Risk factors for peritonitis in patients on continuous ambulatory peritoneal dialysis who undergo colonoscopy: A retrospective multicentre study

doi:10.21203/rs.2.11212/v1

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Risk factors for peritonitis in patients on continuous ambulatory peritoneal dialysis who undergo colonoscopy: A retrospective multicentre study

https://doi.org/10.21203/rs.2.11212/v1

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Background: Colonoscopy is associated with a risk of peritonitis in patients on peritoneal dialysis. However, no study has yet described the risk factors in play. Methods: This was a retrospective multicentre study. The medical records of patients on continuous ambulatory peritoneal dialysis (CAPD) who underwent colonoscopy from January 2003 to December 2012 were analysed. We recorded demographic characteristics, colonoscopic factors, use of prophylactic antibiotics, and development of peritonitis. Colonoscopy-related peritonitis was defined as peritonitis developing within 1 week after colonoscopy. Demographic and clinical characteristics were compared between patients who did and those who did not develop peritonitis. Results: During the study period, 236 patients on CAPD underwent colonoscopy, of whom 9 (3.8%) developed peritonitis. The rates of polypectomy/endoscopic mucosal resection were significantly higher in the peritonitis group than in the no peritonitis group (66.7 vs. 23.4%, p=0.009). Prophylactic antibiotics were prescribed before colonoscopy in 65 patients; none developed peritonitis. No patient who developed peritonitis received prophylactic antibiotics (p=0.067). Conclusions: Advanced procedures including polypectomy or endoscopic mucosal resection increase colonoscopy-related peritonitis in patients on CAPD. Prophylactic antibiotics should be administered before colonoscopy to such patients.

Gastroenterology & Hepatology

Peritoneal dialysis

continuous ambulatory peritoneal dialysis

colonoscopy

peritonitis

Peritoneal dialysis (PD) is a major form of renal replacement. Peritonitis is an important complication associated with technical failure and death, as well as an important quality measure, in patients on PD. [1-4] The International Society for Peritoneal Dialysis recommends an annual peritonitis rate of less than 0.5 episodes per year. [5] Risk factors for PD-related peritonitis are older age, diabetes, hypoalbuminemia, and invasive procedures including hysteroscopy, dental procedures, and colonoscopy. [5-9]

As most gut microorganisms are found in the colon, the gut is a potential source of intra-abdominal infection. [10] Several studies have reported the development of peritonitis after colonoscopy in patients on PD. [11, 12] Recently, the American Society of Gastrointestinal Endoscopy and the International Society for Peritoneal Dialysis recommended that prophylactic antibiotics be prescribed before colonoscopy for such patients. [5, 13] However, little evidence supports this recommendation. One study found that the rate of peritonitis was 6.4% in PD patients undergoing endoscopy. [14] However, the cited work included patients undergoing upper endoscopy and hysteroscopy as well as colonoscopy. [14] Moreover, previous studies could not identify factors contributing to colonoscopy-related peritonitis because of a small sample size. [12, 14, 15] In this multicentre study, we sought to identify factors associated with peritonitis and the effects of antibiotic prophylaxis in patients on PD undergoing colonoscopy.

Study population and methods

This was a multicentre, retrospective, cohort study. The medical records of patients on continuous ambulatory peritoneal dialysis (CAPD) who underwent colonoscopy from January 2003 to December 2012 were analysed. Patients were treated in seven hospitals of the Catholic University of Korea: Incheon St Mary’s Hospital, Vincent Hospital, Bucheon St. Mary’s Hospital, Yeouido St. Mary’s Hospital, Uijeongbu St. Mary’s Hospital, and Seoul St. Mary’s Hospital. The study protocol was approved by the institutional review board of each participating hospital. Written informed consent was waived because the work was retrospective in nature. We recorded demographic characteristics and colonoscopy-related factors, including the indication for colonoscopy, bowel preparation quality, biopsy status, and the need for advanced procedures including polypectomy or endoscopic mucosal resection (EMR) during colonoscopy. The use of prophylactic antibiotics was assessed. Patients were divided into the peritonitis and no peritonitis groups. In those who developed colonoscopy-related peritonitis, the results of peritoneal fluid culture and antibiotic treatment, and the clinical outcomes, were investigated.

