Effect of different exit-site care dressings on preventing peritoneal dialysis related infection from nontropical area: a systematic review and network meta-analysis

Abstract

Object

This study aims to conduct a systematic review and network meta-analysis to comprehensively evaluate the efficacy of various dressings in preventing exit-site infection (ESI) and peritonitis.

Methods

We searched PubMed, Embase, Web of Science, CINAHL Plus with Full Text (EBSCO), Sino Med, Wan Fang Data, China National Knowledge Infrastructure (CNKI) from 1 January 1999 to 10 July 2023. The language restrictions were Chinese and English. Randomized controlled trials, non-randomized controlled trials, and self-controlled trials were included in this study. We used ROB 2 tool to evaluate the quality of the included literature. Two authors independently extracted the data according to the Cochrane Handbook. A Frequentist network meta-analysis was performed using Stata17.0 according to PRISAMA with a random effects model.

Results

From 2092 potentially eligible studies, thirteen studies were selected for analysis, including nine randomized controlled studies, three quasi-experimental studies and one self-controlled trial. A total of 1229 patients were included to compare five types of exit site care dressings, named disinfection dressings, antibacterial dressings, non-antibacterial occlusive dressings, sterile gauze, and no-particular dressings. The outcome of prevention ESI is antibacterial dressings (SUCRA = 97.6) >non-antibacterial occlusive dressings (SUCRA = 68.3) >disinfection dressings (SUCRA = 50.6) >no-particular dressings (SUCRA = 23.9) >sterile gauze (SUCRA = 9.5). The antibacterial dressings were more effective than sterile gauze (OR = 0.13, 95%CI 0.04∼0.44), and no-particular dressing (OR = 0.18, 95%CI 0.07∼0.50) in preventing ESI; the non-antibacterial occlusive dressings were effective than sterile gauze (OR:0.30, 95%CI 0.16∼0.57). There is no statistical significance between no-particular dressings and other types of dressings in preventing the mature ESI. There is no statistical significance in the effectiveness of five types of dressings in preventing peritonitis.

Conclusions

The no-particular dressings maybe more cost-effective for preventing mature ESI. None of the dressings was more effective than another in preventing peritonitis. Then, none of the different types of dressing is strongly recommended for preventing ESI or peritonitis.

RegistrationCRD42022366756

1. Introduction

Chinese National Renal Data System reported that there were currently about 985000 dialysis patients at the end of 2022, including 140,500 individuals undergoing peritoneal dialysis (PD) [1]. Peritoneal dialysis-related infections, such as peritonitis, tunnel infection, and exit-site infection, are still common complications in PD patients. Exit-site infection (ESI) is characterized by the presence of purulent discharge with or without skin erythema at the catheter-epidermal interface [1]. ESI is closely linked to tunnel infection and peritonitis. If left untreated, ESI can lead to PD technical failure resulting in increased hospitalization and high mortality [2]. An estimated 20% of all peritonitis cases are preceded by an exit site or tunnel infection, especially the infection caused by S. aureus or P. aeruginosa [3]. Approximately 15% of ESIs lead to catheter loss, due to either refractory ESI or concomitant peritonitis [4]. The incidence of exit-site infection is closely related to preventive strategies, sanitary conditions, living habits, environment humidity, and population characteristics. The studies showed that the global exit-site infection rate ranges from 0.05 to 0.42/patient year [5]. Risk factors for ESIs included inadequate exit site care, history of catheter-pulling injury, swimming, frequent change of exit-site caregivers, and mechanical stress on the exit site [6]. Although guidelines strictly regulated the exit-site care procedure, there was no recommendation regarding the use of appropriate dressings to prevent ESI [7].

The types of dressings for exit site care include disinfection dressing, antibacterial dressing, antibiotic dressing, regular dressing, sterile gauze, or no particular dressings. The updated guideline for catheter related infection from International Society Peritoneal Dialysis (ISPD) suggested that a dressing covering the exit site was not mandatory after exit site care and topical antibiotic use (2D), and suggested daily topical application of antibiotic cream or ointment (mupirocin or gentamicin) to prevent catheter-related infection (1 C) [7]. Considering the concern of antibiotic resistance, daily topical application of antibiotics must be reevaluated. A Cochrane study [8] reported that the use of oral or topical antibiotic compared with placebo/no treatment, had uncertain effects on the risk of exit-site/tunnel infection (3 studies, 191 patients, RR = 0.45, 95%CI 0.19 ∼ 1.04) and the risk of peritonitis (5 studies, 395 patients, RR = 0.82, 95%CI 0.57 ∼ 1.19). A multicenter cross-sectional survey from China also indicated that the application of antibacterial agents did not have any relationship with lower ESI [6]. But there is no study to conclude and analysis the effect of different dressings without antibiotics in preventing ESI or peritonitis.

