scholarly journals Peritonitis from facultative anaerobic gram-negative bacilli likely due to translocation of bacteria from gut in a patient undergoing peritoneal dialysis

2020 ◽  
Vol 12 (1) ◽  
Author(s):  
Sreedhar Adapa ◽  
Srikanth Naramala ◽  
Harmandeep Singh Tiwana ◽  
Niraj Patel ◽  
Raman Verma ◽  
...  
Keyword(s):  
Peritoneal Dialysis ◽  
Peritoneal Fluid ◽  
Healthcare Providers ◽  
High Morbidity ◽  
Peritoneal Dialysis Catheter ◽  
Gram Negative ◽  
Detection Techniques ◽  
Fluid Analysis ◽  
Gram Negative Organisms ◽  
Oral Ciprofloxacin

The peritonitis caused by gram-negative organisms is a serious complication encountered in patients undergoing peritoneal dialysis, often causing high morbidity and mortality. There has been recognition of peritonitis caused by uncommon organisms because of improved microbiological detection techniques. The healthcare providers involved in the management of these patients should be very vigilant. We report a rare case of peritonitis caused bycA 42-year-old male on peritoneal dialysis for five years presented with abdominal pain and cloudy effluent. The peritoneal fluid analysis was consistent with peritonitis, and peritoneal fluid culture grew Citrobacter freundii. The patient was treated with two courses of double antibiotic coverage with intraperitoneal ceftazidime and oral ciprofloxacin, which failed to resolve the infection and hence resulted in the removal the peritoneal dialysis catheter and dialysis modality change.

scholarly journals Peritonitis due to Moraxella Osloensis: An Emerging Pathogen

2018 ◽  
Vol 2018 ◽  
pp. 1-3
Author(s):  
Sreedhar Adapa ◽  
Purva Gumaste ◽  
Venu Madhav Konala ◽  
Nikhil Agrawal ◽  
Amarinder Singh Garcha ◽  
...  
Keyword(s):  
Peritoneal Dialysis ◽  
Peritoneal Fluid ◽  
Healthcare Providers ◽  
Gram Negative Bacteria ◽  
Gram Negative ◽  
Detection Techniques ◽  
Fluid Analysis ◽  
Moraxella Osloensis ◽  
Gram Negative Organisms ◽  
Fluid Culture

Peritonitis is a very serious complication encountered in patients undergoing peritoneal dialysis and healthcare providers involved in the management should be very vigilant. Gram-positive organisms are the frequent cause of peritonitis compared to gram-negative organisms. There has been recognition of peritonitis caused by uncommon organisms because of improved microbiological detection techniques. We report a case of peritonitis caused by Moraxella osloensis (M. osloensis), which is an unusual cause of infections in humans. A 68-year-old male, who has been on peritoneal dialysis for 2 years, presented with abdominal pain and cloudy effluent. Peritoneal fluid analysis was consistent with peritonitis and peritoneal fluid culture grew gram-negative bacteria. M. osloensis was identified by 16 S PCR phenotypic and sequencing techniques. Patient responded well to the treatment, with intraperitoneal cephalosporin, and repeat peritoneal fluid culture yielded no growth. M. osloensis rarely causes infection in humans and responds well to treatment, as reported in literature.

scholarly journals Peritonitis Secondary to Uncommon Gram-Negative Coccobacillus Transmitted From a Cat in a Patient on Peritoneal Dialysis

2019 ◽  
Vol 7 ◽  
pp. 232470961989516
Author(s):  
Sreedhar Adapa ◽  
Srikanth Naramala ◽  
Bhaskar Reddy Madhira ◽  
Vijay Gayam ◽  
Prem Sahasranam ◽  
...  
Keyword(s):  
Peritoneal Dialysis ◽  
Peritoneal Fluid ◽  
Pasteurella Multocida ◽  
Critical Role ◽  
Training Session ◽  
High Morbidity ◽  
Peritoneal Dialysis Catheter ◽  
Gram Negative ◽  
Detection Techniques ◽  
Gram Negative Organisms

