Exit site infection in Peritoneal dialysis patientYousaf khanRenal Dialysis LecturerIPMS-KMU

Exit site infection Approximately one fifth of peritonitis episode are

temporally associated with exit site and tunnel infection.

Acute exit-site infection is defined as drainage with blood and/or pus from the exit site which may be associated with redness, tenderness, overgrown granulated tissue, and swelling.

Chronic exit-site infection is characterized by granulation tissue at the external exit which is sometimes covered by a large stubborn crust or scab. Pain, redness, and swelling are frequently absent in chronic infections.

Exit site infectionIncidence: Incidence of exit site infection is approximately one

episode every 24 -48 patient months. Patients with previous infections tend to have a higher

frequency of occurrence.

Causes: Exit site infection are predominantly due to S.aureus or

Gram negative organisms particularly Pseudomonas.

S.aureus infection appear to have a distinct pathogenesis as they are associated with nasal and/ or skin carriage of the organsim

Exit site infectionPresentation: Infection round the PD catheter exit site can occur at any

time from insertion of the catheter, Can be graded as Grade 1: area of redness round exit site Grade 2: redness plus small amount of exudate on

dressing, or crusting round exit site. Grade 3: frank pus exuding from exit site Grade 4: abscess at exit site Grade 5: tunnel infection – redness and tenderness on

palpation over subcutaneous tunnel; the diagnosis of tunnel infection can be confirmed by US if necessary, which will show area of loculated fluid along tunnel.

Performing an exit site dressingSupplies: Absorbent perforated dressings, Surgical adhesive tape 1 sterile gallipot, Normal saline 1 packet sterile gauze swabe, 1 alcohol wipe, Alcohol gel Mupirocin nasal ointment or gentamicin cream

Start of procedure: Wash hands with surgical scrub for 1mint Clean work surface with alcowipe Open new dressing ( leave inside wrapper) Open gauze ( leave inside wrapper) Open gallipot ( leave inside wrapper) Fill gallipot with saline solution Remove old dressing

Performing an exit site dressingLooking for infection: Observe dressing- see if there is any staining Observe catheter exit site for sign of infection: redness, swelling pus

or bleeding, tenderness/ pain

Completing dressing change: Apply hand gel and allow to dry Without touching the center of the gauze square, join all 4 corners

together and dip it in to saline solution. Using one circular movement, clean around the catheter, discard

gauze Repeat steps 2 and 3 twice, every time using a new piece of gauze Using gentamicin cream on to the gauze and apply around the exit

site Apply new dressing over the catheter exit site Carefully anchor catheter with tape so that catheter is well

immobilized

Treatment protocolRedness alone No treatment required If redness persists or is associated with itching, consider allergy to

the cleaning fluid or dressing and change to saline alone

Exudate or Pus: It is essential to take a swab for culture before cleaning the exit site The protocol on performing an exit site dressing should be

followed.

Note: Other organism can also be found – follow culture results If no improvement in infection consider catheter removal If tunnel infection present, catheter is more likely to need removal,

particularly if peritonitis also present.

Treatment protocol If infection recurs, consider removal of catheter, particularly if

poor response to another course of antibiotics

If severe subcutaneous infection, patient should be placed on HD and another PD catheter should not be inserted until infection eradicated.

Name DoseAmoxicillin 250 -500 mg bdCefalexin 500 mg bd to tdsCiprofloxacin 250 mg bdClarithromycin 500 mg loading dose, 250 mg

bdErythromycin 500mg qdsFlucolxacillin 250 – 500 mg qdsfluconazole 200 mg od for 2 days, than 100

mg od

Treatment protocol Staphylococcus aureus – flucloxacilllin 250 mg

qds and rifampicin 600 mg PO daily for 2 weeks

MRSA – vancomycin 30 mg/kg IP once a week fro 2 -4 week

Staphylococcus epidermidis – flucloxacillin 250 mg qds PO for 10 – 14 days

Pseudomonas spp – ciprofloxacin 500 mg bd PO and/ or gentamicin 0.6 mg/kg IP daily for 3 weeksCu

ltur

e an

d Se

nsit

ivit

ies

avai

labl

e

Prevention

Prophylactic antibiotics given at the time of catheter insertion reduce the risk of early infection,

Good catheter exit site care will minimize exit site infections.

It is important to reduce the number of S. aureus and Pseudomonas exit site infection as these can result in peritonitis, recurrent exit site infection, tunnel infection and catheter loss.

If MRSA is grown, patient should be placed on full local MRSA eradication protocol and should be isolated from other PD patients

Thanks for Your Attention