Version July 2025
INTRODUCTION —
Peritoneal dialysis requires the placement and maintenance of a catheter that transverses the patient's abdominal wall and extends from the outer abdominal surface into the peritoneal cavity. The catheter exit site, tunnel, and peritoneum are prone to bacterial infection, which can cause morbidity and result in catheter removal.
This topic reviews the prevention, evaluation, and treatment of catheter-related infections, including exit-site infections (ESIs) with or without tunnel infections. The microbiology and treatment of peritonitis and diagnosis of peritonitis in peritoneal dialysis patients are discussed elsewhere:
●(See "Microbiology and therapy of peritonitis in peritoneal dialysis".)
●(See "Fungal peritonitis in peritoneal dialysis".)
●(See "Clinical manifestations and diagnosis of peritonitis in peritoneal dialysis".)
EPIDEMIOLOGY —
Exit-site infections (ESIs) have decreased since clinicians started using antimicrobial prophylaxis and other preventive measures [1-4]. Since daily topical antibiotic cream for infection prophylaxis became the standard of care, the reported rate of ESIs is approximately 12 per 100 patient-years [5]. (See 'Prevention' below.)
Risk factors associated with development of ESI include [6-8]:
●Poor competency of exit-site care
●Catheter mobilization
●Catheter pulling-out injury
●Mechanical compression of the catheter by a waist belt
●Swimming
●Presence of pets during exchanges
●Compression of the exit site by a peritoneal dialysis catheter bag (used in some countries)
Demographic factors such as age, sex, and race, and clinical factors such as diabetes or insulin dependence are not predictive of ESI [9,10].
MICROBIOLOGY
●Source of infection – The catheter and exit site become colonized with bacteria soon after catheter placement. Bacteria secrete a biofilm, which encourages further bacterial growth and protects the colonizing organisms from antibodies, white blood cells, and antimicrobial agents.
Colonization predisposes to infection, which can occur following mild exit-site trauma. The infection may involve the exit site alone, the exit site and tunnel in which the catheter resides, or the tunnel alone [11]. However, a tunnel infection usually occurs in the presence of an exit-site infection (ESI).
●Specific pathogens – Most ESIs, with or without tunnel infections, are caused by gram-positive bacteria, usually Staphylococcus spp or diphtheroids [1,9,12-16]. Gram-negative bacteria (eg, Pseudomonas aeruginosa) cause the majority of the remainder, followed by fungal infections, which are relatively uncommon [1,9,12-16]. Exit-site or tunnel infections rarely may be caused by atypical mycobacteria, nondiphtheria Corynebacteria, and Burkholderia cepacia [9,13-15,17]. In a study that included 44 ESIs [9], the specific pathogens were as follows:
•Gram-positive bacteria in 26 (59 percent), including 8 with Staphylococcus aureus
•Gram-negative bacteria in 10 (23 percent), including 6 with P. aeruginosa
•Fungus (yeast) in 3 (7 percent)
•None identified (culture negative) in 5 (11 percent)
Topical antimicrobial agents, which are routinely used for prophylaxis, may affect the epidemiology of causative organisms. In the study above, only 1 of 15 ESIs (7 percent) was due to a gram-negative organism in patients using topical gentamicin, whereas 9 of 29 infections (31 percent) were due to gram-negative organisms in patients using topical mupirocin [9]. In another study of 147 patients on peritoneal dialysis who received mupirocin prophylaxis for seven years, 11 percent of patients were S. aureus carriers, and 25 percent of these (representing 2.7 percent of the patient population) had mupirocin-resistant S. aureus [18].
Tunnel infection with abscess formation is more likely with infections caused by S. aureus or P. aeruginosa.
MONITORING FOR EARLY DETECTION
●Routine monitoring – The exit site should be examined daily by the patient and monthly by a clinician or the home unit medical staff. In addition, the exit site should be examined by a clinician whenever the patient detects a change in appearance or reports a discharge from the exit site. Any change from the patient's normal, healthy exit site may be a sign of a new exit-site infection (ESI). (See 'Clinical presentation' below.)
Examination of the exit site consists of gross visual inspection. Some clinicians use a magnifying glass for closer observation, though we do not. The catheter tract should be assessed for evidence of erythema or tenderness overlying the tunnel, which contains the part of the catheter between the two cuffs. We typically do not milk the catheter to see if any drainage is present unless we suspect a tunnel infection. (See 'Clinical presentation' below.)