The selection of dressing should depend on the exit-site's characteristics, such as whether it's new or mature, infected or non-infected, draining or non-draining. Additionally, the choice of dressing may be influenced by a physician's expertise, the availability of the dressing at the moment, and the cost [9]. An ideal exit-site dressing should prevent exit-site infections (ESIs), reduce healthcare cost and have few adverse effects. After the systematic review of exit-site dressings in 2003 by JBI, numerous studies have been conducted over the past 20 years to explore the effects of different dressings in preventing ESI [10]. However, they only compared the effects between two type dressings, not multiple dressings. Therefore, this study aims to conduct a systematic review and network meta-analysis to comprehensively evaluate their efficacy of various dressings in preventing ESI and peritonitis.

2. Methods

The protocol has been registered with the registration number CRD42022366756 at PROSPERO. This study is reported according to the Network Meta-Analysis extension of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-NMA) reporting guidelines [11]. The PRISMA-NMA checklist is presented in Table S1 (Appendix 1).

2.1. Patient and public involvement

This meta-analysis included no patient or public involvement; hence, ethics approval and consent for participation were not required.

2.2. Literature search strategy

We searched PubMed, Embase, Web of science, CINAHL Plus with Full Text (EBSCO), Sino Med, Wan Fang Data, China National Knowledge Infrastructure (CNKI) from 1 January 1999 to 10 July 2023.The language restrictions were Chinese and English. The search terms used include four blocks of terms, including PD, dressing, ESI, peritonitis. The search strategy takes PubMed as an example (Appendix 3). We also supplemented the search by screening references from relevant systematic reviews and original studies.

2.3. Inclusion and exclusion criteria

The PICOS of the study design was shown in Table S2 (Appendix 2). Randomized controlled trials, non-randomized controlled trials, and self-controlled trials were included in this study. Because there was a systematic review about the effect of antibiotics use on PD related infection [8], the studies about antibiotic dressings are no longer included. The dressings for exit site care were divided into five categories, named sterile gauze, other non-antibacterial occlusive dressings (having no special antibacterial or disinfectant function, such as 3 M wound dressings, hydrocolloid dressings, Mepilex dressings, IV3000 dressings, etc.), antibacterial dressings (having antibacterial effects, such as JUC Physical Antimicrobial Spray Dressings, polyallylamine spray, propolis, and dextran-curcumin filament cellulose hydrogel dressings, etc.), disinfectant dressing (having disinfection effects, such as Povidone-iodine ointment with a blocking dressing and chlorhexidine with sterile gauze, etc.), and no particular dressings (only cleansing the catheter exit site daily with non-disinfectant soap, 0.9% saline and/or povidone-iodine, without any other particular dressings).

The outcomes include ESI and peritonitis. ESI can be defined by symptom description [12,13] or scoring system [2,14]. Peritonitis should be diagnosed when at least two of the following are present [15]: ①clinical features: abdominal pain and/or cloudy dialysis effluent; ②dialysis effluent white cell count > 100/µL (after a dwell time of at least 2 h), with > 50% polymorphonuclear leukocytes; ③positive dialysis effluent culture.

Studies that met any of the following criteria were excluded: the relevant data could not be extracted or converted from the original research (e.g. only showing a trend of change); the specific type of dressing used in the intervention was unclear; the study was reported in a language other than Chinese or English; the study was about topical antibiotics; the study was a repeat publication, review, or case report.

The screening and management of literature was performed using EndNote X8. Initially, two authors (FCY and LY) screened the titles and abstracts of the studies and then thoroughly read the full texts to determine their inclusion or exclusion based on the pre-determined criteria. If there were any discrepancies in the selection process, the corresponding author was consulted to resolve them.

2.4. Data extraction and quality evaluation

Two authors (FCY and JWY) independently extracted the data according to the Cochrane Handbook, including the following information: title, authors, publication year, study design, sample size, interventions and control measures (including dressings type, time, and frequency), outcome (the rate of ESI, peritonitis, and other complications) and other related results, such as cost, patients' experience, etc.

