Peritoneal dialysis, otherwise referred to as home-based dialysis, is one type of renal replacement therapy that is provided to patients suffering from end-stage renal disease. Peritoneal dialysis requires the patient to insert a specially designed silicon catheter via a subcutaneous tunnel into the peritoneal cavity. An exit site is a region that surrounds the catheter at the outlet segment. Lack of adequate care of the catheters has been significantly linked to exit site infections which if not managed can lead to peritonitis (Shetty, Nagaraj, Lorentz and Bitzan, 2005).
This occurs when organisms found at the exit site move from the skin down to the peritoneal cavity through the subcutaneous tunnel thereby resulting in peritonitis. Exit site infection is one of the major reasons for the removal of catheters from patients suffering from ESRD. Lockwood, Hodgkinson, and Page (2003) state that, “catheter-related peritonitis occurs in up to 20% of patients undergoing continuous ambulatory peritoneal dialysis (CAPD) and exit-site infection may be the cause of catheter removal for more than one-fifth of catheters removed,” (p. 167). However, exit site infections can easily be avoided using several cleaning techniques.
The current management technique of PD exit sites involves the immobilization of the catheter with a dry exit site to prevent the growth of micro-organisms (Tomlins, 2008). However, techniques such as cleaning the exit sites using povidone-iodine swabs have been recommended. This paper analyses a body of literature that supports the effective care of exit sites for peritoneal dialysis catheters.
Effect of education and training programs on exit site infections
Hall, Duffy, Lizak, Schwartz, Bogan, et al. (2004) carried out a study to examine the effect of PD patient training programs on exit site infections and the general patient outcomes. The study used a multi-center, longitudinal prospective quasi-experimental design that was carried out over two years. The patients were categorized into either the experimental group or the control group. In the experimental group, the program administered was an adult learning theory-based curriculum that consisted of PD technique training and diets.
On the other hand, the control group was trained through a non-standardized conventional program. In addition, the length of training was longer in the experimental group than in the control. Using statistical tests such as the Student’s t-test and a Chi-Squared test, the researchers found that the rates of exit-site infections and peritonitis were lower in the experimental group than in the control group (Hall, Duffy, Lizak, Schwartz, Bogan, et al., 2004, p.159-160).
The results imply that the type of training program used for PD patients influences the kind of knowledge that patients acquire concerning the overall care of their condition and the dialysis catheters. This study is almost similar to the one conducted by Dogan, Ekiz, Yucel, Ozturk, and Kazancioglu (2008) who found a negative correlation between education level and exit site infection rates of PD patients. One of the conclusions made was that an increase in the education level of the patients significantly reduces their risk of exit-site infections because they become more aware of effective methods of taking care of themselves and the catheters.
Determining factors of exit-site infections
Young, Contreras, Robert, Vogt, and Courtney (2005) studied the occurrence and determining factors of exit-site infections among patients who use dual and triple lumen dialysis catheters. This study was executed in 11 centers using a total of 711 PD patients. The researchers found that the rate of exit-site infections was 2.1% and was influenced by factors such as “the number of inter-treatment uses, total number of uses, and catheter placement duration,” (Young et al., 2005, p.45).
Most importantly, the researchers attribute the general lower incidence rate of exit-site infections (compared to other studies that found the rates of exit-site infections to range from 3-13%) to stringent measures taken by the patients in the care of the catheters, such as the use of sterile gloves when handling the catheters. The study by Young, Contreras, Robert, Vogt and Courtney (2005) is also similar to the study conducted by Harwood, Wilson, Thompson, Brown, and Young (2008) who also investigated the factors that cause exit site infections.
However, Harwood et al., (2008) found that the type of dressing and the cleansing solution used by patients is strongly related to the incidence of exit-site infections. Young et al., (2008) therefore recommend that suitable clinical evaluation and management of the catheter exit site should be done because it promotes microbial colonization which significantly contributes to exit-site infections and the potential for consequent bacteremia and sepsis (p. 26).
Use of cleaning techniques and solutions
Different cleaning techniques and solutions are used to clean catheters and subsequently to prevent exit-site infections. Examples of such cleaning agents include ExSept and Chlorhexidine. In their landmark study, Astle and Jensen (2005) examined which of the two mentioned cleaning agents is more effective in minimizing skin colonization and exit site infections. The scholars carried out a randomized clinical trial using 121 patients on dialysis catheters.
The study was carried out over three months or until patients developed infections. The scholars found that an equal number of patients developed exit site infections, bacterium, and skin colonization in each of the two groups (Astle and Jensen, 2005, p. 520-521). The conclusion made was that there is no difference between the efficacies of ExSept and Chlorhexidine and therefore either can be used to clean exit sites of catheters.