Some clinicians routinely grade the exit site during these monthly visits (table 1) [19]; however, the use of such grading systems has not been shown to improve clinical outcomes.
●Closer monitoring for patients who may have early infection – Without purulent discharge, signs of inflammation at the exit site (eg, erythema or crust formation) are not sufficient to diagnose an ESI (see 'Establishing the diagnosis' below) but may provide warning that an ESI is imminent.
We ask patients who may have a developing ESI to clean and examine the exit site daily and report the development of any discharge. The exit site should be re-evaluated by the clinician or home unit medical staff in approximately one week, or as soon as a discharge develops. It is important during this time to make sure that the patient is adhering to optimal catheter hygiene and preventive care. (See 'Maintenance preventive care' below.)
CLINICAL PRESENTATION
●Exit-site infection – Typically, an exit-site infection (ESI) presents initially as increased crust formation and/or erythema surrounding the exit site and progresses to serous and purulent drainage arising from the exit site. Exit-site tenderness and edema commonly are present. Patients with an isolated ESI generally do not have fever or chills.
●Tunnel involvement – Tunnel involvement manifests as erythema, edema, induration, or tenderness over the catheter pathway [20]. If untreated, infection may progress to abscess formation within the tunnel. Patients with a tunnel abscess may have systemic signs and symptoms (eg, fever and chills).
DIAGNOSIS —
Our approach to the evaluation and diagnosis of exit-site infections (ESIs) and tunnel infections is consistent with the 2023 International Society for Peritoneal Dialysis (ISPD) guidelines [11].
Initial evaluation — Evaluation of a patient with a suspected exit-site or tunnel infection consists of a physical examination, microbiology studies, and ultrasound imaging in select patients (algorithm 1). Patients with abdominal pain or cloudy effluent should be evaluated for concomitant peritonitis. (See "Clinical manifestations and diagnosis of peritonitis in peritoneal dialysis".)
Our approach to evaluation is as follows:
●Physical examination – We carefully examine the exit site for erythema, skin induration, or increased crust formation. The presence of purulent discharge confirms an ESI (see 'Exit-site infection' below). An exposed external catheter cuff may act as a nidus for infection. (See 'Refractory infection' below.)
After we examine the exit site, we inspect and palpate the catheter tunnel, and we milk the catheter track. Tenderness over the catheter pathway and purulent drainage from the exit site after milking the track indicate tunnel infection. (See 'Tunnel infection' below.)
●Exit-site culture – Purulent drainage should be sent for culture and Gram stain to direct antibiotic therapy. A culture swab is not helpful if drainage is not present, since, in the absence of discharge, positive cultures may just represent colonization. In practice, Gram stain is usually of limited utility: Most microbiology laboratories do not routinely perform Gram stain for exit-site culture swabs.
●Imaging in selected patients – We obtain an ultrasound of the catheter tract only if we suspect a tunnel infection based on symptoms and physical examination (such as tenderness over the catheter pathway or purulent drainage from the site after milking the tract). Ultrasound is effective in revealing the presence of pericatheter fluid collections [21], which are associated with an increased risk of refractory infection. Computed tomography (CT) scanning or gallium scanning may be alternatives to ultrasound. If obtaining an ultrasound, it is important to specify that the catheter tract is the suspected site of infection so that the ultrasound gain is adjusted accordingly.
Imaging results are used as follows:
•Baseline imaging – An initial ultrasound provides baseline imaging to compare with repeat imaging in patients who have a tunnel infection that may prove refractory to antibiotic therapy. In patients with refractory infection, ultrasound findings such as a new fluid collection, or a fluid collection not substantially improved from baseline, are an indication for catheter removal or a catheter salvage procedure. (See 'Refractory infection' below.)
•Obtaining fluid for culture – For patients with a suspected tunnel infection who do not have a concomitant ESI or drainage from the exit site after milking the catheter tract, obtaining an exit-site culture swab to direct antibiotic therapy is impossible. For such patients, ultrasound imaging may identify pericatheter fluid collections amenable to drainage (ie, larger than 1 to 2 cm), in which case we refer to surgery or to interventional nephrology/radiology so that fluid can be drained and sent for culture and Gram stain.
