Management of Exit Site Infections
For uncomplicated exit site infections without systemic signs, start with topical antimicrobial therapy based on culture results—mupirocin for S. aureus or antifungal ointment for Candida—and escalate to systemic antibiotics only if topical therapy fails after 48-72 hours. 1, 2
Immediate Diagnostic Steps
Obtain cultures before initiating any treatment:
- Swab any drainage from the exit site for culture and Gram stain 1, 3
- Draw blood cultures from a peripheral vein if fever, chills, hemodynamic instability, or other systemic signs are present 1, 3
- Do not delay culture collection, as this compromises your ability to tailor definitive therapy 3
Treatment Algorithm Based on Clinical Presentation
Uncomplicated Exit Site Infection (No Systemic Signs, No Purulence)
Initial Management:
- Apply topical mupirocin ointment for S. aureus infections 1, 2
- Apply ketoconazole or clotrimazole ointment for Candida infections 1
- Monitor clinically for improvement over 48-72 hours 2, 3
- Do not remove the catheter at this stage 1, 3
Treatment Duration:
Exit Site Infection with Purulent Drainage or Failed Topical Therapy
Escalate to systemic antibiotics:
- Start empiric coverage targeting Gram-positive organisms, particularly staphylococci 1, 3
- Vancomycin is appropriate if MRSA prevalence is high in your institution 2
- Modify antibiotics once culture and sensitivity results are available 1, 3
- Continue systemic antibiotics for 7-14 days 1, 3
Catheter management:
- Keep the catheter in place if responding to systemic antibiotics 1
- Remove the catheter if systemic antibiotics fail to resolve the infection 1, 2, 3
Exit Site Infection with Systemic Signs
Immediate systemic antibiotic therapy:
- Initiate broad-spectrum coverage for both Gram-positive and Gram-negative organisms 1
- Include vancomycin for MRSA coverage plus a third-generation cephalosporin, carbapenem, or β-lactam/β-lactamase inhibitor for Gram-negative coverage 4
- Reassess at 48-72 hours and obtain repeat blood cultures if bacteremia was present 2
Pathogen-Specific Considerations
Staphylococcus aureus:
- More virulent pathogen requiring aggressive management 2
- Associated with 35% catheter removal rate if refractory 5
- Up to 50% of S. aureus peritonitis cases are preceded by exit site infection 5
Pseudomonas aeruginosa:
- Requires anti-pseudomonal coverage (ceftazidime, cefepime, or carbapenem) 2
- Associated with 28% catheter removal rate if refractory 5
- Consider catheter removal earlier if not responding to appropriate antibiotics 5
Gram-negative organisms:
- Less commonly progress to peritonitis than Gram-positive organisms, but when they do, cure rates are lower 5
Indications for Catheter Removal
Remove the catheter if:
- Systemic antibiotics fail after an adequate treatment course 1, 2, 3
- Tunnel infection develops alongside the exit site infection 1
- Purulent drainage persists despite appropriate therapy 1, 2
- Persistent colonization occurs after initial cure, as this significantly increases risk of technique failure 6
Alternative to removal:
- If tunnel infection develops but other vascular sites are unavailable, consider catheter exchange with a new subcutaneous tunnel to preserve the venous access site 1
Critical Pitfalls to Avoid
Do not remove catheters prematurely:
- Exit site infections alone without systemic involvement do not require catheter removal 1, 3
- Unnecessary catheter removal leads to loss of vascular access and reinsertion complications 2
Do not use vancomycin empirically in low MRSA prevalence settings:
- This promotes vancomycin resistance and has higher failure rates for susceptible organisms 2
Do not continue ineffective therapy indefinitely:
- If no improvement after 48-72 hours of topical therapy, escalate to systemic antibiotics 1, 2, 3
- If no improvement after adequate systemic antibiotic course, proceed to catheter removal 1, 3
Post-Treatment Surveillance
Monitor for colonization after initial cure: