The Effect of Exit-Site Antibacterial Honey Versus Nasal Mupirocin Prophylaxis on the Microbiology and Outcomes of Peritoneal Dialysis-Associated Peritonitis and Exit-Site Infections: A Sub-Study of the Honeypot Trial

Abstract

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Background: The HONEYPOT study recently reported that daily exit-site application of antibacterial honey was not superior to nasal mupirocin prophylaxis for preventing overall peritoneal dialysis (PD)-related infection. This paper reports a secondary outcome analysis of the HONEYPOT study with respect to exit-site infection (ESI) and peritonitis microbiology, infectious hospitalization and technique failure. ♦

Methods: A total of 371 PD patients were randomized to daily exit-site application of antibacterial honey plus usual exit-site care (N = 186) or intranasal mupirocin prophylaxis (in nasal Staphylococcus aureus carriers only) plus usual exit-site care (control, N = 185). Groups were compared on rates of organism-specific ESI and peritonitis, peritonitis- and infection-associated hospitalization, and technique failure (PD withdrawal). ♦

Results: The mean peritonitis rates in the honey and control groups were 0.41 (95% confidence interval [CI] 0.32 - 0.50) and 0.41 (95% CI 0.33 - 0.49) episodes per patient-year, respectively (incidence rate ratio [IRR] 1.01, 95% CI 0.75 - 1.35). When specific causative organisms were examined, no differences were observed between the groups for gram-positive (IRR 0.99, 95% CI 0.66 - 1.49), gram-negative (IRR 0.71, 95% CI 0.39 - 1.29), culture-negative (IRR 2.01, 95% CI 0.91 - 4.42), or polymicrobial peritonitis (IRR 1.08, 95% CI 0.36 - 3.20). Exit-site infection rates were 0.37 (95% CI 0.28 - 0.45) and 0.33 (95% CI 0.26 - 0.40) episodes per patient-year for the honey and control groups, respectively (IRR 1.12, 95% CI 0.81 - 1.53). No significant differences were observed between the groups for gram-positive (IRR 1.10, 95% CI 0.70 - 1.72), gram-negative (IRR: 0.85, 95% CI 0.46 - 1.58), culture-negative (IRR 1.88, 95% CI 0.67 - 5.29), or polymicrobial ESI (IRR 1.00, 95% CI 0.40 - 2.54). Times to first peritonitis-associated and first infection-associated hospitalization were similar in the honey and control groups. The rates of technique failure (PD withdrawal) due to PD-related infection were not significantly different between the groups. ♦

Conclusion: Compared with standard nasal mupirocin prophylaxis, daily topical exit-site application of antibacterial honey resulted in comparable rates of organism-specific peritonitis and ESI, infection-associated hospitalization, and infection-associated technique failure in PD patients.

Keywords: Honey; exit-site infection; hospitalization; microbiology; mupirocin; peritoneal dialysis related infection; peritonitis; technique failure.

Figure 1 —

Forest plot of organisms responsible for peritonitis episodes in the honey and control groups. RR = rate ratio; CI = confidence interval; CNS = coagulase-negative staphylococcus.

Figure 2 —

Forest plot of organisms responsible for ESI episodes in the honey and control groups. ESI = exit-site infection; RR = rate ratio; CI = confidence interval; CNS = coagulase-negative staphylococcus.

Figure 3 —

Survival analysis of first peritonitis-associated hospitalization in the honey and control groups [HR 1.17 (95% CI 0.78–1.75); p=0.45]. HR = hazard ratio; CI = confidence interval.

Figure 4 —

Survival analysis of first infection-associated hospitalization in the honey and control groups [HR 1.11 (95% CI 0.79–1.56); p=0.55]. HR = hazard ratio; CI = confidence interval.

Figure 5 —

Survival analysis of PD withdrawal due to PD-related infection in the honey and control groups [HR 0.73 (95% CI: 0.37–1.45); p=0.37]. PD = peritoneal dialysis; HR = hazard ratio; CI = confidence interval.