Three authors (FCY, JWY, and LY) evaluated the included literature independently according to the randomized controlled trial quality evaluation standards recommended in Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0. The RoB 2 tool provides a framework for assessing the risk of bias in a single result (an estimate of the effect of an experimental intervention compared with a comparator intervention on a particular outcome) from any type of randomized trial [16]. The evaluation indicators comprise seven items, including random sequence generation, allocation concealment, blinding patients and personnel, blinding of outcome assessors, incomplete outcome (i.e. withdrawals), selective outcome reporting, and other risks of bias. Each item was evaluated as 'low risk', 'high risk', or 'uncertain'. If there were any objections, it would be discussed or judged by the corresponding author.

2.5. Data synthesis and statistical analysis

This study used the frequency analysis method and random-effects model to conduct a network meta-analysis (NMA). Using pairwise and network meta-analysis, we estimated summary odds ratios (ORs) for dichotomous outcomes. Before performing the NMA, we evaluated the transitivity hypothesis. This assumption implies that studies comparing different interventions are similar enough to provide valid indirect inferences, and we try to ensure this by applying rigorous inclusion criteria. We did a statistical evaluation of consistency (i.e. the agreement between direct and indirect evidence) using the side-split approach and separating direct and indirect evidence. The loop-specific approach was applied to evaluate the loop consistency in the network structure. The surface under the cumulative ranking curve (SUCRA) value is the probability of each treatment being among the best of those in the network, with larger values representing higher ranking probabilities. The SUCRA value and cumulative ranking plots were used to calculate the ranking probabilities of each intervention. Heterogeneity in each pairwise comparison was assessed using inconsistency tests with the I² statistic (p value > 0.05 indicating consistency). The NMA was performed using Stata17.0. The adjusted funnel plot was created to qualitatively describe the risk of the small sample size effect.

3. Results

3.1. Charatceristic of the include studies

After searching various databases, we identified 2092 potentially eligible studies. However, after removing duplicates, only 935 studies remained (Table 1). We then read the titles and abstracts of these studies and identified 188 studies. Finally, after screening the full text of these 188 studies, we selected 13 studies for network analysis. Among these 13 studies, 6 were in Chinese [17–22] and 7 were in English [23–29]. The basic information of included studies are as Table 2.

Table 1.

PRISMA (preferred Reporting items for systematic reviews and meta-analyses) flow diagram of the selection process of the included studies.

Table 2.

Basic information of included studies.

References	Nation	Publication year	Study type	Study group	Control group	Follow-up time	Inclusion criteria	Study group intervention	Control group intervention	Outcomes
Mevlut Ceri [24]	Turkey	2020	RCT	41	47	555patients-months;	PD > 3months	Povidone–iodine##	0.1%spray polyhexanide	ESI rate※ Peritonitis rate△ Complications rate
						480patients-months
Zhang Fengjie [17]	China	2022	Quasi-experimental study	61	61	6months	PD > 6 months	IV3000 dressing	Sterile gauze	ESI rate#. Complications rate
Zheng Yuanying [18]	China	2017	RCT	30	30	6months	after catheterization	Hydrocolloid dressing	Sterile gauze	ESI rate*. intervals of dressing change
Huang Hongmin [19]	China	2013	RCT	30	30	12months	NI	Mepilex dressing	Sterile gauze	ESI rate&
Tang Aidang [20]	China	2009	Quasi-experimental study	34	32	12months	PD > 4 weeks Without infections	Hydrocolloid dressing	Sterile gauze	ESI rate&
Li Jing [21]	China	2015	Self-controlled trial	104	104	12months	Sterile gauze was used > 1year	3M dressing	Sterile gauze	ESI rate&
Wang Jialin [22]	China	2014	Quasi-experimental study	65	65	33months	NI	Mepilex dressing	Sterile gauze	ESI rate@Complications rate
Luzar [23]	Belgium	1989	RCT	74	53	1year	2 weeks after catheter implantation (85%)	povidone iodine (concentration:20g/L) with sterile gauze	cleansed the catheter exit site daily with nondisinfectant soap on sterile gauze.##	ESI rate@ Peritonitis rate△
M. Núñez-Moral [29]	Spanish	2014	RCT	30	30	12months	Catheteriaztion > 6weeks	polyhexanide solution	traditional care with 0.9% saline and povidone-iodine##	ESI rate※ Peritonitis△
Nancy M. Waite [25]	Canada	1997	RCT	61	56	14.6 weeks	NI	3.5 g of 10% povidone-iodine ointment	Sterile gauze	ESI rate@ Peritonitis rate△ S aureus Carrier rate
						13.2 weeks
Tam [26]	HongKong, China	2014	RCT	37	37	6months	Catheteriaztion > 3 months	JUCSpray dressing	0.05% Chlorhexidine dressing	ESI rate& Complications rate
Liu Haiyan [28]	China	2021	RCT	27	30	11months	5.74 ± 3.19 (years)	Dex-Cur@SF hydrocolloid dressing	Alginate aseptic wound dressing	ESI rate@ Peritonitis Rate△ Readmission rate Patient satisfaction
Lila Moghiseh [27]	Iran	2022	RCT	30	30	6months	PD > 3months	10% propolis ointment + sterile gauze	0.9% normal saline with sterile gauze	ESI rate$ Peritonitis△

