| Abstract|| |
Although there has been a dramatic decrease in the incidence of peritonitis in continuous ambulatory peritoneal dialysis (CAPD), rates > 0.5 episodes per patient per year are still common, with a very high rate of relapse. The nasal, pharyngeal, and skin carriage of Staphylococcus aureus (S. aureus) has been reported to be one of the most important of predisposing factors for peritonitis. Mupirocin application has been introduced to combat S. aureus carriage state with some degree of success. To evaluate the benefits of combining ablution for prayers with mupirocin in eliminating the carrier state of S. aureus and thus preventing peritonitis in CAPD patients, we randomized prospectively 65 patients on CAPD into two groups; group (1) used mupirocin intranasal application alone, and group (2) were instructed, in addition to application of mupirocin, to perform the proper ablution technique. The main outcome measures were the state of nasal, skin and pharyngeal S. aureus carriage state, the incidence of peritonitis, and mal-function-free PD catheter survival. After 3 months of CAPD initiation, S. aureus carrier state was detected in 11 (33.3%) patients in group (1), and in 2 (6.25%) patients in group (2) (p< 0.005), and at the end of the study 10 (30.3%) patients from group (1) and none in group (2) remained S. aureus carriers (p< 0.001). S. aureus peritonitis occurred in 19 occasions in 10 patients of group (1) versus 4 occasions in 3 patients of group (2) (p< 0.001). Malfunction-free catheter survival at 12 months was 72.7% in group (1) versus 90.6% in group (2) patients (p< 0.05). We conclude that combined with mupirocin intranasal application, performing proper ablution is an effective measure against S aureus carriage and hence it decreases the incidence of continuous ambulatory peritoneal dialysis-associated S. aureus peritonitis.
Keywords: CAPD, Staphylococcus aureus,Ablution, Mupirocin, S. aureus carriage
|How to cite this article:|
Al-Hwiesh AK, Abdul Rahman IS. Prevention of Staphylococcal Peritonitis in CAPD Patients Combining Ablution and Mupirocin. Saudi J Kidney Dis Transpl 2008;19:737-45
|How to cite this URL:|
Al-Hwiesh AK, Abdul Rahman IS. Prevention of Staphylococcal Peritonitis in CAPD Patients Combining Ablution and Mupirocin. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2020 May 30];19:737-45. Available from: http://www.sjkdt.org/text.asp?2008/19/5/737/42444
| Introduction|| |
Peritonitis and exit-site infections have been the most frequent complications of continuous ambulatory peritoneal dialysis (CAPD) since the introduction of this modality as a viable treatment for patients with end-stage renal disease (ESRD). , Active or persistent infections may result in technique failure. ,,,, Despite the widespread use of modern disconnect systems for PD, S. aureus and Staphylococcus epidermidis are still a frequent cause of dialysis-related infections.
S. aureus nasal and/or skin carriers are considered to be at greater risk for developing peritonitis. ,,,, Treatment of S. aureus nasal carriers with topical intranasal mupirocin is useful to reduce the number of exit-site infections caused by S. aureus, but not peritonitis. 
Resistance of bacteria to antimicrobial agents has become increasingly common during the last decade. , This increasing prevalence of antimicrobial resistance is due to the two primary factors: indifferent antimicrobial use and transmission of resistant strains from patient to patient.  strategies that limit the spread of antimicrobial resistance in patients with ESRD have been reviewed,  and clinical practice guidelines have been laid down. 
Hands hygiene is stated as the single most important infection-control measure, and should be performed after touching blood, body fluids, secretions, excretions, and contaminated items re-gardless of whether gloves are worn. Hand washing should be performed as frequent as possible to avoid the transfer of microorganisms. ,
Fourteen centuries ago, our Prophet Mohammed (Peace be upon him) gave us a prescription of 26 washing movements (ablution) to be carried out 5 times a day. The holy Quraan stated "O ye who believe! When ye prepare for prayer, wash your faces, and your hands (and arms) to the elbows; Rub your hands (with water); and wash your feet to the ankles. If ye are in a state of ceremonial impurity, bathe your whole body". 
