Assessment of potential peritonitis risk factors in pediatric patients receiving maintenance peritoneal dialysis.

BACKGROUND: Many recommendations regarding peritonitis prevention in international consensus guidelines are opinion-based rather than evidence-based. The aim of this study was to examine the impact of peritoneal dialysis (PD) catheter insertion technique, timing of gastrostomy placement, and use of prophylactic antibiotics prior to dental, gastrointestinal, and genitourinary procedures on the risk of peritonitis in pediatric patients on PD. METHODS: We conducted a retrospective cohort study of pediatric patients on maintenance PD using data from the SCOPE collaborative from 2011 to 2022. Data pertaining to laparoscopic PD catheter insertion (vs. open), gastrostomy placement after PD catheter insertion (vs. before/concurrent), and no prophylactic antibiotics (vs. yes) were obtained. Multivariable generalized linear mixed modeling was used to assess the relationship between each exposure and occurrence of peritonitis. RESULTS: There was no significant association between PD catheter insertion technique and development of peritonitis (aOR = 2.50, 95% CI 0.64-9.80, p = 0.19). Patients who had a gastrostomy placed after PD catheter insertion had higher rates of peritonitis, but the difference was not statistically significant (aOR = 3.19, 95% CI 0.90-11.28, p = 0.07). Most patients received prophylactic antibiotics prior to procedures, but there was no significant association between prophylactic antibiotic use and peritonitis (aOR = 1.74, 95% CI 0.23-13.11, p = 0.59). CONCLUSIONS: PD catheter insertion technique does not appear to have a significant impact on peritonitis risk. Timing of gastrostomy placement may have some impact on peritonitis risk. Further study must be done to clarify the effect of prophylactic antibiotics on peritonitis risk. A higher resolution version of the Graphical abstract is available as Supplementary information.

Retraining programme for older patients undergoing peritoneal dialysis: A randomised controlled trial.

BACKGROUND: Peritonitis is a common cause of hospitalisation and death among patients undergoing peritoneal dialysis. Periodic retraining is recommended to prevent peritonitis, especially in older adults. OBJECTIVES: We evaluated the effectiveness of a retraining programme for reducing peritonitis and exit site infection rates in older adults on peritoneal dialysis. The cost-benefit ratio was also calculated. DESIGN: A two-arm prospective randomised controlled trial. PARTICIPANTS: One hundred and thirty patients aged 55 years or older were recruited. Participants were randomly assigned to the intervention or control group. While both groups received usual care, the intervention group received a retraining programme (a knowledge and practical assessment and a one-on-one retraining session) 90 days after starting home-based continuous ambulatory peritoneal dialysis therapy. MEASUREMENTS: The outcomes included peritonitis rate, exit site infection rate and direct medical costs at 180, 270, and 360 days after starting home-based continuous ambulatory peritoneal dialysis therapy. RESULTS: No significant differences were found in the baseline characteristics between groups. The peritonitis rates were 0.11 episodes per patient-year in the intervention group versus 0.13 in the control group. The incidence of exit site infection was 20.0% in the intervention group and 12.3% in the control group. The cost-benefit ratio of retraining was 1:9.6. None of the results were statistically significant. CONCLUSIONS: The absence of statistical significance may be partly explained by the premature termination of the study. Large-scale multi-centre trials are warranted to examine the effectiveness of retraining. The timing and long-term effects of retraining also need to be examined.

Peritoneal Dialysis-Associated Peritonitis Trends Using Medicare Claims Data, 2013-2017.

