Comparison of topical mupirocin and gentamicin in the prevention of peritoneal dialysis-related infections: A systematic review and meta-analysis

Treatment Effects in Randomized and Nonrandomized Studies of Pharmacological Interventions: A Meta-Analysis

Importance

Randomized clinical trials (RCTs) are widely regarded as the methodological benchmark for assessing clinical efficacy and safety of health interventions. There is growing interest in using nonrandomized studies to assess efficacy and safety of new drugs.

Objective

To determine how treatment effects for the same drug compare when evaluated in nonrandomized vs randomized studies.

Data Sources

Meta-analyses published between 2009 and 2018 were identified in MEDLINE via PubMed and the Cochrane Database of Systematic Reviews. Data analysis was conducted from October 2019 to July 2024.

Study Selection

Meta-analyses of pharmacological interventions were eligible for inclusion if both randomized and nonrandomized studies contributed to a single meta-analytic estimate.

Data Extraction and Synthesis

For this meta-analysis using a meta-epidemiological framework, separate summary effect size estimates were calculated for nonrandomized and randomized studies within each meta-analysis using a random-effects model and then these estimates were compared. The reporting of this study followed the Guidelines for Reporting Meta-Epidemiological Methodology Research and relevant portions of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline.

Main Outcome and Measures

The primary outcome was discrepancies in treatment effects obtained from nonrandomized and randomized studies, as measured by the proportion of meta-analyses where the 2 study types disagreed about the direction or magnitude of effect, disagreed beyond chance about the effect size estimate, and the summary ratio of odds ratios (ROR) obtained from nonrandomized vs randomized studies combined across all meta-analyses.

Results

A total of 346 meta-analyses with 2746 studies were included. Statistical conclusions about drug benefits and harms were different for 130 of 346 meta-analyses (37.6%) when focusing solely on either nonrandomized or randomized studies. Disagreements were beyond chance for 54 meta-analyses (15.6%). Across all meta-analyses, there was no strong evidence of consistent differences in treatment effects obtained from nonrandomized vs randomized studies (summary ROR, 0.95; 95% credible interval [CrI], 0.89-1.02). Compared with experimental nonrandomized studies, randomized studies produced on average a 19% smaller treatment effect (ROR, 0.81; 95% CrI, 0.68-0.97). There was increased heterogeneity in effect size estimates obtained from nonrandomized compared with randomized studies.

Conclusions and Relevance

In this meta-analysis of treatment effects of pharmacological interventions obtained from randomized and nonrandomized studies, there was no overall difference in effect size estimates between study types on average, but nonrandomized studies both overestimated and underestimated treatment effects observed in randomized studies and introduced additional uncertainty. These findings suggest that relying on nonrandomized studies as substitutes for RCTs may introduce additional uncertainty about the therapeutic effects of new drugs.

Reduction of peritoneal dialysis associated infections using a novel exit-site care practice

INTRODUCTION

Peritoneal dialysis (PD) related infections are a significant obstacle leading to PD discontinuation. Since catheter related infections (CRI), defined as exit site infections and/or tunnel infection, can progress to peritonitis, vigorous efforts are implemented in CRI prevention. Following an increased CRI rate in our institution, partially related to environmental organisms found in water distribution systems, we hypothesized that exit site care that includes prevention of water exposure-related pathogens may reduce CRI.

METHODS

In this prospective single center study, we compared a contemporary cohort consisting of PD patients who implemented the modified exit-site care protocol, mainly including water avoidance during shower with stoma bag usage and local Mupirocin ointment against a historical control group before the protocol implementation. The historical cohort was allowed water exposure and used local gentamicin ointment. The primary outcome was the development of a CRI. Secondary outcomes were PD associated peritonitis and infection related outcomes.

RESULTS

There were 55 patients in contemporary cohort and 58 in historical group. The CRI rate was significantly lower in study group (0.11/episodes per patient year [EPP]) compared to control group (0.71 EPP), p < 0.001. A multivariate Cox regression analysis demonstrated a protective effect of being in the contemporary cohort compared to historical group (HR for first CRI = 12.0 95%CI: 4.0-35.7, p < 0.001). Peritonitis rate was significantly lower in contemporary cohort (0.19/EPP) compared to the historical group (0.40/EPP), p = 0.011. Transfer to hemodialysis was significantly lower in contemporary cohort than historical group (7.3% vs 31.0% in contemporary and historical group respectively, HR = 0.2, 95%CI; 0.05-0.6, p = 0.001).

CONCLUSION

An exit site care protocol that includes water avoidance and local Mupirocin use reduced substantially both CRI and peritonitis rate in patients treated with PD.

The efficacy of cuff-shaving combined with negative pressure wound therapy in refractory exit-site and tunnel infections: a single center experience

BACKGROUND

Refractory exit-site infections (ESIs) and tunnel infections (TIs) are challenging complications for patients undergoing peritoneal dialysis (PD). This study compared the outcomes of surgical intervention, notably the cuff-shaving (CS) procedure coupled with negative-pressure wound therapy (NPWT), and conservative management strategies for patients with refractory ESI and TI.