Since ablution may solve the problem of nasal, pharyngeal and skin carrier state of microorganisms that is responsible for CAPDrelated peritonitis, we combined the usage of mupirocin with instructions to our patients about adopting the correct ablution techniques to evaluate the outcome of such strategy on the incidence of peritonitis in our CAPD patients.
| Patients and Methods|| |
We prospectively studied 65 incident patients started on CAPD in a single center (King Fahd University Hospital Al-Khobar, Saudi Arabia), from 2005–2007 (a period of 2 years). They were divided into two groups: (1) incident CAPD patients from February 2005 to January 2006 inclusive (Group (1)–33 patients), in whom only topical mupirocin ointment was used as prophylaxis against Staphylococcus aureus infection, and (2) incident patients from February 2006 to March 2007 inclusive (Group (2)–32 patients), in whom topical mupirocin was combined with the proper ablution technique. Each patient was assessed and counseled by the dialysis coordinator to determine the suitability of the treatment before the elective insertion of a coiled, double-cuff Tenckoff catheter (Accurate Surgical Instruments Corporation, Toronto, Ontario). Antibiotic prophylaxis with intravenous cephazolin was administered prior to surgery. A break-in period of at least 2 weeks was required during which the exit site was visually inspected on days 5 and 10 after catheter placement. Patients and their caregiver(s), if any, were then trained for 1 week on the use of CAPD by a PD nurse. Patients and their caregiver(s) of group 2 were given extra-training of the proper ablution technique for an additional week. The training was delivered by a nephrologist. The doublebag (Ultrabag) system was used for all PD patients. Mupirocin was regularly applied on the exit sites in all incident patients as part of their exit site care. Mupirocin in the form of 2% ointment was applied three to five times per week, after cleaning the area around the site with iodine (single-use swabs sterile packs). An amount of ointment equivalent to the size of match head was applied to each nostril twice daily for 5 days each month. Standard cotton swabs were collected bi-monthly from every patient (and their caregiver(s), if any), one each from the anterior nares, pharynx, the skin folds between the toes, and from the subungual sulci of all fingers of the dominant hand.
All cultures were incubated aerobically at 35° C. The plates were reviewed at 24 hours and again after 48 hours if no growth was observed. Putative S. aureus colonies were identified on the basis of positive Gram stain, catalase test, coagulation tube test, and Pastorex Staph Plus rapid agglutination slide test (Bio-Rad, Montreal, Quebec, Canada). All strains of S. aureus isolated were tested for methicillin and mupirocin resistance. Methicillin resistance was tested using methicillin screening plates containing oxacillin 6 mg/ml and 4% NaCl. Mupirocin resistance was tested using E-test strips (AB Biodisk, Slona, Sweden). Clinical data were collected from patients at the time of swab collection [Table 1]. Peritonitis was diagnosed if at least two of the following were present:
- abdominal pain or tenderness,
- presence of white cells in the peritoneal effluent in excess of 100 cells/ml, comprising at least 50% polymorphs and,
- positive dialysate culture results. The dialysate samples were cultured in Bact-Alert blood culture bottles media (Organon Technika, Durham, NC) and subcultured in 5% sheep blood agar, chocolate, and McConkey agar 24 hours later.
The usual technique of ablution was used with special emphasis on the following items:
- To wash the hands and in between the fingers carefully three times.
- Shift the ring (if any) when washing the hands.
- During mouth washing, rinse it vigorously with water and gurgle the throat, three times.
- Wash the nostrils three times with the right hand, draw the water as deep as possible, and then blow it out with the left hand.
- Swab the ears carefully with water. Clean the inside and outside of the ear.
- When washing the face, arms, and feet, use a little more of water than the compulsory amount. During washing the arms fill the palm with water and then pour it towards the elbow. Repeat this three times in each ablution.
- Wash every limb three times. Every part of the limb must be washed and rubbed with water.
- Swab the head with water using the hand in backwards and forwards movement.
- When washing the feet, wash in between the toes from under them in succession, beginning with the little the of the right foot, and then after finishing with the right foot carry on with the big toe of the left foot towards the little one.
