Treatment Of Exit-site Infections Research Articles

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.

Subcutaneous gentamicin injection around the cuff in treatment of resistant exit site infection in peritoneal dialysis patients: a pilot study.

Background/purposeOne of the most common complications of the peritoneal dialysis (PD) is the infection of the exit site of the peritoneal catheter. The aim of the present study was to evaluate the efficacy of the subcutaneous gentamicin injection around the cuff as a part of routine treatment of the resistant exit site infection (ESI).MethodsIf the exit site remains infected after a 2-week systemic antibiotics treatment, it is defined as resistant ESI. In these cases, systemic antibiotics were discontinued and a subcutaneous 40-mg gentamicin injection was administered around the external cuff of the PD catheter every 3 days. A total of three or four injections were given to each patient.ResultsA subcutaneous gentamicin injection was administered around the cuff in thirteen patients for the treatment of resistant ESI over a 2-year period. The median follow-up time in cured patients was 12 months. Eleven of the thirteen patients had been apparently cured of their resistant ESI, with no recurrence. None of the patients had a gentamicin-resistant species. Subcutaneous gentamicin-related adverse effect was not observed in any patient.ConclusionSubcutaneous gentamicin injection around the cuff is a well-tolerated and effective strategy for treating resistant ESI. To gain widespread approval of this therapy and reach a consensus about ESI management, additional studies are needed.

Peritonitis in children on chronic peritoneal dialysis; experience from a paediatric nephrology centre

Aim To determine variation in clinical manifestations, antibiotic sensitivity, patterns of causative organisms and the outcomes of bacterial peritonitis in children in our institution. Methods This retrospective study population included all those children who developed chronic peritoneal dialysis (CPD) related peritonitis during October 2005–February 2008 at Children Kidney Centre at UHW, Cardiff. The parameters collected were age, presenting symptoms, presence of exit site infection/tunnel infection, nature of peritoneal effluent (PE) at presentation and at 72 h after treatment, type of organism grown, antibiotics sensitivities, response to treatment and outcome. Results Out of 15 patients who were on CPD during 3 years of the study period, 10 patients developed a total of 15 episodes of peritonitis. Risk factors for peritonitis were presence of gastrostomy, use of diapers and exit site infections. Main presenting features were PE with WBC count >100 (87%), abdominal pain and fever (53%), turbid PE and vomiting (40%). Organisms were grown from PE in 13 (86%) episodes and culture was negative in two. Gram positive (GP) organisms accounted for 47%, gram negative (GN) for 27% of episodes and mixed organisms and candida found in one episode each. 86% of GP organisms were sensitive to a glycopeptide and 75% of GN organisms were sensitive to ceftazidime/gentamicin. 10 episodes showed good response to therapy, four episodes improved following removal of PD catheter and one patient died due to Staphylococcus aureus sepsis. Discussion and Conclusions The children with gram negative peritonitis were younger than those who developed gram positive peritonitis. Abdominal pain was common in peritonitis caused by staph aureus, streptococcus and Gram negative organisms. Fever and turbid PE were more likely with Gram negative peritonitis. With appropriate antibiotic therapy, supportive treatment and PD catheter removal where indicated, good clinical improvement was seen in all patients except one (93%). Peritonitis due to staph aureus, pseudomonas and candida were more likely to need PD catheter removal. Those who ultimately need PD catheter removal are more likely to have associated exit site infection, more symptomatic, are culture (effluent) positive and show unsatisfactory response after 72 h of therapy. Strategies to prevent CPD related peritonitis include early detection and treatment of exit site infection, appropriate care of gastrostomy site, optimum placement of PD catheter and avoiding nappy area for catheter exit site in infants. Early detection and prompt initiation of appropriate therapy is essential for a favourable outcome.

Risk Factors for Yeast Superinfection in the Treatment of Suspected Exit Site Infections: A Case-Control Study

Purpose The risk of infection can be reduced in hemodialysis (HD) patients with central venous catheters (CVCs) by using prophylactic intranasal mupirocin or polysporin at the exit site. However, there are concerns about the potential emergence of resistant microorganisms. The purpose of our study was to determine if the use of polysporin double in the treatment of exit site infections was associated with the emergence of yeast positive exit site cultures. Methods In this case control study, we evaluated the risk of developing yeast positive exit site cultures after introducing a polysporin medical directive for the treatment of presumed exit site infections in our HD units. All HD patients using a CVC for blood access at the Ottawa Hospital were eligible for study. Demographic variables, use of polysporin, antibiotics and immunosuppressive medications were compared between those patients with yeast positive exit site cultures and controls. Results There was no differences in age, gender or diabetic status between the cases and controls. However, the use of polysporin, antibiotics and immunocompromised status were associated with an increased risk of yeast positive exit site cultures. The relative importance of each of these factors could not be determined using this study design and requires future prospective study. Conclusions The emergence of yeast positive exit site cultures after the introduction of a new medical directive at a tertiary care hospital highlights the difference between medications used for prophylaxis and those used for treatment of CVC infections in high risk dialysis patients.

