Incidence Of Exit-site Infection Research Articles

A Prospective Randomized Study of the Effect of a Subcutaneously “Buried” Peritoneal Dialysis Catheter Technique versus Standard Technique on the Incidence of Peritonitis and Exit-Site Infection

A new method for implantation of peritoneal dialysis (PD) catheters was described in 1991. The distal part of the catheter is buried subcutaneously and exteriorized at the start of PD. This study was designed to evaluate the effect of such a subcutaneous rest period on the incidence of peritonitis and exit-site infections (ESI). Sixty patients were randomized to either the new method (B group; n = 30) or to not having the distal part buried subcutaneously (NB group; n = 30). Sixty-five patients (NS group) were not randomized as they had to start PD within 1-2 weeks after implantation. The Moncrief-Popovich catheter was used in the B and NB groups and a standard Tenckhoff catheter was used in the NS group. Patients scheduled for PD treatment, judged not in need of PD for at least 6 weeks after implantation. There was no statistically significant difference in the cumulative probability of not developing peritonitis during the first 6, 12, and 24 months. The incidence of the first episode of peritonitis was 1/40, 1/26, and 1/33 treatment-months in the B, NB, and NS groups, respectively. The incidence of ESI was 1/103 and 1/95 treatment-months in the B and NS groups, respectively. The cumulative probability of not developing ESI was similar in both groups. There were no episodes of ESI in the NB group. The difference in the number of ESI between the NB and NS groups was significant (p < 0.05). Subcutaneous burying of the distal catheter segment prior to starting PD does not reduce the risk of contracting peritonitis or exit-site infection.

Lack of efficacy of twice-weekly urokinase in the prevention of complications associated with Hickman catheters: a multicentre randomised comparison of urokinase versus heparin

Hickman catheters (HC) are associated with complications, in particular infection, occlusion and thrombosis. We tested the hypothesis that regular flushing of catheters with urokinase would reduce the frequency of these complications. Patients who required a double-lumen HC for (1) bone marrow or peripheral blood progenitor cell transplantation or (2) intensive combination chemotherapy for haematological malignancies were randomised to receive twice-weekly flushes of either urokinase (5000 units) or heparin (50 units). HC-survival analysis was determined by Cox regression. 100 patients were enrolled (urokinase=52; heparin=48) and treated for a mean of 8.5 weeks. No significant difference was observed in the incidence of HC-associated septicaemic events, which occurred in 8/52 in the urokinase group and 9/48 in the heparin group (actuarial incidence 20% versus 25%, P=0.50). Similarly, there was no differences in the incidence of exit site infections (urokinase=27/52 and heparin=28/48, P=0.122); HC-septic thromboses (urokinase=2/52 and heparin=4/48, P=0.34); lumen occlusion (urokinase=30/52 and heparin=30/48, P=0.681); or venous thrombosis (urokinase=8/52 and heparin=6/48, P=0.726). Overall, a high incidence of HC-related complications was seen in both groups; 40/52 in the urokinase group and 40/48 in the heparin group (actuarial incidence 80% versus 90%, P=0.367). Despite this only 18% of HC required early removal due to complications (urokinase=8, heparin=10). There was no difference in the incidence of complications in patients undergoing transplantation ( n=68) compared with chemotherapy alone ( n=32). Patients with haematological malignancies were more likely to have HC-related infective complications ( P=0.006), and patients with solid tumours more likely to have venous thrombosis ( P=0.027). The cumulative incidence of HC-related complications in this prospective study was higher than in previously reported series. Urokinase did not appear effective in reducing the frequency of these complications.

Laparoscopic implantation of Oreopoulos-Zellermann catheters for peritoneal dialysis.

For the implantation of continuous ambulatory peritoneal dialysis (CAPD) catheters, both the laparoscopic technique and the use of an Oreopoulos-Zellermann catheter have been suggested to be preferable to the open technique using Tenckhoff catheters. Building on advantages of known techniques, we here describe a procedure for the laparoscopic implantation of the Oreopoulos-Zellermann catheter. The procedure is quick, efficient and unstressful to the patient. After nearly 10,000 patient-days of catheter use, we find positive results with regard to permanently good inlet and outlet flows, low incidence of exit site infections and leaks from the catheter tunnel.

Nosocomial coagulase-negative staphylococcal infections in bone marrow transplantation recipients with central vein catheter. A 5-year prospective study.

The purpose of this study was to examine coagulase-negative staphylococcal infections in bone marrow transplantation (BMT) patients with central vein catheters by investigating incidence, clinical relevance, risk factors, methicillin resistance, clinical impact of initial empiric antimicrobial therapy without vancomycin, and management of documented catheter-related infections. A 5-year prospective study was conducted with daily evaluation of 242 BMT patients during hospitalization, including clinical assessment and blood culture via the Hickman/Broviac catheter. If fever or infected appearance occurred, peripheral blood cultures or exit site cultures, respectively, were done. Results showed a septicemia incidence of 7.0%, including in 6 patients following colonization, in 1 patient with tunnel infection, in 1 patient with thrombophlebitis, in 1 patient with exit site infection, and in 8 patients with septicemia of unknown origin. Total colonization incidence was 7%, with colonization only in 11 patients who had 16 episodes; incidence of exit site infection was 3.7%. Age > or = 18 years was the only identified risk factor for developing staphylococcal infection (P = 0.03). Despite a methicillin resistance rate of 45% and omission of vancomycin from the routine initial empiric antimicrobial regimen, the clinical course of coagulase-negative staphylococcal infections was relatively benign. A single patient, who experienced marrow rejection, died on day +31 with septicemia and only one patient experienced microbiological failure with recurrent colonization. Bacteria grown in both aerobic and anaerobic bottles were more likely true bacteremia than contaminant (P = 0.03). We conclude that the hazard of coagulase-negative staphylococcal infection does not mandate inclusion of a glycopeptide in the initial empiric antimicrobial regimen in BMT patients, even during febrile neutropenia. Hickman/Broviac-related staphylococcal infections, except for tunnel infection or thrombophlebitis, can usually be treated successfully without removing the catheter.