- To perform ablution before each prayer, and at least 5 times per day.
| Statistical analysis|| |
Statistical analysis was done using the software of SPSS Inc. for windows to identify the different predictors of the occurrence of peritonitis. Data are expressed as means with SD or median with range. Continuous variables were compared with t-test. Times to the first peritonitis were analyzed using Cox regression analysis. P value < 0.05 was considered to be statistically significant. All the reported p-values were two-tailed.
| Results|| |
The demographics of 65 CAPD patients are presented in [Table 1]. Both groups were similar in terms of co morbidities, serum albumin before the initiation of CAPD, and age at the start of PD. A high proportion of our patients had diabetes or ischemic heart disease, and serum albumin below 30 g/L at entry into the PD program. Isolation of S. aureus from the nostrils was also similar at baseline 15 (45.5%) in group (1) and in 13 (40.6%) in group (2) (p> 0.05). After 3 months and at end of study, S. aureus carrier state was detected in 11 (33.3%) and 2 (6.25%) patients (p< 0.005), and 10 (30.3%) patients versus none (p< 0.001), respectively. None of the S .aureus isolates were MRSA. Mupirocin resistance was found in 12 (18.5%) patients; 10 (15.4%) in group (1), and 2 (3.1%) in group (2) (p< 0.005). S. aureus peritonitis occurred in 19 occasions in 10 patients of group (1) versus 4 occasions in 3 patients of group (2) (p< 0.001). Most of the peritonitis episodes in group (2) patients occurred within 3 months of entry into the trial, whereas those in group (1) continued throughout the trial [Figure 1]. By Cox regression analysis, time to first infection was significantly shorter in group (1) than in group (2) patients (hazard ratio, 2.4; 95% confidence interval 1.0-5.3; p= 0.04). Cumulative evidence of peritonitis was 1 per 9.5 patient months in group (1) and 1 per 24 patient months in group (2) (odds ratio 3.4; 95% CI 1.5 to 8.5; p= 0.004). Six (18.2%) patients in group (1) versus 1 (3.1%) patient in group (2) had PD catheter malfunction necessitating catheter change (p< 0.01). Malfunction-free catheter survival at 12 months was 72.7% in group (1) versus 90.6% in group (2) patients (p< 0.05), [Table 2].
| Discussion|| |
As many as 15% of end stage kidney disease patients in the U.S. are on PD. In other countries such as Canada and the United Kingdom (35%), New Zealand (55%), and Mexico (90%), the rates are higher, but the major limitation to the broader uptake of PD is still an unacceptable rate of peritonitis, which in turn promotes technique failure, more hospitalizations  and increased mortality. ,,, Several PD catheter-related interventions (catheter designs, surgical insertion approaches, and connection methods) have been purported to reduce the risk of peritonitis in PD. Although there has been a dramatic decrease in peritonitis from the inception of CAPD, rates > 0.5 episodes per patient per year are still common, ,, and peritonitis tends to be recurrent, with a very high rate of relapse (~0.5 episodes/patient/year).  The incidence of peritonitis has been reported to vary depending on age, , coexisting disease (e.g., diabetes), nasal carriage of S. aureus, , and race. ,, S. aureus colonizes the skin and mucosa of human beings and several animal species.  Although multiple body sites can be colonized in the human beings, the anterior nares of the nose are the most frequent carriage site for S aureus.  Extra-nasal sites that typically harbour the organism include the skin, perineum, and pharynx. ,,, Most studies on S. aureus nasal carriage have used a cross-sectional design with a single nasal culture to classify an individual as a carrier. However, longitudinal studies distinguish at least three S. aureus nasal carriage patterns in healthy individuals: persistent carriage, intermittent carriage, and non-carriage. ,,,, Some studies make a further distinction between occasional and intermittent carriers. , Therefore, a patient classified as a carrier in cross-sectional studies could be a persistent or an intermittent carrier. This distinction is important because persistent carriers have higher S. aureus loads and a higher risk of acquiring S aureus infection. , Like wise, non-carriers in a cross-sectional study may actually be intermittent carriers. Longitudinal studies show that about 20% (range 12&ndash30%) of individuals are persistent S. aureus nasal carriers and approximately 30% are intermittent carriers (range 16–70%). ,,, The very wide ranges found in the proportions of intermittent carriers are the result of the use of different culture techniques, different populations being studied, and the use of different interpretation guidelines.  