ISPD CATHETER-RELATED INFECTION RECOMMENDATIONS: 2017 UPDATE
Cheuk-Chun Szeto,
1Philip Kam-Tao Li,
1David W. Johnson,
2Judith Bernardini,
3Jie Dong,
4Ana E. Figueiredo,
5Yasuhiko Ito,
6Rumeyza Kazancioglu,
7Thyago Moraes,
8Sadie Van Esch,
9and Edwina A. Brown
10Department of Medicine and Therapeutics,
1Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong;
Department of Nephrology,
2University of Queensland at Princess Alexandra Hospital, Brisbane, Australia; Renal
Electrolyte Division,
3University of Pittsburgh School of Medicine Pittsburgh, PA, USA; Renal Division,
4Department of
Medicine, Peking University First Hospital, Beijing, China; Pontifícia Universidade Católica do Rio Grande do Sul,
5FAENFI, Porto Alegre, Brazil; Division of Nephrology,
6Nagoya University Graduate School of Medicine, Nagoya,
Japan; Division of Nephrology,
7Bezmialem Vakif University, Medical Faculty, Istanbul, Turkey; Pontifícia
Universidade Católica do Paraná,
8Curitiba, Brazil; Elisabeth Tweesteden Hospital,
9Nephrology
Department and Internal Medicine, Tilburg, Netherlands; and Imperial College
Renal and Transplant Centre,
10Hammersmith Hospital, London, UK
ISPD GUIDELINES/RECOMMENDATIONS
KEY WORDS: Infection; antibiotic; peritonitis.
INTRODUCTION
P
eritoneal dialysis (PD) catheter-related infections are a
major predisposing factor to PD-related peritonitis (1–3).
The primary objective of preventing and treating
catheter-related infections is to prevent peritonitis.
Recommendations on the prevention and treatment of
catheter-related infections were published previously together
with recommendations on PD peritonitis under the auspices
of the International Society for Peritoneal Dialysis (ISPD) in
1983 and revised in 1989, 1993, 1996, 2000, 2005, and 2010
(4–9). The present recommendations, however, focus on
catheter-related infections, while peritonitis will be covered
in a separate guideline.
These recommendations are evidence-based where such
evidence exists. The bibliography is not intended to be
com-prehensive. When there are many similar reports on the same
area, the committee prefers to refer to the more recent
publica-tions. In general, these recommendations follow the Grades
of Recommendation Assessment, Development and Evaluation
(GRADE) system for classification of the level of evidence and
grade of recommendations in clinical guideline reports (10).
Within each recommendation, the strength of recommendation
is indicated as Level 1 (We recommend), Level 2 (We suggest),
or Not Graded, and the quality of the supporting evidence is
shown as A (high quality), B (moderate quality), C (low
qual-ity), or D (very low quality). The recommendations are not
meant to be implemented in every situation indiscriminately.
Each PD unit should examine its own pattern of infection,
causative organisms, and sensitivities and adapt the protocols
according to local conditions as necessary. Although many
of the general principles presented here could be applied to
pediatric patients, we focus on catheter-related infections in
adult patients. Clinicians who take care of pediatric PD patients
should refer to the latest consensus guideline in this area for
detailed treatment regimen and dosage (11).
DEFINITIONS
•
We suggest that exit-site infection is defined as the pres-ence of purulent discharge, with or without erythema of
the skin at the catheter-epidermal interface (not graded).
• We suggest that tunnel infection is defined as the presence
of clinical inflammation or ultrasonographic evidence of
collection along the catheter tunnel (not graded).
Correspondence to: Philip Kam-Tao Li, Carol & Richard Yu PDResearch Centre, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong.
Received 14 September 2016; accepted 15 September 2016.
Perit Dial Int 2017; 37(2):141–154 https://doi.org/10.3747/pdi.2016.00120
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In this guideline, catheter-related infections are used as
the collective term to describe both exit-site infection (ESI)
and tunnel infection. These 2 conditions may occur on their
own or simultaneously. Exit-site infection is diagnosed by
the presence of purulent drainage, with or without erythema
of the skin at the catheter-epidermal interface (12,13).
Peri-catheter erythema without purulent drainage is sometimes
an early indication of infection but can also be an allergic
skin reaction, or occur in a recently placed catheter or after
trauma to the catheter (14). Clinical judgment is required to
decide whether to initiate therapy or to follow carefully. A
positive culture with a normal-appearing exit site is indicative
of colonization rather than infection. A tunnel infection may
present as erythema, edema, induration, or tenderness over
the subcutaneous pathway but is often clinically occult, as
shown by sonographic studies (15). A tunnel infection usually
occurs in the presence of an ESI but could occur alone. Exit-site
infections caused by Staphylococcus aureus or Pseudomonas
aeruginosa are often associated with concomitant tunnel
infections (16).
INFECTION RATE
• We recommend that every program should monitor, at least
on a yearly basis, the incidence of catheter-related
infec-tions (1C).
• We suggest that the rate of catheter-related infection
should be presented as number of episodes per year (not
graded).
