1
|
Dukes KC, Hockett Sherlock S, Racila AM, Herwaldt LA, Jacob J, Vijayan A, Kellogg J, Pegues D, Tolomeo PC, Cobb J, Fraer M, Bleasdale SC, Ward MA, Lindsey B, Schweizer ML. Implementing nasal povidone-iodine decolonization to reduce infections in hemodialysis units: a qualitative assessment. Infect Control Hosp Epidemiol 2024:1-6. [PMID: 38779819 DOI: 10.1017/ice.2024.83] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
BACKGROUND A substantial proportion of patients undergoing hemodialysis carry Staphylococcus aureus in their noses, and carriers are at increased risk of S. aureus bloodstream infections. Our pragmatic clinical trial implemented nasal povidone-iodine (PVI) decolonization for the prevention of bloodstream infections in the novel setting of hemodialysis units. OBJECTIVE We aimed to identify pragmatic strategies for implementing PVI decolonization among patients in outpatient hemodialysis units. DESIGN Qualitative descriptive study. SETTING Outpatient hemodialysis units affiliated with five US academic medical centers. Units varied in size, patient demographics, and geographic location. INTERVIEWEES Sixty-six interviewees including nurses, hemodialysis technicians, research coordinators, and other personnel. METHODS We conducted interviews with personnel affiliated with all five academic medical centers and conducted thematic analysis of transcripts. RESULTS Hemodialysis units had varied success with patient recruitment, but interviewees reported that patients and healthcare personnel (HCP) found PVI decolonization acceptable and feasible. Leadership support, HCP engagement, and tailored patient-focused tools or strategies facilitated patient engagement and PVI implementation. Interviewees reported both patients and HCP sometimes underestimated patients' infection risks and experienced infection-prevention fatigue. Other HCP barriers included limited staffing and poor staff engagement. Patient barriers included high health burdens, language barriers, memory issues, and lack of social support. CONCLUSION Our qualitative study suggests that PVI decolonization would be acceptable to patients and clinical personnel, and implementation is feasible for outpatient hemodialysis units. Hemodialysis units could facilitate implementation by engaging unit leaders, patients and personnel, and developing education for patients about their infection risk.
Collapse
Affiliation(s)
- Kimberly C Dukes
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
- Center for Access & Delivery Research & Evaluations (CADRE), Iowa City Veterans Affairs (VA) Health Care System (ICVAHCS), Iowa City, IA, USA
- College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Stacey Hockett Sherlock
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
- Center for Access & Delivery Research & Evaluations (CADRE), Iowa City Veterans Affairs (VA) Health Care System (ICVAHCS), Iowa City, IA, USA
| | - A M Racila
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
- Center for Access & Delivery Research & Evaluations (CADRE), Iowa City Veterans Affairs (VA) Health Care System (ICVAHCS), Iowa City, IA, USA
| | - Loreen A Herwaldt
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
- College of Public Health, University of Iowa, Iowa City, IA, USA
- University of Iowa Hospitals & Clinics, Iowa City, IA, USA
| | - Jesse Jacob
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Anitha Vijayan
- Department of Nephrology, Intermountain Health, Salt Lake City, UT, USA
| | - Joseph Kellogg
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - David Pegues
- Division of Infectious Diseases, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Division of Infectious Diseases, Perelman School of Medicine, Philadelphia, PA, USA
| | - Pam C Tolomeo
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA, USA
| | - Jason Cobb
- Renal Division, Emory University School of Medicine, Atlanta, GA, USA
| | - Mony Fraer
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
- University of Iowa Hospitals & Clinics, Iowa City, IA, USA
| | - Susan C Bleasdale
- University of Illinois Hospital & Health Sciences System, Chicago, IL, USA
- University of Illinois at Chicago, Chicago, IL, USA
| | - Melissa A Ward
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | | | - Marin L Schweizer
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| |
Collapse
|
2
|
A tale of two intensive care units (ICUs): Baseline Staphylococcus aureus colonization and mupirocin susceptibility in neonatal and pediatric patients requiring intensive care. Infect Control Hosp Epidemiol 2023; 44:447-452. [PMID: 35450544 PMCID: PMC10015265 DOI: 10.1017/ice.2022.96] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To assess the incidence rate of S. aureus colonization at baseline along with the mupirocin susceptibility (or resistance) rate in patients in a neonatal intensive care unit (NICU) and a pediatric intensive care unit (PICU) in conjunction with the implementation of universal decolonization as the standard of care. DESIGN Prospective cohort study. SETTING Children's Hospital of Michigan (CHM) inpatient intensive care units (ICUs). PARTICIPANTS Newly admitted pediatric patients to the CHM NICU or PICU aged between 1 day and ≤21 years. INTERVENTIONS Baseline and follow-up S. aureus screening cultures were obtained before patients underwent universal decolonization with mupirocin 2% antibiotic ointment (intranasal and umbilical) and chlorhexidine baths as standard of care to reduce CLABSI rates. RESULTS Baseline S. aureus colonization rates of new admissions to the CHM NICU and PICU were high at 32% and 29%, respectively. Baseline mupirocin susceptibility to any S. aureus growth was 98.4%. All baseline culture isolates whether positive for MRSA or MSSA, with one exception, had minimum inhibitory concentrations (MICs) of ≤0.19 µg/mL. All follow-up study cultures after universal decolonization at 7 days or beyond with any S. aureus growth had mupirocin MICs of ≤0.125 µg/mL. CONCLUSIONS Baseline S. aureus colonization rates of new admissions to the CHM ICUs were high as was baseline mupirocin susceptibility. Follow-up cultures, albeit limited in number, did not detect increasing mupirocin MICs over 1 year, despite broad mupirocin exposure due to the implementation of universal decolonization.
Collapse
|
3
|
Guía clínica de la Sociedad Española de Nefrología para la prevención y tratamiento de la infección peritoneal en diálisis peritoneal. Nefrologia 2022. [DOI: 10.1016/j.nefro.2021.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
4
|
Jeloka TK, Abraham G, Bhalla AK, Balasubramaniam J, Dutta A, Gokulnath, Gupta A, Jha V, Khanna U, Mahajan S, Nayak KS, Prasad KN, Prasad N, Rathi M, Raju S, Rohit A, Sahay M, Sampathkumar K, Sivakumar V, Varughese S. Continuous Ambulatory Peritoneal Dialysis Peritonitis Guidelines - Consensus Statement of Peritoneal Dialysis Society of India - 2020. Indian J Nephrol 2021; 31:425-434. [PMID: 34880551 PMCID: PMC8597799 DOI: 10.4103/ijn.ijn_73_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 05/08/2019] [Accepted: 06/30/2019] [Indexed: 11/25/2022] Open
Abstract
Continuous ambulatory peritoneal dialysis (CAPD) related peritonitis is a major cause of technique failure, morbidity, and mortality in patients on CAPD. Its prevention and management is key to success of CAPD program. Due to variability in practice, microbiological trends and sensitivity towards antibiotics, there is a need for customized guidelines for management of CAPD related peritonitis (CAPDRP) in India. With this need, Peritoneal Dialysis Society of India (PDSI) organized a structured meeting to discuss various aspects of management of CAPDRP and formulated a consensus agreement which will help in management of patients with CAPDRP.
Collapse
Affiliation(s)
- Tarun K Jeloka
- Department of Nephrology, Aditya Birla Memorial Hospital, Pune, Maharashtra, India
| | - Georgi Abraham
- Department of Nephrology, Madras Medical Mission, Chennai, Tamil Nadu, India
| | - A K Bhalla
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, India
| | - J Balasubramaniam
- Department of Nephrology, Kidney Care Centre, Tirunelveli, Tamil Nadu, India
| | - A Dutta
- Department of Nephrology, Fortis Hospital and Kidney Institute, Kolkata, West Bengal, India
| | - Gokulnath
- Department of Nephrology, Apollo Hospital, Bengaluru, Karnataka, India
| | - Amit Gupta
- Department of Nephrology, Sanjay Gandhi Post Graduate Institute, Lucknow, Uttar Pradesh, India
| | - V Jha
- The George Institute for Global Health, New Delhi, India
| | - Umesh Khanna
- Department of Nephrology, Lancelot Kidney and GI Centre, Mumbai, Maharashtra, India
| | - Sandeep Mahajan
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - K S Nayak
- Department of Nephrology, Virinchi Hospitals, Hyderabad, Telangana, India
| | - K N Prasad
- Department of Microbiology, Sanjay Gandhi Post Graduate Institute, Lucknow, Uttar Pradesh, India
| | - Narayan Prasad
- Department of Nephrology, Sanjay Gandhi Post Graduate Institute, Lucknow, Uttar Pradesh, India
| | - Manish Rathi
- Department of Nephrology, Post Graduate Institute, Chandigarh, India
| | - Sreebhushan Raju
- Department of Nephrology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Anusha Rohit
- Department of Microbiology, Madras Medical Mission, Chennai, Tamil Nadu, India
| | - Manisha Sahay
- Department of Nephrology, Osmania Hospital, Hyderabad, Telangana, India
| | - K Sampathkumar
- Department of Nephrology, Meenakshi Mission Hopsital and Research Centre, Madurai, Tamil Nadu, India
| | - V Sivakumar
- Department of Nephrology, SriVenkateshwara Institute of Medical sciences, Tirupati, Andhra Pradesh, India
| | - Santosh Varughese
- Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
| |
Collapse
|
5
|
Racila AM, O'Shea AMJ, Nair R, Dukes K, Herwaldt LA, Boyken L, Diekema D, Ward MA, Cobb J, Jacob J, Pegues D, Bleasdale S, Vijayan A, Mutneja A, Fraer M, O'Connell-Moore D, Tolomeo P, Mendez M, Jaworski E, Schweizer ML. Using nasal povidone-iodine to prevent bloodstream infections and transmission of Staphylococcus aureus among haemodialysis patients: a stepped-wedge cluster randomised control trial protocol. BMJ Open 2021; 11:e048830. [PMID: 34862278 PMCID: PMC8647395 DOI: 10.1136/bmjopen-2021-048830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Approximately 38% of haemodialysis patients carry Staphylococcus aureus in their noses, and carriers have a nearly four-fold increased risk of S. aureus access-related bloodstream infections (BSIs) compared with non-carriers. Our objective is to determine the clinical efficacy and effectiveness of a novel intervention using nasal povidone-iodine (PVI) to prevent BSIs among patients in haemodialysis units. We will survey patients and conduct qualitative interviews with healthcare workers to identify barriers and facilitators to implementing the intervention. METHODS AND ANALYSIS We will perform an open-label, stepped-wedge cluster randomised trial to assess the effectiveness of nasal PVI compared with standard care. Sixteen outpatient haemodialysis units will participate in the study. The 3-year trial period will be divided into a 4-month baseline period and eight additional 4-month time blocks. The primary outcome of the study will be S. aureus BSI, defined as a S. aureus positive blood culture collected in the outpatient setting or within one calendar day after a hospital admission. The study team will evaluate characteristics of individual patients and the clusters by exposure status (control or intervention) to assess the balance between groups, and calculate descriptive statistics such as average responses separately for control and intervention survey questions. ETHICS AND DISSEMINATION This study has received IRB approval from all study sites. A Data Safety and Monitoring Board will monitor this multicentre clinical trial. We will present our results at international meetings. The study team will publish findings in peer-reviewed journals and make each accepted peer-reviewed manuscript publicly available. TRIAL REGISTRATION NUMBER NCT04210505.