RATIONALE & OBJECTIVE: The occurrence and consequences of peritoneal dialysis (PD)-associated peritonitis limit its use in populations with kidney failure. Studies of large clinical populations may enhance our understanding of peritonitis. To facilitate these studies we developed an approach to measuring peritonitis rates using Medicare claims data to characterize peritonitis trends and identify its clinical risk factors. STUDY DESIGN: Retrospective cohort study of PD-associated peritonitis. SETTING & PARTICIPANTS: US Renal Data System standard analysis files were used for claims, eligibility, modality, and demographic information. The sample consisted of patients receiving PD treated at some time between 2013 and 2017 who were covered by Medicare fee-for-service (FFS) insurance with paid claims for dialysis or hospital services. EXPOSURES/PREDICTORS: Peritonitis risk was characterized by year, age, sex, race, ethnicity, vintage of kidney replacement therapy, cause of kidney failure, and prior peritonitis episodes. OUTCOME: The major outcome was peritonitis, identified using ICD-9 and ICD-10 diagnosis codes. Closely spaced peritonitis claims (30 days) were aggregated into 1 peritonitis episode. ANALYTICAL APPROACH: Patient-level risk factors for peritonitis were modeled using Poisson regression. RESULTS: We identified 70,271 peritonitis episodes from 396,289 peritonitis claims. Although various codes were used to record an episode of peritonitis, none was used predominantly. Peritonitis episodes were often identified by multiple aggregated claims, with the mean and median claims per episode being 5.6 and 2, respectively. We found 40% of episodes were exclusively outpatient, 9% exclusively inpatient, and 16% were exclusively based on codes that do not clearly distinguish peritonitis from catheter infections/inflammation ("catheter codes"). The overall peritonitis rate was 0.54 episodes per patient-year (EPPY). The rate was 0.45 EPPY after excluding catheter codes and 0.35 EPPY when limited to episodes that only included claims from nephrologists or dialysis providers. The peritonitis rate declined by 5%/year and varied by patient factors including age (lower rates at higher ages), race (Black > White>Asian), and prior peritonitis episodes (higher rate with each prior episode). LIMITATIONS: Coding heterogeneity indicates a lack of standardization. Episodes based exclusively on catheter codes could represent false positives. Peritonitis episodes were not validated against symptoms or microbiologic data. CONCLUSIONS: PD-associated peritonitis rates decline over time and were lower among older patients. A claims-based approach offers a promising framework for the study of PD-associated peritonitis.

Utilising low-cost, easy-to-use microscopy techniques for early peritonitis infection screening in peritoneal dialysis patients.

Peritoneal dialysis (PD) patients are at high risk for peritonitis, an infection of the peritoneum that affects 13% of PD users annually. Relying on subjective peritonitis symptoms results in delayed treatment, leading to high hospitalisation costs, peritoneal scarring, and premature transition to haemodialysis. We have developed and tested a low-cost, easy-to-use technology that uses microscopy and image analysis to screen for peritonitis across the effluent drain tube. Compared to other technologies, our prototype is made from off-the-shelf, low-cost materials. It can be set up quickly and key stakeholders believe it can improve the overall PD experience. We demonstrate that our prototype classifies infection-indicating and healthy white blood cell levels in clinically collected patient effluent with 94% accuracy. Integration of our technology into PD setups as a screening tool for peritonitis would enable earlier physician notification, allowing for prompt diagnosis and treatment to prevent hospitalisations, reduce scarring, and increase PD longevity. Our findings demonstrate the versatility of microscopy and image analysis for infection screening and are a proof of principle for their future applications in health care.

Self-assessment sheet submission rate predicts technique survival in patients initiating peritoneal dialysis.

AIM: Patients play a crucial role in preventing peritoneal dialysis (PD)-related events, including peritonitis and fluid overload, as PD procedures are mainly carried out at home. We asked patients to submit a PD self-assessment sheet at each outpatient visit in our daily clinical practice and evaluated its usefulness for outcomes in patients initiating PD. METHODS: This retrospective cohort study included patients who underwent PD catheter insertion between January 2008 and October 2018. The submission rate of a PD self-assessment sheet was calculated from medical records until PD cessation or study completion (October 2020). The association between the submission rate and technique survival was analysed. RESULTS: Among the 105 recruited patients (78 men, 60.4 ± 12.2 years), 44 discontinued PD and transferred to haemodialysis during the study period. The follow-up was 52.3 (28.7-79.3) months, and the median submission rate was 78%. The log-rank test showed that technique survival was significantly better in patients with a submission rate ≥ 78% than those with a submission rate <78% (p = .006). The submission rate remained significantly associated with less technique failure (hazard ratio 0.88 per 10%, p = .002) by the Cox regression analysis adjusted for age, sex, Charlson comorbidity index, estimated glomerular filtration rate and geriatric nutritional risk index. CONCLUSION: The submission rate of a PD self-assessment sheet is useful as a predictor of technique survival in patients initiating PD. Instruction that increases submission may improve technique survival in PD patients.

