Chronic Exit Site Care of Healed Exit Site

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Although sterile dressings are recommended until the exit is well-healed, there is no clear consensus as to when patients may begin to shower or change to chronic exit-site care. When the exit-site can be classified as good or equivocal, then showering and chronic care are appropriate [10]. The primary goal of exit-site care is to prevent ESIs and TIs. Exit-site care should include: (1) assessment of the exit-site; (2) cleansing the exit-site; (3) anchoring or immobilizing the catheter; and (4) protecting the exit-site and tunnel from trauma [9].

Assessment of the exit-site by visual inspection and palpation of the tunnel should be a routine part of exit-site care for both health care professionals and patients. Initial patient education should include how to assess the exit-site, signs and symptoms of ESI, and when to notify the PD clinic of exit-site problems. The optimal frequency of exit-site care has not been established. However, frequent cleansing is essential to reduce resident bacteria, and daily care is recommended. Exit-site care should also be repeated more than once a day if the exit becomes grossly dirty or wet. Good hand washing prior to exit care is critical to avoid cross contamination. Optimal chronic exit-site procedures for peritoneal catheters are undetermined. The few controlled studies have focused primarily on the use of dressings or the use of cleansing agents for exit care.

Dressings and Immobilization

Chronic exit-site care in adults showed a similar incidence of ESI in groups with and without dressings [15, 16]. The use of dressings for chronic care is based on anecdotal experience or individual preference. Theoretically, the use of dressings may help to keep the exit clean, protect it from trauma, and help to stabilize the catheter. Furthermore, dressings are indicated for all patients when the exit is infected or likely to become grossly contaminated. Gauze dressings are used most frequently, but semipermeable dressings and occlusive dressings are also used. The catheter should always be kept immobile to prevent pulling and trauma to the exit-site, which may lead to infection.

Antibiotics

The use of mupirocin cream at the exit-site has been shown to lower significantly S. aureus ESIs and peritonitis [7, 17, 18]. Although mupirocin cream is effective against S. aureus, it does not have activity against P. aeruginosa [19]. In a randomized double blinded trial comparing daily use of mupirocin cream (2%) and gentamicin cream (1%), the reduction in S. aureus ESIs were similar in both groups. In addition, there was a significant reduction of P. aeruginosa infection in the gentamicin group [20].

Cleansing Agents and Disinfectants

Antibacterial soap and water are routinely used to clean the exit-site. Povidone-iodine, chlorhexidine and electrolytic chloroxidizing solutions have been used as disinfectants for the routine care of exit-site and PD connection site to prevent or treat ESI/TI and catheter related peritonitis [21-25]. Povidone-iodine application in comparison to pure soap has been shown to reduce infection [24, 25].

An electrolytic chloroxidizing (Amuchina 10% - ExSept Plus) is a clear aqueous liquid that contains 1.15 g/l of sodium hypochlorite, 1.7 g/l of sodium chloride and has a pH of 9, thereby producing long-lasting stability. Nonclinical studies in two animal species over a substantial dose range of Amuchina 10% (ExSept Plus) revealed no potential toxic response [26, 27]. The Minimal Inhibitory Concentration has been found to range from 0.15 to 3.7% in vitro studies with a broad range of micro-organisms [28]. It has been shown to have bactericidal activity in vitro within 1 min against broad range of microorganisms. Irritation and sensitization have been found to be similar to 0.9% NaCl solution.

In a single center randomized trial, Amuchina 10% (ExSept Plus) solution was compared with povidone-iodine 10% solution for exit-site care in 50 ESRD patients receiving PD. The patients with new catheter 4 weeks following catheter placement or with current catheter with no infection were included into

Variables Amuchina 10% Povidone 10%

No patients

25

25

Patient-months

130

109

No diabetics

12

8

Mean age:years

59

53

No ESI

5

7

No ESI-PD

0

1

No catheter loss

0

1

No patients:irritation

14

6

No patients:scab

17

13

ESI/TI*

0.52

0.60

*Episode/patient/year.

ESI = Exit-site infection; PD = peritoneal dialysis; TI = tunnel infection.

*Episode/patient/year.

