Incidence Of Exit-site Infection Research Articles

Infectious and mechanical complications in planned-start vs. urgent-start peritoneal dialysis: a cohort study.

Few studies have compared the infectious and mechanical complications seen in planned-start and urgent-start peritoneal dialysis (PD) patients. To compare the incidence and etiology of mechanical and infectious complications in patients offered planned- and urgent-start PD and assess potential differences in patient survival and time on PD. This retrospective cohort study included patients with chronic kidney disease on planned- and urgent-start PD seen from 2014 to 2020 and compared them for mechanical and infectious complications, clinical outcome, death rates, and need to switch to hemodialysis. Ninety-nine patients on planned-start PD and 206 on urgent-start PD were included. Incidence of exit-site infection (18.9 vs. 17.17%, p=0.71) and peritonitis (24.27 vs. 27.27%, p=0.57) were similar between patients, while pathogens causing peritonitis were different, although non-fermenting Gram-negative bacilli were more commonly seen in the planned-start PD group. Leakage as a mechanical complication and hospitalization were more common among patients needing urgent-start PD (10.68 vs. 2.02%, p=0.0085 and 35.44 vs. 17.17%, p=0.0011, respectively). Patient survival was similar between groups. Cox regression found an association between death and age (HR=1.051, 95% CI 1.026-1.07, p=0.0001) and albumin (HR=0.66, 95% CI 0.501-0.893, p=0.0064), and between peritonitis and a diagnosis of diabetes (HR=2.016, 95% CI 1.25-3.25, p=0.004). Patient survival and time on PD were similar between the planned- and urgent-start PD groups, while leakage was more frequently seen in the urgent-start PD group. Death was associated with lower albumin levels and older age, while peritonitis was associated with diabetes.

Retraining programme for older patients undergoing peritoneal dialysis: A randomised controlled trial.

Peritonitis is a common cause of hospitalisation and death among patients undergoing peritoneal dialysis. Periodic retraining is recommended to prevent peritonitis, especially in older adults. We evaluated the effectiveness of a retraining programme for reducing peritonitis and exit site infection rates in older adults on peritoneal dialysis. The cost-benefit ratio was also calculated. A two-arm prospective randomised controlled trial. One hundred and thirty patients aged 55 years or older were recruited. Participants were randomly assigned to the intervention or control group. While both groups received usual care, the intervention group received a retraining programme (a knowledge and practical assessment and a one-on-one retraining session) 90 days after starting home-based continuous ambulatory peritoneal dialysis therapy. The outcomes included peritonitis rate, exit site infection rate and direct medical costs at 180, 270, and 360 days after starting home-based continuous ambulatory peritoneal dialysis therapy. No significant differences were found in the baseline characteristics between groups. The peritonitis rates were 0.11 episodes per patient-year in the intervention group versus 0.13 in the control group. The incidence of exit site infection was 20.0% in the intervention group and 12.3% in the control group. The cost-benefit ratio of retraining was 1:9.6. None of the results were statistically significant. The absence of statistical significance may be partly explained by the premature termination of the study. Large-scale multi-centre trials are warranted to examine the effectiveness of retraining. The timing and long-term effects of retraining also need to be examined.

Topical application of mupirocin to exit sites in patients on peritoneal dialysis: a systematic review and meta-analysis of randomized controlled trials