Epidemiology, management, and prevention of exit site infections in peritoneal dialysis patients.

Exit site infection (ESI) is a leading complication of peritoneal dialysis (PD), at an incidence of 0.6 episodes per year in the United States, and a major risk factor for catheter removal and peritonitis. An estimated 20% of all peritonitis cases are preceded by an ESI, with up to 50% of Staphylococcus aureus peritonitis associated with ESI. Gram-negative ESIs are less associated with succeeding peritonitis than their gram-positive counterparts, though when present, are associated with a lower peritonitis cure rate. The rate of catheter removal for refractory ESI is relatively highest in ESI due to mycobacteria (up to 40%), S. aureus (35%), Pseudomonas aeruginosa (28%), followed by Corynebacterium, Serratia, and fungi. In review of relevant literature, we found no prophylactic benefit of dressings over nondressings, specific antiseptics over normal saline, or topical honey over topical antibiotic prophylaxis, and thus recommend individualized exit site hygiene. We found topical gentamicin effective for prevention of most ESIs, including gram-negative ESIs, and thus recommend consideration of prophylactic topical gentamicin in areas of high gram-negative peritonitis incidence. With long-term use, observational studies detect up to 25% of gram-positive and 14% of gram-negative ESIs may be mupirocin and gentamicin resistant, respectively. We review empiric and targeted ESI management, including indications for ultrasound, anti-VMRSA, anti-Pseudomonal, and anti-mycobacterial antibiotic use, and catheter removal. We recommend further investigation into the earlier use of second-line treatment agents and the utility of treating post-infectious exit site colonization as avenues to decrease refractory and repeat ESI.

Clinical outcomes, quality of life, and costs evaluation of peritoneal dialysis management models in Shanghai Songjiang District: a multi-center and prospective cohort study.

Background: The new Family-Community-Hospital (FCH) three-level comprehensive management aimed to improve the efficiency and scale of peritoneal dialysis (PD) to meet the increased population of end-stage renal disease (ESRD). Our study focused on the clinical outcomes, quality of life, and costs evaluation of this model in a multi-center and prospective cohort study.Methods: A total of 190 ESRD patients who commenced PD at Shanghai Songjiang District were enrolled. According to different PD management models, patients were divided into the Family-Community-Hospital three-level management model (n = 90) and the conventional all-course central hospital management model (n = 100). The primary outcome was clinical outcomes of PD. The secondary outcomes were health-related quality of life (HRQOL) and medical costs evaluation.Results: Compared to conventional management, community-based FCH management achieved a similar dialysis therapeutic effect, including dropout rate (p = 0.366), peritonitis rate (p = 0.965), patient survival (p = 0.441), and technique survival (p = 0.589). Follow-up data showed that similar levels of the renal and peritoneal functions, serum albumin, cholesterol and triglyceride, PTH, serum calcium, and phosphorus between the two groups (all p > 0.05). HRQOL survey showed that the FCH management model helped to improve the psychological status of PD patients, including social functioning (p = 0.006), role-emotional (p = 0.032), and mental health (p = 0.036). FCH management also reduced the hospitalization (p = 0.009) and outpatient visits (p = 0.001) and saved annual hospitalization costs (p = 0.005), outpatient costs (p = 0.026), and transport costs (p = 0.006).Conclusions: Compared with conventional management, community-based FCH management achieved similar outcomes, improved psychological health, reduced medical budgets, and thus had a good social prospect.

