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One of the most important components of the peritoneal dialysis system is a permanent and trouble-free access to the peritoneal cavity. The double-cuff Tenckhoff catheter, developed in 1968 for treatment of patients with intermittent peritoneal dialysis [1], is also widely used for continuous ambulatory peritoneal dialysis (CAPD); however, CAPD increases catheter-related complications due to higher intraabdominal pressure and numerous daily manipulations. These complications, such as catheter-tip migration, dialysate leaks, and exit site infections are frequently encountered and often related to improper insertion and postimplantation care. Catheter exit site and tunnel infections are frequent in CAPD patients, leading to morbidity, prolonged treatment, recurrent peritonitis and catheter failure. Recent improvement in peritonitis rates due to widespread use of the Y-set has shifted the focus of attention to peritoneal access [2–4]. According to the National CAPD Registry, the overall 3-year survival of the various peritoneal catheters was 13–36% in the 1981–87 period [5]. The results have markedly improved in recent years.

Although guidelines suggest the routine use of mupirocin or gentamicin at the exit site of PD catheter, our PD unit has been using chlorhexidine gluconate 0.5 % as exit-site care protocol. The aim of this study was to ascertain whether mupirocin application is superior to the traditionally applied chlorhexidine-regarding prevention of exit-site infections and peritonitis in our unit.Stable incident and prevalent patients of our unit were randomized to apply mupirocin or chlorhexidine at exit site. The study started on July 1, 2010, and continued till December 2014. End point was the first episode of exit-site infection or peritonitis.Sixty-two patients (mean age 58.5 ± 14.6 years) were randomized. At the end of follow-up, there were 33 patients on mupirocin treatment and 29 on chlorhexidine. The two groups had no differences in age, sex, PD vintage or PD mode. The only difference between the two groups was the percentage of patients with diabetes, 28 % in chlorhexidine group versus 10 % in mupirocin group. Mean time of follow-up was 28.46 ± 16.37 months. Twenty-four episodes of infections (peritonitis and exit site) were recorded. Time to first infection episode was 32 months in mupirocin group (95 % CI 21.4-42.5) versus 29 months (95 % CI 8.6-49.4) in chlorhexidine group. The Kaplan-Meier survival analysis revealed no difference in the infections between the two protocols (log-rank test, p = 0.477).Mupirocin is not superior in preventing infections comparing with chlorhexidine in this cohort of patients.

Introduction: The tunneled cuffed catheter is used in hemodialysis patients for whom an arteriovenous fistula or arteriovenous graft is not suitable or for bridging usage of them. Accurate placement of a tunneled cuffed catheter is necessary for safe hemodialysis, but placement is sometimes difficult because of individual body differences. We developed a new device to support accurate placement of the tunneled cuffed catheter. In this study, we report our first clinical experience of the device. Methods: We made the device by expanded polytetrafluoroethylene with some special processes. The processes enable it to maintain plasticity and temporary shape in the autoclaved condition. The device is laid on the surface of the patient’s body to mark the root of the catheter with a felt-tipped marker before catheterization. That enables us to know the accurate catheter root and tunneled cuffed catheter exit site on the body surface. Ten patients underwent tunneled cuffed catheter insertion according to the marking. Case description: The mean age was 71.3 ± 12.8 years. The tunneled cuffed catheter was safely placed according to the marking in all patients, and all catheter tips were placed in the right atrium. The mean verification tip location difference before and after catheterization was 0.70 ± 0.48 cm. This result indicated that the device could assist in inserting a catheter accurately within an error of 1.18 cm. The tunneled cuffed catheters were patent in all the cases, without replacement and complications until the end of bridging use or during the observation period. Conclusion: Our newly developed insertion support device enhances safety and prevents catheter waste during replacement.

Fungal infection is an extremely rare etiology of exit-site and tunnel infection in patients on continuous ambulatory peritoneal dialysis (CAPD). There are few data available regarding its management—especially choice of antifungals, duration of therapy, and removal of catheter. There are no guidelines pertaining to reinsertion of the CAPD catheter following fungal exit-site and tunnel infection. This case report highlights Candida albicans as a rare cause of exit-site and tunnel infection of the CAPD catheter. The catheter was removed and the patient received appropriate antifungal therapy followed by reinsertion of the CAPD catheter and re-initiation on CAPD.