As part of a continuous quality improvement (CQI)
program, all PD programs should monitor the incidence of
catheter-related infections on a regular basis (17,18). There
are several methods of reporting the rate of catheter-related
infections (8,19). The committee favors reporting the rate
of catheter-related infections as number of episodes per
year because data are presented in a linear scale and easy
to compare. In addition to the overall rate of
catheter-related infections, monitoring may also include the rates
of ESI and tunnel infection separately, as well as the
infec-tion rate of specific organisms (especially Staphylococcus
aureus and Pseudomonas species) and the spectrum of
antibiotic sensitivity (20). With this information,
interven-tions can be implemented when infection rates are rising or
unacceptably high. However, there are insufficient data at
present to suggest a minimum target for the rate of ESI and
tunnel infection.
PREVENTION OF CATHETER-RELATED INFECTIONS
Many prevention strategies aim primarily to reduce the
incidence of peritonitis, and clinical trials in this area often
report the rate of ESI or catheter-related infections as a
sec-ondary outcome. In this guideline, we focus on the prevention
of catheter-related infections. The prevention of peritonitis is
described in a separate guideline.
CATHETER PLACEMENT
•
We recommend that prophylactic antibiotics be adminis-tered immediately before catheter insertion (1A).
• No technique of catheter placement has been demonstrated
to be superior to another for the prevention of
catheter-related infections (not graded).
Detailed description on the recommended practice of PD
catheter insertion has been covered in another ISPD
posi-tion paper (21). A systematic review of available prospective
trials found that prophylactic perioperative intravenous (IV)
antibiotics had no significant effect on the rate of early
cathe-ter-related infections, although the risk of early peritonitis was
significantly reduced (22). There are 3 randomized controlled
trials on the use of perioperative IV cefuroxime (23), cefazolin
(24), and gentamicin (24,25) as compared with no treatment
and reported early catheter-related infections (within 1 month
after catheter placement) as a secondary outcome. One of them
had no catheter-related infection in both study arms (23),
1 study that used cefazolin and gentamicin found no benefit
(24), while the other that used gentamicin alone showed
benefit (25). One additional study found that perioperative
vancomycin, and to a lesser extend cefazolin, reduces the rate
of early peritonitis, but the rate of catheter-related infection
was not reported (26). No data exist on the effectiveness of
routine screening and eradication of S. aureus nasal carriage
before catheter insertion (e.g. by intranasal mupirocin).
Besides prophylactic antibiotics, various techniques of
catheter placement have been tested. With the appropriate
training, there is no difference in the rate of early ESI between
catheters placed by nephrologists and surgeons (27,28). When
percutaneous or laparoscopic techniques are compared with
open catheter placement, one observational study reported
a lower incidence of wound and ESI with the laparoscopic
technique (29), while 3 other studies found no difference in
the rate of early catheter-related infections between different
techniques (30–32). Similarly, vertical tunnel-based low-site
PD catheter implantation does not reduce the risk of ESI (33).
Several randomized trials have compared laparoscopic or
peri-toneoscopic catheter placement with standard laparotomy,
but none of them reported catheter-related infection as a
secondary outcome (34). Two studies compared midline with
lateral incision (35,36), but neither found any difference in
the risk of catheter-related infection.
Before catheter insertion, it is advisable to carefully choose
the location of the exit site so that it could be conveniently
cleaned and the chance of inadvertent trauma (e.g. by the belt)
is minimized (37). After catheter placement, it is generally
considered good surgical practice to cover all incisions and
leave the dressing undisturbed for 3 to 5 days so as to allow
epithelialization and wound healing by primary intention (38).
Although an uncontrolled study suggests that the technique
of burying the PD catheter in subcutaneous tissue for 4 to 6
weeks after implantation is associated with a lower rate of
catheter-related infections (39), 2 randomized controlled
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studies found no difference as compared with the standard
technique (40,41). It remains controversial whether
immedi-ate commencement of PD after catheter insertion is associimmedi-ated
with a higher risk of catheter-related infections (42–45). The
optimal time to start PD remains to be defined (46).
CATHETER DESIGN
• No particular catheter design has been demonstrated to be
superior to another for the prevention of catheter-related
infections (not graded).
There are no convincing data regarding effect of PD catheter
design and configuration on peritonitis risk. Eight randomized
trials have compared straight and coiled PD catheters (36,47–
53) and found no difference in the rate of catheter-related
infections. Two systematic reviews, each with different
exclu-sion criteria and neither of which included all 8 trials, reached
the same conclusion (34,54). Two randomized controlled trials
compared a swan neck design and the traditional Tenckhoff
catheter and reported the rate of catheter-related infection as
a secondary outcome (55,56). One found that the swan neck
design had marginally lower risks of ESI and tunnel infection
(55), while the other found a higher rate of ESI in the swan
neck group but the result was not statistically significant (56).
However, an extended swan neck catheter may be beneficial.
