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NATURE REVIEWS
|
NEPHROLOGY VOLUME 6
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MAY 2010
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259
NEWS & VIEWS
DIALYSIS
The importance of peritoneal
catheter exit-site care
Beth Piraino
The risk of peritonitis associated with infections of the peritoneal catheter
exit site can be reduced by the use of proper exit-site care, such as the
routine administration of prophylactic antibiotics at the exit site. Studies
that demonstrate the efcacy of such an approach or similar approaches
continue to be published.
A recently published study by Chua and
colleagues1 demonstrates the importance
of preventing peritoneal dialysis catheter
exit-site infections to decrease the risk of
peri tonitis in children on peritoneal dialysis
and the beneficial effect that an intervention
that successfully prevents such infections
has on reducing catheter loss. The research-
ers found that replacing the daily topical
applica tion of mupirocin to the peritoneal
dialysis catheter exit site with a daily proto-
col consisting of spraying sodium hypo-
chlorite solution on the peritoneal dialysis
catheter exit site for 1 min followed by the
topical application of mupirocin to the exit
site was advantageous. The dual protocol
reduced, in fact, the rate of exit-site infec-
tion from 1.36 to 0.33 episodes per year,
decreased the rate of peritonitis episodes
from 1.2 to 0.26 episodes per year, and elimi-
nated Pseudomonas aeruginosa peri tonitis.
The combination prophylactic proto col
reduced the rate of peritoneal catheter exit-
site infections caused by Staphylococcus
aureus to a very low rate of 0.03 episodes per
year. As a consequence of the reduction in
infection rates, the rate of peritoneal cath-
eter removal fell and catheter survival was
markedly enhanced in children treated with
the combination protocol. These results are
very impressive and should be achievable by
most peritoneal dialysis programs.
Infections associated with peritoneal
dialy sis are still a major problem in both
adults and children on peritoneal dialysis.
A recent report from Australia and New
Zealand, where exit-site prophylaxis is not
widely practiced, indicated that infection-
related deaths after 6 months on dialysis
were more common among patients on
peritoneal dialysis than among those
on hemodialysis.2 An increased risk of peri-
tonitis among patients on peritoneal dialy-
sis was the cause of the difference in death
rates. A recent audit from the UK, another
location where exit-site prophylaxis is not
commonly used, also showed that peri tonitis
continues to be a considerable problem with
peritoneal dialysis.3
Peritonitis has a number of possible
causes. In some cases this condition results
from the use of connectology or connec-
tion techniques that increase the risk of
contamina tion when the catheter is con-
nected to the dialysis solution. Choice of
the optimal connectology and the training
of patients are both important strategies for
reducing the risk of peri tonitis caused by
contamination. In some cases, the source
of the peritonitis is the bowel, possibly via
transmural migration of bacteria related to
constipation or bowel pathology; however,
little is known about how this pathway
leads to the development of peritonitis.
We know that particular dialysis programs
can, however, implement procedures that
reduce the risk of peri tonitis related to
colonization and subsequent infection of
the peritoneal dialysis catheter.4 Given the
lack of an approach to reduce the risk of
S. aureus colonization, this bacterium is the
major culprit of catheter-related peritonitis,
with P. aeruginosa being the second most
common organism responsible.5
The risk of S. aureus exit-site infections
can be reduced by implementing a protocol
to diminish colonization of the nares or the
peritoneal catheter exit site.6–8 In a random-
ized, controlled trial in which administra-
tion of oral rifampicin 300 mg twice daily
for 5 days every 3 months (a strategy that
reduces S. aureus colonization) was com-
pared with no prophylaxis, the exit-site
infection rate was markedly reduced (0.26
episodes per year versus 0.93 episodes
per year, respectively).6 In a subsequent
random ized, controlled trial that com-
pared the rifampicin protocol just described
with daily applications of mupirocin to the
exit site, S. aureus exit-site infection rates
were low (0.15 episodes per year versus
0.13 episodes per year, respectively).7 The
rifampicin protocol was associ ated with a
higher incidence of adverse events, which
makes topical mupirocin application at
the exit site the more desirable approach.
In a recent double-blind, randomized,
controlled trial, daily application of genta-
micin cream to the exit site was superior
to the application of mupirocin cream in
controlling exit-site infections (0.54 epi-
sodes per year versus 0.23 episodes per year,
respectively).8 Furthermore, the daily use of
gentamicin cream at the exit site was associ-
ated with lower rates of peritonitis (0.52
episodes per year versus 0.34 episodes per
year, respectively).
The use of antibiotic prophylaxis at the
peritoneal dialysis catheter exit site is widely
opposed by infectious disease specialists
who are concerned about the development
of resistance to rifampicin, mupirocin, and
gentamicin. Therefore, alternative prophy-
lactic agents should be sought. Whether
the addition of sodium hypochlorite spray
to mupirocin application will prevent the
development of mupirocin resistance is
unclear. Although no evidence of resis-
tance to mupirocin was noted after using
this agent for 6 years in the center in which
the study by Chua et al. was conducted,1
other peritoneal dialysis centers report the
emergence of such resistance after a decade
of mupirocin use.9,10 Intermittent usage
(that is, less than daily application) might
increase the risk of the development of
mupirocin resistance.10
The study by Chua et al. wa s not a
random ized, controlled trial but a retrospec-
tive chart review conducted to compare
clinical outcomes of two different proto-
cols implemented in successive time periods
within a single program.1 The first protocol,
with which 56 children were treated, con-
sisted of the daily application of mupirocin
to the exit site. This study design meant that
some children who were already on peri-
toneal dialysis when the protocol was initi-
ated were included in this group (prevalent
patients). Therefore, some of these children
may already have developed bacterial—
particularly S. aureus—colonization of the
peritoneal dialysis catheter. If the catheter’s
slime layer is already colonized, applica-
tion of mupirocin at the exit site may not
prevent infection. Such colonization before
‘‘
...exit-site care is extremely
important in preventing exit-site
infections and peritonitis...
