Identification of Targets for Prevention of Peritoneal Catheter Tunnel and Exit-Site Infections in Low Incidence Settings

Abstract

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Background: Peritoneal catheter tunnel and exit-site infection (TESI) complicates the clinical course of peritoneal dialysis (PD) patients. Adherence to recommendations for catheter insertion, exit-site care, and management of Staphylococcus aureus (SAu) carriage reduces, but does not abrogate the risk of these infections. ♦

Objective: To reappraise the risk profile for TESI in an experienced center with a long-term focus on management of SAu carriage and a low incidence of these infections. ♦

Method: Following a retrospective, observational design, we investigated 665 patients incident on PD. The main study variable was survival to the first episode of TESI. We considered selected demographic, clinical, and technical variables, applying multivariate strategies of analysis. ♦

Main results: The overall incidence of TESI was 1 episode/68.5 patient-months. Staphylococcus aureus carriage disclosed at inception of PD (but not if observed sporadically during follow-up) (hazard ratio [HR] 1.53, p = 0.009), PD started shortly after catheter insertion (HR 0.98 per day, p = 0.011), PD after kidney transplant failure (HR 2.18, p = 0.017), lower hemoglobin levels (HR 0.88 per g/dL, p = 0.013) and fast peritoneal transport rates (HR 2.92, p = 0.03) portended an increased risk of TESI. Delaying PD ≥ 30 days after catheter insertion markedly improved the probability of TESI. Carriage of methicillin-resistant SAu since the start of PD was associated with a high incidence of TESI by these bacteria. On the contrary, resistance to mupirocin did not predict such a risk, probably due to the use of an alternative regime in affected patients. ♦

Conclusions: Adherence to current recommendations results in a low incidence of TESI in PD patients. Interventions on specific risk subsets have a potential to bring incidence close to negligible levels. Despite systematic screening and management, SAu carriage is still a predictor of TESI. Antibiotic susceptibility patterns may help to refine stratification of the risk of TESI by these bacteria. Early insertion of the peritoneal catheter should be considered whenever possible, to reduce the risk of later TESI.

Keywords: Peritoneal catheter; Staphylococcus aureus; mupirocin; peritoneal dialysis; tunnel and exit-site infection.

Figure 1 —

Survival to first episode of TESI according to delay between peritoneal catheter insertion and initiation of PD. TESI = tunnel and exit-site infection.

Figure 2 —

Hazard ratios of TESI by year of start of dialysis (modeled by splines with 7 degrees of freedom) and time of follow-up. Adjusted for main covariates (p < 0.001 Cox). TESI = tunnel and exit-site infection; CI = confidence interval.

Figure 3 —

Survival to first episode of TESI by SAu according to carriage of SAu, either detected since inception of PD or later during follow-up. TESI = tunnel and exit-site infection; SAu = Staphylococcus aureus; PD = peritoneal dialysis.

Figure 4 —

Survival to first episode of TESI by SAu according to carriage of MRSAu, either detected since inception of PD or later during follow-up. TESI = tunnel and exit-site infection; SAu = Staphylococcus aureus; MRSAu = methicillin-resistant SAu; PD = peritoneal dialysis.