Definitions

Colonoscopy-related peritonitis was defined as peritonitis developing within 1 week after colonoscopy. Peritonitis was diagnosed when at least two of the following criteria were met: (1) abdominal pain with or without a cloudy dialysis effluent, (2) a peritoneal effluent white cell count >100/μL with >50% polymorphonuclear neutrophils, and (3) a positive dialysis effluent culture. [5]

Statistical analysis

Continuous variables are presented as means ± standard deviations and were compared using Student’s t-test or the Mann–Whitney U-test. Categorical variables are presented as numbers with percentages and were compared using the chi-squared or Fisher’s exact test. Demographic and clinical characteristics were compared between patients who did and those who did not develop peritonitis. A p-value <0.05 was considered significant. All statistical analyses were performed using SAS ver. 9.0 software (SAS Institute, Cary, NC).

Baseline characteristics of the study subjects

During the study period, 236 patients on CAPD underwent colonoscopy, of whom 9 (3.8%) developed peritonitis. The patient baseline characteristics are listed in Table 1. Sex, age, and body mass index were comparable between the two groups. The diabetes rates were 33.3% in the peritonitis group and 37.4% in the no peritonitis group (p=1.000). The CAPD durations were 33.9 and 51.4 months, respectively.

Colonoscopic factors and the use of prophylactic antibiotics

The results of colonoscopy are shown in Table 2. Neither the colonoscopy skills required nor bowel preparation quality differed between the two groups. The colonic mucosa was manipulated/biopsied, and advanced procedures such as polypectomy or EMR performed, in 123 patients. The extent of colonic mucosal manipulation was higher in the peritonitis group than in the no peritonitis group (88.9 vs. 50.7%, p=0.037). Colonic mucosal biopsy did not increase the rate of peritonitis development (peritonitis vs. no peritonitis group: 22.2% vs. 27.3%, p=1.000). However, the rates of polypectomy/EMR were significantly higher in the peritonitis group than in the no peritonitis group (66.7 vs. 23.4, p=0.009). Prophylactic antibiotics were prescribed before colonoscopy to 65 patients (27.5%), and none of these patients developed peritonitis. However, the proportion of patients who received prophylactic antibiotics prior to colonoscopy did not differ significantly between the two groups (peritonitis vs. no peritonitis group: 0 vs. 28.6%; p=0.067). In a subgroup analysis, of the 59 patients who underwent polypectomy or EMR, prophylactic antibiotics were given to 14 (23.7%). Although none of the six patients who developed peritonitis after polypectomy or EMR received prophylactic antibiotics, such antibiotics did not prevent peritonitis statistically (peritonitis vs. no peritonitis group: 0 [0/6 vs. group 26.4% [14/53], p=0.319).

Clinical outcomes

The details of the peritonitis cases are listed in Table 3. The microorganisms isolated from peritoneal effluent were Staphylococcus aureus (n=1), Escherichia coli (n=5), and none (n=3). One patient who underwent no advanced procedure had S. aureus. All patients received at least two antibiotics. The PD catheter was removed from one patient 5 days after antibiotic treatment commenced. We recorded no mortalities.

We sought to identify risk factors for colonoscopy-associated peritonitis in patients on CAPD. The overall peritonitis rate was 3.8%. Both polypectomy and EMR were peritonitis risk factors. Although statistical significance was not attained (p=0.067), peritonitis was absent in patients who received antibiotic prophylaxis prior to colonoscopy. To the best of our knowledge, this is the first multicentre study to explore the risk factors for colonoscopy-related peritonitis in patients on CAPD; we included the largest number of patients evaluated on this subject to date.

The principal causes of PD-related peritonitis are catheter infections, thus contamination of PD catheters and exit site and tunnel infections. Less often, microorganisms from the colon or vagina, or haematogenous dissemination after dental procedures, trigger peritonitis in patients on PD. [16, 17] We found that polypectomy and EMR were risk factors for peritonitis. The colonic mucosa prevents microorganism translocation and controls intestinal permeability. [18, 19] Polypectomy and EMR create colonic mucosal defects facilitating translocation of intestinal microorganisms. We found that colonic biopsy was not associated with a risk of peritonitis. Such mucosal defects may be smaller than those caused by polypectomy or EMR. Also, we removed colon polyps electrically, thus not via cold snaring. Compared with cold-snare polypectomy, hot-snare polypectomy and EMR damage the large bowel wall to greater extents. [20, 21] Thermal injury of the colonic mucosa may act synergistically with a mucosal defect to trigger peritonitis.

