The treatment of Staphylococcus aureus nasal carriage in pediatric peritoneal dialysis patients. A randomized trial of Staphylococcus aureus prophylaxis in peritoneal dialysis patients: mupirocin calcium ointment 2% applied to the exit site versus cyclic oral rifampin. The use of povidone iodine in exit site care for patients undergoing continuous peritoneal dialysis (CAPD). The efficacy of exit site povidone-iodine ointment in the prevention of early peritoneal dialysis-related infections. Prophylactic antibiotics in the insertion of Tenckhoff catheters. Preventing Staphylococcus aureus infection during chronic peritoneal dialysis. Exit-site care and exit-site infection in continuous ambulatory peritoneal dialysis (CAPD): results of a randomized multicenter trial. Randomized controlled trial of prophylactic rifampin for peritoneal dialysis-related infections. Effect of sodium fusidate and ofloxacin on Staphylococcus aureus colonization and infection in patients on continuous ambulatory peritoneal dialysis. Nasal mupirocin prevents Staphylococcus aureus exit-site infection during peritoneal dialysis. Mupirocin Study Group. Vaccination for prevention of CAPD associated staphylococcal infection: results of a prospective multicentre clinical trial. Role of preoperative antibiotic prophylaxis in preventing postoperative peritonitis in newly placed peritoneal dialysis catheters. One-dose cefuroxime i.v. and i.p. reduces microbial growth in PD patients after catheter insertion. Treatment of Staphylococcus aureus nasal carriers in CAPD with mupirocin. Prophylactic cephalexin ineffective in chronic ambulatory peritoneal dialysis. A prospective randomized control study of oral nystatin prophylaxis for Candida peritonitis complicating continuous ambulatory peritoneal dialysis.
This study evaluates the dialysis-related infection rate in children receiving peritoneal dialysis with Staphylococcus aureus nasal carriage. Children with S. aureus nasal carriage were randomized to treatment with rifampin and bacitracin or no treatment. The children were observed for one month after randomization for evidence of a S. aureus dialysis-related infection. Individuals with nasal carriage had a higher incidence of S. aureus dialysis-related infection than those patients without carriage (p < 0.05). Those children treated for nasal carriage had a lower dialysis-related infection rate than those who were untreated (p < 0.05). We conclude that children receiving peritoneal dialysis with nasal carriage of S. aureus are at a greater risk of developing a S. aureus dialysis-related infection. The treatment of nasal carriage in this population decreased the risk of a S. aureus dialysis-related infection. The objective of this study was to compare prophylaxis for Staphylococcus aureus infections in peritoneal dialysis patients using 600 mg cyclic oral rifampin for 5 days every 3 months versus mupirocin calcium ointment 2% applied daily to the exit site. The study design was a prospective randomized trial, controlling for S aureus nasal carriage. Eighty-two continuous ambulatory and continuous cyclic peritoneal dialysis patients (54% male, 71 % white, 34% insulin-dependent, mean prestudy time on peritoneal dialysis 1.2 years) were randomly assigned to cyclic rifampin (n = 41 patients) or daily exit site mupirocin prophylaxis (n = 41 patients). Mean follow-up was 1 year. S aureus catheter infection rates were 0.13/yr with mupirocin and 0.15/yr with rifampin (P = NS). Both rates were significantly lower than the center's historical rate (the period between 1983 and 1992) of 0.46/yr prior to the study (P < 0.001). S aureus peritonitis rates were 0.04/yr with mupirocin and 0.02/yr with rifampin (P = NS), both significantly lower than the center's historical rate of 0.16/yr (P < 0.02). Catheter loss due to S aureus infections was 0.02/yr with mupirocin and 0/yr with rifampin (P = NS), both significantly lower than the center's historical rate of 0.12/yr (P < 0.001). There were no side effects in patients using mupirocin, but 12% were unable to continue rifampin due to side effects. We conclude that mupirocin ointment at the exit site and cyclic oral rifampin are equally effective in reducing S aureus catheter infections. In addition, rifampin or mupirocin significantly reduced S aureus peritonitis and catheter loss due to S aureus infections. Mupirocin at the exit site provides an excellent alternative prophylaxis for S aureus infections, particularly in patients who cannot tolerate oral rifampin therapy. Exit site infection is a major risk factor for the development of peritonitis in continuous ambulatory peritoneal dialysis. The frequency of infection can be reduced by scrupulous exit site care with or without