A population-based study on the incidence and aetiology of infectious complications in peritoneal dialysis in South Sweden

Figures & data

Table 1. Description of implemented terminology, as adapted from the International Society for peritoneal dialysis. [12,13].

Term	Definition
Peritonitis	Presence of at least two of the following: Abdominal pain and/or cloudy dialysis effluent. WBC in dialysis effluent >0.1 × 10^9/L. Positive effluent culture.
Exit-site infection	Presence of purulent discharge, irrespective of erythema of the skin.
Tunnel infection	Presence of clinical inflammation, or collection along the catheter tunnel upon ultrasonographic examination.
Pre-PD peritonitis	An episode occurring prior to commencement of PD treatment.
Catheter insertion-related peritonitis	An episode occurring within 30 days of PD catheter placement.
Recurrent	An episode occurring within 4 weeks of completion of therapy of a prior episode but with a different organism on culture.
Relapsing	Peritonitis occurring within 4 weeks of completion of therapy of a prior episode with either the same organism or negative culture

Figure 1. Flowchart of steps of inclusion.

^aPatients that received PD at centres outside of the county of Skåne, Sweden.

^bPatients that received PD before 1 January 2011 or after 31 December 2020.

Table 2. Baseline characteristics of study population at PD commencement.

Baseline characteristics	n = 675
Age, median (range)	66.5 (0–91)
Female sex, n (%)	208 (30.8%)
BMI, mean (SD)	26.9 (4.7)
CCI^a, median (range)	1 (0–9)
Diabetes, n (%)	267 (39.6%)
Tumour, n (%)	80 (11.9%)
CVA, n (%)	76 (11.3%)
MI, n (%)	71 (10.5%)
CHF, n (%)	59 (8.7%)
COPD, n (%)	40 (5.9%)
Hematologic malignancy, n (%)	12 (1.8%)
Tobacco habits
Smokers, n (%)	106 (15.7%)
Quit smoking ≥1 month, n (%)	254 (37.6%)
Never smoked, n (%)	231 (34.2%)
Immunosuppressive treatment, n (%)	24 (3.6%)
Corticosteroid treatment ≥3 months, n (%)	15 (2.2%)
Tacrolimus, n (%)	7 (1.0%)
APD^a, n (%)	225 (34.6%)
CAPD, n (%)	425 (65.4%)
PD modality unknown, n (%)	25 (3.7%)
Assisted PD, n (%)	190 (28.1%)
Transfer set system
Fresenius, n (%)	250 (37.0%)
Baxter, n (%)	206 (30.5%)
Gambro^b, n (%)	81 (12.0%)
Unknown, n (%)	138 (20.4%)
Months in PD, median (range)	18 (0-128)
Days with idle catheter, median (range)	41 (0–1776)

BMI: body mass index; CVA: cerebrovascular accident; MI: myocardial Infarction; CHF: congestive heart failure; COPD: chronic obstructive pulmonary disease: CCI: charlson comorbidity index; APD: ambulatory peritoneal dialysis; CAPD: continuous ambulatory peritoneal dialysis.

^a All patients utilising APD as part their regimen were assigned to this group, regardless of sporadic supplementary manual exchanges.

^b Swedish-founded manufacturer of medical technology, acquired in 2013 by Baxter International Inc.

Table 3. Aetiology of end-stage renal disease necessitating renal replacement therapy.

Aetiology of ESRD	n (%)
Diabetic nephropathy	193 (29)
Vascular disease	134 (20)
Hypertensive arteriolar nephrosclerosis	119
Renal atheroembolism	10
Glomerulonephritis	130 (19)
IgA nephropathy	42
Focal segmental glomerulosclerosis (FSGS)	17
Membranoproliferative GN (MPGN)	13
Lupus nephritis (SLE)	6
Microscopic nephritis (MPA)	5
Granulomatosis with polyangiitis (GPA)	5
Post-streptococcal GN	3
Goodpasture syndrome	2
Genetic disease or malformation	86 (13)
Polycystic kidney disease (PKD)	56
Congenital malformations	15
Vesicoureteral reflux	7
Nephronophthisis	2
Alport syndrome	2
Laurence-Moon-Biedl syndrome	1
Tubulointerstitial nephritis (TIN)	26 (4)
Toxic injury	9
Neoplastic disease	13 (2)
Amyloidosis	5
Renal cancer, nephrectomy	5
Myeloma kidney	3
Miscellaneous	31 (5)
Acute kidney injury (AKI)	15
Pyelonephritis	9
Obstructive uropathy	4
Haemolytic uraemic syndrome (HUS)	2
Unknown aetiology	62 (9)

GN: glomerulonephritis.