Aim The commonest mode of catheter colonisation is via the extraluminal route with skin bacteria. Catheter-related sepsis causes significant mortality and morbidity in neonates. Our aim was to study the relationships between culture-positive catheter exit site skin swabs, percutaneous central venous catheter segments and blood to determine the magnitude of associations between exit site skin colonisation, catheter colonisation and catheter-related sepsis. Methods In a prospective study, an exit site skin swab and three formerly in vivo catheter segments (proximal, middle and tip) were taken for culture at catheter removal. In those neonates who were clinically unwell at catheter removal, a peripheral blood culture was also collected. Univariate and multivariate analyses were used to study associations. Results Skin swabs were culture positive in 39 (21%) of 187 catheter removals. With a culture-positive skin swab, the risk of associated catheter colonisation was nearly eight times higher (OR: 7.84, 95% CI: 3.59–17.15) and the risk of definite catheter-related sepsis with the same organism was nearly 10 times higher (OR 9.86, 95% CI: 3.13–31.00). Conclusion Culture-positive skin swabs from the catheter exit site were strongly associated with catheter colonisation and with definite catheter-related sepsis with the same organism. These data provide further evidence supporting catheter colonisation via the extraluminal route and highlight the importance of optimising skin disinfection before catheter insertion.

Clinical records show ever increasing functional times of rotary blood pumps implanted in patients. With longer functional time, the problem of driveline infection is becoming more urgent. No material or scaffold has been found, which allows a permanent and stable ingrowth of skin cells that would prevent (pathogenic) germs entering the body. Usually, the epithelial cells die at the exit site and new cells form a sulcus around the driveline, which grows deeper and finally becomes infected. The purpose of this project is to present a solution to this problem by elaborating a new mechanism, the active skin-penetrating device. The device is composed of a tube with a 5-mm diameter, a protective sleeve that surrounds the catheter exit site, and an active traction device. The protective sleeve is made of thin polyurethane covered with polyethylenterephtalat (PET, i.e. Dacron) fibers to permit the attachment of keratinocytes, similar to the standard driveline. The active traction device exerts a constant pull on the protective sleeve. The ingrown keratinocytes slowly give way and the protective sleeve gradually moves out of the body at a rate of a few millimeters per week. Meanwhile, the keratinocytes transform into horny cells and are then shed as in natural skin. Therefore, the formation of a sulcus is avoided, and the protective sleeve remains infection-free. In a first proof of the concept, four of the new devices and 10 control devices were implanted in goats. The devices remained infection-free for a period of 420 days, whereas four of the 10 control devices became infected. On the basis of these experiments, the active skin-penetrating device has been further developed and is being tested again in goats in a refined version. The results so far indicate that with the active-skin penetrating device an infection-resistant percutaneous energy transfer can be achieved for a prolonged period of time.

Heavy bacterial colonization results in exit-site infection. Antiseptic and non antiseptic agents have both been used for exit-site cleansing. An ideal cleansing agent should not only reduce the number of microorganisms, but should also be harmless to the body's defenses and should not interfere with wound healing. In vitro studies using animal cells have demonstrated that some antiseptic agents have adverse effects on wound healing. Strong cytotoxic antiseptics should be discouraged in exit-site cleansing.In choosing an appropriate cleansing agent for exit-site care, the phase of wound healing, the condition of the exit site, and the goal of cleansing should be taken into consideration. Antimicrobial soap is recommended for cleansing a healed exit site, but biocompatible solution is preferred for the postoperative, infected, or traumatized exit site. In vivo studies on the effectiveness of some cleansing agents are still lacking, and clinical study of exit-site cleansing is needed to determine the most effective agents for the task.

