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Clinical |
Division of Nephrology and Dialysis,1 Department of Medicine VI, Wilhelminenspital, Vienna; Nephrology and Hypertensiology,2 University Hospital of Medicine IV, Medical University of Innsbruck; Division of Nephrology and Dialysis,3 Department of Medicine, Landeskrankenhaus Feldkirch; Division of Nephrology and Dialysis,4 Third Department of Medicine, Krankenhaus der Barmherzigen Schwestern vom Hl. Kreuz, Wels; Clinical Division of Nephrology and Dialysis,5 Medical University of Graz; Division of Nephrology and Dialysis,6 First Department of Medicine, A.ö. Krankenhaus St. Pölten; Division of Nephrology and Dialysis,7 Department of Medicine III, Medical University of Vienna, Austria
Correspondence to: A. Vychytil, Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria. andreas.vychytil{at}meduniwien.ac.at
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ABSTRACT |
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 TOP ABSTRACT PATIENTS AND METHODSRESULTSDISCUSSIONDISCLOSUREREFERENCES |
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Background: Catheter-associated infections markedly
contribute to treatment failure in peritoneal dialysis (PD) patients. There is
much controversy surrounding prophylactic strategies to prevent these
infections. Methods: In this nationwide multicenter study we
analyzed strategies to prevent catheter-associated infections as performed in
Austrian PD centers in 2006. A questionnaire was sent to all 23 PD centers in
Austria. Results: Ten different catheter models were used in the
332 patients being treated in the 23 Austrian PD centers. Systemic antibiotics
prior to catheter placement were given by 17 of the 23 PD centers
(glycopeptides, n = 7; cephalosporins, n = 10). Nasal swabs
were taken preoperatively by 17 PD centers; nasal Staphylococcus
aureus carriers were treated prophylactically with mupirocin cream in 15
of these centers. Dressing change was routinely performed in 318 of 332
chronic PD patients (nonocclusive film dressing, n = 58; gauze
dressing, n = 260). Disinfectants for chronic exit-site care included
povidone iodine (n = 155), sodium hypochlorite (n = 31),
povidone iodine + sodium hypochlorite together (n = 102), and
octenidine dihydrochloride/phenoxyethanol (n = 17). Water +
non-disinfectant soap or 0.9% sodium chloride was administered as a cleansing
agent to the exit site by 27 patients. Routine S. aureus screening
(nasal and/or exit-site swabs) in chronic PD patients was performed in 12 PD
centers; carriers were treated with mupirocin cream in 11 of these centers.
Dialysis staff members were screened for S. aureus in 8 PD centers
and spouses were screened for S. aureus in 5 PD centers. The overall
exit-site infection rate was 1 episode/43.9 patient-months, tunnel infection
rate was 1 episode/88.9 patient-months, and peritonitis rate was 1
episode/51.0 patient-months. Patients of centers that have installed a
prophylaxis protocol for treating S. aureus carriers had lower mean
infection rates compared with those not using such a protocol. Conclusion: Various individual prophylactic strategies
are used to prevent catheter-associated infections in Austrian PD centers.
Infection rates are within the range reported in the literature. There is
still scope for improvement in some centers (e.g., by establishing a
prophylaxis protocol).
KEY WORDS: Exit-site infection; tunnel infection; povidone iodine; sodium hypochlorite; tunnel ultrasonography; mupirocin; film dressing; gauze dressing.
Catheter-associated infections are strong contributors to treatment failure in peritoneal dialysis (PD) patients. Therefore it is essential to prevent catheter-associated infections both early after PD catheter placement and during chronic PD treatment. While several trials showed that prophylactic therapy with antibiotic cream applied to the nose or to the exit site significantly decreased the rate of catheter-associated infections in PD patients (1–4), other recent PD guidelines focusing on peritoneal access management are based on a low level of evidence (5). In this latter situation, observational experience may be the only means to clarify the significance of certain therapeutic strategies. The aim of this study was to analyze strategies currently in use for PD catheter placement and acute and chronic exit-site care nationwide in all 23 Austrian PD centers. Furthermore, these strategies are discussed in the light of recently published international recommendations.