BackgroundThe International Society for Peritoneal Dialysis guidelines recommends the topical application of antibiotics on the exit site for the prevention of peritoneal dialysis (PD)-related infections. However, the recommendation is based on meta-analyses on applying nasal mupirocin ointment or observational or retrospective studies. Here, we evaluated the efficacy of topical application of mupirocin on the exit site for the prevention of PD-related infections.MethodsWe searched the databases, MEDLINE and CENTRAL, documenting the topical application of antibiotics on the exit site in PD patients in April 2017. We included only randomized controlled trials (RCTs) with adult patients wherein the effects of mupirocin were examined. Exit site infection (ESI), peritonitis, and technical failure were assessed as the main outcomes.ResultsOverall, six RCTs were included in this study. It was uncertain whether the application of mupirocin ointment prevents ESI (rate ratio (RR), 0.36; 95% CI, 0.13–1.05), peritonitis (RR 0.78, 95% CI 0.50–1.21), and technical failure (RR, 1.35; 95% CI, 0.25–7.21). Moreover, a comparison between mupirocin and gentamicin showed no difference in the incidence of ESI (RR, 1.14; 95% CI, 0.27–4.81), peritonitis (RR, 0.85; 95% CI, 0.32–2.26), and technical failure (RR, 0.58; 95% CI, 0.28–1.20).ConclusionsIt remains unclear whether topical application of mupirocin on the exit site has any significant effects on PD-related infection or technical failure. Large-scale RCTs with high methodological quality are required to confirm the efficacy of topical application of antibiotics on the exit site.Trial registrationUMINR000039267

Invited Commentary

Despite the continuing improvement in outcomes after left ventricular assist device (LVAD) implantation, pump-related infections remain a significant challenge. Up to 50% of patients with continuous-flow LVADs will have a percutaneous driveline infection at some time after implantation. Although the incidence has decreased relative to the previous generation of pulsatile pumps, it is still very high. LVAD-associated infections are treated initially with intravenous antibiotics, and in some cases with surgical debridement of the driveline exit site, or even rarely with pump exchange, depending on the localization of infection. The long-term survival is exceedingly poor, and patients are at high risk for embolic stroke and sepsis leading to multiorgan failure. Previous studies in the era of pulsatile LVADs have demonstrated that heart transplantation with removal of all device-related material was associated with acceptable outcomes. This has not been investigated in the current era of continuous-flow devices until this study by Tong and coauthors [1Tong M.Z. Smedira N.G. Soltesz E.G. et al.Outcomes of heart transplant after left ventricular assist device specific and related infection.Ann Thorac Surg. 2015; 100: 1292-1297Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar]. This analysis included 170 patients who underwent HeartMate II (Thoratec Corp, Pleasanton, CA) LVAD implantation as a bridge to transplantation. Sixty-one (36%) patients had an LVAD-related infection and 26 of these patients went on to heart transplantation. Patients with LVADs with or without infections had an equal likelihood at 1 year of receiving a transplant (40%), and 1-year survival to transplantation was also similar at nearly 80%. Posttransplantation survival was excellent in the cohort with LVAD-related infection, with 1- and 3-year survivals of 96% and 92%, respectively, and was not different from the group without infection. These data again demonstrate that transplantation remains the best strategy for treatment of LVAD-related infections in bridge to transplantation patients with current-generation devices. Of course the best approach to infection in these patients is prevention. This has represented a formidable challenge in the field of durable mechanical circulatory support given the presence of a percutaneous driveline; however, recent retrospective multiinstitutional studies have described driveline externalization techniques that are associated with a less than 10% incidence of exit site infection at 1 year. Longer-term follow-up, as well as a prospective arm of this study, is ongoing. Future generations of LVADs will likely eliminate the need for externalized components, and this will likely be the best solution for prevention of device-related infection. Outcomes of Heart Transplant After Left Ventricular Assist Device Specific and Related InfectionThe Annals of Thoracic SurgeryVol. 100Issue 4PreviewLeft ventricular assist device (LVAD) infections including drivelines, pump pockets, and bacteremia are difficult to manage and conservative treatments may not be effective as the infected foreign material remains. Full-Text PDF

Reduction in catheter-related infections after switching from povidone-iodine to chlorhexidine for the exit-site care of tunneled central venous catheters in children on hemodialysis.