One retrospective study on pre-sternal swan neck catheters
(57) and another prospective study on extended swan neck
catheters with upper abdominal exit site (58) found lower rates
of catheter-related infections as compared with conventional
abdominal catheters. An observational study reported that
the use of a double-cuff catheter is associated with a reduction
in S. aureus peritonitis, but the rate of ESI was not reported
(59). A randomized controlled trial compared double-cuffed
catheter with single-cuffed ones and found no difference in the
rate of catheter-related infections (60). Another randomized
controlled trial that compared downward direction of the exit
site by swan neck catheter to lateral direction by conventional
catheter reported a similar incidence of catheter-related
infec-tions between the groups (61).
An alternative peritoneal catheter exit-site location is
sometimes needed in patients with morbid obesity, intestinal
stomas, or urinary or fecal incontinence. In a prospective
non-randomized study, 2-piece extended catheters, which permit
pre-sternal exit site away from problematic abdominal
condi-tions, was compared to conventional catheters (62). The result
showed that although extended catheters enabled peritoneal
access for patients in whom conventional catheter placement
would be difficult or impossible, they were associated with a
higher risk of relapsing peritonitis episodes, especially those
caused by coagulase-negative staphylococcal species (62).
In addition to the conventional silicone catheter, early
studies suggested that silver-ion coated or implanted catheters
could minimize bacterial colonization and reduce the rate of
catheter-related infections (63,64). However, this type of
catheter is not widely available and the experience is limited.
Antimicrobial-impregnated catheters have also been found to
reduce PD catheter-related infections in rats (65), but further
clinical trials are needed in this area.
CONNECTION METHODS
Several prospective studies compared the Y-connection
systems with the “flush before fill” design with the
tradi-tional spike systems and reported the rate of catheter-related
infection as a secondary outcome (66–70). Although they
generally showed that the risk of peritonitis was reduced by
the Y-systems, the rate of catheter-related infection was not
reduced in any of these trials (66–70). Similarly, 3
random-ized controlled trials compared the double-bag system with
the Y-connection systems (both with the “flush before fill”
design), and all found no significant difference in the rate of
catheter-related infections (71–73).
TRAINING PROGRAMS
• We recommend that the latest ISPD recommendations for
teaching PD patients and their caregivers be followed (74)
(1C).
• We recommend that PD training be conducted by nursing
staff with the appropriate qualifications and experience
(1C).
The detailed recommended practice of PD training is
cov-ered in previous ISPD guidelines (74,75). Every PD program
should prepare the trainers according to this document and
develop a specific curriculum for training. Unfortunately,
high-level evidence guiding how, where, when, and by whom
PD training should be performed is lacking (76). Ideally, each
patient should be trained by a dedicated nurse, whose time
is totally focused on training the patient. However there are
few published data on the optimal nurse-to-patient ratios or
training protocols (76). It is difficult to define “appropriate
qualification and experience,” and there is conflicting
evi-dence regarding the relation between nursing experience and
clinical outcome (77,78).
The method of training is often believed to affect the risk
of catheter-related infections (79,80). An observational study
found that the rate of ESI was reduced 10-fold with a program
that incorporated intensive training of nursing staff and
patients, improved operative aseptic technique and
reduc-tion in S. aureus nasal carriage (81). The training program
should include general theories of adult education as well as
specific knowledge related to PD (74,75). One prospective
non-randomized study showed that training programs that used
an adult learning theory-based curriculum were associated
with a lower rate of ESI as compared with non-standardized
conventional training programs (82). One study reported
that patients with better knowledge had better adherence to
the recommended exchange protocols and lower rate of ESI
(83). Two prospective studies showed that the duration of
PD training and number of training lessons were associated
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with the frequency of peritonitis (84,85), but the incidence
of catheter-related infections was not reported in either of
them. Two more studies reported conflicting results regarding
the relation between nursing experience and peritonitis rate
(77,78), but the incidence of exit-site or tunnel infection was
not reported in either.
Adherence to the guideline recommendations and
antisep-tic procedures are important for maintaining a low incidence
of catheter-related infections (86). After PD training is
com-pleted, a home visit by the PD nurse is usually recommended
to detect problems with exchange technique, adherence to
protocols, and other environmental and behavior issues that
increase the risk of infections (87,88). One case controlled
study reported that home visit programs are associated with
improved technique survival of PD patients (89). However, the
effect of a home visit on catheter-related infections has not
been tested in a prospective study.
In addition to the initial training, regular retraining may
help to reduce mistakes in performing practical procedures
(90,91). Two observational studies suggested that re-training
may reduce peritonitis related to touch-contamination, but the
rate of catheter-related infections was not reported (90,92).
The indication, optimal time, and content of retraining have
not been well defined (76).
TOPICAL ANTIBACTERIAL AND ANTISEPTIC AGENTS
• We recommend daily topical application of antibiotic cream
or ointment to the catheter exit site (1A).
• We suggest that no cleansing agent has been shown to be
superior with respect to preventing catheter-related
infec-tions (2B).
A number of topical cleansing agents have been tested
for the prevention of catheter-related infections (Table 1).
Antibacterial soap and water are commonly used to clean
the exit site, but that efficacy has not been formally tested.