Peritonitis caused by gram-negative organisms is a significant complication encountered in patients undergoing peritoneal dialysis and is associated with high morbidity and mortality. There has been recognition of peritonitis caused by uncommon organisms because of improved microbiological detection techniques. In this article, we report a rare case of peritonitis caused by Pasteurella multocida. We present a 58-year-old male on peritoneal dialysis with fever and abdominal pain. The peritoneal fluid was cloudy, and the analysis was consistent with peritonitis. The peritoneal fluid culture grew Pasteurella multocida. The patient was treated with a 3-week course of intraperitoneal ceftazidime, which resulted in the resolution of infection with the salvation of the peritoneal dialysis catheter. Patient education plays a very critical role in the prevention of peritonitis from Pasteurella multocida, particularly if patients have pets at home. The domestic pets should be kept away from the dialysis equipment and should not be allowed into the room during dialysis treatment. Incorporating the education in handing pets during the training session is the key aspect.

#58: Improving the Peritoneal Dialysis Program in a Pediatric hospital in Honduras Using Six Sigma Methodology

2021 ◽  
Vol 10 (Supplement_1) ◽  
pp. S20-S21
Author(s):  
Sara Eloisa Rivera Molina ◽  
Claudia Romero Quiroz ◽  
Dilcia Sauceda Acosta
Keyword(s):  
Risk Factors ◽  
Peritoneal Dialysis ◽  
Six Sigma ◽  
Peritoneal Fluid ◽  
Dwell Time ◽  
Clinical Signs ◽  
Pediatric Hospital ◽  
Gram Negative ◽  
Six Sigma Methodology ◽  
Fluid Cell

Abstract Background Peritoneal dialysis (PD) is the most common method of renal replacement therapy (RRT) in pediatric patients in Honduras. It has improved survival and quality of life. Unfortunately, there are complications associated with the use of PD catheters, 85% of which, are of infectious origin. These infections carry a high burden of morbidity and mortality, lengthen hospital stays, and increase costs and are a motive for transfer to hemodialysis. Hospital María Especialidades Pediátricas (HMEP) is a pediatric hospital caring for patients with chronic kidney disease in Honduras, PD has been offered as a method for RRT since September 2014. Methods In HMEP, monitoring of PD infection rates through active surveillance began December 1, 2017, as the first step (define and measure) toward the improvement of the PD Program based on Six Sigma methodology. A case of peritonitis was diagnosed when at least 2 of the following 3 criteria were met: (1) Clinical signs or symptoms of peritonitis (cloudy effluent or abdominal pain with fever or vomiting); (2) Altered peritoneal fluid cell count (after a dwell time of 2 hours: a WBC above 100 cells/mm3 in an uncentrifuged sample, with at least 50% neutrophils; or any WBC count with at least 50% neutrophils if the dwell time was less than 2 hours); (3) Positive peritoneal fluid culture. Patient data, risk factors for infection, causative organisms, and event outcomes were recorded. We present the main results of the analysis phase of all peritonitis cases using descriptive statistics. Results From December 1, 2017, through November 30, 2019, 79 patients required PD, representing 8931 catheter-days; and 30 peritonitis episodes occurred among 28 individuals (35%). The peritonitis rate during the 2-year surveillance period was 1.2 infections per patient-years (ideally: <0.67). Twenty-seven (90%) of cases were classified as healthcare associated since these patients underwent PD 3 times a week in the hospital and the catheter was only manipulated by medical staff; the other patients received dialysis at home. The median time from catheter placement to the event was 27 days (5–383 days). All patients had clinical signs or symptoms of peritonitis. Peritoneal fluid cell count results were available for 29 infections, all of which reported altered results. Peritoneal fluid cultures were positive in only 12 events (40%); 6 (50%) reported Gram-negative organisms, 5 (41%) reported Gram-positive and 1 reported Aspergillus spp. Nonfermentative Gram-negative bacteria (Pseudomonas aeruginosa and Acinetobacter lwoffii) were the most common organisms identified; Staphylococcus epidermidis was the most common Gram-positive. Ten events (33%) required removal and replacement of the catheter due to the infection, 6 (20%) required permanent transfer to hemodialysis; 2 (7.1%) patients experienced a relapse. Two (7.1%) died due to infection. Conclusions Implementing Six Sigma methodology allowed us to improve our PD Program by objectively quantifying the magnitude of the problem and identifying risk factors. This supported the infection prevention and control team with the implementation and improvement of preventive measures: change in hand hygiene products (from triclosan to chlorhexidine), increasing hand hygiene compliance, improving connection/disconnection procedure, PD catheter insertion, and maintenance, empowerment of caregivers.