Only a few studies have investigated the optimal exit site management of tunneled central venous catheters (CVCs) in pediatric patients on chronic hemodialysis (HD). The aim of this study was to assess the efficacy of chlorhexidine solutions and a 5% povidone-iodine solution on the incidence of CVC-related infections in children on HD. The incidence of exit-site infection (ESI), tunnel infection (TI), and bloodstream infection (BSI) was assessed in two groups of tunneled CVCs. The iodopovidone group consisted of 14 CVCs used between 1 January 2011 and 30 June 2012 in 10 children, whose median age at the time of CVC placement was 11.8 years (range 1.2-19.2): 5% povidone-iodine was used for CVC exit-site care. From 1 August 2012 to 31 January 2014, 0.5% chlorhexidine gluconate/70% isopropyl alcohol was used for the exit site, and 2% chlorhexidine gluconate/70% isopropyl alcohol spray for the hub in 13 CVCs was used in 10 patients (chlorhexidine group), whose median age at the time of CVC placement was 10 years (range 1.2-19.2). Ten episodes of ESI were diagnosed in the iodopovidone group (incidence 3.4/1000 CVC days), and only one in the chlorhexidine group (incidence 0.36/1000 CVC days, P = 0.008). One TI was observed in the iodopovidone group (0.34/1000 CVC days), and none in the chlorhexidine group. The incidence of BSIs decreased from 1.7/1000 CVC days (5 cases) to 0.36/1000 CVC days (1 case, P = 0.06) after switching to chlorhexidine. Two CVCs were lost due to CVC-related infections in the iodopovidone group, whereas no CVC was lost due to infections in the chlorhexidine group. In comparison with 5% povidone-iodine, the use of chlorhexidine gluconate was associated with a reduction in the incidence of ESI, TI, and BSI in children on HD.

Comparison of exit site infection and peritonitis incidences between povidone-iodine and normal saline use for chronic exit site care in peritoneal dialysis patients

BackgroundCatheter-related exit site infection is a major risk factor for the development of peritonitis and can contribute to failure of treatment maintenance in peritoneal dialysis (PD) patients. Although povidone-iodine can be used for exit site care, the irritation induced by the local application of povidone-iodine could lead to secondary infection. Therefore, we evaluated the clinical effectiveness of normal saline compared with povidone-iodine as a method of exit site care in chronic PD patients. MethodsIn all, 126 patients undergoing PD treatment for>6 months between January 2006 and December 2009 were enrolled. Data were retrospectively analyzed for the incidence of exit site infection and peritonitis for 2 years prior to and after December 2007. In addition, we identified the incidences of catheter-related infections during follow-ups from January 2010 to December 2013. ResultsThe participants׳ mean age was 58.8±12.9 years. The incidences of exit site infection and peritonitis were one episode per 64.6 patients–months and one episode per 40.4 patients–months in the povidone-iodine group, respectively, whereas these were one episode per 57.5 patients–months and one episode per 45.6 patients–months in the normal saline group, respectively. Whereas Gram-positive bacteria most frequently caused catheter-related infections in both groups, culture-negative infections were dominant in the normal saline group. ConclusionExit site care using normal saline did not increase the incidence of exit site infection and peritonitis. Therefore, normal saline may be an alternative treatment for exit site care in patients receiving PD.

Percutaneous and Surgical Insertion of Peritoneal Catheter in Patients Starting in Chronic Dialysis Therapy: A Comparative Study

Percutaneous peritoneal catheter insertion can be performed by trained nephrologists. The objective of this study was to compare the outcome of peritoneal dialysis (PD) catheters percutaneous inserted with the traditional surgical technique. One hundred twenty-one PD catheters were placed in 121 stage-5 Chronic kidney disease patients using three techniques: percutaneous insertion (Group P, n = 53), percutaneous insertion guided by radioscopy (Group R, n = 26), and surgical insertion (Group S, n = 42). The mean age of the whole cohort was 57 ± 16 years and 54% were male. Patients and catheter outcomes were followed up prospectively for 19 months. Gender, age, body mass index, previous abdominal surgeries, and the prevalence of diabetes mellitus were not significantly different among the groups as well as the incidence of bleeding and the presence of catheter dysfunction. In addition, the incidence of exit-site infections and peritonitis was not significantly different among the groups. Finally, the survival catheter rate was not significantly different by the end of the follow-up of 19 months (70% in P group, 85% in R, and 70% in S group (log rank = 0.88, p = 0.95). The outcome of percutaneous implanted catheters, which were inserted by a trained nephrologist, did not demonstrate to be inferior as compared with the traditional surgical approach.

