Infection In Peritoneal Dialysis Research Articles

Severe infections in peritoneal dialysis and home hemodialysis patients: An inception cohort study.

Infections are the most common non-cardiovascular cause of death among dialysis patients. Earlier studies have shown similar or higher risk of infectious complications in peritoneal dialysis (PD) compared to hemodialysis (HD) patients, but comparisons to home HD patients have been rare. We investigated the risk of severe infections after start of continuous ambulatory PD (CAPD) and automated PD (APD) as compared to home HD. All adult patients (n = 536), who were on home dialysis at day 90 from starting kidney replacement therapy (KRT) between 2004 and 2017 in Helsinki healthcare district, were included. We defined severe infection as an infection with C-reactive protein of 100 mg/l or higher. Cumulative incidence of first severe infection was assessed considering death as a competing risk. Hazard ratios were estimated using Cox regression with propensity score adjustment. The risk of getting a severe infection during the first year of dialysis was 35% for CAPD, 25% for APD and 11% for home HD patients. During five years of follow-up, the hazard ratio of severe infection was 2.8 [95% CI 1.6-4.8] for CAPD and 2.2 [95% CI 1.4-3.5] for APD in comparison to home HD. Incidence rate of severe infections per 1000 patient-years was 537 for CAPD, 371 for APD, and 197 for home HD patients. When excluding peritonitis, the incidence rate was not higher among PD than home HD patients. CAPD and APD patients had higher risk of severe infections than home HD patients. This was explained by PD-associated peritonitis.

Clinical guide of the Spanish Society of Nephrology on the prevention and treatment of peritoneal infection in peritoneal dialysis

Peritoneal infections still represent a most feared complication of chronic Peritoneal Dialysis, due to their high incidence and relevant clinical consequences, including direct mortality, technique failure and a significant burden for the health system. The practices for prevention and treatment of this complication show a remarkable heterogeneity emerging, among other factors, from the complexity of the problem and from a paucity of quality evidence which could permit to respond clearly to many of the raised questions. The purpose of this document is to provide a complete and updated review of the main methods of diagnosis, prevention and treatment of these infections. The document has been elaborated taking as a reference the most recent guidelines of the International Society of Peritoneal Dialysis (2016). The diagnostic considerations are presented in a narrative style while, for prevention and therapy, we have used a systematic methodology (GRADE), which specifies the level of evidence and the strength of the proposed suggestions and recommendations and facilitates future updates of the document. The length of the document and the many suggestions and recommendations coming out of the review underline the large number and the complexity of the factors to be taken into consideration for an adequate approach to this complication of Peritoneal Dialysis.

Non-tuberculous mycobacteria infections in peritoneal dialysis: Lessons from a 16-year single-centre experience

Dear Editor, Non-tuberculous mycobacteria (NTM) infections in peritoneal dialysis (PD) patients are uncommon, but they have been increasingly recognised as causes of morbidity. NTM are generally non-pathogenic, but given their abundance in the environment, they pose a threat to PD patients who have broken integument, indwelling devices and relative defects in cell-mediated immunity.1 The growth

First reported case of peritoneal dialysis infection with lactobacillus gasseri: when the body’s friend turns against its host

Summary
 We report a case of lactobacillus gasseri peritonitis in a patient treated by peritoneal dialysis.
 Streptococcus anginus and lactobacillus gasseri bacteria are commensal organisms of human oral, small intestinal, colic and vaginal mucous membranes. An infection with streptococcus anginosus during peritoneal dialysis, one responsible for an intra-abdominal abscess, has already been described, this type of streptococcus being widely associated with abscess formation. In contrast, no case of peritoneal infection with lactobacillus gasseri has ever been described. This bacterium is native to the mucous membranes, and colonizes the digestive tract of infants during childbirth, as they pass through the vaginal canal. It has local adaptation capacities, namely tolerance to acid pH, adhesion to the mucous membrane and resistance to bile salts. It is recognized as having an antimicrobial and probiotic function due to its production of bacteriocin, its local immunomodulatory role, its attenuation of the development of helicobacter pylori, its positive effect on the balance of the vaginal flora and its improvement of infectious diarrhea. This usually makes it an ally that contributes to our systemic balance but its irruption in the peritoneum has made it a pathogenic bacterium. The treatment of this peritoneal infection required a classic duration of treatment of organisms of digestive origin, i.e. 3 weeks

