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Pseudomonas exit-site infections in CAPD patients: evolution and outcome of treatment
Objective:
To examine the natural history of Pseudomonas aeruginosa (PSA) exit-site infections (ESI) in patients treated with antibiotics with or without surgical interventions.
Design:
Retrospective record review from May 1994 to April 1997.
Setting:
A single dialysis unit in a district hospital.
Patients:
The review included 353 patients who had undergone continuous ambulatory peritoneal dialysis (CAPD).
Outcome Measures:
The prevalence and etiology of ESI, the treatment regimen for PSA ESI, and the outcome of treatment.
Results:
The prevalence of ESI was 55%. A total of 131 episodes (range 1-5) of PSA ESI occurred in 78 (40.2%) of the 194 patients who experienced ESI. Among these 78 patients, 4 groups with different outcomes were identified. In group I, 35 patients (44.9%) were treated successfully with antibiotic therapy alone. Among these 35 patients, 4 developed PSA peritonitis at a mean of 5 months (range 2-10 mth) after apparent clinical resolution of PSA ESI. Two of the 4 patients switched to long-term hemodialysis (HD) because of peritoneal failure. In group II, 8 patients (10.3%) responded to a combination of antibiotics and shaving of the external cuff. In group III, 21 patients (26.9%) with recurrent ESI underwent elective Tenckhoff catheter removal and reinsertion. One of the 21 patients had relapse of PSA ESI 14 months after the operation. In group IV, 14 patients (17.9%) had recurrent PSA ESI that failed to respond to multiple courses of antibiotics and shaving of the external cuff. Consent for Tenckhoff catheter removal was not obtained and 4 of these 14 patients subsequently developed PSA peritonitis. One of the 4 patients changed to permanent HD due to peritoneal failure.
Conclusions:
Considering the increased risk and the poor outcome of PSA peritonitis in patients with persistent PSA ESI, early Tenckhoff catheter removal is recommended if the patient fails to respond to antibiotics with or without externalization of the external cuff.
Insights
Pseudomonas aeruginosa exit-site infections (ESI) in continuous ambulatory peritoneal dialysis (CAPD) patients can be treated with antibiotics alone or with surgical intervention. Early catheter removal is recommended for persistent infections to prevent serious complications like peritonitis.
Area of Science:
- Nephrology
- Infectious Diseases
- Surgical Innovation
Background:
- Exit-site infections (ESI) are a common complication in patients undergoing continuous ambulatory peritoneal dialysis (CAPD).
- Pseudomonas aeruginosa (PSA) is a significant pathogen causing ESI, potentially leading to severe outcomes like peritonitis and technique failure.
- Understanding the natural history and treatment outcomes of PSA ESI is crucial for optimizing patient management.
Purpose of the Study:
- To investigate the clinical course and treatment effectiveness of Pseudomonas aeruginosa exit-site infections (PSA ESI) in CAPD patients.
- To evaluate the outcomes of different management strategies, including antibiotic therapy and surgical interventions.
- To identify risk factors and recommend optimal treatment approaches for PSA ESI.
Main Methods:
- Retrospective review of medical records from May 1994 to April 1997 in a single dialysis unit.
- Inclusion of 353 patients on CAPD, analyzing 131 episodes of PSA ESI in 78 patients.
- Categorization of patients into four groups based on treatment and outcomes: antibiotics alone, antibiotics with cuff shaving, catheter removal/reinsertion, and refractory cases.
Main Results:
- The prevalence of ESI was 55%, with PSA ESI occurring in 40.2% of patients experiencing ESI.
- Antibiotic therapy alone achieved successful outcomes in 44.9% of cases, though 10% later developed PSA peritonitis.
- Surgical interventions like cuff shaving or catheter removal/reinsertion were employed in 37.2% of patients, with varying success rates and complications such as peritonitis and peritoneal failure.
Conclusions:
- Antibiotic therapy is effective for some PSA ESI cases, but a significant proportion may progress to peritonitis.
- Early Tenckhoff catheter removal should be considered for patients with persistent PSA ESI unresponsive to antibiotics or cuff shaving.
- Prompt intervention is essential to mitigate the risk of peritonitis and preserve peritoneal dialysis technique.