Povidone-iodine, chlorhexidine, and electrolytic
chloroxidiz-ing solutions have been used as disinfectants for routine care
of the exit site to prevent catheter-related infections. Four
randomized controlled trials compared topical
povidone-iodine to simple soap and water cleansing for exit-site care or
no treatment (93–96); 2 found that topical povidone-iodine
reduced the incidence of ESI (93,94), the third showed no
significant difference (95), while the last one showed that
with topical mupirocin cream, topical povidone-iodine
dress-ing confers no added benefit (96). The peritonitis rate was
similar between povidone-iodine and control groups in all
these studies.
Chlorhexidine gluconate, 0.05% to 2% aqueous solution
with or without isopropyl alcohol, is also commonly used. A
randomized controlled trial showed that daily chlorhexidine
care at the exit site is superior to normal saline cleansing
for the prevention of exit site colonization by S. aureus (97).
Four prospective studies showed that Amuchina solution
(an electrolytic chloroxidizing solution containing sodium
hypochlorite) at 3% to 10% is effective in preventing
infec-tion at the exit site, without any secondary topical reacinfec-tion
(98–101). The addition of sodium hypochlorite solution to
topical mupirocin may further reduce the rate of ESI and
peri-tonitis in pediatric PD patients (102). However, studies with
head-to-head comparison of hypochlorite, chlorhexidine, or
povidone-iodine reported conflicting advantage of one agent
over another (103–105).
Daily application of mupirocin cream or ointment to
the skin around the exit site could prevent ESI caused by
S. aureus. This strategy is proved to be effective by a number
of observational studies, randomized controlled trials, and
meta-analyses (22,34,106–112) and has also been shown to
be cost-effective (113). Although some meta-analyses also
include studies on nasal mupirocin ointment, topical
mupiro-cin over the exit site reduced the risk of S. aureus ESI by 72%
in a pooled analysis (109). The optimal frequency of topical
mupirocin, however, is not clearly defined. One retrospective
study showed that once weekly application was less effective
than thrice weekly administration (114). Mupirocin resistance
has been reported, particularly with intermittent but not daily
administration (115–118). The long-term implication of
mupi-rocin resistance, however, remains unclear and may have been
overstated (119). Although all catheters currently in use are
made of silicone, it is important to note that some mupirocin
ointment contains polyethylene glycol and has a deleterious
effect on polyurethane devices (120). In PD patients with
polyurethane catheters, a randomized controlled trial showed
that topical application of ciprofloxacin otologic solution to
the exit site reduced the rates of ESI caused by S. aureus as
well as Pseudomonas species, as compared with soap and water
cleansing only (121).
Other alternative topical antibacterial agents have been
tested, often with an aim to reduce the risk of
catheter-related infections caused by gram-negative bacteria (especially
Pseudomonas species), which have become a common cause
of catheter-related infections in recent years (122). A
randomized controlled trial showed that daily application
of gentamicin cream to the exit site was highly effective
in reducing ESI caused by Pseudomonas species, and was
as effective as topical mupirocin in reducing S. aureus ESI
(107). Two subsequent prospective studies, however, found
TABLE 1
Topical Antibacterials, Antiseptics, and Cleansing Agents for
the Prevention of Catheter-Related Infections
• povidone-iodine (93–95) • chlorhexidine solution (97,103) • Amuchina solution/hypochlorite solution (98–102) • mupirocin cream (25,56,106–113) • gentamicin cream or ointment (107,108,123) • ciprofloxacin otologic solution (121) • antibacterial honey (128) • polysporin triple ointment (129) • polyhexanide (131) by guest on October 25, 2018 http://www.pdiconnect.com/ Downloaded fromno significant difference in the rates of ESI between topical
gentamicin and mupirocin ointment and actually a marginally
higher rate of gram-positive infections in the gentamicin group
(108,123). Two observa tional studies further suggested that
the change of prophylactic protocol from topical mupirocin
to gentamicin was associated with an increase in ESI caused
by Enterobacteriaceae, Pseudomonas species, and probably
non-tuberculous mycobacteria (124,125). Topical gentamicin
should be considered as an alternative to mupirocin for
pro-phylactic application at the exit site. Alternating mupirocin/
gentamicin is associated with increased risk of fungal
perito-nitis compared with gentamicin alone (126). The incidence
and implications of gentamicin resistance are uncertain (127).
Other prophylactic strategies have been tested. The
HONEYPOT study found that with standard exit-site care, the
rate of catheter-related infection is similar between patients
randomized to receive daily topical application of
antibacte-rial honey to the catheter exit site and those treated with
intranasal mupirocin ointment (128). In the subgroup
analy-ses, honey actually increased the risk of ESI, tunnel infection,
or peritonitis in diabetic patients (128). However, there was
no direct comparison between application of topical
antibac-terial honey and mupirocin to the exit site. In the MP3 study,
patients randomized to topical polysporin triple ointment had
an insignificant trend of higher ESI rate than those treated with
topical mupirocin to the exit site (129). A small randomized
trial reported that topical application of 3% hypertonic saline
is as effective as topical mupirocin cream for the prevention of
ESI (130). Another study reported that topical polyhexanide
resulted in a lower incidence of ESI than povidone-iodine
(131). In contrast, topical polyhexamethylene biguanide
was inferior to mupirocin in another randomized controlled
trial, which was terminated after interim analysis (132). The
effectiveness of nanotechnology antimicrobial spray dressing
in preventing ESI has been reported in a pilot study (133). All
these results should be regarded as preliminary, and further
validation is needed.