ESI = Exit-site infection; PD = peritoneal dialysis; TI = tunnel infection.

the study. All patients underwent double-cuff coiled swan neck catheters implantation surgically with downward exit-site at lower abdomen below the belt line. The patients received cefazolin 1 g IV peri-operatively. All patients underwent exit-site care training session and received written instructions. They were instructed to shower daily and to clean the exit-site with a dedicated soap and water followed by an application of Amuchina 10% or povidone- iodine 10% with one to two cotton tip applicators. The exit-site was then air dried and covered with gauze dressing. Exit-site was examined at least once a month for drainage, crust, pain, swelling, induration or irritation. Drainage was sent for gram stain, culture and sensitivity. Catheter ESI was defined by purulent discharge and erythema with or without tenderness.

The mean age, months on PD, method of dialysis (CAPD/CCPD), and number of diabetic and non-diabetic patients were not statistically different (table 1). ESI/TI rates were lower in the Amuchina group (0.52 episode/patient/year) in comparison to the povidone group (0.60 episode/patient/year). No catheter was lost in the Amuchina group. Local irritation and scab formation were more common in the Amuchina group [21].

Since with the use of Amuchina 10% solution, there was a higher incidence of local irritation at the exit-site in comparison to povidone-iodine 10%, the subsequent study evaluated randomly Amuchina 5% (ExSept) solution comparing povidone-iodine 10% for exit-site care in PD [22]. Thirty nine PD patients were studied over a period of 470 patient-months. Eighteen PD

Variables Amuchina 5% Povidone 10%

No patients

18

21

Patient-months

164

161

No diabetics

5

6

Mean age:years

55

60

No ESI

10

10

No ESI-PD

2

2

No catheter loss

3

1

No patients:irritation

11

7

No patients:scab

12

*Episode/patient/year.

*Episode/patient/year.

patients received exit-site care with Amuchina 5% solution and 21 received exit-site care with povidone-iodine 10% solution. Protocol used in this study was similar to the previous study using Amuchina10% solution for the exit-site care. The mean age, months on PD, number of diabetic and non-diabetic patients were not different (table 2). The ESI/TI rates were 0.66 episode/ patient/year in the Amuchina group and 0.59 episode/patient/year in the povidone-iodine group, respectively (table 2). The ESI/TI rates were not statistically different between two groups. Eleven patients in the Amuchina group had varying degrees of irritation at the exit-site while there were seven in the povidone-iodine group. The scab formation at the exit-site was in equal distribution (table 2). The frequent occurrence of local irritation and scab formation with the use of antiseptic agents including hydrogen peroxide, sodium hypochlorite, chlorhexidine and povidone solution has been reported at the catheter exit-site in PD patients [29, 30]. A retrospective study showed a significant reduction in infection rates (1.8 vs. 3.2/1,000 days; p < 0.05) with ExSept Plus and Alcavis 50 in comparison to povidone-iodine for both exit-site care and PD connection sites [31]. ExSept Plus has been found to be of similar efficacy compared to chlorhexidine for exit-site care of central venous catheters in hemodialysis patients [32].

In conclusion, both Amuchina 10% (ExSept Plus) and Amuchina 5% (ExSept) solutions for daily exit-site care are as effective as povidone-iodine 10% for prevention and treatment of ESI. However, local irritation and scab formations at the exit-site with the use of these disinfectant solutions are of concern.

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Nand K. Wadhwa, MD

Division of Nephrology, Department of Medicine, School of Medicine HSC T-16 Rm-080, SUNY at Stony Brook Stony Brook, NY 11794-8166 (USA)

Tel. +1 631 444 1617, Fax +1 631 444 8831, E-Mail [email protected]

Ronco C, Mishkin GJ (eds): Disinfection by Sodium Hypochlorite: Dialysis Applications. Contrib Nephrol. Basel, Karger, 2007, vol 154, pp 125-128

Successful Use of Sodium Hypochlorite Pack Plus Systemic and Local Antibiotic Therapy for the Treatment of Pseudomonas Infection of Peritoneal Dialysis Catheter Exit-Site

M.P. Rodighiero, R. Dell'Aquila, M. Bonello, E. Spano, P. Di Loreto, F. Nalesso, C. Ronco

Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy

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