Preventing Catheter Infections on Peritoneal Dialysis

By Mark H. Shapiro, MD

Peritoneal dialysis (PD) is one of the better ways to receive treatment for end stage renal disease (ESRD). It helps many people continue to lead a healthy and dynamic lifestyle.

In order to do PD, an area in the abdomen needs to be used to get fluid in and out of the body. A thin, flexible peritoneal dialysis catheter allows fluid to enter or drain from the abdomen when open, and allows the fluid to remain in place to dwell while clamped closed. However, this catheter can also become a potential source of two different types of infections: exit site infection and peritonitis.

What is an exit site infection?

Normal bacteria live on the skin and can sometimes invade damaged tissue, causing an infection on the exit site.

Exit site infections are usually visible. The skin around the exit site will be red and inflamed, and crusts with pus are generally present. There may be some pain and tenderness. If untreated, exit site infections can get worse, possibly leading to peritonitis or requiring removal of the PD catheter. Not all irritated exit sites are infected, and it may be difficult for you to tell if an infection exists. An immediate examination by the PD nurse is recommended if there’s a possibility of an exit site infection.

Mild infections may require more careful PD catheter restraints and local treatment with topical antibiotics, special cleansing solutions and/or hypertonic saline. Severe infections require antibiotics for 2-6 weeks. In cases that don’t improve, intravenous antibiotics or catheter removal may be necessary.

Avoiding injury to the exit site and using daily antibiotic cream are the main means of preventing this problem. Most exit site infections heal completely when appropriate treatment is given in a timely fashion, but the real key to success is to avoid them in the first place.

What is peritonitis?

Peritonitis occurs when bacteria invade the peritoneal cavity. This is usually caused by contamination to the inside of the PD catheter tubing. Other causes are:

  • Bacteria from an exit site infection
  • Bacteria already in the stomach or intestinal tract (due to diverticulitis or appendicitis)
  • Touch contamination (The open end of PD catheter or transfer set touches a non-sterile object, such as a hand or bed sheets; system accidentally disconnects; or a tear develops in the catheter or transfer set.)

Any notion of contamination calls for immediate contact with the PD nurse. Some cases may require a dose of antibiotics, and others may result in a catheter repair or transfer set change. However, contamination events that aren’t treated often lead to peritonitis. Signs of peritonitis include:

  • Abdominal pain
  • PD solution appears cloudy after it’s drained
  • Fever
  • Nausea
  • Diarrhea

If the doctor believes peritonitis is likely, the person is started on antibiotics. Daily visits with the PD nurse until the symptoms improve (2-3 days) are usual. A person diagnosed with peritonitis will receive 2-3 weeks of daily antibiotics. Most patients with peritonitis recover completely and do not require hospitalization. However, severe symptoms may require hospitalization, and peritonitis that doesn’t improve after 4-5 days may involve removal of the PD catheter.

Much of the PD training is intended to help people avoid peritonitis, such as:

  • Proper hand washing and appropriate use of a mask
  • Use of sterile technique when connecting and disconnecting the transfer set
  • Excellent catheter care and daily application of exit site antibiotics

After an episode of peritonitis, the patient is expected to go through additional training to prevent another infection.

Ways to prevent PD catheter infections

When going home with a new PD catheter, instructions are given to keep the abdomen dry and leave the dressings alone. This means no baths, showers or dressing changes for at least one week. This allows the catheter exit site to heal and minimizes the chances of contamination. Additional instructions are given at the first post-operative visit with the dialysis nurse, which usually occurs one week after surgery.

The PD catheter should be properly taped down or restrained so it doesn’t pull or put tension on the exit site, causing skin irritation. If the exit site becomes inflamed, it increases the possibility that bacteria normally living on the skin can infect the traumatized tissue and cause an infection. Cover the actual exit site with gauze to protect it from contact with contaminated surfaces.

The catheter exit site should be cleaned every day with a disinfectant specified by the PD nurse. This is usually done each morning, often after bathing. The exit site should be carefully dabbed dry and then cleaned. In addition, a small amount of antibiotic cream should be applied on the exit site around the base of the catheter using a cotton swab or similar device. The daily use of antibiotic cream has been proven to reduce the risk of infections.

These are places where bacteria exist and can cause a PD catheter infection:

  • Un-chlorinated fresh water (ponds, lakes, rivers)
  • Soaking in a hot tub
  • Faucets
  • Shower heads
  • Colonoscopies
  • Dental cleanings

Swimming in a chlorinated pool or in the ocean is generally fine when you have a PD catheter, but it’s best done with no fluid in the abdomen, and careful drying and cleaning of the exit site should be done immediately afterwards. Sink faucets and shower heads should be cleaned with bleach once a week to reduce bacteria build-up.

Colonoscopies and dental cleanings can allow bacteria to enter the blood stream, causing infections. It’s recommended to call the nurse before such a procedure is planned, because preventative antibiotics may be given in some situations.

Summary

Peritonitis and PD exit site infections are uncommon, but can become a serious health problem. Paying careful attention when taking care of the exit site and doing exchanges should reduce the risk of infections. Seeking immediate help from a PD nurse is best when a possible contamination develops.

About Mark Shapiro, M.D.

Dr. Shapiro is a nephrologist who practices in Escondido, CA. He did his undergraduate training at University of California, Los Angeles, obtained his medical degree at the University of Pittsburgh, and completed his residency training and nephrology fellowship at the University of California, San Diego.

Dr. Shapiro is an Assistant Professor of Medicine at University of California, San Diego, but also maintains an active private nephrology practice in the San Diego area where he is president of Palomar Medical Group. His primary area of medical interest is in peritoneal dialysis (PD). Dr. Shapiro was a medical advisor for PD within Gambro Healthcare, Inc., and is now the National Peritoneal Physician Advisor to DaVita, Inc. In addition, he serves on the Physician Advisory Council and the Pharmacy and Therapeutics Committee within DaVita.

Dr. Shapiro is married and has two sons. He enjoys kayaking, fishing and most other outdoor sports.


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