Collapse
Affiliation(s)
- Ana-Monica Racila
- Internal Medicine, The University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
| | - Amy M J O'Shea
- Internal Medicine, The University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
| | - Rajeshwari Nair
- Internal Medicine, The University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
| | - Kimberly Dukes
- Internal Medicine, The University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
| | - Loreen A Herwaldt
- Internal Medicine, The University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
| | - Linda Boyken
- Internal Medicine, The University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
| | - Daniel Diekema
- Internal Medicine, The University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
| | - Melissa A Ward
- Internal Medicine, The University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
| | - Jason Cobb
- Renal Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jesse Jacob
- Emory Antibiotic Resistance Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - David Pegues
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Susan Bleasdale
- Division of Infectious Diseases, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Anitha Vijayan
- Division of Nephrology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Anubha Mutneja
- Division of Nephrology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Mony Fraer
- Internal Medicine, The University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
| | - Debra O'Connell-Moore
- Clinical Research Unit, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Pam Tolomeo
- Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Minerva Mendez
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Erin Jaworski
- Department of Medicine, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Marin L Schweizer
- Internal Medicine, The University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
| |
Collapse
|
6
|
Ito Y, Ryuzaki M, Sugiyama H, Tomo T, Yamashita AC, Ishikawa Y, Ueda A, Kanazawa Y, Kanno Y, Itami N, Ito M, Kawanishi H, Nakayama M, Tsuruya K, Yokoi H, Fukasawa M, Terawaki H, Nishiyama K, Hataya H, Miura K, Hamada R, Nakakura H, Hattori M, Yuasa H, Nakamoto H. Peritoneal Dialysis Guidelines 2019 Part 1 (Position paper of the Japanese Society for Dialysis Therapy). RENAL REPLACEMENT THERAPY 2021. [DOI: 10.1186/s41100-021-00348-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
AbstractApproximately 10 years have passed since the Peritoneal Dialysis Guidelines were formulated in 2009. Much evidence has been reported during the succeeding years, which were not taken into consideration in the previous guidelines, e.g., the next peritoneal dialysis PD trial of encapsulating peritoneal sclerosis (EPS) in Japan, the significance of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), the effects of icodextrin solution, new developments in peritoneal pathology, and a new international recommendation on a proposal for exit-site management. It is essential to incorporate these new developments into the new clinical practice guidelines. Meanwhile, the process of creating such guidelines has changed dramatically worldwide and differs from the process of creating what were “clinical practice guides.” For this revision, we not only conducted systematic reviews using global standard methods but also decided to adopt a two-part structure to create a reference tool, which could be used widely by the society’s members attending a variety of patients. Through a working group consensus, it was decided that Part 1 would present conventional descriptions and Part 2 would pose clinical questions (CQs) in a systematic review format. Thus, Part 1 vastly covers PD that would satisfy the requirements of the members of the Japanese Society for Dialysis Therapy (JSDT). This article is the duplicated publication from the Japanese version of the guidelines and has been reproduced with permission from the JSDT.
Collapse
|
7
|
González-Sanchidrián S, Nacarino-Muriel MDC, García-Girón AM, Fernández-Vivas F, Pazos-Pacheco MDC, Gallego-Domínguez S. Análisis de las infecciones del orificio de salida del catéter peritoneal. Efectividad de un protocolo basado en la aplicación de mupirocina tópica diaria. ENFERMERÍA NEFROLÓGICA 2021. [DOI: 10.37551/s2254-28842021010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Objetivos: Analizar las infecciones del orificio de salida del catéter peritoneal, identificando los principales factores relacionados con las mismas; asimismo se ha comparado la efectividad de un protocolo basado en la utilización diaria de mupirocina tópica en la cura del orificio de salida frente a la utilización suero salino. Material y Método: Estudio observacional, retrospectivo. Recogimos variables demográficas, clínicas, la etiología y evolución de los episodios de infección del orificio en un periodo de 2 años. Utilizamos un protocolo de profilaxis con suero fisiológico y con mupirocina crema al 2%. Resultados: Estudiamos 75 pacientes, edad media 60,3±13,9 años, 66,7% varones, mediana de tiempo en diálisis peritoneal 24,3 meses (rango intercuartílico 11-48,7). La incidencia de infección del orificio de salida fue del 26,7%, el 77% fueron originadas por microorganismos de piel y mucosas. La infección del orificio de salida se relacionó con el estado portador nasal de Staphylococcus aureus (p=0,048) y la extrusión del dacron externo (p=0,004). De los 4 pacientes que presentaron una peritonitis secundaria a la infección del orificio de salida, 3 fueron trasferidos a hemodiálisis (p=0,025). Con el protocolo de antibioterapia tópica diaria se redujo un 68% la tasa de infecciones. Conclusiones: La exteriorización del anillo externo del catéter peritoneal es un factor predisponente de infecciones. La aplicación diaria de mupirocina es una estrategia efectiva para reducir la incidencia de infección del orificio y peritonitis. La erradicación de portadores nasales de Staphylococcus aureus puede contribuir a reducir la pérdida del catéter y la transferencia a hemodiálisis.
Collapse
Affiliation(s)
- Silvia González-Sanchidrián
- Servicio de Nefrología. Hospital San Pedro de Alcántara. Complejo Hospitalario Universitario de Cáceres. Cáceres. España
| | | | - Ana María García-Girón
- Servicio de Nefrología. Hospital San Pedro de Alcántara. Complejo Hospitalario Universitario de Cáceres. Cáceres. España
| | - Fidel Fernández-Vivas
- Servicio de Nefrología. Hospital San Pedro de Alcántara. Complejo Hospitalario Universitario de Cáceres. Cáceres. España
| | - María del Carmen Pazos-Pacheco
- Servicio de Nefrología. Hospital San Pedro de Alcántara. Complejo Hospitalario Universitario de Cáceres. Cáceres. España
| | - Sandra Gallego-Domínguez
- Servicio de Nefrología. Hospital San Pedro de Alcántara. Complejo Hospitalario Universitario de Cáceres. Cáceres. España
| |
Collapse
|
8
|
Abstract
A review is given of 30 years of development in peritoneal dialysis (PD). After a short description of the first 20 years, the main emphasis is put on the last 10 years. Subjects discussed are the increasing use of PD in high-risk populations, peritonitis and other catheter-related problems, adequacy of dialysis and nutrition, patient outcomes in comparison with hemodialysis, and peritoneal membrane changes with time on PD. Topics that have emerged during the last decade and the challenges for the next decennium are discussed. The great importance of quality assurance in fast-growing PD populations and of prevention of long-term membrane alterations are emphasized.
Collapse
Affiliation(s)
- Raymond T. Krediet
- Division of Nephrology, Department of Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| |
Collapse
|
9
|
Gompelman M, Wertheim HFL, Bleeker-Rovers CP, Wanten GJA. Eradication of Staphylococcus aureus colonization by chronic use of mupirocin in patients on home parenteral nutrition. Nutrition 2020; 81:110985. [PMID: 33059128 DOI: 10.1016/j.nut.2020.110985] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/08/2020] [Accepted: 08/19/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Although in other groups Staphylococcus aureus eradication has proven to be an effective infection prevention measure, to our knowledge, no such studies have been performed in patients on home parenteral nutrition (HPN). The aim of this study was to investigate the efficacy of chronic nasal mupirocin use on S. aureus eradication and prevention of catheter related infections in patients on HPN. METHODS This was a cohort study with data collected from adult patients on HPN who were screened for S. aureus carriage. In case of carriage, the patient was instructed to apply mupirocin nasal ointment monthly. Outcomes were the percentage of successful S. aureus eradication and the effect on the incidence of catheter-related infections and development of mupirocin resistance. RESULTS S. aureus nasal carriage was found in 54% of the patients. Eradication was successful in 66% (70 of 106) of patients treated with mupirocin. Overall S. aureus catheter-related infection rates decreased by 50% (P = 0.02). The decrease was mostly due to a drop in central line-associated bloodstream infection (CLABSI) rates (0.26versus 0.1 per 1000 central venous catheter days; P = 0.04). The overall CLABSI rates decreased as well (incidence ratio rate, 0.43; 95% confidence interval. 0.24-0.76; P < 0.01). Low-level mupirocin resistance was observed in four patients. CONCLUSIONS Findings from the present study highlighted the potential usefulness of mupirocin ointment prophylaxis to establish S. aureus eradication in patients on HPN. However, awareness for the development of mupirocin resistance is prudent. Further research needs to be carried out to validate these findings.
Collapse
Affiliation(s)
- Michelle Gompelman
- Intestinal Failure Unit, Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Heiman F L Wertheim
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Chantal P Bleeker-Rovers
- Department of Internal Medicine, Division of Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Geert J A Wanten
- Intestinal Failure Unit, Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| |
Collapse
|
10
|
Troeman DPR, Van Hout D, Kluytmans JAJW. Antimicrobial approaches in the prevention of Staphylococcus aureus infections: a review. J Antimicrob Chemother 2020; 74:281-294. [PMID: 30376041 PMCID: PMC6337897 DOI: 10.1093/jac/dky421] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background The prophylactic application of antimicrobials that are active against Staphylococcus aureus can prevent infections. However, implementation in clinical practice is limited. We have reviewed antimicrobial approaches for the prevention of S. aureus infections. Methods We searched the Cochrane Central Register of Controlled Trials, PubMed/MEDLINE and EMBASE databases and trial registries using synonyms for S. aureus, infections and prevention as search terms. We included randomized controlled trials and systematic reviews only. Results Most studies were conducted with mupirocin. Mupirocin is effective in preventing S. aureus infections in patients receiving dialysis treatment and in surgical patients, particularly if the patients are carriers of S. aureus. The combination of mupirocin and chlorhexidine, but not chlorhexidine alone, is also effective against S. aureus infections. So far, vaccines have not proven successful in protecting against S. aureus infections. Regarding prophylactic povidone-iodine and systemic antibiotics, there is limited evidence supporting their effectiveness against S. aureus infections. Antimicrobial honey has not been proven to be more effective or non-inferior to mupirocin in protecting against S. aureus infections. Conclusions The current evidence supports the use of mupirocin as prophylaxis for preventing infections with S. aureus, particularly in carriers and in the surgical setting or in patients receiving dialysis treatment. Other antimicrobial agents have not been sufficiently proven to be effective so far, or have been proven ineffective. New trials with vaccines and anti-staphylococcal peptides are currently underway and may lead to new preventive strategies in the future.
Collapse
Affiliation(s)
- D P R Troeman
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht (UMCU), Utrecht University, Heidelberglaan 100, 3584 CG Utrecht, The Netherlands
| | - D Van Hout
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht (UMCU), Utrecht University, Heidelberglaan 100, 3584 CG Utrecht, The Netherlands
| | - J A J W Kluytmans
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht (UMCU), Utrecht University, Heidelberglaan 100, 3584 CG Utrecht, The Netherlands.,Department of Infection Control, Amphia Hospital, Molengracht 21, 4818 CK Breda, The Netherlands
| |
Collapse
|
11
|
Boubes K, Shaikh A, Alsauskas Z, Dwyer A. New Directions in Ensuring Catheter Safety. Adv Chronic Kidney Dis 2020; 27:228-235. [PMID: 32891307 DOI: 10.1053/j.ackd.2020.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 01/20/2020] [Accepted: 02/17/2020] [Indexed: 11/11/2022]
Abstract
Tunneled dialysis catheters remain the most common vascular access used to initiate hemodialysis. Unfortunately, their use is associated with higher morbidity and mortality when compared with arteriovenous fistulae or grafts. Different types of catheters with different designs and material properties function differently. Additional devices and medications can be used to decrease the rates of infection and thrombosis. The current available tunneled dialysis catheters remain far from the desired goal and innovation in the field of dialysis vascular access remains in dire need.
