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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE  
Year : 2011  |  Volume : 22  |  Issue : 5  |  Page : 931-934
The comparison of exit-site care with normal saline and povidone-iodine in preventing exit-site infection and peritonitis in children on chronic peritoneal dialysis treatment


Department of Pediatric Nephrology, Izmir Tepecik Teaching and Research Hospital, Yenisehir, Izmir, Turkey

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Date of Web Publication6-Sep-2011
 

   Abstract 

Peritonitis and catheter exit- site infections (ESI) are important causes of hospitalization and catheter loss in patients undergoing chronic peritoneal dialysis (CPD). The frequency of infection can be reduced by scrupulous exit- site care with or without topical antiseptics. There are no studies showing any benefit in the use of povidone-iodine or normal saline for care of exit- sites in long- term CPD patients. In this study, we aimed to determine the potential effectiveness of the application of povidone-iodine or normal saline at the catheter exit- site in preventing ESI and peritonitis in children on CPD. A total of 98 patients treated with either povidone-iodine or normal saline were included in this study. Group I (34 patients) used povidone-iodine and group II (64 patients) simply cleansed the exit- site with normal saline (0.9% NaCl). Dressings were changed 2 to 3 times in a week. The total cumulative follow- up time was 3233 patient- months. ESIs occurred in 10 (29.4%) of 34 patients using povidone-iodine and in 10 (15.6%) of 64 patients using normal saline. The frequency of ESI was significantly high in group I (povidone-iodine) patients. The mean rate of ESI was 1 episode/60.8 patient- months for group I versus 1 episode/144 patient- months for group II (P < 0.05). The rate of peritonitis was similar in each group (1 episode/21.3 patient- months for group I versus 1 episode/20.17 patient- months for group II) (P > 0.05). In conclusion, exit- site care with normal saline is an effective strategy in reducing the incidence of ESI in children on CPD. It can thus significantly reduce morbidity, catheter loss, and the need to transfer patients on peritoneal dialysis to hemodialysis.

How to cite this article:
Yavascan O, Anil M, Kara OD, Bal A, Akcan N, Senturk S, Unturk S, Aksu N. The comparison of exit-site care with normal saline and povidone-iodine in preventing exit-site infection and peritonitis in children on chronic peritoneal dialysis treatment. Saudi J Kidney Dis Transpl 2011;22:931-4

How to cite this URL:
Yavascan O, Anil M, Kara OD, Bal A, Akcan N, Senturk S, Unturk S, Aksu N. The comparison of exit-site care with normal saline and povidone-iodine in preventing exit-site infection and peritonitis in children on chronic peritoneal dialysis treatment. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2022 Sep 29];22:931-4. Available from: https://www.sjkdt.org/text.asp?2011/22/5/931/84324

   Introduction Top


Chronic peritoneal dialysis (CPD) is now an important and well- established form of renal replacement therapy (RRT). [1] However, despite technical improvements, infection- related complications such as exit- site infection (ESI) and peritonitis remain the most important reasons for catheter removal and method dropout among patients undergoing CPD. [2],[3] Several reports have noted that Staphylococcus aureus is one of the major causes of ESI and catheter- related peritonitis, which are often difficult to treat due to the virulent nature of the organism. As a result, efforts should be focused more on prevention treatment rather than the treatment of ESI as a means of reducing the rate of peritonitis, catheter removal, and patient transfer to hemodialysis. [3] In fact, the frequency of infection can be reduced by scrupulous exit- site care with or without topical antiseptics. Currently, there are no studies showing any benefit in the use of povidone-iodine or normal saline for care of exit- sites in long- term CPD patients. In this study, we aimed to determine the potential effectiveness of the application of povidone-iodine or normal saline for catheter exit- site care in preventing ESI and peritonitis in children on CPD.


   Material and Method Top


The study was conducted at the Department of Pediatric Nephrology, Tepecik Training and Research Hospital, Izmir, Turkey. Ninety- eight children who were on CPD from December 1995 to December 2007 and practicing PD for more than 3 months were included in the study. All PD catheters were placed percutaneously (Seldinger technique) by an experienced pediatric nephrologist in our unit. Tenckhoff swan- neck double- cuff curled catheters were used in all patients. In all subjects, just after the catheter placement procedure was terminated, before the dressings, we applied topical mupirocin to both catheter entry- port and exit- site. Dressings were changed 2 weeks after the catheter placement, followed by 2-3 times weekly. In all patients attending our clinic, exit- site care was performed by either normal saline or povidone-iodine, depending on the dialysis nurse preference.