P1173PERITONEAL DIALYSIS INFECTIONS IN MALTA - TRENDS OVER ELEVEN YEARS

2020 ◽  
Vol 35 (Supplement_3) ◽  
Author(s):  
Angela Borg Cauchi ◽  
Maria Angela Gauci ◽  
Theresia Dalli ◽  
James Gauci ◽  
James Farrugia ◽  
...  
Keyword(s):  
Peritoneal Dialysis ◽  
Coagulase Negative Staphylococcus ◽  
Distributed Data ◽  
Dialysis Modality ◽  
Gram Positive ◽  
Gram Negative ◽  
Male Predominance ◽  
E Coli ◽  
Number Of Patients ◽  
Gram Negative Organisms

Abstract Background and Aims Infections related to peritoneal dialysis (PD) are still a cause of morbidity and mortality. We describe an overview of PD peritonitis and catheter-related infections (CRI) in Malta over a period of eleven years. We also describe trends in dialysis modality over the years. Method All patients undergoing PD in Malta during 2008 and 2018 were analysed. Data from 2008-2012 was retrospective, shown as mean, that from 2013-2018 prospective. International Society for Peritoneal Dialysis (ISPD) definitions were used. Results for categorical responses were summarized using absolute numbers and percentages. Medians (range) were used to describe continuous non-normally distributed data. Results The total number of patients undergoing PD from 2008 till 2018 were 137 (2008-2012), 91, 80, 126, 117, 102, 103 respectively. There was an overall male predominance of 63.5% (61-67). Patient years at risk were 85.80, 85.25, 89.71, 83.70, 79.69, 72.88 since 2013 respectively. The overall incidence of diabetes mellitus was 45.3% (41.8-50), cardiovascular disease 34.2% (33.8-35), hypertension 79.3% (73.8-84.6). PD was used in 50% of dialysis modality prior to 2012, 39% in 2018. Initially 51% used Automated PD (APD), with 21% assisted PD, in 2018 39% used APD, with 6% assisted PD. PD peritonitis rates from 2008 were 0.38, 0.31, 0.35, 0.46, 0.43, 0.57, 0.54, 0.43, 0.39, 0.40, 0.46 episodes/patient year respectively There was marked dominance of Gram-positive peritonitis, mainly Staphylococcal, with a reduction of coagulase-negative-Staphylococcus from 0.26 episodes/patient in 2013 to 0.03 in 2017, 0.11 in 2018. Methicillin-resistant S. aureus (MRSA) peritonitis decreased from 0.03 episodes/patient to nil in 2016, 2017, 0.01 episodes/patient in 2018. Amongst Gram-negative peritonitis, Pseudomonas rates decreased from 0.06 to 0.03 episodes/patient in 2018, nil in 2016. Escherichia coli rates decreased from 0.02 episodes/patient to nil in the last three years. Fungal rates from 0.03 to 0.01 episodes/patient/year, with nil in 2016, 2017. Catheter-related infection rates were 0.39 (2008-2012), 0.35, 0.91, 0.37, 0.38, 0.25, 0.50 episodes/patient/year respectively. There was a higher incidence of recurrent infections in 2014, none in 2015 and 2016. Gram-negative organisms accounted for 57% of all CRI, predominantly Pseudomonas at 0.12 (2008-2012), 0.06, 0.09, 0.09, 0.14, 0.03, 017 episodes/patient/year respectively. Gram-positive CRI were mostly Staphylococcus aureus, peaking in 2014 at 0.38 episodes/patient/year. MRSA rates declined from 0.15 to 0.01 episodes/patient/year in 2018. Conclusion PD peritonitis rates in Malta between 2008 and 2018 were below the ISPD recommended threshold. There were no episodes of MRSA in 2016, 2017, no Pseudomonas in 2016, no E coli in the last three years and no fungal PD peritonitis in 2016, 2017. CRI rates also declined, with an overall predominance of Gram-negative infections.

