Influence of exit-site care on exit-site infection in patients undergoing peritoneal dialysis_West China Medical Journal

Authors：

LIU Danyang ¹ , ZHANG Guangqing ² , YI Zhixiu ¹ , YANG Cong ¹ , ZHONG Xiaohong ¹ , LIN Yanhong ¹ , TANG Dan ¹ , AI Jun ¹ ,  GONG Nirong ¹

1. Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P. R. China;
2. Headquarter Office, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P. R. China;

Corresponding author：

GONG Nirong, Email: 77734601@qq.com

Keywords：

Exit-site care; Peritoneal dialysis; Exit-site infection; Influencing factors

DOI：

10.7507/1002-0179.202106104

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Objective To investigate the status of exit-site care in patients undergoing peritoneal dialysis, and analyze the relationship between exit-site care practice and exit-site infection.Methods The patients undergoing peritoneal dialysis in Nanfang Hospital, Southern Medical University between January and October 2019 were recruited by convenience sampling method. The Exit-site Schaefer Scale was used to diagnose the occurrence of exit-site infection. According to the guidelines of the International Society of Peritoneal Dialysis and relevant research, a questionnaire was developed to investigate the status of exit-site care in all peritoneal dialysis patients. Logistic regression analysis was used to analyze the influence of care practice on exit-site infection.Results A total of 208 peritoneal dialysis patients were recruited. There were 39 patients with (totally 43 times of) exit-site infections, with an exit-site infection incidence of 0.06 episodes per patient-year. The main bacteria were Staphylococcus aureus (30.2%) and Pseudomonas aeruginosa (16.3%). Of the 39 infected patients, 8 (20.5%) had peritonitis and 3 (7.7%) had been infected more than once. The exit-site Schaefer score of the 208 patients was 3.14±2.75. Of the 208 patients, 204 (98.1%) had received training of exit-site care from nurses, 166 (79.8%) could wash their hands and wear masks as required, 196 (94.2%) covered dressings on the exit site, and 184 (88.5%) fixed catheters, but the application of antibiotic ointment did not follow the latest guidelines. The logistic regression analysis revealed that the history of redness and swelling at the exit site [odds ratio (OR)=7.926, 95% confidence interval (CI) (2.367, 26.535), P=0.001] and the history of traction-associated bleeding [OR=5.750, 95%CI (1.878, 17.610), P=0.002] were risk factors of exit-site infection.Conclusions Exit-site infection is common in peritonealdialysis patients. Most patients can perform the exit-site care as required, but the care content is yet to be updated. Nursing staff should improve the training content according to the latest guidelines, strengthen the exit-site assessment, follow-up, and retraining, treat the redness and swelling at the exit site timely, and tell the patients to pay attention to catheter fixation and avoiding excessive traction, to prevent the exit-site infection and the further development of peritonitis.

Citation： LIU Danyang, ZHANG Guangqing, YI Zhixiu, YANG Cong, ZHONG Xiaohong, LIN Yanhong, TANG Dan, AI Jun, GONG Nirong. Influence of exit-site care on exit-site infection in patients undergoing peritoneal dialysis. West China Medical Journal, 2021, 36(7): 859-865. doi: 10.7507/1002-0179.202106104 Copy