topical antiseptics. A randomized trial was performed of 149 catheters in 130 patients to assess any additional benefits conferred by the use of povidine iodine dry powder spray at dressing changes over an existing strict protocol of exit care. Exit infections occurred in 14 (18%) of 77 patients using spray and in 15 (21%) of 72 patients not using spray. The risk of peritonitis was also similar in each group. The proportion of infections caused by Staphylococcus aureus was reduced in the spray group, but those caused by Pseudomonas aeruginosa were increased. Rash occurred in 6% of those using the spray. The use of the spray did not therefore seem justified. Infections are the main complications of peritoneal dialysis, and currently there is no established method for prevention. A prospective, randomized, single-blind study was performed to evaluate the efficacy of regular application of povidone-iodine ointment at the catheter site (during the entire time on the study) in peritoneal dialysis. One hundred twenty patients were randomized; three were excluded for not completing the study. Sixty-one patients received application of povidone-iodine and 56 patients received standard care. Povidone-iodine ointment was effective in delaying infectious complications, with a lower proportion of treated patients having infections (exit site and peritonitis) within 140 days of starting dialysis compared with the controls (P = 0.04, Wilcoxon test). This protective benefit was lost after 140 days on dialysis. Staphylococcus aureus infections developed in only two (3.3%) of the treated patients compared with 10 (21.4%) of the controls (P = 0.009), despite the higher rate of S aureus nasal carriage in the treated group (22 of 61 patients [36%] v 14 of 56 patients [25%]). We assessed the efficacy of preoperative antibiotic prophylaxis in a prospective trial for patients undergoing insertion of Tenckhoff catheters for continuous ambulatory peritoneal dialysis (CAPD). The prophylactic regimen was a single dose of cefazolin (500 mg) and gentamicin (80 mg) given intravenously half an hour before surgery. There was no significant difference in the number of exit site infections (8 in the antibiotic group vs. 8 in the controls) and the number of episodes of peritonitis (5 in the antibiotic group vs. 2 in the controls). Our study showed that prophylactic preoperative antibiotics did not reduce the number of exit site infections and peritonitis after the insertion of Tenckhoff catheters. In the interest of studying the prevention of chronic peritoneal dialysis infections, serial studies of the bacterial epidemiology in peritonitis and of antibiotic prophylaxis, respectively, were carried out. For 18 months, prospective evaluation of catheter exist site cultures, performed at the time patients developed acute peritonitis, showed that Staphylococcus aureus peritonitis was associated with concordant S. aureus at the exist site in 85% of cases, significantly more frequent than that for other organisms (P less than 0.02). Furthermore, active inflammation along with concordant culture results at the exit site characterized more than 60% of S. aureus peritonitis cases, also significantly more than that for other organisms (P less than 0.01). Over the ensuing 2 yr, patients beginning chronic peritoneal dialysis with a new percutaneously placed catheter were prospectively entered into a randomized, controlled trial of long-term antibiotic prophylaxis with trimethoprim-sulfamethoxasole. Patients receiving prophylaxis tended to have fewer episodes of peritonitis; however, the lower rate of peritonitis reached statistical significance only comparing patients who were S. aureus carriers at entry into the study to patients who were not S. aureus carriers. In particular, the prophylaxis trial seemed to reduce the specific incidence of S. aureus peritonitis overall, with S. aureus appearing in only 2 of 28 total peritonitis episodes among treated patients as compared with 11 of 37 total episodes among non-treated patients (P less than 0.01). Further analysis of the time to first peritonitis suggests that the effect of prophylaxis was most prominent during the first 3 months of therapy (P less than 0.02) rather than later in the course of treatment.