Patients' medical records were retrospectively reviewed using a standardized data collection form. Patients were classified into two groups according to exit- site care regimes during the observation period. Group I (34 patients) comprised those who received povidone-iodine and group II (64 patients) comprised those who simply got the exit- site cleansed with non- disinfectant normal saline (0.9% NaCl). We evaluated the effects of the 2 exit- site care regimes on the rate of ESI and peritonitis. Infection- related complications, that is, ESI, peritonitis as well as catheter removal and any other adverse reactions were also monitored.

Exit- site swab cultures from the catheter exit- site were taken only when infection was suspected. Samples of peritoneal effluent were also cultured when, clinically, peritonitis was diagnosed. ESI was defined as erythema, soreness, inflammation, or drainage at the exit site. Peritonitis was defined as cloudy fluid and/or abdominal pain associated with a white blood cell count >100 (with >50% neutrophils). All patients with ESI and peritonitis were treated as per the International Society for Peritoneal Dialysis protocol. [4]

Samples from pericatheter skin obtained with sterile cotton- wool swabs were immediately inoculated onto plates containing sheep blood or Eosin Methylene Blue (EMB) agars. All cultures were incubated at 37°C for 48 hours. Peritoneal effluent specimens were inoculated onto sheep blood, chocolate, and EMB agars for 2 days, Bactec for 1 week and Sabouraud Dextrose agar for four weeks, followed by identification of the microorganism.

Statistical analysis was made using the McNemar chi- square test. A P- value of less than 0.05 was considered to be significant.


   Results Top


A total of 98 patients were classified into one of two exit- site care regimes to evaluate their effects on the rate of ESI and peritonitis. The clinical characteristics and infection- related events of the two groups of exit- site care regimes of the study are shown in [Table 1]. During the 12- year observation period, the total cumulative follow- up time was 3233 (1216 pt- mos in group I, 1917 pt- mos in group II) patient- months. Exit- site infections occurred in 10 (29.4%) of 34 patients treated with povidone-iodine and in 10 (15.6%) of 64 patients using normal saline. There was a significantly higher rate (P < 0.05) of ESI in group I (povidone-iodine). The mean rate of ESI was 1 episode/60.8 patient- months for group I versus 1 episode/144 patient- months for Group II (P < 0.05). Peritonitis occurred in 24 (70.5%) of 34 patients in group I and in 49 (76.5%) of 64 patients in group II. The risk of peritonitis was similar in each group (1 episode/21.3 patient- months for group I versus 1 episode/20.17 patient- months for group II) (P > 0.05). In each group, 2 catheters were removed due to non- responsive peritonitis. Although ESI and peritonitis are most commonly caused by S. aureus, culture- negative peritonitis and ESI were clearly high in our study. Between in patients with povidine-iodine and those with normal saline, causative microorganisms were similar. In group I, 2 patients experienced allergic dermatitis [Table 2].
Table 1: Patient characteristics and infection-related events in terms of exit-site care.

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Table 2: Causative organisms of ESI and peritonitis in terms of exit site care.

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   Discussion Top


There are no studies showing any benefit in the use of povidone-iodine over normal saline for care of exit- sites in long- term CPD patients. To our knowledge, ours is the first study looking into the role of local application of povidone-iodine or normal saline at the exit site on the rate of ESI and peritonitis in CPD children.

