Preventing Exit Site Infections: Prophylaxis

Print PDF

Local application of specific anti-Staph prophylaxis, such as mupirocin ointment or cream, appears to have a substantial advantage over nonspecific local care and reduces the incidence of exit and tunnel infection, peritonitis, and subsequent catheter loss^1-5 .  Mupirocin acts by blocking the activity of isoleucly transfer-RNA synthetase⁴.  Patients with persistent Staph aureus (SA) nasal carriage should benefit from local gentamicin or mupirocin therapy.  A recent study showed that persistent, but not intermittent SA nasal carriage was the major determinant of PD related infections and was associated with a significantly higher consumption of antibiotics.  Incidence rate ratio (IRR) for persistent carriers were: all cause infection 3.52; exit site infection 5.59 and peritonitis 2.19⁶.  Some practitioners apply single or combination preparations (for example, combination antibiotic ointments, single-agent eye drops) in problematic cases^7,8.

A randomized trial of SA prophylaxis comparing the efficacy of oral rifampin versus topical mupirocin ointment showed both regimens to be equally effective in reducing S aureus catheter infections⁹.  However, there are many recent studies that show an increase in the incidence of S aureus resistance^10-17. The numbers of courses of mupirocin and constant therapy with PD have been identified as independent predictors of resistance¹⁵. The significant increase in mupirocin resistance has resulted in an increased incidence of S aureus infection, raising concern about the use of this type of prophylaxis.

Bernadini et al. in a recent randomized, double-blind trial of antibiotic treatment for the prevention of ESI comparing gentamycin and mupirocin creams showed gentamycin superiority in the prevention of catheter infections¹⁸.  Gentamicin cream was as effective as mupirocin in preventing SA infections and superior in reducing Gm negative catheter infections and peritonitis.  Caution must be exercised in view of increased fungal ESI and the possibility of developing gentamicin resistance.  Daily gentamycin cream at the exit site should be the prophylaxis of choice for PD patients based on these data. 

Mupirocin or gentamycin cream but not ointment, should be used with polyurethane catheters (Cruz catheter)⁷. Mupirocin ointment contains alcohol as an inactive ingredient, which can degrade the catheter and cause it to crack.

 Back to Management of Exit Site Infections

References:

1. Coles G (Mupirocin study group).  Nasal mupirocin prevents Staphylococcus aureus exit-site infection during PD.  J Am Soc Nephrol 7:2403-7, 1996
2. Bernardini J, Piraino B, Holley J, Johnston JR, Lutes R.  A randomized trial of staphylococcus aureus prophylaxis in peritoneal dialysis patients: Mupirocin calcium ointment 2% applied to the exit site versus cyclic oral rifampin. Am J Kid Dis 27:695-700, 1996
3. Thodis E, Bhaskaran S, Pasadakis P, Bargman JM, Vas SI, Oreopoulos DG.  Decrease in staphylococcus aureus exit-site infections and peritonitis in CAPD patients by local application of mupirocin ointment at the catheter exit site. Perit Dial Int 18:261-270, 1998
4. Casey M, Taylor J, Clinard P, Graham A,  Mauck V,  Spainhour L, Brown P, Burkart J.  Application of mupirocin cream at the catheter exit site reduces exit-site infections and peritonitis in peritoneal dialysis patients. Perit Dial Int 20:566-568, 2000
5. Lim CT-S, Wong KS, Foo MW-Y.  The impact of topical mupirocin on peritoneal dialysis infection rates in Singapore General Hosptal.  Nephrol Dial Transplant 20:1702-1706, 2005
6. Nouwen JL, Fieren MW, Snijders S, Verbrugh HA, van Belkum A. Persistent (not intermittent) nasal carriage of Staphylococcus aureus is the determinant of CPD-related infections Kidney Int 67:1084-1092, 2005
7. Piraino B, Bailie GR, Bernardini J, Boeschoten E, Gupta A, Holmes C, Kuijper EJ, Li PK-T, Lye W-C, Mujais S, Paterson DL, Perez Fontan M, Ramos A, Schaefer F, Uttley L.  ISPD Guidelines/Recommendations.  Peritoneal dialysis-related infecions recommendations: 2005 Update.  Perit Dial Int 25:107-131, 2005
8. Montenegro J, Saracho R, Aguirre R, Martinez I, Iribar I, Ocharan J. Exit-site care with ciprofloxacin otologic solution prevents polyurethane catheter infection in peritoneal dialysis patients. Perit Dial Int 20:209-214, 2000
9. Bernardini J, Piraino B, Holley J, Johnston JR, Lutes R.  A randomized trial of staphylococcus aureus prophylaxis in peritoneal dialysis patients: Mupirocin calcium ointment 2% applied to the exit site versus cyclic oral rifampin. Am J Kid Dis 27:695-700,1996
10. Vasquez JE, Walker ES, Franzus MS, Overbay BK, Reagan DR, Sarubbi FA.  The epidemiology of mupirocin resistance among methicillin-resistant Staphylococcus aureus at a Veterans’ Affairs hospital.  Infect Control Hosp Epidemiol 21:459-464, 2000
11. Schmitz FJ, Lindenlauf E, Hofmann B, Fluit AC, Verhoef J, Heinz HP, Jones ME.  The prevalence of low-and high-level mupirocin resistance in staphylococci from 19 European hospitals.  J Antimicrob Chemother 42:489-495, 1998 
12. Dos Santos KRN, de Souza Fonseca L, Filho PPG.  Emergence of high-level mupirocin resistance in methicillin-resistant Staphylococcus aureus isolated from Brazilian university hospitals.  Infect Control Hosp Epidemiol 17:813-816, 1996
13. Miller MA, Dascal A, Portnoy J, Mendelson J.  Development of mupirocin resistance among methicillin-resistant Staphylococcus aureus after widespread use of nasal mupirocin ointment.  Infect Control Hosp Epidemiol 17:811-813, 1996
14. Watanabe H, Masaki H, Asoh N, Watanabe K, Oishi K, Furumoto A, Kobayashi S, Sato A, Nagatake T.  Emergence and spread of low-level mupirocin resistance in methicillin-resistant Staphylococcus aureus isolated from a community hospital in Japan.  J Hosp Infect 47:294-300, 2001
15. Rosales M, Perez-Fontan M, Rodriguez-Carmona A, Garcia-Falcon T.  Increasing resistance to mupirocin of Staphylococcus aureus (S Au) strains isolated from peritoneal dialysis (PD) patients and their partners: Long term study (Abstract).  Perit Dial Int 21(Suppl 2):S128, 2001
16. Annigeri R, Conly J, Vas SI, Dedier H, Prakashan KP, Bargman JM, Jassal V, Oreopoulos D.  Emergence of mupirocin-resistant Staphylococcus aureus in chronic peritoneal dialysis patients using mupirocin prophylaxis to prevent exit-site infection.  Perit Dial Int 21:554-559, 2001
17. Lobbedez T, Gardam M, Dedier H, Burdzy D, Chu M, Izatt S, Bargman JM, Jassal SV, Vas S, Brunton J, Oreopoulos DG. Routine use of mupirocin at the peritoneal catheter exit site and mupirocin resistance: still low after 7 years. Nephrol Dial Transplant 19:3140-3143, 2004
18. Bernardini J, Bender F, Florio T, Sloand J, Palmmontalbano L, Fried L, Piraino B. Randomized, double-blind trial of antibiotic exit site cream for prevention of exit site infection in peritoneal dialysis patients. J Am Soc Nephrol 16:539-545, 2005