Explains:

^#Schafer exit-site score(ESS) [2]: ≤1 is classified as good condition; 2 ∼ 3 is classified as suspicious infection. If there are purulent secretions, it can also diagnose infection; ≥4 points is defined as infection.

^&(1) Persistent redness and swelling greater than 13 mm, or elevated granulation tissue at the exit site; (2) there is purulent or bloody discharge at the exit site; (3) pain, tenderness at the exit site or tunnel; (4) the secretion was positive for bacterial culture. If any of the aforementioned items are found, it could be diagnosed as ESI [15].

^※An exit-site infection is defined by the presence of purulent drainage with or without erythema, edema, and tenderness, and the swabs obtained from the exit-site area were sent to a microbiology laboratory for evaluation [13].

*Twardowski score system [38]: exit site infection: The PD tube area had pain, redness, and swelling, with stiff skin and pus/blood drainage.

@ Clinical symptoms: Erythema, purulent exudation, bloody, or pain occur around the catheter.

△Peritonitis [7]: Peritonitis is defined as a cloudy fluid and/or abdominal pain associated with a white blood cell count ≥100/μL (with >50% neutrophils), and dialysate effluent was sent for microscopy and culture.

^$NI: no information.

^##Cleansed the catheter exit site daily with nondisinfectant soap on sterile gauze, traditional care with 0.9% saline and povidone-iodine, and only use povidone–iodine was defined no particular dressingss.

3.2. Quality assessment of included studies

The long-term exit-site caregiver are often patients themselves or their families, it is difficult to blind the participants. It is important to blind the exit-site evaluators for avoiding evaluation bias. Thus, we assessed the 'the evaluators were not blinded' in most studies as 'high risk'. The quality assessment results as Figure 1, there were 7 studies with high risk of bias [18–23,28], 3 studies with an unclear risk of bias [17,24,26] and 3 studies at low risk [25,27,29]. We assessed the risk of publication bias in included trials visually using a funnel plot (Figure S2, Appendix).

Figure 1.

Bias risk of the included studies.

3.3. Results of network meta-analysis

3.3.1. The effect of preventing exit-site infection

There were 13 studies [17–29] with 1229 participants of 5 types dressings included in this NMA study. Two studies are three-arm design [27,28], only relevant data to this study were included. The result of NMA was shown in Figure 2a. The heterogeneity was low (I²=30.0%, p = 0.145, Figure S1, Appendix). It is widely believed that heterogeneity is small when I²<50%. And the loop-specific heterogeneity diagram was shown in Figure S3. The results of side-split-approach on the direct comparison and indirect comparison were shown in Table 3.

Figure 2.

(a) Network meta-analysis of eligible comparisons for preventing ESI. (b) The surface under the cumulative ranking curve (SUCRA) ranking chart for preventing ESI. ABD: antibacterial dressings; NAOD: non-antibacterial occlusive dressings; DD: disinfection dressings; NPD: no particular dressings; SG: sterile gauze.

Table 3.

The comparisons between indirect and direct based on the side-split approach in preventing ESI.

Side	Direct Coef.	Std. Err.	Indirect Coef.	Std. Err.	Difference Coef.	Std. Err.	P>|z|
AB AD AE BC BD BE CD	−1.72 0.34 0.94 1.97 1.67 0.94 1.33	0.88 0.49 0.38 0.82 1.60 0.57 0.29	−0.98 2.20 −1.15 −0.16 2.09 3.05 −0.80	0.63 0.93 0.83 0.72 0.67 0.72 1.05	−0.73 −1.85 2.10 2.14 −0.42 −2.10 2.14	1.08 1.05 0.92 1.09 1.74 0.92 1.09	0.495 0.078 0.022 0.051 0.809 0.022 0.051

Explain: A: disinfection dressings; B: antibacterial dressings; C: non-antibacterial occlusive dressings; D: sterile gauze; E:no particular dressings.