Figure 2. A. Distribution of peritonitis in relation to age groups.B. Peritonitis incidence among age groups.

Figure 3. Temporal trend of PD-peritonitis incidence during the study period.

Table 4. Annual sex- and age-standardised rates of PD-peritonitis.

	EASR^a	95% CI
2011	4.58	3.37–5.79
2012	3.49	2.41–4.57
2013	3.33	2.30–4.36
2014	4.24	3.07–5.42
2015	4.13	2.99–5.26
2016	3.11	2.15–4.08
2017	3.69	2.64–4.73
2018	4.21	3.11–5.31
2019	3.60	2.59–4.61
2020	3.96	2.91–5.00
Mean	3.83	2.75–4.91

^a Episodes per 100,000 population per year.

Figure 4. Microbiological aetiologies to PD-associated peritonitis.

Table 5. Microbiology findings related to early PD-peritonitis (within the first six months after PD commencement) or late-onset peritonitis, i.e. six months after PD commencement.

Microbiological aetiology	Early peritonitis, n (%)	Late peritonitis, n (%)
Number of cultures	88	384
Culture negative	12 (13.6%)	14 (3.6%)
Acinetobacter spp.	3 (3.4%)	9 (2.3%)
Bacteroides spp.	———	10 (2.6%)
Candida spp.	4 (4.5%)	15 (3.9%)
albicans	2 (2.3%)	9 (2.3%)
Citrobacter spp.	3 (3.4%)	11 (2.9%)
Corynebacterium spp.	———	6 (1.6%)
E. cloacae	2 (2.3%)	11 (2.9%)
E. coli	3 (3.4%)	44 (11.5%)
Enterococcus spp.	4 (4.5%)	42 (10.9%)
faecalis	2 (2.3%)	26 (6.8%)
faecium	1 (1.1%)	10 (2.6%)
Klebsiella spp.	8 (9.1%)	23 (6.0%)
oxytoca	6 (6.8%)	12 (3.1%)
pneumoniae	2 (2.3%)	10 (2.6%)
Micrococcus spp.	———	6 (1.6%)
Moraxella spp.	1 (1.1%)	5 (1.3%)
Proteus spp.	———	6 (1.6%)
Pseudomonas spp.	2 (2.3%)	20 (5.2%)
aeruginosa	1 (1.1%)	14 (3.6%)
Serratia spp.	3 (3.4%)	4 (1.0%)
Staphylococcus spp.	36 (40.9%)	167 (43.5%)
aureus	14 (15.9%)	48 (12.5%)
Coagulase-negative	22 (25.0%)	117 (30.5%)
epidermidis	11 (12.5%)	63 (16.4%)
Streptococcus spp.	14 (15.9%)	66 (17.2%)
mitis	5 (5.7%)	24 (6.3%)
salivarius	3 (3.4%)	17 (4.4%)

Table 6. Peritonitis episodes with positive blood cultures.

Year	Peritonitis pathogen (dialysate culture)	Blood culture	Concordant cultures	TTD^a aerobic	TTD anaerobic
2011	C. albicans	Yeast	Yes
2011	Pseudomonas sp.	CoNS
2013	S. pasteuri	S. pasteuri, CoNS	Yes
2013	P. aeruginosa	CoNS
2014	S. aureus	S. epidermidis, S. capitis
2014	E. coli	E. coli	Yes
2014	Negative	K. oxytoca
2015	E. coli	E. coli	Yes	10.2	10.6
2016	C. koseri	CoNS			28.7
2016	E. cloacae	E. cloacae	Yes	7.7	6.2
2017	S. salivarius	CoNS		29.1
2017	E. coli	E. coli	Yes	11.4	10.5
2018	S. epidermidis, S. mitis	S. mitis	Yes	19.6
2019	K. pneumoniae, E. faecalis, S. haemolyticus	CoNS	Yes	21.0
2019	E. coli	E. coli	Yes	5.4	6.5
2020	S. marcescens, K. oxytoca	K. oxytoca	Yes	13.0
2020	K. pneumoniae	Bacillus sp.		18.4
2020	S. salivarius	CoNS			21.6
2020	S. vestibularis	CoNS		23.6
2020	K. pneumoniae	Kocuria sp.		93.7

^a TTD: time to detection (hours).

