Persistent colonization of exit site is associated with modality failure in peritoneal dialysis

Abstract

Exit-site infections (ESIs) increase the risk of developing peritoneal dialysis (PD) peritonitis and PD technique failure. There are no clear guidelines on how to monitor exit site (ES) after ESI with Staphylococcus aureus or Pseudomonas. We report on a 1-year observational study of 23 patients who developed an ESI with one of these serious pathogens. After completing initial antibiotic treatment, swabs were taken every month for 3 months. Primary treatment cure occurred in 19/23 (83%). Colonization of ES after primary cure occurred in 8/19 (42%) patients. In the eight colonized patients, five had subsequent PD technique failure due to infections. By contrast, during an average follow-up period of 7.2 months, none of the 11 patients who were proven noncolonized developed PD technique failure from infections; HR (colonized vs. noncolonized) = 10.89, 95% CI 2.6–45.43, p < 0.05. In conclusion, colonization significantly increased the risk of catheter loss. Increased surveillance and aggressive treatment may ameliorate this risk.

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

“…The ISPD does not formally recommend repeating an exit-site culture 1-2 weeks post antibiotic completion, though small studies have shown that subsequent colonization is associated with a significantly increased risk of catheter loss and repeat ESI [2,68]. Given repeat ESI has an estimated 65% risk of subsequent peritonitis and 50% risk of transfer to HD, there may be utility in repeating and treating a positive exit site culture within 2 weeks of antibiotic completion [10].…”

ISPD Catheter-related Infection Recommendations: 2023 Update

“…However, monitoring culture after primary cure of the exit site infection has been shown to detect persistent colonisation which was associated with higher risks of peritonitis 107 and transfer to haemodialysis. 107,108…”

Reducing and treating peritoneal dialysis catheter-related infections: Nursing implementation from evidence to practice

“…10 In a recently published study on the issue of persistent colonization of PD catheter exit sites, the authors noted that patients who were infected with recurrent Pseudomonas (at the exit site) were reminded to clean their showerhead with bleach monthly. 11 Similarly, a paper on the care of an infected PD catheter exit site has recommended that during a home visit a check on cleaning of the showerhead should be performed. 12 Equally, the UK Kidney Association recommends monthly descaling of showerheads for patients on PD.…”

“…The definitions for repeat, recurrent or chronic are not discussed. We have noticed that recently published studies and guidelines do use differing definitions for repeat 11,16 and for chronic exit-site infections. 6,17 In a review of the epidemiology of PD catheter exit-site infections, the authors also observed that there are no standard definitions for repeat, relapsing or recurring exit-site infections.…”