Catheter revision for the treatment of intractable exit site infection/tunnel infection in peritoneal dialysis patients: A single centre experience

Catheter-related infection is a major cause of catheter loss in peritoneal dialysis (PD). We evaluated the effect of catheter revision on the treatment of intractable exit site infection (ESI)/tunnel infection (TI) in PD patients who required catheter removal. We reviewed the medical records of 764 continuous ambulatory peritoneal dialysis (CAPD) patients from May 1995 to April 2011 at our hospital. One hundred and twenty six patients had more than one occurrence of ESI. Catheter revision was performed to treat intractable ESI/TI. Incidence of ESI, causative organisms and the outcomes of catheter revision were analyzed. The total PD duration of all patients was 32,581 months. Three hundred and twelve ESI episodes occurred in 126 patients and the incidence of ESI was 1/104 patient-months (0.12/patient-year). The most common causative organism was methicillin-sensitive Staphylococcus aureus (MSSA) (98 episodes), followed by Pseudomonas aeruginosa (63 episodes) and methicillin-resistant S. aureus (MRSA) (28 episodes). Among these, catheter revision was required due to intractable ESI/TI in 36 patients. The most common causative organism was MSSA (14 episodes) followed by P. aeruginosa (10 episodes) and MRSA (six episodes) in catheter revision cases. The outcomes of catheter revision were as follows: ESI relapsed in 11 patients (30.6%) after catheter revision. Among them, five patients were treated with antibiotic treatment, two patients required secondary catheter revision, four patients required catheter removal due to ESI/TI accompanying peritonitis. The catheter survival rate after catheter revision was 89.7% in one year. There were no statistical differences in the rates of ESI relapse after catheter revision between ESI caused by P. aeruginosa (5/10, 50%) and ESI caused by S.aureus (6/21, 28.6%). Catheter revision may be an alternative treatment option to treat intractable ESI/TI before catheter removal is considered in PD patients.

Vancomycin flush solution for prevention of catheter-related infections in oncology patients with PICC: a systematic review of the effectiveness

Objective To assess the efficacy of vancomycin flush solution for prevention of catheter-related infections in oncology patients. Methods Randomized controlled trials(RCTs) were searched and identified from Cochrane library, PubMed, EMBASE, CBM, CNKI and related journals were also scanned. In accordance with inclusion and exclusion criteria, we evaluated the quality of the included studies by Jadad scale and analyzed the data of catheter- related sepsis, catheter colonization, exit- site infection by RevMan 5.0. Results We included 5 randomized controlled trials (400 patients). Meta analysis showed that there were statistical differences between vancomycin- heparin mixture and heparin solution on the incidence of catheter-related sepsis, catheter colonization, but no difference was found on the incidence of exit-site infection. Conclusions The current evidences show that contrast with heparin flush solution, van comycin - heparin flush solution can significantly reduce the incidence, of catheter - related sepsis and catheter colonization. But vancomycin-heparin flush solution was more effective, and the results should be further confirmed in prevention of Gram-positive bacterial and fungal catheter-related infections or in non- neutropenic patients. Before draw the conclusions, further high-quality, large scale, double-blind randomized controlled trials are still needed. Key words: Vancomycin; Prophylaxis; CVCs; Infection; Systematic review

Chlorhexidine-based antiseptic solutions effectively reduce catheter-related bacteremia