OTHER ASPECTS OF EXIT-SITE CARE
• We recommend that the exit site be cleansed at least twice
weekly and every time after a shower (1C).
General measures on exit-site care and meticulous hand
hygiene are generally recommended, but none has been
proved by randomized controlled trial to reduce the rate of
catheter-related infections (134). In general, the exit site
should be cleansed at least twice weekly and every time after
a shower (96,135). Immobilization of the catheter is often
recommended, but there is no clinical trial to support this
prac-tice. Although gauze is commonly used for exit-site dressing
and protection, a recent study suggested that regular dressing
may not be necessary (96). Agents other than gauze have also
been tried. For example, the use of Blisterfilm (Medtronic,
Minneapolis, MN, USA), a polyurethane adhesive film that has
greater oxygen permeability, and Fixomull (BSN Medical, Inc.,
Charlotte, NC, USA), a stretchable hypo-allergenic adhesive
dressing material, have been reported (136,137). However,
their efficacy for the prevention of ESI has not been reported.
A randomized controlled trial found that a silver ring mounted
on PD catheter and placed at skin level did not reduce the
inci-dence of ESI as compared with no treatment (138). Although
chlorhexidine-impregnated dressings have been proved to be
effective in preventing catheter-related infection for
intravas-cular catheters (139), they have not been adequately evaluated
in PD. In patients receiving no topical antimicrobial prophylaxis,
about one-half of healthy exit sites are colonized with S. aureus
(140). In these patients, trauma to the exit site may be treated
with a short course of prophylactic oral antibiotics although
there is no clinical trial to directly support this approach. It
is a common practice to have appropriate protection for the
catheter and exit site during bathing or swimming. However,
there are no published data on this area.
OTHER ANTIMICROBIAL APPROACHES
• We suggest screening for nasal S. aureus carriage prior to
PD catheter insertion (2D).
• If nasal carriage of S. aureus is found in PD patients, we
sug-gest treating by topical nasal application of mupirocin (1B).
Nasal carriage of S. aureus is often regarded as a major risk
factor of catheter-related infections. Although there is no
good randomized study to support routine screening of nasal
S. aureus carriage in PD patients, the efficacy of prophylactic
intranasal antibiotics for the treatment of confirmed nasal
carriage of S. aureus has been tested in several prospective
studies. A randomized controlled trial found that intranasal
mupirocin was more effective than nasal neomycin ointment for
the elimination of S. aureus nasal colonization, but the
back-ground incidence of catheter-related infection was very low in
this study (141). A prospective study showed that intranasal
mupirocin reduced S. aureus ESI but not tunnel infection (142).
In another small randomized controlled study, S. aureus grew
less frequently from the exit site in the group randomized
to intranasal sodium fusidate ointment (143). However, it is
important to note that these studies only support the
eradi-cation of confirmed nasal S. aureus carriage; the benefit of
routine screening, as well as the need of repeated screening
after eradication, deserve further study.
One randomized controlled trial that compared cyclical oral
rifampicin therapy (5 days every 3 months) with no treatment
found significant reductions in catheter-related infection rate
with rifampicin (144). In another randomized controlled trial
involving pediatric PD patients who were nasal S. aureus
car-riers, a single course of oral rifampicin plus nasal bacitracin
ointment also led to reduction in catheter-related infections
(145). In another study, cyclic oral rifampicin and daily topical
mupirocin to the exit site were equally effective in reducing the
rate of catheter-related infections caused by S. aureus compared
with historic control (107). However, adverse reactions to
rifampicin were common (107). Drug interaction and rifampicin
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resistance are also genuine concerns (146). The routine use of
oral rifampicin for prophylactic purpose is not recommended.
Other oral antibiotics have also been tested. In a small
randomized controlled study, oral ofloxacin did not reduce the
incidence of S. aureus grown from catheter exit sites compared
with no treatment (143). Two randomized controlled trials
compared prophylactic treatment with oral cotrimoxazole
(147) or cephalexin (148) with no treatment, but neither
reported catheter-related infection as an outcome measure.
The use of the staphylococcal vaccine was tested in a
prospec-tive multicenter placebo-controlled trial (149) that did not
find any difference in the rate of catheter-related infection or
peritonitis between the vaccine and control groups.
OTHER MODIFIABLE RISK FACTORS
Poor glycemic control is an important risk factor of
catheter-related infections (150). Common clinical sense dictates that
one should achieve a reasonable glycemic control in diabetic
PD patients. One study reported that patients undergoing PD
in an area of high air pollution and environmental particulate
matter exposure had a higher infection rate than those with low
exposure (151). It seems logical to advise patients to perform
PD and exit-site care in a clean environment.
