Special Series/Guidelines

ISPD Catheter-related Infection
Recommendations: 2023 Update

Peritoneal Dialysis International
1–19ª The Author(s) 2023
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/08968608231172740
journals.sagepub.com/home/ptd

Kai Ming Chow1,2 , Philip Kam-Tao Li1,2 , Yeoungjee Cho3,4 ,Ali Abu-Alfa5,6, Sunita Bavanandan7, Edwina A Brown8 ,Brett Cullis9 , Dawn Edwards10, Isabelle Ethier11,12,
Helen Hurst13 , Yasuhiko Ito14, Thyago Proença de Moraes15 ,Johann Morelle16, Naomi Runnegar17, Anjali Saxena18,19,
Simon Wai-Yin So20, Na Tian21 and David W Johnson3,4

Abstract
Peritoneal dialysis (PD) catheter-related infections are important risk factors for catheter loss and peritonitis. The 2023
updated recommendations have revised and clarified definitions and classifications of exit site infection and tunnel
infection. A new target for the overall exit site infection rate should be no more than 0.40 episodes per year at risk. The
recommendation about topical antibiotic cream or ointment to catheter exit site has been downgraded. New recommendations include clarified suggestion of exit site dressing cover and updated antibiotic treatment duration withemphasis on early clinical monitoring to ascertain duration of therapy. In addition to catheter removal and reinsertion,other catheter interventions including external cuff removal or shaving, and exit site relocation are suggested.
Keywords
Antibacterial agents, antibiotic prophylaxis, catheter-related infections, exit site infection, ISPD guideline, peritoneal
dialysis, prevention, treatment outcome

1

Department of Medicine and Therapeutics, Prince of Wales Hospital,
The Chinese University of Hong Kong, Hong Kong
2
Carol & Richard Yu Peritoneal Dialysis Research Centre, Departmentof Medicine and Therapeutics, The Chinese University of Hong Kong,
Hong Kong
3
Australasian Kidney Trials Network, University of Queensland,
Brisbane, Australia
4
Department of Nephrology, Princess Alexandra Hospital, Brisbane,
Australia
5
Division of Nephrology and Hypertension, American University ofBeirut, Lebanon
6
Section of Nephrology, Yale School of Medicine, New Haven, CT, USA
7
Department of Nephrology, Hospital Kuala Lumpur, Malaysia
8Imperial College Renal and Transplant Centre, Imperial College NHS
Trust, London, UK
9
Department of Nephrology and Child Health, University of Cape Town,
South Africa
10
National Forum of ESRD Networks, Kidney Patient Advisory Council(KPAC), USA
11
Division of Nephrology, Centre hospitalier de l’Université de Montréal,Canada12
Health Innovation and Evaluation Hub, Centre de recherche du Centre
hospitalier de l’Université de Montréal, Canada
13
School of Health and Society, University of Salford, Salford Royal,
Northern Care Alliance Trust, UK

14

Department of Nephrology and Rheumatology, Aichi Medical
University, Nagakute, Japan
15
Programa de Pós-Graduação em Ciências da Saúde, Pontifı́cia
Universidade Católica do Paraná, Curitiba, Brazil
16
Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium
17
Infectious Management Services, Princess Alexandra Hospital,
University of Queensland, Brisbane, Australia
18
Department of Medicine, Division of Nephrology, Stanford University,
CA, USA
19
Department of Medicine, Division of Nephrology, Santa Clara Valley
Medical Center, San Jose, CA, USA
20
Department of Pharmacy, Alice Ho Miu Ling Nethersole Hospital, Tai
Po, Hong Kong
21
Department of Nephrology, General Hospital of NingXia Medical
University, Yinchuan, China
Corresponding authors:Philip Kam-Tao Li, Carol & Richard Yu Peritoneal Dialysis ResearchCentre, Department of Medicine and Therapeutics, The Chinese
University of Hong Kong, Hong Kong.
Email: philipli@cuhk.edu.hk
David Johnson, Department of Nephrology, Level 2, ARTS Building,Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba,
Brisbane, QLD 4102, Australia.
Email: david.johnson2@health.qld.gov.au

2Peritoneal Dialysis International XX(X)

What’s new with the 2023 update of the
ISPD catheter-related infection guidelines?
 Revised, clarified definition of tunnel infection(Page 2-3).
 New recommendation regarding cause-specificcatheter-related infection (Page 3).
 New definitions of culture-negative catheter-related
infection (Page 3), refractory catheter-related
infection (Page 3-4), infection-related catheter
removal (Page 4).
 Revised, updated recommendations for monitoring
and reporting of catheter-related infections(Page 4).
 New target recommended for exit site infection rate
(Page 4).
 Downgraded recommendation of topical antibiotic
cream or ointment to catheter exit site (Page 6-7).
 Revised, updated recommendations for topical antibacterial agents (Page 6-8).
 Clarified suggestion about need of exit site dressing
cover (Page 6-8).
 Revised recommendations for antibiotics treatment
duration of exit site infection (Page 9-11).
 New salvage options suggested for exit site infection
other than catheter removal (Page 11-13).

Introduction
Peritoneal dialysis (PD)-related infections have been identified by patients, caregivers and clinicians in the Standardised Outcomes in Nephrology – PD (SONG-PD) initiative
as the topmost, critically important clinical outcomes in
PD.1 These include PD catheter-related infections (i.e. exitsite infections and tunnel infections), which can potentiallylead to PD peritonitis, hospitalisation, transfer to haemodialysis and death. Recommendations on the prevention
and treatment of catheter-related infections were publishedpreviously together with recommendations on PD peritonitis under the auspices of the International Society for Peritoneal Dialysis (ISPD) for the first time in 1983 and revised
subsequently including the latest catheter-related infection
guideline from 2017.2 The present guidelines focus oncatheter-related infections, as recommendations pertaining
to peritonitis have been updated recently.3 The recommendations are organised into five sections focusing on:
1. Definitions
2. Monitoring and reporting of catheter-related
infections
3. Prevention of catheter-related infections
4. Management of catheter-related infections
5. Future research
These recommendations are based on contemporary evidence when such evidence is available. If there are multiple

similar reports available on the same topic, the committee
elected to refer to the more recent publications. In general,these recommendations follow the Grades of Recommendation Assessment, Development and Evaluation (GRADE)
system for assessing the quality and level of evidence inclinical reports and for the grading of our recommendations.4 Within each recommendation, the strength of recommendation is indicated as Level 1 (We recommend),
Level 2 (We suggest) or Not Graded, and the quality ofthe supporting evidence if shown as A (high certainty),
B (moderate certainty), C (low certainty) or D (very low
certainty). The recommendations are not meant to be implemented in every situation indiscriminately. Each PD unit
should examine its own pattern of infection, causative organisms and antibiotic susceptibilities and adapt the protocols to
local conditions as necessary. Clinicians caring for paediatric
PD patients should refer to the latest consensus guidelines forthe prevention and treatment of catheter-related infections
and peritonitis in paediatric patients receiving PD.5

Definitions
The definitions pertaining to catheter-related infections canbe further classified according to type, cause, timing (inrelation to catheter insertion and to previous episodes) andoutcomes.

Types of catheter-related infection
Exit site infection
 We suggest that definitive exit site infection isdefined as the presence of purulent discharge, withor without erythema of the skin at the catheterepidermal interface (Not Graded).
 We suggest that, in the absence of purulent discharge, other signs of inflammation at the exit site
(e.g. erythema, tenderness, swelling, granuloma or
crust formation) are insufficient to definitively diagnose exit site infection (Not Graded).
Tunnel infection
 We suggest that tunnel infection is defined as thepresence of clinical inflammation (erythema, swelling, tenderness or induration) with or without ultrasonographic evidence of a fluid collection anywhere
along the catheter tunnel (Not Graded).
The diagnosis of exit site infection is mostly clinical andshould be considered whenever there is a change from thepatient’s normal healthy exit site. Although exit site infection and tunnel infection can occur on their own, they canalso occur concurrently. The diagnosis of exit site infection
can be challenging as peri-catheter erythema without purulent discharge can be observed from allergic skin reaction,in the setting of a recently placed catheter or following

Chow et al.

3

trauma to the catheter,6,7 or after a change in the dressing or
cleansing materials.8 Sometimes, erythema alone may
be an indication of early infection warranting close monitoring for development of purulent discharge and need for
antimicrobial treatment. A positive culture with a normalappearing exit site (e.g. without purulent discharge) is indicative of colonisation rather than true infection. Althoughscoring systems9,10 have been proposed to monitor the exit
site, they have not been appropriately validated. We therefore suggest a diagnosis of exit site infection be based on
the presence of purulent discharge, with or withouterythema of the skin, at the catheter-epidermal interface.
Based on a multi-centre study involving more than 30,000
assessments of exit sites in 3297 incident PD patients, theuse of a scoring system (incorporating hyperaemia,
oedema, pain, scab and granuloma)2,9 for the diagnosis ofexit site infection did not add much information in addition
to the presence of purulent discharge.7
A tunnel infection can present with various componentsof erythema, oedema, induration or tenderness over the
subcutaneous pathway, often with a peri-catheter fluid collection demonstrated using ultrasound.11

When no organism is identified after culture of purulent
drainage from an exit site swab, culture-negative exit site
infection is diagnosed. In the MP3 study,12 culture-negative
exit site infection occurred in five (11.4%) cases of exit site
infection but was less common than culture-negative
peritonitis (19.5%). Bernardini et al. reported a culturenegative exit site infection rate of 0.06 episodes per year
in the mupirocin arm and 0.03 episodes per year in the
gentamicin arm (p ¼ 0.42).13 Culture-negative exit site
infections may occur in the context of recent antibiotic
exposure, suboptimal sample collection or culture methods,
or misclassification from slowly growing atypical organisms (e.g. mycobacteria, fungus).

Cause-specific catheter-related infection

The use of a 30-day cut-point for defining PD catheter
insertion-related exit site and/or tunnel infection was
adopted in line with the ISPD Guidelines on Creating and
Maintaining Optimal PD Access in the Adult Patient14 andthe ISPD Guidelines on Peritonitis.3 Infections occurring
within this time frame are likely to be related to the surgicalprocedure and may be associated with different organisms
and outcomes.

 We recommend that exit site infections be classified
according to organism(s) identified on culture (e.g.
Staphylococcus aureus exit site infection) (1C).
 We suggest that culture-negative exit site infection
is defined when exit site infection is diagnosed using
the criteria above, but no organism is identified on
culture of the exit site swab (Not Graded).
The cause of a catheter-related infection can be broadly
divided according to the organism(s) to inform treatment.
The most commonly isolated organisms reported for exitsite infections in the mupirocin and Polysporin Triple(MP3) randomised controlled trial (RCT) were, in descending order of frequency, diphtheroids (20.5%), S. aureus(13.6%), Pseudomonas aeruginosa (13.6%) and fungus(9.1%).12 In an RCT comparing topical application ofmupirocin versus gentamicin at the exit site, the mostcommonly reported organisms in the mupirocin arm wereS. aureus (0.06 episodes per year), other gram-positive
organism (0.26 episodes per year) and P. aeruginosa(0.11 episodes per year). 13 There were fewer grampositive and gram-negative exit site infections but more
yeast infections in the gentamicin group. It is likely thatthe epidemiology of organisms will vary according toregion, prophylaxis approach, antibiotic usage and so on.
Classifying, monitoring and reporting catheter-related
infections according to causative organisms will facilitate
benchmarking and continuous quality improvement (CQI)
activities, as well as inform more tailored treatment recommendations, as has occurred with the ISPD Peritonitis
Guideline Recommendations over the last decade.

