Background
Prevention of infection is considered essential for satisfactory maintenance of peritoneal dialysis. Infections of the peritoneal dialysis catheter tunnel and exit site are considered to be serious infections that may predispose patients to peritonitis and its consequences.
Objective
To evaluate and summarize the best available evidence on the effectiveness of care for the peritoneal dialysis catheter exit site.
Inclusion criteria
Types of participants
Adult and pediatric patients receiving peritoneal dialysis.
Types of interventions
Antiseptics, topical antimicrobials agents, dressings and educational interventions.
Type of studies
Randomized controlled trials.
Types of outcomes
Incidence of tunnel and exit site infection and peritonitis, caused by Staphylococcus aureus, Pseudomona aeruginosa, Haemophilus, Neisseria, Escherichia coli, etc.
Search strategy
All studies, published (in MEDLINE, CINAHL and COCHRANE databases) and unpublished, in English, Spanish, Portuguese and French, carried out between 1996 and February 2009 were retrieved.
Methodological quality
The methodological quality of included articles was assessed by two independent reviewers using critical appraisal tools from the Joanna Briggs Institute.
Data extraction
Data were independently extracted by two reviewers, using the standardized data extraction tool from the Joanna Briggs Institute.
Data synthesis
Results were combined in meta-analysis where appropriate.
Results
Nine randomized controlled trials were included. In one study that compared the effectiveness of daily application of gentamicin cream with mupirocin, in the gentamicin group there were 15 infections of the exit site compared to the mupirocin group where there were 29 infections (OR= 2.72; 95% CI 1.28-5.77); there were 22 incidences of peritonitis in the gentamicin group, compared to 28 incidences of peritonitis in the mupirocin group (OR= 1.51; 95% CI 0.74-3.05).
In three studies, patients received povidone-iodine and the control group received standard care. The overall results of the meta-analysis estimated an OR=0.83 with 95% CI 0.47-1.45 for the prevention of infection of the exit site and an OR=0.77 with 95% CI 0.44-1.36 for prevention of peritonitis.
One study compared the effectiveness of chlorhexidine versus liquid soap, showing that there was a statistically significant lower exit-site infection rate in the group of patients that used chlorhexidine soap compared with the group that used pure liquid soap.(OR 0.35 with 95% CI 0.13-0.94).
Another study compared povidone-iodine versus chlorhexidine versus sodium hypochlorite, and found no statistical differences between povidone and chlorhexidine, as well as no differences between povidone and sodium hypochlorite.
Another three studies compared mupirocina versus standard care; mupirocina versus fusidic acid; and fusidic acid versus ofloxacin, and found no differences in reducing exit site infections or peritonitis.
Conclusions
Some interventions appear to be more effective than others in terms of peritoneal dialysis catheter exit site care. These advantages are related to a lower number of cases of exit site infection and, consequently, peritonitis. The application of an antiseptic to the peritoneal dialysis catheter exit site reduces infections and prevents peritonitis.
Implications for clinical practice
As a general norm, gentamicin is better than mupirocin to prevent exit site infection and peritonitis.
Prophylactic therapy using gentamicin ointment at the insertion point may decrease the risk of infection of the exit site by Pseudomona aeruginosa. Prophylactic therapy using mupirocin ointment at the insertion point may decrease the risk of infection of the insertion point by S. aureus. During the initial post-operative period, a strict sterile technique needs to be used in order to prevent the development of exit-site infections. In the medium term, the use of antiseptics (povidone iodine and chorhexidine) and antibiotics (mupirocin and gentamicin) is effective in reducing infection rates of the catheter exit site and peritonitis.
In the long term (five to six months), chlorhexidine seems to be better than povidone-iodine in reducing exit site infections and peritonitis
Implications for research
There is a need for new studies with improved methodological designs, such as high-quality clinical trials and longer follow-up periodsthat is, (between six months and one year), to o compare different antiseptics/antimicrobials.