Collapse
|
12
|
Boudville N, Johnson DW, Zhao J, Bieber BA, Pisoni RL, Piraino B, Bernardini J, Nessim SJ, Ito Y, Woodrow G, Brown F, Collins J, Kanjanabuch T, Szeto CC, Perl J. Regional variation in the treatment and prevention of peritoneal dialysis-related infections in the Peritoneal Dialysis Outcomes and Practice Patterns Study. Nephrol Dial Transplant 2020; 34:2118-2126. [PMID: 30053214 DOI: 10.1093/ndt/gfy204] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 05/29/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Peritoneal dialysis (PD)-related infections lead to significant morbidity. The International Society for Peritoneal Dialysis (ISPD) guidelines for the prevention and treatment of PD-related infections are based on variable evidence. We describe practice patterns across facilities participating in the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS). METHODS PDOPPS, a prospective cohort study, enrolled nationally representative samples of PD patients in Australia/New Zealand (ANZ), Canada, Thailand, Japan, the UK and the USA. Data on PD-related infection prevention and treatment practices across facilities were obtained from a survey of medical directors'. RESULTS A total of 170 centers, caring for >11 000 patients, were included. The proportion of facilities reporting antibiotic administration at the time of PD catheter insertion was lowest in the USA (63%) and highest in Canada and the UK (100%). Exit-site antimicrobial prophylaxis was variably used across countries, with Japan (4%) and Thailand (28%) having the lowest proportions. Exit-site mupirocin was the predominant exit-site prophylactic strategy in ANZ (56%), Canada (50%) and the UK (47%), while exit-site aminoglycosides were more common in the USA (72%). Empiric Gram-positive peritonitis treatment with vancomycin was most common in the UK (88%) and USA (83%) compared with 10-45% elsewhere. Empiric Gram-negative peritonitis treatment with aminoglycoside therapy was highest in ANZ (72%) and the UK (77%) compared with 10-45% elsewhere. CONCLUSIONS Variation in PD-related infection prevention and treatment strategies exist across countries with limited uptake of ISPD guideline recommendations. Further work will aim to understand the impact these differences have on the wide variation in infection risk between facilities and other clinically relevant PD outcomes.
Collapse
Affiliation(s)
- Neil Boudville
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Junhui Zhao
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | - Brian A Bieber
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | - Beth Piraino
- Department of Medicine, Renal Electrolyte Division, University of Pittsburgh, Pittsburgh, PA, USA
| | - Judith Bernardini
- Department of Medicine, Renal Electrolyte Division, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sharon J Nessim
- Department of Nephrology, Division of Nephrology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Yasuhiko Ito
- Department of Nephrology and Rheumatology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Graham Woodrow
- Department of Nephrology, St James's University Hospital, Leeds, UK
| | - Fiona Brown
- Department of Nephrology, Monash Medical Centre, Clayton, Victoria, Australia
| | - John Collins
- Department of Renal Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Talerngsak Kanjanabuch
- Division of Nephrology, Department of Internal Medicine, and Kidney & Metabolic Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Cheuk-Chun Szeto
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Jeffrey Perl
- Department of Medicine, Division of Nephrology, St. Michael's Hospital and the Keenan Research Center in the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| |
Collapse
|
13
|
Wong SS, Chu KH, Cheuk A, Tsang WK, Fung SK, Chan HW, Tong MK. Prophylaxis against Gram-Positive Organisms Causing Exit-Site Infection and Peritonitis in Continuous Ambulatory Peritoneal Dialysis Patients by Applying Mupirocin Ointment at the Catheter Exit Site. Perit Dial Int 2020. [DOI: 10.1177/089686080302302s32] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective We evaluated the effectiveness of local application of mupirocin ointment at the catheter exit site in preventing exit-site infection and peritonitis attributable to gram-positive organisms in continuous ambulatory peritoneal dialysis patients. Methods This prospective randomized controlled trial included 154 patients. They were randomly allocated to a mupirocin-treated group (group M) and a control group (group C). Group M included 73 patients (47.4%) who were instructed to apply mupirocin ointment to the catheter exit site once daily after the routine daily exit-site dressing. Group C included 81 patients (52.6%) who continued their usual daily exit-site care without applying mupirocin. The two groups were followed to see whether there would be any difference in the frequency of exit-site infection and peritonitis or in the infecting organisms. Results Interim data were collected at 5 months after the start of the study. Those data showed a significantly lower incidence of exit-site infection and peritonitis attributable to gram-positive organisms in group M as compared with group C. The incidence of gram-positive exit-site infection in group C was 1 episode per 36.8 patient–months; in group M, the incidence was 1 episode per ∞ patient–months (0 incidence in 5 months, p < 0.05). The incidence of gram-positive peritonitis in group C was 1 episode per 40.5 patient–months; in group M, the incidence was 1 episode per 365 patient–months ( p < 0.05). Mupirocin treatment had no significant effect on the incidence of exit-site infection and peritonitis attributable to other organisms. Before mupirocin treatment, we saw a trend toward higher infection rates in diabetic patients and nasal carriers of Staphylococcus aureus as compared with non diabetic patients and nasal non carriers, although the differences were not statistically significant. Mupirocin brought the infection rate attributable to gram-positive organisms to an equally low level in diabetic and non-diabetic patients, and in nasal carriers and nasal non carriers of S. aureus. No adverse effect of local application of mupirocin was reported. Conclusion Local application of mupirocin ointment at the catheter exit site is a safe and effective method of preventing exit-site infection and peritonitis involving gram-positive organisms.
Collapse
Affiliation(s)
- Sunny S.H. Wong
- Division of Nephrology, Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong SAR, China
| | - Kwok Hong Chu
- Division of Nephrology, Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong SAR, China
| | - Au Cheuk
- Division of Nephrology, Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong SAR, China
| | - Wai Kay Tsang
- Division of Nephrology, Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong SAR, China
| | - Samuel K.S. Fung
- Division of Nephrology, Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong SAR, China
| | - Hilda W.H. Chan
- Division of Nephrology, Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong SAR, China
| | - Matthew K.L. Tong
- Division of Nephrology, Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong SAR, China
| |
Collapse
|
14
|
Piraino B, Bailie GR, Bernardini J, Boeschoten E, Gupta A, Holmes C, Kuijper EJ, Li PKT, Lye WC, Mujais S, Paterson DL, Fontan MP, Ramos A, Schaefer F, Uttley L. Peritoneal Dialysis-Related Infections Recommendations: 2005 Update. Perit Dial Int 2020. [DOI: 10.1177/089686080502500203] [Citation(s) in RCA: 516] [Impact Index Per Article: 129.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Beth Piraino
- Renal Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Judith Bernardini
- Renal Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Amit Gupta
- Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Clifford Holmes
- Renal Division, Baxter Healthcare Corporation, McGaw Park, Illinois, USA
| | - Ed J. Kuijper
- Department of Medical Microbiology, University Medical Center, Leiden, The Netherlands
| | - Philip Kam-Tao Li
- Department of Medicine & Therapeutics, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong
| | - Wai-Choong Lye
- Centre for Kidney Diseases, Mount Elizabeth Medical Centre, Singapore
| | - Salim Mujais
- Renal Division, Baxter Healthcare Corporation, McGaw Park, Illinois, USA
| | - David L. Paterson
- Division of Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | - Alfonso Ramos
- Division of Nephrology, Hospital General de Zona #2, Instituto Mexicano del Seguro Social, Hermosillo, Mexico
| | - Franz Schaefer
- Pediatric Nephrology Division, University Children's Hospital, Heidelberg, Germany
| | - Linda Uttley
- Renal Dialysis Treatment, Manchester Royal Infirmary, Manchester, United Kingdom
| |
Collapse
|
15
|
Mahajan S, Tiwari SC, Kalra V, Bhowmik DM, Agarwal SK, Dash SC, Kumar P. Effect of Local Mupirocin Application on Exit-Site Infection and Peritonitis in an Indian Peritoneal Dialysis Population. Perit Dial Int 2020. [DOI: 10.1177/089686080502500512] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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.
Collapse
Affiliation(s)
- Sandeep Mahajan
- Department of Nephrology, All India Institute of Medical Sciences, Ansari Nagar
| | - Suresh C. Tiwari
- Department of Nephrology, All India Institute of Medical Sciences, Ansari Nagar
| | - Vikram Kalra
- Department of Nephrology, All India Institute of Medical Sciences, Ansari Nagar
| | - Dipankar M. Bhowmik
- Department of Nephrology, All India Institute of Medical Sciences, Ansari Nagar
| | - Sanjay K. Agarwal
- Department of Nephrology, All India Institute of Medical Sciences, Ansari Nagar
| | - Suresh C. Dash
- Department of Nephrology, All India Institute of Medical Sciences, Ansari Nagar
| | - Parveen Kumar
- Directorate of Health Services, Delhi Government, DHS Headquarters, New Delhi, India
| |
Collapse
|
16
|
Salzer W. Antimicrobial-Resistant Gram-Positive Bacteria in PD Peritonitis and the Newer Antibiotics Used to Treat Them. Perit Dial Int 2020. [DOI: 10.1177/089686080502500402] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The incidence of resistant gram-positive bacteria in nosocomial and, more recently, community-acquired infections is increasing. Staphylococci, because of their natural habitat on the skin, have always been the leading cause of peritonitis in patients receiving peritoneal dialysis (PD). These organisms have demonstrated a remarkable ability to develop resistance to antibiotics, first with penicillin, then antistaphylococcal penicillins (methicillin-resistant Staphylococcus aureus), and more recently, strains expressing resistance to vancomycin (vancomycin-intermediate and vancomycin-resistant S. aureus) have emerged. Enterococci are normal inhabitants of the gastrointestinal tract and occasionally cause PD peritonitis. In the past 15 years, vancomycin-resistant enterococci have emerged as significant pathogens in many areas. In the past 5 years, novel antibiotics that have activity on gram-positive bacteria, including vancomycin-resistant strains, have become available. The problem of resistant gram-positive bacteria in PD peritonitis, their therapy, and the role of these newer agents, quinupristin/dalfopristin, linezolid, and daptomycin, are reviewed.
Collapse
Affiliation(s)
- William Salzer
- University of Missouri–Columbia School of Medicine, Columbia, Missouri, USA
| |
Collapse
|
17
|
Herwaldt LA, Boyken LD, Coffman S, Hochstetler L, Flanigan MJ. Sources of Staphylococcus Aureus for Patients on Continuous Ambulatory Peritoneal Dialysis. Perit Dial Int 2020. [DOI: 10.1177/089686080302300304] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
← Objective This study was designed to determine whether family members and health care workers are a source of Staphylococcus aureus for patients on peritoneal dialysis. ← Design Over 36 months, cultures were obtained from the nares of patients, family members that cared for the patients’ catheters, and health care workers in a dialysis unit. Pulsed-field gel electrophoresis was performed on all S. aureus isolates. ← Setting A university-based peritoneal dialysis program. ← Participants 74 patients, 32 family members, and 17 health care workers. ← Interventions None. ← Main Outcome Measures The number of patients that acquired S. aureusstrains during the study period. ← Results Of the 48 patients whose initial nares cultures were negative, 7 (15%) acquired S. aureus strains. Overall, 24 of 53 (45%) patients that had 2 or more cultures obtained during the study gained strains. Potential sources were not identified for strains gained by 11 (46%) patients. Five patients appeared to acquire their strains from family members; however, other patients also shared related strains; 8 patients acquired strains shared by other patients. ← Conclusions Family members and other patients appeared to be important sources of S. aureus for patients on peritoneal dialysis. Health care workers that carry S. aureus transiently may be important intermediaries. Good hand hygiene is essential to prevent transmission of S. aureus to these susceptible patients.
Collapse
Affiliation(s)
- Loreen A. Herwaldt
- Department of Internal Medicine, University of Iowa College of Medicine, Iowa City, Iowa, USA
- University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Linda D. Boyken
- Department of Internal Medicine, University of Iowa College of Medicine, Iowa City, Iowa, USA
| | - Stacy Coffman
- Department of Internal Medicine, University of Iowa College of Medicine, Iowa City, Iowa, USA
| | - Linda Hochstetler
- Department of Internal Medicine, University of Iowa College of Medicine, Iowa City, Iowa, USA
| | - Michael J. Flanigan
- Department of Internal Medicine, University of Iowa College of Medicine, Iowa City, Iowa, USA
| |
Collapse
|
18
|
Abstract
Heavy bacterial colonization results in exit-site infection. Antiseptic and non antiseptic agents have both been used for exit-site cleansing. An ideal cleansing agent should not only reduce the number of microorganisms, but should also be harmless to the body's defenses and should not interfere with wound healing. In vitro studies using animal cells have demonstrated that some antiseptic agents have adverse effects on wound healing. Strong cytotoxic antiseptics should be discouraged in exit-site cleansing.In choosing an appropriate cleansing agent for exit-site care, the phase of wound healing, the condition of the exit site, and the goal of cleansing should be taken into consideration. Antimicrobial soap is recommended for cleansing a healed exit site, but biocompatible solution is preferred for the postoperative, infected, or traumatized exit site. In vivo studies on the effectiveness of some cleansing agents are still lacking, and clinical study of exit-site cleansing is needed to determine the most effective agents for the task.