METHODS

We retrospectively reviewed patients who underwent PD at our center, focusing on the incidence and management of ESI and TI. We evaluated and compared treatment outcomes, including ESI scores, frequency of ESI and/or TI, identification of causative microorganisms, and duration of catheter survival or time until removal.

RESULTS

We identified 97 episodes of catheter-related ESI and/or TI across 71 patients with an incidence rate of 0.15 episodes per patient-year. Of the 23 patients with refractory ESI and/or TI, surgical intervention was performed in 8, while 15 chose conservative management. In the one-month follow-up, patients who underwent CS combined with NPWT showed no complications such as leakage, and their local symptoms resolved completely. The mean PD catheter survival time was significantly longer in the surgical group (29.38 ± 7.25 months) than in the conservative group (7.86 ± 2.13 months). Surgical intervention demonstrated a significantly higher therapeutic efficacy and extended catheter survival.

CONCLUSIONS

The combination of CS and NPWT as a surgical approach is crucial for eradicating infectious foci and significantly improving the longevity of PD catheter function. This integrated surgical strategy offers a promising solution for the management of refractory ESI and TI in patients undergoing PD.

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

Exit site infection (ESI) is a leading complication of peritoneal dialysis (PD), at an incidence of 0.6 episodes per year in the United States, and a major risk factor for catheter removal and peritonitis. An estimated 20% of all peritonitis cases are preceded by an ESI, with up to 50% of Staphylococcus aureus peritonitis associated with ESI. Gram-negative ESIs are less associated with succeeding peritonitis than their gram-positive counterparts, though when present, are associated with a lower peritonitis cure rate. The rate of catheter removal for refractory ESI is relatively highest in ESI due to mycobacteria (up to 40%), S. aureus (35%), Pseudomonas aeruginosa (28%), followed by Corynebacterium, Serratia, and fungi. In review of relevant literature, we found no prophylactic benefit of dressings over nondressings, specific antiseptics over normal saline, or topical honey over topical antibiotic prophylaxis, and thus recommend individualized exit site hygiene. We found topical gentamicin effective for prevention of most ESIs, including gram-negative ESIs, and thus recommend consideration of prophylactic topical gentamicin in areas of high gram-negative peritonitis incidence. With long-term use, observational studies detect up to 25% of gram-positive and 14% of gram-negative ESIs may be mupirocin and gentamicin resistant, respectively. We review empiric and targeted ESI management, including indications for ultrasound, anti-VMRSA, anti-Pseudomonal, and anti-mycobacterial antibiotic use, and catheter removal. We recommend further investigation into the earlier use of second-line treatment agents and the utility of treating post-infectious exit site colonization as avenues to decrease refractory and repeat ESI.

Dressing <em>versus</em> non-dressing technique for long-term exit-site care in children on continuous ambulatory peritoneal dialysis: a single-center retrospective cohort study

BACKGROUND There is no consensus on the optimal long-term exit-site care strategy in children on long-term peritoneal dialysis (PD) worldwide. Thus, this study aimed to compared the dressing versus non-dressing technique for long-term exit-site care to prevent PD-related infection. METHODS This retrospective cohort study involved patients aged <18 years with end-stage kidney disease who were on continuous ambulatory PD at the Cipto Mangunkusumo Hospital between March 2014 and March 2019. Long-term exit-site care was initiated within 3 months after the insertion of Tenckhoff catheter. The patients and caregivers can choose to either maintain the dressing method or change to the non-dressing method for the subsequent long-term exit-site care. The follow-up was performed until the following 6 months. RESULTS Out of 34 patients, 18 were treated without dressing and 16 with dressing technique. The peritonitis rates were 0.17 and 0.06 episodes per year at risk in the non-dressing and dressing groups; the adjusted incidence rate ratio was 0.4 (95% confidence interval = 0.04–3.25; p = 0.4). Allergic contact dermatitis occurred in 15/18 (83%) patients in the non-dressing group and 11/16 (69%) in the dressing group before long-term exit-site care was applied. Ultimately, no patient in the non-dressing group developed allergic contact dermatitis, whereas 11 (69%) had allergic contact dermatitis in the dressing group at the end of follow-up. CONCLUSIONS Non-dressing technique may increase the risk of peritonitis in children on long-term PD; however, it is beneficial for children vulnerable to allergic contact dermatitis.

Are Antimicrobial Peptide Dendrimers an Escape from ESKAPE?

Significance: The crisis of antimicrobial resistance (AMR) increases dramatically despite all efforts to use available antibiotics or last resort antimicrobial agents. The spread of the AMR, declared as one of the most important health-related issues, warrants the development of new antimicrobial strategies. Recent Advances: Antimicrobial peptides (AMPs) and AMP dendrimers (AMPDs), as well as polymer dendrimers are relatively new and promising strategies with the potential to overcome drug resistance issues arising in ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species) colonizing chronic wounds. Critical Issues: AMPs-AMPDs suffer from limited efficacy, short-lasting bioactivity, and concerns of toxicity. To circumvent these drawbacks, their covalent coupling to biopolymers and/or encapsulation into different drug carrier systems is investigated, with a special focus on topical applications. Future Directions: Scientists and the pharmaceutical industry should focus on this challenging subject to either improve the activity of existing antimicrobial agents or find new drug candidates. The focus should be put on the discovery of new drugs or the combination of existing drugs for a better synergy, taking into account all kinds of wounds and existing pathogens, and more specifically on the development of next-generation antimicrobial peptides, encompassing the delivery carrier toward improved pharmacokinetics and efficacy.

