Exit Site Infection In Patients Research Articles

Validity of a catheter exit site clinical assessment scale for the early detection of exit site infections in patients on haemodialysis with a central venous catheter: protocol for a multicentre validation study in Spain (EXITA Study)

IntroductionHaemodialysis patients with central venous catheter (HD-CVC) are at increased risk of exit site infections (ESIs) and catheter-related bloodstream infections, causing an increase of hospitalisation, morbidity and mortality rates. The...

(698) - Driveline Angle Is Crucial to Prevent Exit Site Infection in Patients with HeartMate II

(698) - Driveline Angle Is Crucial to Prevent Exit Site Infection in Patients with HeartMate II

Peritonitis and catheter exit-site infection in patients on peritoneal dialysis at home.

Objective: to analyze the complications related to peritonitis and catheter exit-site infections, in patients on peritoneal dialysis at home. Method: quantitative and cross-sectional study, carried out with 90 patients on peritoneal dialysis at home, in a municipality in the Northeast region of Brazil. For data collection, it was used two structured scripts and consultation on medical records. Descriptive analysis and comparison tests among independent groups were used, considering p<0.05 as level of statistical significance. Results: by comparing the frequency of peritonitis and the length of treatment, it was found that patients over two years of peritoneal dialysis were more likely to develop peritonitis (X²=6.39; p=0.01). The number of episodes of peritoneal catheter exit-site infection showed association with the length of treatment (U=224,000; p=0.015). Conclusion: peritonitis and catheter exit-site infection are associated with the length of treatment.

Prevention of gram-positive infections in peritoneal dialysis patients in Hong Kong: A cost-effectiveness analysis

Gram-positive bacteria are the major causative pathogens of peritonitis and exit site infection in patients undergoing peritoneal dialysis (PD). We investigated the cost-effectiveness of regular application of mupirocin at the exit site in PD recipients from the perspective of health care providers in Hong Kong. A decision tree was designed to simulate outcomes of incident PD patients with and without regular application of mupirocin over a 1-year period. Outcome measures included total direct medical costs, quality-adjusted life-years (QALYs) gained, and gram-positive infection-related mortality rate. Model inputs were derived from the literature. Sensitivity analyses evaluated the impact of uncertainty in all model variables. In a base case analysis, the mupirocin group had a higher expected QALY value (0.6496 vs 0.6456), a lower infection-related mortality rate (0.18% vs 1.64%), and a lower total cost per patient (US $258 vs $1661) compared with the control group. The rate of gram-positive peritonitis without mupirocin and the risk of gram-positive peritonitis with mupirocin were influential factors. In 10,000 Monte Carlo simulations, the mupirocin group had significantly lower associated costs, higher QALYs, and a lower mortality rate 99.9% of the time. Topical mupirocin appears to be a cost-effective preventive measure against gram-positive infection in incident patients undergoing PD. The cost-effectiveness of mupirocin is affected by the level of infection risk reduction and subject to resistance against mupirocin.

Abstract No. 286 - Efficacy of biopatch™ in reducing catheter related infections in cuffed, tunneled central venous catheters

Purpose Catheter related infections (CRIs) are an important cause of morbidity and mortality in immunocompromised patients in need of long term central venous access.1 Chlorhexidine impregnated sponges have been shown to decrease infection rates in nontunneled central venous catheters (CVCs).1 The purpose of this study is to evaluate the efficacy of Biopatch™when used with a tunneled, cuffed CVC to reduce CRIs. Materials and Methods All large bore tunneled, cuffed CVCs placed in our department between December 1, 2008 and August 31, 2012 were included in this study. HiIQ™ is used to track all procedural complications and was queried for occurences of local infection and septicemia/bacteremia for all patients who had catheters placed in this period. Endpoints were clinically based: a local or site infection was generally recognized as an erythematous exit site and septicemia/bacteremia was defined as those cases which required catheter removal due to positive blood cultures. This data was analyzed using a Chi Square test. Results Between December 1, 2008 and August 31, 2012, 2491 patients had catheters placed. 1348 patients had catheters placed before the intervention and 1237 after. For the 2 years before the intervention, there were 69 episodes of septicemia/bacteremia with an overall prevalence of 5.1%. After Biopatch™ was employed, there were 51 episodes of septicemia/bacteremia for an overall prevalence of 4.1%. This difference was not statistically significant (P=0.23). With regards to local infection, there were 28 patients who experienced local infection before Biopatch™ and 13 after, for an overall prevalence of 2.0% and 1.0% respectively. This result was statistically significant with a P=0.03. Conclusion There is good historical evidence to support the use of Biopatch™ to reduce CRIs in nontunneled CVCs. Based on our results in this retrospective study, Biopatch™ is also useful in reducing local exit site infections in patients who have tunneled, cuffed catheters. Reference 1. Timsit JF, Schwebel C, Bouadma L, et al. Chlorhexidine impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults: a randomized controlled trial. JAMA 2009; 301:1231-41.