Study on the effect of peritoneal dialysis tube materials on chronic failure analysis related infection

The material membrane dialysis catheter is required for the reproduction of dermatobacteria and fruit. 20 cases of peritoneal dialysis were treated with antibacterial materials and distilled catheter. Compared with that of the control group, the skin level of the 16 expansion group was lower. At the second generation, it was a variety of Sphingomonas under the order of S. The difference of species abundance between groups is mainly the rare species in the control group. The results showed that the use of long-term materials in prevention and treatment of peritoneal dialysis infection has a beneficial long-term effect.

P1198CATHETER-RELATED INFECTIONS DUE TO SERRATIA SPECIES IN PATIENTS RECEIVING PERITONEAL DIALYSIS

Abstract Background and Aims Serratia species can cause catheter-related infections in peritoneal dialysis (PD) patients but data on this clinical entity remains limited. This study aims to investigate the clinical characteristics, antibiotics susceptibility/resistance profiles and treatment outcomes of Serratia catheter-related infections in PD patients. Method We retrospectively reviewed all PD patients who were followed up at Queen Mary Hospital and Tung Wah Hospital, Hong Kong between 2004 to 2017. Patients with Serratia exit site infection (ESI) or peritonitis were included for analysis. Results One hundred and seventy-three patients with Serratia catheter-related infections were included. 161 patients had ESI, of which 10 (6.2%) progressed to tunnel tract involvement and 11 (6.8%) developed PD peritonitis. Skin abnormalities surrounding the exit site were present in 58 patients (36%), and 40 patients (24.8%) were hospitalized within 1 month prior to Serratia ESI. 142 patients (88.2%) with ESI responded to medical therapy alone, and repeat ESI occurred in 56 patients (34.7%) at a median of 12 months. Twenty-two patients had Serratia peritonitis, which accounted for 1% of peritonitis during the study period. Concomitant intra-abdominal pathologies were detected in 12 patients (54.5%). Ten patients (45.5%) responded to medical treatment while the remaining 12 (54.5%) required catheter removal. Nine patients (36.4%) failed PD resumption and switched to chronic haemodialysis. Repeat peritonitis occurred in two patients at 2 months and 3 years after the initial episode respectively. While Serratia species in PD patients are generally susceptible to aminoglycosides, carboxy-/ureido-penicillins and carbapenems, they exhibit substantial rates of resistance to ampicillin, and 1st- and 2nd-generation cephalosporins. Conclusion Serratia ESI responds favourably to medical therapy and seldom progresses to tunnel tract infection or peritonitis. Serratia peritonitis is associated with considerable risk of catheter loss and peritoneal failure.

P1135WHETHER USPD PATIENTS ARE SUITABLE FOR INCREMENTAL PERITONEAL DIALYSIS:YES OR NO?