The aim of this retrospective study was to investigate if the application of chlorhexidine-based solutions (ChloraPrep) to the exit site and the hub of long-term hemodialysis catheters could prevent catheter-related bacteremia (CRB) and prolong catheter survival when compared with povidone-iodine solutions. There were 20,784 catheter days observed. Povidone-iodine solutions (Betadine) were used in the first half of the study and ChloraPrep was used in the second half for all the patients. Both groups received chlorhexidine-impregnated dressings at the exit sites. The use of ChloraPrep significantly decreased the incidence of CRB (1.0 vs 2.2/1,000 catheter days, respectively, P = 0.0415), and hospitalization due to CRB (1.8 days vs 4.1 days/1,000 catheter days, respectively, P = 0.0416). The incidence of exit site infection was similar for the two groups. Both the period of overall catheter survival (207.6 days vs 161.1 days, P = 0.0535) and that of infection-free catheter survival (122.0 days vs 106.9 days, P = 0.1100) tended to be longer for the catheters cleansed with ChloraPrep, with no statistical significance. In conclusion, chlorhexidine-based solutions are more effective for the prevention of CRB than povidone-iodine solutions. This positive impact cannot be explained by decreased number of exit site infections. This study supports the notion that the catheter hub is the entry site for CRB.

Clinical effectiveness of different approaches to peritoneal dialysis catheter exit-site care

The main aim of this review is to evaluate and summarise the best available evidence about peritoneal catheter exit site care to minimise the risk of infection. The specific review questions to be addressed are: •What is the most effective approach to managing peritoneal catheter exit sites during the initial post-operative period? •What is the most effective approach to the long term management of peritoneal catheter exit sites? Inclusion Criteria Types of participants Participants of interests are both adults and children (under 18) with chronic renal failure on maintenance peritoneal dialysis. Studies which analyse diabetic patients separately will be considered for inclusion as a subgroup analysis. Types of interventions Interventions of interest are those used to manage peritoneal catheter exit sites, both in the early post-operative period (from 0 to 14 days post insertion of the catheter), and the long term period (15 or more days post insertion). Interventions of interest include: •Dressing of exit sites, including type of dressing, frequency of dressing and technique (aseptic vs. clean) •Exit site skin care, frequency and type of skin care (or product used). •Education of the person with a peritoneal catheter, or a carer, on exit site management. •Prophylactic treatments involving topic antimicrobial agents or antiseptic and devices. Types of outcome measures The outcomes of interest are those related to the effectiveness of peritoneal catheter exit site care. These outcomes will include incidence of exit site infection and peritonitis.Outcome measures: •Incidence of tunnel or exit site infection: Number of patients with infection inside the tunnel or at the exit site. Infection can be defined as the presence of redness, inflammation, exuberant granulation tissue and purulent/bloody exudate associated with erythema and oedema. •Incidence of peritonitis: two positive (post dialysis cell count > 100 cells/ mm³ with >50% of polimorfonuclear leukocytes), peritoneal liquid cultures in an asymptomatic PD catheter carrier or a single positive in a PD catheter carrier with symptoms of peritonitis (such as abdominal pain, fever and cloudy peritoneal liquid). •Reappearance of the peritonitis (after two to four weeks, due to the same microorganism). •Lapse of time to the first episode of peritonitis. •PD Catheter removal. •Readmission rates related to peritonitis. •Failure of the procedure (transfer from PD to haemodialysis). •Death caused by peritonitis

Controlling exit site infections: Does it decrease the incidence of catheter‐related bacteremia in children on chronic hemodialysis?

