Treatment of exit-site and tunnel infections
Exit-site infection is defined as the presence of purulent discharge from the site where the dialysis catheter exits the skin, with or without erythema of the skin. Tunnel infection is defined as clinical or radiological evidence of inflammation or collection along the catheter tunnel. These infections may occur independently of each other or simultaneously. If exit-site or tunnel infection is associated with peritonitis, intraperitoneal antibiotic therapy is required – see Assessment and aetiology of peritonitis complicating peritoneal dialysis.
Collect swabs or purulent fluid for Gram stain, culture and susceptibility testing to guide management. The most common pathogens in exit-site and tunnel infections are Staphylococcus aureus and Pseudomonas aeruginosa, but other bacteria and fungi may also be involved.
For exit-site or tunnel infection in adults and children without previous infection or colonisation with methicillin-resistant S. aureus (MRSA) or P. aeruginosa, use:
flucloxacillin 500 mg (child: 12.5 mg/kg up to 500 mg) orally, 8-hourly12; see below for duration of therapy. flucloxacillin flucloxacillin flucloxacillin
Cefalexin is often preferred to flucloxacillin in children, because the liquid formulation is better tolerated. For exit-site or tunnel infection in children without previous infection or colonisation with MRSA or P. aeruginosa, use:
cefalexin 12.5 mg/kg up to 500 mg orally, 12-hourly13; see below for duration of therapy. cefalexin cefalexin cefalexin
For exit-site or tunnel infection in adults and children with previous infection or colonisation with MRSA, use an oral antibiotic to which the prior isolate tested susceptible. If susceptibility results are not available, use:
clindamycin 450 mg (child: 10 mg/kg up to 450 mg) orally, 8-hourly14; see below for duration of therapy. clindamycin clindamycin clindamycin
If a suitable formulation of clindamycin is not available for children, seek expert advice.
For exit-site or tunnel infection in adults and children in whom P. aeruginosa is suspected based on previous infection or Gram stain, useLi, Chow, , 2022:
ciprofloxacin 500 mg (child: 12.5 mg/kg up to 500 mg) orally, daily15; see below for duration of therapy. ciprofloxacin ciprofloxacin ciprofloxacin
Phosphate binders bind to ciprofloxacin; separate the doses to avoid reducing absorption and activity of ciprofloxacin. For comprehensive information on drug interactions, consult an appropriate drug information resource.
Modify therapy for exit-site and tunnel infections based on Gram stain, culture and susceptibility results.
The total duration of therapy isChow, 2023:
- for exit-site infection
- caused by P. aeruginosa – 3 weeks
- caused by other pathogens – 2 weeks
- for tunnel infection – 3 weeksChow, 2023.
Consider removing the peritoneal dialysis catheter and reinserting a catheter at a new site if the exit-site or tunnel infection:
- does not resolve with appropriate antibiotic therapy
- progresses to, or occurs simultaneously with, peritonitis due to the same organism.
Seek expert advice for timing of reinsertion of the catheter.