Abstract Background and Aims Incremental Peritoneal Dialysis (IPD) is the practice of initiating PD exchange less than four times a day in consideration of residual renal function (RRF). More clinical studies have confirmed the feasibility and effectiveness of IPD, especially in the protection of residual renal function, which is obviously superior to full-dose PD. Urgent-start peritoneal dialysis (USPD) is a popular PD method. Due to lack of pre-dialysis education, most of patients who were newly diagnosed with ESRD in China chose USPD. Well, can incremental peritoneal dialysis be used for USPD patients when starting dialysis? Compared to full-dose PD, whether incremental PD affects the residual renal function in USPD patients? Here we report the first study of incremental peritoneal dialysis’s effect on residual renal function. Method A retrospective analysis of medical records was performed on 169 patients who received USPD from August 2008 to March 2017. Patients were divided into 2 groups according to dialysis dose: incremental PD(i-PD) group (dialysis dose were less than or equal to 6000ml or 3 exchanges per day) and full-dose PD(f-PD) group (dialysis dose were great than or equal to 8000ml or 4 exchanges per day). The demographics, clinical biochemical indexes, dialysis dose, urine volume, dialysis ultrafiltration volume, RRF, dialysis adequacy, peritoneal dialysis infection complications, mechanical complications and survival rates were compared between two groups in 1 year follow-up. Results: (1).A total of 169 patients were enrolled, including 111 patients (average age 45.01±12.84 years) in i-PD group and 58 patients (average age 43.5±15.62 years) in f-PD group. The demographics and clinical biochemical indexes in the two groups before peritoneal dialysis were similar (P>0.05). (2).During the follow-up period, the dialysis dose in f-PD group(8034.48±262.61ml/d, 8080.00±395.80ml/d, 8155.17±523.21ml/d, 8051.72±906.55ml/d) were more than those in i-PD group(5891.89±528.31ml/d, 6159.57±1185.06ml/d, 6468.47±1588.71ml/d, 6900.90±1543.05ml/d), P<0.05. And the dialysis adequacy in both groups were up to standard: the total Kt/V (i-PD group: 1.96±0.56, 2.01±0.70, 2.02±0.55, 1.90±0.52; f-PD group: 2.18±0.47, 2.22±0.55, 2.05±0.44, 2.03±0.42) were greater than 1.7 and the total Ccr (i-PD group: 79.39±29.75, 79.02±25.11, 78.26±30.00, 73.09±29.14; f-PD group: 89.78±29.89, 91.54±35.56, 82.38±29.27, 72.96±23.75) were greater than 60L. (3).During the whole follow-up period, the residual renal function between two groups had no statistically significant(i-PD group: 3.96±2.52ml/min, 3.46±1.95ml/min, 3.58±2.85ml/min, 2.91±2.33ml/min; f-PD group: 4.31±4.83ml/min, 3.45±2.36ml/min, 3.16±2.15ml/min, 2.36±1.65ml/min), P>0.05. (4).During the whole follow-up period, the blood pressure control, correction of anemia, and correction of calcium and phosphorus abnormalities were also similar in both groups, P>0.05. (5).At 1-month and 6-month, the urine volume were higher in i-PD group(1024.33±492.91ml/d, 1017.03±571.66ml/d) than those in f-PD group(782.93±415.89ml/d, 788.27±491.02ml/d), P<0.05. The dialysis ultrafiltration volume in f-PD group (481.67±723.69ml/d, 632.77±687.89ml/d, 338.87±963.14ml/d, 750.43±849.69ml/d) were higher than those in i-PD group(343.30±520.00ml/d, 495.70±916.76ml/d, 341.78±925.57ml/d, 439.65±1297.13ml/d) during the whole follow-up period, but the differences were not statistically significant (P>0.05). (6).The exit-site infection, peritonitis, mechanical complications and technical survival were similar between the two groups (P>0.05). Conclusion Incremental peritoneal dialysis will not cause rapid decline of residual renal function in USPD patients, and the dialysis effect and complications are similar to full-dose peritoneal dialysis. Therefore, we recommend that USPD patients can be treated by incremental peritoneal dialysis.

Persistent exit-site infection in peritoneal dialysis - An unrecognized window to abdominal viscera.

Exit-site (ES) infection is a common complication in peritoneal dialysis (PD). Pseudomonas spp. is particularly difficult to treat, and catheter removal should be considered in persistent infections. The authors present a chronic ES infection resistant to directed antibiotic therapy in which catheter salvage was not possible. Removal was very difficult due to the presence of white sponge-like tissue with petrous consistency surrounding the catheter, all the way into the peritoneum. Histology revealed well-differentiated adenocarcinoma infiltrates. Abdominal computed tomography scan revealed a solid pancreatic (tail) lesion, nodular images on the greater epiploon, an adnexal lesion and a hepatic solid lesion, consistent with metastasis. The patient was referred for palliative care but maintained PD until untreatable pain and deterioration of general status aroused. Somewhere along the course of a chronic ES infection, the peritoneal catheter (and inflammation) was the metastatic path of an unknown pancreatic cancer, with neoplastic tissue reaching the skin. Catheter removal was crucial for diagnosis.