The mechanisms leading to S. aureus nasal carriage are multifactorial. A recent study in which volunteers (non-carriers and persistent carriers) were artificially inoculated with a mixture of S. aureus strains showed that non-carriers quickly eliminated the inoculated S. aureus strains, whereas most persistent carriers selected their original resident S. aureus strain from the inoculation mixture.  The investigators concluded that host characteristics substantially co-determine the S. aureus carrier state and that an optimal fit between host and bacteria seems to be essential.  This view is further supported by the fact that S. aureus carriage rates vary between different ethnic groups, with higher rates in white people, , and in men, ,, and depends on age. ,, Patients with diabetes mellitus (both insulin-dependent and non-insulin dependent)  , patients with endstage liver disease, , and patients undergoing hemodialysis, , or CAPD for end-stage renal disease  have higher S. aureus carriage rates. Nasal secretions with antimicrobial peptides may have a role in the innate host defence,  however, several studies have found that these antimicrobial peptides have no or little activity against S. aureus or that other peptides are needed to enhance their activity. , The inability of nasal antimicrobial peptides to clear S. aureus from the nose may be explained by
- the anatomy of nose in relation to S. aureus nasal carriage and
- resistance of S. aureus to many antimicrobial peptides. ,
S. aureus predominantly colonizes an area in the vestibulum nasi that is devoid of cilia and relatively free from nasal mucous secretions that containing antimicrobial peptides and immunoglobulins.  Mechanical removal of the organisms by the proper act of ablution seems to be a perfect solution for this problem as shown by our study. S. aureus, in addition, has several other mechanisms of resistance including: staphylokinase  , membrane lipid modification  ,cationic antimicrobial peptides, including defensins and cathelicidins, present in the nasal mucosa. Furthermore, all S. aureus strains are also lysozyme resistant since they possess the peptidoglycan-specific O-acetyltransferase. 
In hemodialysis patients, S. aureus is a frequently found pathogen involving vascular access related infections and bacteremia. The infection rate is higher in nasal and pharyngeal carriers on hemodialysis, with relative risks varying from 1.8 to 4.7. ,,, S. aureus isolates from different sites are usually identical to the one previously isolated from the patient's nose or pharynx.  Multiple studies have demonstrated that long-term eradication of S. aureus nasal and pharyngeal carriage effectively reduces S. aureus infections among patients on maintenance dialysis, thereby decreasing complications and costs. ,,, In patients on CAPD, S. aureus is the leading cause of peritoneal often resulting in catheter loss. S. aureus nasal and pharyngeal carriage was found to be a major risk factor for infections in PD patients mainly associated with exit site and tunnel infections. ,,,,,, Intervention studies consistently demonstrated a substantial reduction in the incidence of exit-site infections, but not a consistent reduction in the incidence of peritonitis. ,,,,, In a recent study it was demonstrated that PD patients with persistent or intermittent S. aureus nasal carriage were at similar increased risk of acquiring dialysisrelated S. aureus infections.  Interventions to prevent continuous peritoneal dialysis-related infections include eliminating the carrier state by personal hygiene, nasal and throat cleansing and prophylactic antibiotic local use since the nasal strains and the infectious strain were found to be the same ,, In our patients, daily application of mupirocin with ablution was more effective in preventing S aureus peritonitis. The act of ablution performed properly not only cleanses the vital parts of the body from dust and dirt but also softens and refreshes them. Especially the germs trapped in the nostrils are mechanically removed. According to a study conducted in Alexandria University, ablution positively affected the inner coating of the nostrils.  Rinsing of the mouth also proved to protect from the infections. 
We conclude that in addition to mupirocin performing ablution properly is an effective measure against Staphylococcus aureus nasal carriage resulting in lesser incidence of CAPD associated peritonitis Further studies at other centers with larger number of patients are needed to confirm this finding.
| Acknowledgement|| |
The authors thank the staff nurses and the health educator in the peritoneal dialysis unit at King Fahd University Hospital for their valuable efforts in the completion of the study.
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Abdulla K Al-Hwiesh
King Fahd University Hospital, P.O. Box 40246, Al-Khobar, 31952
[Table 1], [Table 2]