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PATIENTS AND METHODS |
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TOPABSTRACTPATIENTS AND METHODSRESULTSDISCUSSIONDISCLOSUREREFERENCES |
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65 years: 27.9%); 41.6% of the patients were female and 20.7% were
diabetic. The questionnaire included the following items: type of PD catheters
used, method of implantation, preoperative antibiotic prophylaxis and
Staphylococcus aureus screening, duration of break-in period after PD
catheter insertion, first dressing change after operation, type of dressing
and topical antiseptics/antibiotics used in chronic PD patients, screening for
and eradication of S. aureus in chronic PD patients, frequency of
dressing changes, recommendations to use face masks and to screen staff
members and/or spouses for S. aureus carriage, recommendations for
lifestyle activities of PD patients, and strategies to diagnose and treat
catheter-associated infections. All PD-associated infections (exit-site
infection, tunnel infection peritonitis) that occurred in these patients
between 1 January 2006 and 31 December 2006 were recorded. Definitions of
exit-site infection, tunnel infection, and peritonitis were left to each
investigator and were dependent on each center's standard practice. A relapse
was defined as an infectious episode with the same organism or a sterile
episode that occurred within 4 weeks of completion of antibiotic therapy of a
prior episode. Since the objective of this study was to evaluate center strategies rather than individual risk profiles for infection, no personal demographic data other than age, gender, diagnosis of diabetes, and treatment modality were requested. Final responses were received from all 23 centers by 20 March 2007.
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RESULTS |
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TOPABSTRACTPATIENTS AND METHODSRESULTSDISCUSSIONDISCLOSUREREFERENCES |
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Systemic antibiotics prior to catheter placement were given in 17 of 23 centers (Figure 1). Nasal swabs were taken preoperatively by 17 centers; nasal S. aureus carriers were treated prophylactically with mupirocin cream in 15 of these centers. Two centers did not treat nasal S. aureus carriers with local antibiotic agents preoperatively but intensified general care and hygienic measures during dressing changes in this situation (e.g., using face masks).
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Postoperative dressing changes were performed by renal nurses in 13 centers and by renal nurses and physicians together in 10 centers. In 18 centers, gloves were used for postoperative dressing changes (sterile gloves, n = 11; non-sterile gloves, n = 7) whereas, in 5 centers, postoperative dressing changes were performed after hand washing and disinfection only. In 18 centers, nurses/physicians used face masks when performing postoperative dressing changes.
CHRONIC EXIT-SITE CARE
A dressing change was performed routinely in 318 of the 332 chronic PD
patients (gauze dressing, n = 260; film dressing, n = 58).
Gauze dressing changes were scheduled every other day in 73.8% of PD patients
and daily in 25.8% of PD patients. One patient (0.4%) changed his gauze
dressing every 4 days. The interval between changes of film dressings was more
variable (daily, 1.7%; every other day, 31%; every 3 days, 20.7%; every 4
days, 39.7%; 5 days, 6.9%). All dressings were nonocclusive. Fourteen
patients did not use any dressing at their exit site. Disinfectants in use for
chronic exit-site care included povidone iodine (0.05% iodine, n =
34; 0.75% iodine, n = 23; 1.1% iodine, n = 66; 10% iodine,
n = 32), sodium hypochlorite (0.1%, n = 10; 0.5%, n
= 21), povidone iodine (1.1% iodine) + sodium hypochlorite (0.05%, n
= 1; 0.1%, n = 101) together, and 0.1 g octenidine dihydrochloride/2
g 2-phenoxyethanol solutions (n = 17). Water + non-disinfectant soap
(n = 9) or 0.9% sodium chloride solution (n = 18) was
administered as cleansing agent to the exit site by 27 patients.