Exit site infection in peritoneal dialysis : predictive factors for adverse outcome

Infection-related complications in patients on peritoneal dialysis (PD) is a leading complication.
 Our aim was to evaluate the type and natural course of ESI events in a cohort of PD treated in last decade of our PD program.
 Registry data of ESI events (n=126, in 74 patients) were retrieved. ESI protocols followed standard international guidelines. A systematic quality control is performed.
 The median follow-up was 29.1 (14.0-47.4) months. In this population the adverse outcomes of TI rate and peritonitis rate was 0.12 and 0.13 patient/year, respectively. Male sex (0.048), older age (0.007) and Staphylococcus aureus (SA) agent (0.006) were predictive of TI while non-optional PD and lower levels of albumin were predictive of peritonitis. After grouping the ESI events according to the date of the occurrence of infection (group 1: 2008 to 2012, group 2: 2013 to 2017 and group 3: 2018) a substantial increase of TI in 2018 was evident (P <0.001 when comparing group 3 vs 1 and 0.005 when comparing group 2 and 3). When ESI occurs simultaneous with TI, the probability of not reaching cure is 65%. Drop-out occurred in 50% of ESI without peritonitis vs 86% with peritonitis (P <0.001). SA is the microorganism most implicated in the failure to heal (P 0.002) and drop-out (P 0.010).
 In spite of a number of efforts to reduce ESI, a regular audit still point to the need for protocols review in order to avoid adverse outcomes. Focused training of patients is mandatory but also prophylaxis and antibiotic protocols deserve improvement.

Peritoneal Dialysis Access Associated Infections.

Infection is a significant driver of morbidity and mortality in patients with end-stage renal disease undergoing maintenance dialysis. In the United States, septicemia and other infections account for 8% deaths in patients undergoing dialysis. In patients undergoing peritoneal dialysis (PD), PD-related peritonitis remains the most frequent treatment-related infection and is the greatest contributor to infection-related morbidity, including risk for hospitalization, and temporary or permanent transfer to hemodialysis. In the 4 decades since the introduction of ambulatory PD in clinical practice, a large number of treatment innovations have been shown to be effective in reducing the risk for exit site infection and PD-related peritonitis. Notwithstanding the evidence for efficacy of these innovations and the numerous adverse health consequences with PD-related peritonitis, the uptake of these interventions in clinical practice around the world remains inconsistent. This article reviews current knowledge with regards to prevention of PD-associated infections, and the diagnosis and management of exit site infections and peritonitis.

An “Atypical” Case of Exit Site Infection in Peritoneal Dialysis

An “Atypical” Case of Exit Site Infection in Peritoneal Dialysis

Deciphering the Contribution of Biofilm to the Pathogenesis of Peritoneal Dialysis Infections: Characterization and Microbial Behaviour on Dialysis Fluids.

Infections are major complications in peritoneal dialysis (PD) with a multifactorial etiology that comprises patient, microbial and dialytic factors. This study aimed at investigating the contribution of microbial biofilms on PD catheters to recalcitrant infections and their interplay with PD related-factors. A prospective observational study was performed on 47 patients attending Centro Hospitalar of Porto and Vila Nova de Gaia/Espinho to whom the catheter was removed due to infectious (n = 16) and non-infectious causes (n = 31). Microbial density on the catheter was assessed by culture methods and the isolated microorganisms identified by matrix-assisted laser desorption/ionization time-of-flight intact cell mass spectrometry. The effect of conventional and three biocompatible PD solutions on 16 Coagulase Negative Staphylococci (CNS) and 10 Pseudomonas aeruginosa strains planktonic growth and biofilm formation was evaluated. Cultures were positive in 87.5% of the catheters removed due infectious and 90.3% removed due to non-infectious causes. However, microbial yields were higher on the cuffs of catheters removed due to infection vs. non-infection. Staphylococci (CNS and Staphylococcus aureus) and P. aeruginosa were the predominant species: 32% and 20% in the infection and 43.3% and 22.7% in the non-infection group, respectively. In general, PD solutions had a detrimental effect on planktonic CNS and P. aeruginosa strains growth. All strains formed biofilms in the presence of PD solutions. The solutions had a more detrimental effect on P. aeruginosa than CNS strains. No major differences were observed between conventional and biocompatible solutions, although in icodextrin solution biofilm biomass was lower than in bicarbonate/lactate solution. Overall, we show that microbial biofilm is universal in PD catheters with the subclinical menace of Staphylococci and P. aeruginosa. Cuffs colonization may significantly contribute to infection. PD solutions differentially impact microbial species. This knowledge is important for the development of infection diagnosis, treatment and preventive strategies.

