Outcome and clinical implications of a surveillance and treatment program for Staphylococcus aureus nasal carriage in peritoneal dialysis patients.

Staphylococcus aureus nasal carriage (SANC) is a risk factor for development of S. aureus dialysis-related infections. Reported here are results of a SANC surveillance and treatment program employed by our dialysis unit over a two-year period. Surveillance nasal cultures were performed at 3-month intervals in 129 peritoneal dialysis patients. Those with SANC applied mupirocin ointment intranasally 3 times daily for 5 consecutive days for 3 consecutive months. Treatment was repeated only when subsequent cultures showed SANC. Infection and catheter loss rates were compared to 63 historical controls, and between SANC and non SANC patients of the study group. Patients who were initially non carriers showed increasing probability for acquiring SANC throughout the study period. Following treatment, the probability for recurrence of SANC was 26%, 41%, 58%, and 62% at 1, 3, 6, and 12 months. The rates of S. aureus exit-site or tunnel infection (p = 0.36), peritonitis (p = 0.0002), and catheter loss (p = 0.01) were lower in the study group as compared to controls. Despite treatment, SANC patients demonstrated a twofold increase in exit-site/tunnel infection rate (p = 0.03) and a threefold increase in catheter loss rate (p = 0.1) as compared to non SANC patients. The high rate of SANC recurrence and the long interval between surveillance cultures may explain the failure of the current protocol to completely eliminate the risk for S. aureus infections. The results support a change in the treatment plan to that of continuing the monthly mupirocin regimen indefinitely once SANC has been identified.

Dialysis catheter infection related peritonitis: incidence and time dependent risk.

The aim of this study was to conduct an in-depth analysis of the relationship of exit site and tunnel infection (ES/TI) to peritonitis and catheter loss in peritoneal dialysis patients, with emphasis on the incidence and risk of infection over time. Bacterial epidemiologies of 63 consecutively implanted catheters were studied for a combined total of 1,248 dialysis months. Analyses of bacterial profiles, infection rates, probabilities of time to first infection, and catheter survival were performed. The probability of first ES/TI and peritonitis was greatest during the first postimplant year. The earlier in dialysis history that patients developed an infection, the more infection prone they continued to be during the course of their dialysis experience. Staphylococcus aureus was the predominant organism for both ES/TI and peritonitis. The incidence of S. aureus infection was greatest during the first year and decreased over time on dialysis. S. aureus ES/TI caused significant risk for subsequent development of peritonitis, and 93% of ES/TI related peritonitis episodes were caused by this organism. Half of all ES/TIs that led to related peritonitis occurred by 3.5 months, and 100% by 12.8 months postimplant. S. aureus ES/TI related peritonitis led to catheter loss in 85% of cases. Our study identified a high risk period for infection for as long as 12 months postimplant. The inherent characteristics of ES/TI related peritonitis suggest that prevention should focus on both the organism and time period at risk. These findings are important in considering issues regarding S. aureus prophylaxis regimens versus nasal carrier treatment protocols.

The risk of infection and peritoneal catheter loss from implant procedure exit-site trauma.

OBJECTIVE: To evaluate the role of skin and subcutaneous tissue trauma at the time of catheter implant procedure as a determinant of catheter loss from infectious complications. DESIGN: Nonrandomized study with prospective collection of data. PATIENTS: Consecutive patients were divided into three groups based upon how the catheter was exited through the skin: group 1, procedure involved pulling tubing, with a permanently bonded catheter adapter, through the exit-site wound (n = 43); group 2, same as group 1 except exit wounds were closed around the catheter with a suture (n = 20); group 3, procedure involved pulling only tubing through the exit wound (n = 61). SETTING: Primary medical center for a health maintenance organization. MAIN OUTCOME MEASURES: Log rank comparisons of Kaplan-Meier analyses of first occurrences of infectious events and overall catheter survival. RESULTS: The risk of first exit-site infection (p < 0.001), tunnel infection (p < 0.001), catheter infection-related peritonitis (p < 0.001), and catheter loss (p < 0.01) were greatest in group 1 with large exit wounds, and lowest in group 3 with small exit wounds. CONCLUSIONS: The study demonstrates the importance of careful dissection and exit-site construction. The exit site should consist of the smallest hole possible that permits passage of only the tubing and leaves the skin snug around the catheter. The present report incriminates catheter designs employing permanently bonded adapters that result in large pericannular wounds that are prone to infection and catheter loss.

Long-term experience with polyurethane, pail handle, coiled tip peritoneal dialysis catheters.

Long-term experience with 63 polyurethane, pail handle, coiled tip peritoneal dialysis catheters surgically implanted in 57 consecutive patients with renal failure is presented. One hundred percent follow-up of the study group represented 1,248 patient-months of observation. Cumulative catheter survival rates were 80.8% at 12 months, 62.3% at 24 months, and 48.1% through 51 months. Catheter half-life was 32.6 months. Infection was the most frequent catheter related complication. Incidence rate of peritonitis was 0.73, and exit site/tunnel infection was 0.42 episodes per patient-year. Median time to first episode was 11.7 months for peritonitis, and 26.3 months for exit site/tunnel infection. Infection led to removal of 28.6% of implanted devices, mechanical blockage resulted in 6.4% loss, and pericatheter leak and tubing break each accounted for 1.6% of catheter removals. The polyurethane, pail handle, coiled tip peritoneal catheter was found to be a reliable long-term access device compared with reported performances of other catheter types. An adverse outcome was identified in the current clinical series with a model design using a permanently attached catheter adapter that caused large exit site wounds that were predisposed to infection and catheter loss.