Collapse
Affiliation(s)
- Flora S.Y. Wong
- Renal Dialysis Unit, Alice Ho Miu Ling Nethersole Hospital, Hong Kong SAR, China
| |
Collapse
|
19
|
Conly JM, Vas S. Increasing Mupirocin Resistance of Staphylococcus Aureus in CAPD — Should it Continue to be Used as Prophylaxis? Perit Dial Int 2020. [DOI: 10.1177/089686080202200601] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
This editorial summarizes the mechanisms of mupirocin resistance and the conditions that promote its development. While there is increasing evidence that high-level mupirocin resistance is developing during systematic use of mupirocin as prophylaxis against Staphylococcus aureus, the appearance of resistance does not preclude the beneficial effect of regular prophylaxis. Vigilance has to be exercised to notice larger-scale resistance that may require limiting the use of mupirocin.
Collapse
Affiliation(s)
- John M. Conly
- Centre for Antimicrobial Resistance Calgary Laboratory Services Division of Microbiology University of Calgary Calgary, Alberta Division of Nephrology Toronto Western Hospital Toronto, Ontario, Canada
| | - Stephen Vas
- Centre for Antimicrobial Resistance Calgary Laboratory Services Division of Microbiology University of Calgary Calgary, Alberta Division of Nephrology Toronto Western Hospital Toronto, Ontario, Canada
| |
Collapse
|
20
|
Chu KH, Choy WY, Cheung CCW, Fung KS, Tang HL, Lee W, Cheuk A, Yim KF, Chan WHH, Tong KLM. 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 2020. [DOI: 10.1177/089686080802800514] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BackgroundPeritoneal dialysis (PD)-related infections are the major cause of technique failure. Exit-site infections (ESI) can be prevented by local application of antibiotics. Mupirocin (M) is the most extensively studied drug for this application. Long-term use can result in the development of resistance. Gentamicin (G) is an attractive alternative, with both gram-positive and gram-negative activities. We studied the comparative efficacy of G cream versus M ointment in the prevention of PD-related infections in a Chinese cohort.MethodsThis was a prospective study of adult PD patients of the Princess Margaret Hospital, Hong Kong. Patients were excluded if they had active infection, recent ESI or peritonitis, history of allergy to either drug, or were unable to apply the drug or give consent. Patients were taught to apply the drug daily to the exit site after routine exit-site care. Records were tracked prospectively during hospital admissions and clinic follow-ups.Results95 patients were recruited; 14 discontinued the study. The ESI rates were 0.38 and 0.20 episodes/patient-year for the G group and the M group respectively ( p = 0.36). Gram-positive ESI rates were 0.18 and 0 episodes/patient-year for the G group and the M group respectively. Gram-negative ESI rates were 0.20 episodes/patient-year for both groups ( p = 0.62). The overall peritonitis rates were similar in the two groups ( p = 0.91).DiscussionIn addition to good perioperative care and strict exit-site care, local antibiotic application can prevent ESI. Mupirocin has been extensively studied and shown to be effective. Similar if not superior effects of G cream have been demonstrated. In this study, neither antibiotic gave significantly better results in the prevention of either ESI or peritonitis.ConclusionsBoth gentamicin and mupirocin were effective as prophylaxis for ESI. Longer study is required to determine the long-term efficacy and the potential beneficial effect on the prevention of peritonitis.
Collapse
Affiliation(s)
- Kwok Hong Chu
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong, China
| | - Wai Yee Choy
- Department of Pharmacy, Princess Margaret Hospital, Hong Kong, China
| | | | - Ka Shun Fung
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong, China
| | - Hon Lok Tang
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong, China
| | - William Lee
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong, China
| | - Au Cheuk
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong, China
| | - Ka Fai Yim
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong, China
| | - Wai Han Hilda Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong, China
| | | |
Collapse
|
21
|
Lima RC, Barreira A, Cardoso FL, Lima MH, Leite M. Ciprofloxacin and Cefazolin as a Combination for Empirical Initial Therapy of Peritoneal Dialysis-Related Peritonitis: Five-year Follow-up. Perit Dial Int 2020. [DOI: 10.1177/089686080702700113] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The treatment of peritoneal dialysis (PD)-related peritonitis has been a matter of extensive investigation, frequently generating therapeutic trials. Several combinations of antibiotics have served as newer protocols and tended to be efficacious, comfortable, and cost-effective. According to the more recent recommendations from the International Society for Peritoneal Dialysis, the rationale for empirical initial therapy of clinically detected peritonitis in PD patients has been to follow the bacterial profile derived from cultured specimens of PD effluents.The current study describes 5 year's experience with the use of a new antibiotic regimen for the treatment of peritonitis. We herein analyze the outcome of 95 episodes of peritonitis in 54 patients on either automated PD or continuous ambulatory PD at the dialysis unit of the Federal University of Rio de Janeiro. Peritoneal dialysis-related peritonitis was treated with the combination of oral ciprofloxacin and intraperitoneal cefazolin. The observed cure rate was 85.2% and the sensitivity test was observed to be positive for this combination of antibiotics in 88.9% of positive cultures. Of the 14 unsuccessful episodes, 7 were due to catheter colonization and the rest did not respond to the proposed therapy within 48 hours. These 7 cases were also related to peritoneal fluid cultures that were resistant to both ciprofloxacin and cefazolin.From this study, we propose this combination of oral ciprofloxacin and intraperitoneal cefazolin as a first choice for empirical initial therapy of PD-related peritonitis, given its efficacy and low cost. However, in order to apply the most adequate cost-effective therapy, careful examination of the bacterial profile and sensitivities to antibiotics used in each unit is strongly recommended.
Collapse
Affiliation(s)
- Renata C.S. Lima
- Division of Nephrology Hospital Universitário Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - André Barreira
- Division of Nephrology Hospital Universitário Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Fernando L. Cardoso
- Department of Infectious Disease, Hospital Universitário Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcio H.S. Lima
- Division of Nephrology Hospital Universitário Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Maurilo Leite
- Division of Nephrology Hospital Universitário Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| |
Collapse
|
22
|
Piraino B, Bernardini J, Bender FH. An Analysis of Methods to Prevent Peritoneal Dialysis Catheter Infections. Perit Dial Int 2020. [DOI: 10.1177/089686080802800502] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Beth Piraino
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Judith Bernardini
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Filitsa H. Bender
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
23
|
Nochaiwong S, Ruengorn C, Noppakun K, Panyathong S, Dandecha P, Sood MM, Saenjum C, Awiphan R, Sirilun S, Mongkhon P, Chongruksut W, Thavorn K. Comparative Effectiveness of Local Application of Chlorhexidine Gluconate, Mupirocin Ointment, and Normal Saline for the Prevention of Peritoneal Dialysis-related Infections (COSMO-PD Trial): a multicenter randomized, double-blind, controlled protocol. Trials 2019; 20:754. [PMID: 31856900 PMCID: PMC6924023 DOI: 10.1186/s13063-019-3953-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 12/03/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Current international guidelines recommend the use of a daily topical exit-site antimicrobial to prevent peritoneal dialysis (PD)-related infections. Although nonantibiotic-based therapies are appealing because they may limit antimicrobial resistance, no controlled trials have been conducted to compare topical antimicrobial agents with usual exit-site care for the prevention of PD-related infections among the Thai PD population. We propose a controlled three-arm trial to examine the efficacy and safety of a daily chlorhexidine gluconate-impregnated patch versus mupirocin ointment versus usual exit-site care with normal saline for the prevention of PD-related infections. METHODS/DESIGNS This study is a randomized, double-blind, multicenter, active-controlled, clinical trial. Adult patients aged 18 years or older who have end-stage kidney disease and are undergoing PD will be enrolled at three PD Centers in Thailand. A total of 354 PD patients will be randomly assigned to either the 2% chlorhexidine gluconate-impregnated patch, mupirocin ointment, or usual exit-site care with normal saline dressing according to a computer-generated random allocation sequence. Participants will be followed until discontinuation of PD or completion of 24 months. The primary study outcomes are time to first PD-related infection (exit-site/tunnel infection or peritonitis) event and the overall difference in PD-related infection rates between study arms. Secondary study outcomes will include (i) the rate of infection-related catheter removal and PD technique failure, (ii) rate of nasal and exit-site Staphylococcus aureus colonization, (iii) healthcare costs, and (iv) skin reactions and adverse events. We plan to conduct a cost-utility analysis alongside the trial from the perspectives of patients and society. A Markov simulation model will be used to estimate the total cost and health outcome in terms of quality-adjusted life years (QALYs) over a 20-year time horizon. An incremental cost-effectiveness ratio in Thai Baht and U.S. dollars per QALYs gained will be illustrated. A series of probabilistic sensitivity analyses will be conducted to assess the robustness of the cost-utility analysis findings. DISCUSSION The results from this study will provide new clinical and cost-effectiveness evidence to support the best strategy for the prevention of PD-related infections among the Thai PD population. TRIAL REGISTRATION ClinicalTrials.gov, NCT02547103. Registered on September 11, 2015.
Collapse
Affiliation(s)
- Surapon Nochaiwong
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, 50200, Thailand. .,Pharmacoepidemiology and Statistics Research Center (PESRC), Chiang Mai University, Chiang Mai, 50200, Thailand.
| | - Chidchanok Ruengorn
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, 50200, Thailand.,Pharmacoepidemiology and Statistics Research Center (PESRC), Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Kajohnsak Noppakun
- Pharmacoepidemiology and Statistics Research Center (PESRC), Chiang Mai University, Chiang Mai, 50200, Thailand.,Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Setthapon Panyathong
- Pharmacoepidemiology and Statistics Research Center (PESRC), Chiang Mai University, Chiang Mai, 50200, Thailand.,Kidney Center, Nakornping Hospital, Chiang Mai, 50180, Thailand
| | - Phongsak Dandecha
- Division of Nephrology, Department of Internal Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Manish M Sood
- Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, Ontario, K1H 8L6, Canada.,Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Chalermpong Saenjum
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Ratanaporn Awiphan
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, 50200, Thailand.,Pharmacoepidemiology and Statistics Research Center (PESRC), Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Sasithorn Sirilun
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Pajaree Mongkhon
- Pharmacoepidemiology and Statistics Research Center (PESRC), Chiang Mai University, Chiang Mai, 50200, Thailand.,School of Pharmaceutical Sciences, University of Phayao, Muang, Phayao, 56000, Thailand
| | - Wilaiwan Chongruksut
- Pharmacoepidemiology and Statistics Research Center (PESRC), Chiang Mai University, Chiang Mai, 50200, Thailand.,Depertment of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Kednapa Thavorn
- Pharmacoepidemiology and Statistics Research Center (PESRC), Chiang Mai University, Chiang Mai, 50200, Thailand.,Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, Ontario, K1H 8L6, Canada.,School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, K1G 5Z3, Canada.,Institute of Clinical and Evaluative Sciences, ICES uOttawa, Ottawa, Ontario, K1Y 4E9, Canada
| | | |
Collapse
|
24
|
Abstract
BACKGROUND Surgical site infection (SSI) is one of the most common health care-associated infections. Staphylococcus aureus remains the most common etiologic agent causing SSIs. Studies confirm S aureus carriage increases the risk of S aureus SSIs. The purpose of this article is to review the strategies to reduce SSIs due to S aureus focusing on nasal decolonization. RESULTS Published studies indicate screening patients for S aureus nasal carriage and decolonizing carriers during the preoperative period decreases the risk of S aureus SSIs in cardiac and orthopedic surgery. Mupirocin remains the best topical agent at eradicating nasal S aureus however, concerns over resistance have led to development of alternative agents. Nasal povidone-iodine, alcohol-based nasal antiseptic, and photodynamic therapy are promising new interventions, but more studies are needed. CONCLUSIONS Short term nasal mupirocin is still the most studied and effective topical agent in eradicating S aureus nasal colonization. However, increasing mupirocin resistance remains an ongoing concern and newer agents are needed. Currently, preoperative S aureus decolonization often uses combination chlorhexidine gluconate bathing and nasal mupirocin considering that colonization of multiple body sites is commonly seen.