CONTINUOUS QUALITY IMPROVEMENT
There is a wide variation in adherence to guideline
recom-mendations between PD units, which may contribute to the
development of catheter-related infection and peritonitis
(152). A Continuous Quality Improvement (CQI) program has
been proposed for reducing infection in PD patients (18,153).
The CQI team, usually including nephrologists, nurses, social
workers, and dietitians, should hold regular meetings to
examine all PD-related infections and identify the root cause
of each episode. If a pattern of infections develops, the team
should investigate and plan interventions to rectify the
prob-lem. Observational data suggest that CQI programs reduce
peritonitis rates and improve technique survival (17,153–155).
However, none of these studies reported catheter-related
infection as an outcome measure.
MANAGEMENT OF CATHETER-RELATED INFECTIONS
Exit-site and tunnel infections may be caused by a variety
of microorganisms. The most serious and common exit-site
pathogens are S. aureus and P. aeruginosa, as these organisms
frequently lead to peritonitis. Such infections must be treated
aggressively (156–174). Coagulase-negative staphylococcal
species and other bacteria (diphtheroids, streptococci,
non-tuberculous mycobacteria, and fungi) can also be involved.
CLINICAL PRESENTATION AND ASSESSMENT
As mentioned above, ESI is diagnosed by the presence of
purulent drainage, with or without erythema of the skin at
the catheter-epidermal interface. Tunnel infection typically
presents as erythema, edema, induration or tenderness over
the subcutaneous pathway, and usually occurs in the presence
of ESI. Peri-catheter erythema without purulent drainage is
sometimes an early sign of ESI but can also be a local skin
reaction (e.g. recently placed catheter or after trauma). On the
other hand, a positive culture without erythema and discharge
probably indicates colonization but not infection. The scoring
system described in Table 2 is sometimes recommended for
the monitoring of exit sites (175). However, this system was
developed by pediatricians and has not been formally validated
in adult patients.
Some patients with clinical features of ESI alone actually
have occult infection of the catheter tunnel and internal cuff,
which may be revealed by sonography (15,176–178), and the
presence of occult tunnel involvement predicts subsequent
catheter loss (177). Possible indications for ultrasonographic
examination of catheter tunnel are summarized in Table 3.
However, there are few data to suggest how treatment should
be tailored following ultrasound study.
MICROBIOLOGICAL INVESTIGATIONS
Many organisms can cause exit-site and tunnel infections,
including microorganisms belonging to the normal skin flora,
such as Corynebacteria (6,19). Microbiological examination
should preferably include a combination of microscopy with
aer-obic and anaeraer-obic culture. The Gram stain of exit-site drainage
and microbiological culture findings may not be immediately
TABLE 2
Exit-Site Scoring System
a0 point 1 point 2 points
swelling no <0.5 cm >0.5 cmb
crust no <0.5 cm >0.5 cm
redness no <0.5 cm >0.5 cm
pain no slight severe
drainage no serous purulent
a Modified from Schaefer F et al. (175). b Or involve tunnel.
TABLE 3
Possible Indications for Ultrasonographic Examination of
Catheter Tunnel
• Initial evaluation of suspected tunnel infection, e.g. tunnel swelling without erythema and tenderness.
• Initial evaluation of exit-site infection without clinical features of tunnel involvement (especially if caused by S. aureus) (15,81,177) • Follow-up of exit-site and tunnel infection after antibiotic treatment (168,172) • Relapsing peritonitis episodes (178) by guest on October 25, 2018 http://www.pdiconnect.com/ Downloaded from
available but may help to guide the subsequent therapy. Cultures
should be taken to the laboratory using transport materials
that allow anaerobic bacteria to survive. Sensitivity testing is
important in determining antibiotic therapy.
EXIT-SITE CARE
• We recommend that exit sites be cleansed at least daily
during exit-site infection (1C).
It makes clinical sense to continue with the usual exit-site
care during catheter-related infections, and the committee
suggests that the exit site be cleansed at least daily during
ESI. For granulation tissue over the exit site without
puru-lent discharge or tenderness, intensified local care or a local
antibiotic cream is probably sufficient. However, there is no
published trial on the efficacy of intensified exit care for the
treatment (not prevention) of overt catheter-related
infec-tions. Topical antibacterial agents that have been tested for
the prevention of catheter-related infections are summarized
in Table 1. There are few data, however, on their efficacy in
the treatment of active catheter-related infections. A recent
study reported that topical ofloxacin solution is effective as an
adjuvant to systemic antibiotics for the treatment of persistent
exit-site and tunnel infection (179). The addition of topical
gentamicin cream does not help to eradicate ESI caused by
Pseudomonas species (180). Acetic acid (vinegar) has been
used as a wound antiseptic and has been recommended for
treatment of Pseudomonas wounds infections (181). However,
the experience of acetic acid for the treatment of ESI in PD
patients is limited.
