tunnel infections using mupirocin

KHA-CARI Guidelines – Caring for Australasians with Renal Impairment _________________________________________________________________________________...
Author: Cameron Sanders
1 downloads 0 Views 606KB Size
KHA-CARI Guidelines – Caring for Australasians with Renal Impairment ______________________________________________________________________________________

Prophylaxis for exit site/tunnel infections using mupirocin Date written: May 2013 Author: Josephine Chow

GUIDELINES a. Prophylactic therapy using mupirocin ointment, especially for S. aureus carriage (intranasally or at exit site) is recommended to decrease the risk of S. aureus catheter exit site/tunnel infections and peritonitis (Evidence level 1). b. Mupirocin prophylaxis is also effective at preventing exit site infection due to nonStaphylococcal organisms. (Evidence level I).

SUGGESTIONS FOR CLINICAL CARE (Suggestions are based on Level III and IV evidence) 

There is variable practice as to when to start using prophylactic mupirocin, the site of administration, frequency and duration of treatment. In most of the published studies, nasal mupirocin ointment was applied twice daily for 5 consecutive days every 4 weeks during the trial. Alternatively, mupirocin ointment was applied to the exit site daily and continuously.



We suggest cleaning the peritoneal dialysis catheter exit site daily and applying a topical antimicrobial agent (either mupirocin or gentamicin).

IMPLEMENTATION AND AUDIT   

Units could perform an audit of their S. aureus infection rate. Units could evaluate the organisms causing exit site infection (ESI) and institute a protocol to diminish such risk. Audit the emergence of mupirocin resistance.

BACKGROUND Catheter exit site/tunnel infections are a major cause of S. aureus peritonitis in peritoneal dialysis (PD) patients. Hence, the prevention of ESI and tunnel infection due to S. aureus is important. A number of studies have reported that the application of mupirocin ointment intranasally or to the catheter exit site prophylactically, reduces S. aureus ESI/tunnel infection and peritonitis when compared with historical controls. Some of these studies involving mupirocin treatment dated back to the 1990s. There are a number of recent randomised controlled trials (RCTs), systematic reviews and a Cochrane review evaluating the application of mupirocin which was effective for the prevention of ESI and peritonitis in patients undergoing PD. The daily use of mupirocin does not appear to lead to significant levels of resistance in the short term [1], but the levels of resistant organisms isolated become more significant with longer periods. [2] After 4 years of continuous use, a significant problem can develop. [3] There is currently a RCT underway to investigate daily exit-site application of standardised antibacterial honey. [4]

Peritonitis Treatment and Prophylaxis

(February 2014)

KHA-CARI Guidelines – Caring for Australasians with Renal Impairment ______________________________________________________________________________________

The objective of this guideline is to review the current evidence for the application of mupirocin prophylactically in the prevention and management of catheter exit site and tunnel infection.

SEARCH STRATEGY Databases searched: MeSH terms and text words for peritoneal dialysis were combined with MeSH terms and text words for catheter, peritonitis, exit site infection and tunnel infection. The search was carried out in Medline (1950 – November Week 3, 2009). The Cochrane Renal Group Trials Register was also searched for trials not indexed in Medline. Date of searches: 11 December 2009; 14 October 2010.

WHAT IS THE EVIDENCE? Systematic reviews/meta-analysis Xu et al [5] conducted a systematic review to examine whether the application of mupirocin was effective for the prevention of ESI and peritonitis in PD patients. They found 14 studies discussed in 13 articles, a total of 1233 patients in the mupirocin group versus 1217 controls. These studies evaluated the efficacy of mupirocin intranasally or by topical application to the exit site in which either method demonstrated a risk reduction in the rate of S. aureus infection among the mupirocin-treated patients. Based on the three recent RCTs, the relative risk reduction for mupirocin treatment was found to be 73% (95% CI: 0.63–0.80, P < 0.0001). Furthermore, mupirocin treatment reduced the risk of ESI by 46% (95% CI: 0.35–0.55, P< 0.00001) for infection due to any organism. Peritonitis due to S. aureus was also found to be reduced by 40% (95% CI: 0.17–0.56, P = 0.002). The systematic review concluded that prophylaxis with mupirocin ointment was effective in the prevention of ESI and peritonitis due to S. aureus in PD patients. Mupirocin prophylaxis was also effective in preventing ESI due to other organisms. One limitation of this meta-analysis was the inclusion of both RCTs and historical cohort studies. The three RCTs were conducted before 2003. Strippol et al [6] conducted a Cochrane review on RCTs and quasi-RCTs on the effect of antimicrobial agents on the prevention of peritonitis in PD patients. Nineteen eligible trials (1949 patients) reported in 23 publications were included in this review. It was concluded that nasal mupirocin compared with placebo significantly reduced the exit-site and tunnel infection rate (1 trial, 2716 patient-months): RR 0.58 (95% CI: 0.40-0.85) and S. aureus nasal carriage fell to 10% to 18% in mupirocin-treated patients versus 48% to 61% in placebo-treated patients (P < 0.001). Lockwood et al [7] conducted a systematic review as part of the Joanna Briggs Institute project on the clinical effectiveness of different approaches to PD catheter exit-site care. The results of the review did not strongly recommend any specific antibiotic, antiseptic, or dressing procedure for use in the prevention or reduction of ESI rates or peritonitis. However, it was recommended that prophylactic therapy using mupirocin ointment at the exit site may decrease the risk of S. aureus ESI (Level III.3 - Evidence obtained from comparative studies with historical control, two or more single arm studies, or interrupted time series without a parallel to control group). Randomised controlled trials Sit et al [8] reported a 12-month prospective randomized controlled study (49 patients) conducted in a single centre in Turkey. Twenty-five patients were randomized to have intranasal mupirocin ointment administered to the nares (twice daily for 5 days every 4 weeks) and 24 patients remained on usual practice. It was concluded that the prophylactic administration of intranasal Peritonitis Treatment and Prophylaxis

