Tunnel and peritoneal catheter exit site infections in continuous peritoneal dialysis
- John M Burkart, MD
John M Burkart, MD
- Section Editor — Dialysis
- Professor of Medicine/Nephrology
- Wake Forest University Medical Center
- Anthony Bleyer, MD, MS
Anthony Bleyer, MD, MS
- Professor of Internal Medicine/Nephrology
- Wake Forest University School of Medicine
- Section Editor
- Thomas A Golper, MD
Thomas A Golper, MD
- Section Editor — Dialysis
- Professor of Medicine
- Vanderbilt University Medical Center
Peritoneal dialysis is carried out by moving dialysis fluids into and out of the peritoneal cavity via a catheter made of a biocompatible material that is placed in a fistulous tract connecting the sterile peritoneum with the external, nonsterile environment. It is therefore not surprising that the tract, the exit site, and the peritoneum are prone to bacterial infection from a variety of causes such as catheter colonization, possible contamination at the time of spiking the dialysis fluid bag, or an exit-site or catheter tunnel infection.
There are seven important issues to consider with peritoneal dialysis catheter (tunnel and exit site) related infections:
●Evaluation of the exit site and diagnosis of infection
●Initial antibiotic therapyTo continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Scalamogna A, Castelnovo C, De Vecchi A, Ponticelli C. Exit-site and tunnel infections in continuous ambulatory peritoneal dialysis patients. Am J Kidney Dis 1991; 18:674.
- Nouwen JL, Fieren MW, Snijders S, et al. Persistent (not intermittent) nasal carriage of Staphylococcus aureus is the determinant of CPD-related infections. Kidney Int 2005; 67:1084.
- Tse KC, Lui SL, Cheng VC, et al. A cluster of rapidly growing mycobacterial peritoneal dialysis catheter exit-site infections. Am J Kidney Dis 2007; 50:e1.
- Schiffl H, Mücke C, Lang SM. Exit-site infections by non-diphtheria corynebacteria in CAPD. Perit Dial Int 2004; 24:454.
- Bernardini J, Bender F, Florio T, et al. Randomized, double-blind trial of antibiotic exit site cream for prevention of exit site infection in peritoneal dialysis patients. J Am Soc Nephrol 2005; 16:539.
- McQuillan RF, Chiu E, Nessim S, et al. A randomized controlled trial comparing mupirocin and polysporin triple ointments in peritoneal dialysis patients: the MP3 Study. Clin J Am Soc Nephrol 2012; 7:297.
- Piraino B, Bernardini J, Brown E, et al. ISPD position statement on reducing the risks of peritoneal dialysis-related infections. Perit Dial Int 2011; 31:614.
- O'Seaghdha CM, Foley RN. Septicemia, access, cardiovascular disease, and death in dialysis patients. Perit Dial Int 2005; 25:534.
- Gokal R, Alexander S, Ash S, et al. Peritoneal catheters and exit-site practices toward optimum peritoneal access: 1998 update. (Official report from the International Society for Peritoneal Dialysis). Perit Dial Int 1998; 18:11.
- Piraino B, Bailie GR, Bernardini J, et al. Peritoneal dialysis-related infections recommendations: 2005 update. Perit Dial Int 2005; 25:107.
- Santos C, Pérez-Fontán M, Rodríguez-Carmona A, et al. Identification of Targets for Prevention of Peritoneal Catheter Tunnel and Exit-Site Infections in Low Incidence Settings. Perit Dial Int 2016; 36:43.
- Piraino B, Bernardini J, Bender FH. An analysis of methods to prevent peritoneal dialysis catheter infections. Perit Dial Int 2008; 28:437.
- Chu KH, Choy WY, Cheung CC, et al. A prospective study of the efficacy of local application of gentamicin versus mupirocin in the prevention of peritoneal dialysis catheter-related infections. Perit Dial Int 2008; 28:505.
- Mahaldar A, Weisz M, Kathuria P. Comparison of gentamicin and mupirocin in the prevention of exit-site infection and peritonitis in peritoneal dialysis. Adv Perit Dial 2009; 25:56.
- Lo MW, Mak SK, Wong YY, et al. Atypical mycobacterial exit-site infection and peritonitis in peritoneal dialysis patients on prophylactic exit-site gentamicin cream. Perit Dial Int 2013; 33:267.