EMPIRICAL ANTIBIOTIC TREATMENT
•
We recommend empiric oral antibiotic treatment of exit-site infections with appropriate S. aureus cover such as
a penicillinase-resistant penicillin (e.g. dicloxacillin or
flucloxacillin) or first-generation cephalosporin, unless the
patient has had a prior history of infection or colonization
with methicillin-resistant S. aureus (MRSA) or Pseudomonas
species (in these cases they should receive a glycopeptide or
clindamycin, or appropriate anti-pseudomonal antibiotic,
respectively) (1C).
Oral antibiotic therapy is convenient and has an extensive
clinical experience on its efficacy. Empiric therapy should
primarily cover S. aureus. If the patient has a history of
P. aeruginosa ESI, empiric therapy should include an antibiotic
that would cover this organism. The Gram stain of exit-site
drainage may help to guide the subsequent antibiotic therapy.
Dosing recommendations for frequently used oral antibiotics
are shown in Table 4 (86,144,145,165,182–195). The presence
of granulation tissue over the exit site without other features of
infection does not require antibiotic treatment. Although
anti-fungal prophylaxis (e.g. oral nystatin) is recommended for the
prevention of secondary fungal peritonitis during antibiotic
treatment of peritonitis, there is no study that directly
sup-ports the use of anti-fungal prophylaxis during treatment of
catheter-related infections. However, 1 randomized controlled
trial did report a lower risk of fungal peritonitis with nystatin
prophylaxis whenever antibiotics were prescribed (196).
MODIFICATION OF ANTIBIOTIC REGIMEN
Gram-positive organisms should be treated with oral
penicillinase-resistant (or broad-spectrum) penicillin or a
first-generation cephalosporin. To prevent unnecessary
expo-sure, vancomycin should be avoided in the routine treatment
of gram-positive exit-site and tunnel infections but will be
required for MRSA infections. Sulfamethoxazole-trimethoprim,
linezolid, daptomycin, clindamycin, doxycycline, and
minocy-cline are possible alternatives for the treatment of MRSA. In
slowly resolving or severe S. aureus ESI, rifampicin has been
advocated as an adjunct, although there is no prospective study
to support this practice. Rifampicin should never be given as
monotherapy. Potential interaction with other concurrent
medications (e.g. antihypertensive agents) should also be
considered during rifampicin treatment.
Exit-site infections caused by Pseudomonas species are
particularly difficult to treat and often require prolonged
therapy with 2 antibiotics. Oral fluoroquinolones are
recom-mended as the first-line choice, but resistance may develop
rapidly with fluoroquinolone monotherapy. If quinolones are
given concomitantly with sevelamer, multivalent cations (e.g.
calcium, iron, or zinc preparations), sucralfate,
magnesium-aluminum antacids, or milk, chelation and reduced quinolone
absorption may occur. Administration of the quinolone should
therefore be separated from these drugs by at least 2 hours
TABLE 4
Oral Antibiotics Used in Catheter-Related Infections
Amoxicillin 250–500 mg BD (182)
Amoxicillin/clavulanate 875 mg/125 mg BD (183)
Cephalexin 500 mg BD to TID (86)
Ciprofloxacin 250 mg BD (164) or 500 mg daily (184) Clarithromycin 500 mg loading, then 250 mg BD (165)
Clindamycin 300–450 mg TID (185)
Cloxacillin/flucloxacillin 500 mg QID (186)
Erythromycin 250 mg QID (187)
Fluconazole then 50–100 mg daily (188)oral 200 mg loading,
Levofloxacin 300 mg daily (189)
Linezolid 300–450 mg BD (190–192)
Metronidazole 400 mg TID (193)
Moxifloxacin 400 mg daily (194)
Rifampicin 450 mg daily for BW <50 kg; 600 mg daily
for BW ≥50 kg (144,145)
Trimethoprim/ 80 mg/400 mg daily (8) to
sulfamethoxazole 160 mg/800 mg BD (195)
BD = two times per day; TID = three times per day; QID = four times per day; BW = body weight.
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(with the quinolone administered first). For elderly and
diabetic patients, Achilles tendonitis is an uncommon but
well recognized complication of fluoroquinolone treatment.
If resolution of the infection is slow or if there is recurrent
Pseudomonas ESI, a second anti-pseudomonal drug, such as
intraperitoneal (IP) aminoglycoside or ceftazidime, should be
added. Generally speaking, tobramycin and amikacin are more
active on Pseudomonas species than gentamicin. In recent
years, catheter-related infections caused by Burkholderia
cepa-cia (197,198) and non-tuberculous mycobacteria (199,200)
have been increasingly reported, and their treatment should
be individualized.
MONITORING AND DURATION OF THERAPY
• We recommend that exit-site infection, except episodes
caused by Pseudomonas species, be treated with at least 2
weeks of effective antibiotics (1C).
• We recommend that exit-site infection caused by
Pseudomonas species and any tunnel infection be treated
with at least 3 weeks of effective antibiotics (1C).
