Editor:
Infections of the Tenckhoff catheter exit site and tunnel require antibiotic therapy to treat the infection and to prevent progression to peritonitis (1,2). In general, 2 - 3 weeks of an oral antibiotic eradicates the infection (1). We describe 2 cases of persistent infection (1 of the exit site and 1 of the tunnel) involving an exposed PD catheter outer cuff.
CASE DESCRIPTIONS
Case 1 involved a 50-year-old African American man with an abdominal PD catheter. He had 2 episodes of tunnel infection 2 months apart that grew Pseudomonas aeruginosa. Case 2 involved a 70-year-old African American woman with a presternal PD catheter. She initially grew methicillin-resistant Staphylococcus aureus (MRSA) and P. aeruginosa. One month later she grew MRSA and Achromobacter xylosoxidans.
Both patients were treated with oral ciprofloxacin 500 mg for 14 days with resolution of the initial infection. However, the infection recurred within a short period, with an exposed PD catheter outer cuff. For the surgeon to shave the exposed cuff, the infection had to be cleared. As a supplement to oral antibiotics, 2 drops of ofloxacin otic solution 0.3% was instilled twice daily into the lumen containing the PD catheter to treat the second episode of infection.
Both patients were fortunate in that they did not develop peritonitis as a result of their PD exit-site or tunnel infection, and they were able to retain the Tenckhoff catheter. No further PD exit-site or tunnel infections with the same organism were observed in either patient after treatment with ofloxacin otic solution, oral antibiotics, and cuff-shaving.
DISCUSSION AND CONCLUSIONS
Despite exit-site care, PD patients experience exit-site and tunnel infections (3-5). The standard of care for PD exit-site and tunnel infections is administration of oral antibiotics for 2 - 3 weeks (1).
Our novel approach using ofloxacin otic solution 0.3% reached the PD exit-site or catheter tunnel and provided therapeutic antibiotic concentrations at the site of infection (6). Ofloxacin otic solution is a sterile aqueous solution normally used to treat otitis externa caused by Escherichia coli, P. aeruginosa, and S. aureus (7).
We propose that ofloxacin otic solution be used as adjuvant antibiotic therapy for severe PD exit-site and tunnel infections with P. aeruginosa, MRSA, Klebsiella pneumoniae, or A. xylosoxidans.
Prompt treatment of PD exit-site and tunnel infections prevents progression to peritonitis. A lower peritonitis rate allows patients to continue treatment with PD.
In summary, ofloxacin otic solution 0.3% may be used as adjuvant antibiotic therapy for PD exit-site and tunnel infections.
DISCLOSURES
SQL consults for Gambro Renal Products, and is a site principal investigator in pharmaceutical research for Reata Pharmaceuticals, Questcor Pharmaceuticals, and Amgen. AG has no financial conflicts of interest to declare.
References
- 1. Li PK, Szeto CC, Piraino B, Bernardini J, Figueiredo AE, Gupta A, et al. Peritoneal dialysis-related infections recommendations: 2010 update. Perit Dial Int 2010; 30:393–423 [Erratum in: Perit Dial Int 2011; 31:512] [DOI] [PubMed] [Google Scholar]
- 2. Gupta B, Bernardini J, Piraino B. Peritonitis associated with exit site and tunnel infections. Am J Kidney Dis 1996; 28:415–19 [DOI] [PubMed] [Google Scholar]
- 3. Chua AN, Goldstein SL, Bell D, Brewer ED. Topical mupirocin/sodium hypochlorite reduces peritonitis and exit-site infection rates in children. Clin J Am Soc Nephrol 2009; 4:1939–43 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Wadhwa NK, Reddy GH. Exit-site care in peritoneal dialysis. Contrib Nephrol 2007; 154:117–24 [DOI] [PubMed] [Google Scholar]
- 5. Chu KH, Choy WY, Cheung CC, Fung KS, Tang HL, Lee W, et al. A prospective study of the efficacy of local application of gentamicin versus mupirocin in the prevention of peritoneal dialysis catheter-related infections. Perit Dial Int 2008; 28:505–8 [PubMed] [Google Scholar]
- 6. Ohyama M, Furuta S, Ueno K, Katsuda K, Nobori T, Kiyota R, et al. Ofloxacin otic solution in patients with otitis media: an analysis of drug concentrations. Arch Otolaryngol Head Neck Surg 1999; 125:337–40 [DOI] [PubMed] [Google Scholar]
- 7. Agro AS, Garner ET, Wright JW, 3rd, Caballeros de Escobar I, Villeda B, Seidlin M. Clinical trial of ototopical ofloxacin for treatment of chronic suppurative otitis media. Clin Ther 1998; 20:744–59 [DOI] [PubMed] [Google Scholar]