Less commonly, some centers use initial ultrasound imaging to identify extensive fluid collections that may be treated with an early catheter salvage procedure. However, a trial of antimicrobial therapy is usually pursued before performing a catheter intervention. (See 'Initial empiric therapy' below and 'Refractory infection' below.)
Establishing the diagnosis — ESI and tunnel infection diagnoses are made clinically.
Exit-site infection — We diagnose ESI if there is purulent discharge from the exit site, with or without erythema.
We do not diagnose ESI, at least initially, among patients who present with only erythema, skin induration, or increased crust formation, since these changes alone may not represent an infection [11]. Erythema without infection is commonly observed following placement of the catheter or after mild trauma involving the catheter [22]. Skin erythema also may be a manifestation of an allergic reaction [22] or result from a change in the exit-site dressing or cleaning agent [23]. However, patients with erythema, skin induration, or crust formation at the exit site should be closely followed for progression to ESI. (See 'Monitoring for early detection' above.)
At the time of diagnosis, we take photographs of the ESI with a mobile phone so that accurate comparisons between clinic visits are possible [20]. Photographic documentation helps assess the response of the infection to treatment. (See 'Refractory infection' below.)
As per ISPD guidelines, we do not use scoring systems based on clinical signs and symptoms [24,25] to diagnose ESI. Such schemata have not been validated, and a large multicenter prospective cohort study did not show that using a scoring system to diagnose ESI added benefit compared with using purulent discharge as the sole diagnostic criterion [26].
Tunnel infection — We diagnose tunnel infection if there is erythema, edema, induration, or tenderness over the catheter pathway. Ultrasonographic evidence of a pericatheter fluid collection does not need to be present for the diagnosis of a tunnel infection.
TREATMENT —
Antibiotics are effective in treating exit-site infections (ESIs) and tunnel infections, which, if left untreated, commonly lead to peritonitis [27]. In one retrospective study, over 30 percent of all cases of peritonitis associated with catheter infection were preceded by an ESI or tunnel infection [27].
Increased exit-site care — During an ESI, we ask patients to increase the frequency of exit-site cleaning to at least daily. Patients also should continue to apply daily topical antibiotics. (See 'Cleaning and general care of the exit site' below and 'Antimicrobial prophylaxis' below.)
Antimicrobial therapy — Initial antimicrobial therapy for ESIs is the same as that for tunnel infections. We agree with the 2023 International Society for Peritoneal Dialysis (ISPD) guidelines that all ESIs with or without tunnel involvement should be treated with antibiotics [11].
Role of antifungal prophylaxis — We administer antifungal prophylaxis to patients on peritoneal dialysis who are treated with antibiotics for ESIs or tunnel infections. Treatment with systemic (or intraperitoneal) antibiotics is a major risk factor for the development of fungal peritonitis. Our approach towards antifungal prophylaxis, choice of agent, and dosing among patients on peritoneal dialysis is discussed elsewhere. (See "Risk factors and prevention of peritonitis in peritoneal dialysis", section on 'Antifungal prophylaxis during antibiotic therapy'.)
Initial empiric therapy — For most patients with an ESI or tunnel infection, the initial empiric antibiotic regimen is based on adequate coverage of S. aureus. We suggest initial therapy as follows (algorithm 1):
●A first-generation oral cephalosporin or an oral penicillinase-resistant penicillin (such as dicloxacillin) (table 2). We use oral trimethoprim/sulfamethoxazole or oral clindamycin if the patient is allergic to penicillin (table 2).
There are two exceptions to this approach:
●The patient who has had prior infection or colonization with methicillin-resistant S. aureus (MRSA) should receive empiric treatment for MRSA. To treat possible MRSA, we administer intraperitoneal vancomycin (15 to 30 mg/kg every five to seven days). Serum vancomycin levels should be checked prior to redosing to assure that a therapeutic level (goal 15 to 20 microgram/mL) is achieved, particularly among patients with residual kidney function, who may require a higher maintenance dose or more frequent dosing. For intermittent dosing of intraperitoneal antibiotics, the dwell time should be at least six hours to allow adequate absorption [20].
●The patient who has had prior infection or colonization with Pseudomonas should receive an antipseudomonal antibiotic in addition to appropriate coverage for S. aureus. We usually use oral ciprofloxacin (table 2) [19]. If the patient cannot take ciprofloxacin, we use intraperitoneal ceftazidime [20]. Ceftazidime may be given continuously (500 mg/L loading dose followed by 125 mg/L in all subsequent exchanges) or intermittently (1000 to 1500 mg in one exchange daily). For intermittent dosing of intraperitoneal antibiotics, the dwell time should be at least six hours to allow adequate absorption [20].
