Exit-Site Infection in Continuous Ambulatory Peritoneal Dialysis: A Review

1991 ◽  
Vol 11 (4) ◽  
pp. 333-340 ◽  
Author(s):  
Mary Anne Luzar
Keyword(s):  
Healing Process ◽  
Nasal Carriage ◽  
Epidemiological Studies ◽  
Future Research ◽  
Site Infection ◽  
Exit Site ◽  
Term Care ◽  
Exit Site Infection ◽  
Nasal Carrier ◽  
Catheter Survival

Although the ability of CAPD to successfully treat end-stage renal disease is now well established, exitsite infection (ESI) remains a serious cause of morbidity. The objective of this article is to review recent advancements relating to ESI pathogenesis and its reduction. Current definitions of ESI are reviewed, as are comparative studies of etiology. Emphasis is placed on the literature identifying Staphylococcus aureus as the primary cause of ESI in CAPD. The article reviews reported rates of ESI and discusses reasons for variations of this complication's reported frequency. The selection of catheters available in CAPD are discussed, as are studies demonstrating the threat of S. aureus to catheter survival. The pathogenesis of exit-site infection related to S. aureus nasal carriage in CAPD is reviewed in light of recent findings indicating the pre-CAPD nasal carrier as the patient at risk for subsequent ESI. Postoperative and long-term care of the catheter patient are reviewed for various literature protocols. Treatment recommendations for choice of agents are discussed. Future research should include a better understanding of the morphology of the CAPD catheter exit-site in humans and the healing process. ESI epidemiological studies should be encouraged in tandem with well -designed, controlled studies on the value of prophylactic treatment.

The Efficacy of Silver-Ion Implanted Catheters in Reducing Peritoneal Dialysis-Related Infections

2003 ◽  
Vol 23 (4) ◽  
pp. 368-374 ◽  
Author(s):  
John H. Crabtree ◽  
Raoul J. Burchette ◽  
Rukhsana A. Siddiqi ◽  
Isan T. Huen ◽  
Linda L Hadnott ◽  
...  
Keyword(s):  
Ion Beam ◽  
Controlled Trial ◽  
Silver Ion ◽  
Control Group ◽  
Site Infection ◽  
Control Groups ◽  
Exit Site ◽  
Exit Site Infection ◽  
Catheter Survival ◽  
And Control

♦ Background Dialysis-related infections are the commonest cause of catheter loss and transfer to hemodialysis. Surface modifications of the catheter that reduce infections are of major importance. ♦ Objective The efficacy of silver-ion treated catheters in reducing dialysis-related infections was tested. ♦ Methods The study design was a prospective, randomized controlled trial. Patients were implanted with either a silver-treated study catheter or a control catheter. Prospective collection of data included infectious complications and catheter survival. ♦ Results The subject groups were comprised of 67 silver-treated catheters and 72 control catheters. Demographic characteristics of the study and control groups were equal. Exit-site infection rates for the study group and control group (0.52 and 0.45 episodes/patient-year of dialysis respectively) were not different by Poisson regression analysis ( p > 0.4). Peritonitis rates were identical for the two groups (0.37 episodes/patient-year) and were not different by Poisson analysis ( p > 0.9). Antibiotic-free intervals between infections for the study and control groups were not significantly different for exit-site infections ( p = 0.58), peritonitis ( p = 0.44), or both infections combined ( p = 0.47). Actuarial analyses showed no differences between the groups in the probability of remaining free of exit-site infection ( p> 0.2) or peritonitis ( p > 0.7). Similarly, catheter survival was not significantly different between the groups ( p > 0.6). ♦ Conclusion Surface modification of catheters with ion beam implantation of silver produced no clinical effect with respect to reducing dialysis-related infections.

The Honeypot Study Protocol: A Randomized Controlled Trial of Exit-Site Application of Medihoney Antibacterial Wound Gel for the Prevention of Catheter-Associated Infections in Peritoneal Dialysis Patients

2009 ◽  
Vol 29 (3) ◽  
pp. 303-309 ◽  
Author(s):  
David W. Johnson ◽  
Carolyn Clark ◽  
Nicole M. Isbel ◽  
Carmel M. Hawley ◽  
Elaine Beller ◽  
...  
Keyword(s):  
Randomized Controlled Trial ◽  
Peritoneal Dialysis ◽  
New Zealand ◽  
Controlled Trial ◽  
Nasal Carriage ◽  
Site Infection ◽  
Exit Site ◽  
Exit Site Infection ◽  
Randomized Controlled ◽  
Tunnel Infection

