[Prophylaxis and management of catheter-associated infections in peritoneal dialysis patients: recent studies and guidelines].

Prophylaxis and treatment of catheter-related infections in patients undergoing peritoneal dialysis (PD) are the key to success of this type of renal replacement therapy. Prophylactic antibiotic therapy before catheter implantation significantly reduces the risk of peritonitis in the first month after operation. However, this strategy does not influence the risk of infections of the exit site and catheter tunnel. Although there are no studies showing any benefit in the use of povidon-iodine or sodium hypochlorite for care of exit sites in long-term PD patients, the use of a local disinfectant is recommended in recent guidelines. Another prophylactic approach is the use of local antibiotics, either intranasally or by application to the exit site. The use of mupirocin significantly reduces the rate of exit-site and tunnel infections and also the number of Staphylococcus aureus carriers. Gentamycin cream applied to the exit site is as effective as mupirocin in preventing S. aureus infections and in addition covers Pseudomonas aeruginosa. Both these local antibiotic therapies, however, carry the risk of selection of resistant bacterial strains. Guidelines mostly recommend the use of local antibiotics at least in S. aureus carriers. According to available data, oral antibiotic prophylaxis in long-term PD patients is not recommended, since a positive effect is unproven and systemic side effects have been reported in some studies. Family members and healthcare workers may be a source of S. aureus colonization in PD patients; however, there are no international protocols suggesting screening or treatment of these persons. There is no evidence favoring any dressing protocol (or a dressing change at all). Furthermore, because of lack of data, the question of whether face masks should be used during dressing changes or dialysate exchanges cannot yet be answered. There are no studies showing that it is safe for PD patients to go swimming or to a sauna. Only a few studies have focused on diagnosis and classification of exit-site infections and therefore no international standards exist. In cases of exit-site infection, ultrasonography of the catheter tunnel is a useful tool in the diagnosis of accompanying tunnel involvement and is also helpful in estimating the prognosis of these infections, depending on response to antibiotic therapy. Catheter-related infections should be treated with antibiotics for at least two weeks. With the exception of infection with methicillin-resistant S. aureus, the oral route is as effective as intraperitoneal administration. Currently there is no evidence of the ideal time-point for catheter removal after renal transplantation.