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failure in the technique and even death&#46; Factors that can predict a poor response to treatment are&#58; prior antibiotic treatment&#44; use of just one antibiotic and use of an aminoglycoside versus a third or fourth generation cephalosporin&#46; Beta-lactamase producing germs also have&#44; in general&#44; a poorer prognosis&#46;<span class="elsevierStyleSup">1&#44;2</span></p><p class="elsevierStylePara">It has been proven that local application of mupirocin in the exit site prevents infections caused by S&#46; <span class="elsevierStyleItalic">aureus</span>&#44; but does not reduce <span class="elsevierStyleItalic">Pseudomonas aeruginosa </span>infection nor infection with other gram-negative germs that&#44; on the other hand&#44; are associated with considerable morbidity and mortality&#46; Several studies have reached the conclusion that local daily application of gentamicin on the exit site of the peritoneal catheter reduces infections of <span class="elsevierStyleItalic">P&#46;</span><span class="elsevierStyleItalic">aeruginosa</span> and other gram-negative bacteria in the catheter and reduces peritonitis by 35&#37;&#44; especially those caused by gram-negatives&#46;<span class="elsevierStyleSup">3&#44;4</span></p><p class="elsevierStylePara">An important increase in the percentage of gram-negative peritonitis was observed in our centre&#44; reaching up to 40&#46;62&#37; in 2008&#59; 38&#37; of these cases presented the same bacteria in the peritoneal fluid and exit site&#46; Given the progressive increase in this type of infections and the data that suggests that some episodes of gram-negative peritonitis could come from hidden peritoneal catheter infection&#44; it was decided in January 2009 to change the healing protocol for exit sites&#44; which was previously performed with saline solution&#44; by applying topical gentamicin once a day&#46;</p><p class="elsevierStylePara">Before the change in protocol&#44; pus or fluid was exuded from the catheter exit site in all the patients to evaluate its colonisation&#44; without presenting any acute infection&#46; After 4-5 months of healing with topical gentamicin&#44; the exit site exudation was repeated&#44; observing a decrease in the percentage of gram-negative germs&#44; from 14&#37; to 3&#37; &#40;table 1&#41;&#46;</p><p class="elsevierStylePara">Of the 49 initial patients&#44; 41 were monitored&#59; the rest were excluded due to transfer to haemodialysis&#44; transplant or death&#46;</p><p class="elsevierStylePara">No differences were observed in the percentage of negative cultures after the initial treatment with gentamicin &#40;5 pre-treatment and 6 post-treatment cases&#41;&#46;</p><p class="elsevierStylePara">Of the 41 patients monitored&#44; 9 cases presented exit site infection&#59; the bacteria responsible were&#58; <span class="elsevierStyleItalic">E&#46; coli</span> in 2 cases and 7 cases of gram-positive bacteria&#46; In our sample&#44; no cases of yeast infection in the exit site were reported nor were there any other side effects to the use of topical gentamicin&#46;</p><p class="elsevierStylePara">The percentage of peritonitis caused by gram-negative bacteria in our centre decreased from 40&#46;65&#37; 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Importance of exit site care as peritonitis prophylaxis: experience in our centre
Importancia del cuidado del orificio de salida como profilaxis de peritonitis: experiencia en nuestro centro
O.. Conde Riveraa, J.. Santos Noresa, M.. Borrajo Prola, C.. Pérez Melóna
a Servicio de Nefrología, Complejo Hospitalario de Ourense, Orense,
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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor&#44; </span></p><p class="elsevierStylePara">Over time&#44; peritonitis has been the main complication of peritoneal dialysis&#46; The episodes produced by coagulase-negative staphylococci have decreased since the start of the technique in relation to the improvements made in connection systems and the preoperative and postoperative catheter care&#46;</p><p class="elsevierStylePara">Advances in connection systems over the last decades&#44; as well as prophylaxis for S&#46; <span class="elsevierStyleItalic">aureus</span>&#44; have allowed an important reduction in the incidence of peritonitis caused by gram-positive bacteria&#46; However&#44; the incidence of gram-negative peritonitis has barely changed&#44; which makes these proportionally more important&#46; Meanwhile&#44; gram-negative peritonitis is generally more severe and associated with a worse prognosis&#44; including loss of catheter&#44; failure in the technique and even death&#46; Factors that can predict a poor response to treatment are&#58; prior antibiotic treatment&#44; use of just one antibiotic