Current approach to exit-site infections in patients on peritoneal dialysis.

John Hershey is a 25-year-old man with ESRD secondary to interstitial nephritis. He has a swan-neck, coiled peritoneal dialysis catheter implanted 10 weeks ago and is doing nightly tidal peritoneal dialysis and still has good residual renal function. A week ago John called his primary nurse at the PD clinic to report ‘I think I hurt my exit site. It is red, and there was some drainage’. A culture of the exit site was taken and the patient was given a prescription for oral ciprofloxacin 500 mg twice daily for 10 days. Mr Hershey was also advised to apply mupirocin ointment to the exit once daily. Today Mr Hershey has an exit-site assessment as part of a routine clinic visit. He has completed 7 days Fig. 1. External exit 1 week after trauma. Slightly exuberant granulaof antibiotic therapy. There is a small amount of clear tion tissue from 1 to 3 o’clock; this area looks moist. Purplish-pink drainage on the exit-site dressing. The external exit site skin discoloration adjacent to granulation tissue. (Figure 1) has slightly exuberant granulation tissue from 1 to 3 o’clock and this area looks moist. Some purplish-pink discoloration is seen adjacent to the granulation tissue. The sinus visible in Figure 2 has no epithelium, there is fleshy granulation tissue from 2 to 5 o’clock. It is di cult to di erentiate whether the moisture between the granulation tissue and the catheter is drainage or mupirocin ointment. The exit has deteriorated since the trauma, in spite of local and systemic antibiotic therapy. There was no growth on the exit-site culture, 8 days ago. The granulation tissue is cauterized with a silver nitrate stick. Figure 3 shows the whitish-grey appearance of the granulation tissue after cauterization. Mr. Hershey is told to complete the course of ciprofloxacin and continue using mupirocin ointment daily. One week later Mr. Hershey returns to the clinic for exit-site evaluation. The external exit site (Figure 4)