Staphylococcus aureus screening (nasal and/or exit-site swabs) in chronic PD patients was performed in 12 PD centers (Figure 2); carriers were treated with mupirocin in 11 of these centers (twice daily for 5 days, n = 1; twice daily for 1 week, n = 4; twice daily for 2 weeks, n = 5; once daily until nose cultures become negative, n = 1). None of the centers routinely used local antibiotics at the exit site in all PD patients. In one center, diabetic patients with a history of at least one catheter-associated infection were routinely treated with local antibiotic cream at the exit site. Dialysis staff members were screened for S. aureus in 8 centers and nasal carriers treated with mupirocin cream in 7 centers (twice daily for 5 days, n = 1; twice daily for 1 week, n = 2; twice daily for 2 weeks, n = 3; once daily until nose cultures become negative, n = 1). Spouses were screened for S. aureus in 5 centers and nasal carriers treated with mupirocin cream in 4 centers (twice daily for 5 days, n = 1; twice daily for 1 week, n = 2; twice daily for 2 weeks, n = 1).
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Sixteen centers (70%) trained their patients to routinely use a face mask when performing dressing changes, whereas PD patients of 5 centers did not use such masks. Two centers recommended using a face mask only in situations associated with increased risk of infection (e.g., S. aureus carriers, respiratory infections).
CHRONIC EXIT-SITE CARE AND LIFESTYLE
Twenty-one of 23 Austrian centers allowed their patients to go for a swim;
18 of these centers recommended using a film dressing or a colostomy bag in
this situation. Furthermore, 18 of 23 PD centers asked their patients to
consider water quality (seawater or water of lakes is preferred; public baths
should be avoided). Other recommendations for PD patients going for a swim are
summarized in Table 3.
Seventeen of 23 centers allowed their PD patients to have a sauna.
Recommendations for these patients included using a film dressing or colostomy
bag, performing a dressing change without delay when leaving the sauna, and
enwrapping the titanium adapter, which may become hot when the temperature is
high (Table 4).
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DIAGNOSIS AND TREATMENT OF CATHETER-ASSOCIATED INFECTIONS
Nineteen of the 23 PD centers used the classification of exit sites
published by Twardowski and Prowant in 1996
(9); 2 centers have established
their own classifications and 2 centers diagnosed exit-site infections
clinically without standardized classification. All centers performed
ultrasonography to exclude tunnel involvement in case of an inflamed exit site
or clinical signs of tunnel infection; however, only 5 centers performed
tunnel ultrasonography routinely: at baseline immediately after start of PD,
n = 4; every 6 months, n = 2; once per year, n =
1.
Overall, there were 79 exit-site infections in 3468.8 treatment months (31.6% S. aureus, 45.6% other gram-positive organisms, 6.3% gram-negative organisms, 10.1% polymicrobial, 6.3% culture negative), corresponding to an exit-site infection rate of 1 episode/43.9 treatment months (S. aureus exit-site infections: 1 episode/128.5 treatment months). There were 39 tunnel infections (35.9% S. aureus, 43.6% other gram-positive organisms, 7.7% gram-negative organisms, 2.6% polymicrobial, 10.3% culture-negative), corresponding to a tunnel infection rate of 1 episode/88.9 treatment months (S. aureus tunnel infections: 1 episode/247.8 treatment months). Finally, there were 68 episodes of peritonitis in 3468.8 treatment months (10.3% S. aureus, 51.5% other gram-positive organisms, 5.9% gram-negative organisms, 7.4% polymicrobial, 1.5% yeast, 23.5% culture negative), corresponding to a peritonitis rate of 1 episode/51.0 treatment months (S. aureus peritonitis: 1 episode/433.6 treatment months). The rates of total and S. aureus infections per center are presented in Table 5.