Tumor necrosis factor α is a risk factor for infection in peritoneal dialysis patients.

Background/Aims:It has been shown that circulating tumor necrosis factor α (TNF-α) is elevated in end stage renal disease patients; however, the relationship between TNF-α and the development of infection in these patients is unknown. In this study, we investigated the association of plasma TNF-α and interleukin 6 (IL-6) with infection in peritoneal dialysis (PD) patients. We also evaluated the association of their plasma levels with the production by peripheral blood mononuclear cells (PBMC), and with various clinical parameters.Methods:We enrolled 32 patients on maintenance PD and 10 healthy controls. Plasma and PBMC were isolated from blood. PBMC were stimulated with lipopolysaccharide in vitro.Results:Mean follow-up duration was 775 days. Six patients developed organ infections (five pneumonia and one liver abscess), and six patients developed PD peritonitis and eight developed exit site infection. Plasma TNF-α and IL-6 levels were significantly elevated in organ infections but not in peritonitis or in exit site infection. Plasma TNF-α was the only significant risk factor for organ infections and pneumonia in multivariate regression analysis. Patients with high plasma TNF-α levels showed a significantly greater cumulative hazard rate for organ infections compared to those with low TNF-α levels. Plasma TNF-α levels correlated with TNF-α production by PBMC and showed an inverse association with Kt/V.Conclusions:This is the first study showing that plasma TNF-α is a significant risk factor for infection in PD patients.

Assessment of current practice and barriers to antimicrobial prophylaxis in peritoneal dialysis patients.

Existing Australasian and international guidelines outline antibiotic and antifungal measures to prevent the development of treatment-related infection in peritoneal dialysis (PD) patients. Practice patterns and rates of PD-related infection vary widely across renal units in Australia and New Zealand and are known to vary significantly from guideline recommendations, resulting in PD technique survival rates that are lower than those achieved in many other countries. The aim of this study was to determine if there is an association between current practice and PD-related infection outcomes and to identify the barriers and enablers to good clinical practice. This is a multicentre network study involving eight PD units in Australia and New Zealand, with a focus on adherence to guideline recommendations on antimicrobial prophylaxis in PD patients. Current practice was established by asking the PD unit heads to respond to a short survey about practice/protocols/policies and a 'process map' was constructed following a face-to-face interview with the primary PD nurse at each unit. The perceived barriers/enablers to adherence to the relevant guideline recommendations were obtained from the completion of 'cause and effect' diagrams by the nephrologist and PD nurse at each unit. Data on PD-related infections were obtained for the period 1 January 2011 to 31 December 2011. Perceived barriers that may result in reduced adherence to guideline recommendations included lack of knowledge, procedural lapses, lack of a centralized patient database, patients with non-English speaking background, professional concern about antibiotic resistance, medication cost and the inability of nephrologists and infectious diseases staff to reach consensus on unit protocols. The definitions of PD-related infections used by some units varied from those recommended by the International Society for Peritoneal Dialysis, particularly with exit-site infection (ESI). Wide variations were observed in the rates of ESI (0.06-0.53 episodes per patient-year) and peritonitis (0.31-0.86 episodes per patient-year). Despite the existence of strongly evidence-based guideline recommendations, there was wide variation in adherence to these recommendations between PD units which might contribute to PD-related infection rates, which varied widely between units. Although individual patient characteristics may account for some of this variability, inconsistencies in the processes of care to prevent infection in PD patients also play a role.