1.	Mehrotra R, Devuyst O, Davies SJ, et al. The current state of peritoneal dialysis. J Am Soc Nephrol, 2016, 27(11): 3238-3252.
2.	Li PK, Chow KM, van de Luijtgaarden MW, et al. Changes in the worldwide epidemiology of peritoneal dialysis. Nat Rev Nephrol, 2017, 13(2): 90-103.
3.	Kim H, Ryu DR. A prime determinant in selecting dialysis modality: peritoneal dialysis patient survival. Kidney Res Clin Pract, 2017, 36(1): 22-28.
4.	Einbinder Y, Cohen-Hagai K, Shitrit P, et al. ISPD guideline-driven retraining, exit site care and decreased peritonitis: a single-center experience in Israel. Int Urol Nephrol, 2019, 51(4): 723-727.
5.	van Diepen AT, Tomlinson GA, Jassal SV. The association between exit site infection and subsequent peritonitis among peritoneal dialysis patients. Clin J Am Soc Nephrol, 2012, 7(8): 1266-1271.
6.	Li PK, Szeto CC, Piraino B, et al. ISPD peritonitis recommendations: 2016 update on prevention and treatment. Perit Dial Int, 2016, 36(5): 481-508.
7.	Lloyd A, Tangri N, Shafer LA, et al. The risk of peritonitis after an exit site infection: a time-matched, case-control study. Nephrol Dial Transplant, 2013, 28(7): 1915-1921.
8.	Szeto CC, Li PK, Johnson DW, et al. ISPD catheter-related infection recommendations: 2017 update. Perit Dial Int, 2017, 37(2): 141-154.
9.	Rodríguez-Carmona A, Pérez-Fontán M, López-Muñiz A, et al. Correlation between glycemic control and the incidence of peritoneal and catheter tunnel and exit-site infections in diabetic patients undergoing peritoneal dialysis. Perit Dial Int, 2014, 34(6): 618-626.
10.	林建雄, 梁碧宁, 鲁树超, 等. 老年腹膜透析患者导管出口处感染的特点及危险因素分析. 中华肾脏病杂志, 2020, 36(6): 417-423.
11.	曹竹如, 彭翠翠, 何淑双, 等. 腹膜透析患者并发出口处感染及隧道炎的危险因素及护理对策. 临床护理杂志, 2021, 20(2): 55-58.
12.	Ding XR, Huang HE, Liao YM, et al. Daily self-care practices influence exit-site condition in patients having peritoneal dialysis: a multicenter cross-sectional survey. J Adv Nurs, 2021, 77(5): 2293-2306.
13.	高永祥, 张晋昕. Logistic 回归分析的样本量确定. 循证医学, 2018, 18(2): 122-124.
14.	秦锦, 孙庆华, 苏春燕, 等. 北京地区腹膜透析护士外出口护理和培训实践现状调查. 中国血液净化, 2019, 18(5): 345-348.
15.	Prowant B, Schmidt L, Burrows L, et al. A tool for nursing evaluation of the peritoneal dialysis catheter exit site. ANNA J, 1987, 14(1): 28, 30.
16.	Thodis E, Passadakis P, Ossareh S, et al. Peritoneal catheter exit-site infections: predisposing factors, prevention and treatment. Int J Artif Organs, 2003, 26(8): 698-714.
17.	Cho KH, Jy DO, Park JW, et al. Catheter revision for the treatment of intractable exit site infection/tunnel infection in peritoneal dialysis patients: a single centre experience. Nephrology (Carlton), 2012, 17(8): 760-766.
18.	Abud AC, Kusumota L, Dos SM, et al. Peritonitis and catheter exit-site infection in patients on peritoneal dialysis at home. Rev Lat Am Enfermagem, 2015, 23(5): 902-909.
19.	Beckwith H, Clemenger M, Mcgrory J, et al. Repeat peritoneal dialysis exit-site infection: definition and outcomes. Perit Dial Int, 2019, 39(4): 344-349.
20.	Holley JL, Bernardini J, Piraino B. Risk factors for tunnel infections in continuous peritoneal dialysis. Am J Kidney Dis, 1991, 18(3): 344-348.
21.	Flanigan M, Gokal R. Peritoneal catheters and exit-site practices toward optimum peritoneal access: a review of current developments. Perit Dial Int, 2005, 25(2): 132-139.
22.	Eklund B, Honkanen E, Kyllönen L, et al. Peritoneal dialysis access: prospective randomized comparison of single-cuff and double-cuff straight Tenckhoff catheters. Nephrol Dial Transplant, 1997, 12(12): 2664-2666.
23.	Lo WK, Lui SL, Li FK, et al. A prospective randomized study on three different peritoneal dialysis catheters. Perit Dial Int, 2003, 23(Suppl 2): S127-S131.
24.	Meng C, Beco A, Oliveira A, et al. Peritoneal dialysis cuff-shaving: a salvage therapy for refractory exit-site infections. Perit Dial Int, 2019, 39(3): 276-281.
25.	Hoekstra BP, de Vries-Hoogsteen A, Winkels B, et al. Exit site care in the Netherlands: the use of guidelines in practice. J Ren Care, 2017, 43(3): 156-162.
26.	Figueiredo AE, Bernardini J, Bowes E, et al. A syllabus for teaching peritoneal dialysis to patients and caregivers. Perit Dial Int, 2016, 36(6): 592-605.
27.	Iida H, Kurita N, Fujimoto S, et al. Association between keeping home records of catheter exit-site and incidence of peritoneal dialysis-related infections. Int Urol Nephrol, 2018, 50(4): 763-769.
28.	Bernardini J, Price V, Figueiredo A, et al. Peritoneal dialysis patient training, 2006. Perit Dial Int, 2006, 26(6): 625-632.
29.	Gadola L, Poggi C, Poggio M, et al. Using a multidisciplinary training program to reduce peritonitis in peritoneal dialysis patients. Perit Dial Int, 2013, 33(1): 38-45.
30.	Chern YB, Ho PS, Kuo LC, et al. Lower education level is a major risk factor for peritonitis incidence in chronic peritoneal dialysis patients: a retrospective cohort study with 12-year follow-up. Perit Dial Int, 2013, 33(5): 552-558.
31.	Chang JH, Oh J, Park SK, et al. Frequent patient retraining at home reduces the risks of peritoneal dialysis-related infections: a randomised study. Sci Rep, 2018, 8(1): 12919.
32.	Gonthier D, Bernardini J, Holley JL, et al. Erythema: does it indicate infection in a peritoneal catheter exit site?. Adv Perit Dial, 1992, 8: 230-233.
33.	于海霞, 许莹, 苏琦, 等. 腹膜透析新病人外出口感染原因及护理对策. 中华现代护理杂志, 2008, 14(26): 2789-2790.
34.	Figueiredo AE, De Mattos C, Saraiva C, et al. Comparison between types of dressing following catheter insertion and early exit-site infection in peritoneal dialysis. J Clin Nurs, 2017, 26(21/22): 3658-3663.
35.	Wong SS, Chu KH, Cheuk A, et al. Prophylaxis against Gram-positive organisms causing exit-site infection and peritonitis in continuous ambulatory peritoneal dialysis patients by applying mupirocin ointment at the catheter exit site. Perit Dial Int, 2003, 23(Suppl 2): S153-S158.