To prevent ESI, the head-to-head comparison in Table 4 (the forest figure was shown in Figure S4, Appendix) demonstrated that antibacterial dressings were more effective than sterile gauze (OR:0.13, 95%CI 0.04 ∼ 0.44), and no-particular dressings (OR:0.18, 95%CI 0.07 ∼ 0.50); the non-antibacterial occlusive dressings were more effective than sterile gauze (OR:0.30, 95%CI 0.16 ∼ 0.57). Among various types of dressings, antibacterial dressings (SUCRA = 97.6) had the highest probability of being the optimal dressings to prevent the exit site infection. The SUCRA ranking results were shown in Figure 2b: antibacterial dressings (SUCRA = 97.6) > non-antibacterial occlusive dressings (SUCRA = 68.3) > disinfection dressings (SUCRA = 50.6)> no-particular dressings (SUCRA = 23.9) >sterile gauze (SUCRA = 9.5). The network forest figure was shown in Figure S4.

Table 4.

Head-to-head comparison of different dressings for the prevention of ESI.

DD 3.42(1.25,9.33) 1.49(0.50,4.44) 0.45(0.17,1.22) 0.62(0.24,1.65)

0.29(0.11,0.80) ABD 0.44(0.13,1.45) 0.13(0.04,0.44) 0.18(0.07,0.50)

0.67(0.23,2.00) 2.30(0.69,7.63) NAOD 0.30(0.16,0.57) 0.42(0.10,1.69)

2.21(0.82,5.97) 7.55(2.29,24.86) 3.29(1.77,6.13) SG 1.38(0.35,5.40)

1.60(0.61,4.23) 5.47(2.01,14.86) 2.38(0.59,9.58) 0.72(0.19,2.83) NPD

Explain: DD: disinfection dressings; ABD: antibacterial dressings; NAOD: non-antibacterial occlusive dressings; SG: sterile gauze; NPD: no particular dressings.

3.3.2. Sensitivity analysis

The sensitivity analysis using the method of moving monomial studies found that Liu's study [28] (antibacterial dressings vs non-antibacterial occlusive dressings) was the source of heterogeneity. Heterogeneity improved after this article was excluded (I²=28.9%, p = 0.162, Figure S6).

After comparing different types of dressings in sensitivity analysis (Figure S5, Appendix), the SUCRA results (Figure S9, Appendix) showed that non-antibacterial occlusive dressings had the highest score (SUCRA = 88.3), followed by antibacterial dressings (SUCRA = 82.9), disinfection dressings (SUCRA = 46.8), sterile gauze (SUCRA = 23.9), and no-particular dressings (SUCRA = 8.1).

3.3.3. The effect of preventing mature exit site infection

Mature exit site is defined as after the sinus epithelium has formed and completely healed, which usually 4-8 weeks after surgery [14]. Seven studies [17,21,24,26–29] involving 669 PD patients with mature exit site examined the use of dressings to prevent catheter related infections. The results were summarized in Figure 3a. As shown in Figure S10 (Appendix), the homogeneity test shows that I²=51.7%, p = 0.053. The NMA included only antibacterial dressings, sterile gauze, and non-antibacterial occlusive dressings in a closed loop to prevent ESI. The loop-specific heterogeneity showed tau²<0.001(Figure S11, Appendix). There was no heterogeneity between direct and indirect comparisons based on the side-split approach in sensitivity (p > 0.05).

Figure 3.

(a) Network meta-analysis of eligible comparisons for preventing ESI in patinets with mature exit site. (b) The surface under the cumulative ranking curve (SUCRA) ranking chart for preventing ESI in patinets with mature exit site. ABD: antibacterial dressings; NAOD: non-antibacterial occlusive dressings; DD: disinfection dressings; NPD: no particular dressings; SG: sterile gauze.

The head-to-head comparison in Table 5 demonstrated that antibacterial dressings were more effective than disinfection dressings (OR = 0.18, 95%CI 0.04 ∼ 0.89), non-antibacterial occlusive dressings (OR = 0.18, 95%CI 0.04 ∼ 0.77) and sterile gauze (OR = 0.07, 95%CI 0.01 ∼ 0.34). There was no statistically significant difference between the no particular dressings and other dressings in the prevention of mature ESI. As shown in Figure 3b, the results of SUCRA were antibacterial dressings (SUCRA = 98.1) > no-particular dressings (SUCRA = 64.5) >non-antibacterial occlusive dressings (SUCRA = 42.5)> disinfection dressings (SUCRA = 38.3) >sterile gauze (SUCRA = 6.6).

