Topical application of mupirocin to exit sites in patients on peritoneal dialysis: a systematic review and meta-analysis of randomized controlled trials

Abstract

Background The International Society for Peritoneal Dialysis guidelines recommends the topical application of antibiotics on the exit site for the prevention of peritoneal dialysis (PD)-related infections. However, the recommendation is based on meta-analyses on applying nasal mupirocin ointment or observational or retrospective studies. Here, we evaluated the efficacy of topical application of mupirocin on the exit site for the prevention of PD-related infections. Methods We searched the databases, MEDLINE and CENTRAL, documenting the topical application of antibiotics on the exit site in PD patients in April 2017. We included only randomized controlled trials (RCTs) with adult patients wherein the effects of mupirocin were examined. Exit site infection (ESI), peritonitis, and technical failure were assessed as the main outcomes. Results Overall, six RCTs were included in this study. It was uncertain whether the application of mupirocin ointment prevents ESI (rate ratio (RR), 0.36; 95% CI, 0.13–1.05), peritonitis (RR 0.78, 95% CI 0.50–1.21), and technical failure (RR, 1.35; 95% CI, 0.25–7.21). Moreover, a comparison between mupirocin and gentamicin showed no difference in the incidence of ESI (RR, 1.14; 95% CI, 0.27–4.81), peritonitis (RR, 0.85; 95% CI, 0.32–2.26), and technical failure (RR, 0.58; 95% CI, 0.28–1.20). Conclusions It remains unclear whether topical application of mupirocin on the exit site has any significant effects on PD-related infection or technical failure. Large-scale RCTs with high methodological quality are required to confirm the efficacy of topical application of antibiotics on the exit site. Trial registration UMINR000039267

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

“…Two recent systematic reviews have investigated the use of prophylactic topical gentamicin against both S. aureus and P. aeruginosa (Table 3). Obata et al reviewed three randomized control trials (RCTs) comparing mupirocin versus gentamicin prophylaxis, and found no difference in the incidence of ESI between the two antibiotics [6]. Sixteen of 147 patients (10.9%) were found to be SA carriers: we found mupirocin-resistant strains (MuRSA) in four patients (25%).…”

“…However, recent literature suggests that the ISPD definition is sufficient to diagnose ESI, and such a clinical scale adds little diagnostic utility [4]. Concomitant tunnel infection is defined as clinical inflammation (erythema, edema, induration, or tenderness over the subcutaneous pathway) and/or ultrasonographic evidence of collection along the catheter tunnel [5,6]. Catheter-related infections can refer to either or both ESIs and tunnel infections.…”

“…If an ESI occurs within 3 weeks after completion of therapy for a prior ESI of a different organism, it is considered recurring ESI. Drawing from recent literature, if an episode occurs more than 3 weeks but less than 12 months after completion of therapy of a prior episode with the same organism, it would be considered a repeat ESI [6].…”

Análisis del uso de mupirocina en la cura del orificio sano en diálisis peritoneal

“…Sin embargo, esta recomendación contrasta con la frecuencia en la aplicación de antibiótico tópico, recomendándolo de manera diaria. Esta recomendación no está refrendada por la revisión sistemática de Obata Y. et al 12 de 2020, la cual explica que la ISPD basó las recomendaciones del uso diario de mupirocina en resultados que pueden dar lugar a una interpretación engañosa sobre el establecimiento de las directrices. Sus conclusiones exponen que no hubo evidencia suficiente para recomendar la aplicación rutinaria de antibióticos tópicos en el sitio de salida para la prevención de infecciones relacionadas con la diálisis peritoneal.…”

ISPD Catheter-related Infection Recommendations: 2023 Update

“…Obata and colleagues have recently completed an updated systematic review and meta-analysis of RCTs (six studies), examining topical exit site application of mupirocin compared to other exit site care interventions. 51 In contrast to previous findings of superior benefit compared to standard care, their systematic review demonstrated that it was uncertain whether the application of mupirocin ointment prevents exit site infection (RR 0.36, 95% CI 0.13–1.05). This analysis is limited by the moderately high level of heterogeneity ( I 2 = 61%, p = 0.07) between the studies.…”