1. Mehrotra R, Devuyst O, Davies SJ, et al. The current state of peritoneal dialysis. J Am Soc Nephrol, 2016, 27(11): 3238-3252.
2. Li PK, Chow KM, van de Luijtgaarden MW, et al. Changes in the worldwide epidemiology of peritoneal dialysis. Nat Rev Nephrol, 2017, 13(2): 90-103.
3. Kim H, Ryu DR. A prime determinant in selecting dialysis modality: peritoneal dialysis patient survival. Kidney Res Clin Pract, 2017, 36(1): 22-28.
4. Einbinder Y, Cohen-Hagai K, Shitrit P, et al. ISPD guideline-driven retraining, exit site care and decreased peritonitis: a single-center experience in Israel. Int Urol Nephrol, 2019, 51(4): 723-727.
5. van Diepen AT, Tomlinson GA, Jassal SV. The association between exit site infection and subsequent peritonitis among peritoneal dialysis patients. Clin J Am Soc Nephrol, 2012, 7(8): 1266-1271.
6. Li PK, Szeto CC, Piraino B, et al. ISPD peritonitis recommendations: 2016 update on prevention and treatment. Perit Dial Int, 2016, 36(5): 481-508.
7. Lloyd A, Tangri N, Shafer LA, et al. The risk of peritonitis after an exit site infection: a time-matched, case-control study. Nephrol Dial Transplant, 2013, 28(7): 1915-1921.
8. Szeto CC, Li PK, Johnson DW, et al. ISPD catheter-related infection recommendations: 2017 update. Perit Dial Int, 2017, 37(2): 141-154.
9. Rodríguez-Carmona A, Pérez-Fontán M, López-Muñiz A, et al. Correlation between glycemic control and the incidence of peritoneal and catheter tunnel and exit-site infections in diabetic patients undergoing peritoneal dialysis. Perit Dial Int, 2014, 34(6): 618-626.
10. 林建雄, 梁碧宁, 鲁树超, 等. 老年腹膜透析患者导管出口处感染的特点及危险因素分析. 中华肾脏病杂志, 2020, 36(6): 417-423.
11. 曹竹如, 彭翠翠, 何淑双, 等. 腹膜透析患者并发出口处感染及隧道炎的危险因素及护理对策. 临床护理杂志, 2021, 20(2): 55-58.
12. Ding XR, Huang HE, Liao YM, et al. Daily self-care practices influence exit-site condition in patients having peritoneal dialysis: a multicenter cross-sectional survey. J Adv Nurs, 2021, 77(5): 2293-2306.
13. 高永祥, 张晋昕. Logistic 回归分析的样本量确定. 循证医学, 2018, 18(2): 122-124.
14. 秦锦, 孙庆华, 苏春燕, 等. 北京地区腹膜透析护士外出口护理和培训实践现状调查. 中国血液净化, 2019, 18(5): 345-348.
15. Prowant B, Schmidt L, Burrows L, et al. A tool for nursing evaluation of the peritoneal dialysis catheter exit site. ANNA J, 1987, 14(1): 28, 30.
16. Thodis E, Passadakis P, Ossareh S, et al. Peritoneal catheter exit-site infections: predisposing factors, prevention and treatment. Int J Artif Organs, 2003, 26(8): 698-714.
17. Cho KH, Jy DO, Park JW, et al. Catheter revision for the treatment of intractable exit site infection/tunnel infection in peritoneal dialysis patients: a single centre experience. Nephrology (Carlton), 2012, 17(8): 760-766.
18. Abud AC, Kusumota L, Dos SM, et al. Peritonitis and catheter exit-site infection in patients on peritoneal dialysis at home. Rev Lat Am Enfermagem, 2015, 23(5): 902-909.
19. Beckwith H, Clemenger M, Mcgrory J, et al. Repeat peritoneal dialysis exit-site infection: definition and outcomes. Perit Dial Int, 2019, 39(4): 344-349.