’’
nrneph_N&V_MAY10.indd 259 8/4/10 10:36:25
© 20 Macmillan Publishers Limited. All rights reserved10
260
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may 2010
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volume 6 www.nature.com/nrneph
NEWS & VIEWS
implementation of prophylaxis might be
the reason why the rate of S. aureus exit-
site infection during the first time period
was relatively high (0.25 episodes per year).
By comparison, the S. aureus exit-site
infection rate in the mupirocin group in
Bernardini et al.’s double-blind, random-
ized, controlled trial was 0.06 episodes
per year.8 The study by Bernardini et al.
also included both prevalent and incident
patients, but all patients were on mupirocin
before randomization. In the study by Chua
et al., 52% of the patients included in the
group treated with the second (combina-
tion) prophylactic protocol had also been
treated with the first protocol involving
mupirocin application alone. The remain-
ing patients in the second protocol group
were incident patients who had started
peritoneal dialysis using prophylaxis. These
differences in the make-up of study groups
may in part explain why children treated
with the combination prophylaxis regimen
had a markedly lower S. aureus exit-site
infection rate (0.03 episodes per year) than
children treated with mupirocin alone. This
rate was very similar to the rate reported by
Bernardini et al. for the prophylaxis with
mupirocin alone (0.06 episodes per year).
Because of the study design, it is difficult to
ascertain the contribution of the addition
of the sodium hypochlorite spray on the
excellent outcomes.
What is very clear from the results of the
study by Chua et al. is that exit-site care is
extremely important in preventing exit-
site infections and peritonitis due to exit-site
infections, and in prolonging catheter sur-
vival.1 A future study of interest might
be a randomized, controlled trial of inci-
dent patients on peritoneal dialysis with
three arms: one arm treated with sodium
hypochlorite spray alone, one arm with
mupirocin applied to the exit site, and one
arm with gentamicin applied to the exit site.
The take-home message from Chua et al.’s
study is that protocols that use the combina-
tion of an antibiotic applied prophylactically
on a daily basis to the peritoneal dialysis
exit site together with an antiseptic are very
effective in preventing serious infections
in patients on peritoneal dialysis. Every
peri toneal dialysis program should adopt
a protocol that reduces the rate of exit-site
infection and peritonitis related to exit-
site infection. Effective protocols include
daily application of mupirocin to the exit
site from the start of peritoneal dialysis,
daily applica tion of mupirocin combined
with sodium hypochlorite spraying to the
exit site, and daily exit-site application
of gentamicin.
University of Pittsburgh School of Medicine,
Suite 200, 3504 Fifth Avenue, Pittsburgh,
PA 15213, USA.
piraino@pitt.edu
doi:10.1038/nrneph.2010.45
Practice points
Peritoneal dialysis-related infections
continue to be serious complications in
children and adults on peritoneal dialysis.
The rates of such infections can be reduced
if dialysis centers implement protocols that
reduce peritoneal catheter colonization and
infection.
Competing interests
The author declares no competing interests.
1. Chua, A. N., Goldstein, S. L., Bell, D. &
Brewer, E. D. Topical mupirocin/sodium
hypochlorite reduces peritonitis and exit-site
infection rates in children. Clin. J. Am. Soc.
Nephrol. 4, 1939–1943 (2009).
2. Johnson, D. W. et al. Associations of dialysis
modality and infectious mortality in incident
dialysis patients in Australia and New Zealand.
Am. J. Kidney Dis. 53, 290–297 (2009).
3. Davenport, A. Peritonitis remains the major
clinical complication of peritoneal dialysis:
the London, UK, peritonitis audit 2002–2003.
Perit. Dial. Int. 29, 297–302 (2009).
4. Swartz, R., Messana, J., Starmann, B.,
Weber. M. & Reynolds, J. Preventing
Staphylococcus aureus infection during chronic
peritoneal dialysis. J. Am. Soc. Nephrol. 2,
1085–1091 (1991).
5. Gupta, B., Bernardini, J. & Piraino, B. Peritonitis
associated with exit site and tunnel infections.
Am. J. Kidney Dis. 28, 415–419 (1996).
6. Zimmerman, S. W. et al. Randomized controlled
trial of prophylactic rifampin for peritoneal
dialysis-related infections. Am. J. Kidney Dis.
18, 225–231 (1991).
7. Bernardini, J., Piraino, B., Holley, J.,
Johnston, J. R. & Lutes, R. A randomized trial of
Staphylococcus aureus prophylaxis in peritoneal
dialysis patients: mupirocin calcium ointment
2% applied to the exit site versus cyclic oral
rifampin. Am. J. Kidney Dis. 27, 695–700
(1996).
8. Bernardini, J. et al. Randomized, double-blind
trial of antibiotic exit site cream for prevention
of exit site infection in peritoneal dialysis
patients. J. Am. Soc. Nephrol. 16, 539–545
(2005).
9. Pérez-Fontan, M., Rosales, M.,
Rodríguez-Carmona, A., Falcón, T. G. &
Valdés, F. Mupirocin resistance after long-term
use for Staphylococcus aureus colonization in
patients undergoing chronic peritoneal dialysis.
Am. J. Kidney Dis. 39, 337–341 (2002).
10. Annigeri, R. et al. Emergence of mupirocin-
resistant Staphylococcus aureus in chronic
peritoneal dialysis patients using mupirocin
prophylaxis to prevent exit-site infection. Perit.
Dial. Int. 21, 554–559 (2001).
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© 20 Macmillan Publishers Limited. All rights reserved10
