Treatment of Exit Site Infections in CAPD
Start empiric antibiotics targeting Gram-positive organisms (particularly staphylococci) immediately after obtaining exit site cultures, treat for 7-14 days, and reserve catheter removal only for treatment failure, tunnel infection, or peritonitis development. 1
Initial Assessment and Culture Collection
Before initiating any antibiotic therapy, obtain cultures from the exit site drainage to guide definitive treatment and prevent antibiotic resistance. 1
- Swab any visible exudate at the exit site for both culture and Gram staining 1
- Collect blood cultures only if systemic infection signs are present (fever, chills, hemodynamic instability) 1
- Consider ultrasound evaluation if clinical response is uncertain or to assess for tunnel involvement—a sonolucent zone >1 mm around the external cuff after antibiotic treatment predicts poor clinical outcome 2
Empiric Antibiotic Therapy
Empiric coverage must focus on Gram-positive organisms, especially staphylococci, as these are the most common pathogens. 1
- Start empiric antibiotics immediately after culture collection 1
- Oral ciprofloxacin (500 mg twice daily) can successfully treat the majority (83%) of Pseudomonas exit site infections when combined with local care 3
- Modify antibiotics once culture and sensitivity results return to targeted therapy 1
Treatment Duration
Standard treatment is 7-14 days for uncomplicated exit site infections. 1 Continue therapy for 2 days after signs and symptoms resolve, though complicated infections may require longer courses. 4
Catheter Management Strategy
The catheter does NOT require removal for exit site infections alone in most cases. 1 Management depends on the causative organism and treatment response:
Indications for Catheter Removal:
- Failure to respond to appropriate antibiotics after adequate treatment duration 1
- Development of tunnel infection or peritonitis 1
- Pseudomonas aeruginosa infections have uniformly poor outcomes regardless of sonographic findings, with 28% requiring catheter removal 5, 2
- Mycobacterial infections require catheter removal in up to 40% of cases 5
- Staphylococcus aureus infections require removal in approximately 35% of cases 5
Salvage Procedures Before Removal:
If tunnel infection develops with antibiotic-resistant S. aureus, consider deroofing and outer cuff shaving—this resolves infection in approximately 48% of cases without catheter removal. 6 If this fails, proceed to catheter exchange with a new subcutaneous tunnel to preserve the access site. 1
Organism-Specific Considerations
Pseudomonas aeruginosa: Despite oral ciprofloxacin success in 83% of cases, approximately 17% require catheter removal and 22% develop peritonitis months after apparent resolution. 3 Long-term gentamicin use may lead to 14% resistance rates. 5
Staphylococcus aureus: Associated with up to 50% of peritonitis cases when ESI is present. 5 Approximately 20% of all peritonitis episodes are preceded by exit site infections. 5
Critical Pitfalls to Avoid
- Never delay culture collection before starting antibiotics—this compromises your ability to tailor therapy and contributes to resistance 1
- Do not continue ineffective therapy indefinitely—if no improvement occurs after an appropriate antibiotic course, proceed to catheter removal or salvage procedures 1
- Recognize that approximately 25% of Gram-positive organisms may be mupirocin-resistant with long-term prophylactic use 5