Tackling PD related infection appropriately for better outcome

PD Masterclass7th October 2018

Outline

• Incidence and impact PD related infection

• Risk factors

• Prevention

• Treatment

Introduction

• Peritonitis and catheter related infection are common and serious complication of peritoneal dialysis (PD)

• In many studies, peritonitis is a direct/ major contributing cause of death in around 16% of PD patients.

Peritonitis rate in Malaysia

In Malaysia 18% of PD patient drop out due to peritonitis.

32%

31%

11-30%

Obesity and severe obesity were associated with increased hazard ratio for time to first peritonitis

Obesity and severe obesity were independently associated with increased incidence rate ratios of all forms of organism-specific peritonitis

Poorer technique survival and patient survival in early peritonitis

>30 days

Poorly controlled DM had a significantly higher incidence of catheter tunnel and exit-site infections (0.23 episodes vs 0.12 episodes per patient–year) and shorter time to a first infection episode (64 months vs 76 months, p = 0.004).

PREVENTION

ISPD Recommendations to minimise the risk of infection both before and after catheter placement

• Ensuring an experienced operator for catheter insertion

• Placement of catheter with a downward facing exit site

• Prophylactic antibiotics at time of catheter insertion

• No technique of catheter placement are superior

• Carefully choose the location of the exit site so that it could be conveniently cleaned and the chance of in trauma (e.g. by the belt) is minimized

• No particular catheter design are superior.

• Eradication of nasal carriage of Staphylococcus aureus (no data exist on the effectiveness of routine screening and eradication nasal carriage before insertion)

• If nasal carriage of S. aureus is found in PD patients, treat with topical nasal application of mupirocin.

Care of exit site

• Daily topical application of antibiotic cream or ointment to the catheter exit site.

• No cleansing agent has been shown to be superior.

• Exit site be cleansed at least twice weekly and every time after a shower.

ISPD position statement 2017

Acute exit site care

• The overall goal in the early postoperative period is to – promote healing– minimise bacterial colonisation of the catheter and

tunnel as the open wound is at increased risk of infection

• Good surgical practice to cover all incisions and leave the dressing undisturbed for 3 to 5 days so as to allow epithelialization and wound healing by primary intention

Hand hygiene

• Patients must carefully and thoroughly wash their hands with antibacterial soap or use an alcohol-based cleaning agent in addition, prior to touching the exit site.

• Thorough hand washing should leave the hands visibly clean.

Touch contamination of connection devices in peritoneal dialysis--a quantitative microbiologic analysis PDI 1996

• A study of the relationship of hand dampness after hand washing to

bacterial translocation following touch contamination

• Accidental touch contact of connecting devices

• Hand drying with an air towel before touch contact reduces the numbers

translocation by 95%-99%.

Importance of drying hands, regardless of the agent used

Unprepared hands Hands are wet at the time of contact

Number of translocation of 500 micro-organisms

Number translocation can be as high as 4500 micro-organisms

Hand hygiene

• Wearing even ONE ring was associated with• microbial species isolated • carriage of gram-negative organisms after hand washing

• Use of artificial fingernails increase risk of infection by 7x

• Polish nail increase risk of bacterial contamination by 2x

Bowel and Gynaecological source infection / modifiable risk factor

• Antibiotic prophylaxis prior to colonoscopy and invasive gynaecological procedure

• Before extensive dental procedure

• After wet contamination

Secondary prevention

• Recommend anti-fungal prophylaxis when PD patients receive antibiotic to prevent fungal peritonitis

Continuous Quality Improvement

• Monitor incidence of catheter-related infections and peritonitis.

• Parameters to be monitored: – the overall peritonitis rate

– peritonitis rates of specific organisms,

– the percentage of patients per year who are peritonitis-free,

– antimicrobial susceptibilities of the infecting organisms

Multidisciplinary peritoneal education programme

PDI Sept 2018

Hospital antibiotic stewardship programme

• Control of multidrug resistance organisms in healthcare must include judicious use of antibiotic use

• Antibiotic stewardship programme has shown to reduce antibiotic resistance and Clostridium difficile

Training Programme

• Latest ISPD recommendations for teaching PD patients and their caregivers be followed.

• PD training be conducted by nursing staff with the appropriate qualifications and experience.

• Training of patients should be continue until trainer is satisfied with patients competency.

• PD nurses are central to a successful PD program with low infection rates.

• Overburdening the nurse with excessive numbers of patients will result in shortened training times and difficulty in retraining patients.

• The Committee recommends home visits. These may be very useful in detecting problems with exchange technique,

Proper training

Indication for PD re training

Treatment of catheter related infection

Exit site scoring

Tunnel infection

Treatment of catheter related infection

• Empiric oral antibiotic treatment with covering S. aureus (penicillinase-resistant penicillin (e.g. dicloxacillin or flucloxacillin) or first-generation cephalosporin)

• Prior history of infection or colonization with methicillin-resistant S. aureus (MRSA) or Pseudomonas species – cover with appropriate antibiotic.

