Peritonites por Estafilococos em Diálise Peritoneal: Fatores de Risco e Associados à Resposta Clínica em uma Coorte Brasileira de Pacientes Incidentes
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2019-12-06
Autores
Pinotti, Douglas Gonçalves
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Universidade Estadual Paulista (Unesp)
Resumo
A peritoniteé complicação grave e responsável pela maioria dos casos de falência da técnica de diálise peritoneal (DP). Os cocos Gram-positivos são o grupo etiológico principal, sendo os estafilococos coagulase-negativa (ECN) os germes mais comuns e o Staphylococcus aureus(S.aureus), associado a episódios mais graves e commenor frequência de resolução. O conhecimento dos fatores de risco e dospreditoresda sua evolução podem contribuir para a melhoria das estratégias de prevenção e de tratamento. Objetivo:Os objetivos do presente estudo foram avaliar os fatores de risco para o primeiro episódio de peritonite por estafilococos e os fatores associados à resolução e falência da técnica após resolução do episódio de peritonite, em uma grande coorte brasileira de pacientes em DP (BRAZPD). Métodos:De uma coorte de 5707 pacientes incidentes adultos, com mais de 90 dias de tratamento por DP, foram incluídos, entre dezembro de 2004 e novembro de 2011, aqueles que apresentaram um primeiro episódio de peritonite por S. aureus ou ECN. As covariáveis, potencialmente associadas aos desfechos, foram testadas em análise univariada e aquelas com p ≤ 0,10 incluídas no modelo multivariado. Resultados:Durante o seguimento,389pacientes apresentaram um primeiro episódio de peritonite estafilocócica. Destes, 234 foram causados por S. aureus e 155 por ECN. Os grupos que apresentaram peritonite por S. aureus ou por ECN foram semelhantes para a maior parte das características basais. Entre os pacientes com peritonite por S. aureus, houve resolução em 190 (81,2%); falência da técnica em 41 (21,6%) e18 óbitos(7,7%) relacionados à peritonite. Entre asperitonites por ECN, houve 127 casos curados (82,6%); 33 falências da técnica (25,8%), e 12 óbitos relacionadosao episódio (7,7%). Essas diferenças não foram estatisticamente significantes. HD prévia se associou a maior risco para a primeira peritonite por ECN (SHR= 1,45, p=0,03), enquanto a presença de função renal residual (FRR) (SHR=0,51, p=0,02) e cor de pele branca (SHR=0,76, p=0,049) se associaram a menor risco para as infecções por S. aureus. Peritonites por S. aureus e por ECN não diferiram quanto ao risco de não resolução e falência da técnica. A prescrição de antimicrobianos para tratamento inicial das peritonites estafilocócicas, que não a vancomicina ou cefalosporina da 1ª geração, foi fortemente associada ao risco de não-resolução (OR= 5,78, p=0,008).Conclusão:HD prévia, ausência de FRR e cor da pele não branca se associam a maior risco de peritonite, respectivamente por ECN e por S.aureus.A prescrição de antimicrobianos não recomendados pelas diretrizes internacionais se associa à não resolução das peritonites.
Peritonitis is a serious complication of peritoneal dialysis (PD) and the main cause of technique failure. Gram-positive cocci are the most frequent etiological group, coagulase-negative staphylococci (CNS) are the most common germs, and Staphylococcus aureus (S. aureus) is associated with more severe episodes and lower resolution rate. Objective: The objectives of this study were to evaluate the risk factors for the first episode of staphylococcal peritonitis, and the factors associated with resolution and technique failure after peritonitis episode resolution, in a large Brazilian cohort of PD patients (BRAZPD). Methods: From a cohort of 5707 adult incident patients with more than 90 days of PD treatment, between December 2004 and November 2011, those who had a first episode of S. aureus or CNS peritonitis were included. The covariates potentially associated with the outcomes were tested in univariate analysis and those with p ≤ 0.10 included in the multivariate model. Results: During follow-up, 389 patients had a first episode of staphylococcal peritonitis. Of these, 234 were caused by S. aureus and 155 by CNS. The groups of patients with S. aureus or CNS peritonitis were similar for most baseline characteristics. Among S. aureus peritonitis, there was resolution in 190 (81.2%); technique failure in 41 (21.6%), and episode-related death in 18 (7.7%). In the episodes by CNS, there were 127 resolutions (82.6%); 33 technique failures (25.8%), and 12 episode-related deaths (7.7%). These differences were not statistically significant. Prior HD was associated with a higher risk for the first CNS peritonitis (SHR=1.45, p =0.03), while the presence of residual renal function (RRF) (SHR=0.51, p=0.02) and White race was associated with lower risk for S. aureus infections (SHR=0.76, p=0.049). S. aureus and CNS peritonitis did not differ regarding the risk of non-resolution and technique failure. The prescription of antimicrobials for initial treatment of staphylococcal peritonitis other than 1st generation vancomycin or cephalosporin was strongly associated with the risk of non-resolution (OR=5.78, p =0.008). Conclusion: Prior HD, absence of RRF and non-White race are associated with higher risk of peritonitis, respectively by CNS and S. aureus. The prescription of antimicrobials not recommended by international guidelines is associated with non-resolution of peritonitis.
Peritonitis is a serious complication of peritoneal dialysis (PD) and the main cause of technique failure. Gram-positive cocci are the most frequent etiological group, coagulase-negative staphylococci (CNS) are the most common germs, and Staphylococcus aureus (S. aureus) is associated with more severe episodes and lower resolution rate. Objective: The objectives of this study were to evaluate the risk factors for the first episode of staphylococcal peritonitis, and the factors associated with resolution and technique failure after peritonitis episode resolution, in a large Brazilian cohort of PD patients (BRAZPD). Methods: From a cohort of 5707 adult incident patients with more than 90 days of PD treatment, between December 2004 and November 2011, those who had a first episode of S. aureus or CNS peritonitis were included. The covariates potentially associated with the outcomes were tested in univariate analysis and those with p ≤ 0.10 included in the multivariate model. Results: During follow-up, 389 patients had a first episode of staphylococcal peritonitis. Of these, 234 were caused by S. aureus and 155 by CNS. The groups of patients with S. aureus or CNS peritonitis were similar for most baseline characteristics. Among S. aureus peritonitis, there was resolution in 190 (81.2%); technique failure in 41 (21.6%), and episode-related death in 18 (7.7%). In the episodes by CNS, there were 127 resolutions (82.6%); 33 technique failures (25.8%), and 12 episode-related deaths (7.7%). These differences were not statistically significant. Prior HD was associated with a higher risk for the first CNS peritonitis (SHR=1.45, p =0.03), while the presence of residual renal function (RRF) (SHR=0.51, p=0.02) and White race was associated with lower risk for S. aureus infections (SHR=0.76, p=0.049). S. aureus and CNS peritonitis did not differ regarding the risk of non-resolution and technique failure. The prescription of antimicrobials for initial treatment of staphylococcal peritonitis other than 1st generation vancomycin or cephalosporin was strongly associated with the risk of non-resolution (OR=5.78, p =0.008). Conclusion: Prior HD, absence of RRF and non-White race are associated with higher risk of peritonitis, respectively by CNS and S. aureus. The prescription of antimicrobials not recommended by international guidelines is associated with non-resolution of peritonitis.
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Palavras-chave
Peritonite, Diálise peritoneal, Staphylococcus aureus, Estafilococos coagulase-negativa, Fatores de risco, Desfechos clínicos, Peritonitis, Peritoneal dialysis, Coagulase negative staphylococci, Risk factors, Linical outcomes