Of the 113 patients who did not undergo mucosal manipulation, peritonitis occurred in only 1 (0.8%). The causative organism was S. aureus. The causative organism depends on the infection site. Usually, Gram-positive bacteria cause catheter-related infections. However, Gram-negative bacteria are commonly translocated from the colon or vagina. [5] S. aureus is the most common causative agent of catheter-related peritonitis; [16] we could not exclude the possibility of catheter-related peritonitis in the abovementioned patient. Peritonitis resolved after catheter removal.

Were prophylactic antibiotics useful? Of the 236 patients, only 65 received such antibiotics. The overall peritonitis rate after colonoscopy was 3.8%. When we divided the patients into those who received prophylactic antibiotics and those who did not, the peritonitis rates were 0 (0/65) and 5.3% (9/171), respectively. Although statistical significance was not attained (p=0.067), peritonitis did not develop in any patient who received prophylactic antibiotics, in line with the findings of previous studies. [12, 14] Most studies found that the use of prophylactic antibiotics did not attain statistical significance in terms of peritonitis development. It is unethical to give patients placebos. We included patients on CAPD who underwent colonoscopy from 2003 to 2012, of whom a relatively small proportion (27.5%) received antibiotics prior to colonoscopy. We gave antibiotics prior to colonoscopy from 2010. Colonic neoplasms are found in up to 50% of patients undergoing colonoscopy. [22-25] Although diagnostic colonoscopy lacking a therapeutic procedure may not cause peritonitis, physicians cannot predict the presence of colon polyps. Therefore, prophylactic antibiotics should be given to all patients on CAPD prior to colonoscopy.

Our study had several strengths. First, this is the first multicentre study to explore whether colonoscopy triggers peritonitis in patients on PD. Second, we investigated factors causing peritonitis and identified advanced procedures such as polypectomy and EMR as triggers.

Several limitations of the study should be addressed. The work was retrospective in nature. Some data were lacking. Colonoscopy procedure time, which might affect peritonitis development, was not recorded. We did not include patients on automated PD (APD), but rather only CAPD patients. Peritoneal fluid triggers peritonitis. As patients on APD do not retain peritoneal fluid during the day, we hypothesized that patients on CAPD are at a higher risk of colonoscopy-related peritonitis than are patients on APD; thus, our findings may not be applicable to patients on APD.

In conclusion, advanced procedures including polypectomy and EMR increase the risk of colonoscopy-associated peritonitis in patients on CAPD. Prophylactic antibiotics should be administered prior to colonoscopy.

CAPD: Continuous ambulatory peritoneal dialysis, PD: Peritoneal dialysis, EMR: Endoscopic mucosal resection

Declarations

Ethics approval

This study was approved by the Institutional Review Board of the Catholic University of Korea (XC12RIMI0106V).

Consent for publication

Not applicable

Availability of data and materials

The datasets generated or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interest.

Funding

Not applicable

Author’s contributions

Jung SH, Lee KM and Choi H planned and designed the review. Kim SW, Cheung DY and Lee BI carried out data collection. Data analysis was performed by Gweon TG under the supervision of SH Jung. Lee BI and Lee KM supervised the writing of the manuscript. All authors reviewed and approved the final draft of the manuscript.