Occasionally, empiric therapy may need to be based on local patterns of infection and trends in antibiotic resistance, although generally this does not overly influence the choice of initial antibiotic [9]. An exit-site culture is obtained, and antibiotic usage is adjusted based upon the results.
Subsequent therapy — Results of cultures and antimicrobial susceptibility testing should be used to make appropriate adjustments to the initial antibiotic regimen (algorithm 2 and algorithm 3). For the minority of patients who receive initial empiric treatment with broad-spectrum intraperitoneal antibiotics (see 'Initial empiric therapy' above), culture results usually can be used to switch antimicrobial therapy to an oral and more narrow regimen.
After one week of antibiotics, we reassess the patient. Our subsequent approach to antimicrobial therapy is based on the clinical status as follows:
●If the patient is improving, we continue antibiotics until the infection has completely resolved and, additionally, for a minimum duration that varies according to the presence of tunnel infection and Pseudomonas:
•If the patient has tunnel involvement or a Pseudomonas infection, we treat for a minimum of three weeks.
•If the patient does not have tunnel involvement or a Pseudomonas infection, we typically treat for a minimum of 10 to 14 days. However, the optimal duration of antibiotic therapy in this setting is uncertain, and some clinicians treat for a minimum of 7 to 10 days [11].
We continue antibiotics for up to six weeks without surgical intervention provided that continued improvement is seen. (See 'Indications for catheter removal' below.).
●If the patient is not improving, our approach depends on the culture and sensitivity results:
•If the organism is a Staphylococcus spp and there is no improvement after one week, then oral rifampin should be added to the regimen (algorithm 2). Rifampin has good tissue penetration and acts synergistically with antistaphylococcal penicillins and vancomycin. Rifampin should not be given as single-agent therapy (table 2) [24,28].
•If the organism is a Pseudomonas spp and the patient has not responded within one week, we add a second antipseudomonal drug (algorithm 3), such as intraperitoneal ceftazidime (dosed continuously [500 mg/L loading dose followed by 125 mg/L in all subsequent exchanges] or intermittently [1000 to 1500 mg in one exchange daily]) or intraperitoneal aminoglycoside (such as amikacin, 2 mg/kg in one exchange per day, or tobramycin, 0.6 mg/kg in one exchange per day). Intraperitoneal aminoglycosides should be given intermittently rather than continuously. For intermittent dosing of intraperitoneal antibiotics, the dwell time should be at least six hours to allow adequate absorption [20].
Other options for a second antipseudomonal drug to complement oral ciprofloxacin include intraperitoneal cefepime, piperacillin, imipenem, or meropenem [19,24,28].
•For all other organisms, we ensure that cultured organisms are sensitive to the antibiotic regimen. If initial culture results are considered unreliable, the culture should be repeated.
•If the initial cultures are negative, we reculture, switch oral gram-positive antibiotic coverage to intraperitoneal vancomycin, and add oral gram-negative antibiotic coverage (eg, ciprofloxacin) if not already prescribed. (See 'Initial empiric therapy' above.)
Patients without clinical improvement after two weeks total of antimicrobial therapy require additional evaluation and management (see 'Refractory infection' below). Patients without improvement after three weeks total of antimicrobial therapy or complete resolution of infection after six weeks total of antimicrobial therapy should have their catheters removed. (See 'Indications for catheter removal' below.)
Fungal infection — Fungal infections are a rare cause of ESI and warrant removal of the catheter to prevent progression to fungal peritonitis, which has high morbidity and mortality (see "Fungal peritonitis in peritoneal dialysis"). However, it is important to ascertain that the fungus identified in the culture is not a contaminant by repeating a culture and demonstrating the absence of other organisms. (See 'Indications for catheter removal' below.)
Refractory infection — Refractory infection is defined by lack of improvement despite at least two weeks of optimal management. Surgical interventions are often indicated for refractory infections [28]. The evaluation and management of refractory infections are detailed below.
