FP568INCIDENCE OF EXIT-SITE INFECTION IN PERITONEAL DIALYSIS PATIENTS WITHOUT ANTIBIOTIC PROPHYLAXIS

Abstract

Introduction and Aims: Exit-site infection (ESI) is a major cause of morbidity in peritoneal dialysis (PD) patients; its prevention is the primary goal of exit-site care. A number of protocols for the prevention of PD-related infections have been proposed. Daily application of mupirocin to the skin around the exit-site has been effective in reducing S. aureus ESI and peritonitis in several reports. Gentamycin cream is a possible alternative. However, the possibility of antibiotic resistance developing is a growing problem. The International Society of Peritoneal Dialysis guidelines recommend prophylaxis with topical antibiotic either at the catheter exit-site or intranasally or both in all PD patients. However, studies on prevention of PD-related infections are still limited both in number and in quality, and guidelines are therefore not yet appropriate. The aim of our study was to evaluate the incidence of ESI during a six-year period in a cohort of patients not on prophylaxis therapy. Methods: The rates of ESI in a population of prevalent and incident PD patients at our Center from 1st January 2009 to 31st December 2014 was examined. Routine exit-site care by the patient consists of flat dressing after daily cleansing with chlorhexidine and sodium hypochlorite 0.115%. Exit-sites are evaluated routinely at our Center at every extension set change and at every change of the appearance of exit-site. An ESI was defined by the presence of at least one of the following: swelling, pain, redness, or drainage from the exit-site. Additional features of inflammation are regression of epidermis and exuberance of granulation tissue ('proud flesh'). Results: During the six-year study, 82/479 (17%) PD patients (44 M, 38 F), developed an ESI (overall 125 events, 0.28 episode/patient-year). Twenty-seven (33%) patients suffered from 2 or more episodes. Microbiology of ESIs is reported in table 1. Average peritonitis rate was 1 episode/45 patient-months. Treatment consisted of empiric topic antibiotic therapy in 122 cases, possibly modified on the basis of the susceptibility testing results; systemic antibiotic was added in 55 cases; local antibiotic infiltration in 30 cases; cutaneous caustication with silver nitrate in 23 cases. Complete resolution of the infection was observed in 103 cases (82.4%); in 6 patients ESIs was still in progress at the end of the period of observation. Two patients died while being still under treatment for an ESI (one from sepsis caused by S. aureus, the same agent isolated from the exit-site). Surgical therapy was required in 25 cases (20%), with external cuff removal or cuff shaving in 11 cases (8.8%) and catheter avulsion or replacement in 14 cases (11.2%). ESIs were complicated by subsequent peritonitis with the same bacterial strain in 5 cases (4%, 3 from P. aeruginosa and 2 from S. aureus), all requiring catheter avulsion. Conclusions: Despite prophylaxis therapy is not routinely adopted in our Centre, the incidence of ESIs was low: 0.28 episode per patient-year, near the best results reported in current literature (0.20-0.80 episode per patient-year); only 5/125 events (4%) were complicated by peritonitis. Further studies are required to assess whether strategies to improve the early detection of ESIs may be useful in the prevention of peritonitis and serve to question whether current treatment of ESIs is beneficial. (Table Presented).