- Pérez-Fontán M, Rosales M, Rodríguez-Carmona A, et al. Treatment of Staphylococcus aureus nasal carriers in CAPD with mupirocin. Adv Perit Dial 1992; 8:242.
- Nasal mupirocin prevents Staphylococcus aureus exit-site infection during peritoneal dialysis. Mupirocin Study Group. J Am Soc Nephrol 1996; 7:2403.
- Strippoli GF, Tong A, Johnson D, et al. Antimicrobial agents to prevent peritonitis in peritoneal dialysis: a systematic review of randomized controlled trials. Am J Kidney Dis 2004; 44:591.
- Thodis E, Bhaskaran S, Pasadakis P, et al. Decrease in Staphylococcus aureus exit-site infections and peritonitis in CAPD patients by local application of mupirocin ointment at the catheter exit site. Perit Dial Int 1998; 18:261.
- Casey M, Taylor J, Clinard P, et al. Application of mupirocin cream at the catheter exit site reduces exit-site infections and peritonitis in peritoneal dialysis patients. Perit Dial Int 2000; 20:566.
- Ritzau J, Hoffman RM, Tzamaloukas AH. Effect of preventing Staphylococcus aureus carriage on rates of peritoneal catheter-related staphylococcal infections. Literature synthesis. Perit Dial Int 2001; 21:471.
- Piraino B, Bernardini J, Florio T, Fried L. Staphylococcus aureus prophylaxis and trends in gram-negative infections in peritoneal dialysis patients. Perit Dial Int 2003; 23:456.
- Conly JM, Vas S. Increasing mupirocin resistance of Staphylococcus aureus in CAPD--should it continue to be used as prophylaxis? Perit Dial Int 2002; 22:649.
- Bernardini J, Piraino B, Holley J, et al. A randomized trial of Staphylococcus aureus prophylaxis in peritoneal dialysis patients: mupirocin calcium ointment 2% applied to the exit site versus cyclic oral rifampin. Am J Kidney Dis 1996; 27:695.
- Xu G, Tu W, Xu C. Mupirocin for preventing exit-site infection and peritonitis in patients undergoing peritoneal dialysis. Nephrol Dial Transplant 2010; 25:587.
- Lim CT, Wong KS, Foo MW. The impact of topical mupirocin on peritoneal dialysis infection rates in Singapore General Hospital. Nephrol Dial Transplant 2005; 20:1702.
- Piraino B. Mupirocin for preventing exit-site infection and peritonitis in patients undergoing peritoneal dialysis. Was it effective? Nephrol Dial Transplant 2010; 25:349.
- Pérez-Fontán M, Rosales M, Rodríguez-Carmona A, et al. Mupirocin resistance after long-term use for Staphylococcus aureus colonization in patients undergoing chronic peritoneal dialysis. Am J Kidney Dis 2002; 39:337.
- Lobbedez T, Gardam M, Dedier H, et al. Routine use of mupirocin at the peritoneal catheter exit site and mupirocin resistance: still low after 7 years. Nephrol Dial Transplant 2004; 19:3140.
- Cavdar C, Atay T, Zeybel M, et al. Emergence of resistance in staphylococci after long-term mupirocin application in patients on continuous ambulatory peritoneal dialysis. Adv Perit Dial 2004; 20:67.
- Khandelwal M, Bailey S, Izatt S, et al. Structural changes in silicon rubber peritoneal dialysis catheters in patients using mupirocin at the exit site. Int J Artif Organs 2003; 26:913.
- Chua AN, Goldstein SL, Bell D, Brewer ED. Topical mupirocin/sodium hypochlorite reduces peritonitis and exit-site infection rates in children. Clin J Am Soc Nephrol 2009; 4:1939.
- Montenegro J, Saracho R, Aguirre R, et al. Exit-site care with ciprofloxacin otologic solution prevents polyurethane catheter infection in peritoneal dialysis patients. Perit Dial Int 2000; 20:209.
- Danguilan RA, Evangelista LP, Abrenica MS, Rondilla SM. Comparative study of mupirocin and sodium fucidate in the prophylaxis of exit-site infections in CAPD patients. Perit Dial Int 2003; 23:593.
