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Mupirocin vs. Gentamicin in the Prevention of PD-related Infections. Mary Elliot Nov. 23, 2010. Outline. Objectives Overview of case DRPs Background on peritoneal dialysis and peritonitis Clinical question Literature Review Recommendation and monitoring plan. Objectives.
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Mupirocin vs. Gentamicin in the Prevention of PD-related Infections Mary Elliot Nov. 23, 2010
Outline • Objectives • Overview of case • DRPs • Background on peritoneal dialysis and peritonitis • Clinical question • Literature Review • Recommendation and monitoring plan
Objectives • Be able to describe the mechanism of peritoneal dialysis (PD) as related back to JW • Know the 3 types of infections that can occur as complications during peritoneal dialysis • Understand the current evidence behind choosing a prophylactic treatment for PD related infections and be able to apply this back to JW
Pertinent Lab Values • Anemia • Mineral bone disease • Electrolytes and other values of interest
DRPs • JW is at risk of developing a peritoneal dialysis related infection upon restarting PD and requires review of technique and assessment of prophylactic therapy • JW is at JW is at risk of increased drowsiness secondary to a recently increase in dose of pregabalin for the treatment of neuropathic pain and requires monitoring.
Peritoneal Dialysis http://solacedme.com/Renal.aspx
Peritoneal Dialysis • Various regimens available: • CAPD (continuous ambulatory PD) where multiple exchanges, generally 4, are performed daily with 2L at each exchange • APD (automated PD) where a mechanized cycler infuses and drains dialysate at night • CCPD (continuous cycling PD) involves using the cycler at night plus a daytime fill. • Desirable for people who wish to keep a flexible, active lifestyle, to whom dialysis units are not easily accessible, or who cannot tolerate the fluid shifts and blood-pressure swings associated with hemodialysis.
Peritoneal Dialysis • Complications • Exit site infections (ESI) • Purulent drainage from exit site +/- erythema • Tunnel infections • Erythema, edema, or tenderness over SQ pathway • Peritonitis • Patients typically present with abdominal pain, fever, and cloudy dialysate solution. • Most commonly caused by Staph aureus or Pseudomonas aeruginosa.
Peritonitis Prevention • Proper technique for exit site care • Flushing the line with dialysate prior to filling the abdomen reduces the risk of peritonitis from contamination. • Antibiotic ointment to exit site daily after cleansing • Mupirocin: covers gram positive (S. Aureus) • Gentamicin: covers S. Aureus and gram negative (including pseudomonas) • Either of these therapies are recommended in the ISPD guidelines. Perit Dial Int. 2005 Mar-Apr;25(2):107-31
Goals of Therapy • Prevent recurrence of exit site infection and peritonitis in JW. • Prevent complications of peritonitis in JW such as peritoneal membrane failure, hospitalization, and death. • Avoid adverse effects such as exit site irritation and rash.
Search Strategy • Pubmed, Embase, Web of Science • Search terms: mupirocin, gentamicin, peritonitis, peritoneal dialysis • Limits: English, humans • Results: 3 studies directly comparing mupirocin and gentamicin in PD patients. • Local research
Randomized, Double-Blind Trial of Antibiotic Exit Site Cream for Prevention of Exit Site Infection in Peritoneal Dialysis Patients; Bernardini et al. J Am Soc Nephrol 2005;16:539-45
Randomized, Double-Blind Trial of Antibiotic Exit Site Cream for Prevention of Exit Site Infection in Peritoneal Dialysis Patients; Bernardini et al. J Am Soc Nephrol 2005;16:539-45
Randomized, Double-Blind Trial of Antibiotic Exit Site Cream for Prevention of Exit Site Infection in Peritoneal Dialysis Patients; Bernardini et al. J Am Soc Nephrol 2005;16:539-45
Randomized, Double-Blind Trial of Antibiotic Exit Site Cream for Prevention of Exit Site Infection in Peritoneal Dialysis Patients; Bernardini et al. J Am Soc Nephrol 2005;16:539-45 • Catheter removal rates similar between two groups • Adverse effects: Exit site irritation, led to withdrawal in 7 patients of each arm. • Conclusion: Gentamicin applied to exit site was highly effective in reducing P. aeruginosa infections and was as effective as mupirocin in preventing S. aureus infections. • Comments: • Designed to look at exit site infection rates as opposed to peritonitis rates, however, still found a difference. • Stopped early
A PROSPECTIVE STUDY OF THE EFFICACY OF LOCAL APPLICATION OF GENTAMICIN VERSUS MUPIROCIN IN THE PREVENTION OF PERITONEAL DIALYSIS CATHETER-RELATED INFECTIONS. Chu et al. Pert Dial Int. 2008;28:505-8
A PROSPECTIVE STUDY OF THE EFFICACY OF LOCAL APPLICATION OF GENTAMICIN VERSUS MUPIROCIN IN THE PREVENTION OF PERITONEAL DIALYSIS CATHETER-RELATED INFECTIONS. Chu et al. Pent Dial Int. 2008 Sep-Oct:28(5);505-8 • Side effects notes were local irritation, itching, and rash • Conclusions: • Peritonitis occurred at the same rates in both groups. • Gentamicin was not superior to mupirocin in the prevention of exit site infections • Catheter removal required in 1 x mup and 2 x gent • Limitations: • Small sample size, single site • No mention of randomization or blinding • No power calculation performed • No parameters specified for diagnosis of infection
Comparison of Gentamicin and Mupirocin in the Prevention of Exit-Site Infection and Peritonitis in Peritoneal Dialysis. Mahaldar et al. Adv Perit Dial. 2009;25:56-9.
p = 0.75 p = 0.22 p = 0.45 Adv Perit Dial. 2009;25:56-9.
p = 0.07 p = 0.08 p = 0.83 Adv Perit Dial. 2009;25:56-9.
Comparison of Gentamicin and Mupirocin in the Prevention of Exit-Site Infection and Peritonitis in Peritoneal Dialysis. Mahaldar et al. Adv Perit Dial. 2009;25:56-9. • Conclusion: No difference in rates of ESI between the two groups, with a non-statistically significant trend towards higher rates of peritonitis in gentamicin group. • Limitations: • Small sample size and infection rate • Retrospective, therefore not controlled for other contributing factors such as aseptic exit-site care. • Inaccurate chart documentation may have led to over to under reporting of cases of infection. • Single site
Comparison of gentamicin ointment to mupirocin ointment for prevention of peritoneal dialysis catheter-related infections. VGH based study – Wu, Greanya, Shalansky
Comparison of gentamicin ointment to mupirocin ointment for prevention of peritoneal dialysis catheter-related infections. VGH based study – Wu, Greanya, Shalansky • Conclusion: Similar incidence in infection rate in gentamicin arm as mupirocin arm with less peritonitis and similar gram +ve infection rates. • Limitations: Interim analysis with gentamicin arm incomplete. Mupirocin arm is retrospective therefore data could be missing or incomplete. * P = peritonitis
Summary • Efficacy • Bernardini et al: Gentamicin arm showed a statistically significant lower rate in both exit site infections and peritonitis over the mupirocin arm. • No other study showed a statistically significant difference between the two groups. • Safety • Side effects were minimal in both groups and included exit site irritation, itching, and rash • Cost: • Mupirocin: $14.14 Gentamicin: $14.31
Back to the Case • JW has recently had his catheter removed secondary to recurrent exit site infections, for which cultures have grown gram positive cocci. • Evidence shows gentamicin ointment prevents gram negative and gram positive infections. • Once the catheter is reinserted recommend using gentamicin applied daily to exit site for prevention of PD related infections.