Prevention and management of peritonitis and exit-site infection in patients on continuous ambulatory peritoneal dialysis.

Peritoneal dialysis (PD) is an important and lifesaving form of renal replacement therapy for more than 100 000 patients worldwide. Peritonitis, catheter exitsite, and tunnel infections are serious problems in PD patients. Peritonitis accounts for 15–35% of hospital admissions, is the major cause (40– 45%) of transfer to haemodialysis (technique failure), and finally is associated with mortality (7–10% of deaths) either as a primary or contributing factor w1x. In the early 1980s peritonitis incidence was high, with rates as high as 6.3 episodes per patient year. During the 1980s and early 1990s the peritonitis rate dropped to 1.1–1.3 episodes per patient year. With improvements in connection technology (introduction of Y-set and double-bag systems) the peritonitis rates declined further to around 0.5 episodes per patient year w2x.

Protection from ototoxicity of intraperitoneal gentamicin in guinea pig

Aminoglycoside antibiotics are common to treat peritonitis and exit-site infections in patients on peritoneal dialysis. Ototoxicity (loss of hearing or balance) is a well-documented adverse effect of aminoglycosides, and severe ototoxic reactions have been noted in patients receiving these drugs by intraperitoneal lavage. We have proposed a free-radical hypothesis for the mechanism of aminoglycoside ototoxicity and suggested a therapeutic prevention by the concomitant administration of antioxidants or iron chelators. Here we investigate whether 2, 3-dihydroxybenzoate can prevent the ototoxicity of intraperitoneal gentamicin. Two strains of pigmented guinea pigs received daily intraperitoneal injections of gentamicin. Both strains developed ototoxicity, although different dosages were needed to produce similar auditory deficits (120 mg gentamicin base/kg body weight daily for 19 days vs. 135 mg/kg for 14 days). Dihydroxybenzoate was administered intraperitoneally once or twice daily. Auditory thresholds were measured by evoked brain stem response. Pathology was assessed as a loss of sensory cells in surface preparations of the organ of Corti. The auditory threshold shifts and hair cell loss were similar to the pathology observed following subcutaneous injections of gentamicin. Animals sustained almost complete loss of outer hair cells in the basal cochlea and a progressive hearing loss with threshold shifts of 60 dB at 18 kHz. The concomitant administration of dihydroxybenzoate significantly attenuated the threshold shift to less than 30 dB and reduced the loss of hair cells. The treatment with dihydroxybenzoate did not affect serum gentamicin levels. Antioxidant therapy is a promising approach to prevent aminoglycoside-induced hearing loss following intraperitoneal application.

New strategies for the use of mupirocin for the prevention of serious infection

Nasal mupirocin has an important role to play in the prevention of Staphylococcus aureus infection by eliminating nasal carriage of this organism. Indeed, in many countries nasal mupirocin is one of the mainstays for controlling outbreaks of methicillin-resistant S. aureus. Eradication of nasal S. aureus with mupirocin has been shown to be effective in preventing postoperative infections in patients undergoing cardiothoracic surgery and in preventing exit-site infections in patients undergoing haemodialysis. It has been proposed that the use of mupirocin should be extended to other situations, such as the prevention of postoperative infections in patients undergoing implant surgery and the prevention of bacteraemias in high-risk patients. Clinical trials are needed to establish the efficacy of mupirocin in these situations. Both low-level and high-level resistance have been reported during treatment with nasal mupirocin. Low-level resistance does not represent a significant clinical problem but high-level resistance resulting from indiscriminate use may give grounds for concern. Further review of these issues is required. As with any antibiotic, mupirocin should be used judiciously, as part of an integrated programme of infection control.

The use of vaccines in renal failure.