OBJECTIVE: To compare the incidence of exit site colonization, local catheter-related infection and catheter-related bacteremia in patients randomized to receive either topical 2% mupirocin or placebo at the catheter exit site.PATIENTS AND METHODS: Patients requiring central venous catheters for more than three days were randomized to receive in a double-blind fashion either topical mupirocin or an identical placebo at the exit site three times weekly at the time of dressing change. Insertion, site care and removal of catheters were standardized. Serial semiquantitataive cultures of the skin at the catheter insertion site were performed using a sterile 25 cm2template. The distal and proximal catheter segments were cultured using a standardized semiquantitative technique, and any suspect catheter-related bacteremia was investigated with two sets of peripheral blood cultures, a 10 mL sample of infusate and clinical assessment. Both univariate and multivariate analyses were conducted on individual risk factors to determine factors that might influence the outcomes of local or systemic catheter-related infection.RESULTS: Local catheter-related infection (defined as more than 15 colony forming units [cfu] on culture of the proximal or distal catheter segment) occurred in six of 57 (10.5%) in the mupirocin group versus 18 of 69 (26%) in the placebo group (P3cfu/mL/25 cm2(OR 2.6; CI 1.0 to 6.9) and the use of placebo (OR 3.3; CI 1.2 to 9.0) were significant factors predicting local catheter-related infection; whereas mupirocin was associated with reciprocal protective effect (OR 0.3; 95% CI 0.1 to 0.8).CONCLUSIONS: These findings suggest that patients receiving topical mupirocin at the exit site for long term central venous catheters have significantly less local catheter-related infection, and there is a trend towards less catheter-related bacteremia.

This paper shows the technical feasibility of using a modified double lumen catheter for the delivery of fluids at the skin-catheter interface in an in vivo rabbit model. The modified catheter permits the extrusion of suspensions at the site of contact between the skin and the modified catheter (exit site). The modification consisted in the addition of a second lumen, exterior to the original one of the catheter and of shorter length, ending in an extrusion port placed subdermally. An external fluid pump was attached to the catheter and the whole system was tested in vitro in human skin, in a cadaver model and in an in vivo rabbit model. Experiments were performed by delivering solutions of methylene blue in a controlled manner to the subcutaneous area to analyze the skin response to the process. Results indicate that this technique of pumping the material is effective in producing observable epithelial changes in the short term. The modification of the catheter addresses catheter exit site lack of integration of skin and works as a model that can be implemented in a number of percutaneous devices for long-term implantation.

Background and Objectives: Peritoneal dialysis (PD) is a common maintenance renal replacement modality for children with ESRD frequently compromised by infectious peritonitis and catheter exit site and tunnel infections (ESI/TI). The effect of topical mupirocin (Mup) and sodium hypochlorite (NaOCl) solution was evaluated as part of routine daily exit site care on peritonitis and ESI/TI rates, causative microorganisms, and catheter survival rates. Design, setting, participants, & measurements: Retrospective chart review of children on home continuous cycling PD between April 1, 2001 and June 30, 2007 was performed. Infection rates were examined based on exit site protocol used in two different periods: Mup alone, April 1, 2001 to November 17, 2004; and Mup and NaOCl (Mup+NaOCl), November 18, 2004 to June 30, 2007. Results: Eighty-three patients (mean PD initiation age: 12.1 ± 5.8 yr) received home PD over 2009 patient months. Annualized rates (ARs) for peritonitis decreased from 1.2 in the Mup period to 0.26 in the Mup+NaOCl period (P < 0.0001). ARs for ESI/TI decreased from 1.36 in the Mup period to 0.33 in the Mup+NaOCl period (P < 0.0001). No infections with Mup-resistant organisms were observed when either Mup or Mup+NaOCl was used for prophylaxis. Gram-negative-organism associated peritonitis decreased from an AR of 0.31 in the Mup period to 0.07 in the Mup+NaOCl period (P < 0.001). Infection-related catheter removal rates decreased from 1 in 38.9 catheter-months in the Mup period to 1 in 94.2 in the Mup+NaOCl period (P = 0.01). Catheter survival rates were longer in the Mup+NaOCl period (Kaplan–Meier, P < 0.009). Conclusions: The combination Mup+NaOCl in daily exit site care was very effective to reduce PD catheter-associated infections and prolong catheter survival in pediatric patients.