[Comparative assessment of prognostic systems for secondary peritonitis outcome]. / Sravnitel'naya otsenka sistem prognoza iskhoda vtorichnogo peritonita.

OBJECTIVE: To compare the most common prognostic systems in patients with peritonitis. MATERIAL AND METHODS: The study included 352 patients with secondary peritonitis. At admission, sepsis was diagnosed in 15 (4.3%) patients, septic shock - in 4 (1.1%) cases. Mortality was associated with the following main causes: purulent intoxication and/or sepsis - 51 cases (87.9%), cancer-induced intoxication - 4 (6.9%) cases, acute cardiovascular failure - 3 cases (5.2%). We analyzed the efficacy of Manheim Peritoneal Index (MPI), WSES prognostic score, APACHE-II scale, gSOFA score and Peritonitis Prediction System (PPS) developed by the authors. RESULTS: Age of a patient, malignant tumor, exudate nature, sepsis (septic shock) and organ failure not associated with peritonitis are the most important criteria in predicting fatal outcome. ROC analysis was used to assess prognostic value of various prediction systems. Standard error was less than 0.05 for all scales. Therefore, all prediction systems can be considered accurate for prediction of mortality in patients with peritonitis. CONCLUSION: PPS (AUC 0.942) has the greatest accuracy in predicting fatal outcome in patients with advanced secondary peritonitis, APACHE II (AUC 0.840) - minimum accuracy. MPI had predictive accuracy > 90% too.

The Peritoneal Dialysis Transfer Set Replacement Procedure.

Peritoneal dialysis transfer sets (extension lines) are replaced every six to nine months to minimize peritoneal dialysis catheter complications. The aim of this study was to compare a revised non-bag transfer set exchange procedure with the standard bag exchange procedure on nursing time, costs, and safety. Thirty-three people were randomized to two groups - a standard bag exchange procedure group (n = 16) and a non-bag transfer set exchange procedure group (n = 17). The standard bag exchange procedure took a median of 32 minutes (interquartile range [IQR] 25 to 38 minutes) compared to the non-bag transfer set exchange procedure of 6 minutes (IQR 4 to 8 minutes) (p Ò 0.0001). There was one episode of peritonitis in each group within the 72-hour follow-up period. The average cost of the non-bag transfer set exchange procedure was $24.54 lower, a 37% cost reduction. This study has shown the revised non-bag transfer set replacement procedure appears to be safe, consume less participant and staff time, and decreases costs.

Factors associated with high-cost hospitalization for peritonitis in children receiving chronic peritoneal dialysis in the United States.

BACKGROUND: Although peritonitis causes significant morbidity and mortality in children receiving chronic peritoneal dialysis (CPD), little is known about costs associated with treatment. METHODS: We analyzed 246 peritonitis-related hospitalizations in the USA, linked by the Standardized Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) and Pediatric Health Information Systems (PHIS) databases. Multivariable logistic regression was used to assess the relationship between high-cost hospitalizations (at or above the 75th percentile) and patient characteristics. Multivariable modeling was used to assess differences in the service-line specific geometric mean between (1) high- and low-cost (below the 75th percentile) hospitalizations and (2) fungal versus other types of peritonitis. Wage-adjusted hospitalization charges were converted to estimated costs using reported cost-to-charge ratios to estimate the cost of hospitalization. RESULTS: High-cost hospitalizations were associated with the following: age 3-12 years, Hispanic ethnicity, intensive care unit (ICU) stay, length of stay (LOS), and fungal peritonitis. Whereas absolute standardized cost by service line was significantly different when comparing high- and low-cost hospitalizations, the percentage of total cost by service line was similar in the two groups. Cost per case for fungal peritonitis was higher (p < 0.001) in every service line except pharmacy when compared to other peritonitis cases. The median (IQR) cost of hospitalization for the treatment of peritonitis was $13,655 ($7871, $28434) USD. CONCLUSIONS: Hospitalization-related costs for peritonitis treatment are substantial and arise from a variety of service lines. Fungal peritonitis is associated with high-cost hospitalization.