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In a subanalysis we divided centers into two groups: those performing prophylactic mupirocin therapy in S. aureus carriers (n = 11) and those without a prophylaxis protocol (n = 12). There was no significant difference in age, number of diabetic patients, or female/male ratio between the two groups (data not shown). Patients of centers with a prophylaxis protocol had lower exit-site infection rates (total: 1 episode/75.2 months vs 1 episode/36.6 months; S. aureus: 1 episode/188.0 months vs 1 episode/111.5 months), lower tunnel infection rates (total: 1 episode/102.6 months vs 1 episode/83.6 months; S. aureus: 1 episode/376.1 months vs 1 episode/212.8 months), and lower peritonitis rates (total: 1 episode/56.4 months vs 1 episode/48.8 months; S. aureus: 1 episode/1128.2 months vs 1 episode/334.4 months) compared to those treated in centers not using such a protocol. Exclusion of centers treating fewer than 15 PD patients from the analysis did not change these results (data not shown). However, since the study design did not allow analysis of independent effects of mupirocin on infection rates, the results of these subanalyses should be interpreted with caution.
Catheter removal was required in 1 case of exit-site infection (polymicrobial), 2 cases of tunnel infection (S. aureus, n = 2), and 4 cases of peritonitis (Candida parapsilosis, n = 1; S. epidermidis, n = 1; Streptococcus species, n = 1; Enterococcus faecalis, n = 1). Relapses occurred after 1 exit-site infection (culture negative), 4 tunnel infections (Pseudomonas aeruginosa, n = 1; S. epidermidis, n = 1; S. aureus, n = 2), and 2 episodes of peritonitis (Acinetobacter, n = 1; S. epidermidis, n = 1). All relapses were cured without necessity for catheter removal.
Antibiotics used for treatment of exit-site infections and tunnel infections are summarized in Table 6. A minimal duration of treatment of at least 2 weeks was chosen in case of exit-site infection by only 57% of centers, and in case of tunnel infection by only 52% of centers (Table 7).
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DISCUSSION |
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TOPABSTRACTPATIENTS AND METHODSRESULTSDISCUSSIONDISCLOSUREREFERENCES |
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Immediate start with PD after catheter implantation may be associated with increased incidences of both dialysate leakage and early catheter infection (17). Furthermore, frequent dressing changes immediately after catheter insertion could lead to mechanical trauma to the exit site and secondary infection. Therefore, the EBPG recommend leaving an interval of at least 2 weeks between catheter implantation and start of PD (5). It is also suggested to do the first dressing change only 1 week after catheter implantation. However, no adequately powered randomized trials have been published confirming these recommendations. Accordingly, a broad spectrum of strategies (including start of PD 1 day after operation as well as leaving a break-in period of at least 4 weeks) has been developed in Austrian centers. A break-in period of at least 2 weeks is preferred by 61% of centers. The recommendation to perform the first dressing change 1 week after catheter placement is followed by 1 center only, whereas 43% of centers continue performing the first dressing change on day 1 or day 2 after implantation.
The role of topical disinfectants for chronic exit-site care remains unclear. In a randomized controlled trial, local application of povidone iodine solution at the exit site significantly reduced the rate of exit-site infections, compared to local treatment with water and non-disinfectant soap (18). Other povidone iodine preparations, including ointment and powder spray, seem to have no important impact on prevention of infectious complications in PD patients (19). The EBPG emphasize that, due to epithelial toxicity, povidone iodine preparations and hydrogen peroxide should be avoided, especially during the early healing phase immediately following catheter implantation (5). In German-speaking countries, sodium hypochlorite is frequently used for chronic exit-site care in PD patients. We are aware of only one randomized trial that revealed no influence of local treatment with sodium hypochlorite compared with povidone iodine solution or chlorhexidine (which is not commonly used in Europe) on PD catheter-associated infections. However, the number of included patients was small (20). In addition to their unclear prophylactic effect and potential epithelial toxicity, application of topical disinfectants may be also associated with the risk of selection of other bacteria and the occurrence of allergic reactions (21).