(ABSTRACT TRUNCATED AT 250 WORDS) A total of 127 patients from 8 hospitals were randomized into 1 of 2 exit-site care regimes to evaluate their effect on rate of exit-site infection (ESI). Group 1 used povidone iodine and nonocclusive dressings changed 2 to 3 times weekly; Group 2 simply cleansed the exit site with nondisinfectant soap and water. Incidence, cause, duration, and treatment of ESI and peritonitis (P) were noted. Groups were analysed for age, sex, end-stage renal disease (ESRD), catheter, and systems. Total cumulative follow up time was 95.6 years. There was a significantly higher rate (p = 0.0183) of ESI in Group 2 (soap and water). The mean rate of ESI was 0.27 episodes/patient year for Group 1 versus 0.71 episodes/patient year for Group 2. Rates of P for the two groups were not significantly different (p greater than 0.50): 0.446 episodes/year for Group 1 versus 0.574 episodes/year for Group 2. S. aureus was responsible for 83% of ESI in Group 1 and 67% of ESI in Group 2. Protective dressing with a disinfectant is associated with significantly less ESI than minimum care. However, further research in exit-site care aimed specifically at reducing S. aureus infection is still required. Staphylococcal infections are a major cause of catheter infections and peritonitis in peritoneal dialysis patients. Since catheter-related infections are associated with nasal carriage of Staphylococcus aureus in this population, we studied the effect of intermittent rifampin, an antibiotic known to decrease S aureus nasal carriage, on catheter-related infections and peritonitis. We randomly assigned 64 patients to receive either rifampin 300 mg twice daily for 5 days every 3 months or no treatment. The rifampin-treated patients had a significant delay in time to first catheter-related infection (P less than 0.015) and significantly fewer catheter-related infections overall (P less than 0.001). The catheter-related infection rate in rifampin-treated patients was .26 per patient-year versus .93 per patient-year in untreated patients. Multivariate analysis defined baseline colonization of nares or catheter exit-site and prior renal transplant as risk factors for catheter-related infections. There was no significant difference in peritonitis rates between groups, although the trend was for a delayed time to first episodes and fewer episodes in rifampin-treated patients. Adverse effects necessitated withdrawal of rifampin in four patients. We conclude that intermittent rifampin administration is effective in decreasing catheter-related infections in a peritoneal dialysis population. The effectiveness of sodium fusidate and ofloxacin to eliminate nasal and catheter exit-site Staphylococcus aureus colonization and to prevent infections was compared in 31 patients on continuous ambulatory peritoneal dialysis (CAPD). In a prospective randomized study, 9 patients were treated with topical 2% sodium fusidate ointment applied in the anterior nares and in the pericatheter skin twice daily for 5 days; 9 subjects received oral ofloxacin 200 mg taken every 48 hours for 5 days and 13 subjects were in the control group. Treatment courses were repeated at one-month intervals. Mean duration of follow-up was 7.8 months (242 patients-month). Follow-up samples from the nares and the catheter exit-site were obtained every month from all participants to determine the presence of S. aureus. Development of S. aureus exit-site infection and peritonitis were assessed. During the study, S. aureus was recovered from 45%, 59% and 52% of the samples from the nares and/or exit-site in the sodium fusidate, ofloxacin and control groups, respectively (p = 0.13). S. aureus grew less frequently (p < 0.01) in samples from the exit-site in the sodium fusidate than in the other two groups. Eradication of nasal colonization (two negative cultures within one month) was observed in 43%, 40% and 33% of the cases in the sodium fusidate, ofloxacin and control groups, respectively (p > 0.50). The corresponding figures for exit-site eradication were 43%, 33% and 11%, respectively (p = 0.34). Twenty-four S. aureus-associated infection episodes (12 of exit-site and 12 of peritonitis) were diagnosed in 16 of the 31 patients.(ABSTRACT TRUNCATED AT 250 WORDS) A total of 1144 patients receiving continuous ambulatory peritoneal dialysis in nine European centers was screened for nasal carriage of Staphylococcus aureus. Two hundred sixty-seven subjects were defined as carriers of S. aureus by having had at least two positive swab results from samples taken on separate occasions, and were randomly allocated to treatment or control groups. Members of each group used a nasal ointment twice daily for 5 consecutive days every 4 wk. The treatment group used calcium mupirocin 2% (Bactroban nasal; SmithKline Beecham, Welwyn Garden City, United Kingdom) and the control group used placebo ointment. Patients were followed-up for a maximum period of 18 months. There were 134 individuals in the mupirocin group, and 133 individuals acted as control subjects. There were no differences in demographic data, cause of renal failure, type of catheter, system used, or method of exit-site care between the