and use of an aminoglycoside versus a third or fourth generation cephalosporin&#46; Beta-lactamase producing germs also have&#44; in general&#44; a poorer prognosis&#46;<span class="elsevierStyleSup">1&#44;2</span></p><p class="elsevierStylePara">It has been proven that local application of mupirocin in the exit site prevents infections caused by S&#46; <span class="elsevierStyleItalic">aureus</span>&#44; but does not reduce <span class="elsevierStyleItalic">Pseudomonas aeruginosa </span>infection nor infection with other gram-negative germs that&#44; on the other hand&#44; are associated with considerable morbidity and mortality&#46; Several studies have reached the conclusion that local daily application of gentamicin on the exit site of the peritoneal catheter reduces infections of <span class="elsevierStyleItalic">P&#46;</span><span class="elsevierStyleItalic">aeruginosa</span> and other gram-negative bacteria in the catheter and reduces peritonitis by 35&#37;&#44; especially those caused by gram-negatives&#46;<span class="elsevierStyleSup">3&#44;4</span></p><p class="elsevierStylePara">An important increase in the percentage of gram-negative peritonitis was observed in our centre&#44; reaching up to 40&#46;62&#37; in 2008&#59; 38&#37; of these cases presented the same bacteria in the peritoneal fluid and exit site&#46; Given the progressive increase in this type of infections and the data that suggests that some episodes of gram-negative peritonitis could come from hidden peritoneal catheter infection&#44; it was decided in January 2009 to change the healing protocol for exit sites&#44; which was previously performed with saline solution&#44; by applying topical gentamicin once a day&#46;</p><p class="elsevierStylePara">Before the change in protocol&#44; pus or fluid was exuded from the catheter exit site in all the patients to evaluate its colonisation&#44; without presenting any acute infection&#46; After 4-5 months of healing with topical gentamicin&#44; the exit site exudation was repeated&#44; observing a decrease in the percentage of gram-negative germs&#44; from 14&#37; to 3&#37; &#40;table 1&#41;&#46;</p><p class="elsevierStylePara">Of the 49 initial patients&#44; 41 were monitored&#59; the rest were excluded due to transfer to haemodialysis&#44; transplant or death&#46;</p><p class="elsevierStylePara">No differences were observed in the percentage of negative cultures after the initial treatment with gentamicin &#40;5 pre-treatment and 6 post-treatment cases&#41;&#46;</p><p class="elsevierStylePara">Of the 41 patients monitored&#44; 9 cases presented exit site infection&#59; the bacteria responsible were&#58; <span class="elsevierStyleItalic">E&#46; coli</span> in 2 cases and 7 cases of gram-positive bacteria&#46; In our sample&#44; no cases of yeast infection in the exit site were reported nor were there any other side effects to the use of topical gentamicin&#46;</p><p class="elsevierStylePara">The percentage of peritonitis caused by gram-negative bacteria in our centre decreased from 40&#46;65&#37; in 2008 to 21&#46;6&#37; in 2009&#46; Only one case in our sample presented the same bacteria in the exit site and in the peritoneal fluid&#44; this patient was also careless in the healing process as well as in administering the topical antibiotic&#44; admitting that they administered it irregularly&#46;</p><p class="elsevierStylePara">In a high percentage of cases of peritonitis caused by gram-negative bacteria&#44; the catheter had to be removed &#40;above all if the bacteria produced beta-lactamases&#41;&#46; In our centre&#44; removal percentage was 80&#37; in 2007&#46; Return to peritoneal dialysis&#44; in these cases&#44; tends to be difficult&#44; either because of the formation of multiple adherences or because of peritoneal membrane injury&#46;<span class="elsevierStyleSup">5</span>&#160;The gentamicin probably does not influence the incidence of gram-negative peritonitis where the source of infection is intestine contamination&#44; but it does affect the relationship with pericatheter contamination&#46;</p><p class="elsevierStylePara">Furthermore&#44; topical gentamicin is associated with few side effects&#46; The most significant are <span class="elsevierStyleItalic">Candida</span> infections&#44; that are generally resolved with an oral antifungal treatment with no major consequences&#46;<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara"><a href="grande&#47;10480&#95;108&#95;9214&#95;en&#95;10480&#95;t1&#46;jpg" class="elsevierStyleCrossRefs"><img src="10480_108_9214_en_10480_t1.jpg" alt="Exit site colonisation"></img></a></p><p class="elsevierStylePara">Table &#46; Exit site colonisation</p>"
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ISSN: 20132514
Original language: English
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