This Practice Point commentary discusses the findings and limitations of a meta-analysis that evaluated the use of prophylactic antibiotics for hemodialysis catheters. Use of prophylactic topical antibiotics at the catheter exit site was associated with a significant reduction in catheter-related bacteremia, exit-site infections, catheter removals due to secondary complications, hospitalizations for infection, and patient mortality. Use of prophylactic intraluminal antibiotic instillation was associated with a significantly reduced risk of catheter-related bacteremia and need for catheter removal. This commentary highlights the issues that should be considered when interpreting and generalizing these results, including the variability of antibiotic type and catheter type (nontunneled vs tunneled), the use of co-interventions in the various trials, and potential publication bias. The known benefits of prophylactic antibiotic use in patients with hemodialysis catheters are strongly supported by this meta-analysis.

We evaluated the use of telemedicine in the long-term control of stable patients undergoing peritoneal dialysis at home. From September 2003 to August 2005, patients were randomly selected from current cases and invited to join study group A, in which they had telemedicine support. Patients not selected for this group, or who refused the invitation, were placed in study group B, and used for comparison. There were 25 patients in group A and 32 patients in group B. Videoconferencing equipment was installed in each patient's home, connected to a videoconferencing unit at the hospital by three ISDN lines. Patients in group A were followed for a mean of 8 months (range 3–24) with alternate months of teleconsultations and hospital visits. A total of 172 teleconsultations were conducted. A mean of 22 min (SD 9) were spent on each teleconsultation, significantly less than in hospital consultations, which took a mean of 33 min (SD 8) ( P

The epidemiology and risks of Staphylococcus aureus carriage in continuous peritoneal dialysis (CPD) patients was studied in a single tertiary-care institution. On outpatient visits samples for culture were routinely taken prospectively from the CPD catheter exit site and the vestibulum nasi. Seventy-five patients with at least one culture positive for S. aureus in this period were included: 43 had genotypically identical S. aureus strains in over 80% of the cultures and were classified as persistent carriers; 32 were intermittent carriers. Persistent carriage was associated with a threefold higher risk for CPD-related infections and sixfold higher rates of vancomycin consumption compared to those for the intermittent carriers. No methicillin or vancomycin resistance was detected.

Catheter-related infections (CRI) are the second most common cause of nosocomial infection and are associated with a substantial morbidity. Suspicion of CRI is a frequent problem in the ICU and frequently leads to unnecessary removal of the catheter. The management of suspected CRI relates to the underlying illness (cardiac prosthesis, immunosuppression), the severity of the acute illness, and the micro-organisms involved or suspected.

The use of central venous access devices is increasingly common within healthcare, and such devices carry an associated risk of infection. Additional risk reduction strategies need exploring to reduce avoidable infections. A prospective 12-month audit was performed on the use of 2% chlorhexidine gluconate transparent, antimicrobial dressing to cover the catheter exit site in patients receiving total parenteral nutrition. The results showed a decrease in catheter-related bloodstream infection (CRBSI) from eight cases to zero (P=0.057), making this film dressing a possible useful addition in the goal of zero avoidable CRBSIs within this high risk group of patients.

Summary A dependable central venous access is an essential prerequisite for the delivery of care to the cancer patients. This has become easier since the introduction of indwelling central venous catheters. However, pancytopenia, often encountered in haematological malignancies, does influence the morbidity associated with these catheters. In this study the effects of two different placement techniques of Hickman catheters were evaluated. A total of 177 Hickman catheters were inserted in patients suffering from haematological malignancies. In 112 patients the catheters were placed percutaneously into subclavian veins without prior tunnelling; in the other 65 patients these were introduced, after having been tunnelled, into cephalic/external jugular veins by a cut-down technique. The catheters remained in use in each patient for between 18 and 253 days. Excessive bleeding and haematoma formation occurred in a significantly higher proportion of patients from the cut-down group (61% and 41%, respectively) compared to patients from the percutaneous group (8% and 0%, respectively). These in turn had a profound impact on the incidence of infective complications. Catheter exit site infection, tunnel infection and septicaemia were observed in 26%, 18%, and 41%, respectively, of the patients from the cut-down group, while in patients from the percutaneous group, skin exit site infection was noted only in 7% and septicaemia in 19% of patients. It was concluded that the placement technique of these catheters exerts a significant influence on the immediate as well as delayed complications. The results indicate that the insertion technique requiring minimal dissection is more beneficial. It is therefore recommended that percutaneous insertion without tunnelling should be the technique of choice for catheter placement.

