Comparison of Topical Chlorhexidine and Mupirocin for the Prevention of Exit-Site Infection in Incident Peritoneal Dialysis Patients

Prevalence and risk factors of exit-site infection in incident peritoneal dialysis patients

BACKGROUND

Exit-site infection (ESI) is a common complication in peritoneal dialysis (PD) patients. Clearly understanding the risk factors may be useful for the prevention of ESI. This study was to explore the prevalence and risk factors of ESI in incident PD patients.

METHODS

We evaluated ESI in incident PD patients who had catheter insertion in our center between 1 January 2009 and 31 December 2013, with follow-up for 1 year. We collected data on demographics, clinical features, and nursing care methods of the exit site (ES).

RESULTS

We recruited 1133 incident PD patients (687 male (60.6%); mean age 47.0 ± 15.1 years), and 245 (21.6%) had diabetes. Median follow-up was 12.0 months. One hundred and thirty-one patients had 139 episodes of ESI with a rate of 92.8 patient-months per episode (0.13 episodes per year). Coagulase-negative staphylococcus was the main pathogen, accounting for 33.8% of the ESIs. Gram-positive rods, Staphylococcus aureus, Pseudomonas, fungi, and other organisms accounted for 23.0%, 15.8%, 1.4%, 1.4%, and 2.9%, respectively. No bacterial growth was found in 15.1%. There were no differences in demographic and laboratory data (age, gender, primary kidney disease, hemoglobin, white blood cell, serum albumin, blood urea nitrogen, serum creatinine, and C-reactive protein) between the ESI and non-ESI groups. Poor competency of ES care, poor catheter immobilization, history of catheter-pulling injury, and mechanical stress on the ES were significantly associated with increased risk of ESI.

CONCLUSIONS

The prevalence of ESI was 0.13 episodes per year. Poor competency of ES care, catheter mobilization, history of catheter-pulling injury, and mechanical stress by waist belt or the protective bag of PD on ES were risk factors for ESI.

Chlorhexidine-impregnated sponge dressing for prevention of catheter exit-site infection in peritoneal dialysis patients: a pilot study

PURPOSE

The study aimed to examine effect of chlorhexidine dressing in the prevention of peritoneal dialysis (PD)-related infection in PD patients.

METHODS

This single-center pilot study recruited 50 incident PD patients to use weekly chlorhexidine dressing. The primary outcome was exit-site/tunnel infection rate. Secondary outcomes were peritonitis rate, time to first PD-related infection, infection-related hospitalization, technique and patient survival, adverse events, and chlorhexidine dressing acceptability. These clinical outcomes were compared with those of a historical cohort (2016-2017) using daily gentamicin cream.

RESULTS

A total of 50 patients were recruited to use chlorhexidine and followed up for one year. The exit-site/tunnel infection rate was 0.09 (95% confidence interval [CI] 0.02-0.22) and peritonitis rate was 0.07 (95% CI 0.01-0.19) episodes per patient-year with chlorhexidine dressing. The 1-year infection-free survival rates for exit-site/tunnel infection and peritonitis were 92% and 94%, respectively. The 1-year technique and patient survival rates were 86% and 96%, respectively. Overall, 12% of participants developed localized contact dermatitis with chlorhexidine. Most participants (73%) reported that chlorhexidine dressings were very acceptable. Compared to a historical cohort using gentamicin cream (n = 238), the chlorhexidine group had similar exit-site/tunnel infection rates (incidence rate ratio [IRR] 0.65, 95% CI 0.22-1.92) but had lower peritonitis rates (IRR 0.24, 95% CI 0.07-0.77), and lower PD infection-related hospitalization rates (IRR 0.21, 95% CI 0.06-0.69) after adjusting for age, sex, race, primary kidney disease, and diabetes mellitus.

CONCLUSION

Weekly chlorhexidine dressing was associated with acceptable PD-related infection outcomes and was well-accepted by patients, although had a 12% rate of delayed localized contact dermatitis.

TRIAL REGISTRATION NUMBER AND DATE

The study was registered under www.clinicaltrials.gov with the reference number of NCT03406520 on 23 January 2018.

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

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.

Current epidemiology and practice patterns in prevention and treatment of PD-related infections in Poland

BACKGROUND

Peritoneal dialysis (PD) related infections are associated with technique failure and mortality. The aim of this multicentre study was to examine epidemiology, treatment and outcomes of PD-related infections in Poland as well as practice patterns for prevention of these complications in the context of current ISPD recommendations.

METHODS

A survey on PD practices in relation to infectious complications was conducted in 11 large Polish PD centres. Epidemiology of peritonitis and exit-site infections (ESI) was examined in all patients treated in these units over a 2 year period.

RESULTS

The study included data on 559 PD patients with 62.4% on CAPD. Practice patterns for prevention of infectious complications are presented. The rate of peritonitis was 0.29 episodes per year at risk, with Gram positive microorganisms responsible for more than 50% of infections and 85.8% effectively treated. Diagnosis and treatment followed ISPD guidelines however most units did not provide an anti-fungal prophylaxis. Although neither of the centres reported routine topical mupirocin on catheter exit-site, the rate of ESI was low (0.1 episodes per year at risk), with Staphylococcus aureus as most common pathogen and full recovery in 78.3% of cases.

CONCLUSION

The study shows rewarding outcomes in prevention and treatment of PD-associated infections, mainly due to a thorough compliance with the current ISPD guidelines, although some deviations from the recommendations in terms of practice patterns have been observed. More studies are needed in large numbers of patients to differentiate the importance of specific recommendations and further support the guidelines.