- Pommer W, Brauner M, Westphale HJ, et al. Effect of a silver device in preventing catheter-related infections in peritoneal dialysis patients: silver ring prophylaxis at the catheter exit study. Am J Kidney Dis 1998; 32:752.
- Crabtree JH, Burchette RJ, Siddiqi RA, et al. The efficacy of silver-ion implanted catheters in reducing peritoneal dialysis-related infections. Perit Dial Int 2003; 23:368.
- Castro Notario MJ. Cuidados del orificio de salida del cater peritoneal. In: Manual Practico de Dialisis Peritoneal, Coronel F, Montenegro J, Selgas R, et al (Eds), Atrium Communicacion Estrategica, Barcelona, Spin 2005. p.293.
- Núñez-Moral M, Sánchez-Álvarez E, González-Díaz I, et al. Exit-site infection of peritoneal catheter is reduced by the use of polyhexanide. results of a prospective randomized trial. Perit Dial Int 2014; 34:271.
- Findlay A, Serrano C, Punzalan S, Fan SL. Increased peritoneal dialysis exit site infections using topical antiseptic polyhexamethylene biguanide compared to mupirocin: results of a safety interim analysis of an open-label prospective randomized study. Antimicrob Agents Chemother 2013; 57:2026.
- Zimmerman SW, Ahrens E, Johnson CA, et al. Randomized controlled trial of prophylactic rifampin for peritoneal dialysis-related infections. Am J Kidney Dis 1991; 18:225.
- Falagas ME, Fragoulis KN, Bliziotis IA. Oral rifampin for prevention of S. aureus carriage-related infections in patients with renal failure--a meta-analysis of randomized controlled trials. Nephrol Dial Transplant 2006; 21:2536.
- Strippoli GF, Tong A, Johnson D, et al. Catheter-related interventions to prevent peritonitis in peritoneal dialysis: a systematic review of randomized, controlled trials. J Am Soc Nephrol 2004; 15:2735.
- Johnson DW, Clark C, Isbel NM, et al. The honeypot study protocol: a randomized controlled trial of exit-site application of medihoney antibacterial wound gel for the prevention of catheter-associated infections in peritoneal dialysis patients. Perit Dial Int 2009; 29:303.
- Johnson DW, van Eps C, Mudge DW, et al. Randomized, controlled trial of topical exit-site application of honey (Medihoney) versus mupirocin for the prevention of catheter-associated infections in hemodialysis patients. J Am Soc Nephrol 2005; 16:1456.
- Golper TA, Brier ME, Bunke M, et al. Risk factors for peritonitis in long-term peritoneal dialysis: the Network 9 peritonitis and catheter survival studies. Academic Subcommittee of the Steering Committee of the Network 9 Peritonitis and Catheter Survival Studies. Am J Kidney Dis 1996; 28:428.
- Broughton A, Verger C, Goffin E. Pets-related peritonitis in peritoneal dialysis: companion animals or trojan horses? Semin Dial 2010; 23:306.
- Teitelbaum I, Burkart J. Peritoneal dialysis. Am J Kidney Dis 2003; 42:1082.
- Li PK, Szeto CC, Piraino B, et al. Peritoneal dialysis-related infections recommendations: 2010 update. Perit Dial Int 2010; 30:393.
- Keane WF, Bailie GR, Boeschoten E, et al. Adult peritoneal dialysis-related peritonitis treatment recommendations: 2000 update. Perit Dial Int 2000; 20:396.
- Kwan TH, Tong MK, Siu YP, et al. Ultrasonography in the management of exit site infections in peritoneal dialysis patients. Nephrology (Carlton) 2004; 9:348.
- Twardowski ZJ, Prowant BF. Current approach to exit-site infections in patients on peritoneal dialysis. Nephrol Dial Transplant 1997; 12:1284.
- Kazmi HR, Raffone FD, Kliger AS, Finkelstein FO. Pseudomonas exit site infections in continuous ambulatory peritoneal dialysis patients. J Am Soc Nephrol 1992; 2:1498.
- Záruba K, Peters J, Jungbluth H. Successful prophylaxis for fungal peritonitis in patients on continuous ambulatory peritoneal dialysis: six years' experience. Am J Kidney Dis 1991; 17:43.