Peritoneal dialysis. Prevention and control of infection.

In spite of the reduction in peritonitis and catheter-related infection rates in patients undergoing peritoneal dialysis, these infections remain major sources of morbidity and transfer to haemodialysis. Touch contamination at the time of doing the exchanges is still a major cause of peritonitis and leads to Gram-positive organisms (coagulation-negative staphylococcus) being the most common pathogens. Newer exchange techniques have reduced this incidence but the more serious pathogens (Staphylococcal aureus, pseudomonas and fungi) remain a major problem. Treatment has to be immediate, and hence empirical, giving adequate cover for both Gram-positive and Gram-negative organisms. The use of vancomycin as an initial antibacterial has been discontinued because of the problem of vancomycin-resistant enterococcus. Recent guidelines advocate the use of a first generation cephalosporin combined with ceftazidime (if the urine output is >100 ml/day) or an aminoglycoside in anuric patients. Subsequent therapy changes are made upon bacterial isolation and sensitivities. Vancomycin is reserved for methicillin-resistant staphylococcus. Peritoneal catheter-related infections (exit site and tunnel) are predominantly caused by S. aureus and pseudomonal organisms and can be difficult to eradicate. Tunnel infections invariably involve the catheter dacron cuffs and therefore are more likely to lead to peritonitis; in this situation catheter removal is the treatment of choice. Treatment of exit-site infections is with oral antibacterials (penicillinase-resistant penicillins, cefalexin). Vancomycin is avoided if possible. The identification that nasal carriage of S. aureus predisposes to exit-site and tunnel infections has led to prophylactic regimens to combat this problem. Mupirocin applied at the exit site leads to a reduction in catheter-related infections and peritonitis.

A Randomized Prospective Study of the Cost -Effectiveness of the Conventional Spike, O-Set, and Uvxd Techniques in Continuous Ambulatory Peritoneal Dialysis

To compare the clinical outcome and cost-effectiveness of three techniques for continuous ambulatory peritoneal dialysis (CAPD): the conventional spike technique (C), the O-set (O), and UVXD (U, ultraviolet irradiation connection box). A randomized and prospective comparison of three CAPD techniques. A tertiary referral and a satellite dialysis center. One hundred patients with end-stage renal failure between 10 and 70 years of age, with good hand-eye coordination and not anticipated to receive a living related transplant within 6 months. Patients were randomized by referral to a table of random numbers to perform one of the three CAPD techniques. Training time, details of peritonitis and exit-site infection (ESI) including the costs of antibiotic treatment, outpatient visits, hospital stays, technique, and patient survival were analyzed after a minimum follow-up period of one year. There were 38, 31, and 31 patients in groups C, O, and U, respectively, and the total observation periods were 838, 802, and 745 patient-months, respectively. The peritonitis rates for C, O, and U were 21.5, 30.8, and 29.8 patient-months/episode, respectively. The corresponding ESI rates were 16.4, 14.9, and 24 patient-months/episode, respectively. When the time from the commencement of CAPD to the first infection was expressed using the Kaplan-Meier life table analysis, 39.5%, 67.7%, and 61.3% of patients in Groups C, O, and U were free from peritonitis at one year (p = 0.088). The corresponding figures for ESI were 52.6%, 48.4%, and 61.3% (p = 0.35). There was no significant difference in technique survival in the three treatment groups. An analysis of the costs related to the use of antibiotics, outpatient visits, and hospital stays necessary for the treatment of peritonitis and ESI and those related to training time, additional equipment, and consumables required for the three CAPD techniques showed that, overall, the cost in O was the lowest, followed by U and C (U.S. $158, $170, and $179 per patient-month, respectively). It was concluded that the O-set is a more cost-effective CAPD technique than UVXD, while both are more cost-effective than the conventional spike technique.

Antimicrobial therapy for CAPD-associated peritonitis.

Infectious peritonitis continues to be the leading cause of morbidity in patients on continuous ambulatory peritoneal dialysis (CAPD). Optimum management of CAPD-associated peritonitis requires a concerted effort toward the establishment of the specific agent causing the episode. We have reviewed the current literature relating to the diagnosis and institution of antimicrobial therapy. Controlled comparative trials are needed to determine the efficacy of potentially less toxic therapeutic regimens for peritonitis, for definition of and treatment of exit-site infections, and timing of catheter replacement.