(February 2014)

KHA-CARI Guidelines – Caring for Australasians with Renal Impairment ______________________________________________________________________________________

mupirocin ointment was highly effective for the eradication of S. aureus nasal carriage, but it did not reduce the number of peritonitis episodes that occurred. Davey et al [9] conducted a prospective, placebo-controlled RCT. A total of 267 CAPD patients were studied by measuring the benefits of elimination of nasal carriage of S. aureus by calcium mupirocin ointment. The rate of ESI caused by S. aureus was significantly reduced from 1 in 28.1 patient-months to 1 in 99.3 patient-months (P = 0.006). Patients with ESI in the mupirocin group had lower antibiotic costs (P = 0.02) and hospitalisation costs (P = 0.065) compared with the placebo group. However, the overall costs of antibiotic treatment (for all infections combined) were not significantly different (P = 0.2) and total antibiotic costs (including mupirocin) were significantly higher in the mupirocin group (P = 0.001). The Mupirocin Study Group [10] performed a RCT evaluating 267 PD patients who had been diagnosed as nasal carriers of S. aureus (determined by two positive nasal swabs on two separate occasions). Patients randomised to the intervention group were treated with nasal mupirocin ointment twice daily for 5 consecutive days every 4 weeks. Forty-four episodes of ESI due to S. aureus were reported in the control group compared with 14 in the mupirocin group (P = 0.006). There were no differences in the rates of tunnel infection or peritonitis. There was no evidence of a progressive increase in resistance to mupirocin with time. It was concluded that regular use of nasal mupirocin in PD patients who are nasal carriers of S. aureus significantly reduces the number of ESIs that occur because of this organism. Perez-Fontan [11] ran a randomised trial comparing intranasal mupirocin ointment with neomycin sulphate nasal ointment to treat S. aureus nasal carriers. Re-treatment with mupirocin was successful in 66% of cases compared with 20% of those given neomycin. There was a very low incidence of S. aureus peritonitis or catheter-related infections in the patients treated with mupirocin. Historical studies Casey et al [12] reported on a prospective, historically-controlled study involving the daily application of mupirocin cream to the catheter exit site of 291 PD patients. Data was collected over an 11-month period and compared with data for all patients from the 11 months prior to the change. There was a 49% relative reduction in the rate of ESI (P < 0.001) and 31% reduction in episodes of peritonitis (P = 0.003) in the mupirocin treatment group. There was also a 68% reduction (P = 0.05) in the rate of S. aureus peritonitis and 37% decrease (P = 0.19) in catheter loss in the mupirocin group. Thodis et al [13] performed a prospective historically-controlled study of 181 PD patients to evaluate the effectiveness of applying mupirocin ointment to the exit site either daily or three-timesweekly for 1 year. Infection rates found during the study year were compared with the retrospective data. It was reported that the daily application of mupirocin cream significantly reduced the incidence of ESIs due to S. aureus by 91% and reduced peritonitis due to S. aureus by 69%. In addition, the overall rate of peritonitis was significantly reduced (P < 0.01). There was no mupirocin resistance 1 year after the institution of local mupirocin use at the catheter exit site to prevent ESI.

