Access Care Guide: Infectious Complications: Management of the Exit-site/Tunnel Infection

Infectious Complications: Management of the Exit-site/Tunnel Infection

Introduction

“An exit-site infection is defined by the presence of purulent drainage with or without erythema of the skin at the catheter-epidermal interface.”27

Key Assessments

  • Purulent discharge from exit site, spontaneous or expressed from tunnel, cuff or sinus
  • Persistant erythema may be precursor to purulent drainage
  • Pain or tenderness at exit site or over the tunnel
  • If exit site is reddened, without drainage and culture positive, may indicate colonization
  • Erythema or skin reaction may be noted following catheter implantation or trauma
  • Staphylococcus aureus carrier status/use of prophylaxis
  • Compliance with prophylaxis
  • Precipitating or contributing conditions (break in technique, gross contamination, etc.)
  • Suboptimal exit-site care

Key Activities

Initiate the following:6

  • Culture and Gram stain of purulent exudate and/or drainage
    • Experienced PD nurse may express fluid by pressing on the superficial cuff or with a gentle downward pull of catheter
  • Initiate empiric antibiotic therapy as indicated by clinical appearance
    • Empiric therapy should include Staphylococcus aureus coverage
    • In patients with history of pseudomonas ESI, empiric therapy should include targeted antibiotic therapy
  • In the absence of purulence, tenderness or swelling, consider intensified local care (e.g. hypertonic saline soaks-see right)
  • Monitor, classify and document condition of exit site, sinus and tunnel
  • ESI due to SA and pseudomonas may be related to tunnel involvement
  • If tunnel infection suspected, ultrasound of subcutaneous pathway may be helpful
  • Increase frequency of exit-site care and dressing changes
  • Retrain patient on appropriate exit-site care
  • Schedule clinic visits to evaluate response to treatment plan

Patient Education

  • Revise exit-site care
    • Clean 1 to 2 times a day
    • Avoid toxic agents entering sinus
    • Change cleansing agent if required
  • In the case of severe exit-site infection, saline soaks in addition to antibiotics may be used. Add 1 tablespoon of salt to 1 pint (500mL) sterile water. This solution is applied to gauze and wrapped around the exit site for 15 minutes, one to two times per day27
  • Soften crust and scabs with saline or soap and water
  • Never forcibly remove crusts and scabs
  • Apply new sterile dressing with each cleansing procedure until infection resolved, even if not routinely used
  • Protect exit site from exposure to organisms and trauma
  • Review antibiotic/antacid/food interactions

Note: Quinolone absorption may be reduced when given in combination with sevelamer hydrochloride, calcium salts, oral iron preparations, magnesium/ aluminum containing antacids, zinc, sucralfate or milk. Administration should be staggered as much as possible. The quinolone should be administered first, allowing at least 2 hours between each preparation. Rifampin can induce drug metabolizing enzymes reducing levels of medications ie., anticonvulsants, warfarin and statins.

Outcomes Evaluation

Collect data to include:

  • Date of culture, organism identified, drug therapy used
  • Date infection resolved
  • Recurrent organisms, date of drug therapy
  • Date of reeducation/training
  • Antibiotic prophylaxis regimen used

Enter data into catheter management database

Diagnosis and Management of Exit-site/Tunnel Infection

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