20. Holley JL, Bernardini J, Piraino B. Risk factors for tunnel infections in continuous peritoneal dialysis. Am J Kidney Dis, 1991, 18(3): 344-348.
21. Flanigan M, Gokal R. Peritoneal catheters and exit-site practices toward optimum peritoneal access: a review of current developments. Perit Dial Int, 2005, 25(2): 132-139.
22. Eklund B, Honkanen E, Kyllönen L, et al. Peritoneal dialysis access: prospective randomized comparison of single-cuff and double-cuff straight Tenckhoff catheters. Nephrol Dial Transplant, 1997, 12(12): 2664-2666.
23. Lo WK, Lui SL, Li FK, et al. A prospective randomized study on three different peritoneal dialysis catheters. Perit Dial Int, 2003, 23(Suppl 2): S127-S131.
24. Meng C, Beco A, Oliveira A, et al. Peritoneal dialysis cuff-shaving: a salvage therapy for refractory exit-site infections. Perit Dial Int, 2019, 39(3): 276-281.
25. Hoekstra BP, de Vries-Hoogsteen A, Winkels B, et al. Exit site care in the Netherlands: the use of guidelines in practice. J Ren Care, 2017, 43(3): 156-162.
26. Figueiredo AE, Bernardini J, Bowes E, et al. A syllabus for teaching peritoneal dialysis to patients and caregivers. Perit Dial Int, 2016, 36(6): 592-605.
27. Iida H, Kurita N, Fujimoto S, et al. Association between keeping home records of catheter exit-site and incidence of peritoneal dialysis-related infections. Int Urol Nephrol, 2018, 50(4): 763-769.
28. Bernardini J, Price V, Figueiredo A, et al. Peritoneal dialysis patient training, 2006. Perit Dial Int, 2006, 26(6): 625-632.
29. Gadola L, Poggi C, Poggio M, et al. Using a multidisciplinary training program to reduce peritonitis in peritoneal dialysis patients. Perit Dial Int, 2013, 33(1): 38-45.
30. Chern YB, Ho PS, Kuo LC, et al. Lower education level is a major risk factor for peritonitis incidence in chronic peritoneal dialysis patients: a retrospective cohort study with 12-year follow-up. Perit Dial Int, 2013, 33(5): 552-558.
31. Chang JH, Oh J, Park SK, et al. Frequent patient retraining at home reduces the risks of peritoneal dialysis-related infections: a randomised study. Sci Rep, 2018, 8(1): 12919.
32. Gonthier D, Bernardini J, Holley JL, et al. Erythema: does it indicate infection in a peritoneal catheter exit site?. Adv Perit Dial, 1992, 8: 230-233.
33. 于海霞, 许莹, 苏琦, 等. 腹膜透析新病人外出口感染原因及护理对策. 中华现代护理杂志, 2008, 14(26): 2789-2790.
34. Figueiredo AE, De Mattos C, Saraiva C, et al. Comparison between types of dressing following catheter insertion and early exit-site infection in peritoneal dialysis. J Clin Nurs, 2017, 26(21/22): 3658-3663.
35. Wong SS, Chu KH, Cheuk A, et al. Prophylaxis against Gram-positive organisms causing exit-site infection and peritonitis in continuous ambulatory peritoneal dialysis patients by applying mupirocin ointment at the catheter exit site. Perit Dial Int, 2003, 23(Suppl 2): S153-S158.

West China Medical Journal

Influence of exit-site care on exit-site infection in patients undergoing peritoneal dialysis

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