Management for Peritoneal Dialysis Access 18_12_2019

Management for Peritoneal Dialysis Access 20 Dec 2019 Nipa Aiyasanon Medicine Nursing Division, Nursing Department of, Siriraj Hospital,Mahidol University,

Excellent exit site

Pathogenesis and microbiology of exit site infection in peritoneal dialysis patients • Staphylococcus aureus is a Gram-positive coccus (MSSA, MRSA). • Coagulase-negative staphylococci (CNS) are skin flora that can cause ESI. • Other Gram-positive organisms are common skin commensals .

Pathogenesis and microbiology of exit site infection in peritoneal dialysis patients • Pseudomonas aeruginosa is a Gram-negative rod-shaped bacterium. • Other Gram-negative organisms and anaerobes. • Mycobacterium • Fungi

Clinical features and evaluation of exit site infection in peritoneal dialysis patients • Purulent discharge • Erythema around the PD catheter • Exit site traumatization • Presence of crust around the exit site • Increased crust formation Perit Dial Int 2017; 37(2):141–154 https://doi.org/10.3747/pdi.2016.00120

Purulent discharge

Clinical features and evaluation of exit site infection in peritoneal dialysis patients • Palpation of the tunnel tract and expression of discharge from the exit site. • The discharge should be sent for microbiological examination. (Gram smear, culture and sensitivity pattern) • Ultrasonography has also been used to assess exit site infection. Perit Dial Int 2017; 37(2):141–154 https://doi.org/10.3747/pdi.2016.00120

Prevention of exit site infection in peritoneal dialysis patients • early postoperative period (1-2 weeks) – the exit site should be kept dry until it is well healed – the exit site should be covered with sterile dressing – the change of dressing should be done by experienced nursing staff before the patient is properly trained – Hand hygiene is a key measure to decrease ESI in PD patients.

Management of exit site infection in peritoneal dialysis patients • Methicillin-sensitive or resistant S. aureus • Pseudomonas aeruginosa • Other Gram-negative organisms • Mycobacterium • Fungal exit site infection



Definitions of exit site infection • Exit-site infection is defined as the presence of purulent discharge, with or without erythema of the skin at the catheter-epidermal interface (not graded). • Tunnel infection is defined as the presence of clinical inflammation or ultrasonographic evidence of collection along the catheter tunnel (not graded). Perit Dial Int 2017; 37(2):141–154 https://doi.org/10.3747/pdi.2016.00120

INFECTION RATE • Every program should monitor, atleast on a yearly basis, the incidence of catheter-related infections (1C). • The rate of catheter-related infection should be presented as number of episodes per year (not graded). Perit Dial Int 2017; 37(2):141–154 https://doi.org/10.3747/pdi.2016.00120

PREVENTION OF CATHETER-RELATED INFECTIONS CATHETER PLACEMENT • Prophylactic antibiotics be administered 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). Perit Dial Int 2017; 37(2):141–154 https://doi.org/10.3747/pdi.2016.00120

PREVENTION OF CATHETER-RELATED INFECTIONS CATHETER DESIGN • No particular catheter design has been demonstrated to be superior to another for the prevention of catheter-related infections (not graded). CONNECTION METHODS • All found no significant difference in the rate of catheter-related infections. Perit Dial Int 2017; 37(2):141–154 https://doi.org/10.3747/pdi.2016.00120

PREVENTION OF CATHETER-RELATED INFECTIONS TRAINING PROGRAMS • The latest ISPD recommendations for teaching PD patients and their caregivers be followed (1C). • PD training be conducted by nursingstaff with the appropriate qualifications and experience (1C). Perit Dial Int 2017; 37(2):141–154 https://doi.org/10.3747/pdi.2016.00120

PREVENTION OF CATHETER-RELATED INFECTIONS TOPICAL ANTIBACTERIAL AND ANTISEPTIC AGENTS • Daily topical application of antibiotic cream or ointment to the catheter exit site (1A). • No cleansing agent has been shown tobe superior with respect to preventing catheter-related infections (2B). Perit Dial Int 2017; 37(2):141–154 https://doi.org/10.3747/pdi.2016.00120