- Wadhwa NK, Suh H, Cabralda T. Antifungal prophylaxis for secondary fungal peritonitis in peritoneal dialysis patients. Adv Perit Dial 1996; 12:189.
- Restrepo C, Chacon J, Manjarres G. Fungal peritonitis in peritoneal dialysis patients: successful prophylaxis with fluconazole, as demonstrated by prospective randomized control trial. Perit Dial Int 2010; 30:619.
- Vychytil A, Lilaj T, Lorenz M, et al. Ultrasonography of the catheter tunnel in peritoneal dialysis patients: what are the indications? Am J Kidney Dis 1999; 33:722.
- Piraino B, Bernardini J, Pietzman A, Sorkin M. Failure of peritoneal catheter cuff shaving to eradicate infection. Perit Dial Bull 1987; 7:179.
- Scalamogna A, De Vecchi A, Maccario M, et al. Cuff-shaving procedure. A rescue treatment for exit-site infection unresponsive to medical therapy. Nephrol Dial Transplant 1995; 10:2325.
- Wu YM, Tsai MK, Chao SH, et al. Surgical management of refractory exit-site/tunnel infection of Tenckhoff catheter: technical innovations of partial replantation. Perit Dial Int 1999; 19:451.
- Clouâtre Y, Cartier P, Charbonneau R, et al. Outpatient CAPD catheter salvage for persistent exit-site/tunnel infection. Nephrol Dial Transplant 2000; 15:231.
- Fukasawa M, Matsushita K, Tanabe N, et al. A novel salvage technique that does not require catheter removal for exit-site infection. Perit Dial Int 2002; 22:618.
- Goldie SJ, Kiernan-Tridle L, Torres C, et al. Fungal peritonitis in a large chronic peritoneal dialysis population: a report of 55 episodes. Am J Kidney Dis 1996; 28:86.
- Wang AY, Yu AW, Li PK, et al. Factors predicting outcome of fungal peritonitis in peritoneal dialysis: analysis of a 9-year experience of fungal peritonitis in a single center. Am J Kidney Dis 2000; 36:1183.
- Basturk T, Koc Y, Unsal A, et al. Fungal peritonitis in peritoneal dialysis: a 10 year retrospective analysis in a single center. Eur Rev Med Pharmacol Sci 2012; 16:1696.
- Elkabir JJ, Riaz AA, Agarwal SK, Williams G. Delayed complications following Tenckhoff catheter removal. Nephrol Dial Transplant 1999; 14:1550.
- Singhal MK, Vas SI, Oreopoulos DG. Treatment of peritoneal dialysis catheter-related infections by simultaneous catheter removal and replacement. Is it safe? Perit Dial Int 1998; 18:565.
- Swartz R, Messana J, Reynolds J, Ranjit U. Simultaneous catheter replacement and removal in refractory peritoneal dialysis infections. Kidney Int 1991; 40:1160.
- Lui SL, Yip T, Tse KC, et al. Treatment of refractory pseudomonas aeruginosa exit-site infection by simultaneous removal and reinsertion of peritoneal dialysis catheter. Perit Dial Int 2005; 25:560.
- Plum J, Sudkamp S, Grabensee B. Results of ultrasound-assisted diagnosis of tunnel infections in continuous ambulatory peritoneal dialysis. Am J Kidney Dis 1994; 23:99.
- PREVENTION OF CATHETER INFECTIONS
- Exit-site care
- - Acute care
- - Chronic care
- Antimicrobial prophylaxis
- - Gentamicin cream
- - Mupirocin
- Other prophylactic agents and approaches
- Miscellaneous considerations
- EVALUATION OF THE EXIT SITE AND DIAGNOSIS OF INFECTION
- Grading systems
- INITIAL ANTIBIOTIC THERAPY
- Mild infection
- Moderate infection
- Fungal infections
- RESISTANT INFECTION
- ANTI-FUNGAL PROPHYLAXIS
- INDICATIONS FOR CATHETER REMOVAL
- SITE AND TIMING OF NEW CATHETER PLACEMENT
- PREVENTION/TREATMENT OF RECURRENT INFECTION
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS