Peritoneal Dialysis Exit Site Care

Introduction

Catheter-related infection  is one of the most common peritoneal dialysis (PD)-related complications and can lead to peritonitis and exit-site infections (20%), permanent loss of peritoneal catheter (20%), and transfer to hemodialysis (15%-20%)(1). Therefore, the primary goal of exit-site care is to prevent infections in peritoneal dialysis. This article will discuss early exit-site care following peritoneal catheter insertion (post-operative care) and chronic exit-site care for chronic PD patients (routine exit-site care).

Early Exit-Site Care

Early exit site care starts following the peritoneal catheter insertion, and the goal is to prevent infection during healing period(2).   The usual practice after catheter implantation is to cover the exit site with several layers of sterile gauze. Gauze dressings are generally preferred because they pull the drainage away from the exit site. Transparent, occlusive dressings should not be used because drainage tends to pool at the exit site(3). Unless there is obvious bleeding or signs of infection, the initial surgical dressing should remain intact for 5 to 10 days. Dressing changes should be avoided in the immediate post-implantation period in order to minimize contamination and local trauma to the exit site(4). Additionally, it is recommended that nurses be trained on the use aseptic techniques, and apply these while changing the dressings once weekly until the exit site is completely healed(5,6). The catheter should be immobilized using dressing, tape, or with a specially designed device to prevent pressure injury around the exit site. Special care should be taken to avoid local trauma or bleeding from the exit site, as this may increase the risk for potential bacterial colonization(6). In addition, patients should be instructed to keep the exit site dry; submerging the exit site in water may cause exposure to water-borne pathogens and result in bacterial colonization. Thus, bathing and showering are not recommended until healing is complete, which may take two or more weeks(5). When cleansing the exit sites, non-cytotoxic agents such as normal saline or pure soap are recommended during early exit-site care. Antiseptic agents may be utilized as well; however, they should be non-cytotoxic because cytotoxic agents such as high concentration povidone iodine and hydrogen peroxide may cause tissue damage and delay wound healing. Finally, suture use at the exit site is contraindicated(5).

Patients should be advised to monitor the exit site for signs of exit-site infections (ESIs), which may include: redness, firmness, or tenderness of the skin around the catheter, and pus-like drainage from the exit site(4). In terms of switching from early exit-site care to routine care by the patient, the switch may occur once the exit site is completely healed or when it can classified as good or equivocal according to Twardowski’s exit-site evaluation and classification system(7).

Chronic Exit-Site Care

Chronic PD patients need to continue to monitor the exit site and perform routine care to prevent catheter infections. Initial patient education should include how to assess the exit site, including visual inspection and palpation of the tunnel, recognizing signs and symptoms of exit-site infection, and when to notify the PD unit of exit-site problems. Additionally, educating patients on aseptic techniques including proper hygiene and hand washing to prevent touch contamination is vital to the successful exit-site care. Use of 70% of alcohol-based hand rubs for 15 seconds is the most effective according to the U.S. Center for Disease Control and Prevention. However, visibly dirty hands must be washed with soap and water(5). It is recommended to wash the catheter exit sites daily with liquid or antibacterial soap. Povidone iodine every 2-3 days has also been shown to decrease infection rates when compared to daily nonbactericial soap and water(8). It is important not to forcibly remove crusts or scabs during cleansing because this may traumatize the exit, causing a break in the skin and increasing the risk of infection. Pat the exit site dry after cleansing. It is not necessary to use sterile gauze or cotton-tipped applicators for care of the healed exit; a clean washcloth and towel would work well. Sudden or extreme traction on the catheter should be avoided to prevent extrusion of the external cuff. The use of dressings may help keep the exit site clean, protect it from trauma, and help to stabilize the catheter(2,3,7,9). However, whether to wear a dressing or not is based solely on individual preference. A recent study showed that those who did not use dressings after daily cleansing had similar rates of exit-site infections compared to those who used dressing and performed daily cleansing(10).