Table 7. Antimicrobiological resistance in peritonitis.

	S. aureus		CoNS		Klebsiella spp.		E. coli		Proteus spp.		Enterobacter spp.		Pseudomonas spp.		Serratia spp.		Citrobacter spp.		Morganella spp.
Antibiotic	R	n	R	n	R	n	R	n	R	n	R	n	R	n	R	n	R	n	R	n
Penicillin G	41	51
Cefoxitin	0	40	49	90
Fusidic acid	1	57	26	103
Gentamycin	0	59	33	101	0	31	4	47	0	4	0	12	0	6	0	8	1	14	0	2
Imipenem	0	16			0	31	0	46	0	4	0	12	1	22	0	8	0	14	0	2
Isoxazolyl penicillins	0	58	46	84
Clindamycin	0	55	37	103
Linezolid	0	57	0	101
Norfloxacin	1	56	44	102
Piperacillin/tazobactam	0	17			0	31	2	47	0	4	1	12	0	21	0	8	0	14	0	2
Rifampicin	1	59	3	101
Tigecycline	0	38	0	72	0	31	0	20							0	1	1	7
Tobramycin	1	46	32	92	0	31	3	46	1	5	0	12	0	22	0	8	0	14	0	2
Trimethoprim-Sulfamethoxazole	0	56	28	103	0	31	6	43	1	3	0	7	1	1	0	7	1	9	0	2
Vancomycin	0	55	0	100			1	1					2	2
Erythromycin			49	98
Phenoxymethylpenicillin (PcV)			3	5
Tetracycline			0	3
Amikacin					0	8	0	14	0	1	0	8	0	4	0	2	0	4
Cefadroxil					0	24	3	39	1	3	4	5			6	6	8	10
Cefotaxime					0	31	3	47	0	4	3	12			0	8	5	14	0	2
Ceftazidime					0	31	3	47	0	4	2	10	0	22	0	8	4	14	0	2
Ciprofloxacin					0	31	4	46	1	4	1	12	1	22	0	8	0	14	0	2
Meropenem					0	31	0	45	0	4	0	12	1	22	0	8	0	14	0	2

CoNS: Coagulase-negative staphylococci.

Table 8. Antimicrobial resistance in exit site infections.

	S. aureus		CoNS		Klebsiella spp.		E. coli		Proteus spp.		Enterobacter spp.		Pseudomonas spp.		Serratia spp.		Citrobacter spp.		Morganella spp.
Antibiotic	R	N	R	N	R	N	R	N	R	N	R	N	R	N	R	N	R	N	R	N
Penicillin G	3	3
Cefoxitin	1	43	1	7
Fusidic acid	1	55	0	8
Gentamycin	1	4	1	1	0	12	0	5	0	1	0	1			0	7			0	1
Imipenem	1	102			0	11	0	3			0	1	2	37	0	6			0	1
Isoxazolyl penicillins	1	139	1	6
Clindamycin	7	139	0	8
Linezolid	0	4	0	1
Norfloxacin	2	54	1	8
Piperacillin/tazobactam	1	102			0	11	0	3			0	1	0	37	0	6			0	1
Rifampicin	0	4	0	1
Tigecycline	0	3	0	1	0	1	0	2							0	1
Tobramycin	1	4			0	11	0	3			0	1	0	37	0	6			0	1
Trimethoprim-Sulfamethoxazole	1	55	1	8	1	21	2	8	3	5	0	4			1	12			1	2
Vancomycin	0	7
Erythromycin			0	8
Phenoxymethylpenicillin (PcV)			1	1
Tetracycline
Amikacin							0	1
Cefadroxil					2	22	1	8	0	5	4	4			12	12
Cefotaxime					1	19	1	6	0	4	0	4			0	11			1	2
Ceftazidime					0	19	1	5	0	4	0	4	0	37	0	11			1	2
Ciprofloxacin					1	22	1	8	0	5	0	4	5	37	0	12			0	2
Meropenem					0	20	0	6	0	5	0	4	0	37	0	12			0	2

CoNS: coagulase-negative staphylococci.

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