Clinical utility of a traditional score system for the evaluation of the peritoneal dialysis exit-site infection in a national multicentric cohort study

Abstract

Introduction: Exit-site infection (ESI) is an important risk factor for peritonitis in patients under chronic peritoneal dialysis (PD). The International Society for Peritoneal Dialysis (ISPD) recommend its diagnosis as the presence of purulent drainage in the exit site (ES) but time-consuming scores using others skin signs are routinely used. Objective: To investigate the correlation between the diagnosis of ESI with a score based on five clinical signs obtained from ES inspection, and also if there are interaction with patient’s race. Methods: Multicenter and prospective cohort. We included adult patients from 122 clinics, incident on PD and with a 12-month stay in therapy. The event of interest was ESI, defined as purulent drainage. The clinical score used was composed of hyperemia, edema, pain, scab, and granuloma. Statistical analysis was performed using multilevel logistic regression model, likelihood test, and Cohen concordance analysis. Results: A total of 35,354 ES assessments were performed during the first year of dialysis in 3297 patients. There was a rate of 10.1 (9.1–11.2) episodes of ESI per 1000 patients/month. In patients with ESI, the prevalence of hyperemia was 55.9%, edema 67.3%, pain 31.8%, and scab 23.2%. The agreement with the score was 60.6% and showed differences according to the patient’s race, being 53.2% for African Americans descendants and 65.4% for others. The use of scales for the diagnosis of ESI does not add much information in addition to the presence of purulent secretion as currently recommended by the ISPD.

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

“…An exit-site scoring system initially developed for pediatric ESIs can be utilized to clinically evaluate the exit site [3], Table 1). 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].…”

Negative-pressure wound therapy is effective for peritoneal dialysis catheter exit-site management in the early postoperative period

“…Using this scoring, ESI is diagnosed via ≥ 4 points or through the presence of purulent discharge with or without skin erythema at the catheter–epidermal interface. There has been uncertainty regarding the usefulness of this scoring system, as observed in some recent studies 27 , 28 . Furthermore, regularly monitoring exit-site score itself cannot predict or prevent CRIs.…”

ISPD Catheter-related Infection Recommendations: 2023 Update

“…Although exit site infection and tunnel infection can occur on their own, they can also occur concurrently. The diagnosis of exit site infection can be challenging as peri-catheter erythema without purulent discharge can be observed from allergic skin reaction, in the setting of a recently placed catheter or following trauma to the catheter, 6,7 or after a change in the dressing or cleansing materials. 8 Sometimes, erythema alone may be an indication of early infection warranting close monitoring for development of purulent discharge and need for antimicrobial treatment.…”

“…Based on a multi-centre study involving more than 30,000 assessments of exit sites in 3297 incident PD patients, the use of a scoring system (incorporating hyperaemia, oedema, pain, scab and granuloma) 2,9 for the diagnosis of exit site infection did not add much information in addition to the presence of purulent discharge. 7…”

“…Based on a multi-centre study involving more than 30,000 assessments of exit sites in 3297 incident PD patients, the use of a scoring system (incorporating hyperaemia, oedema, pain, scab and granuloma) 2,9 for the diagnosis of exit site infection did not add much information in addition to the presence of purulent discharge. 7 A tunnel infection can present with various components of erythema, oedema, induration or tenderness over the subcutaneous pathway, often with a peri-catheter fluid collection demonstrated using ultrasound. 11…”