A Prospective Study of the Efficacy of Local Application of Gentamicin versus Mupirocin in the Prevention of Peritoneal Dialysis Catheter-Related Infections

2008 ◽  
Vol 28 (5) ◽  
pp. 505-508 ◽  
Author(s):  
Kwok Hong Chu ◽  
Wai Yee Choy ◽  
Chi Chung William Cheung ◽  
Ka Shun Fung ◽  
Hon Lok Tang ◽  
...  
Keyword(s):  
Peritoneal Dialysis ◽  
Prospective Study ◽  
Hospital Admissions ◽  
Local Application ◽  
Peritoneal Dialysis Catheter ◽  
Exit Site ◽  
Gram Positive ◽  
Gram Negative ◽  
A Prospective Study

Background Peritoneal dialysis (PD)-related infections are the major cause of technique failure. Exit-site infections (ESI) can be prevented by local application of antibiotics. Mupirocin (M) is the most extensively studied drug for this application. Long-term use can result in the development of resistance. Gentamicin (G) is an attractive alternative, with both gram-positive and gram-negative activities. We studied the comparative efficacy of G cream versus M ointment in the prevention of PD-related infections in a Chinese cohort. Methods This was a prospective study of adult PD patients of the Princess Margaret Hospital, Hong Kong. Patients were excluded if they had active infection, recent ESI or peritonitis, history of allergy to either drug, or were unable to apply the drug or give consent. Patients were taught to apply the drug daily to the exit site after routine exit-site care. Records were tracked prospectively during hospital admissions and clinic follow-ups. Results 95 patients were recruited; 14 discontinued the study. The ESI rates were 0.38 and 0.20 episodes/patient-year for the G group and the M group respectively ( p = 0.36). Gram-positive ESI rates were 0.18 and 0 episodes/patient-year for the G group and the M group respectively. Gram-negative ESI rates were 0.20 episodes/patient-year for both groups ( p = 0.62). The overall peritonitis rates were similar in the two groups ( p = 0.91). Discussion In addition to good perioperative care and strict exit-site care, local antibiotic application can prevent ESI. Mupirocin has been extensively studied and shown to be effective. Similar if not superior effects of G cream have been demonstrated. In this study, neither antibiotic gave significantly better results in the prevention of either ESI or peritonitis. Conclusions Both gentamicin and mupirocin were effective as prophylaxis for ESI. Longer study is required to determine the long-term efficacy and the potential beneficial effect on the prevention of peritonitis.