Collapse
Affiliation(s)
- Edward J Septimus
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA; Division of Internal Medicine, Texas A&M College of Medicine, Houston, TX.
| |
Collapse
|
25
|
Kim JJ, Blevins MW, Brooks DJ, Stehle Jr JR, McLouth CJ, Viviano JP, Holmes IV JH, Bischoff WE. Successful control of a methicillin-resistant Staphylococcus aureus outbreak in a burn intensive care unit by addition of universal decolonization with intranasal mupirocin to basic infection prevention measures. Am J Infect Control 2019; 47:661-665. [PMID: 30616934 DOI: 10.1016/j.ajic.2018.11.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Revised: 11/15/2018] [Accepted: 11/26/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Methicillin-resistant Staphylococcus aureus (MRSA) is frequently implicated in health care-associated outbreaks in burn intensive care units, incurring substantial morbidity and mortality to these high-risk patients and excess costs to health care systems. METHODS MRSA health care-associated infections (HAIs) were noted before and after the implementation of basic infection prevention measures and the subsequent implementation of universal decolonization with intranasal mupirocin. Pulsed-field gel electrophoresis was used to determine the relatedness of clinical isolates. A case-control study was conducted to characterize the risk factors for MRSA HAIs. RESULTS Basic interventions failed to decrease the rate of MRSA HAIs, although compliance with these interventions was high throughout the study. MRSA HAIs decreased from 8.53 HAIs per 1,000 patient days before the implementation of intranasal mupirocin to 3.61 HAIs per 1,000 patient days after the implementation of intranasal mupirocin (P = .033). Pulsed-field gel electrophoresis disclosed 10 unique clones with no large clusters. The case-control study revealed a significant association between MRSA HAIs and lengths of stay, body surface area burned, intubation, pressor requirement, leukocytosis, lactic acidosis, development of pneumonia, MRSA colonization, and death. CONCLUSIONS Basic environmental and behavioral interventions fell short of controlling a low-count, sporadic, and multiclonal MRSA outbreak in the burn intensive care unit of a tertiary medical center. However, the added implementation of universal decolonization with intranasal mupirocin was effective. Burn victims with greater disease severity were at higher risk for MRSA HAIs.
Collapse
|
26
|
Szeto CC, Lo WK, Li PK. Clinical practice guidelines for the provision of renal service in Hong Kong: Peritoneal Dialysis. Nephrology (Carlton) 2019; 24 Suppl 1:27-40. [PMID: 30900337 DOI: 10.1111/nep.13505] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Cheuk Chun Szeto
- Carol and Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine and TherapeuticsPrince of Wales Hospital, The Chinese University of Hong Kong Shatin Hong Kong SAR, China
| | - Wai Kei Lo
- Department of MedicineTung Wah Hospital Hong Kong SAR, China
- Dialysis CentreGleneagles Hospital Hong Kong SAR, China
| | - Philip Kam‐Tao Li
- Carol and Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine and TherapeuticsPrince of Wales Hospital, The Chinese University of Hong Kong Shatin Hong Kong SAR, China
| |
Collapse
|
27
|
Parthasarathy R, Kashem T, NicFhogartaigh C, Melzer M, Fan SL. Clinical Value of Screening Peritoneal Dialysis Patients for Bacterial Colonization or Contamination. Perit Dial Int 2019; 39:126-133. [PMID: 30739095 DOI: 10.3747/pdi.2018.00082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 10/08/2018] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION The adoption of the International Society for Peritoneal Dialysis guideline of using mupirocin ointment has been limited by fear of developing mupirocin-resistant organisms. We performed a surveillance program of a large peritoneal dialysis (PD) unit. METHODS We performed 1,175 surveillance swabs from anterior nares, PD catheter exit site, groin, and axilla, from 240 patients. The mean interval between swabs was 3.3 months. RESULTS Colonization by Staphylococcus aureus (S. aureus) or Pseudomonas species was 9.5% and 10.9%, respectively. Despite adopting a universal policy of applying mupirocin to PD catheter exit sites in 2001, no instances of mupirocin-resistant S. aureus were identified. Moreover, patients who grew S. aureus from surveillance swabs did not experience higher peritonitis rates than those with "no growth." This was in contrast to patients who grew Pseudomonas or enteric organisms. There were no differences in patient demographics for those who grew S. aureus, Pseudomonas, or enteric organisms (compared with "no-growth" patients). CONCLUSION Our results suggest that the application of mupirocin ointment appeared to minimize peritonitis of patients colonized with S. aureus. The use of mupirocin in this patient cohort has not led to mupirocin resistance. The increased peritonitis rate of patients who grew Pseudomonas or enteric organisms is of interest. We propose that greater attention to hygiene and catheter care in these patients is warranted. The increasing use of paid healthcare workers attending patients daily to help perform PD (assisted PD) gives an opportunity for us to address these wider issues.
Collapse
Affiliation(s)
| | - Tasnuva Kashem
- Department of Renal Medicine and Transplantation, Barts Health NHS Trust, London, UK
| | | | - Mark Melzer
- Department of Microbiology, Barts Health NHS Trust, London, UK
| | - Stanley L Fan
- Department of Renal Medicine and Transplantation, Barts Health NHS Trust, London, UK
| |
Collapse
|
28
|
Bieber S, Mehrotra R. Peritoneal Dialysis Access Associated Infections. Adv Chronic Kidney Dis 2019; 26:23-29. [PMID: 30876613 DOI: 10.1053/j.ackd.2018.09.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 09/04/2018] [Accepted: 09/05/2018] [Indexed: 11/11/2022]
Abstract
Infection is a significant driver of morbidity and mortality in patients with end-stage renal disease undergoing maintenance dialysis. In the United States, septicemia and other infections account for 8% deaths in patients undergoing dialysis. In patients undergoing peritoneal dialysis (PD), PD-related peritonitis remains the most frequent treatment-related infection and is the greatest contributor to infection-related morbidity, including risk for hospitalization, and temporary or permanent transfer to hemodialysis. In the 4 decades since the introduction of ambulatory PD in clinical practice, a large number of treatment innovations have been shown to be effective in reducing the risk for exit site infection and PD-related peritonitis. Notwithstanding the evidence for efficacy of these innovations and the numerous adverse health consequences with PD-related peritonitis, the uptake of these interventions in clinical practice around the world remains inconsistent. This article reviews current knowledge with regards to prevention of PD-associated infections, and the diagnosis and management of exit site infections and peritonitis.
Collapse
|
29
|
Current and Emerging Topical Antibacterials and Antiseptics: Agents, Action, and Resistance Patterns. Clin Microbiol Rev 2017; 30:827-860. [PMID: 28592405 DOI: 10.1128/cmr.00112-16] [Citation(s) in RCA: 188] [Impact Index Per Article: 26.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Bacterial skin infections represent some of the most common infectious diseases globally. Prevention and treatment of skin infections can involve application of a topical antimicrobial, which may be an antibiotic (such as mupirocin or fusidic acid) or an antiseptic (such as chlorhexidine or alcohol). However, there is limited evidence to support the widespread prophylactic or therapeutic use of topical agents. Challenges involved in the use of topical antimicrobials include increasing rates of bacterial resistance, local hypersensitivity reactions (particularly to older agents, such as bacitracin), and concerns about the indiscriminate use of antiseptics potentially coselecting for antibiotic resistance. We review the evidence for the major clinical uses of topical antibiotics and antiseptics. In addition, we review the mechanisms of action of common topical agents and define the clinical and molecular epidemiology of antimicrobial resistance in these agents. Moreover, we review the potential use of newer and emerging agents, such as retapamulin and ebselen, and discuss the role of antiseptic agents in preventing bacterial skin infections. A comprehensive understanding of the clinical efficacy and drivers of resistance to topical agents will inform the optimal use of these agents to preserve their activity in the future.
Collapse
|
30
|
Szeto CC, Li PKT, Johnson DW, Bernardini J, Dong J, Figueiredo AE, Ito Y, Kazancioglu R, Moraes T, Van Esch S, Brown EA. ISPD Catheter-Related Infection Recommendations: 2017 Update. Perit Dial Int 2017; 37:141-154. [DOI: 10.3747/pdi.2016.00120] [Citation(s) in RCA: 193] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 09/15/2016] [Indexed: 12/18/2022] Open
Affiliation(s)
- Cheuk-Chun Szeto
- Department of Medicine and Therapeutics, Hammersmith Hospital, London, UK
| | - Philip Kam-Tao Li
- Department of Medicine and Therapeutics, Hammersmith Hospital, London, UK
| | - David W. Johnson
- Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong; Department of Nephrology, Hammersmith Hospital, London, UK
| | - Judith Bernardini
- University of Queensland at Princess Alexandra Hospital, Brisbane, Australia; Renal Electrolyte Division, Hammersmith Hospital, London, UK
| | - Jie Dong
- University of Pittsburgh School of Medicine Pittsburgh, PA, USA; Renal Division, Hammersmith Hospital, London, UK
| | - Ana E. Figueiredo
- Department of Medicine, Peking University First Hospital, Beijing, China; Pontifícia Universidade Católica do Rio Grande do Sul, Hammersmith Hospital, London, UK
| | - Yasuhiko Ito
- FAENFI, Porto Alegre, Brazil; Division of Nephrology, Hammersmith Hospital, London, UK
| | - Rumeyza Kazancioglu
- Nagoya University Graduate School of Medicine, Nagoya, Japan; Division of Nephrology, Hammersmith Hospital, London, UK
| | - Thyago Moraes
- Bezmialem Vakif University, Medical Faculty, Istanbul, Turkey; Pontifícia Universidade Católica do Paraná, Hammersmith Hospital, London, UK
| | - Sadie Van Esch
- Curitiba, Brazil; Elisabeth Tweesteden Hospital, Hammersmith Hospital, London, UK
| | - Edwina A. Brown
- Nephrology Department and Internal Medicine, Tilburg, Netherlands; and Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, UK
| |
Collapse
|
31
|
Htay H, Johnson DW, Wu SY, Oei EL, Foo MWY, Choo JCJ. Comparison of Topical Chlorhexidine and Mupirocin for the Prevention of Exit-Site Infection in Incident Peritoneal Dialysis Patients. Perit Dial Int 2017; 37:266-272. [PMID: 28183858 DOI: 10.3747/pdi.2016.00257] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 11/22/2016] [Indexed: 11/15/2022] Open
Abstract
♦ OBJECTIVE: Prevention of exit-site infection (ESI) is of paramount importance to peritoneal dialysis (PD) patients. The aim of this study was to evaluate the effectiveness of chlorhexidine in the prevention of ESI in incident PD patients compared with mupirocin. ♦ METHODS: This retrospective, pre-test/post-test observational study included all incident PD patients at Singapore General Hospital from 2012 to 2015. Patients received daily topical exit-site application of either mupirocin (2012 - 2013) or chlorhexidine (2014 - 2015) in addition to routine exit-site cleaning with 10% povidone-iodine. The primary outcome was ESI rate during the 2 time periods. Secondary outcomes were peritonitis rate, times to first ESI and peritonitis, hospitalization rate, and infection-related catheter removal. Event rates were analyzed using Poisson regression, and infection-free survival was estimated using Kaplan-Meier and Cox regression survival analyses. ♦ RESULTS: The study included 162 patients in the mupirocin period (follow-up 141.5 patient-years) and 175 patients in the chlorhexidine period (follow-up 136.9 patient-years). Compared with mupirocin-treated patients, chlorhexidine-treated patients experienced more frequent ESIs (0.22 vs 0.12 episodes/patient-year, p = 0.048), although this was no longer statistically significant following multivariable analysis (incidence rate ratio [IRR] 1.78, 95% confidence interval [CI] 0.98 - 3.26, p = 0.06). No significant differences were observed between the 2 groups with respect to time to first ESI (p = 0.10), peritonitis rate (p = 0.95), time to first peritonitis (p = 0.60), hospitalization rate (p = 0.21) or catheter removal rate (0.03 vs 0.04/patient-year, p = 0.56). ♦ CONCLUSIONS: Topical exit-site application of chlorhexidine cream was associated with a borderline significant, higher rate of ESI in incident PD patients compared with mupirocin cream.