PD catheter insertion-related exit site and/or
tunnel infection
 We suggest that PD catheter insertion-related exitsite and/or tunnel infection be defined as an episodeof exit site infection/tunnel infection that occurs
within 30 days of PD catheter insertion (Not
Graded).

Outcome-specific definitions of catheter-related
infection
 We suggest that refractory catheter-related infection
is defined as failure to respond after 2 weeks ofeffective antibiotic therapy and appropriately intensified exit site care, or 3 weeks for infection due toPseudomonas species (Not Graded).
 We suggest that infection-related catheter removal isdefined as catheter removal due to catheter-related
infection not responding to appropriate antibiotic
therapy or surgical salvage procedures (Not Graded).
A minimum 2-week course of antibiotics has been recommended for most catheter-related infections, except for
those caused by Pseudomonas for which a 3-week course
is recommended. In the literature, refractory tunnel
infection has even been defined as failure to heal within
4 weeks.15 Catheter-related infections that fail to completely resolve following the recommended antibiotic
course duration can be defined as refractory catheterrelated infections, thereby necessitating surgical salvage
interventions or catheter removal.

4Peritoneal Dialysis International XX(X)

Monitoring and reporting ofcatheter-related infections
 We recommend that every programme should measure and monitor, at least on a yearly basis, theincidence of catheter-related infections (1C).
 We suggest that the rate of catheter-related infection, including organism-specific catheter-related
infection, should be reported as number of episodes
per year at risk (Not Graded).
 We suggest that exit site and tunnel infection rates,
including organism-specific rates, should also be
separately reported as number of episodes per year
(Not Graded).
 We recommend that the overall exit site infection
rate should be no more than 0.40 episodes per year
at risk (2C).
 We suggest the proportion of PD catheter insertionrelated infection within 30 days of PD catheter insertion should be less than 5% of all catheters inserted(2C).
At regular intervals, all PD programmes should monitor theincidence of catheter-related infections as part of a CQI
programme.16 Application of a standardised metric to measure outcome is critical to benchmark performance, monitor progress and implement strategies based on observed
findings. Catheter-related infection rates should be measured as number of exit site infection or tunnel infection
episodes divided by number of patient years at risk (i.e.
number of years on PD starting from the time of PD catheter insertion), reported as episodes per patient years. This isdifferent from the way of calculating rate of peritonitis,which is modified by whether or not PD exchange is being
performed. As stated in the ISPD Guidelines on Peritonitis,3 peritonitis rates are calculated separately for the period
between PD catheter insertion and PD commencement(pre-PD peritonitis) and the period following PD commencement (PD peritonitis). Such separation is not applicable incalculating catheter-related infections because it is not modified by whether or not PD exchange is being performed.
Unlike PD-related peritonitis, catheter-related infections(i.e. exit site infections and tunnel infections) are generally
not currently captured by kidney registries, including theAustralia and New Zealand Dialysis and Transplant(ANZDATA) Registry and the US Renal Data System(USRDS). The PD Outcomes and Practice Patterns Study(PDOPPS) has reported a wide variation in the practice ofmonitoring for exit site infections across PD programmes
from six countries (range: 41–100%/country).17 Reported
incidences of exit site infections have varied largely, ranging from 0.06 to 0.42 episodes per year.13,18–24 In the HONEYPOT trial involving 371 PD patients from 26 centres in
3 countries (Australia, New Zealand and Singapore)
between 2008 and 2012, the exit site infection rate was
0.29 episodes per year in the standard of care arm usingmupirocin versus 0.37 episodes per year in the antibacterial
honey arm.22 However, the incidence rate of exit site infection is expected to be higher in real life than in the setting ofrandomised trial, where patient selection occurs. We suggest that the overall exit site infection rate be no more than
0.40 episodes per patient years at risk. Although registrydata are unavailable, this should be an achievable standard
based on published literature and should be used as an
initiative to reduce the burden of exit site infection rates
globally. We also suggest PD units measure and report the
proportion of PD catheter insertion-related infection, whichshould be less than 5% within 30 days of all cathetersinserted in line with the ISPD Guideline on Creating and
Maintaining Optimal PD Access in the Adult Patient.14

Prevention of catheter-related infections
Catheter placement
 We recommend that prophylactic antibiotics beadministered immediately before catheter insertion
for prevention of peritonitis (1A), although theireffects on catheter-related infections are uncertain.
 We recommend the use of nasal antibiotic prophylaxis if patients are identified as being nasal S. aureus carriers on screening prior to PD catheter
insertion (1C).
 We suggest that choice of PD catheter placement
technique be left to shared decision-making between
the individual clinician and patient as the comparative efficacies and safety of reported catheter
placement techniques for the prevention of catheterrelated infections are uncertain (2C).
 We suggest that the exit site dressing should be left
intact for 7 days after PD catheter insertion, unlesssoiled, to immobilise the new catheter and reducerisk of infection (Not Graded).
The recommended practice and standard of PD catheter
insertion has been detailed in the 2019 ISPD guideline on
Creating and Maintaining Optimal Peritoneal Dialysis
Access in the Adult Patient.14 The 2022 Update of the ISPD
Guidelines on Peritonitis Prevention and Treatment recommend ‘that systemic prophylactic antibiotics be administered immediately prior to catheter placement (1A)’ inorder to reduce the risk of catheter insertion-related peritonitis.3 In a Cochrane systematic review and meta-analysisof antimicrobial agents for preventing infection in PD
patients compared with placebo, pre- or peri-operative antibiotic prophylaxis had uncertain effects on catheter-related
infection rates (4 studies, 379 participants; vancomycin risk
ratio [RR] 0.36, 95% confidence interval [CI] 0.10–1.32,
cefazolin RR 0.74, 95% CI 0.27–2.05, gentamicin RR 0.07,
95% CI 0–1.06, cefazolin þ gentamicin RR 0.86, 95% CI
0.34–2.19, cefuroxime not estimable).25 There are not sufficient data available to inform the preferred choice of IV

Chow et al.
antibiotics due to low methodological quality of studies
conducted on this topic, although coverage of grampositive organisms is likely important. No difference incatheter-related infection rate was observed between vancomycin 1000 mg IV administered 12 h before PD catheter
insertion and cefazolin 1000 mg IV administered 3 h before
PD catheter insertion (1 study, 178 participants: RR 0.49,
95% CI 0.13–1.89).25,26 The use of nasal antibiotic prophylaxis had uncertain effects on the risk of exit site and tunnel
infections (3 studies, 338 participants: RR 1.34, 95% CI
0.62–2.87), but there was evidence of a significant reduction in catheter-related infection among patients who wereS. aureus nasal carriers treated with mupirocin ointment(nasal application, twice daily for 5 days, every 4 weeks
for up to 18 months; 1 study, 2626 patient-months: RR
0.57, 95% CI 0.39–0.84). 25 A systematic review andmeta-analysis showed that mupirocin ointment treatmentof S. aureus nasal carriers was associated with a 74% lower
probability of skin infection at the PD catheter exit sitecaused by S. aureus compared with the control group(OR 0.26, 95% CI, 0.14–0.46).27
A systematic review of 17 RCTs reported no significant
impact of different types of catheter placement techniqueson preventing catheter-related infection. However, thenumber of studies examining the impact of insertion technique or placement on catheter-related infections was small
with variable methodological quality at risk of imprecision.
For example, laparoscopic insertion compared to laparotomy made little or no difference to the incidence of catheterrelated infections (3 studies, 270 participants: RR 1.00,
95% CI 0.43–2.31, p ¼ 0.99). Similar results were observed
for the subcutaneous burying or embedding of the PD
catheter 6 weeks before initiation of PD (2 studies, 2511
patient-months: RR 1.15, 95% CI 0.39–3.42, p ¼ 0.8), midline versus lateral insertion of the PD catheter (2 studies,120 participants: RR 0.56, 95% CI 0.12–2.58, p ¼ 0.45)
and percutaneous insertion versus open surgical insertion(2 studies, 96 participants: RR 0.16, 95% CI 0.02–1.30,
p ¼ 0.08).28
More recently, a systematic review and meta-analysis
that included both observational (non-randomised) studies
and RCTs found that, in low certainty evidence, percutaneous PD catheter insertion may have been associated withlower risks of early (within 1 month) exit site infection(7 studies; RR 0.36, 95% CI 0.24–0.53) and overall exit
infection (16 studies; RR 0.61, 95% CI 0.46–0.82), but little
or no difference in tunnel infection (7 studies; RR 0.76,
95% CI 0.38–1.51) compared with surgical (open andlaparoscopic) PD catheter insertion.29
Prior to catheter insertion, it is advisable to carefully
identify the optimal location of the exit site that will allow
the patient to be able to see their exit site, clean it andavoid inadvertently traumatising it (e.g. by the belt).14
An alternative peritoneal catheter exit site location (e.g.
upper abdominal, pre-sternal) may be particularly important for patients with morbid obesity, intestinal stomas or

5urinary or faecal incontinence. Ideally, the location of theexit site should be chosen in advance of catheter insertion
with the patient in the seated position. Preoperative mapping with sample catheters or a marking stencil may be
helpful for choosing an appropriate catheter type. Following
catheter insertion, in keeping with other post-surgical care,
the insertion site is covered and left undisturbed to allow
wound healing by primary intention.14,30 The exit site dressing should best be left intact for 7 days unless soiled toimmobilise the new catheter and reduce risk of infection.14,30,31 Cytotoxic agents such as povidone-iodine orhydrogen peroxide are to be avoided till the sinus has
healed.30 In general, PD is recommended to start at least
2 weeks after catheter insertion.14 Earlier commencementof PD has been shown to increase the risk of dialysate leak(1 study, 122 participants: RR 3.90, 95% CI 1.56–9.78)
with uncertain effect on the risk of exit site infection(2 cohort studies, 337 participants: RR 1.43, 95% CI
0.24–8.61; 1 case–control study, 104 participants: RR
1.20, 95% CI 0.41–3.50).32

Catheter design
 We suggest that the type of PD catheter used be left toshared decision-making between the individual clinician and patient as no catheter design has been
demonstrated to be superior to another for the prevention of catheter-related infections (Not Graded).
The risk of catheter-related infection is not influenced
by the type of PD catheter (straight vs. coiled; 10 studies,826 participants: RR 1.12, 95% CI 0.92–1.34, p ¼ 0.22).
However, these studies were of varying characteristics interms of study duration, types of catheters (double cuff vs.
single cuff; Tenckhoff vs. swan-neck catheter) and risk of
attrition bias.28 Use of a double cuff PD catheter has beenshown to reduce the risk of peritonitis (RR 0.90, 95% CI
0.80–1.01, p ¼ 0.08), especially S. aureus peritonitis rate
(RR 0.46, 95% CI 0.33–0.64, p < 0.001), in a retrospective
observational study involving 4247 incident PD patientsfrom Canada.33 However, the effectiveness of double cuff
catheter on reducing the risk of catheter-related infection
has not been clearly demonstrated.34 Alternative catheter
designs to decrease bacterial colonisation, such as silverion implanted35 or antimicrobial-impregnated catheters,36
have not been able to demonstrate consistent effectivenesswith limited clinical experience to inform their use in aroutine setting.

Training programmes
 We recommend that the latest ISPD recommendations for teaching PD patients and their caregivers befollowed (1C).
 We suggest that retraining may reduce the risk of
PD catheter-related infections (2C).

