Exit site infection

Peritonitis Exit-site infections Tunnel infections... 

Exit-site infections present with purulent drainage at the site. Erythema may or may not be present with an exit-site infection. Tunnel infections are generally an extension of the exit-site infection and rarely occur alone. Symptoms of a tunnel infection may include tenderness, edema, and erythema over the tunnel pathway, but are often asymptomatic. Ultrasound can be used to detect tunnel infections in asymptomatic patients. Exit-site infections caused by S. aureus and P. aeruginosa often spread to tunnel infections and are the most common causes of catheter-infection-related peritonitis. 

Treatment Exit-site infections may be treated immediately with empiric coverage, or treatment may be delayed until cultures return. Empiric treatment of catheter-related infections should cover S. aureus. Coverage for P. aeruginosa should also be included if the patient has a history of infections with this organism.49 Cultures and sensitivity testing are particularly important in tailoring antibiotic therapy for catheter-related infections to ensure eradication of the organism and prevent recurrence or related peritonitis. 

Intranasal S. aureus increases the risk of S. aureus exit-site infections, tunnel infections, peritonitis, and subsequent catheter loss.49 Several measures have been used to decrease the risk of peritonitis caused by S. aureus, including mupirocin cream applied daily around the exit site, intranasal mupirocin cream twice daily for 5 days each month, or rifampin 300 mg orally twice daily for 5 days, repeated every 3 months.49 Mupirocin use is preferred over rifampin to prevent the development of resistance to rifampin, although mupirocin resistance has also been reported.49 Other measures that have been used to decrease both S. aureus and P. aeruginosa infections include gentamicin cream applied twice daily and ciprofloxacin otic solution applied daily to the exit site.49... 

An 84-year-old man with diabetic nephropathy and end-stage renal disease began continuous ambulatory peritoneal dialysis and over the next year had four episodes of exit-site infection and peritonitis and used mupirocin ointment. The exit-site catheter became dilated and during an episode of infection for which he used mupirocin on 6 successive days, a longitudinal rupture developed in the peritoneal catheter, which was removed. The peritoneal liquid contained Escherichia coli and Proteus mirabilis and the catheter tip contained E. coli and Enterobacter cloacae. He was treated with ciprofloxacin, without complications, and after 1 month a new peritoneal catheter was inserted. 

The placement of the exit site of the catheter is one of the factors related to the development or prevention of exit-site infections and peritonitis. Many new catheters and surgical techniques for catheter placement have recently been developed. The driving forces for this... 

FIGURE 45-6. Management strategy of exit-site infections for peritoneal dialysis patients. 

Rodriguez-Carmona A, Perez FM, Garcia FT, et al. A comparative analysis on the incidence of peritonitis and exit-site infection in CAPD and automated peritoneal dialysis. Perit Dial Int 1999 19 253-258. 

Leehey DJ, Gandhi VC, Daugirdas JT. Peritonitis and exit site infection. In Daugirdas JT, Blake PG, Ing TS, editors. Handbook of Dialysis. Philadelphia, Lippincott Williams Wilkins, 2001 373-398. 

Delayed catheter-related infections are divided into (1) exit site infections, (2) subcutaneous turmel or pocket infection, and (3) catheter-related bacteremia or sepsis (Raad and Bodey 1992). Exit site infections are defined as erythema and tenderness confined to 1 cm around the catheter exit site. A purulent exudate may also be present. The more serious turmel or pocket infection presents with tenderness and erythema over the pocket or along the turmel. Fluctuation suggests a subcutaneous abscess and demands immediate attention. Patients with catheter-related bacteremia often present with fever and a leukocytosis. Unfortunately, this is often a diagnosis of exclusion in a patient with a febrile illness with an indweUing catheter and no other apparent source of infection. More specific indications of a true... 

Exit site infections are common and are recognized by redness, exudation and crusting. Topical agents applied to catheter exit site, such as povidone iodine, mupirocin, bacitracin zinc and polymixin B sulphate ointments have been proven effective [20, 21]. Oral rifampin or nasal mupirocin ointment reduced the incidence of S. aureus bacteremia [22]. 

Most adult PD catheters have three possible internal diameters (2.6, 3.1, 3.5 mm). All have an outer diameter of approximately 5 mm. Most catheters currently manufactured are made of silicone rubber. Polyurethane may also be used but much less commonly. The published literature indicates catheters with a coiled in-traperitoneal end have a longer, 3-year survival [18,19]. Similarly, catheters with two cuffs have a lower incident of exit site infection and a longer lifespan than single-cuff catheters. The Swan-neck catheters appear to have lower overall incidents of exit site infection than those with a straight subcutaneous segment, although this is most likely due to a catheter exit that faces caudad as opposed to cephalad. 

Danielsson A, Blohme L, Tranaeus A, Hy-lander B A prospective randomized study of the effect of a subcutaneously buried peritoneal dialysis catheter technique versus standard technique on the incidence of peritonitis and exit-site infection. Perit Dial Int 2002 22 211-219. 

Cardiovascular In a study about the use of PHMB to prevent catheter exit-site infection, significantly more cardiovascular events were found in the PHMB group (compared to patients treated with mupirodn). However, the results were confounded by a higher proportion of diabetics in the PHMB group [5(P]. 

Findlay A, Serrano C, Punzalan S, Fan SL. Increased peritoneal dialysis exit site infections using topical antiseptic polyhexamethylene bigu-anide compared to mupirocin results of a safety interim analysis of an open-label prospective randomized study. Antimicrob Agents Che-mother 2013 57(5) 2026-8. 

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