Studies on other prophylactic topical agents 1. Randomised controlled trials Chu et al [14] randomised 95 patients to either daily application of gentamicin cream or daily application of mupirocin at the exit site. The ESI rates were 0.38 and 0.20 episodes/patient-year for the gentamicin group and the mupirocin group, respectively (P = 0.36). Gram-positive ESI rates were 0.18 and 0 episodes/patient-year for the gentamicin group and the mupriocin group, respectively. Gram-negative ESI rates were 0.20 episodes/patient-year for both groups (P = 0.62). It was concluded that both therapies were effective as prophylaxis for ESI.

Peritonitis Treatment and Prophylaxis

(February 2014)

KHA-CARI Guidelines – Caring for Australasians with Renal Impairment ______________________________________________________________________________________

Danguilan et al [15] reported a RCT of 100 patients. Fifty patients were randomized and had mupirocin ointment applied to their exit site and 50 patients had sodium fucidate ointment applied to their exit site at least once a week. There was no significant difference (P = 1.0) between the use of mupirocin and the use of sodium fucidate as prophylaxis for ESI. Bernardini et al [16] conducted a prospective randomised trial, controlling for S. aureus nasal carriage. Eighty-two PD patients were randomised to receive prophylaxis for S. aureus infections using either 600 mg cyclic oral rifampin for 5 days every 3 months or mupirocin ointment 2% applied daily to the exit site. ESI rates were 0.13/year with mupirocin and 0.15/year with rifampin (P = ns). The centre’s historical rate was 0.46/year. Rates for peritonitis and catheter loss for both treatment groups were significantly lower than the centre’s historical rate of 0.12/year (P < 0.001). Mupirocin ointment at the exit site and cyclic oral rifampin were considered to be equally effective in reducing ESI, peritonitis and catheter loss due to S. aureus. However, mupirocin ointment at the exit site was inferior to the alternate therapy in this study, particularly in patients who cannot tolerate oral rifampin therapy (12%). Bernardini et al [17] reported a double-blinded RCT with daily mupirocin (n = 67) or daily gentamicin cream (n = 66) to the exit site. It was concluded that gentamicin cream was as effective as mupirocin in preventing S. aureus infections. However, gentamicin cream reduced Pseudomonas spp. infection by 25% in this study. Sesso et al [18] reported a single unblinded RCT of 31 CAPD patients using 2% sodium fusidate ointment applied to the exit site and anterior nares twice per day for 5 days (n = 9), compared with a 5-day regimen of oral ofloxacin (n = 9) (200 mg/48 h) or placebo tablets (n = 13). A mean followup period of 7.8 months occurred. No significant differences in the risk of ESI (P = 0.13) or peritonitis (P = 0.22) due to S. aureus were found between the sodium fusidate and the control groups. 2. Historical studies Lim et al [19] conducted a retrospective comparison (740 patients) at a single centre in Singapore in the application of topical mupirocin at the exit site. Mupirocin ointment (2%) was applied three to five times per week to the exit site. It was concluded that the application of topical mupirocin at the exit site led to a significant reduction in the rate of peritonitis (0.443 vs 0.339 episodes per patientyear, P < 0.0005) and in ESI (0.168 vs 0.156 episodes per patient-year, P < 0.005). This result was primarily due to the significant (P < 0.005) reduction in S. aureus infection. Tse et al [20] reported on 5 patients who applied topical gentamicin ointment for treatment and prophylaxis and were followed up for 20 months. It was concluded that increased ESI with atypical mycobacteria may occur with prolonged systemic or topical use of gentamicin ointment. Montenegro et al [21] reported a prospective comparison with historical control study. Ciprofloxacin (1mg in 0.5mL daily) was applied topically to the exit site in addition to standard care in 78 patients. The historical group (n = 86) performed only the standard care of a daily cleansing with soap and water, drying, then applying a sterile gauze covering. Daily use of ciprofloxacin reduced the risk of ESIs to 15% of the controls (P < 0.001). All ESI in the ciprofloxacin group were due to S. aureus which showed a significant reduction in the risk of infection due to this organism (P < 0.00001). The risk of peritonitis due to S. aureus was also significantly reduced (P = 0.04).

SUMMARY OF THE EVIDENCE In addition to the previous CARI publication with RCTs that assessed the use of intranasal mupirocin treatment to prevent ESI, tunnel infection and peritonitis, there are now a systematic review and Cochrane review on this area of practice, which strengthened the recommendations of this document. Further studies have been published evaluating the benefits of eliminating the

Peritonitis Treatment and Prophylaxis

(February 2014)

KHA-CARI Guidelines – Caring for Australasians with Renal Impairment ______________________________________________________________________________________

nasal carriage of S. aureus with mupirocin ointment compared with placebo. There was a statistically significant reduction in the rate of ESI due to S. aureus in all of the studies. There were further RCTs comparing topical mupirocin treatment against other agents such as oral rifampin therapy and sodium fucidate ointment, to prevent ESI, tunnel infection and peritonitis. There was no difference between the groups in the rate of ESI, peritonitis and catheter loss due to S. aureus.