[Peritonitis aggressiveness assessment]. / Opredelenie agressivnosti techeniia peritonita (pilotnoe issledovanie).

Peritonitis due to perforated duodenal ulcer was taken as a model. Patients were conditionally divided into three groups depending on the time after perforation: 6-12, 13-24 and over 24 hours. Analysis of microflora and pH of abdominal exudate was performed immediately after laparotomy. AIM: simple and reproducible method for determining the aggressiveness of peritonitis was developed. The authors believe that the diagnostic test is useful to individualize surgical approach in patient with advanced. peritonitis regardless time after perforation.

Postoperative Peritonitis After Digestive Tract Surgery: Surgical Management and Risk Factors for Morbidity and Mortality, a Cohort of 191 Patients.

BACKGROUND: Postoperative peritonitis (POP) following gastrointestinal surgery is associated with significant morbidity and mortality, with no clear management option proposed. The aim of this study was to report our surgical management of POP and identify pre- and perioperative risk factors for morbidity and mortality. METHODS: All patients with POP undergoing relaparotomy in our department between January 2004 and December 2013 were included. Pre- and perioperative data were analyzed to identify predictors of morbidity and mortality. RESULTS: A total of 191 patients required relaparotomy for POP, of which 16.8% required >1 reinterventions. The commonest cause of POP was anastomotic leakage (66.5%) followed by perforation (20.9%). POP was mostly treated by anastomotic takedown (51.8%), suture with derivative stoma (11.5%), enteral resection and stoma (12%), drainage of the leak (8.9%), stoma on perforation (8.4%), duodenal intubation (7.3%) or intubation of the leak (3.1%). The overall mortality rate was 14%, of which 40% died within the first 48 h. Major complications (Dindo-Clavien > 2) were seen in 47% of the cohort. Stoma formation occurred in 81.6% of patients following relaparotomy. Independent risk factors for mortality were: ASA > 2 (OR = 2.75, 95% CI = 1.07-7.62, p = 0.037), multiorgan failure (MOF) (OR = 5.22, 95% CI = 2.11-13.5, p = 0.0037), perioperative transfusion (OR = 2.7, 95% CI = 1.05-7.47, p = 0.04) and upper GI origin (OR = 3.55, 95% CI = 1.32-9.56, p = 0.013). Independent risk factors for morbidity were: MOF (OR = 2.74, 95% CI = 1.26-6.19, p = 0.013), upper GI origin (OR = 3.74, 95% CI = 1.59-9.44, p = 0.0034) and delayed extubation (OR = 0.27, 95% CI = 0.14-0.55, p = 0.0027). CONCLUSION: Mortality following POP remains a significant issue; however, it is decreasing due to effective and aggressive surgical intervention. Predictors of poor outcomes will help tailor management options.

Risk of Catastrophic Health Expenditure in Rwandan Surgical Patients with Peritonitis.

BACKGROUND: Surgical procedures are cost-effective compared with various medical and public health interventions. While peritonitis often requires surgery, little is known regarding the associated costs, particularly in low- and middle-income countries. The aim of this study was to determine in-hospital charges for patients with peritonitis and if patients are at risk of catastrophic health expenditure. METHODS: As part of a larger study examining the epidemiology and outcomes of patients with peritonitis at a referral hospital in Rwanda, patients undergoing operation for peritonitis were enrolled and hospital charges were examined. The primary outcome was the percentage of patients at risk for catastrophic health expenditure. Logistic regression was used to determine the association of various factors with risk for catastrophic health expenditure. RESULTS: Over a 6-month period, 280 patients underwent operation for peritonitis. In-hospital charges were available for 245 patients. A total of 240 (98%) patients had health insurance. Median total hospital charges were 308.1 USD, and the median amount paid by patients was 26.9 USD. Thirty-three (14%) patients were at risk of catastrophic health expenditure based on direct medical expenses. Estimating out-of-pocket non-medical expenses, 68 (28%) patients were at risk of catastrophic health expenditure. Unplanned reoperation was associated with increased risk of catastrophic health expenditure (p < 0.001), whereas patients with community-based health insurance had decreased risk of catastrophic health expenditure (p < 0.001). CONCLUSIONS: The median hospital charges paid out-of-pocket by patients with health insurance were small in relation to total charges. A significant number of patients with peritonitis are at risk of catastrophic health expenditure.

