1 / 36

Mupirocin vs. Gentamicin in the Prevention of PD-related Infections

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.

oria
Download Presentation

Mupirocin vs. Gentamicin in the Prevention of PD-related Infections

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Mupirocin vs. Gentamicin in the Prevention of PD-related Infections Mary Elliot Nov. 23, 2010

  2. Outline • Objectives • Overview of case • DRPs • Background on peritoneal dialysis and peritonitis • Clinical question • Literature Review • Recommendation and monitoring plan

  3. 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

  4. The Man of the Hour

  5. The Man of the Hour

  6. The Man of the Hour

  7. Current Medications

  8. Current Medications

  9. Pertinent Lab Values • Anemia • Mineral bone disease • Electrolytes and other values of interest

  10. 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.

  11. Peritoneal Dialysis http://solacedme.com/Renal.aspx

  12. 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.

  13. 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.

  14. 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

  15. 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.

  16. PICO

  17. 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

  18. 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

  19. J Am Soc Nephrol 2005;16:539-45

  20. 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

  21. 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

  22. 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

  23. 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

  24. Pent Dial Int. 2008 Sep-Oct:28(5);505-8

  25. Pent Dial Int. 2008 Sep-Oct:28(5);505-8

  26. 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

  27. 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.

  28. p = 0.75 p = 0.22 p = 0.45 Adv Perit Dial. 2009;25:56-9.

  29. p = 0.07 p = 0.08 p = 0.83 Adv Perit Dial. 2009;25:56-9.

  30. 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

  31. Comparison of gentamicin ointment to mupirocin ointment for prevention of peritoneal dialysis catheter-related infections. VGH based study – Wu, Greanya, Shalansky

  32. 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

  33. 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

  34. 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.

  35. Monitoring

  36. Thank-you!Questions?

More Related