Pharmacokinetics of Oral Ciprofloxacin in Continuous Cycling Peritoneal Dialysis

2004 ◽  
Vol 24 (5) ◽  
pp. 447-453 ◽  
Author(s):  
Sharon M. Yeung ◽  
Scott E. Walker ◽  
Sandra A.N. Tailor ◽  
Linda Awdishu ◽  
Sheldon Tobe ◽  
...  
Keyword(s):  
Peritoneal Dialysis ◽  
Serum Concentration ◽  
Empirical Treatment ◽  
Klebsiella Species ◽  
Maximum Serum ◽  
Gram Negative ◽  
E Coli ◽  
Continuous Cycling ◽  
Maximum Serum Concentration ◽  
Oral Ciprofloxacin

Background In order to avoid aminoglycosides, the International Society for Peritoneal Dialysis recommends cefazolin and ceftazidime for empirical treatment of peritonitis. Ciprofloxacin covers relevant gram-negative pathogens without the resistance associated with ceftazidime. However, ciprofloxacin pharmacokinetic data in patients on continuous cycling peritoneal dialysis (CCPD) are lacking. Objectives ( 1 ) To determine the pharmacokinetics of oral ciprofloxacin in CCPD patients, ( 2 ) to compare serum and dialysate ciprofloxacin concentrations with minimum inhibitory concentrations (MIC) of the gram-negative bacteria associated with peritonitis, and ( 3 ) to establish oral ciprofloxacin dosing guidelines for the empirical treatment of peritonitis in patients receiving CCPD. Methods Eligible CCPD patients received 2 doses of ciprofloxacin: 750 mg orally every 12 hours. Serial blood and end-of-dwell dialysate samples were collected during the first 12-hour interval; an end-of-dwell dialysate sample from the overnight dwell and a final blood sample were collected at the end of the second 12-hour interval. Ciprofloxacin concentrations were determined using a liquid chromatographic (HPLC)-fluorescence method. Pharmacokinetic calculations were completed assuming a one-compartment model. Results Eight patients completed the study. The pharmacokinetic parameters determined for ciprofloxacin were (mean ± SEM) serum half-life 10.1 ± 1.2 hours, maximum serum concentration 2.7 ± 0.5 mg/L, time to maximum serum concentration 1.6 ± 0.1 hours after the first dose, and peritoneal clearance 1.2% ± 0.1% of the mean calculated total body clearance. While all patients achieved serum area under the concentration-time curve: MIC > 125 for Escherichia coli and Klebsiella species after the first dose, only 2 patients achieved this goal for Pseudomonas aeruginosa. End-of-dwell dialysate concentrations were above the MIC for E. coli, Klebsiella spp, and P. aeruginosa after the second dose. Conclusion Ciprofloxacin 750 mg orally every 12 hours in CCPD patients may be useful for empirical gram-negative coverage of CCPD peritonitis and for treatment of documented peritonitis caused by sensitive E. coli or Klebsiella species. While ceftazidime may be required for documented pseudomonal peritonitis, the oral ciprofloxacin regimen achieved adequate serum concentrations to treat systemic gram-negative infections caused by sensitive E. coli or Klebsiella species.

scholarly journals Frequency and Antimicrobial Susceptibility of Bacterial Agents Causing Peritoneal Dialysis-Related Peritonitis: A Two-Center Experience

2020 ◽  
Vol 7 (4) ◽  
Author(s):  
Fariba Shirvani ◽  
Nakysa Hooman ◽  
Abdollah Karimi ◽  
Shahnaz Armin ◽  
Alireza Fahimzad ◽  
...  
Keyword(s):  
Abdominal Pain ◽  
Peritoneal Dialysis ◽  
Therapeutic Option ◽  
Intraperitoneal Administration ◽  
Clinical Manifestations ◽  
Empiric Therapy ◽  
Fungal Peritonitis ◽  
Gram Negative ◽  
Oxacillin Resistance ◽  
Gram Negative Organisms