Table 5.

Head-to-head comparison of different dressings for the prevention of mature ESI.

DD 5.62(1.12,28.15) 1.02(0.12,8.86) 0.40(0.04,3.77) 2.18(0.31,15.48)

0.18(0.04,0.89) ABD 0.18(0.04,0.77) 0.07(0.01,0.34) 0.39(0.13,1.19)

0.98(0.11,8.55) 5.52(1.30,23.43) NAOD 0.39(0.17,0.90) 2.14(0.34,13.31)

2.52(0.27,24.02) 14.20(2.94,68.65) 2.57(1.12,5.93) SG 5.49(0.79,37.99)

0.46(0.06,3.27) 2.58(0.84,7.93) 0.47(0.08,2.91) 0.18(0.03,1.26) NPD

Explain: DD: disinfection dressings; ABD: antibacterial dressings; NAOD: non-antibacterial occlusive dressings; SG: sterile gauze; NPD: no particular dressings.

3.3.4. The effect of preventing peritonitis

A total of 509 individuals were included in six studies that reported peritonitis outcomes [23,24,27–29]. Disinfection dressings (n = 135), antibacterial dressings (n = 134), non-antibacterial occlusive dressings (n = 30), sterile gauze (n = 83), and no-particular dressings (n = 127) were compared. The result of NMA was shown in Figure 4a. The homogeneity test shows that I²=0, p = 0.785(Figure S13, Appendix). The NMA included only disinfection dressings, antibacterial dressings, sterile gauze, and no-particular dressings in a closed loop to prevent peritonitis (Figure S14, Appendix). The loop-specific heterogeneity showed tau²<0.001. There is no statistical significance in the effectiveness of disinfection dressings, antibacterial dressings, non-antibacterial occlusive dressings, sterile gauze, or no-particular dressings in preventing peritonitis (Table S5).

Figure 4.

(a) Network meta-analysis of eligible comparisons for preventing peritonitis. (b) The surface under the cumulative ranking curve (SUCRA) ranking chart for preventing peritonitis. ABD: antibacterial dressings; NAOD: non-antibacterial occlusive dressings; DD: disinfection dressings; NPD: no particular dressings; SG: sterile gauze.

As shown in Figure 4b, the results of SUCRA were antibacterial dressings (SUCRA = 62.6) >non-antibacterial occlusive dressings (SUCRA = 57.4) >disinfection dressings (SUCRA = 53.1) >sterile gauze (SUCRA = 48.1)> no-particular dressings (SUCRA = 28.7).

3.4. Descriptive analysis

3.4.1. The adverse effects of different types of dressings

Among the 13 studies included, only five reported adverse reactions to dressings [17,22,24–26]. Two of them found that non-antibacterial occlusive dressings had lower rates of adverse reactions compared to sterile gauze [17,22]. Zhang Fengjie et al. [17] reported fewer cases of pruritus (0 vs 2 cases), erythema (0 vs 2 cases), and blisters (1 vs 4 cases) at the exit site using non-antibacterial occlusive dressings compared with sterile gauze. Wang Jialin et al. [22] reported nearly the same results, there were fewer cases of erythema (3 vs 6), pain (0 vs 7), dampness (3 vs 18), and burning sensation (6 vs 26) in the exit site using non-antibacterial occlusive dressings compared with sterile gauze.

Three literatures reported the adverse effects of antibacterial and disinfection dressings [24–26]. Only in the study of Mevlut Ceri et al. [24], a randomized controlled trial of 93 people, reported 2 cases of skin allergy caused by polyhexanide solution (a kind of antibacterial solution).

3.4.2. The cost of different types of dressings in preventing ESI

Tam et al. [26] reported that antibacterial spray dressings (JUC spray dressings) were cheaper (0.5 vs. 3 HK$) than disinfection dressings (0.05% chlorhexidine). Some studies stated that non-antibacterial occlusive dressings had 2 to 4 times longer dressing change interval than sterile gauze, which could help balance the higher cost of non-antibacterial occlusive dressings to some extent. Zheng Yuanying et al. [18] reported all 30 patients in the sterile gauze group changed the dressing within 72 h, while only 8 patients in the hydrocolloid dressing group changed the dressing within 72 h. Hongmin et al. [19] stated that sterile gauze would be changed 2-3 times a week if keeping dry, while non-antibacterial occlusive dressings, such as Mepilex, should be changed once every 5 to 7 days if the exudate makes less than 1/2 of the dressings contamination.