The aim of this retrospective study was to investigate whether the application of a chlorhexidine-impregnated dressing (Biopatch) at the exit site of tunneled-cuffed hemodialysis catheters has any effect on the incidence and etiology of catheter-related bacteremia (CRB). This study was carried out over a 5-year period in a single center, where, in the first 2(1/2) years, the exit sites were cleansed with betadine at every hemodialysis session and then covered with a transparent dressing (pre-Biopatch Era). During the next 2(1/2) years, Biopatch was applied to the exit site once a week after cleansing with betadine, and then covered with a transparent dressing (Biopatch Era). The application of Biopatch significantly decreased the incidence of exit site infections (ESI) (P<0.05). However, there was no difference in the incidence of CRBs or their microbiological distribution. The improved ESI rate had no effect on the overall catheter survival time. The antimicrobial sensitivities of the Gram-positive microorganisms were statistically different for the 2 different types of infections (P<0.05). In conclusion, even though Biopatch is effective in decreasing the incidence of ESI, it has no effect on the incidence of CRB, the etiology of CRB, or the overall catheter survival time. The distinct difference between the antimicrobial sensitivities of the ESI and CRB suggests that they are not a spectrum of the same pathogenesis. These preliminary data support the intraluminal pathogenesis of CRB, rather than the exit site as a possible entry point for the extraluminal route.

Surveillance cultures of tunneled cuffed catheter exit sites in chronic hemodialysis patients are of no benefit

Catheter-related infections are a major cause of morbidity and mortality in hemodialysis (HD) patients. This study evaluated the utility of surveillance swab cultures (Ssc) of tunneled cuffed catheter (TCC) exit sites as a prediction and prevention strategy for infection. A 6-month prospective-controlled trial with 94 chronic HD patients with a TCC who received monthly Ssc and were stratified by dialysis day into topical therapy based on Ssc results (Group A) or no therapy (Group B). Outcomes were exit site infection (ESI) and catheter-associated bacteremia (CAB). The overall monthly prevalence of positive Ssc was 14.9%. There was no difference in the number of positive Ssc (17.7% vs. 11.6%, p > 0.05) or ESI (19.6% vs.16.3%, p > 0.05) between Groups A and B, respectively. Catheter-associated bacteremia was higher in Group A (17.7% vs. 4.7%, p = 0.05). There were significantly more ESI in the patients treated for a positive Ssc. In Group A, the incidence of ESI was significantly higher in those treated for a positive vs. negative Ssc (55% vs. 12%, p = 0.009) and CAB rates trended higher with positive Ssc (22.2% vs. 16.7%, p > 0.05). The strategy of treating positive surveillance cultures is not beneficial. Positive Ssc do not predict the occurrence of catheter-related infection, and treatment of these cultures may lead to increased infection rates.

Conversion of Temporary Hemodialysis Catheters to Permanent Hemodialysis Catheters: A Retrospective Study of Catheter Exchange versus Classic de novo Placement

Many clinicians believe that de novo access is required when converting temporary hemodialysis (HD) catheters to long-term or permanent catheters. However, since vascular access sites are at a premium in the dialysis patient, it is important to preserve existing central venous catheters and conserve future access sites. In this retrospective study, data from 94 patients referred to interventional radiology for placement of long-term, tunneled HD catheters between July 2001 and September 2002 were reviewed. The study group consisted of 42 patients in whom the temporary catheter was exchanged for a peel-away sheath and a tunneled catheter inserted using the existing venous access site. The control group included 52 patients who received traditional de novo placement of permanent catheters. Based on available follow-up data, we report a 100% technical success rate, with 72% patency at 30 days in the study group (n = 32; mean age 58 years). By comparison, de novo catheter placement (n = 35; mean age 59 years) yielded a 100% technical success rate, with 83% patency at 30 days. The overall infection rate was 0.30 per 100 catheter-days (total 3036 catheter-days) and 0.36 per 100 catheter-days (total 3295 catheter-days), respectively (chi2 = 0.64, p > or = 0.05). There was no incidence of exit site infection, tunnel infection, or florid sepsis in either group. Likewise, no stenosis or bleeding complication was noted. Thus conversion of a temporary HD catheter to a tunneled catheter using the same venous insertion site is safe, does not increase the risk of infection, and allows conservation of other central venous access sites.