Objectives The primary objective of this study is to determine whether daily exit-site application of standardized antibacterial honey (Medihoney Antibacterial Wound Gel; Comvita, Te Puke, New Zealand) results in a reduced risk of catheter-associated infections in peritoneal dialysis (PD) patients compared with standard topical mupirocin prophylaxis of nasal staphylococcal carriers. Design Multicenter, prospective, open label, randomized controlled trial. Setting PD units throughout Australia and New Zealand. Participants The study will include both incident and prevalent PD patients (adults and children) for whom informed consent can be provided. Patients will be excluded if they have had ( 1 ) a history of psychological illness or condition that interferes with their ability to understand or comply with the requirements of the study; ( 2 ) recent (within 1 month) exit-site infection, peritonitis, or tunnel infection; ( 3 ) known hypersensitivity to, or intolerance of, honey or mupirocin; ( 4 ) current or recent (within 4 weeks) treatment with an antibiotic administered by any route; or ( 5 ) nasal carriage of mupirocin-resistant Staphylococcus aureus. Methods 370 subjects will be randomized 1:1 to receive either daily topical exit-site application of Medihoney Antibacterial Wound Gel (all patients) or nasal application of mupirocin if staphylococcal nasal carriage is demonstrated. All patients in the control and intervention groups will perform their usual exit-site care according to local practice. The study will continue until 12 months after the last patient is recruited (anticipated recruitment time is 24 months). Main Outcome Measures The primary outcome measure will be time to first episode of exit-site infection, tunnel infection, or peritonitis, whichever comes first. Secondary outcome measures will include time to first exit-site infection, time to first tunnel infection, time to first peritonitis, time to infection-associated catheter removal, catheter-associated infection rates, causative organisms, incidence of mupirocin-resistant microbial isolates, and other adverse reactions. Conclusions This multicenter Australian and New Zealand study has been designed to provide evidence to help nephrologists and their PD patients determine the optimal strategy for preventing PD catheter-associated infections. Demonstration of a significant improvement in PD catheter-associated infections with topical Medihoney will provide clinicians with an important new prophylactic strategy with a low propensity for promoting antimicrobial resistance.

Peritonitis and Exit-Site Infection in Pediatric Automated Peritoneal Dialysis

2008 ◽  
Vol 28 (3_suppl) ◽  
pp. 179-182
Author(s):  
Man-Chun Chiu ◽  
Pak-Chiu Tong ◽  
Wai-Ming Lai ◽  
Shing-Chi Lau
Keyword(s):  
Pseudomonas Aeruginosa ◽  
Peritoneal Dialysis ◽  
Nasal Carriage ◽  
Patient Specific ◽  
Coagulase Negative Staphylococcus ◽  
Site Infection ◽  
Automated Peritoneal Dialysis ◽  
Exit Site ◽  
Humid Climate ◽  
Exit Site Infection

We reviewed 30 patients in an automated peritoneal dialysis (APD) program from 2002 to 2006 for peritonitis. Patients were 11.6 ± 5.5 years old at initiation of peritoneal dialysis (PD) and had a total of 976 PD months. The overall peritonitis rate was 1 episode in 54.2 patient– months, for a rate of 0.22 episode annually. The rate was considered low, which other than being an APD program, may be attributed to adherence to guidelines and in-charge nurse policy. A total of 17 episodes of peritonitis were identified in 9 patients, and the distribution of patient-specific peritonitis incidence appeared bimodal: 87% patients had no or only 1 episode of peritonitis, and 4 patients accounted for 12 episodes, with an average peritonitis rate of 1.0 annually. Causative organisms included Staphylococcus aureus, coagulase-negative Staphylococcus, methicillin-resistant S. aureus (MRSA), Pseudomonas aeruginosa, enterococci, alpha-hemolytic Streptococcus. Five episodes had concurrent exit-site infection with the same organism. During the same period in these 30 patients, 40 episodes of exit-site infection (ESI) were recorded in 23 patients. The overall ESI rate was 1 episode in 24.4 PD months. S. aureus and Pseudomonas aeruginosa were the two most common pathogens, accounting for 70% of the infections. Nasal carriage of MRSA was found in 4 patients, and MRSA ESIs in 2. The ESI rate was not low as that observed in peritonitis, which may be attributed to the humid climate.

scholarly journals Nasal mupirocin prevents Staphylococcus aureus exit-site infection during peritoneal dialysis. Mupirocin Study Group.