Collapse
Affiliation(s)
- Htay Htay
- Department of Renal Medicine, Singapore General Hospital, Singapore .,Department of Nephrology, Princess Alexandra Hospital, Australia
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Australia.,Australasian Kidney Trials Network, School of Medicine, University of Queensland, Brisbane, Australia.,Translational Research Institute, Brisbane, Australia
| | - Sin Yan Wu
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | | | | | | |
Collapse
|
32
|
Taheri S, Ahmadnia M, Mortazavi M, Karimi S, Reihani H, Seirafian S. Comparing the Effect of Dressing Versus No-dressing on Exit Site Infection and Peritonitis in Chronic Ambulatory Peritoneal Dialysis Patients. Adv Biomed Res 2017; 6:5. [PMID: 28217650 PMCID: PMC5309448 DOI: 10.4103/2277-9175.199263] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Bachground: Peritonitis and exit site (ES) infection are two main complications of peritoneal dialysis. There are some controversies regard to preventive strategies for ES care. In this study we compared peritonitis and ES infection rates in patients with and without dressing. Materials and Methods: This historical cohort study carried out on 72 patients under continuous ambulatory peritoneal dialysis treatment, 54 with dressing versus 18 patients without dressing, followed from October 1, 2010 to March 31, 2011 for peritonitis and ES infection. Results: A total of 17 episodes of ES infection occurred in 12 patients in dressing group, but no case was seen in no-dressing group (P = 0.02). Twenty-one episodes of peritonitis occurred in 15 patients in both groups (one episode every 20.6 patient-months). In no-dressing group two episodes occurred in only one patient (one episode every 54 patient-months), and in dressing group, 19 episode in 14 patients (one episode every 17.1 patient-months) (P = 0.03). Peritonitis was significantly more frequent in male versus female in overall patients (38% vs. 14%, P = 0.025) and in dressing group (52% vs. 15%, P = 0.003). In dressing group, peritonitis was more frequent in diabetics versus non-diabetics (48% vs. 11%, P = 0.01). Odds ratio for developing peritonitis was 9.4 in dressing group (95% confidence interval [CI] =1.05 − 84.4; P = 0.045), and 4.4 in men (95% CI = 1.26 − 15.19; P = 0.02). Conclusion: In this study, chronic ES care without dressing was associated with lower risk of peritonitis and ES infection.
Collapse
Affiliation(s)
- Shahram Taheri
- Isfahan Kidney Diseases Research Center, Department of Internal Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mahdieh Ahmadnia
- Isfahan Kidney Diseases Research Center, Department of Internal Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mojgan Mortazavi
- Isfahan Kidney Diseases Research Center, Department of Internal Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shirin Karimi
- Isfahan Kidney Diseases Research Center, Peritoneal Dialysis Ward, Al-Zahra University Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Homa Reihani
- Isfahan Kidney Diseases Research Center, Peritoneal Dialysis Ward, Al-Zahra University Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shiva Seirafian
- Isfahan Kidney Diseases Research Center, Department of Internal Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| |
Collapse
|
33
|
|
34
|
Abstract
Colonization with health care-associated pathogens such as Staphylococcus aureus, enterococci, Gram-negative organisms, and Clostridium difficile is associated with increased risk of infection. Decolonization is an evidence-based intervention that can be used to prevent health care-associated infections (HAIs). This review evaluates agents used for nasal topical decolonization, topical (e.g., skin) decolonization, oral decolonization, and selective digestive or oropharyngeal decontamination. Although the majority of studies performed to date have focused on S. aureus decolonization, there is increasing interest in how to apply decolonization strategies to reduce infections due to Gram-negative organisms, especially those that are multidrug resistant. Nasal topical decolonization agents reviewed include mupirocin, bacitracin, retapamulin, povidone-iodine, alcohol-based nasal antiseptic, tea tree oil, photodynamic therapy, omiganan pentahydrochloride, and lysostaphin. Mupirocin is still the gold standard agent for S. aureus nasal decolonization, but there is concern about mupirocin resistance, and alternative agents are needed. Of the other nasal decolonization agents, large clinical trials are still needed to evaluate the effectiveness of retapamulin, povidone-iodine, alcohol-based nasal antiseptic, tea tree oil, omiganan pentahydrochloride, and lysostaphin. Given inferior outcomes and increased risk of allergic dermatitis, the use of bacitracin-containing compounds cannot be recommended as a decolonization strategy. Topical decolonization agents reviewed included chlorhexidine gluconate (CHG), hexachlorophane, povidone-iodine, triclosan, and sodium hypochlorite. Of these, CHG is the skin decolonization agent that has the strongest evidence base, and sodium hypochlorite can also be recommended. CHG is associated with prevention of infections due to Gram-positive and Gram-negative organisms as well as Candida. Conversely, triclosan use is discouraged, and topical decolonization with hexachlorophane and povidone-iodine cannot be recommended at this time. There is also evidence to support use of selective digestive decontamination and selective oropharyngeal decontamination, but additional studies are needed to assess resistance to these agents, especially selection for resistance among Gram-negative organisms. The strongest evidence for decolonization is for use among surgical patients as a strategy to prevent surgical site infections.
Collapse
|
35
|
Chlorhexidine for routine PD catheter exit-site care. Int Urol Nephrol 2016; 48:1543-6. [PMID: 27432412 DOI: 10.1007/s11255-016-1370-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 07/11/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Although guidelines suggest the routine use of mupirocin or gentamicin at the exit site of PD catheter, our PD unit has been using chlorhexidine gluconate 0.5 % as exit-site care protocol. The aim of this study was to ascertain whether mupirocin application is superior to the traditionally applied chlorhexidine-regarding prevention of exit-site infections and peritonitis in our unit. METHODS Stable incident and prevalent patients of our unit were randomized to apply mupirocin or chlorhexidine at exit site. The study started on July 1, 2010, and continued till December 2014. End point was the first episode of exit-site infection or peritonitis. RESULTS Sixty-two patients (mean age 58.5 ± 14.6 years) were randomized. At the end of follow-up, there were 33 patients on mupirocin treatment and 29 on chlorhexidine. The two groups had no differences in age, sex, PD vintage or PD mode. The only difference between the two groups was the percentage of patients with diabetes, 28 % in chlorhexidine group versus 10 % in mupirocin group. Mean time of follow-up was 28.46 ± 16.37 months. Twenty-four episodes of infections (peritonitis and exit site) were recorded. Time to first infection episode was 32 months in mupirocin group (95 % CI 21.4-42.5) versus 29 months (95 % CI 8.6-49.4) in chlorhexidine group. The Kaplan-Meier survival analysis revealed no difference in the infections between the two protocols (log-rank test, p = 0.477). CONCLUSIONS Mupirocin is not superior in preventing infections comparing with chlorhexidine in this cohort of patients.
Collapse
|
36
|
Li PKT, Szeto CC, Piraino B, de Arteaga J, Fan S, Figueiredo AE, Fish DN, Goffin E, Kim YL, Salzer W, Struijk DG, Teitelbaum I, Johnson DW. ISPD Peritonitis Recommendations: 2016 Update on Prevention and Treatment. Perit Dial Int 2016; 36:481-508. [PMID: 27282851 PMCID: PMC5033625 DOI: 10.3747/pdi.2016.00078] [Citation(s) in RCA: 619] [Impact Index Per Article: 77.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 05/04/2016] [Indexed: 12/19/2022] Open
Affiliation(s)
- Philip Kam-Tao Li
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Cheuk Chun Szeto
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Beth Piraino
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Javier de Arteaga
- Department of Nephrology, Hospital Privado and Catholic University, Cordoba, Argentina
| | - Stanley Fan
- Department of Renal Medicine and Transplantation, Barts Health NHS Trust, London, UK
| | - Ana E Figueiredo
- Nursing School-FAENFI, Pontificia Universidade Catolica do Rio Grande do Sul, Porto Alegre, Brazil
| | - Douglas N Fish
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA
| | - Eric Goffin
- Department of Nephrology, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Belgium
| | - Yong-Lim Kim
- Department of Internal Medicine, Kyungpook National University School of Medicine, Clinical Research Center for End Stage Renal Disease, Daegu, Korea
| | - William Salzer
- University of Missouri-Columbia School of Medicine, Department of Internal Medicine, Section of Infectious Disease, MI, USA
| | - Dirk G Struijk
- Department of Nephrology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | | - David W Johnson
- Department of Nephrology, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia
| |
Collapse
|
37
|
Torres EG, Lindmair-Snell JM, Langan JW, Burnikel BG. Is Preoperative Nasal Povidone-Iodine as Efficient and Cost-Effective as Standard Methicillin-Resistant Staphylococcus aureus Screening Protocol in Total Joint Arthroplasty? J Arthroplasty 2016; 31:215-8. [PMID: 26521129 DOI: 10.1016/j.arth.2015.09.030] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 09/04/2015] [Accepted: 09/15/2015] [Indexed: 02/01/2023] Open
Abstract
The purpose of this study was to compare nasal povidone-iodine swab for total joint arthroplasty patients to methicillin-resistant Staphylococcus aureus (MRSA) screening on the incidence of 90-day postoperative surgical site infections in total knee and hip arthroplasties as well as the cost-effectiveness. This is a single-center retrospective review of primary or revision total knee or hip arthroplasty patients. There were 849 patients screened for MRSA and 1004 patients in the nasal swab groups, both with an infection rate of 0.8%. The mean cost for the nasal swab was $27.21 (SD, 0), significantly different (P ≤ .01) than the mean cost for MRSA screens, $121.16 (SD, 26.18). There were significant cost savings with no difference in infection rates; therefore, nasal povidone-iodine swab antiseptic is financially and clinically successful.
Collapse
Affiliation(s)
| | | | | | - Brian G Burnikel
- Steadman Hawkins Clinic of the Carolinas, Greenville Health System, Greenville, South Carolina
| |
Collapse
|
38
|
Clinical and Molecular Features of Decreased Chlorhexidine Susceptibility among Nosocomial Staphylococcus aureus Isolates at Texas Children's Hospital. Antimicrob Agents Chemother 2015; 60:1121-8. [PMID: 26666947 DOI: 10.1128/aac.02011-15] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 12/03/2015] [Indexed: 01/18/2023] Open
Abstract
One of the strategies utilized to decrease infections in the hospital setting relies on topical antimicrobials and antiseptics. While their use is beneficial, concerns arise over the potential to develop resistance or tolerance to these agents. We examined nosocomial Staphylococcus aureus isolates from 2007 to 2013 for the presence of genes associated with tolerance to chlorhexidine. Isolates and patients were identified from an S. aureus surveillance study at Texas Children's Hospital. Nosocomial S. aureus isolates (those causing infection at ≥72 h of hospitalization) were identified and underwent PCR for the qacA or qacB (qacA/B) and smr genes associated with elevated minimum bactericidal concentrations of chlorhexidine. Molecular typing with pulsed-field gel electrophoresis (PFGE), multilocus sequence typing (MLST), and agr typing and a review of the medical record were performed. Two hundred forty-seven nosocomial S. aureus infections were identified. Overall, 111 isolates carried one or both genes (44.9%); 33.1% were positive for smr, 22.7% were positive for qacA/B, and 10.9% of the isolates possessed both genes. The smr-positive isolates were more often resistant to methicillin, ciprofloxacin, and/or clindamycin. The isolates positive for qacA/B were more often associated with indwelling central venous catheters and a vancomycin MIC of ≥2 μg/ml. Isolates carrying either smr or qacA/B were associated with a diagnosis of bacteremia. The smr-positive isolates more often belonged to sequence type 8 (ST8) than the isolates that were positive for qacA/B. Mupirocin resistance was detected in 2.8% of the isolates. Antiseptic-tolerant S. aureus strains are common in our children's hospital and are associated with decreased susceptibility to other systemic antimicrobials and with bloodstream infections. Further work is needed to understand the implications that these organisms have on the hospital environment and antiseptic use in the future.