Evaluation — For patients with lack of improvement after at least two weeks of appropriate antimicrobial therapy (see 'Antimicrobial therapy' above), we ensure adherence to the therapeutic regimen and conduct an additional evaluation as follows:
●We perform a thorough repeat physical examination to determine whether an ESI has progressed to a tunnel infection (see 'Initial evaluation' above and 'Tunnel infection' above) and whether the external catheter cuff has extruded.
●We obtain an ultrasound to help identify a fluid collection (ie, abscess) in the tunnel [29]. For patients in whom a baseline ultrasound was previously obtained (see 'Initial evaluation' above), we assess for interval radiographic change.
●For patients with negative cultures or cultures growing diphtheroids or Corynebacterium, we test for nontuberculous mycobacteria with specific stains and culture media [30]. Nontuberculous mycobacteria are sometimes misidentified as diphtheroids or Corynebacterium spp.
Management — Our management of patients with lack of improvement after at least two weeks of appropriate antimicrobial therapy (see 'Antimicrobial therapy' above) depends on the ultrasound findings, whether the external cuff of the catheter is exposed, and the therapeutic options available at a given center.
●For patients with ultrasonographic evidence of deep cuff involvement, we remove the catheter.
●For other patients, the approach depends on the availability of catheter salvage procedures (eg, external cuff shaving and exit-site relocation). Most centers do not offer such procedures, and the evidence to support their use consists of observational (and usually single-center) studies rather than randomized trials.
•For patients at centers that do not offer catheter salvage procedures, our approach is as follows:
-For patients who have physical examination findings of a new or worsening tunnel infection, ultrasonographic evidence of a fluid collection that is new or not substantially improved from prior, or who have an exposed external cuff, we remove the catheter.
-For all other patients, we treat with another week of antibiotic therapy. After a total of three weeks of antibiotics, if there is still no improvement, the patient should have the catheter removed. (See 'Indications for catheter removal' below.)
•For patients at centers that offer catheter salvage procedures, the approaches vary substantially. The most common procedures are external cuff removal or shaving, typically used for refractory ESIs, and catheter exit-site relocation, which is used for refractory ESI and tunnel infections. These procedures are discussed below.
-Removal of the external cuff is typically performed under sterile conditions and local anesthesia either at the patient's bedside or in an outpatient office [31]. The techniques used vary depending upon the clinician's preference and experience. As examples, cuffs can be teased away from the catheter using blunt forceps [32]. Another method of cuff removal is called "cuff shaving." While some clinicians use scalpels for cuff shaving, others prefer to use abrasives such as sandpaper, emery boards, or bovine scrapers to remove the cuff, which have a much lower risk of damage to the catheter compared with scalpels. Because cuff shaving can damage the catheter, it needs to be performed by a clinician experienced with the technique [33]. If the cuff is only partially exposed, the tunnel may need to be deroofed for complete exposure and removal.
Conflicting results have been observed with the cuff-shaving procedure [1,32,34-36]. In some studies, cuff shaving was effective for resistant ESIs [33,35,36]. In one study, for example, 48 patients underwent 53 cuff-shaving procedures [33]. Among these patients, 34 percent of the infections were due to S. aureus, 17 percent due to Corynebacterium spp, 15 percent due to P. aeruginosa, and 8 percent due to fungal agents. Cuff shaving was associated with resolution of 39 of the 53 infections (74 percent), with the remaining patients requiring catheter removal due to persistent infection or leak.
-An alternative to cuff shaving is relocation of the exit site with removal of the external cuff, which can also be performed as a day procedure under local anesthesia. This procedure is also not available at many centers, and most descriptions of this procedure are from single centers. One retrospective study from the United Kingdom analyzed outcomes of 27 patients with a resistant ESI (mostly Pseudomonas and S. aureus infections) who were treated with exit-site relocation and cuff removal [37]. Patients were permitted to resume peritoneal dialysis immediately following the procedure, and oral antibiotics were continued for two to four weeks until healthy granulation tissue was observed. At a follow-up of four years (range 11 to 79 months), most patients (74 percent) had long-term resolution of infection; seven required catheter removal due to recurrent ESI (n = 5) or tunnel infection (n = 2). While these findings are encouraging, the independent benefit of the procedure is difficult to assess given the lack of a control group and the administration of cointerventions, including cuff removal and additional antibiotic therapy.