Exit-Site Dressing and Infection in Peritoneal Dialysis: A Randomized Controlled Pilot Trial

♦ Peritoneal dialysis (PD)-related infection is a common cause of catheter loss and the main reason for PD drop-out. Exit-site infection (ESI) is a pathway to developing tunnel infection and peritonitis, hence rigorous exit-site care has always been emphasized in PD therapy. The aim of this study was to evaluate the effect of exit-site dressing vs non-dressing on the rate of PD-related infection. ♦ A prospective randomized controlled study was conducted in prevalent PD patients at the Hospital Tuanku Jaafar Seremban, Negeri Sembilan, Malaysia, from April 2011 until April 2013. All patients were required to perform daily washing of the exit site with antibacterial soap during a shower. In the dressing group (n = 54), patients were required to clean their exit site using povidone-iodine after drying, followed by topical mupirocin antibiotic application to the exit site. The exit site was then covered with a sterile gauze dressing and the catheter immobilized with tape. In the non-dressing group (n = 54), patients were not required to do any further dressing after drying. They were only required to apply mupirocin cream to the exit site and then left the exit site uncovered. The catheter was immobilized with tape. The primary outcome was ESI. The secondary outcomes were evidence of tunnel infection or peritonitis. ♦ A total of 97 patients completed the study. There were a total of 12 ESI episodes: 4 episodes in 4 patients in the dressing group vs 8 episodes in 4 patients in the non-dressing group. This corresponds to 1 episode per 241.3 patient-months vs 1 episode per 111.1 patient-months in the dressing and non-dressing groups respectively. Median time to first ESI episode was shorter in the non-dressing than in the dressing group, but not significant (p = 0.25). The incidence of gram-positive ESI in both groups was similar. There were no gram-negative ESI in the non-dressing group compared with 2 in the dressing group. The peritonitis rate was 1 per 37.1 patient-month in the dressing group and 1 per 44.4 patient-months in the non-dressing group. Median time to first peritonitis episode was significantly shorter in the dressing group compared to non-dressing (p = 0.03). There was no impact of dressing disruptions in the occurrence of major PD catheter-related infection. ♦ Use of a non-dressing technique with only prophylactic topical mupirocin cream application is effective in preventing PD-related infection. The non-dressing technique is more cost-effective and convenient for PD patients, with fewer disposables.

Peritoneal dialysis infections: An opportunity for improvement

Peritoneal dialysis (PD) catheter-associated infections remain a challenging cause of technique failure. Patient training and preventive measures are key elements in the management of infection rates. Twenty-seven of the 167 PD catheter transfer sets analyzed (19%) yielded a positive microbial culture (58% gram-negative bacteria). These results show that subclinical contamination, particularly from environmental gram-negative bacteria, is a potential hazard, indicating the need for a protocol for regular transfer set changes.

Ofloxacin Solution for Persistent Exit-Site and Tunnel Infection in Peritoneal Dialysis

Ofloxacin Solution for Persistent Exit-Site and Tunnel Infection in Peritoneal Dialysis

The clinical course of rapidly growing nontuberculous mycobacterial peritoneal dialysis infections in Asians: A case series and literature review

Peritoneal dialysis (PD)-related infections due to rapidly growing nontuberculous mycobacterium (RGNTM) are rare in Asians and have variable clinical outcomes. We analysed retrospectively a series of RGNTM infections in a single-centre multi-ethnic Asian population over a 5-year period. Clinical features, treatment, risk factors and outcomes are discussed. Ten infections are described. They constituted 3% of all culture-positive exit site infection (ESI) and PD peritonitis. Seventy percent were due to Mycobacterium abscessus (three ESI and four peritonitis). There were two Mycobacterim fortuitum and one Mycobacterium chelonei peritonitis. No specific findings differentiated RGNTM infections from those caused by traditional organisms. Six cases had received prior antibiotics, two being topical gentamicin. Initial routine culture and alcohol acid fast bacillus were negative except for one case of M. abscessus. A confirmatory diagnosis was made a median 9 days post culture. No infection responded to routine antibiotics. Antibiotic resistance was variable but M. abscessus was universally sensitive to clarithromycin. Combined antibiotics based on sensitivity profile were successfully used in 70% of the cases. PD catheter loss was 80%. Three-month mortality was 40% (vs. 8.5% and 12% in non-RGNTM ESI and peritonitis, respectively). This may be related to the cohort high mean Charlson score of 7.5. RGNTM PD infections are commoner in Asians than previously reported. Their early diagnosis requires a high index of suspicion and appropriate treatment started promptly. They are associated with prior antibiotic use and refractory culture-negative infections, delayed diagnosis and lead to significant catheter loss and death.

