How to manage proud flesh on a Peritoneal Dialysis (PD) catheter exit site?

Management of Proud Flesh on PD Catheter Exit Site

For proud flesh (excessive granulation tissue) at a peritoneal dialysis catheter exit site, treatment with topical antimicrobial agents and appropriate dressing changes is recommended, with catheter removal reserved for cases with persistent infection or complications.

Diagnosis and Assessment

• Examine the exit site for signs of infection including erythema, drainage, tenderness, and granulation tissue (proud flesh) 1, 2
• If there is exudate at the exit site, obtain a swab for culture and Gram staining before starting antimicrobial therapy 1
• Blood cultures should be obtained if there are systemic signs of infection such as fever 1
• Evaluate for signs of tunnel infection (erythema, tenderness, or induration along the subcutaneous tunnel) which would indicate a more serious infection 1, 3

Initial Management of Proud Flesh

• Use sterile gauze rather than transparent dressings for exit sites with granulation tissue or drainage 1
• Apply topical antimicrobial agents based on exit site culture results 1:
  • For uncomplicated exit site infections without systemic signs, use topical antimicrobial agents 1
  • Mupirocin ointment for Staphylococcus aureus 1, 4
  • Antifungal ointment (ketoconazole or lotrimin) for Candida infections 1
• Consider polyhexanide solution for exit site care, which has been shown to reduce exit site infections compared to traditional povidone-iodine care 5
• Avoid submerging the catheter or exit site in water 1

Dressing Change Protocol

• Replace dressings when they become damp, loosened, or visibly soiled 1
• Use chlorhexidine solutions with alcohol for skin preparation during dressing changes 1
• Allow antiseptics to dry according to manufacturer's recommendations 1
• Both patient and healthcare provider should wear surgical masks during dressing changes to prevent contamination 1
• Monitor the exit site regularly for signs of worsening infection 1, 2

When to Escalate Treatment

• If the proud flesh/granulation tissue does not respond to topical treatment or if signs of infection worsen, administer systemic antibiotics based on culture results 1
• For persistent exit site infections despite topical and systemic antibiotics, consider catheter revision (repositioning the exit site while maintaining the deep portion of the catheter) 3
• Catheter removal is indicated in cases of 1, 6:
  • Tunnel infection or peritonitis that develops from the exit site infection
  • Infections with difficult-to-treat organisms like Mycobacterium abscessus
  • Persistent infection despite appropriate antimicrobial therapy

Prevention Strategies

• Regular application of mupirocin at the exit site can prevent Staphylococcus aureus infections, particularly in nasal carriers 1, 4
• Daily exit site care with appropriate antiseptic solutions reduces infection risk 5
• Proper exit site care technique and patient education are essential for preventing infections 1

Common Pitfalls and Caveats

• Do not mistake all erythema for infection; however, untreated erythema can progress to tunnel infection or peritonitis, particularly when caused by S. aureus 2
• Avoid using topical antibiotic creams indiscriminately as they may promote fungal infections and antimicrobial resistance 1
• Catheter revision rather than immediate removal may be successful in many cases of persistent exit site infection, preserving peritoneal dialysis as a treatment option 3
• Proud flesh/granulation tissue may appear alarming but often responds to appropriate local care; unnecessary catheter removal should be avoided 3, 2