Denise J Campbell1, Fiona G Brown2, Jonathan C Craig1, Martin P Gallagher3, David W Johnson4, Geoffrey S Kirkland5, Subramanian K Kumar6, Wai H Lim7, Dwarakanathan Ranganathan8, Walaa Saweirs9, Kamal Sud10, Nigel D Toussaint11, Rowan G Walker12, Lesley A Williams8, Maha Yehia13, David W Mudge4. 1. Centre for Kidney Research, Sydney Children's Hospital Network (Westmead), Westmead, NSW, Australia School of Public Health, University of Sydney, Sydney, NSW, Australia. 2. Monash University, Clayton, VIC, Australia. 3. University of Sydney and George Institute for Global Health, Sydney, NSW, Australia. 4. University of Queensland at Princess Alexandra Hospital, Brisbane, QLD, Australia. 5. Royal Hobart Hospital, Hobart, TAS, Australia. 6. Gosford Hospital, Gosford, NSW, Australia. 7. Sir Charles Gairdner Hospital, Perth, WA, Australia. 8. Royal Brisbane and Women's Hospital, Herston, QLD, Australia. 9. Whangarei Hospital, Northland District Health Board, Whangarei, New Zealand University of Auckland, Auckland, New Zealand. 10. Nepean Clinical School, University of Sydney, Sydney, NSW, Australia Westmead and Nepean Hospitals, NSW, Australia. 11. Western Health, Footscray, VIC, Australia The Royal Melbourne Hospital, Parkville, VIC, Australia. 12. The Royal Melbourne Hospital, Parkville, VIC, Australia The Alfred Hospital, Prahran, VIC, Australia. 13. Auckland City Hospital, Auckland, New Zealand.
Abstract
BACKGROUND: 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. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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.
BACKGROUND: 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. METHODS: 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 PDpatients. 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. RESULTS: 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). CONCLUSIONS: 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 PDpatients also play a role.
Authors: Philip Kam-Tao Li; Kai Ming Chow; Moniek W M Van de Luijtgaarden; David W Johnson; Kitty J Jager; Rajnish Mehrotra; Sarala Naicker; Roberto Pecoits-Filho; Xue Qing Yu; Norbert Lameire Journal: Nat Rev Nephrol Date: 2016-12-28 Impact factor: 28.314