Best Practice of Peritoneal Dialysis-Associated Gram-Negative Peritonitis in Children: Insights From the International Pediatric Peritoneal Dialysis Network Registry

IntroductionGram-negative peritonitis (GNP) is associated with significant morbidity in children receiving long-term peritoneal dialysis (PD) and current treatment recommendations are based on limited data. Methods: Analysis of 379 GNP episodes in 308 children (median age 6.9 years, IQR 3.0-13.6) from 45 centers in 28 countries reported to the International Pediatric Peritoneal Dialysis Network (IPPN) registry between 2011–2023. Results: Overall, 74% of episodes responded well to empiric therapy and full functional recovery (FFR) was achieved in 82% of cases. In vitro bacterial susceptibility to empiric antibiotics and lack of severe abdominal pain at onset were associated with a good initial response. Risk factors for failure to achieve FFR included severe abdominal pain at onset and at 60-72 hours from treatment initiation (OR, 3.81 [95%CI,2.01-7.2] and OR, 3.94 [95%CI,1.06-14.67], respectively), Pseudomonas spp. etiology (OR, 1.73 [95% CI, 1.71-4.21]) and in vitro bacterial resistance to empiric antibiotics (OR, 2.40 [95%CI, 1.21-4.79]); the risk was lower with the use of monotherapy as definitive treatment (OR, 0.40 [95%CI, 0.21-0.77]). Multivariate analysis showed no benefit of dual antibiotic therapy for treatment of Pseudomonas peritonitis after adjustment for age, presenting symptomatology, 60–72-hour treatment response and treatment duration. Monotherapy with cefazolin in susceptible Enterobacterales peritonitis resulted in a similar FFR rate (91 vs. 93%) as treatment with ceftazidime or cefepime monotherapy. Conclusions: Detailed microbiological assessment, consisting of patient- and center- specific antimicrobial susceptibility data, should guide empiric treatment. Treatment "de-escalation" with use of monotherapy and narrow spectrum antibiotics according to susceptibility data is not associated with inferior outcomes and should be advocated in the context of emerging bacterial resistance.