Background: Peritonitis remains a significant complication of peritoneal dialysis (PD) in children. Objectives: The current study aimed to evaluate the causative agents of PD-related peritonitis in pediatric patients treated by continuous ambulatory peritoneal dialysis (CAPD) in order to provide evidence for improving the empirical treatment of PD-related peritonitis and avoid antimicrobial resistance. Methods: The medical records of children diagnosed with PD-related peritonitis hospitalized at Mofid and Ali-Asghar Children’s Hospitals from January 2018 to December 2019 were retrospectively reviewed. Cases of relapsing peritonitis and fungal peritonitis were excluded. Data on demographics, clinical manifestations, para-clinical evaluations, peritoneal fluid culture and antibiogram, and antibiotic regimen were analyzed. Results: A total of 23 CAPD children aged 1 - 17 years were hospitalized with a confirmed diagnosis of PD-related peritonitis, accounting for a total of 27 peritonitis cases. The most frequent manifestation of peritonitis was cloudy dialysate (85.2%), followed by abdominal pain (59.3%). Gram-negative organisms were isolated in 48.1% of cases, and 4 cases had negative cultures. The frequency of antibiotic prescription within 14 days of admission was significantly higher in culture-negative cases (P = 0.002), and abdominal pain was more prevalent in Gram-negative peritonitis (P = 0.004). All Gram-negative organisms were sensitive to ceftazidime and imipenem; while 61.6% of them were sensitive to gentamycin. All Gram-positive organisms were sensitive to cefazolin, and vancomycin was effective against all Staphylococcus strains. Oxacillin resistance was reported in 50% of Staphylococcus strains. Conclusions: PD-related peritonitis should be suspected even in cases with clear dialysis effluent who present with other manifestations of peritonitis such as fever or abdominal pain. Moreover, intraperitoneal administration of a first-generation cephalosporin (cefazolin) combined with ceftazidime was an appropriate therapeutic option for empiric therapy.

scholarly journals Extended Spectrum Beta-Lactamase (ESBL) Produced by Gram-Negative Bacteria in Trinidad and Tobago

2021 ◽  
Vol 2021 ◽  
pp. 1-16
Author(s):  
Patrick Eberechi Akpaka ◽  
Angel Vaillant ◽  
Clyde Wilson ◽  
Padman Jayaratne
Keyword(s):  
Trinidad And Tobago ◽  
Bacterial Infections ◽  
High Morbidity ◽  
Beta Lactamase ◽  
Beta Lactam ◽  
Esbl Production ◽  
Gram Negative ◽  
Extended Spectrum Beta Lactamase ◽  
Extended Spectrum ◽  
Gram Negative Organisms

Gram-negative bacterial infections are a global health problem. The production of beta-lactamase is still the most vital factor leading to beta-lactam resistance. In Trinidad and Tobago, extended spectrum beta-lactamase (ESBL) production has been detected and reported mainly in the isolates of Klebsiella pneumoniae and Escherichia coli and constitutes a public health emergency that causes high morbidity and mortality in some patients. In this literature review, the authors cover vast information on ESBL frequency and laboratory detection using both conventional and molecular methods from clinical data. The aim is to make the reader reflect on how the actual knowledge can be used for rapid detection and understanding of the spread of antimicrobial resistance problems stemming from ESBL production among common Gram-negative organisms in the health care system.

Antimicrobial Resistance in the Intensive Care Unit

2016 ◽  
Vol 32 (1) ◽  
pp. 25-37 ◽  
Author(s):  
Shawn H. MacVane
Keyword(s):  
Intensive Care ◽  
Antimicrobial Resistance ◽  
Bacterial Infections ◽  
Antimicrobial Agents ◽  
Treatment Options ◽  
Hospital Costs ◽  
High Morbidity ◽  
Gram Negative Bacteria ◽  
Gram Negative ◽  
Gram Negative Organisms