groups. Similarly, there were no differences in patient outcome or incidence of adverse events between both groups. Nasal carriage fell to 10% in those subjects who received active treatment and 48% in those who used the placebo ointment. There were 55 exit-site infections in 1236 patient-months in the control group and 33 in 1390 patient-months in the treatment group (not significant). S. aureus caused 14 episodes of exit-site infection in the mupirocin group and 44 in the control group (P = 0.006, mixed effects Poisson regression model). There were no differences in the rate of tunnel infection or peritonitis. There was no evidence of a progressive increase in resistance to mupirocin with time. Regular use of nasal mupirocin in continuous ambulatory peritoneal dialysis patients who are nasal carriers of S. aureus significantly reduces the rate of exit-site infections that occurs because of this organism. 124 stable CAPD patients from 8 Australian and 3 New Zealand centers were randomly assigned in a blinded fashion to one of two groups to study the effect of vaccination using commercial preparations consisting of a combined staphylococcus toxoid and whole killed staphylococci (SB) or normal saline solution (SS) on the incidence of peritonitis and exit site infection and S. aureus nasal carriage over a 12-month prospective period. In addition, levels of IgG, IgA, IgM, C3 and C4 were monitored during the trial period in serum and dialysate; serum levels of anti-alpha hemolysin and dialysate levels of fibronectin and specific antistaphylococcal antibodies were also measured. Over the period, treatment with SB or SS did not affect the incidence of peritonitis, catheter-related infection or S. aureus nasal carriage. However, vaccination with SB elicited a significant increase in the level of serum anti-alpha hemolysin throughout the 12 month duration of the study, although the level of increase was unrelated to the subsequent rate of peritonitis. Vaccination with SB but not SS elicited a significant increase in the dialysate level of specific antibodies against S. aureus. Serum levels of IgG, IgA, IgM, complement C3 and C4 were within the normal range in the CAPD patients studied and remained unaffected by vaccination with SB. In addition, dialysate levels of IgG, IgA, IgM, complement C3 and C4 were 50-100 times lower than corresponding serum levels and remained unaffected by vaccination. In summary, immunisation with an anti-staphylococcal agent was not successful in reducing peritonitis or exit site infection in CAPD patients. The role of vancomycin and other antibiotics in the treatment of acute peritonitis in peritoneal dialysis (PD) patients is well established. However, the role of preoperative vancomycin or cephalosporins in preventing early infection in newly placed PD catheters remains controversial. We performed a prospective randomized study to examine the role of vancomycin or cefazolin prophylaxis in decreasing the incidence of postoperative peritonitis. Over a 6-year period, 221 patients undergoing 254 permanent peritoneal catheter placement procedures were randomized into three groups. Group I patients (86 procedures) were administered a single intravenous (IV) dose of vancomycin, 1,000 mg, 12 hours before peritoneal catheter placement procedures, whereas group II patients (85 procedures) were administered a single IV dose of cefazolin, 1,000 mg, 3 hours before the procedure. Group III patients (83 procedures) were not administered antibiotics preoperatively for at least 1 week before the procedure. Patients were monitored for peritonitis in the following 14 days. Peritonitis developed in 1 patient (1%) in group I (vancomycin group) and 6 patients (7%) in group II (cefazolin group) compared with 10 patients (12%) in group III (control group); P = 0.02. We conclude that the use of preoperative single-dose IV vancomycin prophylaxis for permanent PD catheter placement reduces the risk for postoperative peritonitis. Single-dose vancomycin is superior to single-dose cefazolin in reducing the risk for postoperative peritonitis. Absence of prophylaxis is associated with a high risk for developing postoperative peritonitis. When a peritoneal dialysis catheter is inserted intra-abdominally in a patient starting peritoneal dialysis (PD) there is always a risk for postoperative wound infection and peritonitis. At our centre, PD is started immediately after the dialysis catheter is inserted. This may increase the postoperative risk for peritonitis and wound infection. The aim of this prospective, randomized, study was to evaluate whether the incidence of microbial growth postoperatively (within 10 days) after catheter insertion could be reduced by prophylactic antibiotic therapy.