Peritoneal access is a key factor in the longevity of peritoneal dialysis. As an implanted foreign body, the peritoneal dialysis (PD) catheter poses a risk for both cutaneous and peritoneal infections. Despite advances in catheter design and dialysis techniques, catheter related infections remain an important cause of patient morbidity and a significant cause of technique failure (1).

One of the most important components of the peritoneal dialysis system is a permanent and trouble free access to the peritoneal cavity. The double cuff Tenckhoff catheter, developed in 1968 for treatment of patients with intermittent peritoneal dialysis [1], is also widely used for continuous ambulatory peritoneal dialysis (CAPD); however, CAPD increases catheter related complications due to higher intraabdominal pressure and numerous daily manipulations. These complications, such as catheter tip migration, dialysate leaks, and exit site infections are frequently encountered and often related to improper insertion and postimplantation care. Catheter exit site and tunnel infections are frequent in CAPD patients leading to morbidity, prolonged treatment, recurrent peritonitis, and catheter failure. Recent improvement in peritonitis rates due to wide-spread use of the Y-set has shifted the focus of attention to peritoneal access [2, 3, 4]. According to the National CAPD Registry, the overall three year survival of the various peritoneal catheters was 13–36% in the 1981–1987 period [5].

A prospective randomized study in patients receiving central venous catheters for ≥ 3 days comparing gauze versus transparent dressings utilizing serial quantitative cultures of the exit site (25 cm2) done at each dressing change revealed a mean count of ≥ 103 cfu/mL in 29/34 (85%) with versus 8/42 (19%) without local catheter-related infection (p

Peritoneal dialysis (PD) is a growing alternative to hemodialysis. Despite major technological advances, peritonitis and catheter exit-site infections remain significant causes of morbidity and eventual failure of this dialysis modality.

Indwelling tunnelled central venous catheters are widely used for venous access in patients who require intravenous nutrition, fluids, antibiotics, chemotherapy, and other drugs for protracted periods.1 2 Maintaining these central venous catheters warrants meticulous adherence to protocol, which includes adequately flushing after drug administration and leaving a heparin lock for preventing blockages, rigorous care of the catheter exit site on the skin, and, most important, strict observation of aseptic techniques when handling the external tubing so as to minimise the risk of infection, which is the main complication of long use intravenous catheters.3 4 Failure immediately to flush a port venous access device after delivery of drugs can have grave consequences The advent of completely implanted subcutaneous port systems5 has simplified long term venous access and also appears to have reduced significantly the risk of infection.1 6 Central venous placement of port linked catheters is similar to that of external catheters, but the venous catheter of a port system, instead of exiting through the skin, is attached to a reservoir within a port …

During a 3 month study the effectiveness of two methods of handwashing was assessed in a group of 31 patients undergoing continuous ambulatory peritoneal dialysis. A defined, double rinse with alcohol, prior to bag exchange, was found to be more convenient and significantly more effective than povidone-iodine alone or povidone-iodine followed by alcohol. Spraying the tubing around the bag connector with 70 per cent ethanol reduced the numbers of adherent skin organisms so reducing the likelihood of bacteria being drawn into the dialysate. Although there was no difference in the overall incidence of peritonitis in the two groups of patients studied, there was an unexpected drop in the incidence of peritonitis caused by coagulase-negative skin staphylococci. This was attributed to an overall awareness of the importance of handwashing and aseptic procedures during bag exchange. Monitoring the bacteriology of the catheter exit site may give some prior indication as to the likelihood of subsequent peritonitis especially with Staphylococcus aureus and Gram-negative bacilli.

A modified techniquue of internal jugular catheterization is described, especially suitable for patients in whom subclavian vein catheterization may be dangerous. After introduction into the internal jugular vein, the catheter is tunneled to exit on the chest wall, using the same needle used for venipuncture. A catheter exit site on the chest wall is comfortable for the patient and makes nursing care easy. This factor, in combination with the safety of internal jugular vein cannulation, makes this an ideal method of central vein catheterization for both nutritional support and monitoring.

The use of outpatient dobutamine infusions by a small, portable infusion pump in 3 patients with intractable congestive heart failure (CHF) is described. With this therapy left ventricular function improved and CHF resolved in each. Tolerance to dobutamine was obviated by giving infusions twice weekly. Except for 3 mild infections around the catheter exit site, there have been no complications of this therapy is 58 cumulative patient weeks.

