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Morrisette et al
with PD receive antibiotic courses, as it has been shown that
preceding bacterial peritonitis and antibiotic therapy can be
associated with fungal peritonitis episodes.3,13-15 In our study,
those patients who received antifungal therapy for prophylaxis/treatment of fungal infections throughout their hospitalization had a statistically significant increased LOS (9%
vs 27%; P = 0.021). However, it is quite possible that
patients with ICU admission, ID consultation, or who
received antifungal therapy had a higher acuity of illness and
other confounding variables that could have led to their
increased LOS.
For patients presenting with PDAP, PD catheter removal
and HD conversion throughout their hospitalization and/or
as their primary mode of RRT may be clinically indicated.
Our study showed that there was an increased LOS in patients
who had their PD catheter removed (15% vs 48%; P = .001)
and/or switched to HD (17% vs 52%; P < .001). Troidle et al
conducted a retrospective analysis evaluating the outcomes
of patients on chronic PD who had their catheter removed
due to peritonitis and showed that only 20% of patients who
had their catheter removed remained on PD 1 year after catheter removal.16 Nearly all of the patients in our study who
had their PD catheter removed were switched to HD and had
a prolonged LOS. It is likely that many of these patients will
remain on HD as suggested by previous studies.
Hyperglycemia can be a common complication of PD due
to the utilization of dextrose-containing dialysis effluents.17,18
Extensive data indicate that hyperglycemia throughout hospitalization can lead to increased complications.19-22 Szeto
et al showed that new-onset hyperglycemia is common in
patients started on PD and that even mild hyperglycemia is
associated with increased mortality.18 Our study supports an
associated increased LOS with more frequent episodes of
hyperglycemia.
Staphylococcus aureus and Staphylococcus epidermidis
are the most causative pathogens of PDAP, as PDAP is most
often caused by skin flora contamination.4,23 Kofteridis et al
found no differences in peritonitis course due to the type of
infecting organism, while Bunke et al found that outcomes in
non-Pseudomonas spp. Gram-negative pathogens were significantly worse than those compared with Staphylococcal
species.2,24 Although there were no differences in LOS
between baseline causative pathogens in the present study,
the trend toward decreased LOS with MRSA and increased
LOS with Acinetobacter spp. should be further evaluated, as
earlier studies have shown conflicting results in peritonitis
course due to baseline pathogen.2,24,25
Although there were no statistically significant differences between the 2 groups in number of patients with appropriate antimicrobial de-escalation, this study highlights the
lack of ASP within the PDAP population. One area for
improvement relates to route of antibiotic administration.
The 2016 ISPD Peritonitis Guidelines recommend that the
preferred route of antibiotic administration is IP in patients
who lack systemic signs of sepsis.3 It was hypothesized that

55
most inpatient providers likely lack comfort with IP administration and may be prone to administer antimicrobials by the
IV route. It was also hypothesized that if providers did give
antibiotics via the IP route, they may be less likely to deescalate. Based on lack of SIRS criteria on presentation, 65%
of patients in the reduced LOS group and 75% of patients in
the prolonged LOS group were eligible for IP antibiotics
only. Only 13% of patients received antibiotics strictly via
the IP route, and these patients were all in the reduced LOS
group (P = .026). It is common for patients with PDAP to
present to the emergency department, and they will likely
receive an initial dose of antibiotics via the IV route.
Important to note, however, is that of the 54 patients (60%)
in the total population who received IV and IP administration, only 14 patients (16%) received just one dose of IV
antibiotics prior to their switch to IP antibiotics. Although
some patients did have other suspected/confirmed infection
present, the majority of included patients in our study solely
had PDAP as their infectious pathology, which indicates that
IV therapy was inappropriately continued. This could be due,
in part, to the lack of comfort by providers with IP antimicrobial administration, further emphasized by the fact that only
59% of patients were prescribed IP antibiotics on discharge
to complete their treatment. It is crucial to re-emphasize that
patients who lack systemic signs of infection who are admitted to the hospital should be switched to the IP route, as this
approach promotes maximal antimicrobial concentrations at
the infection site and could help facilitate discharge.
Furthermore, opportunities for antimicrobial de-escalation
were missed in nearly 40% of our total patient population,
emphasizing opportunities to improve ASP efforts in the
PDAP population. Numerous studies have shown hospital
LOS can be reduced through ASP efforts.26-28 Promoting IP
administration for PDAP and antimicrobial de-escalation are
important ASP principles that could be of benefit to patients
and health care systems. Antimicrobial stewardship efforts
could be improved through development of inpatient PDAP
treatment protocols.
Limitations of our study included the retrospective nature
of our analysis, that we lacked the ability to account for readmissions to other facilities, and that we did not determine the
obtainment of nephrology consultations between the 2
groups. Also, given that hospital LOS defined our 2 groups
for comparison, there are confounding variables that could
have led to an increased hospital LOS. For example, one
confounding variable could have been reason(s) for ICU
admission (which was not collected). A standardized acuity
or mortality indicator (other than SIRS) could have further
classified severity of disease in each group, but this was not
collected. With regard to our patient population, it is important to note that patients in our study were included prior to
the 2016 ISPD Peritonitis Guideline update, and the definition of PDAP did vary slightly in the previous guidelines;
however, we considered the updated definition to be stricter
and we included patients who met these criteria, irrespective
Hospital Pharmacy - February 2020

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