Cost analysis of laparoscopic lavage compared with sigmoid resection for perforated diverticulitis in the Ladies trial.

BACKGROUND: Laparoscopic peritoneal lavage is an alternative to sigmoid resection in selected patients presenting with purulent peritonitis from perforated diverticulitis. Although recent trials have lacked superiority for lavage in terms of morbidity, mortality was not compromised, and beneficial secondary outcomes were shown. These included shorter duration of surgery, less stoma formation and less surgical reintervention (including stoma reversal) for laparoscopic lavage versus sigmoid resection respectively. The cost analysis of laparoscopic lavage for perforated diverticulitis in the Ladies RCT was assessed in the present study. METHODS: This study involved an economic evaluation of the randomized LOLA (LaparOscopic LAvage) arm of the Ladies trial (comparing laparoscopic lavage with sigmoid resection in patients with purulent peritonitis due to perforated diverticulitis). The actual resource use per individual patient was documented prospectively and analysed (according to intention-to-treat) for up to 1 year after randomization. RESULTS: Eighty-eight patients were randomized to either laparoscopic lavage (46) or sigmoid resection (42). The total medical costs for lavage were lower (mean difference € - 3512, 95 per cent bias-corrected and accelerated c.i. -16 020 to 8149). Surgical reintervention increased costs in the lavage group, whereas stoma reversal increased costs in the sigmoid resection group. Differences in favour of laparoscopy were robust when costs were varied by ±20 per cent in a sensitivity analysis (mean cost difference € - 2509 to -4438). CONCLUSION: Laparoscopic lavage for perforated diverticulitis is more cost-effective than sigmoid resection.

Economic Impact of a Peritoneal Dialysis Continuous Quality Improvement Program in Colombia.

♦ BACKGROUND: There is little information regarding the financial burden of peritonitis and the economic impact of continuous quality improvement (CQI) programs in peritoneal dialysis (PD) patients. The objectives of this study were to measure the costs of peritonitis, and determine the net savings of a PD CQI program in Colombia. ♦ METHODS: The Renal Therapy Services (RTS) network in Colombia, along with Coomeva EPS, provided healthcare resource utilization data for PD patients with and without peritonitis between January 2012 and December 2013. Propensity score matching and regression analysis were performed to estimate the incremental cost of peritonitis. Patient months at risk, episodes of peritonitis pre- and post-CQI, and costs of CQI were obtained. Annual net savings of the CQI program were estimated based on the number of peritonitis events prevented. ♦ RESULTS: The incremental cost of a peritonitis episode was $250. In an 8-year period, peritonitis decreased from 1,837 episodes per 38,596 patient-months in 2006 to 841 episodes per 50,910 patient-months in 2014. Overall, the CQI program prevented an estimated 10,409 episodes of peritonitis. The cost of implementing the CQI program was $147,000 in the first year and $119,000 annually thereafter. Using a five percent discount rate, the net present value of the program was $1,346,431, with an average annual net savings of $207,027. The return on investment (i.e. total savings-program cost/program cost) of CQI was 169%. ♦ CONCLUSION: Continuous quality improvement initiatives designed to reduce rates of peritonitis have a strong potential to generate cost savings.

A contemporary approach to the prevention of peritoneal dialysis-related peritonitis in children: the role of improvement science.

Peritonitis is a leading cause of hospitalizations, morbidity, and modality change in pediatric chronic peritoneal dialysis (CPD) patients. Despite guidelines published by the International Society for Peritoneal Dialysis aimed at reducing the risk of peritonitis, registry data have revealed significant variability in peritonitis rates among centers caring for children on CPD, which suggests variability in practice. Improvement science methods have been used to reduce a variety of healthcare-associated infections and are also being applied successfully to decrease rates of peritonitis in children. A successful quality improvement program with the goal of decreasing peritonitis will not only include primary drivers directly linked to the outcome of peritonitis, but will also direct attention to secondary drivers that are important for the achievement of primary drivers, such as health literacy and patient and family engagement strategies. In this review, we describe a comprehensive improvement science model for the reduction of peritonitis in pediatric patients on CPD.

