Adherence to guideline recommendations for infection prophylaxis in peritoneal dialysis patients

Sir,

As compared to the patients on haemodialysis, those on peritoneal dialysis (PD) are at increased risk of dying from infections [1]. Catheter-related infections in PD increase the risk of subsequent peritonitis, catheter removal, technique failures and infectious deaths. Based on level II evidence from one randomized controlled trial, the Caring for Australasians with Renal Insufficiency (CARI) Guidelines recommend intranasal mupirocin prophylaxis for PD patients with nasal Staphylococcus aureus carriage to reduce the risk of PD-associated infections [2,3]. However, it is not known how well these guidelines have been implemented into clinical practice.

The Australasian Kidney Trials Network is currently conducting a trial of exit-site application of antibacterial honey (Medihoney™) for the prevention of catheter-associated infections in PD (the HONEYPOT study) [4]. A prospective survey of exit-site care in PD units interested in participating in the HONEYPOT study was performed to facilitate the study design and methodology.

Thirty of 61 (49.2%) PD units providing care to 65.7% of all PD patients in Australia and New Zealand responded to the survey questionnaire. Thirteen units were of moderate size (20–50 patients), and 9 were larger units with >100 patients. Fourteen (47%) units had no fixed policy for using prophylaxis against ESI. Thirteen (43%) units routinely screened PD patients to identify nasal carriers of S. aureus (Table 1). Only three (10%) units routinely prescribed prophylaxis to all patients. Twelve (40%) and 5 (17%) units prescribed nasal and topical exit-site mupirocin, respectively (Table 2). Four units prescribed either nasal or topical mupirocin and 1 unit prescribed nasal chloramphenicol. Ten (33%) units recommended daily exit-site cleaning with 2% chlorhexidine. Only 13 (43%) units followed the standard practice of using a premoistened nasal swab incubating it in enrichment nutrient broth for 24 h before plating onto solid media [5].

Table 1.

Prophylaxis against exit-site infections

	Number of centres (%)
Routinely prescribe	3 (10)
prophylaxis to all patients
All patients are screened to	13 (43%)
identify nasal carriers of S.
aureus
No fixed policy	14 (47%)

Table 2.

Choice of prophylaxis

Prophylaxis	Number of centres (%)
Nasal mupirocin	12 (40%)
Topical (exit-site) mupirocin	5 (17%)
Nasal or topical mupirocin	4 (13%)
No fixed policy	7 (24%)
Others	1 (3%)
No response	1 (3%)

The results of this survey highlight poor adherence to the national guidelines (CARI) and the absence of a uniform, standard practice of exit-site care. Failure to follow appropriate procedures for screening S. aureus carriage may result in poor detection rates. Very few centres routinely prescribed prophylaxis to all patients, probably due to concern about mupirocin resistance. Although we did not explore the causes of poor adherence to the guidelines, the absence of level I evidence could be a major reason. The other major limitations of this survey are poor response rates, and possibility of a recall bias. The survey was not designed to perform a formal clinical audit.

Further attention to enhancing continuous quality improvement in PD via developing effective strategies for implementation of best-practice nephrology guidelines and conducting regular practice audits is recommended.

Conflict of interest statement. D.W.J. has received consultancy fees, research grants and speakers’ honoraria from Baxter Healthcare; and speakers’ honoraria and research grants from Fresenius.