Effect of Local Mupirocin Application on Exit-Site Infection and Peritonitis in an Indian Peritoneal Dialysis Population

Staphylococcus aureus-associated peritonitis and catheter exit-site infections (ESIs) are important causes of hospitalization and catheter loss in patients undergoing chronic peritoneal dialysis. Intranasal and topical use of mupirocin has been found to be an effective strategy in decreasing S. aureus-related infectious complications in persons who are carriers of S. aureus; however, there is no consensus regarding the prophylactic use of mupirocin irrespective of carrier status. We aimed to determine the potential effectiveness of application of mupirocin cream at the catheter exit site in preventing ESI and peritonitis irrespective of carrier status in a tropical country such as India. This prospective historically controlled study was done in a total of 40 patients. From August 2003, all patients, incident and prevalent, were instructed to apply 2% mupirocin cream daily to the exit site instead of the older practice of povidone-iodine and gauze dressing. Patients were not screened to determine whether they were S. aureus carriers. The infection-related data for 1 year, until July 2004, were compared with the historical control, which was infection-related data for the year preceding the year of mupirocin application. Mean age of the study population was 62 years, with 61.8% being male and 64.3% being diabetic. Local application of mupirocin led to a significant reduction in the incidence density per patient-month of both ESI and peritonitis compared to controls (0.15 vs 0.37 and 0.37 vs 0.67, p = 0.01 for both). This amounted to a relative reduction of 60.5% and 55% respectively. ESI and peritonitis due to S. aureus were also significantly lower in the study group compared to controls (incidence density per patient-month 0.05 vs 0.13 and zero vs 0.17 respectively, p < 0.01 for both). There occurred no catheter removal due to infection-related complications during the study period compared to two during the control period. None of the patients reported a mupirocin-related adverse effect. Daily application of mupirocin at the exit site is a well-tolerated and effective strategy in reducing the incidence of ESI and peritonitis in a tropical country such as India. It can thus significantly reduce morbidity, catheter loss, and transfer to hemodialysis in peritoneal dialysis patients.

Survival and Complications of Indwelling Venous Catheters for Permanent Use in Hemodialysis Patients

The risk factors influencing the survival of indwelling central vein catheters and their potential complications have not been assessed in depth and on a large scale. We investigated the general characteristics of 245 single lumen cuffed tunneled catheters and analyzed their survival by Kaplan-Meier and Cox regression analysis. Risk factors for bacteremia and thrombosis were assessed by logistic regression analysis. The incidence of exit-site infection, tunnel infection, bacteremia and thrombotic events was 0.35, 0.25, 1.71, and 1.94/1000 catheter days, respectively. The mean survival time per catheter was 276 days. After censoring for non catheter-related events leading to the removal of the catheter (n = 245 with 120 catheters censored and 125 events), the mean survival time of the catheter appeared to be 615 +/- 67 days (95% CI of 483-747) and the median survival time 310 +/- 50 days (95% CI of 212-408). The localization of the catheter into the right internal jugular vein results in significantly better survival as compared with other insertion sites both in Kaplan-Meier (mean survival of 650 days compared to a mean survival of 519 days, P value < 0.009) and in Cox regression analysis (relative risk of 0.537, P value < 0.001). Localization of the catheter into the right internal jugular vein seemed to increase the risk for bacteremia (relative risk of 1.798, P value of 0.063). The use of anticoagulant agents was not protective for thrombosis, although this might be due to lack of power (relative risk of 0.626, P value of 0.141). We provide evidence of a mean survival in long-term hemodialysis catheter close to 2 years with an acceptable complication rate. If a long-term hemodialysis catheter is required, it is best placed in the right internal jugular vein.