6

Peritoneal Dialysis International XX(X)

PD programmes should use the ISPD Training Guideline to
implement standardised training for their trainers andpatients in the PD unit.37 However, currently there is noclear evidence to inform the best way to deliver training interms of place, person or approach,38 including optimalnurse-to-patient ratios. Recent data from PDOPPS including 1376 PD patients from 120 facilities across 7 countries
demonstrated that PD training was most frequently performed at the facility (81%) by facility-affiliated nurses(87%) in a 1:1 setting (79%).39 There was no convincing
type of training-related characteristic that was consistently
associated with a reduced risk of peritonitis; catheterrelated infection outcomes were not examined.39
Even though the most optimal way to deliver PD training remains uncertain, PD training has been shown to play avital role in decreasing the risk of catheter-related infections. A single-centre, retrospective observational study
from the United Kingdom has observed a 10-fold reductionin the burden of exit site infection after implementing a
preventive programme focusing on training nurses andpatients,40 improving operative aseptic technique andreducing S. aureus nasal carriage. The training curriculum
is advised to incorporate general theories of adult learning
principles as a lower rate of exit site infection has been
observed in association with this practice in a prospective
observational study.41 Currently, research is underway toidentify how to best deliver training42 incorporating anadult learning theory-based curriculum. Until further evidence is available, a dedicated nurse to support individual
patient’s training focusing on adherence to guideline recommendations and antiseptic procedures is currently
recommended.43 Following completion of PD training, ahome visit by the PD nurse is recommended to identify any
environmental issues that may affect the risk of infection as
well as confirm ongoing adherence to protocols and an
acceptable standard of exchange technique.
In addition to the initial training at the time of PD commencement, regular retraining may be helpful to decrease
the risk of catheter-related infection. An RCT of 104 incident PD patients from the Republic of Korea demonstrated
that implementing frequent retraining in incident PD
patients decreased the incidence of exit site infections over
24 months compared to the control group.44 The indication,
optimal frequency, duration and content of retraining havenot been defined.38

Exit site care
 We recommend daily topical application of antibiotic cream or ointment (mupirocin or gentamicin) tothe catheter exit site to prevent catheter-related
infection (1C).
 We suggest that the comparative efficacies of topicalmupirocin versus topical gentamicin or exit site versus nasal application of mupirocin for preventing
catheter-related infection are uncertain (2C).

 We suggest that no cleansing agent has been shown
to be superior to any other with respect to preventing
catheter-related infections (2B).
 We recommend that the exit site be cleansed at least
twice weekly and every time after a shower or vigorous exercise, including running, cycling, swimming and water sports (1C).
 We recommend that PD catheter exit site care becontinued after interruption or discontinuation of
PD for as long as the catheter remains in place (Not
Graded).
 We suggest that a dressing cover over the exit site is
not mandatory after exit site care and topical antibiotic application (2D).
 We recommend that the PD catheter be immobilised
to avoid traction injury of the exit site (1C).
Daily application of mupirocin to the exit site has beenshown to be a cost-effective strategy to decrease the riskof exit site infection from S. aureus, in observational studies, RCTs and meta-analyses.45–47 Application of mupirocin was reported to reduce the risk of exit site infections by
62% among patients undergoing PD (five studies: RR 0.38,
95% CI 0.22–0.67).46 In this systematic review, three studies involved nasal mupirocin application and two involved
exit site application. Indeed, the site, frequency and duration of mupirocin treatment have been highly variable
across the studies conducted to date thereby limiting theirability to inform standardised practice.48 Daily administration is not as likely to induce mupirocin resistance comparedwith intermittent dosing, but the long-term implication
remains uncertain.49,50 A Cochrane systematic review andmeta-analysis reported that topical nasal application ofmupirocin had uncertain effects on exit site infection (3studies, 338 participants: RR 1.34, 95% CI 0.62–2.87).25
Unfortunately, exit site application of mupirocin wasgrouped with oral antibiotic prophylaxis (floxacin, cephalexin, rifampin or cotrimoxazole). While the overall analysis showed an uncertain effect of oral or topicalantimicrobial prophylaxis on exit site infection (5 studies,395 participants: RR 0.82, 95% CI 0.57–1.19) with moderate heterogeneity (I2 ¼ 40%, p ¼ 0.17), the specific effectof topical exit site mupirocin was not evaluated. Obata andcolleagues have recently completed an updated systematic
review and meta-analysis of RCTs (six studies), examining
topical exit site application of mupirocin compared to otherexit site care interventions.51 In contrast to previous findingsof superior benefit compared to standard care, their systematic review demonstrated that it was uncertain whether
the application of mupirocin ointment prevents exit site
infection (RR 0.36, 95% CI 0.13–1.05). This analysis islimited by the moderately high level of heterogeneity(I2 ¼ 61%, p ¼ 0.07) between the studies.51 In summary,the available evidence from systematic reviews and metaanalyses of RCTs suggest that topical mupirocin prophylaxis may reduce the risk of catheter-related infections.

Chow et al.
However, the certainty of this evidence is reduced by indirectness (highly variable approaches to administering theintervention including nasal vs. exit site application), riskof bias and inconsistency. There is also a lack of directcomparison between nasal and exit site application ofmupirocin with respect to risk of catheter-related infection.
For these reasons, the Guideline Working Group downgraded the strength of the topical mupirocin prophylaxis
recommendation from 1A in the 2017 Guidelines to 1C
currently. It also was not able to recommend the optimalsite of topical application (nasal vs. exit site). Currently,
there is a multi-centre, double-blind RCT underway inThailand (COSMO-PD Trial) examining the comparative
effectiveness of local application of chlorhexidine gluconate, mupirocin ointment and normal saline for preventionof PD-related infections.52 Hopefully, the results from thistrial will help guide future recommendations on this topic.
An alternative topical antibacterial prophylactic agent isgentamicin. Daily application of gentamicin to the exit site
was shown to be highly effective in preventing exit site
infection caused by Pseudomonas species, and as effective
as topical mupirocin in reducing S. aureus exit site infections in a three centre, double-blind RCT (n ¼ 133).13
However, its broad implementation has been restrictedby limited availability and concerns of a change in the
microbiologic profile of organisms responsible forcatheter-related infection, gentamicin resistance53,54 anddevelopment of other atypical infections.55 Alternating
between mupirocin and gentamicin exit site application
has been discouraged due to observed increase in the risk
of fungal peritonitis compared with gentamicin alone.56
A recent systematic review and meta-analysis observed
no difference in the rate of exit site infection between topical exit site application of mupirocin or gentamicin (2 studies, 228 participants: RR 1.14, 95% CI 0.27–4.81) withhigh heterogeneity (I2 ¼ 87%, p ¼ 0.005).51
Other prophylactic strategies examined include the useof medical-grade antibacterial honey at the exit site, which
has been shown to have a similar risk of catheter-related
infections to that of patients treated with intranasal mupirocin appointment (incidence rate ratio [IRR] 1.12, 95% CI
0.81–1.53).57 More importantly, exit site application ofhoney increased the risk of catheter-related infection andperitonitis among patients with diabetes, thereby precluding its use in this subgroup.22 There are several other studies showing mixed results pertaining to the use of topicalpolysporin triple ointment,58 topical polyhexanide59 andpolyhexamethylene biguanide60 and nanotechnology antimicrobial spray dressing61 to prevent exit site infections.
Further studies on these agents are required prior to consideration for their broad use in clinical settings.
It should also be noted that contact between ointments/
creams and the PD catheter should be minimised as there
have been reports that the polyethylene glycol base inmupirocin can damage polyurethane catheters and that
gentamicin cream may damage silicone catheters.62–64

7
A PDOPPS study of infection prevention strategies by
170 centres caring for 11,389 patients in 7 countries
reported wide variation in exit site cleaning strategies,
including antibacterial soap, non-antibacterial soap, chlorhexidine, povidone-iodine, sodium hypochlorite and otheragents.17 Antibacterial soap was used to clean the catheter
exit sites in 57% of US, 40% of Canadian and 39% ofAustralian and New Zealand units.17 There have been studies comparing its effectiveness against other topical cleaning agents, with varying results. Povidone-iodine, also
known as iodopovidone, is an antiseptic commonly used
for skin disinfection before and after surgery. Its effectiveness compared to soap and water or no specific care in
reducing the incidence of catheter-related infection has
been inconsistently demonstrated. For example, in an RCT
including 127 patients from 8 hospitals, participants receiving povidone-iodine had a significantly lower occurrenceof exit site infection compared to those using soap andwater (0.27 episodes/patient-year vs. 0.71 episodes/
patient-year).65 However, similar results have not been
observed by others.66 Moreover, there have been concerns
regarding the risk of irritation induced by the regular application of povidone-iodine precipitating secondary exit site
infection.67 Similar concerns of local irritability have beenraised for chlorhexidine gluconate (0.05–2% aqueous solution with or without isopropyl alcohol with broad-spectrum
antimicrobial activities). As an alternative, chlorhexidineimpregnated sponge dressing has been developed allowing
weekly application. A single-centre pilot study of 50 incident PD patients from Singapore using chlorhexidineimpregnated sponge demonstrated low catheter-related
infection rates (0.09 episodes/patient-year, 95% CI 0.02–
0.22) with 92% 1-year infection-free survival. Although
73% of participants reported these dressings to be acceptable, 12% developed localised contact dermatitis.68 The
outcomes from this study should be interpreted with caution due to the lack of concurrent comparison group andsmall sample size, warranting further studies to be conducted prior to broader implementation. Another cleansing
agent, Amuchina solution, an electrolytic chloroxidizing
solution containing sodium hypochlorite (3–10%), hasbeen shown to be effective in preventing exit site infection
in paediatric patients69 without any secondary skin reaction. A retrospective observational study of 83 paediatric
PD patients observed a significant reduction in catheterrelated infection rates from 1.36 episodes per patient-yearwith application of mupirocin at exit site to 0.33 episodes
per patient-year when mupirocin was augmented withsodium hypochlorite solution (p < 0.0001) without occurrence of mupirocin-resistant organisms.70 However, thesefindings should be interpreted carefully due to the limitations of study sample size and design. There have also been
inconsistent outcomes among studies in which head-tohead comparisons of different types of disinfectants (i.e.
povidone-iodine, chlorhexidine, hypochlorite) were performed to inform clinical decision-making. 71,72 A8Cochrane systematic review and meta-analysis reported
very low certainty evidence that various dressing systems(chlorhexidine, povidone-iodine, sodium hypochlorite
gauze þ fixomull, blister film) may make little or no difference to exit site infection rates.25 New topical antiseptic
such as polyhexanide had also been tested, albeit in anunderpowered study.73
In addition to the therapeutic benefit of dressing or antiseptic agents, we should be cautious about contaminatedproducts, especially when they are not considered to bepharmaceutical products. Suboptimal manufacturing practice or preparation could have been the cause of contaminated aqueous chlorhexidine solution, 74–76 leading toseveral Burkholderia cepacia complex PD catheter exitsite infection outbreaks, as reported in New Zealand77 andHong Kong.74
The optimal frequency of exit site care has not beentested by RCTs. However, exit site care frequency less than
twice weekly appeared to be associated with higher odds ofcatheter-related infections.78 Exit site care is therefore recommended at least twice weekly, and every time after
water contamination or vigorous exercise, to keep clean
and dry.79 Preliminary data suggested avoidance of water
exposure to prevent introduction of water-derived organisms. In a small single-centre observational (non-randomised) study, application of a stoma bag during the daily
shower was associated with reduction of exit site infection.80 However, this evidence was very low certainty.
Covering the exit site during swimming has also been recommended by the 2022 ISPD Guidelines on Physical
Activity and Exercise in Peritoneal Dialysis to protect theexit site from getting wet.79 These guidelines further suggest that ‘swimming or other water sports should preferably
take place in either sea water or swimming pools that are
known to be well maintained (private or municipal) to limit
exposure to waterborne pathogens. (2D)’79 The evidence
underpinning this guideline is very low certainty based on
anecdotal experience.
Although previous ISPD guidelines have not addressed
the care of exit site after PD discontinuation (in the settingof catheter dysfunction, hernia complication or waiting forcatheter removal after kidney transplantation or transfer tohaemodialysis), we recommend similar intensity or frequency of exit site care. The patient should be given information about the need to cleanse and monitor the exit siteeven after PD interruption or discontinuation.
Contrary to the previous recommendation to protect theexit site with dressing material such as sterile gauze coverage, continuing this practice beyond the immediate postoperative period is not supported by one RCT18 and two
observational studies.78,81 A single-centre, open-label RCT
involving 97 participants in Malaysia showed that simple
washing and cleansing of the exit site followed by topicalmupirocin with or without a dressing cover resulted insimilar incidences of catheter-related infection. 18 The
exceptionally low exit site infection rate in this study, at