Topical application of mupirocin to exit sites in patients on peritoneal dialysis: a systematic review and meta-analysis of randomized controlled trials

Background

The International Society for Peritoneal Dialysis guidelines recommends the topical application of antibiotics on the exit site for the prevention of peritoneal dialysis (PD)-related infections. However, the recommendation is based on meta-analyses on applying nasal mupirocin ointment or observational or retrospective studies. Here, we evaluated the efficacy of topical application of mupirocin on the exit site for the prevention of PD-related infections.

Methods

We searched the databases, MEDLINE and CENTRAL, documenting the topical application of antibiotics on the exit site in PD patients in April 2017. We included only randomized controlled trials (RCTs) with adult patients wherein the effects of mupirocin were examined. Exit site infection (ESI), peritonitis, and technical failure were assessed as the main outcomes.

Results

Overall, six RCTs were included in this study. It was uncertain whether the application of mupirocin ointment prevents ESI (rate ratio (RR), 0.36; 95% CI, 0.13–1.05), peritonitis (RR 0.78, 95% CI 0.50–1.21), and technical failure (RR, 1.35; 95% CI, 0.25–7.21). Moreover, a comparison between mupirocin and gentamicin showed no difference in the incidence of ESI (RR, 1.14; 95% CI, 0.27–4.81), peritonitis (RR, 0.85; 95% CI, 0.32–2.26), and technical failure (RR, 0.58; 95% CI, 0.28–1.20).

Conclusions

It remains unclear whether topical application of mupirocin on the exit site has any significant effects on PD-related infection or technical failure. Large-scale RCTs with high methodological quality are required to confirm the efficacy of topical application of antibiotics on the exit site.

Trial registration

UMINR000039267

Effect of Local Polyhexanide Application in Preventing Exit-Site Infection and Peritonitis: A Randomized Controlled Trial

Topical antibiotic and antiseptic agents have been documented to reduce exit-site infection (ESI) and peritonitis in PD. The aim of this randomized controlled study was to evaluate the efficacy of polyhexanide in the prevention of ESI and peritonitis. Patients were excluded if they had active infection, > 18 years of age, ESI and peritonitis within the previous 4 weeks, received PD for less than 3-months and history of allergy to either drug. All patients were followed up until catheter removal, death, switch to dialysis, transplantation or the end of the study. ESI, tunnel infection, peritonitis, catheter removal and microorganism cause of catheter-related infection were recorded prospectively during clinic follow-up. A total of 88 patients (41 povidone-iodine group; 47 polyhexanide group) were enrolled with a total follow-up duration of 480 and 555 patient-months for povidone-iodine and alternating group, respectively. There were no significant differences in the age, sex, BMI, time of PD, rate of DM, and S. aureus carriage state. A total of 8 ESI and 25 peritonitis episodes were detected during the study. ESI and peritonitis rates tended to be lower in polyhexanide group compared with the povidone-iodine group (0.06 episodes/patient-year vs. 0.12 episodes/patient-year; 0.26 episodes/patient-year vs. 0.32 episodes/patient-year, respectively), but were not significant statistically. Moreover, catheter removal was similar in both groups (0.04 / patient-year vs. 0.05 / patient-year). Polyhexanide is efficient and safe for the prevention of ESI and peritonitis and it may be used as an alternative procedure for the care of healthy exit sites.

Effects of Preoperative Iodine Administration on Thyroidectomy for Hyperthyroidism: A Systematic Review and Meta-analysis

OBJECTIVE

The current guidelines recommend that potassium iodide be given in the immediate preoperative period for patients with Graves' disease who are undergoing thyroidectomy. Nonetheless, the evidence behind this recommendation is tenuous. The purpose of this study is to clarify the benefits of preoperative iodine administration from published comparative studies.

DATA SOURCES

We searched PubMed, Embase, Cochrane, and CINAHL from 1980 to June 2018.

REVIEW METHODS

Studies were included that compared preoperative iodine administration and no premedication before thyroidectomy. For the meta-analysis, studies were pooled with the random-effects model.

RESULTS

A total of 510 patients were divided into the iodine (n = 223) and control (n = 287) groups from 9 selected studies. Preoperative iodine administration was significantly associated with decreased thyroid vascularity and intraoperative blood loss. Significant heterogeneity was present among studies. We found no significant difference in thyroid volume or operative time. Furthermore, the meta-analysis showed no difference in the risk of postoperative complications, including vocal cord palsy, hypoparathyroidism/hypocalcemia, and hemorrhage or hematoma after thyroidectomy.

CONCLUSION

Preoperative iodine administration decreases thyroid vascularity and intraoperative blood loss. Nonetheless, it does not translate to more clinically meaningful differences in terms of operative time and postoperative complications.