For the prevention of ESIs and subsequent peritoneal infection, aseptic care is most important. [5] Although the use of disconnect systems has greatly reduced the incidence of Staphylococcal peritonitis, it has not altered the risk of ESI, increasing its importance as a precursor of peritonitis. Povidone-iodine derived from polyvinylpyrrolidone-iodine is a widely used antiseptic in patients on CPD. In the literature, there is no consensus regarding the use of povidone-iodine or other antiseptics or antibiotics such as mupirocin at the exit site prophylactically in all patients. Protocols for exit- site care vary from cleaning with soap and water, applying povidone-iodine or applying hydrogen peroxide plus soap or povidone-iodine scrub. [5],[6],[7] A large randomized trial showed that a non- occlusive dressing plus povidone-iodine was associated with a lower rate of exit- site infection than soap and water alone (0.27 vs. 0.71 episodes/patient- year). [5] However, Wilson et al suggested that both ESI and risk of peritonitis was similar in patients using spray and in patients not using spray. [6] In addition, they showed that the proportion of infections caused by S. aureus was lower in the spray group, but those caused by Pseudomonas aeruginosa were higher. In addition, allergic dermatitis around the catheter exit- site, even anaphylaxis, caused by povidone-iodine is increasingly reported as a complication. It is the most frequent cause for which patients stop the use of povidone-iodine. In our study, 2 of 34 patients in the povidone-iodine group experienced allergic dermatitis, which resolved upon termination of the regime. Previously, we ourselves have reported our own clinical experience in these two children with allergic reaction due to povidone-iodine. [8]

We showed that ESI in patients using povidone-iodine was significantly higher than in those using normal saline. The mean rate of ESI was 1 episode/60.8 patient- months for patients using povidone-iodine versus 1 episode/144 patient- months for patients using normal saline (P < 0.05). However, we found no difference in the risk of peritonitis and removed catheter numbers. Furthermore, between in patients with povidone-iodine and those with normal saline, causative microorganisms were found not to be different. It is not clear how normal saline protected ESI. Also, based on our microbiological findings, a definite comment regarding causative microorganisms and exit- site care is not possible, because culture- negative peritonitis and ESI were high in our study.

In conclusion, exit- site care with normal saline is a well- tolerated and effective strategy in reducing the incidence of ESI in children on CPD. Probably, it can significantly reduce morbidity, catheter loss, and transfer to hemodialysis as well as allergic reactions in peritoneal dialysis patients.

 
   References Top

1.United States Renal Data System. USRDS 1999 Annual Data Report. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 1999.  Back to cited text no. 1
    
2.Canada- USA (CANUSA) Peritoneal Dialysis Study Group. Adequacy of dialysis and nutrition in continuous peritoneal dialysis: association with clinical outcomes. J Am Soc Nephrol 1996;7(1):198.  Back to cited text no. 2
    
3.Mahajan S, Tiwari SC, Kalra V, et al. Effect of local mupirocin application on exit- site infection and peritonitis in an Indian peritoneal dialysis population. Perit Dial Int 2005;25(5):473- 7.  Back to cited text no. 3
    
4.Keane WF, Baillie GR, Boeschoten E, et al. Adult peritonitis treatment recommendations: 2000 update. Perit Dial Int 2000;20(6):828.  Back to cited text no. 4
    
5.Luzar MA, Brown CB, Balf D, et al. Exit site care and exit site infection in continuous ambulatory peritoneal dialysis (CAPD): results of a randomized multicenter trial. Perit Dial Int 1990;10(1):25.  Back to cited text no. 5
    
6.Wilson AP, Lewis C, O'Sullivan H, Shetty N, Neild GH, Mansell M. The use of povidone iodine in exit site care for patients undergoing continuous peritoneal dialysis (CAPD). J Hosp Infect 1997;35(4): 287.  Back to cited text no. 6
    
7.Zeybel M, Ozder A, Sanlidag C, et al. The effects of weekly mupirocin application on infections in continuous ambulatory peritoneal dialysis patients. Adv Perit Dial 2003;19(1):198.  Back to cited text no. 7
    
8.Yavascan O, Kara OD, Sozen G, Aksu N. Allergic dermatitis caused by povidone iodine: an uncommon complication of chronic peritoneal dialysis treatment. Adv Perit Dial 2005;21(1):131.  Back to cited text no. 8
    

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Correspondence Address:
Onder Yavascan
Department of Pediatric Nephrology, Izmir Tepecik Teaching and Research Hospital, Yenisehir, Izmir
Turkey
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Source of Support: None, Conflict of Interest: None


PMID: 21912021

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    Tables

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    Abstract
   Introduction
   Material and Method
   Results
   Discussion
    References
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