Effect of Local Mupirocin Application on Exit-Site Infection and Peritonitis in an Indian Peritoneal Dialysis Population

Abstract

Background Staphylococcus aureus-associated peritonitis and catheter exit-site infections (ESIs) are important causes of hospitalization and catheter loss in patients undergoing chronic peritoneal dialysis. Intranasal and topical use of mupirocin has been found to be an effective strategy in decreasing S. aureus-related infectious complications in persons who are carriers of S. aureus; however, there is no consensus regarding the prophylactic use of mupirocin irrespective of carrier status. We aimed to determine the potential effectiveness of application of mupirocin cream at the catheter exit site in preventing ESI and peritonitis irrespective of carrier status in a tropical country such as India. Methods This prospective historically controlled study was done in a total of 40 patients. From August 2003, all patients, incident and prevalent, were instructed to apply 2% mupirocin cream daily to the exit site instead of the older practice of povidone-iodine and gauze dressing. Patients were not screened to determine whether they were S. aureus carriers. The infection-related data for 1 year, until July 2004, were compared with the historical control, which was infection-related data for the year preceding the year of mupirocin application. Results Mean age of the study population was 62 years, with 61.8% being male and 64.3% being diabetic. Local application of mupirocin led to a significant reduction in the incidence density per patient-month of both ESI and peritonitis compared to controls (0.15 vs 0.37 and 0.37 vs 0.67, p = 0.01 for both). This amounted to a relative reduction of 60.5% and 55% respectively. ESI and peritonitis due to S. aureus were also significantly lower in the study group compared to controls (incidence density per patient-month 0.05 vs 0.13 and zero vs 0.17 respectively, p < 0.01 for both). There occurred no catheter removal due to infection-related complications during the study period compared to two during the control period. None of the patients reported a mupirocin-related adverse effect. Conclusions Daily application of mupirocin at the exit site is a well-tolerated and effective strategy in reducing the incidence of ESI and peritonitis in a tropical country such as India. It can thus significantly reduce morbidity, catheter loss, and transfer to hemodialysis in peritoneal dialysis patients.

Prevention of infectious complications in peritoneal dialysis: best demonstrated practices

“…52 Subsequent studies have confirmed these results. [53][54][55][56][57][58][59] Over time, implementation of this protocol in our program has almost eliminated both S. aureus exit-site infections and peritonitis, indicating that most S. aureus peritonitis is derived from S. aureus at the exit site ( Figure 2). Review articles have evaluated the efficacy of various antibiotic prophylaxis protocols at the exit site.…”

Clinical practice guidelines for the provision of renal service in Hong Kong: Infection Control in Renal Service

“…The results demonstrated that gentamicin ointment had similar efficacy for preventing S. aureus exit‐site infection as mupirocin but with an added value of preventing Pseudomonas exit‐site infections. Other emerging prophylactic therapies for PD exit site include the use of MediHoney and Polysporin triple (Bacitracin, gramicidin and polymixin B) ointment …”

Diagnosis and Management of Exit Site Infection in Peritoneal Dialysis Patients

“…The application of exit site prophylaxis can markedly diminish the PDrelated S. aureus infection and thus should be undertaken in all PD patients [7,28]. In this context, topical mupirocin has demonstrated its effectiveness as prophylaxis for S. aureus ESI [7,[28][29][30][31][32]. In one previous observational study involving more than 700 new PD patients, the use of topical mupirocin as exit site prophylaxis leads to a significant reduction in both ESI (0.168 vs. 0.156 episodes per patient-year) and peritonitis (0.443 vs. 0.339 episodes per patientyear) [32].…”