                During a period of 27 months, 38 patients, who consecutively entered the PD programme, (11 women and 27 men, mean age 57 years) were included in the study. Eighteen patients were given cefuroxime 1.5 g i.v. preoperatively and 250 mg i.p. in the first dialysis bag (containing 1 litre fluid) as prophylaxis. Twenty patients were not given prophylactic antibiotics (control group). All catheter insertions were performed in an operating theatre by the same surgeons using the same technique.
                In the test group, none of the patients showed microbial growth in the dialysis fluid during the post-operative period, while in the control group six of 20 patients (30%) suffered from such growth (P = 0.021).
                Prophylactic treatment by cefuroxime i.v. pre- and i.p. perioperatively may reduce the risk for microbial growth and peritonitis after insertion of a Tenckhoff catheter. We have studied the efficacy of topical Mupirocin for elimination of Staphylococcus aureus (Staph. aureus) nasal carriage in CAPD patients. Staph. aureus nasal carriers in our CAPD program were randomized to one of two groups: Group 1, treated with Mupirocin, and Group 2, treated with neomycin sulphate nasal ointment. The prevalence of Staph. aureus nasal colonization was 44% for patients (24/54) and 17% for dialysis partners (5/29). Group 1 included 11 patients and 1 partner, and Group 2, 8 patients and 2 partners. In Group 1, the eradication rate was 100%, and the recolonization rate was 0, 8, 41, 55 and 66% at 1, 2, 3, 6 and 10 months. In Group 2, the eradication rate was 40%, with a recolonization rate of 0.25 and 75% at 1, 2 and 3 months. Re-treatment with mupirocin was successful in 66% of the cases, compared to 20% for neomycin. The MIC90 of mupirocin for Staph. aureus was 0.5 mcg/mL, with an increase to 4 mcg/mL towards the end of the study. During the study period, there was a very low incidence of Staph. aureus peritonitis or catheter-related infections in patients treated with mupirocin. Secondary effects of mupirocin were negligible. Mupirocin is more effective than neomycin sulphate for the elimination of Staph. aureus nasal colonization in patients undergoing CAPD. Periodic re-treatment is frequently necessary, given the significant recolonization rate. nan A prospective randomized study of the prevention of candida peritonitis (CP) in continuous ambulatory peritoneal dialysis patients using oral nystatin given concomitantly with antibiotic therapy was carried out for 2 years. Patients were randomized into two groups. Nystatin tablets 500,000 units four times a day were given to group 1 but not group 2 patients whenever antibiotics were prescribed. There were 199 patients at risk (mean follow-up, 18.0 months) in group 1 and 198 patients at risk (mean follow-up, 16.6 months) in group 2. The peritonitis and antibiotic prescription rates were comparable between the two groups. There were four episodes of CP in four patients in group 1 and 12 episodes in 11 patients in group 2. The probability of CP-free survival at 2 years was higher in group 1 compared with group 2 (0.974 v 0.915; P < 0.05). However, only three (75%) CP episodes in group 1 and six (50%) in group 2 were considered "antibiotics related." The incidence of antibiotics-related CP was 1.39 and 3.19 per 100 peritonitis episodes and 0.66 and 1.43 per 100 antibiotic prescriptions in groups 1 and 2, respectively (P = NS). We conclude that oral nystatin prophylaxis with each antibiotic prescription reduced the rate of CP in patients on continuous ambulatory peritoneal dialysis irrespective of its apparent temporal relationship to antibiotic prescription.
This review demonstrates that nasal mupirocin reduces exit-site/tunnel infection but not peritonitis. Preoperative intravenous prophylaxis reduces early peritonitis but not exit-site/tunnel infection. No other antimicrobial interventions have proven efficacy. Given the large number of patients on PD and the importance of peritonitis, the lack of adequately powered RCTs to inform decision making about strategies to prevent peritonitis is striking.