Patients should be followed with the catheter tunnel and
exit site examined in order to determine the clinical response
to treatment. Photographic record (for example, by mobile
phone) is increasingly used and probably valuable for serial
monitoring. Antibiotic therapy should be continued until the
exit site appears entirely normal. For ESI, effective antibiotic
should be continued for at least 2 weeks. However, treatment for
3 weeks is recommended for tunnel infection or ESI caused by
Pseudomonas species. Close follow-up is necessary to determine
the response to therapy and relapse. Repeating exit-site wound
swab for bacterial culture 1 to 2 weeks after the discontinuation
of antibiotic treatment has been advocated for risk assessment
(9), but there is no clinical trial on this area.
Ultrasonography of the catheter tunnel has been advocated
for evaluating the response to therapy, and may be used to
determine the need for surgical intervention (Table 3). One
uncontrolled study reported that amongst patients with clinical
ESI, ultrasonography of the exit site after finishing a course of
antibiotic therapy had prognostic value (168). In this study, a
sonolucent zone around the external cuff of over 1 mm thick
following antibiotic treatment and the involvement of the
proximal cuff were associated with poor clinical outcomes
(168). In another uncontrolled study, patients who had a
clini-cal tunnel infection caused by S. aureus and significant decline
of the sonographic hypoechogenic area around the cuff after 2
weeks of antibiotic therapy did not require catheter removal,
while no significant decline was observed in patients who later
lost their catheters (172).
CATHETER REMOVAL AND REINSERTION
• We recommend simultaneous removal and reinsertion of
the dialysis catheter with a new exit site under antibiotic
coverage in PD patients with refractory exit-site or tunnel
infection without peritonitis, defined as failure to respond
after 3 weeks of effective antibiotic therapy (1C).
• We suggest removal of the dialysis catheter in PD patients
with exit-site infections that progress to, or occur
simul-taneously with, peritonitis (2C).
• We suggest that, for patients who have undergone dialysis
catheter removal for simultaneous exit-site or tunnel
infection and peritonitis, any reinsertion of a PD catheter
be performed at least 2 weeks after catheter removal and
complete resolution of peritoneal symptoms (2D).
The indications of catheter removal for catheter-related
infections are summarized in Table 5. Patients with ESIs that
progress to, or occur simultaneously with, peritonitis
gener-ally require catheter removal. Catheter removal should also
be considered for isolated catheter-related infections (i.e.
without peritonitis) if prolonged therapy with appropriate
antibiotics (e.g. over 3 weeks) fails to resolve the infection.
For patients with simultaneous exit-site or tunnel infections
and peritonitis, PD catheter removal should be followed by
temporary hemodialysis with no attempted reinsertion of the
PD catheter until at least 2 weeks after catheter removal and
complete resolution of peritoneal symptoms. In the scenario
of catheter infections, however, a few observational studies
showed that simultaneous removal and reinsertion of the
dialy-sis catheter with a new exit site under antibiotic coverage is
effective in eradicating the infections (169–171,174,201,202).
However, there is no controlled trial in this area.
OTHER CATHETER INTERVENTIONS
In addition to catheter removal, a number of interventions
have been tried for the treatment of chronic or refractory
catheter infections. A few observational studies reported that
cuff-shaving is a reasonable alternative to catheter replacement
for persistent tunnel infection (173,203,204). The un-roofing
technique, with or without en bloc resection of the skin and
tissues around the peripheral cuff, has been advocated but is
associated with considerable risk of peritonitis (203–207).
In contrast, observational data suggest that partial catheter
re-implantation (200) and catheter diversion procedure with
exit-site renewal (208–213) could be considered for catheter
salvage. The latter technique has been extensively reported
as an alternative to catheter removal for refractory exit-site
TABLE 5
Possible Indications for Catheter Removal in
Catheter-Related Infections
• Catheter infections that occur simultaneously with peritonitis episodes
• Catheter infections that lead to subsequent peritonitis episodes • Refractory catheter infections*
* Defined as failure to respond after 3 weeks of effective antibiotic therapy; simultaneous catheter reinsertion could be considered.
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or tunnel infections, although no randomized controlled trial
has been completed. The precise methods for this strategy
have been described in detail previously (205,210,213,214).
FUTURE RESEARCH
Clinical trials are required on the primary and secondary
prevention of catheter-related infections. Specifically, the
optimal method of exit-site care and the critical components of
a good patient-training program remain to be defined. Further
studies are also needed to assess the efficacy and safety of
various treatment regimens, as well as the optimal duration
of treatment. The biology and management of catheter biofilm
is another area to be explored.
DISCLOSURES
CCS receives a research grant and consultancy fees from Baxter Healthcare. DWJ has received consultancy fees, research grants, speaker’s honoraria and travel sponsorships from Baxter Healthcare and Fresenius Medical Care. JB serves as a consultant for Baxter Healthcare. AEF received travel grants and a speaker honorarium from Baxter Healthcare. YI received research grants or speaker honoraria from Baxter, Terumo, JMS, Chugai, Kirin, Eisai, and Kissei pharmaceu-tical companies. RK has previously received fees for invited lectures from Baxter. TM receives a speaker honorarium, consultant fees, and travel grant from Baxter. SVE receives speaker’s fees from Baxter. EAB receives research funding and speaker honoraria from Baxter Healthcare and speaker honoraria from Fresenius Medical Care. The others declare no conflict of interest.
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