J Bernardini

The Influence of Peritoneal Catheter Exit-Site Infections on Peritonitis, Tunnel Infections, and Catheter Loss in Patients on Continuous Ambulatory Peritoneal Dialysis

The importance of exit-site infections (ESIs) as a source of peritonitis and catheter loss in continuous ambulatory peritoneal dialysis (CAPD) patients is unknown. We collected data on 137 CAPD patients over a 5-year period (2,052 cumulative patient months). Patients with a history of ESIs were more likely to have peritonitis and tunnel infections than patients without a history of ESIs. A larger percentage of patients with a history of ESIs lost catheters and transferred to hemodialysis than those without such a history, independent of the effect of peritonitis. These data confirm the importance of reducing the incidence of ESIs. More information is needed to determine the nature of the relationship between ESIs and peritonitis.

Peritonitis associated with exit site and tunnel infections

We reviewed all episodes of peritonitis associated with exit site and/or tunnel infection (n = 87; rate, 0.1/yr; 13% of all peritonitis episodes) occurring from 1979 to 1995. The exit site or tunnel infection was diagnosed at the time or shortly after the patient presented with peritonitis in 66% of the episodes. In the other one third the exit site or tunnel infection was diagnosed a median of 40 days prior to the development of peritonitis. Staphylococcus aureus accounted for 52% of episodes. Pseudomonas aeruginosa was the next most common organism. In 63 (72%) of the episodes the catheter was removed to resolve the infection at a median of 8 days (range, 0 to 226 days) from the onset of peritonitis. Catheter removal after 5 days predominately for refractory peritonitis (n = 23; median time to removal, 8 days) or relapsing peritonitis (n = 11; median time to catheter removal, 103 days). Patients with relapsing peritonitis suffered two to four episodes prior to removal of the catheter. Patients with peritonitis associated with tunnel infection were more likely to lose their catheter than patients with peritonitis associated with exit site infection (86% v 58%), while Staphylococcus epidermidis infections were less likely to result in catheter loss compared with all other organisms (15% v 82%). After a protocol to reduce S aureus catheter infections was implemented in 1990, the rate of catheter-related peritonitis decreased from 0.14/yr to 0.05/yr due to a decrease in S aureus episodes. We conclude that peritonitis episodes associated with a tunnel infection infrequently resolve without catheter removal. Delayed catheter removal in such circumstances often results in refractory or relapsing peritonitis. Therefore, catheter removal should be done promptly. Antibiotic prophylaxis for S aureus can reduce catheter-related peritonitis.

A Five-Year Study of the Microbiologic Results of Exit Site Infections and Peritonitis in Continuous Ambulatory Peritoneal Dialysis

We studied the culture results from 321 continuous ambulatory peritoneal dialysis (CAPD) related infections (exit site, tunnel infections, and peritonitis) in 137 patients over a 5-year period to determine the contribution of exit site and tunnel infections to peritonitis and catheter loss. Seventeen percent of peritonitis episodes were associated temporally and by microbiologic results with exit site or tunnel infections. Twenty-one percent of exit site and tunnel infections and 20% of peritonitis episodes resulted in catheter loss. Peritonitis due to Staphylococcus aureus was more likely to be associated with an exit site or tunnel infection and was more likely to result in loss of the catheter than peritonitis due to Staphylococcus epidermidis. Peritonitis and exit site infections due to Pseudomonas sp also frequently resulted in catheter removal. We found that exit site infections cause significant morbidity in CAPD patients. Further studies in this area are needed.