PREVENTION OF CATHETER-RELATED INFECTIONS Topical Antibacterials, Antiseptics, and Cleansing Agents for the Prevention of Catheter-Related Infections • povidone-iodine • chlorhexidinesolution • Amuchinasolution/hypochlorite solution • mupirocincream • gentamicin cream or ointment • ciprofloxacin otologic solution • antibacterial honey • polysporin triple ointment • polyhexanide Perit Dial Int 2017; 37(2):141–154 https://doi.org/10.3747/pdi.2016.00120

PREVENTION OF CATHETER-RELATED INFECTIONS OTHER ASPECTS OF EXIT-SITE CARE • Theexit site be cleansed at least twice weekly and every time after a shower (1C). Perit Dial Int 2017; 37(2):141–154 https://doi.org/10.3747/pdi.2016.00120

PREVENTION OF CATHETER-RELATED INFECTIONS OTHER ANTIMICROBIAL APPROACHES • Screening for nasal S. aureus carriage prior to PD catheter insertion (2D). • If nasal carriage of S. aureus is found in PD patients, we suggest treating by topical nasal application of mupirocin (1B). Perit Dial Int 2017; 37(2):141–154 https://doi.org/10.3747/pdi.2016.00120

PREVENTION OF CATHETER-RELATED INFECTIONS OTHER MODIFIABLE RISK FACTORS • Poor glycemic control is an important risk factor of catheter related infections. 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 . It seems logical to advise patients to perform PD and exit-site care in a clean environment Perit Dial Int 2017; 37(2):141–154 https://doi.org/10.3747/pdi.2016.00120

Management of catheter-Related infections Perit Dial Int 2017; 37(2):141–154 https://doi.org/10.3747/pdi.2016.00120

MICROBIOLOGICAL INVESTIGATIONS Perit Dial Int 2017; 37(2):141–154 https://doi.org/10.3747/pdi.2016.00120

Possible Indications for Ultrasonographic Examination of Catheter Tunnel • Initial evaluationof 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) • Follow-up of exit-site and tunnel infection after antibiotictreatment • Relapsing peritonitis episodes Perit Dial Int 2017; 37(2):141–154 https://doi.org/10.3747/pdi.2016.00120

EXIT-SITE CARE • exit sites be cleansed at least daily during exit-site infection (1C).

EMPIRICAL ANTIBIOTIC TREATMENT • 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).

Perit Dial Int 2017; 37(2):141–154 https://doi.org/10.3747/pdi.2016.00120

MONITORING AND DURATION OF THERAPY • Exit-site infection, exceptepisodes caused by Pseudomonas species, be treated with at least 2 weeks of effective antibiotics(1C). • Exit-site infection caused by Pseudomonas species and any tunnel infection be treated with at least 3 weeks of effective antibiotics (1C)

MONITORING AND DURATION OF THERAPY • Exit-site infection, exceptepisodes caused by Pseudomonas species, be treated with at least 2 weeks of effective antibiotics(1C). • Exit-site infection caused by Pseudomonas species and any tunnel infection be treated with at least 3 weeks of effective antibiotics (1C)

CATHETER REMOVAL AND REINSERTION • 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). • Suggest removal of the dialysis catheter in PD patients with exit-site infections that progress to, or occur simultaneously with, peritonitis (2C). • 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).

Indications for Catheter Removal

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.

Algorithm for exit site care Evaluation of the exit site Infected Exit site No Infected Exit site During 2 wk after catheter insertion Immediate Retraining Dressing with 0.9%NSS untill healing After 2 wk c/s from exit site Dressing with 2% Chlohexidine gluconate And start ATB per protocol or povidine solution with mupirocin cream Adjust ATB according to culture result application untill excellent healing 1 wk after Rx Follow every visit Re evaluate No improvement Remove cath Every 1-2 wk Infection improve Continue antibiotic as per protocol Infection resolved Stop antibiotic

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