• Recommendation: exit-site infection- treat with at least 2 weeks of effective antibiotics.

• Recommendation: exit-site infection caused by Pseudomonas species and any tunnel infection- treated with at least 3 weeks of effective antibiotics.

Continue antibiotics till exit site appears normal (minimum 2 weeks, 3 weeks for Pseudomonas infection)

Continue antibiotics till exit site appears normal (minimum 2 weeks, 3 weeks for Pseudomonas infection)

Adjust treatment according to culture resultsAdjust treatment according to culture results

Initiate empirical oral antibioticsInitiate empirical oral antibiotics

Quinolones for gram negative coverQuinolones for gram negative cover

Penicillinase resistant penicillin (cloxacillin) or first generation cephalosporin (cephalexin) for gram positive cover

Penicillinase resistant penicillin (cloxacillin) or first generation cephalosporin (cephalexin) for gram positive cover

Cauterize exuberant granulation tissue using copper sulphate crystals or silver nitrateCauterize exuberant granulation tissue using copper sulphate crystals or silver nitrate

Exit site Swab for Culture and gram stain

Catheter removal and reinsertion

• PD patients with refractory exit-site or tunnel infection without peritonitis :simultaneous removal and reinsertion of the dialysis catheter with a new exit site under antibiotic coverage

• Removal of the dialysis catheter in PD patients with exit-site infections that progress to, or occur simultaneously with, peritonitis.

Case presentation 1

Lady with chronic exit site infection and a granuloma at exit site

Treatment:

Catheter splicing

Titanium extender

New exit site and tunnel

Case presentation 2

Lady with diabetes mellitus, no vascular access and pd tunnel infection

Treatment:• cuff de-roofing

– performed under local anesthesia, an incision is made to the depth of the outer cuff.

De-roofing and cuff shaving

Case presentation 3

Gentleman with exposed external cuff with exit site infection

Treatment:cuff-shaving provided an effective salvage therapy for exit site infections considered unresponsive to treatment

Peritonitis

Clinical Presentation and Diagnosis of Peritonitis

• At least 2 of the following are present:– clinical features consistent with peritonitis, i.e.

abdominal pain and/or cloudy dialysis effluent;– dialysis effluent white cell count > 100/μL or > 0.1

x 109/L (after a dwell time of at least 2 hours), with > 50% polymorphonuclear;

– positive dialysis effluent culture.

• PD effluent be tested for cell count, differential, Gram stain, and culture.

Empirical antibiotic therapy be initiated as soon as possible after appropriate microbiological specimens have been obtained

Identification of organism/ empiric antibiotic: recommendation

• Blood-culture bottle be the preferred technique for bacterial culture of PD effluent.

• Sampling and culture methods be reviewed and improved if more than 15% of peritonitis episodes are culture-negative.

• Bedside inoculation of 5-10mls effluent in 2 (aerobic and anaerobic) blood culture bottles

• Yield enhanced – by inoculating the fluid directly into rapid blood culture

kits– Centrifugation of 50mls PD effluent at 3000g for 15 min

followed by re-suspension of sediment in 3-5mls supernatant and inoculation on a solid culture media or blood culture media ( 5-10x)

• Inoculated culture bottle incubated at 37 C if delay to lab

Malaysian RRT CPG 3rd Edition

Catheter removal for catheter related infection

• Reinsertion of a PD catheter be performed at least 2 weeks after catheter removal and complete resolution of peritoneal symptoms.

Complications

• 30 consecutive PD patients from 1997 to 2008 with recurrent loculated peritoneal collection after catheter removal for severe peritonitis

• 1.6% (1928 episodes)developed recurrent peritoneal collection that required percutaneous drainage.

• Median time to diagnosis- 12 days after catheter removal.

• In 25 patients (83.3%), aspirate of the abdominal collection was culture negative.

• In 17 patients (56.7%), the abdominal collection was recurrent and required repeated aspiration.

• Catheter reinsertion failed in the other 18 ptsbecause of peritoneal adhesion (15 pts) or limited intra-peritoneal space (3 pts).

• Only 3 patients had successful reinsertion of the peritoneal catheter but all had reduced small solute clearance after returning to PD.

Summary

• Identify the risk factor for peritonitis/ catheter related infection in your PD patients

• Preventive measures in-cooperate into your PD programme

• Appropriate and aggressive treatment can salvage the PD catheter and reduce complications.

References

• ISPD catheter-related infection recommendations: 2017 update

• ISPD peritonitis recommendations: 2016 update on prevention and treatment

• Malaysian RRT CPG Guideline 3rd edition

Special Thanks to

• Dr Irene Wong and PD team in HTAR