縮短腹膜炎症狀起始至聯絡腹膜透析中心的時間間隔可改善腹膜透析相關腹膜炎的預後

Shorter time between symptoms onset and patient notify peritoneal dialysis center improve outcome of peritoneal dialysis peritonitis

吳珮瑜(Pei-Yu Wu)

指導教授 ： 邱怡文

高雄醫學大學/醫學院/臨床醫學研究所碩士班/碩士(2020年)

摘要

導論：腹膜相關的腹膜炎在腹膜透析患者是常見併發症，可能導致腹膜透析技術失敗。最近的一項研究表明，從醫院到達抗生素治療的時間與腹膜透析衰竭有關。我們想知道患者覺察腹膜炎症狀是否會通過延遲抗生素給藥時間來影響結果。此研究目的是研究患者腹膜炎症狀發作到通知腹膜透析中心的時間間隔對腹膜炎的預後的影響。
研究方法：此研究回顧在台灣南部某醫學中心從2011年9月至2018年2月所有腹膜透析相關腹膜炎的病例。通知時間定義為從症狀發作到患者通知腹膜透析中心之間的時間。該研究的預後為腹膜透析相關的腹膜炎治療失敗，治療失敗定義為腹膜透析導管移除或腹膜炎相關的死亡。使用generalized estimating equations進行統計分析，分析通知時間與預後之間的關係。
結果：本研究共收入發生於57位腹膜透析患者身上的89例腹膜炎進行分析，其中9例腹膜透析導管移除，有5例死亡（平均年齡52.9±13.4歲，男性占33.3%，糖尿病發生佔15.8%，接受腹膜透析時間為 4.4[1.8-7.0]年）。根據是否治療失敗，將腹膜炎發作分為兩組。保留導管組有79例腹膜炎，治療失敗組有11例。治療失敗組年齡較大、高血壓患病率較高，冠心病患病率較低。根據通知時間≥6小時vs. <6小時、≥12小時vs. <12小時、≥18小時vs. <18小時、≥24小時vs. <24小時進行分組，共分析了4個統計模組。在多變量分析中，通知持續時間≥24小時(vs. 24小時，勝算比為11.67； 95％信賴區間為2.67至50.91； p = 0.001)和年齡(勝算比為1.08；95％信賴區間為1.01至1.15； p = 0.025)與治療失敗的風險增加具顯著相關。女性(vs.男性，勝算比為0.23; 95％信賴區間為0.06至0.90; p = 0.035)和培養陽性(vs.陰性，勝算比為0.17; 95％信賴區間為0.04至0.74; p = 0.018)與治療失敗的風險降低具顯著相關。
結論：從腹膜炎症狀發作開始到患者通知腹膜透析中心之間的時間如果超過24小時，會增加腹膜透析腹膜炎治療失敗的風險。老年和腹膜透析引出液培養陰性也與腹膜炎治療失敗有關。

關鍵字

腹膜透析 ； 腹膜炎 ； 通知時間 ； 抗生素給予 ； 治療失敗

並列摘要

Introduction: Peritoneal dialysis (PD) associated peritonitis is the main complication of PD, which increases the risk of PD technical failure, hospitalization, and all-cause mortality. The earlier antibiotics administration decreased mortality in septic shock and pneumonia, and a recent study showed the time from hospital arrival to antibiotic treatment was associated with PD failure. We wonder the patients’ awareness of the symptom of peritonitis may affect the outcome by delaying the timing of antibiotics administration. This study aims to investigate the effect of the time between symptoms onset and patients notify PD staff on outcomes of PD associated peritonitis.
Material and method: We reviewed all PD-related peritonitis from September 2011 to February 2018 at a medical center in Southern Taiwan. We defined notice duration as the duration from patients’ awareness of peritonitis symptom to patients calling PD center in PD peritonitis. The outcome in this study was the treatment failure of PD-related peritonitis, which was defined as PD catheter removal or peritonitis related mortality. Generalized estimating equations was used to check the association between notice duration and outcome.
Result: A total 89 episodes of peritonitis in 7 PD patients entered into final analysis in this study, 9 episodes removed PD catheter and there were 5 deaths (mean age 52.9± 13.4 years, Male:33.3 %, DM:15.8 %, PD vintage: 4.4(1.8-7.0) years ). Peritonitis episodes were stratified into two groups by treatment failure. There were 78 episodes of peritonitis in catheter reserved group and 11 episodes in treatment failure group. Those in treatment failure group were older, higher prevalence of hypertension and lower prevalence of coronary artery disease. We performed 4 statistical models according notice duration ≧6 hours vs.<6 hours, ≧12hours vs.<12 hours, ≧18hours vs.<18 hours and ≧24hours vs.<24 hours.
In multivariable analysis model 4, notice duration (OR, 11.67; 95% CI, 2.67 to 50.91; p=0.001) and age (OR, 1.08; 95% CI, 1.01 to 1.15; p=0.025) were significantly associated with increased risk of treatment failure. Female (vs. Male, OR, 0.23; 95% CI, 0.06 to 0.90; p=0.035) and culture positive (vs. negative, OR, 0.17; 95% CI, 0.04 to 0.74; p=0.018) were significantly associated with decreased risk of treatment failure.
Conclusion
The time between symptoms onset and patients notify PD center greater than 24 hours increased the risk of treatment failure in PD peritonitis. Elderly and effluent culture negative were also associated with treatment failure in PD peritonitis.
Key word: peritoneal dialysis, peritonitis, notice duration, antibiotic administration.

並列關鍵字

peritoneal dialysis ； peritonitis ； notice duration ； antibiotic administration

參考文獻

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