Acknowledgements

Not applicable

Davenport A: Peritonitis remains the major clinical complication of peritoneal dialysis: the London, UK, peritonitis audit 2002-2003. Peritoneal dialysis international : journal of the International Society for Peritoneal Dialysis 2009, 29(3):297-302.
Perez Fontan M, Rodriguez-Carmona A, Garcia-Naveiro R, Rosales M, Villaverde P, Valdes F: Peritonitis-related mortality in patients undergoing chronic peritoneal dialysis. Peritoneal dialysis international : journal of the International Society for Peritoneal Dialysis 2005, 25(3):274-284.
Fried LF, Bernardini J, Johnston JR, Piraino B: Peritonitis influences mortality in peritoneal dialysis patients. Journal of the American Society of Nephrology : JASN 1996, 7(10):2176-2182.
Oliveira LG, Luengo J, Caramori JC, Montelli AC, Cunha Mde L, Barretti P: Peritonitis in recent years: clinical findings and predictors of treatment response of 170 episodes at a single Brazilian center. International urology and nephrology 2012, 44(5):1529-1537.
Li PK, Szeto CC, Piraino B, de Arteaga J, Fan S, Figueiredo AE, Fish DN, Goffin E, Kim YL, Salzer W et al: ISPD Peritonitis Recommendations: 2016 Update on Prevention and Treatment. Peritoneal dialysis international : journal of the International Society for Peritoneal Dialysis 2016, 36(5):481-508.
Nessim SJ, Bargman JM, Austin PC, Nisenbaum R, Jassal SV: Predictors of peritonitis in patients on peritoneal dialysis: results of a large, prospective Canadian database. Clinical journal of the American Society of Nephrology : CJASN 2009, 4(7):1195-1200.
Okayama M, Inoue T, Nodaira Y, Kimura Y, Nobe K, Seto T, Sueyoshi K, Takane H, Takenaka T, Okada H et al: Aging is an important risk factor for peritoneal dialysis-associated peritonitis. Advances in peritoneal dialysis Conference on Peritoneal Dialysis 2012, 28:50-54.
Fan X, Huang R, Wang J, Ye H, Guo Q, Yi C, Lin J, Zhou Q, Shao F, Yu X et al: Risk factors for the first episode of peritonitis in Southern Chinese continuous ambulatory peritoneal dialysis patients. PloS one 2014, 9(9):e107485.
Tian Y, Xie X, Xiang S, Yang X, Zhang X, Shou Z, Chen J: Risk factors and outcomes of high peritonitis rate in continuous ambulatory peritoneal dialysis patients: A retrospective study. Medicine 2016, 95(49):e5569.
Quigley EM: Gut bacteria in health and disease. Gastroenterology & hepatology 2013, 9(9):560-569.
Ray SM, Piraino B, Holley J: Peritonitis following colonoscopy in a peritoneal dialysis patient. Peritoneal dialysis international : journal of the International Society for Peritoneal Dialysis 1990, 10(1):97-98.
Yip T, Tse KC, Lam MF, Cheng SW, Lui SL, Tang S, Ng M, Chan TM, Lai KN, Lo WK: Risks and outcomes of peritonitis after flexible colonoscopy in CAPD patients. Peritoneal dialysis international : journal of the International Society for Peritoneal Dialysis 2007, 27(5):560-564.
Committee ASoP, Khashab MA, Chithadi KV, Acosta RD, Bruining DH, Chandrasekhara V, Eloubeidi MA, Fanelli RD, Faulx AL, Fonkalsrud L et al: Antibiotic prophylaxis for GI endoscopy. Gastrointest Endosc 2015, 81(1):81-89.
RWu HH, Li IJ, Weng CH, Lee CC, Chen YC, Chang MY, Fang JT, Hung CC, Yang CW, Tian YC: Prophylactic antibiotics for endoscopy-associated peritonitis in peritoneal dialysis patients. PloS one 2013, 8(8):e71532.
Al-Hwiesh AK, Abdul-Rahman IS, Hussameldeen MA, Al-Audah N, Abdelrahman A, Moaigel HM, El-Salamony T, Noor AS, Al-Osail A, Al-Sayel D et al: Colonoscopy in automated peritoneal dialysis patients: value of prophylactic antibiotics: a prospective study on a single antibiotic. The International journal of artificial organs 2017, 40(10):550-557.
Szeto CC, Li PK, Johnson DW, Bernardini J, Dong J, Figueiredo AE, Ito Y, Kazancioglu R, Moraes T, Van Esch S et al: ISPD Catheter-Related Infection Recommendations: 2017 Update. Peritoneal dialysis international : journal of the International Society for Peritoneal Dialysis 2017, 37(2):141-154.
Salzer WL: Peritoneal dialysis-related peritonitis: challenges and solutions. International journal of nephrology and renovascular disease 2018, 11:173-186.
Lee SH: Intestinal permeability regulation by tight junction: implication on inflammatory bowel diseases. Intestinal research 2015, 13(1):11-18.
Oshima T, Miwa H: Gastrointestinal mucosal barrier function and diseases. Journal of gastroenterology 2016, 51(8):768-778.
Horiuchi A, Nakayama Y, Kajiyama M, Tanaka N, Sano K, Graham DY: Removal of small colorectal polyps in anticoagulated patients: a prospective randomized comparison of cold snare and conventional polypectomy. Gastrointest Endosc 2014, 79(3):417-423.
Ferlitsch M, Moss A, Hassan C, Bhandari P, Dumonceau JM, Paspatis G, Jover R, Langner C, Bronzwaer M, Nalankilli K et al: Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2017, 49(3):270-297.
Gweon TG, Kim SW, Noh YS, Hwang S, Kim NY, Lee Y, Lee SW, Lee SW, Lee JY, Lim CH et al: Prospective, randomized comparison of same-day dose of 2 different bowel cleanser for afternoon colonoscopy: picosulfate, magnesium oxide, and citric acid versus polyethylene glycol. Medicine 2015, 94(13):e628.
Kwon SC, Choi SW, Choi SH, Park HS, Lee SH, Kim BG, Seo EH, Jang M, Ryu SM, Kim DH et al: The Effect of Indigocarmine on Improvement of the Polyp Detection Rate during Colonoscopic Examination with Hood Cap. Intestinal research 2014, 12(1):60-65.
Huh CW, Gweon TG, Seo M, Ji JS, Kim BW, Choi H: Validation of same-day bowel preparation regimen using 4L polyethylene glycol: Comparison of morning and afternoon colonoscopy. Medicine 2018, 97(37):e12431.
Lee SW, Chang JH, Ji JS, Maeong IH, Cheung DY, Kim JS, Cho YS, Chung WJ, Lee BI, Kim SW et al: Effect of Dynamic Position Changes on Adenoma Detection During Colonoscope Withdrawal: A Randomized Controlled Multicenter Trial. Am J Gastroenterol 2016, 111(1):63-69.

