Vychytil A, Lorenz M, Schneider B, Hörl W H, Haag-Weber M
Department of Medicine III, University Hospital of Vienna, Austria.
J Am Soc Nephrol. 1998 Feb;9(2):290-6. doi: 10.1681/ASN.V92290.
Catheter-related infection is one of the most important causes of technical dropout in peritoneal dialysis patients. Both the type of cultured organism and the extent of inflammation are well known prognostic factors for the outcome of these infections. From December 1994 to November 1996, 96 catheter-related infections without simultaneous peritonitis occurred in 49 of 86 peritoneal dialysis patients treated in this study. During the observation period, only single-cuff catheters were used. Staphylococcus aureus was the most common organism cultured (51%). Involvement of the tunnel was diagnosed by sonography in 57.1% of all Staphylococcus aureus cases, but only in 26.1% of Staphylococcus epidermidis-related exit-site infections. Ten of the 96 catheter-related infections (10.4%) resulted in catheter loss. Catheter removal was necessary only in cases of deep tunnel infection caused by Staphylococcus aureus. The number of gram-negative catheter infections was too small to allow conclusive analysis. Although sonography of the catheter tunnel is now well established in the early diagnosis of tunnel infections, no clear guidelines exist for management of these infections. In this study, patients with deep tunnel infection who did not require catheter removal showed a significant decline of the hypoechogenic area around the cuff (from 7.02 +/- 0.70 to 3.75 +/- 1.04 mm, P < 0.002) 2 wk after initiation of therapy. No significant decline was observed in patients who later lost their catheters. On the basis of these data, it is concluded that in cases of exit-site and superficial tunnel infection, conservative treatment should be performed. In cases of deep tunnel infection without peritonitis caused by Staphylococcus aureus, antibiotic treatment should be started and sonographic examination should be performed every second week. If the hypoechogenic area around the cuff decreases (> 30%), conservative treatment should be prolonged. In cases without sonographic improvement (< 30%) 2 wk after therapy, catheter removal is recommended.
导管相关感染是腹膜透析患者技术失败的最重要原因之一。培养出的生物体类型和炎症程度都是这些感染预后的重要已知预测因素。1994年12月至1996年11月，本研究中86例接受腹膜透析治疗的患者中有49例发生了96次无并发腹膜炎的导管相关感染。在观察期内，仅使用了单涤纶套导管。金黄色葡萄球菌是培养出的最常见生物体（51%）。在所有金黄色葡萄球菌病例中，57.1%通过超声检查诊断为隧道感染，但在表皮葡萄球菌相关出口部位感染中仅为26.1%。96次导管相关感染中有10次（10.4%）导致导管丢失。仅在金黄色葡萄球菌引起的深部隧道感染病例中才需要拔除导管。革兰阴性菌导管感染的数量过少，无法进行确定性分析。尽管导管隧道超声检查现已在隧道感染的早期诊断中广泛应用，但对于这些感染的管理尚无明确指南。在本研究中，不需要拔除导管的深部隧道感染患者在治疗开始2周后，涤纶套周围低回声区显著缩小（从7.02±0.70降至3.75±1.04 mm，P<0.002）。后来丢失导管的患者未观察到显著缩小。基于这些数据，得出结论：在出口部位和浅表隧道感染病例中，应进行保守治疗。在金黄色葡萄球菌引起的无腹膜炎的深部隧道感染病例中，应开始抗生素治疗，并每两周进行一次超声检查。如果涤纶套周围低回声区缩小（>30%），应延长保守治疗时间。在治疗2周后超声检查无改善（<30%）的病例中，建议拔除导管。