Other observational studies have also found benefit with relocation of the exit site. In one study of 52 patients with intractable ESI or tunnel infections who underwent cuff shaving and creation of a new tunnel, infection-free catheter survival at 6 and 12 months was 57 and 35 percent, respectively [38]. Another study that evaluated 40 catheter diversion procedures among 33 patients with ESI or tunnel infection found the infection-free rate was 90 percent at 30 days and 67 percent at 90 days [39]. Importantly, the median peritoneal dialysis catheter survival was 84 months, and patients undergoing catheter diversion had longer catheter survival and were more likely to stay on peritoneal dialysis than patients who had their catheters removed and replaced.
If patients are still without improvement after a catheter salvage procedure despite a total of three weeks of antibiotics, the catheter should be removed. (See 'Indications for catheter removal' below.)
Indications for catheter removal — Catheter removal is required for some ESIs and tunnel infections. The following are indications for catheter removal [20]:
●ESI or tunnel infection progressing to, or occurring simultaneously with, peritonitis.
●The ESI or tunnel infection shows no improvement after three weeks of appropriate antibiotics (with/or without a catheter salvage procedure such as cuff shaving) or has not completely resolved after six weeks.
●The ESI or tunnel infection is caused by fungus or mycobacteria.
In all cases, perioperative antibiotics should be given [24] and then continued for one to two weeks after catheter removal.
The catheter should be removed by surgical dissection rather than by traction. Removal by traction may result in retention of the peritoneal and/or subcutaneous cuffs, which could lead to local infection or sepsis. In one study, a change in removal practice from traction to surgical dissection resulted in a significant reduction in the incidence of local infections (0 versus 24 percent) [40].
If there is no peritonitis associated with the ESI, the infected catheter can be removed and a new catheter placed simultaneously in the opposite lower quadrant [41]. The "clean" step of inserting the new catheter on the opposite side of the abdomen is performed before the "dirty" step of removing the old catheter, with care to avoid cross-contamination of wounds. This procedure is commonly performed in the pediatric population and has also been shown to be effective in adults [42,43]. In one study, simultaneous catheter placement and removal was successful in 30 of 36 patients [42]. In the remaining six, persistent infection developed in two, and the procedure was not successful for technical reasons in four.
A new catheter should not be placed at the time the infected catheter is removed if active peritonitis is present. We wait at least two weeks after catheter removal and complete resolution of peritoneal symptoms before placing a new catheter. This practice is consistent with the 2023 update of the ISPD recommendations [20]. However, simultaneous catheter removal and replacement can be performed for relapsing peritonitis caused by the Staphylococcus spp if antibiotic therapy resolves abdominal symptoms and the peritoneal fluid cell count is <100/microL. This practice is consistent with the 2019 ISPD guidelines on creating and maintaining the peritoneal dialysis catheter [44]. (See "Microbiology and therapy of peritonitis in peritoneal dialysis".)
PREVENTION —
The risk of exit-site infection (ESI) and tunnel infection is decreased by preventive measures instituted prior to and immediately after catheter placement, as well as throughout the life of the catheter [45]. The following measures are largely consistent with the International Society for Peritoneal Dialysis (ISPD) published guidelines [11,46].
Prior to catheter placement — We administer systemic antibiotics immediately prior to surgery. The 2017 Kidney Disease: Improving Global Outcomes (KDIGO) and 2023 ISPD guidelines recommend screening and treating patients for S. aureus nasal carriage prior to peritoneal dialysis catheter insertion. However, we do not routinely test for S. aureus carriage because patient adherence to treatment of it is often suboptimal and because routine exit-site care includes the application of either gentamicin or mupirocin cream, both of which treat S. aureus [20,47]. Specific recommendations for systemic antibiotics are discussed elsewhere. (See "Placement of the peritoneal dialysis catheter".).
Immediately after surgery — After placement of the catheter, the incision should be covered and the dressing left undisturbed for approximately one week. Any dressing changes required during this time (such as for a soiled dressing) should be done by a peritoneal dialysis nurse rather than the patient. The site should be kept dry, which precludes taking showers for at least three weeks [48].
Maintenance preventive care — Routine maintenance measures to prevent infection include cleaning the exit site and applying topical antimicrobial agents.
Cleaning and general care of the exit site — Once the exit site is healed, it should be cleaned at least twice weekly and after water exposure (as occurs with a shower or swimming) or strenuous exercise. In our practice, we prefer daily cleaning with an unscented antibacterial soap. Other acceptable cleaning agents include an antiseptic such as povidone iodine solution (10%) or chlorhexidine solution (0.05 to 2%). Hydrogen peroxide should not be used, since it tends to dry out the site and may be toxic to the normal granulation tissue.