4. Discussion

This is the first systematic review and network-meta-analysis to comprehensively analysis the efficacy dressings for preventing ESI in peritoneal dialysis patients. In this NMA, we included 13 studies with 1229 participants. We compared the effectiveness of disinfection dressings, antibacterial dressings, non-antibacterial occlusive dressings, sterile gauze, and no-particular dressings in preventing exit site infection and peritonitis in PD patients. Compared with sterile gauze, the effect of most dressings in preventing exit site infection was statistically significant. Our NMA found that antibacterial dressings ranked first in preventing exit site infection compared with other interventions. No-particular dressings may be a best choice for preventing mature ESI. However, in terms of the effects for preventing peritonitis, there was no statistical significance among all five types of dressings.

4.1. Antibacterial dressings may be a better choice for preventing ESI

This study found that antibacterial dressings have obvious advantages in the prevention of ESI. Antibacterial dressings include JUC Physical Antimicrobial Spray Dressings, polyallylamine spray, propolis, and dextran-curcumin filament cellulose hydrogel dressings, etc. Antibacterial dressings generally have the same anti-staphylococcus aureus, anaerobic bacteria and other effects as antibiotics. They have a high decontamination effect, and can counter the problem of drug resistance. Some studies have found that antibacterial honey can better inhibit Staphylococcus aureus [30,31], the HONEYPOT study found that with standard catheter exit care, the incidence of catheter-related infections was similar between patients randomly receiving daily local antibacterial honey treatment and patients receiving mupirocin nasal ointment treatment [32]. In addition, natural Chinese herbs with antibacterial effects have also brought us new sight, such as curcumin. But in the current study, it is combined with dextran, the effect of preventing ESI alone still needs further studies [28]. The cost of antibacterial dressing may be cheaper than other dressings for preventing ESI as well. There is one research reported that the using polyhexanide is less expensive than performing the traditional approach with povidone-iodine [29], and one research reported that JUC physical antimicrobial dressing are cheaper than chlorhexidine dressing [26]. Although antibacterial dressings have lots of advantages, attention should be paid to adverse reaction.

Disinfectant dressings include povidone-iodine ointment with a blocking dressing and chlorhexidine with sterile gauze, etc. Although current studies have shown that disinfection dressings can reduce the infection of Staphylococcus aureus [25,29] to prevent ESI and peritonitis, the choice of disinfection dressings should be careful due to more adverse reactions. According to a study conducted by Htay et al. [33], 12% of patients developed contact dermatitis after using chlorhexidine-impregnated sponge dressing for a year. This may have been related to a longer duration of exposure to chlorhexidine gluconate in PD patients. It should be noticed that povidone-iodine ointment cannot be used in patients who are allergic to iodine. It is also recommended to monitor the thyroid function of patients who use it for a long time [23].

4.2. No-particular dressings may be a better choice for preventing mature ESI

Although the SUCRA suggested that antibacterial dressings are better than others in preventing mature ESI, we noticed that there is no statistical significance between no-particular dressings and other dressings. Some RCTs showed that patients who used a routine cleaning procedure with a dressing over the exit site had no significant difference in the number of infections compared to those using the same procedure but who left the exit site open [34]. This is the same as the results of this study. And a pilot study found that the absence of P. aeruginosa ESI and no increased risk of developing S. aureus ESI in the non-dressing group as compared to the dressing group [35]. This may be interpreted as a covered dressing does not provide an inhibitory effect on micro-organism growth but, conversely, provides a milieu for accelerated bacterial growth [35].

Considering the costs of dressings, to choose no-particular dressing may become the choice for more peritoneal dialysis patients in the future. This conclusion goes in the same direction as the guidelines [7].

4.3. The choice of dressings should consider the clinical situation

Because sterile gauze costs less and are more versatile, they still dominate the medical market [36]. Even though the frequency of dressing change is higher, and the effect of preventing ESI is not as good as other dressings, the sterile gauze is more cost-effective for early more exudative exit site which require frequently dressing change. A cohort study claimed that suggests that a nurse should change the initial dressing after the first week following catheter insertion, independently of dressing type used [37]. The ideal dressings for new exit-site are uncertain. New exit sites can be categorized into four types [38]: fast-healing exits; slow-healing exits without infection; healing interrupted by infection initially looked identical to the fast-healing exit, but within 6 weeks the epidermis did not progress or regress; slow-healing exits due to early infection, granulation tissue became soft or fleshy and/or drainage became purulent by 2-3 weeks. Therefore, the selection of new exit-site dressing should according to the different clinical situations.

