Peritoneal Dialysis Cuff-Shaving—A Salvage Therapy for Refractory Exit-Site Infections

Abstract

Introduction Cuff-shaving has been described as a salvage technique for refractory exit-site infections, with conflicting data regarding infection and catheter outcomes. We describe our experience with cuff-shaving as a rescue therapy for exit-site infections unresponsive to systemic therapy. Methods We retrospectively reviewed patients who underwent cuff-shaving between January 2012 and June 2017. Refractory exit-site infection was defined as purulent discharge from the exit site with no clinical response after 3 weeks of systemic antibiotic treatment. Results Fifty-three cuff-shavings were included, mean age was 53.4 ± 13.4 years, 26 patients were male. Median dialysis vintage was 29 months (interquartile range [IQR] 14.3 – 38), and 39 (73.6%) were on continuous ambulatory peritoneal dialysis (CAPD). The exit-site infection rate before cuff-shaving was 1.12 episodes per patient-year and the median time from infection to shaving was 52 days (IQR 35 – 76). The most frequent agents were Staphylococcus aureus (34%), Corynebacterium spp. (17%) and Pseudomonas aeruginosa (15%). Median follow-up was 9 months (IQR 1 – 18.5), during which time 35 catheters were removed, 5 due to non-infectious reasons. Using the Kaplan-Meier survival analysis, median catheter survival was 24 months (95% confidence interval [CI] 4.17 – 43.83). At 12 months, the probability of catheter survival was 54% and was not statistically different between gram-positive and gram-negative agents, although it was significantly shorter for fungal agents. Conclusion Cuff-shaving is a feasible rescue therapy to treat refractory exit-site infections. In our experience, it allowed resolution of infections in a significant proportion of cases, except for fungal agents, and therefore extended catheter survival time, besides being associated with a small rate of complications.

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

“…This may suggest another source of the gramnegative peritonitis, such as bowel or touch contamination. Regardless of the bacteriologic cause, the presence of ESI was associated with a lower complete cure rate but not primary response rate in gram-negative peritonitis [40]. Approximately 2.8% of Enterococcus faecalis ESI and 12.8% of Serratia ESI were associated with catheter loss [9,41].…”

“…If no improvement is seen after 3 weeks of antibiotic therapy for any ESI, the infection is considered a refractory ESI [40]. Catheter replacement or removal is often considered for refractory ESI.…”

Simultaneous catheter removal and reinsertion, is it acceptable in M. abscessus exit site infection?

“…Additionally, prior reports have shown that M. abscessus ESI/TI can spread through the para-catheter route to cause peritonitis [20]. Together, these results suggest that while surgical interventions such as cuff shaving, deroofing, and SCRR may have promising outcomes in PD technique survival in otherwise uncomplicated ESI, these approaches appear inappropriate for M. abscessus ESI/TI [4,5,21].…”

Extrusion of both Superficial and Deep Cuffs of a Functional Double-Cuff Peritoneal Dialysis Catheter after Significant Weight Loss

“…No literature to date describes extrusion of the deep cuff in a still functional PD catheter. Extrusion of the superficial catheter cuff may require interventions such as cuff-shaving to increase the longevity of PD catheters and reduce the need for replacement of such catheters and prevent catheter-related infections [ 3 , 7 , 8 ].…”