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

Peritoneal dialysis-related infections in elderly patients

This review outlines the epidemiology, characteristics, risk factors, and prognosis of peritoneal dialysis (PD)-related peritonitis, PD catheter-related infections, and the effects of assisted PD in elderly patients from the Japanese perspective. Based on the literature, the incidence of peritonitis is likely to be higher in elderly patients than in younger patients. The most frequent causative bacteria in elderly patients are Gram-positive bacteria, as in adult PD patients, most commonly due to transcatheter infection. However, elderly patients may have difficulty recognizing cloudy drainage fluid due to decreased visual acuity. Hypokalemia, the use of gastric acid suppressants, prophylactic antibiotic use before endoscopy, biocompatible fluids and hypoalbuminemia considered modifiable risk factors for peritonitis. However, the mechanism by which treatment of hypokalemia prevents peritonitis is unknown. Currently, the relationship between gastric acid suppression therapy and peritonitis in elderly patients is debatable, with no evidence to strongly recommend uniform discontinuation of gastric acid suppression therapy. Exit-site infection (ESI) is a major risk factor for the development of peritonitis, and appropriate prevention and management of ESI may reduce infection-related hospitalizations in PD patients. Currently, no randomized, controlled trials have verified the effectiveness of antibiotic application for ESI in Japan, but results from other countries are awaited. In assisted PD, it is extremely important that family members, caregivers, and nurses who support the procedure receive sufficient education and training from medical professionals familiar with PD. Early detection and treatment of PD-related infections are required because the risk of death increases in elderly patients.

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

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

Incertidumbre durante la atención enfermera en el cuidado del orificio de salida sano del catéter peritoneal

Estimado editor jefe de la revista Enfermería Nefrológica,Desde mi responsabilidad como vocal de diálisis peritoneal de la Sociedad Española de Enfermería Nefrológica (SEDEN), me gustaría aportar unas reflexiones acerca de la cura del orificio de salida sano del catéter peritoneal para centrar el enfoque de la evidencia aplicada a la práctica clínica. Uno de los objetivos de la atención enfermera en el ámbito de la diálisis peritoneal es prevenir y tratar las infecciones relacionadas con el catéter, para evitar una complicación mayor, la peritonitis. Como postula la International Society Peritoneal Dialysis (ISPD) en 20171.