Effect of catheter placement process on exit site infections
The process used during the placement of the catheter plays a great factor in either minimizing or promoting the risks of exit-site infections and peritonitis. The study carried out by Bender, Bernardini, and Piraino (2006) investigates how the rates of exit-site infections can be reduced during the catheter insertion process. The authors argue that the body habitus of the patient should be considered when placing the catheter and determining the location of the exit site which can be achieved through preoperative stenciling. In addition, a puncture hole, rather than a scalpel, should be used to make the exit site produce a tight fit of the skin surrounding the catheter.
Like the study done by Astle and Jensen (2005), the study by Bender, Bernardini, and Piraino (2006) also suggests that antibiotics are an effective method of caring for the exit site by minimizing the rates of infection, particularly during the catheter insertion process. The sample used by Bender, Bernardini, and Piraino (2006) consisted of 600 PD patients studied over more than two decades. In addition, the authors recommend that a sterile dressing should be applied on the site after the operation and maintained for at least 7 days. Regular dressing changes should be done if the dressing becomes soaked or contaminated. The attending nurse doing the dressing should also wear gloves and use sterile cleansing agents to avoid contamination followed by an antibiotic liniment (Crabtree, 2006).
Peritoneal dialysis (PD) has been depicted as a readily accessible and uncomplicated strategy for careful filtration of surplus water, electrolytes, and metabolites. It has also been found to elevate enhanced well-being and greater individual autonomy than hemodialysis due to its associated less restricted lifestyle adjustments. It has also been asserted that PD ought to be provided to all suitable end-stage renal failure patients.
However, PD usually causes infections and peritonitis if the catheter is not well taken care of. Prevention of infection is regarded as fundamental for the effective maintenance of PD. Methods used to prevent or reduce the risk of infection are many and include rigorous exit-site care, catheter care, and thorough attention to the utilization of a clean touch method for dialysis exchanges. Exit-site care is essential to PD management. Research evidence suggests that exit-site infections can move through to the peritoneal cavity, thereby causing peritonitis or malfunction of PD therapy.
Evidence from the reviewed literature above shows that the education and training of patients significantly affect the rates of exit-site infections. Patients who have a higher education level and are adequately trained are more likely than their counterparts to suffer from exit-site infections and peritonitis. This is because such patients can discern the best methods of taking care of themselves as well as their gadgets. In addition, the evidence shows that caring for the exit sites can be done through antibiotics, sterile dressing, gloves, and cleaning agents. These measures significantly reduce the rate of exit-site infections and the potential for developing peritonitis.
Astle, C.M., & Jensen, L. (2005). A trial of ExSept for hemodialysis central venous catheters. Nephrology Nursing Journal, 32(4), 517-525.
Bender, F.H., Bernardini, J., & Piraino, B. (2006). Prevention of infectious complications in peritoneal dialysis: best-demonstrated practices. Kidney International, 70, S44-S54.
Crabtree, J.H. (2006). Selected best-demonstrated practices in peritoneal dialysis access. Kidney International, 70, S27-S37.
Dogan, S., Ekiz, S., Yucel, L., Ozturk, S., & Kazancioglu, R. (2008). Relation of the demographic, clinic, and biochemical parameters to peritonitis in peritoneal dialysis. Journal of Renal Care, 34(1), 5-8.
Hall, G., Duffy, A., Lizak, H., Schwartz, N., Bogan, A., Greene, S., Nabut, J., Dreis, S., Kelley, K., & Schinker, V. (2004). New directions in peritoneal dialysis: patient training. Nephrology Nursing Journal, 31(2), 149-163.
Harwood, L., Wilson, B., Thompson, B., Brown, E., & Young, D. (2008). Predictors of hemodialysis central venous catheter exit-site infections. The CANNT Journal, 18(2), 27-35.
Lockwood, C., Hodgkinson, B., & Page, T. (2003). Clinical effectiveness of different approaches to peritoneal dialysis catheter exit-site care. JBI Reports, 1(6), 167-201.
Shetty, A.K., Nagaraj, S.K., Lorentz, W.B., & Bitzan, M. (2005). Peritonitis due to neisseria mucosa in an adolescent receiving peritoneal dialysis. Infection, 33(5/6), 390-392.
Tomlins, M.J. (2008). Practice change in peritoneal dialysis exit site care. Renal Society of Australasia Journal, 4(1), 26-29.
Young, E., Contreras, G., Robert, N., Vogt, N., & Courtney, T. (2005). Incidence and influencing factors associated with exit site infections in temporary catheters for hemodialysis and apheresis. Nephrology Nursing Journal, 32(1), 41-50.