Management of peritoneal catheter exit-site infections that occur in the absence of peritonitis in adults*

* This algorithm does not address fungal infections. Fungal infections are a rare cause of exit-site infections and warrant removal of the catheter. However, it is important to confirm that cultured fungus is not a contaminant by repeating the culture and demonstrating the absence of other organisms.
¶ We diagnose exit-site infection if there is purulent discharge from the exit-site with or without erythema or if there is severe acute erythema without purulent discharge, which develops in the absence of acute trauma to the catheter.
Δ If the patient has a history of infection or colonization with methicillin-resistant Staphylococcus aureus (MRSA), we empirically treat gram-positive infections with oral cephalexin or oral ciprofloxacin for broad-spectrum coverage plus intraperitoneal vancomycin. Vancomycin should not be used for empiric therapy in the absence of history of MRSA, since there is a high incidence of vancomycin-resistant organisms.
◊ If the patient has a history of infection or colonization with Pseudomonas, some clinicians treat gram-negative organisms or an indeterminate Gram stain with an intraperitoneal aminoglycoside, such as amikacin, in addition to other antibiotics (ie, oral ciprofloxacin or intraperitoneal ceftazidime, for gram-negative organisms, or oral ciprofloxacin and an oral penicillinase-resistant penicillin or oral first-generation cephalosporin for an indeterminate Gram stain).
§ Refer to UpToDate topic on peritoneal catheter exit-site and tunnel infections in peritoneal dialysis for discussion of treatment of resistant infection.