Peritoneal Dialysis International XX(X)
0.05–0.11 episodes per year, could have limited the external validity of their findings. Rates of exit site infection
were also not associated with application of dressings
according to a multi-centre cross-sectional survey of1204 patients from 12 PD centres in China.78 Another retrospective study showed that routine dressing of the exitsite (n ¼ 54) was associated with higher exit site infection
rate than in the non-dressing group (n ¼ 12).81 Transparent
or semi-occlusive dressing material did not appear to be
associated with exit site infection rates in 2460 participantsin the BRAZPD II study.82 Taken together, current evidence is not sufficient to support the use of covered dressings. Furthermore, concerns have been raised about thepotential for covered dressings to cause local allergic reactions and acceleration of local bacterial growth. This information needs to be balanced against other considerations
with respect to dressings, such as mitigating exposure toenvironmental dusts and animal danders, avoiding stainingof clothing by topical antimicrobial ointment, providing
extra padding and facilitating catheter immobilisation.
While there is insufficient evidence to support covering the exit site, fixing or immobilising the catheter inplace is recommended to prevent traction of or frictional
injury to the exit site. The practice of fixing the catheterby waist belt, protective bag or securing the transfer/extension set to the abdomen by adhesive tape is supported by several observational studies on risk factors ofexit site infection. A history of catheter pulling injury or
traction bleeding, based on multivariate regression analysis, was associated with increased exit site infections in
two studies (hazard ratio 1.78, 95% CI 1.02–3.1119 and
2.44, 95% CI 1.47–4.0478). We believe this recommendation of fixing the PD catheter also aligns with the
ISPD and the Global Renal Exercise Network practicerecommendations79 to avoid repetitive rubbing of thecatheter site during sports activity, and the use of a belt
during sports to provide protection.

Management of catheter-related
infections
Clinical assessment
Culture swab should be taken from an exit site with purulent discharge. Gram stain is not routinely performed forexit site swab in most microbiology laboratories, unlessthere is drainable component. If there is a purulent discharge that can be drained, Gram stain of the drainage canbe used to guide treatment.
After examination of the exit site, the tunnel of thecatheter should be inspected and palpated. Tenderness overthe catheter pathway and drainage from the exit site after
milking the track would indicate tunnel infection which,
if untreated, can progress to abscess formation or catheterrelated peritonitis. Ultrasound examination can be helpful
to detect tunnel involvement.83,84 A positive finding with aChow et al.
sonolucent peri-catheter fluid collection helps to establish adiagnosis of tunnel infection,83,85 although a negative
examination does not rule out the condition. Additional
information from colour Doppler and contrast-enhanced
ultrasound might provide additional information of hypervascularity, indicative of an inflammatory process.86,87

Care of the infected exit site
During exit site infection, the frequency of exit site inspection and cleansing is suggested to be at least daily, although
there are no data to specifically support this frequency.
A major goal of treatment of exit site infection is earlyrecognition of worsening infection, including the concomitant or subsequent development of a tunnel infection.
Another major reason to suggest daily care is review of theneed for additional therapeutic options. Granulomas overthe exit site may require additional exit site care because
they are associated with exacerbated breakdown of the exitsite. Treatment options include silver nitrate cauterisation,88 topical chlorhexidine application88 and silver ionbased dressing.89 Although silver nitrate cauterisation has
been most commonly used, this chemical agent can cause
skin burns and pain. A small RCT involving 44 participants
showed that chlorhexidine swab stick had similar efficacyof healing rate when compared to silver nitrate but had
lower pain scores and less adverse reactions (burning sensation and staining around the exit site).88

Empirical antibiotic treatment
 We recommend empiric oral antibiotic treatment ofexit site infections with appropriate S. aureus coverage such as first-generation cephalosporin or
anti-staphylococcal penicillin, unless the patient hasa prior history of infection or colonisation withmethicillin-resistant S. aureus (MRSA) or Pseudomonas species, in which case a glycopeptide such as
vancomycin (or clindamycin if known to be susceptible) or antipseudomonal antibiotic, respectively,
are appropriate (1C).
Oral antibiotic therapy is often used empirically based onconvenience and should primarily cover S. aureus (Figure 1).
In the absence of RCTs showing head-to-head comparison
for empiric antibiotic choices, the recommendation is basedon clinician’s preference and patient’s risk profile.
Dosing recommendations for frequently used oral antibiotics are shown in Tables 1 and 2.77,90 In line withthe 2022 Update of the ISPD Guidelines on Peritonitis
Prevention and Treatment, concomitant antifungal prophylaxis should be prescribed whenever patients receive antibiotics for any reason to mitigate the risk of fungal
peritonitis.3

9

Monitoring and duration of therapy
 We suggest that antimicrobial treatment duration forexit site infection be adjusted according to clinicalresponse, swab culture and in vitro susceptibility
result (2C).
 We suggest that a fixed 2-week antibiotic treatment
duration for exit site infection can be shortened to
7–10 days if resolution of infection is confirmed byclinical evaluation at around 1 week (2D).
 We recommend that exit site infection causedby Pseudomonas species be treated with at least
3 weeks of effective antibiotics (1C).
 We recommend that any tunnel infection be treatedwith at least 3 weeks of effective antibiotics (1D).
The overarching principle is to monitor and adjust according to both clinical response and microbiological results.
Patients should be reviewed within 1 week after treatment(Figure 1). Susceptibility testing is important to guidedrug modification. The currently recommended first-line
oral antibiotics (Table 1) might not work for organisms
with increasing resistance. 91,92 The most rational
approach is to arrange early review of exit site conditionand susceptibility results to guide the choice and durationof treatment.
Within 1 week after initiation of treatment, physicalexamination of the exit site should be performed by either
clinicians or nurses experienced in managing exit site
infection. Remote treatment monitoring93 coupled withreal-time high-resolution image of the exit site by zoom
device is considered less satisfactory because tunnel infection may need ultrasound examination.
The duration of antibiotic treatment of catheter-related
infection used to be guided by entrenched practice rather
than informed by high-quality evidence. Given the growing
concern with unduly prolonged antibiotic therapy, we
believe that duration of antibiotic treatment of exit site
infection should be addressed. Although the previous
guideline in 2017 recommended a minimum of 2 weeks
of antibiotics for exit site infection (graded as 1C recommendation),2 there is a lack of high-quality evidence for the
mandatory 2-week treatment. The majority of the previously published guidelines and recommendations for the
management of severe skin and soft tissue infections did
not provide specific suggestions on the duration of therapy.94 The Infectious Diseases Society of America (IDSA)
guidelines suggest a 5-day therapy for cellulitis with anextended duration in the absence of improvement, and7 days for superficial streptococcal and staphylococcal
infections.95 On the other hand, exit site infection of PD
catheter is different from simple cellulitis or soft tissue
infection because of the presence of foreign material. Since
there are no biomarkers to accurately guide discontinuationof exit site infection antibiotic treatment, we believe clinical assessment is an integral basis of decision-making.

10

Peritoneal Dialysis International XX(X)

Figure 1. Management of PD exit site infections.
*PD patients are recommended to receive concomitant antifungal prophylaxis.
PD: peritoneal dialysis.
Table 1. First-line empirical oral antibiotics used in catheterrelated infections.

Table 2. Alternative oral antibiotics used in catheter-related
infections.

Amoxicillin/clavulanate
Cephalexin
Cloxacillin or
dicloxacillin

Ciprofloxacin
Clarithromycin
Clindamycin
Levofloxacin
Linezolid

500 mg/125 mg or 250 mg/125 mg BD
250–500 mg BD
500 mg QID

BD: two times per day; QID: four times per day.

Definitive antimicrobial treatment and duration are best
guided by clinical response and, when available, resultsof wound culture and susceptibility. Our suggestion to take
into consideration the clinical response is aimed to balance
the risk of prolonged antibiotic therapy. It should be notedthat many observational studies of fungal peritonitis in PD
patients confirmed the risk factor of antibiotic use within
1 month of peritonitis onset.96,97 Recommended treatment
duration of exit site infection should count from the day ofeffective antibiotics. Since there are insufficient data to
support a fixed 2-week course, we believe it is reasonable
to prescribe antibiotics for a period of 7–10 days (Figure 1),
the time required for an uncomplicated acute infection to
heal. More prolonged antibiotic therapy is required when
there are complicated conditions such as tunnel infection(Figure 2) or virulent organisms such as Pseudomonas species. There is no RCT evidence to guide treatment duration
for tunnel infections, so the recommendation for at least 3
weeks treatment with effective antibiotics was assigned a
1D level. Despite previously recommended treatment

500–750 mg daily
500 mg loading, then 250 mg BD
300–450 mg TID to QID
250 daily or 500 mg every 48 h
600 mg BD for 48 h, then 300 mg BD
600 mg daily if used for NTM infection90
Moxifloxacin
400 mg daily
Rifampicina
450 mg daily (for BW < 50 kg)
600 mg daily (for BW  50 kg)
Trimethoprim/
80 mg/400 mg (one single-strength tablet)
sulfamethoxazole
daily or BD77 or 160 mg/800 mg (onedouble-strength tablet) daily
BD: two times per day; BW: body weight; QID: four times per day; TID:
three times per day.
a
Rifampicin is used for treating S. aureus synergistically with other antibiotics and should not be given as single-agent therapy.

duration of at least 3 weeks for Pseudomonas exit site
infection,2 there had also been reports of antibiotic treatment for 2 weeks.98–100 When there is unsatisfactory treatment response to Pseudomonas exit site infection, a second
antipseudomonal drug should be added. In case of S. aureus
infection with slow response, oral rifampicin can be considered but should never be given as monotherapy. Thereis, however, a lack of high-quality studies supporting
adjunctive rifampicin therapy for S. aureus exit site infection. Such recommendation is mostly extrapolated from theexperience of peritonitis treatment 101 and treatment

Chow et al.

