Prevention of Infections in Peritoneal Dialysis: Survey Among Young Tunisian Nephrologists

Abstract

Peritonitis is a severe complication in peritoneal dialysis (PD) patients, contributing to technique failure and patient mortality. Tunisia lacks a national dialysis registry, making the incidence of peritonitis unclear. The International Society for Peritoneal Dialysis (ISPD) published guidelines from 2016 to 2022, outlining effective strategies for preventing infections in PD patients. This study was conducted between June and July 2022 to assess Tunisian nephrologists’ knowledge and practices for preventing infections. Using an online questionnaire, 44 participants (67.69% response rate) provided insights. Findings revealed an average score of 4.45 out of 7, indicating significant confusion among respondents. Many incorrectly believe that protecting the catheter under the skin until renal replacement therapy is initiated reduces infections. Questions also addressed nasal Staphylococcus aureus screening, antibiotic prophylaxis, surgical techniques, timing of dressing changes, and local antibiotic use. Responses varied, with 59.1% supporting systematic nasal screening but differing concerning eradication strategies. The study highlights discrepancies between current practices and ISPD guidelines among young Tunisian nephrologists. Recommendations include establishing a national dialysis registry to enhance surveillance and developing tailored national guidelines. A working group from the Tunisian Society of Nephrology, Dialysis, and Transplantation is already developing protocols to address identified gaps and improve PD patient outcomes.

Introduction

Peritoneal dialysis (PD) is one of the modalities of renal replacement therapy for patients with end-stage renal disease. In 2015, estimates suggested that 272,000 individuals globally were undergoing PD, accounting for approximately 11% of the dialysis population[1]. PD is an ambulatory technique, but patients need to receive training and education from specialized nurses beforehand to minimize the risk of bacterial contamination during the connection maneuvers of the catheter to dialysate bags. Infectious complications are the most feared complications of this technique. There are two main types of infections: exit-site infections and infections of the dialysis fluid (peritonitis). In Tunisia, at a center in Sousse, the authors report a rate of 0.44 peritonitis episodes per patient[2]. However, in France, according to the French Language Peritoneal Dialysis Registry (RDPLF), the incidence of peritonitis is one episode in every 32 patient–months (i.e., 0.37 episodes per year)[3][4]. Despite the existence of international guidelines for diagnosis, prevention, and treatment issued by the International Society of Peritoneal Dialysis (ISPD)[5], the incidence of infectious complications remains high and varies from one country to another. Prevention in its various forms remains the central focus of management. Nevertheless, we did not find any articles in the literature that evaluate the knowledge of young nephrologists regarding preventive measures against PD infection complications.

This work aims to assess the theoretical knowledge and practical approaches of young Tunisian nephrologists concerning the prevention of infectious complications, identify and address the difficulties encountered, and, subsequently, review the preventive measures for PD-related infections.

Materials and Methods

Participants:

This is a descriptive cross-sectional observational study conducted between 2022 June and July, targeting young nephrologists. These nephrologists were required to complete an anonymous online questionnaire. A total of 65 questionnaires were sent to various physicians (residents-in-training and hospital–university assistants). Forty-four physicians (67.69%) responded to the questionnaire.

Inclusion Criteria:

• Young nephrologists who are residents and hospital–university assistants

Non-Inclusion Criteria:

• Nephrologists who were not practicing at the time of the study

• Nephrologists practicing abroad

• Associate professors and full professors

Exclusion Criteria:

• There were no exclusion criteria, as the online platform receiving the responses only accepted fully completed questionnaires

The Questionnaire

The questionnaire consisted of 11 questions: four regarding the physicians’ status and the training they received concerning PD, and seven on the prevention of infections in PD. There were 10 single-choice questions and one multiple-choice question.

The questionnaire focused on the following themes:

• Prophylactic antibiotic therapy and infections

• Technical procedures and infections

• Screening for nasal carriage of Staphylococcus aureus and its eradication

• Timing of the first dressing change

• Systematic local antibiotic therapy and infections

The seven questions assessing the theoretical and practical knowledge of young nephrologists (residents and hospital–university assistants) regarding the prevention of infections in PD were scored on a scale of 0 to 7. Each question was scored as either correct (1 point) or incorrect (0 points). There was no partial credit: 0 points for an incorrect response and 1 point for a correct response. The total score ranged from 0 to 7.

The questionnaire was distributed to young nephrologists via email and through social media platforms. Responses were collected using the Google Forms interface and through email for analysis.

Statistical Analysis

We computed simple frequencies and relative frequencies (percentages) for qualitative variables. For quantitative variables, we calculated means, medians, and standard deviations and identified extreme values.

Results

Forty-four questionnaires were completed and validated. The maximum score was 7 out of 7, and the minimum score was 1 out of 7. Four physicians achieved a score of seven.

Characteristics of the study population

Question 1: Are you a resident?

Thirty-four physicians (77.27%) who responded to the questionnaire are residents. The distribution of residents according to residency year is shown inFigure 1.

Figure 1.Distribution of respondents by year of residency

Figure 2.Distribution of respondents by year of assistantship. HUA= hospital university assistant

Question 2: Are you a hospital–university assistant?

Ten physicians (22.73%) are hospital–university assistants. The distribution of physicians according to assistantship year is shown inFigure 2.

Question 3: Did you receive specialized training in peritoneal dialysis?

In response to this question, 50% of the respondents answered that they did not receive specialized training. Moreover, 22 physicians had received training from Baxter in PD, and one physician obtained a university diploma in PD. Only one physician received two types of specialized training (university diploma in PD and Baxter training in PD).

Question 4: Have you undergone training in peritoneal dialysis during your practice?

Among the respondents, 40.9% said that they had not undergone training in PD for a period lasting at least 3 months.

Descriptive study of questions regarding theoretical and practical knowledge on the prevention of infections in peritoneal dialysis

Question 5: Do you believe that burying a catheter (Moncrief method) reduces the incidence of exit-site infections?

Regarding this question, 63.6% of physicians incorrectly answered yes, stating that burying the catheter under the skin until the need to initiate renal replacement therapy reduces the incidence of exit-site infections.

Question 6: Do you believe that a preoperative antibiotic injection is recommended to reduce the risk of infection?

Among the participants, 90.9% (n = 40) answered this question correctly.

Question 7: Do you believe that screening for nasal carriage of Staphylococcus aureus should be performed systematically after catheter placement?

Responses were divided: 59.1%

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