Health economic analysis of laparoscopic lavage versus Hartmann's procedure for diverticulitis in the randomized DILALA trial.

BACKGROUND: Open surgery with resection and colostomy (Hartmann's procedure) has been the standard treatment for perforated diverticulitis with purulent peritonitis. In recent years laparoscopic lavage has emerged as an alternative, with potential benefits for patients with purulent peritonitis, Hinchey grade III. The aim of this study was to compare laparoscopic lavage and Hartmann's procedure with health economic evaluation within the framework of the DILALA (DIverticulitis - LAparoscopic LAvage versus resection (Hartmann's procedure) for acute diverticulitis with peritonitis) trial. METHODS: Clinical effectiveness and resource use were derived from the DILALA trial and unit costs from Swedish sources. Costs were analysed from the perspective of the healthcare sector. The study period was divided into short-term analysis (base-case A), within 12 months, and long-term analysis (base-case B), from inclusion in the trial throughout the patient's expected life. RESULTS: The study included 43 patients who underwent laparoscopic lavage and 40 who had Hartmann's procedure in Denmark and Sweden during 2010-2014. In base-case A, the difference in mean cost per patient between laparoscopic lavage and Hartmann's procedure was €-8983 (95 per cent c.i. -16 232 to -1735). The mean(s.d.) costs per patient in base-case B were €25 703(27 544) and €45 498(38 928) for laparoscopic lavage and Hartmann's procedure respectively, resulting in a difference of €-19 794 (95 per cent c.i. -34 657 to -4931). The results were robust as demonstrated in sensitivity analyses. CONCLUSION: The significant cost reduction in this study, together with results of safety and efficacy from RCTs, support the routine use of laparoscopic lavage as treatment for complicated diverticulitis with purulent peritonitis.

Diabetes Is Associated with Clinical Decompensation Events in Patients with Cirrhosis.

OBJECTIVES: Liver cirrhosis is a leading cause of morbidity and mortality in the USA. Diabetes is common and increasing in incidence. Patients with compensated cirrhosis and diabetes may be at greater risk of clinical decompensation. We examined the risk of decompensation among a large sample of working-aged insured patients dually diagnosed with compensated cirrhosis and diabetes. METHODS: This retrospective study used MarketScan® Commercial Claims and Encounters and Medicare Supplemental Databases (2000-2013). Decompensation events included incident ascites, spontaneous bacterial peritonitis, variceal bleeding, hepatic encephalopathy, acute renal failure, and hepatocellular carcinoma. Dually diagnosed patients were defined as patients with cirrhosis and diabetes using previously published ICD-9 coding strategies. Adjusted odds ratios (ORs), hazard ratios (HRs), and confidence intervals (CI) were estimated using logistic regression and Cox proportional hazard models. RESULTS: Of 72,731 patients with compensated cirrhosis, 20,477 patients (28.15 %) were diagnosed with diabetes. After controlling for patient characteristics and medication usage, the odds of developing any decompensation event were 1.14 times higher for patients with cirrhosis and diabetes than for patients with cirrhosis only (95 % CI 1.08-1.21, P value <0.01). In the Cox proportional hazard model, patients who were dually diagnosed with diabetes had a 1.32 times higher HR (95 % CI 1.26-1.39, P value <0.01) after controlling for time-to-event. CONCLUSIONS: Patients dually diagnosed with compensated cirrhosis and diabetes had a higher risk of having decompensation events. Careful management of diabetes in patients with liver disease may reduce the risk of clinical decompensation in this population.

Assessment of current practice and barriers to antimicrobial prophylaxis in peritoneal dialysis patients.

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.