11

Figure 2. Management of PD catheter tunnel infections.
*PD patients are recommended to receive concomitant antifungal prophylaxis.
PD: peritoneal dialysis.

guidelines of treating S. aureus bacteremia associated with
infected prosthetic material.102
Refractory exit site infection should raise the suspicionof atypical organisms such as non-tuberculous mycobacteria (NTM). NTM can be misidentified as diphtheroids or
Corynebacterium species, leading to delayed diagnosis.
When suspected, examination for acid-fast bacilli byZiehl–Neelsen staining and culture on specific media
should be requested. The most common species is Mycobacterium fortuitum, followed by M. abscessus and M.
chelonae.103,104 It is necessary to differentiate isolates
identified as ‘M. chelonae/abscessus’ to the species isolated since therapy for M. abscessus is more challenging.104,105 In general, treatment with two agents within vitro activity against the clinical isolate for a minimumof 4 months of therapy is needed for NTM infection. Thereis no standardised treatment recommendation for NTM exitsite infection, but the IDSA guidelines highlight the needfor removal of any foreign body to provide a high likelihood of cure, especially for M. abscessus.104
Finally, observational data show the adjunctive role ofultrasonography in evaluation of treatment response. Preliminary findings suggested that a hypoechogenic zone ofmore than 1 mm thickness around the external cuff 1 week
after completion of antibiotic treatment can predict a poor
clinical outcome.85 Another study of 43 patients with tunnel infection of single-cuff catheters showed thatsignificant decline in the hypoechogenic zone at 2 weeks
after initiating antibiotics was associated with a lower likelihood of catheter removal.106
There is no consensus whether routine exit site woundculture should be undertaken 1–2 weeks after completion of
antibiotic treatment. However, monitoring culture after primary cure of the exit site infection has been shown to detectpersistent colonisation which was associated with higher
risks of peritonitis107 and transfer to haemodialysis.107,108

Surgical interventions for catheter-related infection
 We suggest removal of PD catheter in patients withexit site or tunnel infection that progresses to, or
occurs simultaneously with, peritonitis due to thesame organism (2C).
 We suggest simultaneous removal and reinsertionof PD catheters with a new exit site under antibiotic coverage when exit site infection or tunnel
infection do not resolve with effective antibiotic
therapy (2C).
 We recommend simultaneous removal and reinsertion of PD catheters be avoided when there is deep
Dacron cuff involvement of concurrent peritonitis(1C).
 We suggest that a surgical salvage procedure can beconsidered as an alternative to simultaneous catheter
replacement in selected patients (2C).

12

Peritoneal Dialysis International XX(X) We suggest that cuff removal or shaving be considered in PD patients with external cuff extrusion andexit site infection refractory to antibiotics (2C).
 We suggest exit site relocation be considered inpatients with exit site infection refractory to antibiotics (2C).

Source control remains the key management strategy forcatheter-related infection when there are ongoing infection
and infectious foci. As highlighted in the ISPD 2022
updated recommendations for peritonitis, simultaneous
removal and reinsertion of PD catheter should not be
attempted in the presence of unresolved peritonitis.3 Catheter removal is suggested when catheter infection occurs
simultaneously with peritonitis (Figure 1). This is followedby temporary haemodialysis with no attempted reinsertionof the PD catheter until at least 2 weeks after catheter
removal and complete resolution of peritonitis. There arelittle data on timing of reinsertion of a PD catheter removed
for infectious reasons.109 A minimal wait of 2 weeks seems
reasonable.
For catheter infection alone, simultaneous removal andreinsertion of the PD catheter is an option to minimise PD
interruptions and alleviate the need for unplanned transfer
to haemodialysis. This approach has been supported byobservational studies.110–114 The feasibility of removal
and reinsertion at a single operation has been studied in
37 cases of refractory P. aeruginosa exit site infection.
All patients were kept on antibiotics for 1 week postoperatively. At 4 weeks, there was no relapse of P. aeruginosa exit site infection. 110 Post-operative antibiotic
coverage duration had been extended to 2 weeks in twoother case series in which patients with tunnel infection(majority of the causative organisms being P. aeruginosaand S. aureus) were also included.112,115 Effectiveness of
simultaneous catheter removal and reinsertion was more
likely in S. aureus tunnel infection (including cases ofsimultaneous peritonitis which showed improvement
including effluent white cell count).115 Treatment success,however, was only 50% in relapsing P. aeruginosa peritonitis and tunnel infection.115
The option of simultaneous catheter removal and reinsertion for resistant organisms including NTM can also be
considered, but data for the clinical outcomes remain limited.112,116 However, M. abscessus infection should bemanaged by catheter removal given the high failure rateof simultaneous catheter replacement.104,105,117
Although simultaneous replacement of catheter has highlikelihood of resolving catheter-related infection, this procedure is subject to potential complications of a new catheter, such as peri-catheter leaks and flow dysfunction.14
Other salvage strategies have therefore been proposed.118
Extrusion of the external cuff through the exit site is amechanical complication resulting from shape-memory
resilience forces induced by bending a catheter in the
subcutaneous track that has a straight intercuff tubing

segment.14 Over time, the tubing returns to its native
straight configuration with migration of the external cuff
towards the exit site. If the extruded cuff is not managed, it
can become seeded with bacteria and predispose to exit site
infection. For patients with exposed external cuff and persistent exit site infection, removal or shaving of the external
cuff can be considered when infection is limited to the exitsite. Such practice was initially recommended in patients
who developed relapse/repeat of Pseudomonas exit site
infection.119 More data supporting this practice come fromobservational studies of patients with exit site infection
secondary to other causative organisms such as Staphylococcus aureus and/or epidermidis, Corynebacterium andsometimes Gram-negative species.120–122 The benefit ofexternal cuff shaving for S. aureus exit site infection has
been shown in three studies, in which relapse/repeat of exitsite infection or peritonitis occurred in 17%,120 50%122 and44%.121 There is insufficient evidence to recommend shaving or removing the external cuff in the absence of infection, such as extrusion of cuff after substantial weightloss122 or shape-memory resiliency forces of the catheter.
We also recognise the need to balance the benefit and riskof potential complications of the procedure. In general,shaving or removing the external cuff is performed understerile condition at the bedside or outpatient office. Techniques commonly practiced include teasing away cuffs
from the PD catheters using blunt forceps.14,120,122 Shaving
the cuff using scalpels can also be performed by applying
the sharp blade parallel to the exposed cuff.121,123 Sharp
dissection, however, should be cautiously performed by anexperienced clinician to minimise risk of catheter damage.
The blade has also to be changed often to assure ease ofremoving the cuff material without undue or excessive
pressure from a used blade, that might cut inadvertently
into the catheter lumen. Another variation of the procedure
consists of deroofing the tunnel, when the cuff is partially
exposed.14 Some nephrologists give prophylactic topical orsystemic antibiotics either before or after the procedure tofurther aid in resolution of infection.120–122 If there is purulent discharge at the exposed cuff, specimens should becollected for culture to guide the use of antibiotics.
In addition to removing the external cuff for refractory
exit site infection, there is an alternative option of relocating the exit site. Under local anaesthesia, this outpatient
procedure is performed after preoperative intravenous antibiotic administration.124 Exposure of the external cuff isachieved by excising the exit site and the skin overlying
the subcutaneous track en bloc with the underlying tissue
around the catheter segment. Infected materials adjacent to
the exit site and/or tunnel are removed, whereas the
exposed catheter is sterilised by covering with gauzes
soaked with chlorhexidine 2% solution for at least 5 min.124
The exteriorised catheter is tunnelled subcutaneously to a
new site.124,125 Alternatively, the extraperitoneal portion of
the PD catheter is cut and a new sterile catheter segmentwith a cuff is connected to the original one (internal cuff

Chow et al.

13

Table 3. Outcome summary of various surgical interventions for isolated catheter-related infection without concurrent peritonitis.
Surgical wound Number of Success rate ofclassificationa
studies
intervention (%)

Salvage procedures
Simultaneous catheter intervention110,112,114,115,131
Relocating exit site: catheter splicing with removal of infected catheter
remnant126,127,129,132–135
Catheter diversion with cuff shaving125,136
Unroofing, wound excision or en bloc resection with cuff shaving15,120,121,128,130,137,138
a

Clean
Clean

5
7

92/95 (96.8%)
144/175 (82.3%)

Dirty
Dirty

2
7

47/51 (92.2%)
120/185 (64.9%)

Surgical wound is classified using the National Healthcare Safety Network wound class139 as clean, clean-contaminated, contaminated or dirty/infected(referring to old wounds with retained devitalised tissue and those that involve existing clinical infection, suggesting that organisms causing postoperative infection were present in the operative field before the operation).

side) via a double barbed titanium connector.126,127 There
have been four or more single-centre observational studies
that suggest a potential benefit of relocating the exit sitein patients with exit site infection refractory to antibiotics.15,124,125,127 Catheter exit site relocation success,defined as complete remission of infection not requiring
additional procedures beyond 1 month after the revision,
was 83% out of 52 patients,15 90% out of 33 patients127 and
69% out of 36 patients.125 Although there are no RCTs
comparing different strategies, the median PD catheter survival was 84 months, statistically higher than 49 months
among a comparative group treated conservatively, in one
observational study.127 Importantly, this procedure allows
continuation of PD. The strategy has also been reported tobe beneficial in managing NTM exit site infection.127
Treatment success without removing the entire catheter
depends on the level of infection; infection should not go
deeper than the superficial cuff.127,128 In case the inner cuff
is involved with infection as shown by ultrasound preoperatively129 or during the course of operative procedure, thewhole PD catheter should be removed.
According to a recent systematic review,130 as a whole,the quality of published evidence of these salvage interventions is considered low by virtue of study design. Metaanalysis was not possible, such that it remains uncertain as
to whether any technique is superior to others. Pooled analysis of cuff shaving or relocating exit site (including en
bloc resection of the infected tissue) showed that thesetechniques are safe with procedure complication rates at
2.7%.130 Table 3 summarises the reported outcomes ofdifferent surgical interventions.110,112,114,115,125–138,140,141

Future research
The optimal method of exit site care to prevent infection
remains poorly defined. Deciphering the risk factors andmechanisms underlying catheter infection and resolution of
infection may allow for greater progress in prevention andtreatment.
Adequately powered trials are also needed to better
define the optimal prophylactic interventions and treatment
durations for exit site infections and tunnel infections.
RCTs evaluating various antibiotic durations for treating

prosthetic joint infection142 and intraabdominal infection143 have been previously performed, but this has not
yet occurred for exit site infection complicating PD. Preliminary results144 or in vitro data145 for novel treatment
option such as antimicrobial action of vinegar or its active
ingredient acetic acid against Pseudomonas exit site infection should be explored. Emerging techniques, such as salvage with catheter exit site relocation, may improve PD
outcomes but have not yet been systematically evaluated.
Future improvements in catheter infection treatment may
include point-of-care ultrasound assessment and monitoring of treatment response.86 The incidence and prevalenceof NTM catheter infection rate is increasing.103 Given thepersistent nature of the infection, ongoing prospective collection of data from registries should clarify the recommended treatment strategy.
Finally, the benchmark for exit site infection rate, which
may in the long run drive the PD community to develop
more effective preventive strategies, has not yet been precisely established.
Acknowledgement
None.

Authors’ note
Philip Li and David Johnson are co-chairs of the ISPD Catheterrelated Infection Guidelines Working Group.

Author contributions
PKTL and DWJ contributed to the conceptualisation of the guideline. SWY, DWJ, YC, KMC, and PKTL conducted literaturesearch. DWJ, YC, KMC, PKTL wrote the original draft. All
authors contributed to the revision of the manuscript and the final
approval of the manuscript.