Collapse
|
39
|
Mushahar L, Mei LW, Yusuf WS, Sivathasan S, Kamaruddin N, Idzham NJM. Exit-Site Dressing and Infection in Peritoneal Dialysis: A Randomized Controlled Pilot Trial. Perit Dial Int 2015; 36:135-9. [PMID: 26374836 DOI: 10.3747/pdi.2014.00195] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Accepted: 12/08/2014] [Indexed: 11/15/2022] Open
Abstract
UNLABELLED ♦ OBJECTIVE Peritoneal dialysis (PD)-related infection is a common cause of catheter loss and the main reason for PD drop-out. Exit-site infection (ESI) is a pathway to developing tunnel infection and peritonitis, hence rigorous exit-site care has always been emphasized in PD therapy. The aim of this study was to evaluate the effect of exit-site dressing vs non-dressing on the rate of PD-related infection. ♦ METHODS A prospective randomized controlled study was conducted in prevalent PD patients at the Hospital Tuanku Jaafar Seremban, Negeri Sembilan, Malaysia, from April 2011 until April 2013. All patients were required to perform daily washing of the exit site with antibacterial soap during a shower. In the dressing group (n = 54), patients were required to clean their exit site using povidone-iodine after drying, followed by topical mupirocin antibiotic application to the exit site. The exit site was then covered with a sterile gauze dressing and the catheter immobilized with tape. In the non-dressing group (n = 54), patients were not required to do any further dressing after drying. They were only required to apply mupirocin cream to the exit site and then left the exit site uncovered. The catheter was immobilized with tape. The primary outcome was ESI. The secondary outcomes were evidence of tunnel infection or peritonitis. ♦ RESULTS A total of 97 patients completed the study. There were a total of 12 ESI episodes: 4 episodes in 4 patients in the dressing group vs 8 episodes in 4 patients in the non-dressing group. This corresponds to 1 episode per 241.3 patient-months vs 1 episode per 111.1 patient-months in the dressing and non-dressing groups respectively. Median time to first ESI episode was shorter in the non-dressing than in the dressing group, but not significant (p = 0.25). The incidence of gram-positive ESI in both groups was similar. There were no gram-negative ESI in the non-dressing group compared with 2 in the dressing group. The peritonitis rate was 1 per 37.1 patient-month in the dressing group and 1 per 44.4 patient-months in the non-dressing group. Median time to first peritonitis episode was significantly shorter in the dressing group compared to non-dressing (p = 0.03). There was no impact of dressing disruptions in the occurrence of major PD catheter-related infection. ♦ CONCLUSION Use of a non-dressing technique with only prophylactic topical mupirocin cream application is effective in preventing PD-related infection. The non-dressing technique is more cost-effective and convenient for PD patients, with fewer disposables.
Collapse
Affiliation(s)
- Lily Mushahar
- Department of Nephrology, Hospital Tuanku Ja'afar, Seremban, Negeri Sembilan, Malaysia
| | - Lim Wei Mei
- Department of Nephrology, Hospital Tuanku Ja'afar, Seremban, Negeri Sembilan, Malaysia
| | - Wan Shaariah Yusuf
- Department of Nephrology, Hospital Tuanku Ja'afar, Seremban, Negeri Sembilan, Malaysia
| | - Sudhaharan Sivathasan
- Department of Nephrology, Hospital Tuanku Ja'afar, Seremban, Negeri Sembilan, Malaysia
| | - Norilah Kamaruddin
- Department of Nephrology, Hospital Tuanku Ja'afar, Seremban, Negeri Sembilan, Malaysia
| | | |
Collapse
|
40
|
Zhang L, Badve SV, Pascoe EM, Beller E, Cass A, Clark C, de Zoysa J, Isbel NM, McTaggart S, Morrish AT, Playford EG, Scaria A, Snelling P, Vergara LA, Hawley CM, Johnson DW. The Effect of Exit-Site Antibacterial Honey Versus Nasal Mupirocin Prophylaxis on the Microbiology and Outcomes of Peritoneal Dialysis-Associated Peritonitis and Exit-Site Infections: A Sub-Study of the Honeypot Trial. Perit Dial Int 2015. [PMID: 26224790 DOI: 10.3747/pdi.2014.00206] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
UNLABELLED ♦ BACKGROUND The HONEYPOT study recently reported that daily exit-site application of antibacterial honey was not superior to nasal mupirocin prophylaxis for preventing overall peritoneal dialysis (PD)-related infection. This paper reports a secondary outcome analysis of the HONEYPOT study with respect to exit-site infection (ESI) and peritonitis microbiology, infectious hospitalization and technique failure. ♦ METHODS A total of 371 PD patients were randomized to daily exit-site application of antibacterial honey plus usual exit-site care (N = 186) or intranasal mupirocin prophylaxis (in nasal Staphylococcus aureus carriers only) plus usual exit-site care (control, N = 185). Groups were compared on rates of organism-specific ESI and peritonitis, peritonitis- and infection-associated hospitalization, and technique failure (PD withdrawal). ♦ RESULTS The mean peritonitis rates in the honey and control groups were 0.41 (95% confidence interval [CI] 0.32 - 0.50) and 0.41 (95% CI 0.33 - 0.49) episodes per patient-year, respectively (incidence rate ratio [IRR] 1.01, 95% CI 0.75 - 1.35). When specific causative organisms were examined, no differences were observed between the groups for gram-positive (IRR 0.99, 95% CI 0.66 - 1.49), gram-negative (IRR 0.71, 95% CI 0.39 - 1.29), culture-negative (IRR 2.01, 95% CI 0.91 - 4.42), or polymicrobial peritonitis (IRR 1.08, 95% CI 0.36 - 3.20). Exit-site infection rates were 0.37 (95% CI 0.28 - 0.45) and 0.33 (95% CI 0.26 - 0.40) episodes per patient-year for the honey and control groups, respectively (IRR 1.12, 95% CI 0.81 - 1.53). No significant differences were observed between the groups for gram-positive (IRR 1.10, 95% CI 0.70 - 1.72), gram-negative (IRR: 0.85, 95% CI 0.46 - 1.58), culture-negative (IRR 1.88, 95% CI 0.67 - 5.29), or polymicrobial ESI (IRR 1.00, 95% CI 0.40 - 2.54). Times to first peritonitis-associated and first infection-associated hospitalization were similar in the honey and control groups. The rates of technique failure (PD withdrawal) due to PD-related infection were not significantly different between the groups. ♦ CONCLUSION Compared with standard nasal mupirocin prophylaxis, daily topical exit-site application of antibacterial honey resulted in comparable rates of organism-specific peritonitis and ESI, infection-associated hospitalization, and infection-associated technique failure in PD patients.
Collapse
Affiliation(s)
- Lei Zhang
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Sunil V Badve
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Elaine M Pascoe
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia
| | - Elaine Beller
- Centre for Research in Evidence-Based Practice, Bond University, Gold Coast, Australia
| | - Alan Cass
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia Menzies School of Health Research, Darwin, Australia
| | - Carolyn Clark
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia Department of Nephrology, Nambour Hospital, Nambour, Australia
| | - Janak de Zoysa
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia Department of Renal Medicine, North Shore Hospital, Auckland, New Zealand
| | - Nicole M Isbel
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Steven McTaggart
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia Child & Adolescent Renal Service, Royal Children's and Mater Children's Hospitals, Brisbane, Australia
| | - Alicia T Morrish
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia
| | - E Geoffrey Playford
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia Infection Management Services, Princess Alexandra Hospital, Brisbane, Australia
| | - Anish Scaria
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia
| | - Paul Snelling
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia Department of Nephrology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Liza A Vergara
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia
| | - Carmel M Hawley
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - David W Johnson
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | | |
Collapse
|
41
|
Efficacy of skin and nasal povidone-iodine preparation against mupirocin-resistant methicillin-resistant Staphylococcus aureus and S. aureus within the anterior nares. Antimicrob Agents Chemother 2015; 59:2765-73. [PMID: 25733504 DOI: 10.1128/aac.04624-14] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 02/16/2015] [Indexed: 11/20/2022] Open
Abstract
Mupirocin decolonization of nasal Staphylococcus aureus prior to surgery decreases surgical-site infections; however, treatment requires 5 days, compliance is low, and resistance occurs. In 2010, 3M Company introduced povidone-iodine (PVP-I)-based skin and nasal antiseptic (Skin and Nasal Prep [SNP]). SNP has rapid, broad-spectrum antimicrobial activity. We tested SNP's efficacy using full-thickness tissue (porcine mucosal [PM] and human skin) explant models and human subjects. Prior to or following infection with methicillin-resistant Staphylococcus aureus (MRSA) (mupirocin sensitive and resistant), explants were treated with Betadine ophthalmic preparation (Bet), SNP, or mupirocin (Bactroban nasal ointment [BN]) or left untreated. One hour posttreatment, explants were washed with phosphate-buffered saline (PBS) plus 2% mucin. One, 6, or 12 h later, bacteria were recovered and enumerated. Alternatively, following baseline sampling, human subjects applied two consecutive applications of SNP or saline to their anterior nares. One, 6, and 12 h after application of the preparation (postprep), nasal swabs were obtained, and S. aureus was enumerated. We observed that treatment of infected PM or human skin explants with SNP resulted in >2.0 log10 CFU reduction in MRSA, regardless of mupirocin sensitivity, which was significantly different from the values for BN- and Bet-treated explants and untreated controls 1 h, 6 h, and 12 h after being washed with PBS plus mucin. Swabbing the anterior nares of human subjects with SNP significantly reduced resident S. aureus compared to saline 1, 6, and 12 h postprep. Finally, pretreatment of PM explants with SNP, followed by a mucin rinse prior to infection, completely prevented MRSA infection. We conclude that SNP may be an attractive alternative for reducing the bioburden of anterior nares prior to surgery.
Collapse
|
42
|
Narasimha Krishna V, Allon M. What is the significance of Staphylococcus aureus colonization in hemodialysis patients? Nephron Clin Pract 2015; 129:75-8. [PMID: 25677104 DOI: 10.1159/000375325] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 12/18/2014] [Indexed: 11/19/2022] Open
|
43
|
Boyce JM. Prevention of Central Line–Associated Bloodstream Infections in Hemodialysis Patients. Infect Control Hosp Epidemiol 2015; 33:936-44. [DOI: 10.1086/667369] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
An increasing proportion of central line-associated bloodstream infections (CLABSIs) are seen in outpatient settings. Many of such infections are due to hemodialysis catheters (HD-CLABSIs). Such infections are associated with substantial morbidity, mortality, and excess healthcare costs. Patients who receive dialysis through a catheter are 2–3 times more likely to be hospitalized for infection and to die of septic complications than dialysis patients with grafts or fistulas. Prevention measures include minimizing the use of hemodialysis catheters, use of CLABSI prevention bundles for line insertion and maintenance, and application of antimicrobial ointment to the catheter exit site. Instillation into dialysis catheters of antimicrobial solutions that remain in the catheter lumen between dialyses (antimicrobial lock solutions) has been studied, but it is not yet standard practice in some dialysis units. At least 34 studies have evaluated the impact of antimicrobial lock solutions on HD-CLABSI rates. Thirty-two (94%) of the 34 studies demonstrated reductions in HD-CLABSI rates among patients treated with antimicrobial lock solutions. Recent multicenter randomized controlled trials demonstrated that the use of such solutions resulted in significantly lower HD-CLABSI rates, even though such rates were low in control groups. The available evidence supports more routine use of antimicrobial lock solutions as an HD-CLABSI prevention measure in hemodialysis units.