When cleaning the exit site, crusts, if present, should not be forcibly removed. The exit should be dabbed dry after cleaning using a clean cloth or towel. A nonocclusive dressing (such as gauze) to cover the exit site may be used, but is not mandatory [49].
We suggest that patients immobilize the catheter with tape to prevent accidental injury to the exit site, although there are no data that specifically support this practice [6].
Antimicrobial prophylaxis — In addition to the measures defined above (see 'Cleaning and general care of the exit site' above), we use topical antibiotics daily to prevent catheter-related infections. We also administer oral antibiotics following catheter trauma.
●Daily topical antibiotics at exit site – We suggest daily application of a topical antibiotic [11]. Contact between topical antibiotics and the catheter should be minimized; mupirocin ointment and gentamicin cream have been associated with damage to polyurethane and silicone catheters, respectively [50,51].
Two commonly used topical antibiotics are mupirocin and gentamicin. Some experts prefer mupirocin while others use 0.1% topical gentamicin sulfate. Gentamicin is as effective as mupirocin against S. aureus and other gram-positive organisms and may be more effective against gram-negative organisms [9,52-54]. Gentamicin is generally less expensive than mupirocin. We do not alternate between mupirocin and gentamicin due to a potential risk of increased fungal peritonitis [55]. Many other topical and oral antimicrobial agents, including Medihoney, have been studied but are generally considered experimental or unproven [15,56-68].
Older studies reported that topical antibiotics decreased the risk of ESIs and peritonitis [2,56,69-74]; however, many such studies were small, did not distinguish between exit-site or nasal mupirocin, or predominantly targeted patients harboring nasal S. aureus. Definitive evidence that topical exit-site antibiotics decrease the risk of catheter-related infections is lacking [75]. Daily, compared with less frequent, application of topical antibiotics has been associated with fewer ESIs and a lower level of antimicrobial resistance [18,76-78].
●Oral antibiotics following catheter trauma – We administer systemic oral antibiotics to all patients who report trauma to their exit site, although there are no data that specifically support this approach.
We give cephalexin for three days (table 2). If the patient is allergic to cephalosporins, we give ciprofloxacin for three days (table 2).
Granulomas occasionally occur at the exit site, and often become infected. To prevent this, a trained nurse can apply silver nitrate to the granuloma on one occasion for cauterization. Another option is for the patient to apply chlorhexidine daily. In a randomized trial of 44 patients with exit-site granulomas, rates of healing were similar between chlorhexidine and silver nitrate (94 versus 100 percent, respectively) [79]. There was less pain associated with chlorhexidine application.
●Topical nasal antibiotics – We do not use nasal antimicrobial agents for maintenance prophylaxis. Application of nasal antimicrobial agents is uncomfortable and of limited clinical benefit. In one trial of 267 patients, nasal application of mupirocin was associated with reduced incidence of ESI due to S. aureus (14 versus 44 infections over 18 months); however, the rates of peritonitis and all ESI were similar (33 per 1390 versus 55 per 1236 patient-months) [47,80,81].
Environment and lifestyle — A clean environment and certain lifestyle changes may help reduce the rate of ESIs and tunnel infections, as suggested by observational data [82,83].
Peritoneal dialysis patients are generally discouraged from taking baths, using hot tubs, or swimming in rivers, lakes, or the ocean. Swimming in swimming pools and salt water bodies may be safer, but not completely without risk of ESI and peritonitis [7]. In a cross-sectional survey of 39 Australian peritoneal dialysis units where swimming among patients was near-universal, seven episodes of ESI and two of peritonitis were attributed to swimming [7].
However, when patients choose to swim or take a bath, we advise them to cover the catheter and exit site with an ostomy bag and to immobilize the catheter (ie, with tape). We instruct patients to perform exit-site care after swimming or bathing in a tub. (See 'Cleaning and general care of the exit site' above.)
Pets in the house may increase the risk of infection, although zoonotic bacteria account for a low percentage of peritonitis episodes (0.03 to 0.54 percent) [84]. Although we generally do not actively discourage patients from having pets, we advise that pets remain out of the room when exchanges are performed.
