Effectiveness of different types of care for the peritoneal dialysis catheter exit site: a systematic review

Abstract

Background Prevention of infection is considered essential for satisfactory maintenance of peritoneal dialysis. Infections of the peritoneal dialysis catheter tunnel and exit site are considered to be serious infections that may predispose patients to peritonitis and its consequences. Objective To evaluate and summarise the best available evidence on the effectiveness of care for the peritoneal dialysis catheter exit site. Inclusion criteria Types of participants Adult and paediatric patients receiving peritoneal dialysis Types of Interventions Antiseptics, topical antimicrobials agents, dressings and educational interventions Type of studies Randomised controlled trials Types of Outcomes Incidence of tunnel and exit site infection and peritonitis, caused by Staphylococcus aureus, Pseudomona aeruginosa, Haemophilus, Neisseria, Escherichia coli, etc. Search strategy All studies, published (in MEDLINE, CINAHL and COCHRANE databases) and unpublished, in English, Spanish, Portuguese and French, carried out between 1996 and February 2009 were retrieved. ,. Methodological quality The methodological quality of included articles was assessed by two independent reviewers using critical appraisal tools from the Joanna Briggs Institute. Data extraction Data were independently extracted by two reviewers, using the standardised data extraction tool from the Joanna Briggs Institute. Data synthesis Results were combined in meta-analysis where appropriate. Results Nine randomized controlled trials were included. In one study that compared the effectiveness of daily application of gentamicin cream with mupirocin, in the gentamicin group there were a total of 15 infections of the exit site compared to the mupirocin group where there were 29 infections (OR= 2.72; 95% CI 1.28-5.77); there were 22 incidences of peritonitis in the gentamicin group, compared to 28 incidences of peritonitis in the mupirocin group ( OR= 1.51; 95% CI 0.74-3.05). In three studies, patients received povidone-iodine and the control group received standard care. The overall results of the meta-analysis estimated an OR=0.83 with 95% CI 0.47–1.45 for the prevention of infection of the exit site and an OR=0.77 with 95% CI 0.44–1.36 for prevention of peritonitis. One study compared the effectiveness of chlorhexidine versus liquid soap, showing that there was a statistically significant lower exit-site infection rate in the group of patients that used chlorhexidine soap compared with the group that used pure liquid soap.(OR 0.35 with 95% CI 0.13-0.94). Another study compared povidone-iodine vs. chlorhexidine vs. sodium hypochlorite, and found no statistically differences between povidone and chlorhexidine and found no differences between the use of povidone and sodium hypochlorite. Another three studies compared mupirocina vs. standard care; mupirocina vs. fusidic acid; and fusidic acid vs. ofloxacin, and found no differences in reducing exit site infections or peritonitis. Conclusions Some interventions appear to be more effective than others in terms of peritoneal dialysis catheter exit site care. These advantages are related to a lower number of cases of exit site infection and, consequently, peritonitis. The application of an antiseptic to the peritoneal dialysis catheter exit site reduces infections and prevents the peritonitis that is a consequence of exit site infection; however, the results do not demonstrate the superiority of any one of povidone, chlorhexidine, hypochlorite or washing with soap.