Four-year experience with swan neck presternal peritoneal dialysis catheter

The swan neck presternal catheter is composed of two flexible (silicon rubber) tubes joined by a titanium connector at the time of implantation. The exit site is located in the presternal or parasternal area. The catheter located on the chest was designed to reduce the incidence of exit site infections compared with peritoneal dialysis catheters with abdominal exit sites. From August 1991 to May 1995, 24 swan neck presternal catheters have been implanted in 24 patients for the following reasons: obesity nine patients, ostomies three patients, a suprapubic catheter one patient, previous problems with abdominal catheters two patients, desire to use a bathtub five patients, need to use a whirlpool one patient, need to wear sweatpants with an elastic waistband one patient, and body image two patients. In the same period, 47 abdominal swan neck catheters were implanted in 44 patients who preferred catheters with the exit on the abdomen. Presternal catheters tended to perform better 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 0.88 ± 0.14 (±SE). Recurrent/refractory peritonitis was the only reason of catheter failure. The differences in results between presternal and abdominal catheters were statistically insignificant; only the use of antibiotics to treat exit site infection was significantly higher with abdominal catheters. Patient acceptance of the exit position was good; at least seven patients preferred presternal catheter for psychological or body image reasons. We conclude that the swan neck presternal catheters provide excellent results comparable to those achieved with swan neck abdominal catheters. The catheter seems suitable for any patient commencing peritoneal dialysis and is particularly useful in extremely obese patients (body mass index >40 kg/m 2) and those with ostomies. The catheter exit location in the chest may be preferred by some patients, both men and women, for psychological or body image reasons. No specific contraindications to the presternal catheter implantation have been identified.

Exit-Site Infection during Continuous and Cycling Peritoneal Dialysis in Children

A 10-year retrospective review of pediatric patients on peritoneal dialysis showed that 50 of 83 had 132 episodes of exit-site infection (ESI). Thirty-nine episodes were purulent. The most prevalent organism was Staphylococcus aureus. Staphylococcus epidermidis was also common, usually occurring in purulent infections. Gramnegative organisms were responsible for 23 ESls, with Pseudomonas species being the most common. Age, sex, concomitant primary disease type, length of training, dressing techniques, quality of daily dialysis technique, use of diapers, and pyelostomies did not affect the incidence of ESI. However, 40% of children with a skin infection from other sites had associated peritoneal catheter ESI. Thirty-eight episodes of ESI in 28 patients resulted in peritonitis; the main organisms involved were Staphylococcus and Pseudomonas species. Catheters were replaced in 13 patients with peritonitis, but there was no difference in the incidence of ESI before and after catheter replacement.

Exit-Site Infection during Continuous and Cycling Peritoneal Dialysis in Children

A 10-year retrospective review of pediatric patients on peritoneal dialysis showed that 50 of 83 had 132 episodes of exit-site infection (ESI). Thirty-nine episodes were purulent. The most prevalent organism was Staphylococcus aureus. Staphylococcus epidermidis was also common, usually occurring in purulent infections. Gram-negative organisms were responsible for 23 ESIs, with Pseudomonas species being the most common. Age, sex, concomitant primary disease type, length of training, dressing techniques, quality of daily dialysis technique, use of diapers, and pyelostomies did not affect the incidence of ESI. However, 40% of children with a skin infection from other sites had associated peritoneal catheter ESI. Thirty-eight episodes of ESI in 28 patients resulted in peritonitis; the main organisms involved were Staphylococcus and Pseudomonas species. Catheters were replaced in 13 patients with peritonitis, but there was no difference in the incidence of ESI before and after catheter replacement.

The Influence of Peritoneal Catheter Exit-Site Infections on Peritonitis, Tunnel Infections, and Catheter Loss in Patients on Continuous Ambulatory Peritoneal Dialysis

The importance of exit-site infections (ESIs) as a source of peritonitis and catheter loss in continuous ambulatory peritoneal dialysis (CAPD) patients is unknown. We collected data on 137 CAPD patients over a 5-year period (2,052 cumulative patient months). Patients with a history of ESIs were more likely to have peritonitis and tunnel infections than patients without a history of ESIs. A larger percentage of patients with a history of ESIs lost catheters and transferred to hemodialysis than those without such a history, independent of the effect of peritonitis. These data confirm the importance of reducing the incidence of ESIs. More information is needed to determine the nature of the relationship between ESIs and peritonitis.