STAPHYLOCOCCAL INFECTIONS IN PD: MONITORING, SCREENING AND PREVENTION

Peritonitis and catheter infections remain a major complication of peritoneal dialysis, accounting for much of the morbidity associated with the technique. The most common source of infection is contamination with predominantly Gram positive skin flora, Staphylococcus (S) epidermidis and S. aureus. The aims of this study were, (a) to determine the incidence of S. aureus and S. epidermidis infections in the unit, (b) to examine whether treatment of S. aureus carriers may reduce the incidence of exit site infection and (c) to examine whether improving patient education may reduce S. epidermidis peritonitis rate.

Preliminary experience with a new design for a tunneled, cuffed catheter for hemodialysis

Purpose: The use of tunneled, cuffed central venous catheters for hemodialysis is associated with poor flow, thrombosis, and infections due to the transcutaneous nature of these devices. A new design for a sutureless, tunneled cuffed catheter was evaluated in hemodialysis patients to determine the effect of its design on the incidence of exit site infection. Methods: A polyurethane conduit with a uniquely designed cuff and subcutaneous skirt covered with Dacron velour was attached to standard double lumen central venous catheters. Seven (7) Ash catheters and one (1) Tesio catheter were fitted with the overtube and skirt and implanted in eight (8) patients undergoing routine hemodialysis. Patients were monitored for exit site infection, tunnel infection, bacteremia, cuff extrusion, and serosanguineous exudate. Results: Catheters were implanted for 6 to 26 weeks. All catheters remained patent and no cases of bacteremia were observed. There was no evidence of exit site or tunnel infection, and no reported serosanguineous exudate from the exit site. Exit site care consisted of soap and water cleansing by the patient. Patients were able to shower or bathe 4 weeks post‐implant. Conclusions: The new design for a subcutaneous cuff and skirt appears to inhibit exit site infection and other common complications of central venous catheters.

Presternal peritoneal catheter.

The swan neck presternal catheter is composed of 2 flexible (silicon rubber) tubes joined by a titanium connector at the time of implantation. The exit site is located in the parasternal area. The catheter located on the chest was designed to reduce the incidence of exit site infections compared to peritoneal dialysis catheters with abdominal exits. From August 1991 to September 30, 2001, 974 swan neck presternal catheters were implanted worldwide. At the university of Missouri, 150 of these catheters were implanted and followed for over 130 patient years. Presternal catheters tended to perform better than swan neck abdominal catheters regarding exit and tunnel infections, even though they were implanted in several patients in whom regular catheters with the exit on the abdomen would be difficult or impossible to implant. Two-year survival probability of presternal catheters was 0.95. Recurrent/refractory peritonitis was the only reason for catheter failure. The catheter is particularly useful in obese patients (body mass index >35), patients with ostomies, children with diapers and fecal incontinence, and patients who want to take baths without the risk of exit contamination. Many patients prefer presternal catheter because of better body image. Disadvantages of the presternal catheter are minimal. Compared with abdominal catheters, dialysis-solution flow is slightly slower because of the increased catheter length; however, slower flow is insignificant clinically. There is a possibility of catheter disconnection in the tunnel, but this complication is extremely rare in adults and easily corrected. Finally, the implantation technique is more challenging compared with that of single-piece, abdominal catheters.

Access-related complications in peritoneal dialysis in developing countries

Access-related complications differ considerably between acute and chronic peritoneal dialysis as a result of differences in catheter design, catheter material, number of cuffs, break in period, and the duration of peritoneal dialysis. Pain, which is the commonest complication of acute peritoneal dialysis, is seen in 56% to 75% followed by blood tinged dialysate effluent in 30%, pericatheter leak in 14% to 36%, catheter malfunction in 12% to 28%, bowel injury in 0.1% to 1.3%, rarely bladder injury and peritonitis in 2.5%. In chronic peritoneal dialysis, the incidence of exit-site infections are seen anywhere between 1 episode in 27.3 patients months to 1 episode in 41.9 patients months, and pericatheter leak is seen in 5.2%. Technique of exit-site care is variable in different countries, and regular use of mupirocin ointment at the exit site is practiced in different centers.