Preventing Exit Site Infections

Peritoneal dialysis related infections continue to burden chronic PD patients, and are one the most common reasons for treatment failure. Without appropriate prophylaxis patient may suffer exit-site infection (ESI), which may progress into peritonitis and treatment failure. Therefore, ESI prophylaxis is vital part of patient care in PD.

Pharmacologic Prophylaxis – Use of Antibiotics

Local application of specific anti-Staphlococcus prophylaxis appears to have a substantial advantage over nonspecific local care and reduces the incidence of exit-site and tunnel infections, peritonitis, and subsequent catheter loss(1–5). Thus, patients with persistent Staphylococcus aureus (SA) nasal carriage could benefit from local antibiotic therapy. A recent study showed that persistent, but not intermittent S. aureus (SA) nasal carriage was the major determinant of PD-related infections and was associated with a significantly higher consumption of antibiotics. Incidence rate ratios (IRRs) for persistent carriers were: 3.52 for all-cause infection; 5.59 for exit-site infection and 2.19 for peritonitis(6). Some practitioners apply single or combination preparations (for example, combination antibiotic ointments, single-agent eye drops) in problematic cases(7,8). A randomized trial of SA prophylaxis comparing the efficacy of oral versus topical ointment therapy showed both regimens to be equally effective in reducing SA catheter infections(2). Another randomized, double-blind trial comparing topical antibiotic treatments for the prevention of ESIs showed that some may be superior to others with respect to the prevention of Gram-negative catheter infections and peritonitis(9). The authors state that caution must be exercised in view of increased fungal ESIs and the possibility of developing antibiotic resistance.

Notably, some studies indicate significant increases in certain types of antibiotic resistance that has resulted in an increased incidence of SA infection(10–16). This has raised concern about the use of antibiotic prophylaxis. The numbers of courses and constant therapy with PD have been identified as independent predictors of resistance(17). Therefore, caution must be exercised when using such therapy, especially in view of increased incidence of fungal ESIs.

References

  1. The Mupirocin Study Group. Nasal mupirocin prevents Staphylococcus aureus exit-site infection during peritoneal dialysis. Mupirocin Study Group. J Am Soc Nephrol. 1996;7(11):2403-2408. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8959632.
  2. Bernardini J, Piraino B, Holley J, Johnston JR, 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. 1996;27(5):695-700. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8629630.
  3. Thodis E, Bhaskaran S, Pasadakis P, Bargman JM, Vas SI, Oreopoulos DG. Decrease in Staphylococcus aureus exit-site infections and peritonitis in CAPD patients by local application of mupirocin ointment at the catheter exit site. Perit Dial Int. 1998;18(3):261-270. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9663889.
  4. Casey M, Taylor J, Clinard P, Graham A, Mauck V, Spainhour L, Brown P, Burkart J. Application of mupirocin cream at the catheter exit site reduces exit-site infections and peritonitis in peritoneal dialysis patients. Perit Dial Int. 2000;20(5):566-568. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11117248.
  5. Lim CT-S, Wong K-S, Foo MW-Y. The impact of topical mupirocin on peritoneal dialysis infection rates in Singapore General Hospital. Nephrol Dial Transplant. 2005;20(8):1702-1706. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15855200.
  6. Nouwen JL, Fieren MWJA, Snijders S, Verbrugh HA, van Belkum A. Persistent (not intermittent) nasal carriage of Staphylococcus aureus is the determinant of CPD-related infections. Kidney Int. 2005;67(3):1084-1092. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15698449.
  7. Piraino B, Bailie GR, Bernardini J, Boeschoten E, Gupta A, Holmes C, Kuijper EJ, Li PK-T, Lye W-C, Mujais S, et al. Peritoneal dialysis-related infections recommendations: 2005 update. Perit Dial Int. 2005;25(2):107-131. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15796137.
  8. Montenegro J, Saracho R, Aguirre R, Martínez I, Iribar I, Ocharán J. Exit-site care with ciprofloxacin otologic solution prevents polyurethane catheter infection in peritoneal dialysis patients. Perit Dial Int. 2000;20(2):209-214. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10809245.
  9. 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.
  10. Vasquez JE, Walker ES, Franzus BW, Overbay BK, Reagan DR, Sarubbi FA. The epidemiology of mupirocin resistance among methicillin-resistant Staphylococcus aureus at a Veterans’ Affairs hospital. Infect Control Hosp Epidemiol. 2000;21(7):459-464. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10926396.
  11. Schmitz FJ, Lindenlauf E, Hofmann B, Fluit AC, Verhoef J, Heinz HP, Jones ME. The prevalence of low- and high-level mupirocin resistance in staphylococci from 19 European hospitals. J Antimicrob Chemother. 1998;42(4):489-495. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9818748.
  12. Netto dos Santos KR, de Souza Fonseca L, Gontijo Filho PP. Emergence of high-level mupirocin resistance in methicillin-resistant Staphylococcus aureus isolated from Brazilian university hospitals. Infect Control Hosp Epidemiol. 1996;17(12):813-816. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8985770.
  13. Miller MA, Dascal A, Portnoy J, Mendelson J. Development of mupirocin resistance among methicillin-resistant Staphylococcus aureus after widespread use of nasal mupirocin ointment. Infect Control Hosp Epidemiol. 1996;17(12):811-813. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8985769.
  14. Watanabe H, Masaki H, Asoh N, Watanabe K, Oishi K, Furumoto A, Kobayashi S, Sato A, Nagatake T. Emergence and spread of low-level mupirocin resistance in methicillin-resistant Staphylococcus aureus isolated from a community hospital in Japan. J Hosp Infect. 2001;47(4):294-300. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11289773.
  15. Annigeri R, Conly J, Vas S, Dedier H, Prakashan KP, Bargman JM, Jassal V, Oreopoulos D. Emergence of mupirocin-resistant Staphylococcus aureus in chronic peritoneal dialysis patients using mupirocin prophylaxis to prevent exit-site infection. Perit Dial Int. 2001;21(6):554-559. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11783763.
  16. Lobbedez T, Gardam M, Dedier H, Burdzy D, Chu M, Izatt S, Bargman JM, Jassal S V, Vas S, Brunton J, et al. Routine use of mupirocin at the peritoneal catheter exit site and mupirocin resistance: still low after 7 years. Nephrol Dial Transplant. 2004;19(12):3140-3143. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15466881.
  17. Pérez-Fontán M, Rosales M, Rodríguez-Carmona A, Falcón TG, Valdés F. Mupirocin resistance after long-term use for Staphylococcus aureus colonization in patients undergoing chronic peritoneal dialysis. Am J Kidney Dis. 2002;39(2):337-341. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11840374.

P/N 102511-01 Rev A 07/2016