Declaration of conflicting interests
The author(s) declared the following potential conflicts of interest
with respect to the research, authorship, and/or publication of thisarticle: David Johnson has received consultancy fees, research
grants, speaker’s honoraria and travel sponsorships from Baxter
Healthcare and Fresenius Medical Care, consultancy fees from
Astra Zeneca, Bayer and AWAK, speaker’s honoraria from ONO
and Boehringer Ingelheim & Lilly, and travel sponsorships from
Ono and Amgen. He is a current recipient of an Australian14
National Health and Medical Research Council Leadership Investigator Grant. Edwina Brown has received speaker and/or consultancy fees from Baxter Healthcare, Fresenius Medical Care,
Vifor, liberDi, AWAK. Yasuhiko Ito has received research funding and/or lecture fees from Baxter, Terumo Corp. and JMS Co.,
Ltd. Ali Abu-Alfa has received grant support and/or speaking feesfrom Baxter Healthcare. Philip Li received speaker honoraria
from Astra Zeneca, Baxter Healthcare, Kyowa Kirin. Yeoungjee
Cho has received research grants and speaker’s honoraria from
Baxter Healthcare and Fresenius Medical Care. She is a current
recipient of an Australian National Health and Medical ResearchCouncil Emerging Leadership Investigator Grant and Queensland
Health Advancing Research Fellowship.

Ethical approval
Not applicable.

Funding
The author(s) received no financial support for the research,authorship, and/or publication of this article.

ORCID iDs
Kai Ming Chow
https://orcid.org/0000-0001-5310-5197
Philip Kam-Tao Li
https://orcid.org/0000-0001-9879-8388
Yeoungjee Cho
https://orcid.org/0000-0002-3502-9837
Edwina A Brown
https://orcid.org/0000-0002-4453-6486
Brett Cullis
https://orcid.org/0000-0001-8909-686X
Helen Hurst
https://orcid.org/0000-0002-7268-171X
Thyago Proença de Moraes
https://orcid.org/0000-00022983-3968
David W Johnson
https://orcid.org/0000-0001-5491-3460

Informed consent
Not applicable

References
1. Manera KE, Johnson DW, Craig JC, et al. Establishing a coreoutcome set for peritoneal dialysis: report of the SONG-PD(Standardized Outcomes in Nephrology-Peritoneal Dialysis)
consensus workshop. Am J Kidney Dis 2020; 75(3): 404–412.
2. Szeto CC, Li PK, Johnson DW, et al. ISPD catheter-related
infection recommendations: 2017 update. Perit Dial Int 2017;37(2): 141–154.
3. Li PK, Chow KM, Cho Y, et al. ISPD peritonitis guideline
recommendations: 2022 update on prevention and treatment.
Perit Dial Int 2022; 42(2): 110–153.
4. Atkins D, Best D, Briss PA, et al. Grading quality of evidence
and strength of recommendations. BMJ 2004; 328(7454):
1490.
5. Warady BA, Bakkaloglu S, Newland J, et al. Consensus
guidelines for the prevention and treatment of catheterrelated infections and peritonitis in pediatric patients receiving peritoneal dialysis: 2012 update. Perit Dial Int 2012;
32(Suppl 2): S32–S86.
6. Gonthier D, Bernardini J, Holley JL, et al. Erythema: Does it
indicate infection in a peritoneal catheter exit site? Adv Perit
Dial 1992; 8: 230–233.

Peritoneal Dialysis International XX(X)
7. Rigo M, Pecoits-Filho R, Lambie M, et al. Clinical utility of a
traditional score system for the evaluation of the peritoneal
dialysis exit-site infection in a national multicentric cohort
study. Perit Dial Int 2021; 41(3): 292–297.
8. Schmitt R, Haller H and Hiss M. Quiz page September 2012:
erythematous rash around peritoneal dialysis catheter exitsite. Am J Kidney Dis 2012; 60(3): A29–A31.
9. Schaefer F, Klaus G, Muller-Wiefel DE, et al. Intermittent
versus continuous intraperitoneal glycopeptide/ceftazidime
treatment in children with peritoneal dialysis-associated peritonitis. The Mid-European Pediatric Peritoneal Dialysis
Study Group (MEPPS). J Am Soc Nephrol 1999; 10(1):136–145.
10. Twardowski ZJ and Prowant BF. Classification of normal anddiseased exit sites. Perit Dial Int 1996; 16(Suppl 3):
S32–S50.
11. Plum J, Sudkamp S and Grabensee B. Results of ultrasoundassisted diagnosis of tunnel infections in continuous ambulatory peritoneal dialysis. Am J Kidney Dis 1994; 23(1):99–104.
12. van Diepen AT, Tomlinson GA and Jassal SV. The association between exit site infection and subsequent peritonitis
among peritoneal dialysis patients. Clin J Am Soc Nephrol
2012; 7(8): 1266–1271.
13. Bernardini J, Bender F, Florio T, et al. Randomized, doubleblind trial of antibiotic exit site cream for prevention of exitsite infection in peritoneal dialysis patients. J Am Soc Nephrol
2005; 16(2): 539–545.
14. Crabtree JH, Shrestha BM, Chow KM, et al. Creating andmaintaining optimal peritoneal dialysis access in the adultpatient: 2019 update. Perit Dial Int 2019; 39(5): 414–436.
15. Kang SH, Cho KH, Kim AY, et al. Catheter salvage using
revision for a peritoneal dialysis catheter with intractable
exit site and/or tunnel infections. Semin Dial 2022; 36(1):53–56.
16. Nataatmadja M, Cho Y and Johnson DW. Continuous quality
improvement initiatives to sustainably reduce peritoneal
dialysis-related infections in Australia and New Zealand.
Perit Dial Int 2016; 36(5): 472–477.
17. Boudville N, Johnson DW, Zhao J, et al. Regional variation in
the treatment and prevention of peritoneal dialysis-related
infections in the peritoneal dialysis outcomes and practicepatterns study. Nephrol Dial Transplant 2019; 34(12):2118–2126.
18. Mushahar L, Mei LW, Yusuf WS, et al. Exit-site dressing andinfection in peritoneal dialysis: a randomized controlled pilot
trial. Perit Dial Int 2016; 36(2): 135–139.
19. Lin J, Ye H, Li J, et al. Prevalence and risk factors of exit-site
infection in incident peritoneal dialysis patients. Perit Dial
Int 2020; 40(2): 164–170.
20. Htay H, Johnson DW, Wu SY, et al. Comparison of topicalchlorhexidine and mupirocin for the prevention of exit-site
infection in incident peritoneal dialysis patients. Perit Dial
Int 2017; 37(3): 266–272.

Chow et al.
21. Committee HTW, Zhang L, Badve SV, et al. Representativeness of honeypot trial participants to Australasian PD
patients. Perit Dial Int 2017; 37(5): 516–522.
22. Johnson DW, Badve SV, Pascoe EM, et al. Antibacterial
honey for the prevention of peritoneal-dialysis-related infections (HONEYPOT): a randomised trial. Lancet Infect Dis
2014; 14(1): 23–30.
23. Chen SS, Sheth H, Piraino B, et al. Long-term exit-site gentamicin prophylaxis and gentamicin resistance in a peritoneal
dialysis program. Perit Dial Int 2016; 36(4): 387–389.
24. Ferreira AC, Fernandes V, Rodrigues A, et al. Peritoneal
dialysis exit-site care protocols in Portugal and its association
with catheter-related infections. Blood Purif 2023; 52: 1–7.
25. Campbell D, Mudge DW, Craig JC, et al. Antimicrobial
agents for preventing peritonitis in peritoneal dialysis
patients. Cochrane Database Syst Rev 2017; 4: CD004679.
26. Gadallah MF, Ramdeen G, Torres C, et al. Preoperative vancomycin prophylaxis for newly placed peritoneal dialysis
catheters prevents postoperative peritonitis. Adv Perit Dial
2000; 16: 199–203.
27. Grothe C, Taminato M, Belasco A, et al. Prophylactic treatment of chronic renal disease in patients undergoing peritoneal dialysis and colonized by Staphylococcus aureus: asystematic review and meta-analysis. BMC Nephrol 2016;17(1): 115.
28. Htay H, Johnson DW, Craig JC, et al. Catheter type, placement and insertion techniques for preventing catheter-related
infections in chronic peritoneal dialysis patients. Cochrane
Database Syst Rev 2019; 5: CD004680.
29. Agarwal A, Whitlock RH, Bamforth RJ, et al. Percutaneous
versus surgical insertion of peritoneal dialysis catheters: asystematic review and meta-analysis. Can J Kidney Health
Dis 2021; 8: 20543581211052731.
30. Dombros N, Dratwa M, Feriani M, et al. European best practice guidelines for peritoneal dialysis. 3 Peritoneal access.
Nephrol Dial Transplant 2005; 20(Suppl 9): ix8–ix12.
31. Prowant BF and Twardowski ZJ. Recommendations for exit
care. Perit Dial Int 1996; 16(Suppl 3): S94–S99.
32. Htay H, Johnson DW, Craig JC, et al. Urgent-start peritoneal
dialysis versus conventional-start peritoneal dialysis for people with chronic kidney disease. Cochrane Database Syst Rev
2020; 12: CD012913.
33. Nessim SJ, Bargman JM and Jassal SV. Relationship between
double-cuff versus single-cuff peritoneal dialysis catheters
and risk of peritonitis. Nephrol Dial Transplant 2010;25(7): 2310–2314.
34. Eklund B, Honkanen E, Kyllonen L, et al. Peritoneal dialysis
access: prospective randomized comparison of single-cuff
and double-cuff straight Tenckhoff catheters. Nephrol Dial
Transplant 1997; 12(12): 2664–2666.
35. Crabtree JH, Burchette RJ, Siddiqi RA, et al. The efficacy
of silver-ion implanted catheters in reducing peritoneal
dialysis-related infections. Perit Dial Int 2003; 23(4):368–374.
36. Kim CY, Kumar A, Sampath L, et al. Evaluation of an
antimicrobial-impregnated continuous ambulatory peritoneal