Bacterial infections are a frequent cause of hospitalization, and nosocomial infections are an increasingly common condition, particularly within the acute/critical care setting. Infection control practices and new antimicrobial development have primarily focused on gram-positive bacteria; however, in recent years, the incidence of infections caused by gram-negative bacteria has risen considerably in intensive care units. Infections caused by multidrug-resistant (MDR) gram-negative organisms are associated with high morbidity and mortality, with significant direct and indirect costs resulting from prolonged hospitalizations due to antibiotic treatment failures. Of particular concern is the increasing prevalence of antimicrobial resistance to β-lactam antibiotics (including carbapenems) among Pseudomonas aeruginosa and Acinetobacter baumannii and, recently, among pathogens of the Enterobacteriaceae family. Treatment options for infections caused by these pathogens are limited. Antimicrobial stewardship programs focus on optimizing the appropriate use of currently available antimicrobial agents with the goals of improving outcomes for patients with infections caused by MDR gram-negative organisms, slowing the progression of antimicrobial resistance, and reducing hospital costs. Newly approved treatment options are available, such as β-lactam/β-lactamase inhibitor combinations, which significantly extend the armamentarium against MDR gram-negative bacteria.

Continuous Ambulatory Peritoneal Dialysis Catheter Infections: Diagnosis and Management

1994 ◽  
Vol 14 (3) ◽  
pp. 248-254 ◽  
Author(s):  
Michael J. Flanigan ◽  
Linda A. Hochstetler ◽  
Donita Langholdt ◽  
Victoria S. Lim
Keyword(s):  
Peritoneal Dialysis ◽  
Antibiotic Therapy ◽  
Minimal Risk ◽  
Peritoneal Dialysis Catheter ◽  
Dialysis Catheter ◽  
Exit Site ◽  
Gram Negative ◽  
Home Dialysis ◽  
Serous Discharge ◽  
Catheter Infections

Purpose To develop diagnostic and treatment strategies for peritoneal dialysis catheter exit-site and tunnel infections. Population All consenting peritoneal dialysis patients performing home dialysis through the University of Iowa Hospitals and Clinics Home Dialysis Training Center. This is a state-owned teaching hospital serving a rural population of approximately one million people in Iowa and western Illinois. Methods Four dialysis nurses collected information on a prospectively designed data acquisition tool. Patients were randomly assigned to one of two treatment groups, intraperitoneal vancomycin plus oral rifampin or oral trimethoprim/ sulfamethoxazole (TMP/SMX), and their initial antibiotic therapy determined by that assignment. If the infection was gram -negative, the initial antibiotics were discontinued and an alternative therapy begun. Therapy was initiated by the nursing staff and required physician notification within 48 hours. Results There were 126 recorded catheter infections (exit-site, tunnel, or cuff infection) resulting in a rate of 0.67 episodes per patient year of exposure. Staphylococcus aureus was isolated from the majority (60%) of these events. Pseudomonas aeruginosa was the next most common isolate and accounted for 21% of infections. Rubor, dolor, and turgor are the classic signs of inflammation, and at least one of these was present in 79% of the episodes. Isolated pericatheter erythema or serous discharge was associated with a minimal risk «2%) of catheter loss. The presence of a purulent exit-site discharge identified patients who had a 30% chance of failing systemic antibiotic therapy and a 20% risk of catheter loss. The concurrent presence of exit-site tenderness or swelling identified the most severe infections. Staphylococcal infections responded equally well to local cleaning and vancomycin plus rifampin (86% cured) or oral trimethoprim/sulfamethoxazole (89% cured) therapy. Gram-negative infections were frequent (27%) and appeared to respond best to a combination of tobramycin and ciprofloxacin. Conclusion Exit-site/tunnel inflammation is detectable by patients and can be used to guide therapy. An isolated finding of erythema or serous discharge is not indicative of an acute infection and may not require systemic antibiotics. The presence of purulence identifies patients at risk for catheter loss, and these patients benefit from systemic therapy. The combination of a purulent exit-site discharge plus pericatheter tenderness or swelling identifies patients likely to suffer treatment failure and require subsequent catheter removal. The cure rate of gram -positive catheter infections treated with vancomycin plus rifampin was indistinguishable from that achieved with oral trimethoprim/sulfamethoxazole (p = 0.99).

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