Home parenteral nutrition allows patients with gut failure to maintain a near-normal life-style. The technique restores normal nutritional status, and patients often are able to resume their previous occupation. A safe, permanent venous access is first provided by placement of a catheter in the subclavian vein. The patient is then taught how to care for the catheter, how to mix nutrient fluids and use the intravenous fluid infusion pump, how to monitor metabolic balance, and how to do emergency repairs of the catheter. Complications relate mainly to infection in the catheter exit site and to metabolic imbalance, and prophylactic measures should be taken.

The main complication of continuous ambulatory peritoneal dialysis (CAPD) is peritonitis. This paper describes our experience in the diagnosis and management of this complication in 66 patients during the three years to October 1982. The overall incidence of peritonitis was one episode every 6.75 patient months. Staphylococcus albus and Staphylococcus aureus together accounted for 46 per cent of the episodes, and 24 per cent were culture negative. Catheter exit site infections due to Staphylococcus aureus were common and they may have predisposed to peritonitis with gram -ve organisms as well as to staphylococcal peritonitis. Antimicrobial therapy was effective in 60 per cent of peritonitis episodes. The culture negative episodes usually responded to treatment while those due to fungi, though uncommon, did not. Twenty-nine per cent of these CAPD patients were transferred to haemodialysis because of peritonitis which failed to respond to treatment or which recurred repeatedly.

To define the possible mechanisms involved in the production of skin exit site infection in patients on CAPD, a histological evaluation of the skin around the catheter exit site was performed in nine patients.

We assessed infectious complications of long-term percutaneous central venous catheterization in patients with acquired immunodeficiency syndrome (AIDS). We evaluated 98 consecutive patients, accounting for 6,298 catheter days. Catheter-associated bacteremia occurred in 3% of patients, a rate of 0.128%/patient-catheter day. Only bacterial pathogens--Pseudomonas, Serratia, and Staphylococcus species--were isolated. Five patients had infection at the catheter exit site. The length of time catheters were indwelling was not significantly different in patients with and those without infections. Percutaneous, multiple-use central venous catheters are safe and well accepted by patients with AIDS.

Infections, primarily those of peritonitis and catheter exit site, are complications of the chronic peritoneal dialysis therapies for children and adults, despite years of experience with these techniques [1–8]. These problems are shared by the two most frequently used forms of maintenance peritoneal dialysis, continuous ambulatory peritoneal dialysis (CAPD) and continuous cycling peritoneal dialysis (CCPD) [9–19]. The same can be said for any variation in either of these two methods, an example being a regimen composed of nightly dialysis, utilizing the concepts of what historically has been termed intermittent peritoneal dialysis (IPD) [2–5, 20–22]. Thus, the clinical import of infectious complications would appear to be the same regardless of the particular form of chronic peritoneal dialysis used, assuming no alterations in the basic procedure. Recurring or unresponsive peritonitis or chronic exit site infection continue to be responsible for a considerable number of treatment interruptions or failures, as well as concern regarding associated morbidity and mortality [9–14, 23–27, 30, 31]. Discouraging and persistent problems of this kind can lead to the abandonment of peritoneal dialysis in some dialysis programs.

• From January 1977 to June 1980, coagulase-negative staphylococci caused bacteremia in 22 (17%) of 130 patients receiving immunosuppressive therapy and were the most common cause of all bacteremias. Sixteen (73%) of the 22 patients had granulocytopenia, and eight were isolated in a laminar air-flow room. A Broviac or Hickman central intravenous (IV) catheter was present in 20 (91%) of 22 patients, and soft-tissue inflammation at the catheter exit site was a significant risk factor for bacteremia. Except for debilitating fevers and local mucocutaneous infections, there were no distinguishing clinical features in patients with bacteremia. Most infections responded to cefazolin sodium or vancomycin hydrochloride therapy; catheter removal was necessary in only seven patients. These data show that coagulase-negative staphylococci can be important pathogens in patients receiving immunosuppressive therapy, even when the patients are isolated in a laminar air-flow room, if normal mucocutaneous, host-defense barriers are interrupted by IV catheter-insertion or chemotherapy. ( Arch Intern Med 1983;143:32-36)