Epidemiology, management, and prevention of exit site infections in peritoneal dialysis patients

Abstract

Exit site infection (ESI) is a leading complication of peritoneal dialysis (PD), at an incidence of 0.6 episodes per year in the United States, and a major risk factor for catheter removal and peritonitis. An estimated 20% of all peritonitis cases are preceded by an ESI, with up to 50% of Staphylococcus aureus peritonitis associated with ESI. Gram-negative ESIs are less associated with succeeding peritonitis than their gram-positive counterparts, though when present, are associated with a lower peritonitis cure rate. The rate of catheter removal for refractory ESI is relatively highest in ESI due to mycobacteria (up to 40%), S. aureus (35%), Pseudomonas aeruginosa (28%), followed by Corynebacterium, Serratia, and fungi. In review of relevant literature, we found no prophylactic benefit of dressings over nondressings, specific antiseptics over normal saline, or topical honey over topical antibiotic prophylaxis, and thus recommend individualized exit site hygiene. We found

Efficacy of sucrose and povidone–iodine mixtures in peritoneal dialysis catheter exit-site care

“…As expected, the proportion of these patients was relatively high at 27.1%. Gram-positive bacteria were predominant in this study, consistent with findings in previous reports [ 5 , 19 , 33 ]. The details regarding the frequency discrepancy between peritonitis and ESI remain unclear.…”

“…In contrast, we recorded an incidence of all-cause peritonitis of 0.20 per patient-year, near the Japanese average, achieving the target recommended by the International Society for Peritoneal Dialysis (ISPD) of 0.40 [ 7 , 32 ]. Between 10 and 20% of all peritonitis cases have been estimated to be preceded by catheter infections, despite variations depending on the type of causative pathogen [ 33 , 34 ]. As expected, the proportion of these patients was relatively high at 27.1%.…”

Factors associated with time to first dialysis-associated peritonitis episode: Data from the Peritonitis Prevention Study (PEPS)

“…9,46 The low use of topical antibiotic exit-site prophylaxis in this study, which was likely a result of the fact that the health authorities in the Scandinavian and Baltic countries do not encourage long-term antibiotic prophylaxis, due to the risk of development of resistant bacterial strains, may also reduce the generalisability to other PD populations, in which antibiotic prophylaxis is more common. The incidence of exit-site infection, which is reported to vary broadly between studies from 0.1 to 1.2 episodes/patient-year, 47 was 0.28 episodes/patient-year in this study. The proportion of peritonitis episodes with a concomitant exit-site or tunnel infection of 10% in this study of appears to be low, as it has been estimated that 20% of all peritonitis episodes and up to 50% of S. aureus peritonitis are preceded by an exit-site infection.…”

“…The proportion of peritonitis episodes with a concomitant exit-site or tunnel infection of 10% in this study of appears to be low, as it has been estimated that 20% of all peritonitis episodes and up to 50% of S. aureus peritonitis are preceded by an exit-site infection. 47 In conclusion, the result of the present prospective study of incident CAPD and APD patients demonstrated that older age, higher number of PD bags connected per day, higher body weight and low serum albumin levels at baseline were independently associated with early peritonitis onset. This indicates a possible benefit of incremental PD, which starts with a lower PD dose, but such a strategy should be tested in further studies.…”

Reducing and treating peritoneal dialysis catheter-related infections: Nursing implementation from evidence to practice

“…6,17 In a review of the epidemiology of PD catheter exit-site infections, the authors also observed that there are no standard definitions for repeat, relapsing or recurring exit-site infections. 18 While such analogous classifications for PD-related peritonitis are well defined, 19 it would be beneficial for PD nurses to have classifications for PD catheter exit-site infections clearly defined. Serial monitoring and documentation of PD exit-site infections are part of PD nurses’ responsibilities, thus, a recommendation for a photographic record of a PD patient’s exit-site infection in a future guideline would be helpful, as it is quite common practice for monitoring wounds, 20 as mentioned in the 2017 Guidelines.…”