Flanigan M J, Hochstetler L A, Langholdt D, Lim V S
Department of Medicine, University of Iowa Hospital and Clinics, Iowa City 52240.
Perit Dial Int. 1994;14(3):248-54.
To develop diagnostic and treatment strategies for peritoneal dialysis catheter exit-site and tunnel infections.
All consenting peritoneal dialysis patients performing home dialysis through the University of Iowa Hospitals and Clinics Home Dialysis Training Center. This is a state-owned teaching hospital serving a rural population of approximately one million people in Iowa and western Illinois.
Four dialysis nurses collected information on a prospectively designed data acquisition tool. Patients were randomly assigned to one of two treatment groups, intraperitoneal vancomycin plus oral rifampin or oral trimethoprim/sulfamethoxazole (TMP/SMX), and their initial antibiotic therapy determined by that assignment. If the infection was gram-negative, the initial antibiotics were discontinued and an alternative therapy begun. Therapy was initiated by the nursing staff and required physician notification within 48 hours.
There were 126 recorded catheter infections (exit-site, tunnel, or cuff infection) resulting in a rate of 0.67 episodes per patient year of exposure. Staphylococcus aureus was isolated from the majority (60%) of these events. Pseudomonas aeruginosa was the next most common isolate and accounted for 21% of infections. Rubor, dolor, and turgor are the classic signs of inflammation, and at least one of these was present in 79% of the episodes. Isolated pericatheter erythema or serous discharge was associated with a minimal risk (< 2%) of catheter loss. The presence of a purulent exit-site discharge identified patients who had a 30% chance of failing systemic antibiotic therapy and a 20% risk of catheter loss. The concurrent presence of exit-site tenderness or swelling identified the most severe infections. Staphylococcal infections responded equally well to local cleaning and vancomycin plus rifampin (86% cured) or oral trimethoprim/sulfamethoxazole (89% cured) therapy. Gram-negative infections were frequent (27%) and appeared to respond best to a combination of tobramycin and ciprofloxacin.
Exit-site/tunnel inflammation is detectable by patients and can be used to guide therapy. An isolated finding of erythema or serous discharge is not indicative of an acute infection and may not require systemic antibiotics. The presence of purulence identifies patients at risk for catheter loss, and these patients benefit from systemic therapy. The combination of a purulent exit-site discharge plus pericatheter tenderness or swelling identifies patients likely to suffer treatment failure and require subsequent catheter removal. The cure rate of gram-positive catheter infections treated with vancomycin plus rifampin was indistinguishable from that achieved with oral trimethoprim/sulfamethoxazole (p = 0.99).
制定腹膜透析导管出口处及隧道感染的诊断和治疗策略。
所有通过爱荷华大学医院及诊所家庭透析培训中心进行家庭透析的腹膜透析患者。这是一家国有教学医院，服务于爱荷华州及伊利诺伊州西部约100万农村人口。
4名透析护士通过前瞻性设计的数据采集工具收集信息。患者被随机分配至两个治疗组之一，即腹腔内注射万古霉素加口服利福平或口服甲氧苄啶/磺胺甲恶唑（TMP/SMX），其初始抗生素治疗根据分组确定。如果感染为革兰阴性菌，则停用初始抗生素并开始替代治疗。治疗由护理人员启动，且需在48小时内通知医生。
共记录了126例导管感染（出口处、隧道或袖套感染），患者每年暴露的感染发生率为0.67次。这些感染事件中，大多数（60%）分离出金黄色葡萄球菌。铜绿假单胞菌是其次最常见的分离菌，占感染的21%。红、肿、热是炎症的典型体征，79%的感染事件中至少出现其中一项。孤立的导管周围红斑或浆液性渗出与导管丢失的风险极小（<2%）相关。脓性出口处渗出物的出现表明患者有30%的概率全身抗生素治疗失败，有20%的导管丢失风险。出口处压痛或肿胀同时出现提示感染最为严重。金黄色葡萄球菌感染对局部清洁以及万古霉素加利福平（86%治愈）或口服甲氧苄啶/磺胺甲恶唑（89%治愈）治疗的反应同样良好。革兰阴性菌感染较为常见（27%），似乎对妥布霉素和环丙沙星联合治疗反应最佳。
患者可察觉到出口处/隧道炎症，其可用于指导治疗。孤立的红斑或浆液性渗出并非急性感染的指征，可能无需全身使用抗生素。脓性渗出物的出现提示患者有导管丢失风险，这些患者可从全身治疗中获益。脓性出口处渗出物加上导管周围压痛或肿胀提示患者可能治疗失败，需要随后拔除导管。用万古霉素加利福平治疗革兰阳性导管感染的治愈率与口服甲氧苄啶/磺胺甲恶唑的治愈率无显著差异（p = 0.99）。