Collapse
|
44
|
Campbell DJ, Johnson DW, Mudge DW, Gallagher MP, Craig JC. Prevention of peritoneal dialysis-related infections. Nephrol Dial Transplant 2014; 30:1461-72. [DOI: 10.1093/ndt/gfu313] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 09/02/2014] [Indexed: 11/12/2022] Open
|
45
|
Santos C, Pérez-Fontán M, Rodríguez-Carmona A, Calvo-Rodríguez M, López-Muñiz A, López-Calviño B, García-Falcón T. Identification of Targets for Prevention of Peritoneal Catheter Tunnel and Exit-Site Infections in Low Incidence Settings. Perit Dial Int 2014; 36:43-51. [PMID: 25292406 DOI: 10.3747/pdi.2014.00131] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 07/29/2014] [Indexed: 11/15/2022] Open
Abstract
UNLABELLED ♦ BACKGROUND Peritoneal catheter tunnel and exit-site infection (TESI) complicates the clinical course of peritoneal dialysis (PD) patients. Adherence to recommendations for catheter insertion, exit-site care, and management of Staphylococcus aureus (SAu) carriage reduces, but does not abrogate the risk of these infections. ♦ OBJECTIVE To reappraise the risk profile for TESI in an experienced center with a long-term focus on management of SAu carriage and a low incidence of these infections. ♦ METHOD Following a retrospective, observational design, we investigated 665 patients incident on PD. The main study variable was survival to the first episode of TESI. We considered selected demographic, clinical, and technical variables, applying multivariate strategies of analysis. ♦ MAIN RESULTS The overall incidence of TESI was 1 episode/68.5 patient-months. Staphylococcus aureus carriage disclosed at inception of PD (but not if observed sporadically during follow-up) (hazard ratio [HR] 1.53, p = 0.009), PD started shortly after catheter insertion (HR 0.98 per day, p = 0.011), PD after kidney transplant failure (HR 2.18, p = 0.017), lower hemoglobin levels (HR 0.88 per g/dL, p = 0.013) and fast peritoneal transport rates (HR 2.92, p = 0.03) portended an increased risk of TESI. Delaying PD ≥ 30 days after catheter insertion markedly improved the probability of TESI. Carriage of methicillin-resistant SAu since the start of PD was associated with a high incidence of TESI by these bacteria. On the contrary, resistance to mupirocin did not predict such a risk, probably due to the use of an alternative regime in affected patients. ♦ CONCLUSIONS Adherence to current recommendations results in a low incidence of TESI in PD patients. Interventions on specific risk subsets have a potential to bring incidence close to negligible levels. Despite systematic screening and management, SAu carriage is still a predictor of TESI. Antibiotic susceptibility patterns may help to refine stratification of the risk of TESI by these bacteria. Early insertion of the peritoneal catheter should be considered whenever possible, to reduce the risk of later TESI.
Collapse
Affiliation(s)
- Clara Santos
- Division of Nephrology, Vilanova da Gaia/Espinho Hospital Center, Portugal
| | - Miguel Pérez-Fontán
- Health Sciences Faculty, University of A Coruña, Spain Division of Nephrology, University Hospital of A Coruña, Spain
| | | | | | | | | | | |
Collapse
|
46
|
Barbero Allende JM, Romanyk Cabrera J, Montero Ruiz E, Vallés Purroy A, Melgar Molero V, Agudo López R, Gete García L, López Álvarez J. [Eradication of Staphylococcus aureus in carrier patients undergoing joint arthroplasty]. Enferm Infecc Microbiol Clin 2014; 33:95-100. [PMID: 24880651 DOI: 10.1016/j.eimc.2014.03.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Revised: 02/25/2014] [Accepted: 03/03/2014] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Prosthetic joint infection (PJI) is a complication with serious repercussions and its main cause is Staphylococcus aureus. The purpose of this study is to determine whether decolonization of S.aureus carriers helps to reduce the incidence of PJI by S.aureus. MATERIAL AND METHODS An S.aureus screening test was performed on nasal carriers in patients undergoing knee or hip arthroplasty between January and December 2011. Patients with a positive test were treated with intranasal mupirocin and chlorhexidine soap 5 days. The incidence of PJI was compared with patients undergoing the same surgery between January and December 2010. RESULTS A total of 393 joint replacements were performed in 391 patients from the control group, with 416 joint replacements being performed in the intervention group. Colonization study was performed in 382 patients (91.8%), of which 102 were positive (26.7%) and treated. There was 2 PJI due S.aureus compared with 9 in the control group (0.5% vs 2.3%, odds ratio [OR]: 0.2, 95% confidence interval [CI]: 0.4 to 2.3, P=.04). CONCLUSIONS In our study, the detection of colonization and eradication of S.aureus carriers achieved a significant decrease in PJI due to S.aureus compared to a historical group.
Collapse
Affiliation(s)
| | - Juan Romanyk Cabrera
- Servicio de Microbiología, Hospital Príncipe de Asturias, Alcalá de Henares, España
| | - Eduardo Montero Ruiz
- Servicio de Medicina Interna, Hospital Príncipe de Asturias, Alcalá de Henares, España
| | - Alfonso Vallés Purroy
- Servicio de Cirugía Ortopédica y Traumatológica, Hospital Príncipe de Asturias, Alcalá de Henares, España
| | | | - Rosa Agudo López
- Servicio de Medicina Interna, Hospital Príncipe de Asturias, Alcalá de Henares, España
| | - Luis Gete García
- Servicio de Medicina Interna, Hospital Príncipe de Asturias, Alcalá de Henares, España
| | - Joaquín López Álvarez
- Servicio de Medicina Interna, Hospital Príncipe de Asturias, Alcalá de Henares, España
| |
Collapse
|
47
|
Cho Y, Johnson DW. Peritoneal dialysis-related peritonitis: towards improving evidence, practices, and outcomes. Am J Kidney Dis 2014; 64:278-89. [PMID: 24751170 DOI: 10.1053/j.ajkd.2014.02.025] [Citation(s) in RCA: 147] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 02/20/2014] [Indexed: 11/11/2022]
Abstract
Peritonitis is a common serious complication of peritoneal dialysis that results in considerable morbidity, mortality, and health care costs. It also significantly limits the use of this important dialysis modality. Despite its importance as a patient safety issue, peritonitis practices and outcomes vary markedly and unacceptably among different centers, regions, and countries. This article reviews peritonitis risk factors, diagnosis, treatment, and prevention, particularly focusing on potential drivers of variable practices and outcomes, controversial or unresolved areas, and promising avenues warranting further research. Potential strategies for augmenting the existing limited evidence base and reducing the gap between evidence-based best practice and actual practice also are discussed.
Collapse
Affiliation(s)
- Yeoungjee Cho
- Centre for Kidney Disease Research, Translational Research Institute at University of Queensland, Brisbane, Australia; Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - David W Johnson
- Centre for Kidney Disease Research, Translational Research Institute at University of Queensland, Brisbane, Australia; Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia.
| |
Collapse
|
48
|
Wong C, Luk IW, Ip M, You JH. Prevention of gram-positive infections in peritoneal dialysis patients in Hong Kong: a cost-effectiveness analysis. Am J Infect Control 2014; 42:412-6. [PMID: 24679568 DOI: 10.1016/j.ajic.2013.12.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Revised: 12/09/2013] [Accepted: 12/09/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Gram-positive bacteria are the major causative pathogens of peritonitis and exit site infection in patients undergoing peritoneal dialysis (PD). We investigated the cost-effectiveness of regular application of mupirocin at the exit site in PD recipients from the perspective of health care providers in Hong Kong. METHODS A decision tree was designed to simulate outcomes of incident PD patients with and without regular application of mupirocin over a 1-year period. Outcome measures included total direct medical costs, quality-adjusted life-years (QALYs) gained, and gram-positive infection-related mortality rate. Model inputs were derived from the literature. Sensitivity analyses evaluated the impact of uncertainty in all model variables. RESULTS In a base case analysis, the mupirocin group had a higher expected QALY value (0.6496 vs 0.6456), a lower infection-related mortality rate (0.18% vs 1.64%), and a lower total cost per patient (US $258 vs $1661) compared with the control group. The rate of gram-positive peritonitis without mupirocin and the risk of gram-positive peritonitis with mupirocin were influential factors. In 10,000 Monte Carlo simulations, the mupirocin group had significantly lower associated costs, higher QALYs, and a lower mortality rate 99.9% of the time. CONCLUSIONS Topical mupirocin appears to be a cost-effective preventive measure against gram-positive infection in incident patients undergoing PD. The cost-effectiveness of mupirocin is affected by the level of infection risk reduction and subject to resistance against mupirocin.
Collapse
|
49
|
Zacharioudakis IM, Zervou FN, Ziakas PD, Mylonakis E. Meta-analysis of methicillin-resistant Staphylococcus aureus colonization and risk of infection in dialysis patients. J Am Soc Nephrol 2014; 25:2131-41. [PMID: 24652802 DOI: 10.1681/asn.2013091028] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Patients undergoing dialysis are particularly vulnerable to methicillin-resistant Staphylococcus aureus (MRSA) infections. We performed a meta-analysis of published studies to estimate the prevalence of MRSA colonization in dialysis patients, time trends, and long-term risk of subsequent MRSA infections. Our search of the PubMed and Embase databases returned 5743 nonduplicate citations, from which we identified 38 relevant studies that included data on 5596 dialysis patients. The estimated prevalence of MRSA colonization was 6.2% (95% confidence interval [95% CI], 4.2% to 8.5%). The prevalence increased over time but remained stable after 2000. Stratification of patients according to dialysis modality and setting revealed that 7.2% (95% CI, 4.9% to 9.9%) of patients on hemodialysis were colonized with MRSA compared with 1.3% (95% CI, 0.5% to 2.4%) of patients on peritoneal dialysis (P=0.01), and that a statistically significant difference existed in the percentage of colonized inpatients and outpatients (14.2% [95% CI, 8.0% to 21.8%] versus 5.4% [95% CI, 3.5% to 7.7%], respectively; P=0.04). Notably, the risk of developing MRSA infections increased among colonized hemodialysis patients compared with noncolonized patients (relative risk, 11.5 [95% CI, 4.7 to 28.0]). The long-term (6-20 months) probability of developing a MRSA infection was 19% among colonized hemodialysis patients compared with only 2% among noncolonized patients. In summary, 6.2% of dialysis patients are MRSA colonized, and the average prevalence of colonization has remained stable since 2000. Colonization in hemodialysis patients is associated with increased risk of MRSA infection.
Collapse
Affiliation(s)
- Ioannis M Zacharioudakis
- Infectious Diseases Division, Rhode Island Hospital, Providence, Rhode Island; and Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Fainareti N Zervou
- Infectious Diseases Division, Rhode Island Hospital, Providence, Rhode Island; and Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Panayiotis D Ziakas
- Infectious Diseases Division, Rhode Island Hospital, Providence, Rhode Island; and Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Eleftherios Mylonakis
- Infectious Diseases Division, Rhode Island Hospital, Providence, Rhode Island; and Warren Alpert Medical School of Brown University, Providence, Rhode Island
| |
Collapse
|
50
|
Abstract
Reducing the frequency of peritonitis for patients undergoing peritoneal dialysis (PD) continues to be a challenge. This review focuses on recent updates in catheter care and other patient factors that influence infection rates. An experienced nursing staff plays an important role in teaching proper PD technique to new patients, but nursing staff must be cognizant of each patient's unique educational needs. Over time, many patients become less adherent to proper dialysis technique, such as washing hands or wearing a mask. This behavior is associated with higher risk of peritonitis and is modifiable with re-training. Prophylactic antibiotics before PD catheter placement can decrease the infection risk immediately after catheter placement. In addition, some studies suggest that prophylaxis against fungal superinfection after antibiotic exposure is effective in reducing fungal peritonitis, although larger randomized studies are needed before this practice can be recommended for all patients. Over time, exit site and nasal colonization with pathogenic organisms can lead to exit-site infections and peritonitis. For patients with Staphylococcus aureus colonization, exit-site prophylaxis with either mupirocin or gentamicin cream reduces clinical infection with this organism. Although there are limited data for support, antibiotic prophylaxis before gastrointestinal, gynecologic, or dental procedures may also help reduce the risk of peritonitis.
Collapse
Affiliation(s)
- Jonathan H Segal
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | | |
Collapse
|