The longer the interval between dressing changes at the exit-site, the lower the rate of bacterial culture [39]. The literature included in this study showed that the dressing change interval for non-antibacterial occlusive dressings is 2-4 times longer than that of sterile gauze [18,19]. Considering non-antibacterial occlusive dressings often cost more than sterile gauze, they may be better for less exudative exit-site in non-humid area. It is important to note that non-antibacterial occlusive dressings can cause adverse reactions such as allergies due to different materials [40]. More research is required to determine the most appropriate dressing or whether no-particular dressing should be used for different stages of the exit site.

4.4. No one dressing has been found to be superior in preventing peritonitis

This study found there is no one dressing was superior in preventing peritonitis. A study reported that polyhexanide group and the mupirocin had the same incidence in peritonitis [41]. This study is similar to the previous results, perhaps due to the less incidence of peritonitis in the included literature or the short follow-up time, the statistical results of the five dressings in this study did not have statistical significance. Additionally, microbial biofilm is universal in PD catheters with the subclinical menace of Staphylococci and P. aeruginosa [42], which is also a risk factor for peritonitis while dressings may not affect them. Although microorganisms may access the peritoneum through the catheter exit-site and tunnel, the association between peritonitis and catheter ESI was described in just less than 13% of all peritonitis episodes [43]. It is not clear to claim the relationship between ESI and peritonitis, more rigorous randomized controlled studies with larger samples are needed to explore the effect of exit site care for preventing peritonitis.

5. Limitations

It's important to note that the study has some limitations. Firstly, due to the limited number of original studies, we cannot accurate to conclude that one dressing is superior than the other, such as hydrocolloid dressings and 3 M wound dressings. Additionally, dressings produced by different manufacturers may have slightly different compositions, which was not considered. Secondly, other factors such as dialysis duration and history of infection at the exit site were not analyzed, which could have contributed to the heterogeneity between studies. Thirdly, the ESI definition was various in different studies, thus the information bias may exist. Fourth, categorization of early exit site and mature exit site was not completed due to less information provided in some included literature to provide recommendations for the selection of dressings for early exit site care. Fifth, the literature included in this study spanned a wide range of publication time, and the quality of the literature included studies was relatively low. Sixth, we defined dressings with disinfectant as disinfection dressings, it is unclear if the overall reduction of exit-site infection was due to dressing or disinfectant or their synergism. Seventh, the language of the selected studies was only restricted to Chinese and English, which is a potential bias. Most of the studies included in this meta-analysis were originated from China (8/13) and the rest is coming from non-tropical area. Therefore, the results of this study may not be applicable to humid tropical countries. Furthermore, the selected studies included quasi-experimental studies and before-after studies in addition to randomized controlled studies, which may be the source of the heterogeneity of this paper. Therefore, further high-quality randomized controlled trials are needed to support and supplement these conclusions.

6. Conclusion

Overall, antibacterial dressings may be superior in preventing exit-site infection compared with disinfection dressings, non-antibacterial occlusive dressings, sterile gauze, and no-particular dressings. This may be due to its not only provides a wet environment conducive to wound growth and reduces the number of dressing changes, but also has antibacterial effect. However, no one dressing has been found to be superior in preventing peritonitis. Therefore, the patient's individual circumstances, the stage of the exit site, the adverse reactions of the dressing, and the cost should be considered when select an appropriate dressing for PD patients' exit site care. No one dressing is strongly recommended for preventing exit site infection or peritonitis. More rigorous scientific studies are still needed to explore the effect of using different dressings to prevent exit site infection and peritonitis, in order to provide more evidence-based choices for exit site care in PD patients.

Funding Statement

This study was supported by Peking University Evidence-Based Nursing Research Fund (XZJJ-2022-09).

Authors' contributions

F CY and LY contributed to the conception and design of the study, literature search, data extraction, risk of bias assessment, data analysis, and drafting of the manuscript. J WY made significant contributions to the conception and design of the literature search and risk of bias assessment. L MY contributed to drafting of the manuscript. S CY, as the corresponding author, made substantial contributions to the conception and design, literature search and critically important intellectual content revisions of the manuscript. All authors have read and approved the final version of the manuscript and agree with the order of the authors' presentation.

Disclosure statement

The authors declared no conflicts of interest in any part of the study.