1996 ◽  
Vol 7 (11) ◽  
pp. 2403-2408
Keyword(s):  
Staphylococcus Aureus ◽  
Peritoneal Dialysis ◽  
Treatment Group ◽  
Continuous Ambulatory Peritoneal Dialysis ◽  
Nasal Carriage ◽  
Control Group ◽  
Site Infection ◽  
Exit Site ◽  
Exit Site Infection ◽  
Nasal Mupirocin

A total of 1144 patients receiving continuous ambulatory peritoneal dialysis in nine European centers was screened for nasal carriage of Staphylococcus aureus. Two hundred sixty-seven subjects were defined as carriers of S. aureus by having had at least two positive swab results from samples taken on separate occasions, and were randomly allocated to treatment or control groups. Members of each group used a nasal ointment twice daily for 5 consecutive days every 4 wk. The treatment group used calcium mupirocin 2% (Bactroban nasal; SmithKline Beecham, Welwyn Garden City, United Kingdom) and the control group used placebo ointment. Patients were followed-up for a maximum period of 18 months. There were 134 individuals in the mupirocin group, and 133 individuals acted as control subjects. There were no differences in demographic data, cause of renal failure, type of catheter, system used, or method of exit-site care between the groups. Similarly, there were no differences in patient outcome or incidence of adverse events between both groups. Nasal carriage fell to 10% in those subjects who received active treatment and 48% in those who used the placebo ointment. There were 55 exit-site infections in 1236 patient-months in the control group and 33 in 1390 patient-months in the treatment group (not significant). S. aureus caused 14 episodes of exit-site infection in the mupirocin group and 44 in the control group (P = 0.006, mixed effects Poisson regression model). There were no differences in the rate of tunnel infection or peritonitis. There was no evidence of a progressive increase in resistance to mupirocin with time. Regular use of nasal mupirocin in continuous ambulatory peritoneal dialysis patients who are nasal carriers of S. aureus significantly reduces the rate of exit-site infections that occurs because of this organism.

Failure of Peritoneal Catheter CUFF Shaving to Eradicate Infection

1987 ◽  
Vol 7 (3) ◽  
pp. 179-183 ◽  
Author(s):  
Beth Piraino Judy ◽  
Bernardini Andrew Peitzman ◽  
Michael Sorkin
Keyword(s):  
Antibiotic Therapy ◽  
Survival Time ◽  
Alternative Methods ◽  
Catheter Removal ◽  
Site Infection ◽  
Exit Site ◽  
Peritoneal Catheter ◽  
Exit Site Infection ◽  
Catheter Survival ◽  
Catheter Infection

Often the catheter is lost when exitsite infections fail to resolve with antibiotic therapy. Excision of the external cuff has been proposed as an alternative to catheter removal. Prospectively we recorded the results of 22 cuff-shaving procedures and all subsequent CAPD-related infections. After the cuff shaving we encountered six dialysate leaks, which resulted in catheter removal. In 10 other patients, four developed peritonitis, four tunnel infection and two recurrent exit..site infection with the same micro-organism that caused the original exit site infection. Cuff shaving did not decrease the exit-site infection and peritonitis rates. Median catheter survival time after the cuff shaving was 1.5 months (range from 0 to 23 months). In conclusion, cuff shaving often fails to eradicate catheter infection. We need to develop alternative methods for treating and preventing exit-site infections.

Staphylococcus Aureus Peritonitis is Associated with Staphylococcus Aureus Nasal Carriage in Peritoneal Dialysis Patients

1993 ◽  
Vol 13 (2_suppl) ◽  
pp. 232-335 ◽  
Author(s):  
Beth Piraino ◽  
Jeffrey A. Perlmutter ◽  
Jean L. Holley ◽  
Judith Bernardini
Keyword(s):  
Staphylococcus Aureus ◽  
Peritoneal Dialysis ◽  
Nasal Carriage ◽  
Site Infection ◽  
Dialysis Patients ◽  
Exit Site ◽  
Exit Site Infection ◽  
Increased Risk ◽  
Definition Of ◽  
The Relationship

Although the definition of S. aureus nasal carriage in peritoneal dialysis patients Is variable, carriage is often defined as 2 or more positive cultures for S. aureus. We Investigated the relationship between S. aureus Infections and nasal carriage (defined as 1 or more positive nose cultures) In 138 patients on peritoneal dialysis. By this definition, approximately 50% of the patients were carriers. The rates of S. aureus exit-site infection (0.28/year vs 0.43/year, p<0.001) and peritonitis (0.08/year vs 0.20/year, p<0.001) were lower in the noncarriers (patients with no positive nose cultures) than in those patients who had 1 or more positive nose cultures. Patients with only 1 positive nose culture had a similar S. aureus exit-site infection rate (0.31/year vs 0.28/year), but a higher peritonitis rate (0.24/year vs 0.08/year, p<0.001) compared to those petients with no positive nose cultures. However, patients with 2 or more positive nose cultures were at Increased risk for both S. aureus exit-site Infections and peritonitis. This relationship held even when only petients with frequent nose cultures were Included In the analysis. Thus patients with even 1 positive nose culture for S. aureus are at risk for S. aureus peritonitis and should not be classified as noncarriers.