Table 1. Baseline characteristics

Characteristics	Peritonitis (n = 9)	No peritonitis (n = 227)	P
Male, n (%)	5 (55.6)	123 (54.2)	1.000
Age, years (± SD)	52.6 (± 11.1)	50.4 (± 16.7)	0.061
BMI, kg/m² (± SD)	24.3 (± 2.2)	24.2 (± 3.3)	0.796
Etiology of ESRD			1.000
Diabetes, n (%)	3 (33.3)	85 (37.4)
Non-diabetes, n (%)	6 (66.7)	142 (62.6)
Duration of CAPD, months	33.9±25.5	51.4±53.7	0.207

SD, standard deviation; ESRD, end stage renal disease; CAPD, continuous ambulatory peritoneal dialysis

Table 2. Factors related to colonoscopy

Characteristics	Peritonitis (n = 9)	No peritonitis (n = 227)	P
Colonoscopist, n (%)			0.505
Expert, n (%)	3 (33.3)	118 (52.0)
Trainee, n (%)	6 (66.7)	109 (48.0)
Bowel preparation quality n (%)
Excellent or good	9 (100)	216 (95.2)
Fair	0 (0)	11 (4.8)
Colonoscopic procedure	8 (88.9)	115 (50.7)	0.037
Colon biopsy, n (%)	2 (22.2)	62 (27.3)	1.000
Polypectomy / EMR, n (%)	6 (66.7)	53 (23.4)	0.009
Use of prophylactic anbitiobitcs, n (%)			0.067
Yes	0 (0)	65 (28.6)
No	9 (100)	162 (71.4)

EMR, endoscopic mucosal resection

Table 3. Details of peritonitis

Patient number	Sex	Age	Procedure	Culture	Treatment	Outcome
1	Female	74	No procedure	S. aureus	Cefazolin + gentamycin	Catheter removal
2	Female	58	EMR	No growth	Cefamezin + gentamycin	Recovered
3	Female	22	Colon biopsy	No growth	Cefazolin + gentamycin	Recovered
4	Male	52	EMR	E. coli	Cefamezin + gentamycin	Recovered
5	Male	38	EMR	No growth	Cefazolin + gentamycin	Recovered
6	Male	64	Polypectomy	E. coli	Cefazolin + gentamycin	Recovered
7	Male	34	Polypectomy	E. coli	Vancomycin + ceftazidime	Recovered
8	Female	64	Colon biopsy	E. coli	Ceftazidime + metronidazole	Recovered
9	Male	48	EMR	E. coli	Cefamezine + tobramycin	Recovered

EMR, endoscopic mucosal resection

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Journal Publication

published 06 Nov, 2019

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Editorial decision: Minor revision
23 Aug, 2019
Reviewer #2 agreed at journal
18 Aug, 2019
Review #2 received at journal
18 Aug, 2019
Review #1 received at journal
14 Aug, 2019
Reviewers invited by journal
12 Aug, 2019
Reviewer #1 agreed at journal
12 Aug, 2019
Editor assigned by journal
29 Jul, 2019
Submission checks completed at journal
07 Jul, 2019
Editor invited by journal
07 Jul, 2019
First submitted to journal
07 Jun, 2019

You are reading this older preprint version

Read the latest preprint version →

Risk factors for peritonitis in patients on continuous ambulatory peritoneal dialysis who undergo colonoscopy: A retrospective multicentre study

Status:

Journal Publication

Version 1

Abstract

Background

Methods

Results

Discussion

Abbreviations

Declarations

References

Tables

Status:

Journal Publication

Version 1