Several trials, including randomized studies, reported that mupirocin applied to the nose or to the exit site, either in S. aureus carriers or independently of carrier status, reduces the risk of catheter-associated infection (1–3,22,23). A recent randomized controlled trial showed that routine treatment of the exit site with gentamicin cream further reduces the risk of both exit-site infection and peritonitis compared to local treatment with mupirocin (4). Based on these data, the EBPG recommend routine application of antibiotic cream (mupirocin or aminoglycoside) to the exit site in chronic PD patients (5). The guidelines of the International Society for Peritoneal Dialysis (ISPD) 2005 also recommend installing an antibiotic protocol but they do not specify what measure should be taken (antibiotic cream at the exit site, either in carriers or in all patients independently of carrier status, or, alternatively, intranasal mupirocin in carriers) (24). Accordingly, 15 of the 23 Austrian centers have installed a preoperative prophylaxis protocol with mupirocin in S. aureus carriers. Additionally, in 11 of the 23 centers, chronic PD patients with S. aureus carrier status are treated with mupirocin but none of the centers routinely applies antibiotics to the bland exit site of PD patients independently of carrier status. For chronic exit-site care, Austrian centers prefer using topical antiseptics at the time of dressing changes, including povidone iodine and sodium hypochlorite as the most frequently used agents. This decision may be explained by the fear of selection of other bacteria and a possible increase in bacterial resistance to mupirocin or, more importantly, aminoglycosides, when using these topical agents routinely in long-term patients. Bernardini et al. reported a nonsignificant increase in fungal exit-site infections during local antibiotic treatment; however, these infections were easy to treat with local therapy (4). Pérez Fontán et al. showed that pericatheter mupirocin therapy was associated with later colonization of the exit site by gram-negative bacteria; however, there was only a poor correlation between colonization and increased risk of gram-negative infection (25). Schaefer et al. found that, in pediatric PD patients, in addition to frequent cleaning of the exit site and the use of non-sterile cleansing agents, prophylactic treatment with mupirocin at the exit site increased the risk of Pseudomonas peritonitis (26). Other studies, however, did not show any influence of mupirocin on the incidence of gram-negative infections (2,23) or even report a decrease in gram-negative peritonitis rates (3,27). Therefore, the majority of currently available data and the low resistance rate of bacteria to mupirocin do not question the favorable risk-to-benefit ratio of prophylactic topical antibiotic therapy in PD patients (5).
There is much controversy over whether and what type of dressing change should be done in chronic PD patients (28,29). In our experience, only a few patients do not use a dressing at their exit site. Even centers that offer this possibility state that many patients feel unsafe without dressing. It is noteworthy that, although gauze dressings are still the most commonly used, 18% of Austrian patients prefer film dressings. This may reflect the trend of many PD patients toward a more active lifestyle since this type of dressing has to be changed at longer intervals and makes some activities, for example swimming, easier. Film dressings are also an alternative to other adhesives in case of allergies. In contrast to the EBPG, which recommend daily changes of gauze dressings (5), dressings are changed every other day in most of the Austrian centers. The interval between changes of film dressings seems to be more variable. The recommendation of some centers to change this type of dressing at short intervals (e.g., every other day) may reflect the fact that 17.4% of the patients used gauze pads under the film dressing (data not shown).
Hand washing and hand disinfection before dressing and dialysate changes are of huge importance for preventing PD-associated infections (30). Accordingly, these aspects are part of patient training in all PD centers. Data on the usefulness of face masks during dialysate changes are scarce and controversial (31–33). Furthermore, we are not aware of any study that focused on the prophylactic impact of using face masks during dressing changes. Nevertheless, two thirds of Austrian centers recommend their patients use face masks routinely or, less frequently, at least in special situations (e.g., respiratory infection). Few PD centers perform S. aureus screening and eradication in spouses of patients, whereas screening and prophylactic treatment of staff members is more frequently done.
Swimming or going to the sauna contributes significantly to an improved quality of life in many dialysis patients. Nevertheless, there is some concern that PD patients may be exposed to an increased risk of infection during these activities. The literature contributes almost nothing to clarify this issue. One study of pediatric swimmers on PD using a colostomy pouch did not show an increased risk of infectious complications (34). All but two of the Austrian centers allow their patients to go for a swim. The most important recommendations to these patients included avoiding public baths and using a waterproof coverage of the exit site (e.g., film dressing). Austrian centers are somewhat more restrictive in allowing their patients to visit the sauna.