Antibiotic Use in Exit-site Care

In order to provide appropriate exit-site care, antibiotic prophylaxis should be employed to reduce the risk of S. aureus and P. aeruginosa catheter infections. Antibiotics to prevent exit-site infections (ESI) may be selected based on the organisms that are being targeted, and typically are utilized daily during the course of exit-site care(11). According to the International Society for Peritoneal Dialysis (ISPD) guidelines, it is suggested that patients use one of the following protocols: a topical antibiotic cream applied at the exit site, an intranasal antibiotic, or a combination of both antibiotic protocols in order to maximize efficacy. However, it is important to note that topical antibiotic ointments, as opposed to creams, are not recommended for use at the exit site of polyurethane type catheters because they have the potential to cause spontaneous catheter rupture(6).

Conclusion

It is important to practice good exit-site care for prevention of catheter infections in peritoneal dialysis patients. Regardless of early or chronic care, proper hand hygiene and aseptic techniques should be emphasized to prevent touch contamination. In addition to aseptic techniques, routine antibiotics may be recommended by the physician to further prevent bacterial infections.

References

  1. Nunez-Moral M, Sanchez-Alvarez E, Gonzalez-Diaz I, Pelaez-Requejo B, Fernandez-Vina A, Quintana-Fernandez A, Rodriguez-Suarez C. Exit-Site Infection of Peritoneal Catheter is Reduced by the Use of Polyhexanide. Results of a Prospective Randomized Trial. Perit Dial Int. 2014;34(3):271-277. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=4033327&tool=p….
  2. Wadhwa NK, Reddy GH. Exit-Site Care in Peritoneal Dialysis. (Ronco C, Mishkin GJ, eds.). Basel: KARGER; 2006. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17099306.
  3. Gokal R, Alexander S, Ash S, Chen TW, Danielson A, Holmes C, Joffe P, Moncrief J, Nichols K, Piraino B, et al. Peritoneal catheters and exit-site practices toward optimum peritoneal access: 1998 update. (Official report from the International Society for Peritoneal Dialysis). Perit Dial Int. 1998;18(1):11-33. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9527026.
  4. Li PK-T, Szeto CC, Piraino B, Bernardini J, Figueiredo AE, Gupta A, Johnson DW, Kuijper EJ, Lye W-C, Salzer W, et al. Peritoneal dialysis-related infections recommendations: 2010 update. Perit Dial Int. 2010;30(4):393-423. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20628102.
  5. Piraino B, Bernardini J, Brown E, Figueiredo A, Johnson DW, Lye W-C, Price V, Ramalakshmi S, Szeto C-C. ISPD position statement on reducing the risks of peritoneal dialysis-related infections. Perit Dial Int. 2011;31(6):614-630. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21880990.
  6. Dombros N, Dratwa M, Feriani M, Gokal R, Heimbürger O, Krediet R, Plum J, Rodrigues A, Selgas R, Struijk D, et al. European best practice guidelines for peritoneal dialysis. 9 PD and transplantation. Nephrol Dial Transplant. 2005;20 Suppl 9:ix34-ix35. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16263751.
  7. Twardowski ZJ, Prowant BF. Classification of normal and diseased exit sites. Perit Dial Int. 1996;16 Suppl 3:S32-S50. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8860149.
  8. Segal JH, Messana JM. Prevention of peritonitis in peritoneal dialysis. Semin Dial. 2013;26(4):494-502. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23859192.
  9. Nikitidou O, Liakopoulos V, Kiparissi T, Divani M, Leivaditis K, Dombros N. Peritoneal dialysis-related infections recommendations: 2010 update. What is new? Int Urol Nephrol. 2012;44(2):593-600. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21744125.
  10. Mushahar L, Mei LW, Yusuf WS, Sivathasan S, Kamaruddin N, Idzham NJM. Exit-Site Dressing and Infection in Peritoneal Dialysis: A Randomized Controlled Pilot Trial. Perit Dial Int. 2016;36(2):135-139. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26374836.
  11. Bernardini J, Bender F, Florio T, Sloand J, Palmmontalbano L, Fried L, Piraino B. Randomized, double-blind trial of antibiotic exit site cream for prevention of exit site infection in peritoneal dialysis patients. J Am Soc Nephrol. 2005;16(2):539-545. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15625071.

P/N 102493-01 Rev. A 07/2016