: An Outbreak in the Peritoneal Dialysis Unit.

is a ubiquitous, opportunistic, environmental gram-negative bacillus which most commonly affects cystic fibrosis and immunocompromised patients. Rarely, it can cause peritoneal dialysis (PD) exit-site infection (ESI). Information relating to predisposing factors, clinical course, and treatment options for ESIs is limited. Although reports of healthcare-associated infections exist, outbreaks in PD units have not previously been reported. A recent outbreak of ESI in our PD unit provided a unique opportunity to study ESIs and to outline an approach to investigating such an outbreak.After unexpectedly identifying as the cause of PD catheter ESIs in 3 patients over an 11-week period, we began systematically screening our PD population for exit-site colonization. A further 6 patients were found to be affected, 3 with asymptomatic colonization and 3 with symptomatic ESI. Four of the 6 developed tunnel infections requiring multiple courses of antibiotic treatment, and 3 patients required catheter removal; 2 patients with symptomatic ESIs without tunnel involvement responded to oral and topical antibiotics. Further investigation implicated 4% chlorhexidine aqueous bodywash used by all patients as the probable source of the outbreak.This is the first reported outbreak of ESIs. We noted an association between diabetes mellitus and refractory/more extensive infection. Our experience suggests that isolated ESIs can be treated successfully with oral antibiotics whereas tunnel infections generally require catheter removal.