15
dialysis catheter for infection control in rats. Am J Kidney Dis
2002; 39(1): 165–173.
37. Figueiredo AE, Bernardini J, Bowes E, et al. A syllabus forteaching peritoneal dialysis to patients and caregivers. Perit
Dial Int 2016; 36(6): 592–605.
38. Zhang L, Hawley CM, Johnson DW. Focus on peritoneal
dialysis training: working to decrease peritonitis rates.
Nephrol Dial Transplant 2016; 31(2): 214–222.
39. Cheetham MS, Zhao J, McCullough K, et al. International
peritoneal dialysis training practices and the risk of peritonitis. Nephrol Dial Transplant 2022; 37(5): 937–949.
40. Dryden MS, Ludlam HA, Wing AJ, et al. Active intervention
dramatically reduces CAPD-associated infection. Adv Perit
Dial 1991; 7: 125–128.
41. Hall G, Bogan A, Dreis S, et al. New directions in peritoneal
dialysis patient training. Nephrol Nurs J 2004; 31(2):149–154. 159–163.
42. Chow JS, Adams K, Cho Y, et al. Targeted Education
ApproaCH to improve Peritoneal Dialysis Outcomes(TEACH-PD): a feasibility study. Perit Dial Int 2020;40(2): 153–163.
43. Gokal R, Ash SR, Helfrich GB, et al. Peritoneal catheters andexit-site practices: toward optimum peritoneal access. Perit
Dial Int 1993; 13(1): 29–39.
44. Chang JH, Oh J, Park SK, et al. Frequent patient retraining at
home reduces the risks of peritoneal dialysis-related infections: a randomised study. Sci Rep 2018; 8(1): 12919.
45. Strippoli GF, Tong A, Johnson D, et al. Antimicrobial agentsto prevent peritonitis in peritoneal dialysis: a systematic
review of randomized controlled trials. Am J Kidney Dis
2004; 44(4): 591–603.
46. Tacconelli E, Carmeli Y, Aizer A, et al. Mupirocin prophylaxis to prevent Staphylococcus aureus infection in patients
undergoing dialysis: a meta-analysis. Clin Infect Dis 2003;
37(12): 1629–1638.
47. Bernardini J, Piraino B, Holley J, et al. A randomized trial of
Staphylococcus aureus prophylaxis in peritoneal dialysis
patients: mupirocin calcium ointment 2% applied to the exitsite versus cyclic oral rifampin. Am J Kidney Dis 1996; 27(5):695–700.
48. Xu G, Tu W and Xu C. Mupirocin for preventing exit-site
infection and peritonitis in patients undergoing peritoneal
dialysis. Nephrol Dial Transplant 2010; 25(2): 587–592.
49. Perez-Fontan M, Rosales M, Rodriguez-Carmona A, et al.
Mupirocin resistance after long-term use for staphylococcus
aureus colonization in patients undergoing chronic peritoneal
dialysis. Am J Kidney Dis 2002; 39(2): 337–341.
50. Piraino B.Mupirocin for preventing exit-site infection andperitonitis in patients undergoing peritoneal dialysis. Was it
effective? Nephrol Dial Transplant 2010; 25(2): 349–352.
51. Obata Y, Murashima M, Toda N, et al. Topical application ofmupirocin to exit sites in patients on peritoneal dialysis: asystematic review and meta-analysis of randomized controlled trials. Ren Replace Ther 2020; 6: 12.
52. Nochaiwong S, Ruengorn C, Noppakun K, et al. Comparative
Effectiveness of Local Application of Chlorhexidine

16
Gluconate, Mupirocin Ointment, and Normal Saline for thePrevention of Peritoneal Dialysis-related Infections(COSMO-PD Trial): a multicenter randomized, doubleblind, controlled protocol. Trials 2019; 20(1): 754.
53. Nessim SJ and Jassal SV. Gentamicin-resistant infections inperitoneal dialysis patients using topical gentamicin exit-site
prophylaxis: a report of two cases. Perit Dial Int 2012; 32(3):339–341.
54. Pierce DA, Williamson JC, Mauck VS, et al. The effect onperitoneal dialysis pathogens of changing topical antibiotic
prophylaxis. Perit Dial Int 2012; 32(5): 525–530.
55. Lo MW, Mak SK, Wong YY, et al. Atypical mycobacterial
exit-site infection and peritonitis in peritoneal dialysis
patients on prophylactic exit-site gentamicin cream. Perit
Dial Int 2013; 33(3): 267–272.
56. Wong PN, Tong GM, Wong YY, et al. Alternating mupirocin/gentamicin is associated with increased risk of fungal
peritonitis as compared with gentamicin alone – results of arandomized open-label controlled trial. Perit Dial Int 2016;
36(3): 340–346.
57. Zhang L, Badve SV, Pascoe EM, et al. The effect of exit-site
antibacterial honey versus nasal mupirocin prophylaxis on the
microbiology and outcomes of peritoneal dialysis-associatedperitonitis and exit-site infections: a sub-study of the honeypot trial. Perit Dial Int 2015; 35(7): 712–721.
58. McQuillan RF, Chiu E, Nessim S, et al. A randomized controlled trial comparing mupirocin and polysporin triple ointments in peritoneal dialysis patients: the MP3 Study. Clin
J Am Soc Nephrol 2012; 7(2): 297–303.
59. Nunez-Moral M, Sanchez-Alvarez E, Gonzalez-Diaz I, et al.
Exit-site infection of peritoneal catheter is reduced by the useof polyhexanide. Results of a prospective randomized trial.
Perit Dial Int 2014; 34(3): 271–277.
60. Findlay A, Serrano C, Punzalan S, et al. Increased peritoneal
dialysis exit site infections using topical antiseptic polyhexamethylene biguanide compared to mupirocin: results of asafety interim analysis of an open-label prospective randomized study. Antimicrob Agents Chemother 2013; 57(5):2026–2028.
61. Tam BM and Chow SK. A preliminary report on the effectiveness of nanotechnology anti-microbial spray dressing inpreventing Tenckhoff catheter exit-site infection. Perit Dial
Int 2014; 34(6): 670–673.
62. Khandelwal M, Bailey S, Izatt S, et al. Structural changes insilicon rubber peritoneal dialysis catheters in patients usingmupirocin at the exit site. Int J Artif Organs 2003; 26(10):913–917.
63. Gardezi AI, Schlageter KW, Foster DM, et al. Erosion of thesilicone peritoneal dialysis catheter with the use of gentamicin cream at the exit site. Adv Perit Dial 2016; 32: 15–18.
64. Riu S, Ruiz CG, Martinez-Vea A, et al. Spontaneous ruptureof polyurethane peritoneal catheter. A possible deleterious
effect of mupirocin ointment. Nephrol Dial Transplant
1998; 13(7): 1870–1871.
65. Luzar MA, Brown CB, Balf D, et al. Exit-site care and exitsite infection in continuous ambulatory peritoneal dialysis

Peritoneal Dialysis International XX(X)(CAPD): results of a randomized multicenter trial. Perit Dial
Int 1990; 10(1): 25–29.
66. Wilson AP, Lewis C, O’Sullivan H, et al. The use of povidone
iodine in exit site care for patients undergoing continuous
peritoneal dialysis (CAPD). J Hosp Infect 1997; 35(4):287–293.
67. Berns JS and Tokars JI. Preventing bacterial infections andantimicrobial resistance in dialysis patients. Am J Kidney Dis
2002; 40(5): 886–898.
68. Htay H, Choo JCJ, Johnson DW, et al. Chlorhexidineimpregnated sponge dressing for prevention of catheter
exit-site infection in peritoneal dialysis patients: a pilot study.
Int Urol Nephrol 2021; 53(4): 803–812.
69. Mendoza-Guevara L, Castro-Vazquez F, Aguilar-Kitsu A,
et al. Amuchina 10% solution, safe antiseptic for preventing
infections of exit-site of Tenckhoff catheters, in the pediatricpopulation of a dialysis program. Contrib Nephrol 2007; 154:
139–144.
70. Chua AN, Goldstein SL, Bell D, et al. Topical mupirocin/
sodium hypochlorite reduces peritonitis and exit-site infection rates in children. Clin J Am Soc Nephrol 2009; 4(12):1939–1943.
71. Jones LL, Tweedy L and Warady BA. The impact of exit-sitecare and catheter design on the incidence of catheter-related
infections. Adv Perit Dial 1995; 11: 302–305.
72. Shelton DM. A comparison of the effects of two antiseptic
agents on Staphylococcus epidermidis colony forming units
at the peritoneal dialysis catheter exit site. Adv Perit Dial
1991; 7: 120–124.
73. Ceri M, Yilmaz SR, Unverdi S, et al. Effect of local polyhexanide application in preventing exit-site infection andperitonitis: a randomized controlled trial. Ther Apher Dial
2020; 24(1): 81–84.
74. Wong SCY, Wong SC, Chen JHK, et al. Polyclonal Burkholderia cepacia complex outbreak in peritoneal dialysis
patients caused by contaminated aqueous chlorhexidine.
Emerg Infect Dis 2020; 26(9): 1987–1997.
75. Romero-Gomez MP, Quiles-Melero MI, Pena Garcia P, et al.
Outbreak of Burkholderia cepacia bacteremia caused bycontaminated chlorhexidine in a hemodialysis unit. InfectControl Hosp Epidemiol 2008; 29(4): 377–378.
76. Kaitwatcharachai C, Silpapojakul K, Jitsurong S, et al. An
outbreak of Burkholderia cepacia bacteremia in hemodialysis
patients: an epidemiologic and molecular study. Am J Kidney
Dis 2000; 36(1): 199–204.
77. Gleeson S, Mulroy E, Bryce E, et al. Burkholderia cepacia:
an outbreak in the peritoneal dialysis unit. Perit Dial Int
2019; 39(1): 92–95.
78. Ding XR, Huang HE, Liao YM, et al. Daily self-care practices influence exit-site condition in patients having peritoneal dialysis: a multicenter cross-sectional survey. J Adv Nurs
2021; 77(5): 2293–2306.
79. Bennett PN, Bohm C, Harasemiw O, et al. Physical activity
and exercise in peritoneal dialysis: International Society for
Peritoneal Dialysis and the global renal exercise network
practice recommendations. Perit Dial Int 2022; 42(1): 8–24.

Chow et al.
80. Soetendorp H, Kliuk-Ben Bassat O, Wasserman A, et al.
Water avoidance and modification of exit-site care withstoma bag results in reduced exit-site infection rate in peritoneal dialysis patients. Clin Nephrol 2021; 95(6): 323–331.
81. Taheri S, Ahmadnia M, Mortazavi M, et al. Comparing theeffect of dressing versus no-dressing on exit site infection
and peritonitis in chronic ambulatory peritoneal dialysis
patients. Adv Biomed Res 2017; 6: 5.
82. Figueiredo AE, de Mattos C, Saraiva C, et al. Comparison
between types of dressing following catheter insertion andearly exit-site infection in peritoneal dialysis. J Clin Nurs
2017; 26(21–22): 3658–3663.
83. Vychytil A, Lilaj T, Lorenz M, et al. Ultrasonography of thecatheter tunnel in peritoneal dialysis patients: What are theindications? Am J Kidney Dis 1999; 33(4): 722–727.
84. Korzets Z, Erdberg A, Golan E, et al. Frequent involvementof the internal cuff segment in CAPD peritonitis and exitsite infection – an ultrasound study. Nephrol Dial Transplant 1996; 11(2): 336–339.
85. Kwan TH, Tong MK, Siu YP, et al. Ultrasonography in the
management of exit site infections in peritoneal dialysis
patients. Nephrology (Carlton) 2004; 9(6): 348–352.
86. Granata A, Rahbari E, Di Nicolo P, et al. The underrated
role of ultrasound in peritoneal dialysis. J Ultrasound Med
2022; 41(2): 301–310.
87. Granata A, Rahbari E, Pesce F, et al. Contrast-enhanced
ultrasound in peritoneal dialysis: when and how to perform
it. J Nephrol 2022; 35(5): 1329–1337.
88. Hui YH, So WK, Ng MS, et al. Treating peritoneal dialysis
catheter exit-site granulomas with chlorhexidine swabstick:a pilot study. J Ren Care 2021; 47(2): 103–112.
89. Matinfar M, Taheri S, Karimi S, et al. Successful treatmentof peritoneal dialysis catheter exit-site granuloma with silver
ion-based dressing. J Vasc Access 2021; 22(4): 685–686.
90. Winthrop KL, Ku JH, Marras TK, et al. The tolerability oflinezolid in the treatment of nontuberculous mycobacterial
disease. Eur Respir J 2015; 45(4): 1177–1179.
91. Au CWH, Yap DYH, Chan JFW, et al. Exit site infection
and peritonitis due to Serratia species in patients receiving
peritoneal dialysis: epidemiology and clinical outcomes.
Nephrology (Carlton) 2021; 26(3): 255–261.
92. Yap DY, Choy CB, Mok MM, et al. Burkholderia cepacia –an uncommon cause of exit-site infection in a peritoneal
dialysis patient. Perit Dial Int 2014; 34(4): 471–472.
93. Lew SQ, Wallace EL, Srivatana V, et al. Telehealth forhome dialysis in COVID-19 and beyond: a perspective fromthe American society of nephrology COVID-19 home dialysis subcommittee. Am J Kidney Dis 2021; 77(1): 142–148.
94. Montravers P, Snauwaert A and Welsch C. Current guidelines and recommendations for the management of skin andsoft tissue infections. Curr Opin Infect Dis 2016; 29(2):131–138.
95. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft
tissue infections: 2014 update by the Infectious Diseases
Society of America. Clin Infect Dis 2014; 59(2): 147–159.

