Pseudomonasexit-site infection: treatment outcomes with topical gentamicin in addition to systemic antibiotics

Abstract

BackgroundAlthough, Pseudomonas exit-site infection (ESI) is recognized as a major complication of peritoneal dialysis (PD) with high risk of catheter loss due to refractory/recurrent infection or peritonitis, there is remarkably little literature about treatment outcomes. International Society for Peritoneal Dialysis guidelines advise the use of one to two antibiotics; in addition, we change standard exit-site care by stopping prophylactic mupirocin and starting regular use of gentamicin 1% cream.MethodsRetrospective review of outcomes of Pseudomonas ESI from January 2012 to March 2015.ResultsDuring the study period, a total of 135 patients were on PD with an overall incidence of any ESI of 0.36/patient-year. There were 14 patients with ESI episodes with Pseudomonas with a rate of 0.12/patient-year. In total, 13 of 14 patients with ESI episodes were treated with oral ciprofloxacin and/or intraperitoneal (IP) gentamicin or ceftazidime, plus topical gentamicin, with a success rate of 38% (5/13). One patient had gentamicin-resistant Pseudomonas species and was treated successfully with topical polymyxin/bacitracin cream. Median follow-up time in cured patients was 385 days (range 74–1107). Six patients had associated with Pseudomonas peritonitis, four during follow-up and two at initial presentation. Three patients had recurrent ESI with Pseudomonas, with one successfully re-treated with topical and IP gentamicin. In total, in only 50% of the patients was Pseudomonas ESI successfully treated. Five of the patients (36%) changed modality to permanent haemodialysis following catheter removal.ConclusionEradication of Pseudomonas ESI remains difficult even with the addition of topical gentamicin to the exit site. There should be a low threshold for catheter replacement.

Causative organisms and outcomes of peritoneal dialysis-related peritonitis in Sarawak General Hospital, Kuching, Malaysia: a 3-year analysis

“…As the number of patients with Pseudomonas peritonitis in current study was small, this remains an interesting observation and may be an area of future research. The superiority of either exit-site mupirocin or gentamicin in preventing PD peritonitis remains the subject of further investigation even though there are more evidence showing exit-site gentamicin to be associated with lower overall peritonitis rate [23,24].…”

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

“…Our analysis suggests that subcutaneous gentamicin injection around the cuff can be an important option in the treatment of PD patients with resistant ESI. The overall cure rate of 85% in our population was better than previously reported cure rates with different treatment methods 22–24. Therefore, subcutaneous gentamicin injection around the cuff is feasible for eradicating resistant ESI, as evidenced by the low incidence of recurrence of ESI after the procedure.…”

“…Bernardini et al showed that the daily application of the gentamicin cream to the exit site was effective in preventing the development of ESI by both gram-positive and gram-negative organisms 27. But the topical gentamicin cream did not show similar success rates in the treatment of pseudomonas ESI in Burkhalter et al’s study and the success rate of this treatment is not higher than 50%–60% 24. The biofilm formed by bacteria lowers the efficacy of the topical gentamicin in the treatment of ESI and systemic antibiotics cannot probably reach sufficient concentrations in the pericatheteral area in PD patients with ESI.…”

Exit-site Infections in Continuous Ambulatory Peritoneal Dialysis Patients, Taif, Saudi Arabia

“…In our study, found that E.coli was the most frequent Gram negative agent 12(23.5%), followed by P. aeruginosa 9(17.6%),while, P. aeruginosa was the most frequent Gram negative agent (8% -12%), followed by other Enterobacteriaceae (7% -14%).Felix et al (2015) found that, Pseudomonas ESI in PD patients from 135 patient presented in low range of 14(10.3%) (21). Chia et al (2014), found that Acinetobacter baumannii after 2000, was 9 (64%)was the most common species identified from the effluent, and the leading causes of infection were sterility break and GI microflora translocation (33).…”