Hospital Pharmacy - February 2020 - 50

817944
research-article2018

HPXXXX10.1177/0018578718817944Hospital PharmacyMorrisette et al

Original Article

Factors Associated With Increased
Hospital Length of Stay in Peritoneal
Dialysis Patients With Peritonitis: A
Need for Antimicrobial Stewardship?

Hospital Pharmacy
2020, Vol. 55(1) 50-57
© The Author(s) 2018
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https://doi.org/10.1177/0018578718817944
DOI: 10.1177/0018578718817944
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Taylor Morrisette1, Robert B. Canada2, Danielle Padgett3,
and Joanna Q. Hudson2

Abstract
Background: Peritonitis remains a complication of peritoneal dialysis (PD) and contributes to morbidity. Adherence
to evidence-based recommendations should resolve peritonitis within 5 days; however, hospital length of stay (LOS) for
patients with PD-associated peritonitis (PDAP) varies. Factors contributing to increased LOS and vigilance with antimicrobial
stewardship (ASP) in this population are not well described. Methods: This was a system-wide, retrospective cohort of
adult patients presenting with PDAP from August 2012 to August 2017. Patients were divided into 2 groups based on LOS:
<7 days (reduced LOS) versus ≥7 days (prolonged LOS). Patient demographics, resolution of peritonitis by day 5, intensive
care unit (ICU) admission, infectious diseases (ID) consultation, changes in dialysis modality, blood glucose, and pathogen/
antimicrobial characteristics were compared. In-hospital mortality and 30-day readmissions were also evaluated. Results: Of
the 401 patients screened, 90 were included: 53% women, 88% African American, age 52 ± 2 years (reduced LOS: 46 patients;
prolonged LOS: 44 patients). Increased LOS was associated with ICU admission (P = .014), ID consultation (P = .015), PD
catheter removal (P = .001), hemodialysis conversion (P < .001), antifungal therapy (P = .021), and days with blood glucose
>180 mg/dL (P = .028). Opportunities for antimicrobial de-escalation were identified in 24 (52%) and 22 (50%) patients in
the reduced and prolonged LOS groups, respectively; however, de-escalation occurred in only 5 (21%) and 6 (27%) of these
patients. There were no differences in mortality or 30-day readmissions. Conclusions: Longer LOS was influenced by acuity
of illness and possibly lack of enforced ASP. Improvement of ASP within the PDAP population is necessary.
Keywords
anti-infectives, infectious diseases, nephrology

Introduction
Of the more than 480,000 patients requiring renal replacement therapy (RRT) for the treatment of end-stage renal disease (ESRD) in the United States, nearly 10% of patients
receive peritoneal dialysis (PD). While the number of
patients receiving PD is relatively low compared with hemodialysis (HD), PD use has continued to rise over the past
decade to a rate that is over 70% higher than in 2007.1
Unfortunately, the number of patients maintained on PD is
declining, in part, due to the high incidence of peritonitis.2-3
Although hospital admission rates for patients with PD have
decreased 24% in the past decade, peritonitis remains the
most common reason for infection-related hospitalizations in
patients with PD and contributes to increased health care
costs and mortality.1,4-5
The International Society of Peritoneal Dialysis (ISPD)
Peritonitis Guidelines provide recommendations on empiric

treatment of suspected/confirmed peritonitis, duration of
treatment, and antimicrobial de-escalation while supporting
the intraperitoneal (IP) route as the preferred route for antibiotic administration.3 In the outpatient setting, dialysis facilities commonly rely on these recommendations to design
treatment algorithms; however, peritonitis treatment regimens are inconsistent in the inpatient setting. Lack of inpatient peritoneal dialysis-associated peritonitis (PDAP)
protocols can lead to variations in antibiotic selection, dosing
regimens, route of administration, and the prescribed
1

University of Colorado Anschutz Medical Campus, Aurora, CO, USA
University of Tennessee Health Science Center, Memphis, TN, USA
3
Methodist University Hospital, Memphis, TN, USA
2

Corresponding Author:
Taylor Morrisette, 12850 E Montview Blvd, Aurora, CO 80045, USA.
Email: Taylor.morrisette@ucdenver.edu
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