Peritoneal Dialysis Cuff-Shaving—A Salvage Therapy for Refractory Exit-Site Infections

2019 ◽  
Vol 39 (3) ◽  
pp. 276-281 ◽  
Author(s):  
Catarina Meng ◽  
Ana Beco ◽  
Ana Oliveira ◽  
Luciano Pereira ◽  
Manuel Pestana
Keyword(s):  
Peritoneal Dialysis ◽  
Rescue Therapy ◽  
Significant Proportion ◽  
Purulent Discharge ◽  
Site Infection ◽  
Exit Site ◽  
Exit Site Infection ◽  
Catheter Survival ◽  
Kaplan Meier ◽  
Dialysis Vintage

Introduction Cuff-shaving has been described as a salvage technique for refractory exit-site infections, with conflicting data regarding infection and catheter outcomes. We describe our experience with cuff-shaving as a rescue therapy for exit-site infections unresponsive to systemic therapy. Methods We retrospectively reviewed patients who underwent cuff-shaving between January 2012 and June 2017. Refractory exit-site infection was defined as purulent discharge from the exit site with no clinical response after 3 weeks of systemic antibiotic treatment. Results Fifty-three cuff-shavings were included, mean age was 53.4 ± 13.4 years, 26 patients were male. Median dialysis vintage was 29 months (interquartile range [IQR] 14.3 – 38), and 39 (73.6%) were on continuous ambulatory peritoneal dialysis (CAPD). The exit-site infection rate before cuff-shaving was 1.12 episodes per patient-year and the median time from infection to shaving was 52 days (IQR 35 – 76). The most frequent agents were Staphylococcus aureus (34%), Corynebacterium spp. (17%) and Pseudomonas aeruginosa (15%). Median follow-up was 9 months (IQR 1 – 18.5), during which time 35 catheters were removed, 5 due to non-infectious reasons. Using the Kaplan-Meier survival analysis, median catheter survival was 24 months (95% confidence interval [CI] 4.17 – 43.83). At 12 months, the probability of catheter survival was 54% and was not statistically different between gram-positive and gram-negative agents, although it was significantly shorter for fungal agents. Conclusion Cuff-shaving is a feasible rescue therapy to treat refractory exit-site infections. In our experience, it allowed resolution of infections in a significant proportion of cases, except for fungal agents, and therefore extended catheter survival time, besides being associated with a small rate of complications.

Lower Malfunction Rate with Self-Locating Catheters

2001 ◽  
Vol 21 (3_suppl) ◽  
pp. 209-212 ◽  
Author(s):  
Ignacio Minguela ◽  
Manuel Lanuza ◽  
Ramón Ruiz De Gauna ◽  
Raquél Rodado ◽  
Soledad Alegría ◽  
...  
Keyword(s):  
Peritoneal Dialysis ◽  
T Test ◽  
Catheter Removal ◽  
Control Group ◽  
Site Infection ◽  
Exit Site ◽  
Exit Site Infection ◽  
Catheter Survival ◽  
Tenckhoff Catheter ◽  
Kaplan Meier

Objective We analyzed malfunction rates (obstruction, omental wrapping, displacement) and catheter survival for self-locating catheters as compared with other Tenckhoff catheter designs. Patients and Methods We conducted our survey at two centers, prospectively studying all self-locating catheters implanted from May 1997 to October 2000 and used for peritoneal dialysis (PD). Tenckhoff catheters of other designs used previously in our units were used as the control group. We analyzed removal causes and catheter survival. Results We studied 173 catheters (105 self-locating catheters, 53 straight catheters, and 15 coiled catheters) implanted in 139 patients (43% of them women) with a mean age of 53 ± 14 years. The analysis of catheter removal showed that 3 of 105 self-locating catheters, 3 of 15 coiled catheters, and 17 of 53 straight catheters were removed owing to malfunction (c 2: p = 0.0000). Kaplan–Meier curves showed that the bulk of removals for malfunction occurred within the first 3 months after PD start. The group of self-locating catheters showed better survival (log-rank: p = 0.0009). Other causes for catheter removal included peritonitis ( n = 22), exit-site infection alone ( n = 4), and end of PD treatment ( n = 66). No significant differences were seen in the annual peritonitis rate (straight-tip: 0.955 ± 2.315 episodes annually; coiled-tip: 0.651 ± 0.864 episodes annually; self-locating: 0.720 ± 1.417 episodes annually; t-test: p > 0.400). No gut or bladder perforations were observed. Conclusion In our survey, self-locating catheters were associated with better survival and fewer removals for malfunction than were Tenckhoff catheters of other designs.

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