PROGNOSIS —
Most exit-site infections (ESIs) resolve with appropriate treatment. However, some infections do not resolve. Catheter infections with Pseudomonas are particularly problematic, with lack of response to treatment in approximately 50 percent of cases [85]. In a series of 14 patients with Pseudomonas ESI treated with oral and intraperitoneal antibiotics, only six patients had a cure with no recurrence [86].
If the ESI is not treated or does not respond to treatment, two major complications may result, including peritonitis and removal of the catheter.
Peritonitis is the most serious complication [27]. Patients who develop an ESI are much more likely to develop peritonitis, even if the ESI was appropriately treated [87].
Peritonitis most commonly results from S. aureus or P. aeruginosa-related ESIs with tunnel infections. In the study cited above, among 14 patients with Pseudomonas ESI, two patients had Pseudomonas peritonitis at presentation, and four developed Pseudomonas peritonitis [86].
Resistant ESIs may also result in removal of the catheter, requiring the temporary or permanent switch from peritoneal dialysis to hemodialysis [27]. In the study above, of 14 patients, the catheter was removed in four patients because of peritonitis and in three patients because of the severity or recurrence of the ESI [86]. (See "Microbiology and therapy of peritonitis in peritoneal dialysis", section on 'Prognosis'.)
ESIs are rarely a direct cause of mortality unless they are untreated and progress to bacterial or fungal peritonitis.
INFORMATION FOR PATIENTS —
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Beyond the Basics topic (see "Patient education: Peritoneal dialysis (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Microbiology – Peritoneal dialysis requires the placement and maintenance of a catheter in the peritoneal cavity. The exit site and catheter tunnel are prone to bacterial infection. More than 50 percent of infections are caused by gram-positive organisms, with Pseudomonas aeruginosa and Escherichia coli causing the majority of the remainder. (See 'Introduction' above and 'Microbiology' above.)
●Monitoring, evaluation, and diagnosis – The exit site should be examined daily by the patient and at least monthly by a clinician and whenever the patient detects a change in the appearance of the exit site. The clinical presentation, evaluation, and diagnosis of exit-site infections (ESIs) and tunnel infections are described above (algorithm 1). (See 'Clinical presentation' above and 'Diagnosis' above.)
●Treatment – We treat all patients with ESIs and/or tunnel infections with systemic antibiotics (algorithm 1). For most patients with an ESI or tunnel infection, we suggest initial therapy with a first-generation oral cephalosporin or an oral penicillinase-resistant penicillin (such as dicloxacillin) rather than other antibiotic regimens (table 2) (Grade 2C). (See 'Treatment' above and 'Initial empiric therapy' above.)
Results of cultures and antimicrobial susceptibility testing should be used to make appropriate adjustments to the initial antibiotic regimen. We reassess the patient after one week of antibiotics and base our subsequent approach on the clinical status. (See 'Subsequent therapy' above.)
●Refractory infection – Refractory infection is defined by lack of improvement after at least two weeks of appropriate antimicrobial therapy. The management of refractory ESI or tunnel infection depends on physical examination findings, ultrasound imaging results, and the availability of catheter salvage procedures. (See 'Refractory infection' above.)
●Catheter removal – Catheter removal is required for some ESIs and tunnel infections. The following are indications for catheter removal (see 'Indications for catheter removal' above):
•ESI or tunnel infection progressing to, or occurring simultaneously with, peritonitis.
•The ESI or tunnel infection shows no improvement after three weeks of appropriate antibiotics (with/or without a catheter salvage procedure such as cuff shaving) or has not completely resolved after six weeks.
We also remove the catheter for infections due to specific microbes that are difficult to treat or are associated with high mortality should peritonitis develop. For patients with ESIs or tunnel infections due to Mycobacteria spp or fungus, we suggest catheter removal and antimicrobial therapy rather than antimicrobial therapy alone (Grade 2C). (See 'Fungal infection' above.)
●Prevention – ESIs and tunnel infections are decreased by preventive measures. In addition to washing the exit site daily, we suggest application of topical antibiotics (Grade 2C). We use 0.1% topical gentamicin sulfate administered daily; mupirocin is also effective. Preventive systemic antibiotics are also given prior to catheter placement and following any inadvertent trauma to the catheter. (See 'Prior to catheter placement' above and 'Antimicrobial prophylaxis' above.)