Renal insufficiency is characterised by impaired host defences, which are compromised further by each of the 3 modes of renal replacement--haemodialysis, continuous ambulatory peritoneal dialysis (CAPD) and renal transplantation. Reduced renal clearance of unknown toxins, possible development of nutritional deficiencies and administration of immunosuppressive medications lead to aberrant immune regulation early in the course of renal failure. This results subsequently in increased frequency and severity of infection. Vaccination plays an important role in attenuating this infection risk, but impaired cell-mediated and humoral immunity contraindicates the use of live vaccines and engenders suboptimal and short-lived antibody responses to inactivated vaccines. Reinforced vaccination schedules, increased vaccine dosage and concomitantly administered adjuvant immunomodulators have variably improved the defective antibody responses to certain vaccines. Immunisation against hepatitis B virus has resulted in a significant decrease in prevalence and incidence of this infection in haemodialysis units. Similarly, the inoculation of influenza vaccine in patients with uraemia and of polyvalent pneumococcal vaccine in special risk circumstances has been recommended because of perceived reductions in morbidity and mortality from infection with these agents. Cytomegalovirus (CMV) vaccine may attenuate CMV disease severity in recipients of renal allografts. Staphylococcus aureus vaccine, on the other hand, is ineffective in preventing peritonitis or exit site infections in patients receiving CAPD. Other killed vaccines have not been comprehensively studied, but generally have the same indications for use as in normal individuals. However, the protection that these vaccines afford may be either inadequate or transient, so that other infection control strategies should be simultaneously implemented.

Single and Multiple-Dose Kinetics of Ofloxacin in Patients on Continuous Ambulatory Peritoneal Dialysis (CAPD)

To evaluate the pharmacokinetics of ofloxacin, a novel quinolone antibiotic, in patients with end-stage renal disease (ESRD) on continuous ambulatory peritoneal dialysis (CAPD), we investigated 6 patients in a single-dose study and 9 patients in a multiple-dose study, all without peritonitis. In the single-dose study, patients received 200 mg ofloxacin orally. Serum concentrations (Cmax) peaked at 3.1 +/- 0.3 mg/L (mean +/- SEM), 1.6 +/- 0.5 h after p.o. administration of the drug. Elimination half-life (t1/2) was 26.8 +/- 2.5 h. Peritoneal clearance accounted for 10% of the total body clearance. After 5-h dwell time, ofloxacin concentrations in the dialysate were 1.5 +/- 0.2 mg/L, which is above the MIC90 for most bacteria responsible for peritonitis in patients on CAPD. In the multiple dose study, 200 mg ofloxacin were administered twice, with a time interval of 12 h, followed by 200 mg for 9 days every morning. Mean trough serum levels were 2.6 +/- 1.0 mg/L, mean peak concentrations were 4.1 +/- 1.7 mg/L. Mean ofloxacin concentrations in the peritoneal effluent were 1.9 +/- 0.9 mg/L. It is concluded that an oral loading dose of 400 mg on the first day and a maintenance dose of 200 mg ofloxacin/day does not lead to significant accumulation, even though the elimination by the peritoneal route is only small. The proposed dosing regimen could be an adequate therapy of peritonitis and exit-site infections in patients on CAPD since levels reached in the dialysate effluent are bactericidal. The clinical usefulness in the treatment of peritonitis has to be proven in further studies.

Ultrasound as a tool in the diagnosis and management of exit-site infections in patients undergoing continuous ambulatory peritoneal dialysis.

Ultrasonographic examination of the subcutaneous course and exit site of the Tenckhoff catheter in patients undergoing continuous ambulatory peritoneal dialysis (CAPD) was performed to evaluate catheter-related infections. Real-time ultrasound studies were performed in 24 patients with initial exit-site infections; clinically suspected tunnel infections were excluded from analysis. A peri-catheter sonolucent fluid collection, considered a positive study, was demonstrated in 13 ultrasound examinations and tended to be organism-specific; eight of 12 Staphylococcus aureus exit-site infections and three of four gram-negative exit-site infections had positive studies. Only two of seven Staphylococcus epidermidis exit-site infections were initially positive on ultrasound examination. Nine of 13 patients with positive ultrasound studies ultimately lost their catheters to infection despite weeks of parenteral antibiotic therapy and local incision and drainage. There were 11 negative ultrasound studies. Only one of these patients' catheters was lost because of infection. In some episodes of CAPD-associated exit-site infections, especially those caused by S aureus and gram-negative organisms, ultrasound examination of the catheter course may be useful to diagnose unsuspected tunnel infections, direct early therapy, and confirm resolution or persistence of the infections.