The Honeypot Study Protocol: A Randomized Controlled Trial of Exit-Site Application of Medihoney Antibacterial Wound Gel for the Prevention of Catheter-Associated Infections in Peritoneal Dialysis Patients

The primary objective of this study is to determine whether daily exit-site application of standardized antibacterial honey (Medihoney Antibacterial Wound Gel; Comvita, Te Puke, New Zealand) results in a reduced risk of catheter-associated infections in peritoneal dialysis (PD) patients compared with standard topical mupirocin prophylaxis of nasal staphylococcal carriers. Multicenter, prospective, open label, randomized controlled trial. PD units throughout Australia and New Zealand. The study will include both incident and prevalent PD patients (adults and children) for whom informed consent can be provided. Patients will be excluded if they have had (1) a history of psychological illness or condition that interferes with their ability to understand or comply with the requirements of the study; (2) recent (within 1 month) exit-site infection, peritonitis, or tunnel infection; (3) known hypersensitivity to, or intolerance of, honey or mupirocin; (4) current or recent (within 4 weeks) treatment with an antibiotic administered by any route; or (5) nasal carriage of mupirocin-resistant Staphylococcus aureus. 370 subjects will be randomized 1:1 to receive either daily topical exit-site application of Medihoney Antibacterial Wound Gel (all patients) or nasal application of mupirocin if staphylococcal nasal carriage is demonstrated. All patients in the control and intervention groups will perform their usual exit-site care according to local practice. The study will continue until 12 months after the last patient is recruited (anticipated recruitment time is 24 months). The primary outcome measure will be time to first episode of exit-site infection, tunnel infection, or peritonitis, whichever comes first. Secondary outcome measures will include time to first exit-site infection, time to first tunnel infection, time to first peritonitis, time to infection-associated catheter removal, catheter-associated infection rates, causative organisms, incidence of mupirocin-resistant microbial isolates, and other adverse reactions. This multicenter Australian and New Zealand study has been designed to provide evidence to help nephrologists and their PD patients determine the optimal strategy for preventing PD catheter-associated infections. Demonstration of a significant improvement in PD catheter-associated infections with topical Medihoney will provide clinicians with an important new prophylactic strategy with a low propensity for promoting antimicrobial resistance.

Nontuberculous Mycobacterial Peritonitis in a Patient Undergoing Continuous Ambulatory Peritoneal Dialysis

Non-tubercuous mycobacterial (NTM) infection in peritoneal dialysis (PD) patients has been rarely reported. We report a case of a 55-year-old female on continuous ambulatory peritoneal dialysis (CAPD). After a 2-year-history of recurrent exit-site infection of a PD catheter caused by Mycobacterium abscessus (M. abscessus), the patient was admitted to the hospital with signs of peritonitis. Since the same species, M. abscessus, was isolated from the CAPD effluent, multiple antibiotics were administered. However, the treatments could not relieve the symptoms of her infection. Consequently, the PD catheter was removed. Her condition gradually recovered over the course of subsequent, long-term, empirical antimicrobial therapies. NTMs, especially a rapidly growing NTM infection, have rarely been reported in PD patients and are commonly resistant to a variety of antimicrobial agents. Routine acid-fast staining is most likely helpful in promptly initiating treatment against NTM infection in PD patients. Moreover, an appropriate treatment regimen for a rapidly growing NTM infection should be established by accumulating data from cases as reported here.