fewer (dis)connections and is always done at home, allowing hygienic control of the environment as at home may allow better aseptic control (Fijter C. d., et al., 1991). As said by Huang, Hung, Yen, Wu & Tsai (2001) APD is an important treatment modality for PD patients, especially when there is a particular need to minimize the risk of peritonitis.

4.5- Further Research and Development
A number of areas needing further development were identified in the retrieved trials. One of the issues was the small sample size that was used in the three RCT’s (Fijter C. d., et al., 1991, Fijter C. W., et al., 1994, Bro et al., 1999). In fact all of these studies have suggested using larger sample size of people so that a statistical power could be achieved and this would lead to a statistical difference between the two groups that are being studied. Longer duration of the time of the study was also mentioned as these trials are not appropriate for the assessment of long term clinical outcomes (Rabindranath, Adams, Ali, Daly, & MacLeod, 2007). Another issue that was found in all of the remaining seven studies (three prospective cohort studies and four retrospective cohort studies) which these are all non randomized studies was, that all of the authors agreed that more RCT’s should be done to test the incidence of peritonitis between APD and CAPD in end stage renal disease.

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4.6- Local Situation
Currently in Malta, in the Main General Hospital Dei Renal Unit there are about 97 patients who are receiving treatment for end stage renal disease. Out of these 97 patients (100%), 44 patients (45%) are on the treatment of automated peritoneal dialysis (APD) and 53 patients (55%) were on the treatment of continuous ambulatory peritoneal dialysis (CAPD). No research was traced locally on the incidence of peritonitis in the Maltese society between the treatment of APD and CAPD. The Incidence Of Peritonitis In Patients Essay. The only statistics that were retrieved from the renal unit is the total amount of peritonitis in the APD and CAPD group between the periods of January 2012 –October 2012. The total amount of incidence of peritonitis was 32 episodes. No information was given whether the episodes of peritonitis were recurrent or from different persons and also no information about which group produced these episodes of infection. Hence the information from the local situation does not give reliable results to draw conclusions. Moreover foreign research can be implemented to see which method produces less incidence of infection. Also a pilot study should be done on the local situation to see which method produces less infection.

4.7- Conclusion
In this chapter discussion of the findings were discussed in relation to the research question which was structured in Chapter 1. The next chapter will provide recommendation and implications for Practice, education and research. The Incidence Of Peritonitis In Patients Essay.