The huge variability in the incidence of catheter-associated infections reported in the literature may be partly explained by the fact that several definitions for exit-site infection are currently used, including the Twardowski classification (9) and the simpler exit-site score recommended by the ISPD (24). Most (83%) Austrian centers use the Twardowski classification of exit sites. However, each center stated that, apart from this classification, clinical judgment is important for confirming the diagnosis of infection. The wide distribution of the Twardowski classification in Austrian PD units may be explained by the fact that one of the PD supplies companies distributed a brochure including this classification to all Austrian centers. Furthermore, nurses of several smaller units were trained by one larger center that uses this classification.
Ultrasonography of the catheter tunnel in case of exit-site infection is an important tool for both early diagnosis and estimating the prognosis of tunnel infections (35–37). Accordingly, all Austrian PD centers use ultrasonography in case of infection but only a few centers perform it routinely (e.g., at baseline).
In contrast to peritonitis (which should occur less frequently than 1 episode/18 – 24 months), international guidelines have not yet defined a target to be reached for catheter-associated infections. After prophylactic treatment with mupirocin, overall exit-site infection rates from <0.1 to 0.54 episodes per year and S. aureus exit-site infection rates <0.1 episodes/year have been reported in the literature (3,4,27). Exit-site infection rates in Austrian centers are within this range; however, the mean infection rate in centers treating S. aureus carriers with mupirocin was strikingly lower than that of centers without a prophylaxis protocol. The large variation in infection rates within both groups of centers (those using and those not using a prophylaxis protocol) confirms that, in addition to eradication of positive S. aureus carriage status, other influencing factors also have to be considered. Peritonitis rates are lower than the maximum acceptable target recommended by recent guidelines. The most common antibiotics used for first-line treatment of catheter-associated infections in Austrian centers include chinolones, aminopenicillins, and cephalosporins. However, in only approximately half the centers, duration of antibiotic therapy for catheter-associated infections is at least 2 weeks, as recommended in recent guidelines (24).
The fact that this was a nationwide survey and included the whole PD population of our country has to be considered a strength of the study. In addition, previous data on management of exit-site care and especially on recommendations given to patients (e.g., those that go for a swim or to the sauna) were scarce. The objective of this study was to evaluate center strategies used for exit-site care. However, the study design did not allow identification of individual risk profiles or provide answers to the question of which factors independently influence infection rates in these patients. This has to be considered a limitation and requires further study.
In summary, a variety of prophylactic strategies are used to prevent infectious complications in PD patients treated in Austrian PD centers. The infection rates of most centers were within the range reported in the literature; however, centers that did not perform S. aureus prophylaxis had overall higher infection rates than those that had a prophylaxis protocol. Further studies should identify independent risk factors (in addition to S. aureus carrier status, diabetes, immunosuppression) that influence the rate of catheter-associated infection and peritonitis in PD patients. It should be clarified whether the risk-to-benefit ratio of treating only a more selected group of patients with a higher infection "risk profile" with local antibiotics is less favorable than treating all patients, independent of the presence of risk factors. Of course, cost implications also have to be considered (e.g., identifying risk factors may be more expensive than treating all patients).
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DISCLOSURE |
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TOPABSTRACTPATIENTS AND METHODSRESULTSDISCUSSIONDISCLOSUREREFERENCES |
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FOOTNOTES |
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Received 21 December 2007; accepted 8 September 2008.
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TOPABSTRACTPATIENTS AND METHODSRESULTSDISCUSSIONDISCLOSUREREFERENCES |
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This article has been cited by other articles:
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  B. Piraino CAN WE REDUCE RATES OF STAPHYLOCOCCUS AUREUS AND OTHER PERITONITIS IN PERITONEAL DIALYSIS PATIENTS? Perit. Dial. Int., May 1, 2010; 30(3): 277 - 279. [Full Text] [PDF]
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 B. Piraino Mupirocin for preventing exit-site infection and peritonitis in patients undergoing peritoneal dialysis. Was it effective? Nephrol. Dial. Transplant., February 1, 2010; 25(2): 349 - 352. [Full Text] [PDF]
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