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Empiric antibiotic therapy is started immediately for tunnel and exit site infections, pending culture results. It should at least cover Gram-positive organisms.
 Exit Site Infection Treatment Algorithm and Table.
Complete removal of the superficial cuff can be performed when antibiotics do not resolve an infection. However, it must be noted that peritonitis with the same organism occurs in 50% of patients who undergo cuff shaving for Staph aureus and may result in eventual removal of the catheter. Additionally, topical treatment can be used as an adjunct to systemic antibiotics in the treatment of exit infections or initial therapy for low-grade infection (equivocal). The topical antibiotics that have been successfully used include mupirocin, gentamicin, and neosporin. Topical antibiotic therapy is not appropriate for acute and chronic exit infections. Cauterization of exuberant granulation tissue in the sinus may be necessary. Systemic antibiotics may be used in cases unresponsive to topical therapy. Hypertonic saline dressings may be beneficial.
Other topical treatments include application of soaks to the exit 2-4 times per day, as well as the application of dry heat. Soaking solutions include 0.9% saline, sodium hypochlorite, dilute hydrogen peroxide, and povidone iodine. There are no controlled studies assessing the effectiveness of these topical treatments.
Care of the infected exit site includes daily or twice daily exit site care, do not forcibly remove the crusts or scabs, but gradually softened with hydrogen peroxide, saline, soap and water, or exit soaks. Sterile dressings are used to absorb drainage, reduce exposure to microorganisms and protect the site from trauma.
When an exit site, cuff, or tunnel infection is associated with peritonitis due to the same organism, catheter removal is considered, unless the organism is Staph epidermidis. Even though the effluent may clear with antibiotic use, the culture often remains positive and the peritonitis will recur unless the source catheter is removed. The catheter is also typically removed with refractory or recurrent peritonitis with exit or tunnel infections or extensive cellulitis unresponsive to antibiotics. Early catheter removal is necessary if pseudomonal ESIs fail to respond to anti-pseudomonal antibiotic therapy and shaving of the external cuff. |