Adherence to guideline recommendations for infection prophylaxis in peritoneal dialysis patients.

Abstract

Sir, As compared to the patients on haemodialysis, those on peritoneal dialysis (PD) are at increased risk of dying from infections [1]. Catheter-related infections in PD increase the risk of subsequent peritonitis, catheter removal, technique failures and infectious deaths. Based on level II evidence from one randomized controlled trial, the Caring for Australasians with Renal Insufficiency (CARI) Guidelines recommend intranasal mupirocin prophylaxis for PD patients with nasal Staphylococcus aureus carriage to reduce the risk of PD-associated infections [2,3]. However, it is not known how well these guidelines have been implemented into clinical practice. TheAustralasianKidneyTrialsNetworkiscurrentlyconducting a trial of exit-site application of antibacterial honey (Medihoney TM )forthepreventionofcatheter-associatedinfections in PD (the HONEYPOT study) [4]. A prospective survey of exit-site care in PD units interested in participating in the HONEYPOT study was performed to facilitate the study design and methodology. Thirtyof61(49.2%)PDunitsprovidingcareto65.7%of all PD patients in Australia and New Zealand responded to the survey questionnaire. Thirteen units were of moderate size (20–50 patients), and 9 were larger units with >100 patients. Fourteen (47%) units had no fixed policy for using prophylaxis against ESI. Thirteen (43%) units routinely screened PD patients to identify nasal carriers of S. aureus (Table 1). Only three (10%) units routinely prescribed prophylaxis to all patients. Twelve (40%) and 5 (17%) units prescribed nasal and topical exit-site mupirocin, respectively (Table 2). Four units prescribed either nasal or topical mupirocinand1unitprescribednasalchloramphenicol.Ten (33%) units recommended daily exit-site cleaning with 2% chlorhexidine. Only 13 (43%) units followed the standard practice of using a premoistened nasal swab incubating it in enrichment nutrient broth for 24 h before plating onto solid media [5]. The results of this survey highlight poor adherence to the national guidelines (CARI) and the absence of a uniform, standard practice of exit-site care. Failure to follow appropriate procedures for screening S. aureus carriage may resultinpoordetectionrates.Veryfewcentresroutinelyprescribed prophylaxis to all patients, probably due to concern about mupirocin resistance. Although we did not explore the causes of poor adherence to the guidelines, the absence