17
96. Auricchio S, Giovenzana ME, Pozzi M, et al. Fungal peritonitis in peritoneal dialysis: a 34-year single centre evaluation.
Clin Kidney J 2018; 11(6): 874–880.
97. Li R, Zhang D, He J, et al. Characteristics analysis, clinicaloutcome and risk factors for fungal peritonitis in peritoneal
dialysis patients: a 10-year case-control study. Front Med(Lausanne) 2021; 8: 774946.
98. Lo CY, Chu WL, Wan KM, et al. Pseudomonas exit-site
infections in CAPD patients: evolution and outcome of treatment. Perit Dial Int 1998; 18(6): 637–640.
99. Kazmi HR, Raffone FD, Kliger AS, et al. Pseudomonas exitsite infections in continuous ambulatory peritoneal dialysis
patients. J Am Soc Nephrol 1992; 2(10): 1498–1501.
100. Burkhalter F, Clemenger M, Haddoub SS, et al. Pseudomonas exit-site infection: treatment outcomes with topical gentamicin in addition to systemic antibiotics. Clin Kidney J
2015; 8(6): 781–784.
101. Szeto CC, Chow KM, Kwan BC, et al. Staphylococcus aureus peritonitis complicates peritoneal dialysis: review of
245 consecutive cases. Clin J Am Soc Nephrol 2007; 2(2):245–251.
102. Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for thetreatment of methicillin-resistant Staphylococcus aureus
infections in adults and children: executive summary. Clin
Infect Dis 2011; 52(3): 285–292.
103. Bnaya A, Wiener-Well Y, Soetendorp H, et al. Nontuberculous mycobacteria infections of peritoneal dialysis
patients: a multicenter study. Perit Dial Int 2021; 41(3):284–291.
104. Griffith DE, Aksamit T, Brown-Elliott BA, et al. An official
ATS/IDSA statement: diagnosis, treatment, and preventionof nontuberculous mycobacterial diseases. Am J Respir Crit
Care Med 2007; 175(4): 367–416.
105. Chamarthi G, Modi D, Andreoni K, et al. Simultaneouscatheter removal and reinsertion, is it acceptable in
M. abscessus exit site infection? CEN Case Rep 2021;
10(4): 483–489.
106. Vychytil A, Lorenz M, Schneider B, et al. New criteria for
management of catheter infections in peritoneal dialysis
patients using ultrasonography. J Am Soc Nephrol 1998;
9(2): 290–296.
107. Beckwith H, Clemenger M, McGrory J, et al. Repeat peritoneal dialysis exit-site infection: definition and outcomes.
Perit Dial Int 2019; 39(4): 344–349.
108. Nadarajah L, Yaqoob MM and Fan S. Persistent colonization of exit site is associated with modality failure in peritoneal dialysis. Perit Dial Int 2022; 42(1): 96–99.
109. Szeto CC, Chow KM, Wong TY, et al. Feasibility of resuming peritoneal dialysis after severe peritonitis and Tenckhoff
catheter removal. J Am Soc Nephrol 2002; 13(4):1040–1045.
110. Lui SL, Yip T, Tse KC, et al. Treatment of refractory Pseudomonas aeruginosa exit-site infection by simultaneous
removal and reinsertion of peritoneal dialysis catheter. Perit
Dial Int 2005; 25(6): 560–563.

18111. Posthuma N, Borgstein PJ, Eijsbouts Q, et al. Simultaneous
peritoneal dialysis catheter insertion and removal incatheter-related infections without interruption of peritoneal
dialysis. Nephrol Dial Transplant 1998; 13(3): 700–703.
112. Crabtree JH and Siddiqi RA. Simultaneous catheter replacement for infectious and mechanical complications without
interruption of peritoneal dialysis. Perit Dial Int 2016;
36(2): 182–187.
113. Paterson AD, Bishop MC, Morgan AG, et al. Removal andreplacement of Tenckhoff catheter at a single operation:
successful treatment of resistant peritonitis in continuous
ambulatory peritoneal dialysis. Lancet 1986; 2(8518):
1245–1247.
114. Swartz R, Messana J, Reynolds J, et al. Simultaneous catheter replacement and removal in refractory peritoneal dialysis
infections. Kidney Int 1991; 40(6): 1160–1165.
115. Scalamogna A, Nardelli L, Zubidat D, et al. Simultaneous
replacement and removal of the peritoneal catheter is effective in patients with refractory tunnel infections sustained by
S. aureus. Int Urol Nephrol 2023; 55(1): 151–155.
116. Washida N and Itoh H. The role of non-tuberculous mycobacteria in peritoneal dialysis-related infections: a literature
review. Contrib Nephrol 2018; 196: 155–161.
117. Yoshimura R, Kawanishi M, Fujii S, et al. Peritoneal
dialysis-associated infection caused by Mycobacterium
abscessus: a case report. BMC Nephrol 2018; 19(1): 341.
118. Scalamogna A, Nardelli L and Castellano G. The use ofmini-invasive surgical techniques to treat refractory exitsite and tunnel infections in peritoneal dialysis patients: aclinical approach. J Nephrol. Epub ahead of print 15 Dec
2022. DOI: 10.1007/s40620-022-01479-7.
119. Taber TE, Hegeman TF, York SM, et al. Treatment of pseudomonas infections in peritoneal dialysis patients. Perit Dial
Int 1991; 11(3): 213–216.
120. Meng C, Beco A, Oliveira A, et al. Peritoneal dialysis cuffshaving – a salvage therapy for refractory exit-site infections. Perit Dial Int 2019; 39(3): 276–281.
121. Scalamogna A, De Vecchi A, Maccario M, et al. Cuffshaving procedure. A rescue treatment for exit-site infection
unresponsive to medical therapy. Nephrol Dial Transplant
1995; 10(12): 2325–2327.
122. Debowski JA, Waerp C, Kjellevold SA, et al. Cuff extrusionin peritoneal dialysis: single-centre experience with thecuff-shaving procedure in five patients over a 4-year period.
Clin Kidney J 2017; 10(1): 131–134.
123. Tan SY and Thiruventhiran T. Catheter cuff shaving using anovel technique: a rescue treatment for persistent exit-site
infections. Perit Dial Int 2000; 20(4): 471–472.
124. Kirmizis D, Bowes E, Ansari B, et al. Exit-site relocation: anovel, straightforward technique for exit-site infections.
Perit Dial Int 2019; 39(4): 350–355.
125. Cho KH, Do JY, Park JW, et al. Catheter revision for thetreatment of intractable exit site infection/tunnel infection inperitoneal dialysis patients: a single centre experience.
Nephrology (Carlton) 2012; 17(8): 760–766.

Peritoneal Dialysis International XX(X)126. Clouatre Y, Cartier P, Charbonneau R, et al. Outpatient
CAPD catheter salvage for persistent exit-site/tunnel infection. Nephrol Dial Transplant 2000; 15(2): 231–234.
127. Oki R, Hamasaki Y, Komaru Y, et al. Catheter diversion
procedure with exit-site renewal promotes peritoneal dialysis catheter survival. Kidney Int Rep 2021; 6(2):325–332.
128. Nichols WK and Nolph KD. A technique for managing exitsite and cuff infection in Tenckhoff catheters. Perit Dial Int
1983; 3(4): 4–5.
129. Muraoka K, Ishibashi Y, Yamaguchi J, et al. Early partial
re-implantation of Tenckhoff catheters to treat intractable
exit-site or tunnel infection. Perit Dial Int 2011; 31(3):350–353.
130. Soon JJY, Ng NZP, Lee SQ, et al. Are salvage techniquessafe and effective in the treatment of peritoneal dialysis
catheter-related exit-site and tunnel infections? A systematic
review and description of the authors’ preferred technique.
Perit Dial Int 2022; 42(6): 591–601.
131. Cancarini GC, Manili L, Brunori G, et al. Simultaneous catheter replacement-removal during infectious complications inperitoneal dialysis. Adv Perit Dial 1994; 10: 210–213.
132. Cheung AH, Wheeler MS, Limm WM, et al. A salvage technique for continuous ambulatory peritoneal dialysis catheterswith exit-site infections. Am J Surg 1995; 170(1): 60–61.
133. Wu YM, Tsai MK, Chao SH, et al. Surgical management ofrefractory exit-site/tunnel infection of Tenckhoff catheter:
technical innovations of partial replantation. Perit Dial Int
1999; 19(5): 451–454.
134. Fukasawa M, Matsushita K, Tanabe N, et al. A novel salvage technique that does not require catheter removal for
exit-site infection. Perit Dial Int 2002; 22(5): 618–621.
135. Yang PJ, Lee CY, Yeh CC, et al. Mini-laparotomy implantation of peritoneal dialysis catheters: outcome and rescue.
Perit Dial Int 2010; 30(5): 513–518.
136. Macchini F, Testa S, Valade A, et al. Conservative surgicalmanagement of catheter infections in children on peritoneal
dialysis. Pediatr Surg Int 2009; 25(8): 703–707.
137. Crabtree JH and Burchette RJ. Surgical salvage of peritoneal
dialysis catheters from chronic exit-site and tunnel infections. Am J Surg 2005; 190(1): 4–8.
138. Terawaki H, Nakano H, Ogura M, et al. Unroofing surgery
with en bloc resection of the skin and tissues around the
peripheral cuff. Perit Dial Int 2013; 33(5): 573–576.
139. Mangram AJ, Horan TC, Pearson ML, et al. Guideline forprevention of surgical site infection, 1999. Hospital infection control practices advisory committee. Infect Control
Hosp Epidemiol 1999; 20(4): 250–278. quiz 279–280.
140. Schroder CH, Severijnen RS, de Jong MC, et al. Chronic
tunnel infections in children: removal and replacement of
the continuous ambulatory peritoneal dialysis catheter in asingle operation. Perit Dial Int 1993; 13(3): 198–200.
141. Goldraich I, Mariano M, Rosito N, et al. One-step peritoneal
catheter replacement in children. Adv Perit Dial 1993; 9:
325–328.

Chow et al.
142. Bernard L, Arvieux C, Brunschweiler B, et al. Antibiotic
therapy for 6 or 12 weeks for prosthetic joint infection.
N Engl J Med 2021; 384(21): 1991–2001.
143. Sawyer RG, Claridge JA, Nathens AB, et al. Trial of shortcourse antimicrobial therapy for intraabdominal infection.
N Engl J Med 2015; 372(21): 1996–2005.
144. Leung DKC, Mok WFM, Yu DMW, et al. Use of distilled
white vinegar dressing supplemental to oral antibiotics in19
the management of Pseudomonas aeruginosa exit site infection in continuous ambulatory peritoneal dialysis patients.
Hong Kong J Nephrol 2001; 3(1): 38–40.
145. Carson CF, Ash O and Chakera A. In vitro data support
the investigation of vinegar as an antimicrobial agent for
PD-associated Pseudomonas exit site infections. Nephrology (Carlton) 2017; 22(2): 179–181.