What is the treatment for wet contamination of a peritoneal catheter?

Treatment of Wet Contamination of Peritoneal Catheter

If a peritoneal catheter becomes wet contaminated, immediately remove the dressing, clean the exit site with 2% chlorhexidine gluconate in 70% isopropyl alcohol (or aqueous chlorhexidine if alcohol is contraindicated), allow it to completely dry, and apply a fresh sterile dressing—preferably sterile gauze if moisture is present, otherwise a transparent semi-permeable dressing. 1

Immediate Management Steps

Exit Site Cleaning Protocol

• Remove the contaminated dressing immediately upon discovery of wet contamination to prevent bacterial migration along the catheter tract 1

• Clean the exit site with 2% chlorhexidine gluconate in 70% isopropyl alcohol, which is the most appropriate antiseptic for catheter exit site care 1

• If the catheter manufacturer prohibits alcohol use (such as with some polyurethane catheters), use aqueous chlorhexidine gluconate solution instead 1

• Allow the antiseptic to air dry completely before applying a new dressing—this drying time is critical for antimicrobial efficacy 1, 2

• Alternatively, alcoholic povidone-iodine can be used in patients with chlorhexidine sensitivity 1

Dressing Selection After Wet Contamination

• Apply sterile gauze dressing if moisture, perspiration, or any oozing is present at the exit site, as gauze is preferred when moisture is an issue 1, 3

• Change gauze dressings every 2 days until the site is completely dry 1, 3

• Once the site is dry and stable, transition to a sterile transparent semi-permeable polyurethane dressing, which can remain in place for up to 7 days 1

• Replace any dressing immediately if it becomes damp, loosened, or soiled again 1, 3

Monitoring for Infection After Wet Contamination

Clinical Assessment

• Inspect the exit site daily for signs of infection: erythema, purulent drainage, tenderness, or induration within 2 cm of the exit site 1, 4

• If purulent drainage or exudate develops, obtain cultures by swabbing the drainage and send for Gram staining and culture 1

• Monitor for systemic signs including fever, which may indicate progression to tunnel infection or peritonitis 4, 5

Exit Site Infection Management

• Uncomplicated exit site infections without systemic signs should be treated with topical antimicrobials based on culture results—mupirocin ointment for Staphylococcus aureus and antifungal ointment for Candida 1, 3

• If exit site infection fails to resolve with topical therapy or if purulent drainage develops, initiate systemic antibiotics based on culture and sensitivity results 1

• Do not use glycol-containing ointments on polyurethane catheters as certain manufacturers contraindicate this practice 3

Prevention of Future Wet Contamination

Patient Education

• Instruct patients to protect the catheter during showering by covering it with a waterproof barrier 1

• Never submerge the catheter or exit site in water (baths, swimming pools, hot tubs) as this dramatically increases infection risk 1, 6

• Teach patients to immediately report any dressing that becomes wet or loose 1, 3

Ongoing Exit Site Care

• Consider daily application of topical mupirocin to the exit site in patients with nasal Staphylococcus aureus carriage to reduce infection risk 3, 4

• Polyhexanide solution may be superior to traditional povidone-iodine for routine exit site care, with studies showing significantly fewer infections (1 episode per 102.7 patient-months versus 1 per 36.6 patient-months) 7

• Maintain a regular dressing change schedule: gauze every 2 days, transparent dressings every 7 days, or sooner if compromised 1, 3

Critical Pitfalls to Avoid

• Never apply antiseptic and immediately cover with a dressing—the drying time is essential for antimicrobial activity and failure to allow drying is a common cause of preventable infections 1, 2

• Do not use organic solvents (acetone, ether) on the skin before or after antiseptic application 1

• Avoid routine use of antimicrobial ointments at the exit site as they are not effective for prevention and may promote fungal infections and antimicrobial resistance 1

• Do not ignore early signs of exit site infection—exit site infections are associated with significantly lower cure rates when they progress to tunnel infections or peritonitis (22.1% complete cure rate with concomitant exit site infection versus higher rates without) 8

When to Escalate Care

• If tunnel infection develops (diagnosed by ultrasonography showing hypoechogenic area around the cuff), initiate systemic antibiotics and perform serial ultrasounds every 2 weeks 5

• Remove the catheter if deep tunnel infection caused by Staphylococcus aureus fails to show >30% reduction in hypoechogenic area after 2 weeks of antibiotic therapy 5

• Catheter removal is mandatory for tunnel infection with concurrent peritonitis, severe sepsis, or infections with S. aureus, fungi, or Pseudomonas species that fail to respond within 48-72 hours 1, 8