WHAT DO THE OTHER GUIDELINES SAY? Kidney Disease Outcomes Quality Initiative: No recommendation. UK Renal Association: Guideline 5.1.6 (2010) [22] We recommend that topical antibiotic administration should be used to reduce the frequency of S. aureus and Gram-negative exit site infection and peritonitis. (1A) Canadian Society of Nephrology: No recommendation. European Renal Best Practice Guidelines: [23] European Guidelines on Best Practice for the Management of Peritoneal Dialysis (2002). Mupirocin ointment, either intranasal or at the exit site, reduces exit site infections especially in patients who are S. aureus carriers. (Level A). International Guidelines: ISPD Guidelines/Recommendations (2005). [24] Prophylaxis with daily application of mupirocin cream or ointment to the skin around the exit site has been effective in reducing S. aureus exit-site infection and peritonitis in a number of reports. (Mupirocin ointment at the exit site, in contrast to mupirocin cream, should be avoided in patients with polyurethane catheters, as structural damage to the catheter has been reported.)

SUGGESTIONS FOR FUTURE RESEARCH 1. Perform long term RCTs with sufficient power and blinding to investigate the potential for the development of resistance to mupirocin including taking routine swabs to identify and document the presence of resistant organisms. 2. Perform comparison study on different methods of exit site care in randomized trials so as to recommend a specific protocol.

CONFLICT OF INTEREST Josephine Chow has no relevant financial affiliations that would cause a conflict of interest according to the conflict of interest statement set down by CARI.

Peritonitis Treatment and Prophylaxis

(February 2014)

KHA-CARI Guidelines – Caring for Australasians with Renal Impairment ______________________________________________________________________________________

REFERENCES 1. Vas SI, Conly J, Bargman JM, et al. Resistance to mupirocin: no indication of it to date while using mupirocin ointment for prevention of Staphylococcus aureus exit-site infections in peritoneal dialysis patients. Perit Dial Int 1999; 19: 313-34. 2. 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: 337-41. 3. Annigeri R Conly J, Vas S, et al. Emergence of mupirocin-resistant Staphylococcus aureus in chronic peritoneal dialysis patients using mupirocin prophylaxis to prevent exit-site infection. Perit Dial Int 2001; 21: 554-59. 4. Johnson DW, Clark C, Isbel NM, et al. The honeypot study protocol: a randomized controlled trial of exit-site application of medihoney antibacterial wound gel for the prevention of catheterassociated infections in peritoneal dialysis patients. Perit Dial Int 2009; 29: 303-09. 5. Xu G, Tu W, Xu C. Mupirocin for preventing exit-site infection and peritonitis in patients undergoing peritoneal dialysis. Nephrol Dial Transplant 2010; 25: 587–92. 6. Strippoli GFM, Tong A, Johnson DW, et al. Antimicrobial agents for preventing peritonitis in peritoneal dialysis patients. Cochrane Database of Systematic Reviews. 2004, Issue 4. Art. No.: CD004679. DOI: 10.1002/14651858. CD 004679.pub2. 7. Lockwood C, Hodgkinson B, Page T. Clinical effectiveness of different approaches to peritoneal dialysis catheter exit-site care. Joanna Briggs Institute Reports 2003; 1: 167-201. 8. Sit D, Kadiroglu AK, Kayabasi H, et al. Prophylactic intranasal mupirocin ointment in the treatment of peritonitis in continuous ambulatory peritoneal dialysis patients. Adv Ther 2007; 24: 387-93. 9. Davey P, Craig AM, Hau C, et al. Cost-effectiveness of prophylactic nasal mupirocin in patients undergoing peritoneal dialysis based on a randomized, placebo-controlled trial. J Antimicrob Chemother 1999; 43: 105-12. 10. Mupirocin Study Group. Nasal mupirocin prevents Staphylococcus aureus exit-site infection during peritoneal dialysis. J Am Soc Nephrol 1996; 7: 2403-08. 11. Perez-Fontan M, Rosales M, Rodriguez-Carmona A, et al. Treatment of Staphylococcus aureus nasal carriers in CAPD with mupirocin. Adv Perit Dial 1992; 8: 242-45. 12. Casey M, Taylor J, Clinard P, et al. Application of mupirocin cream at the catheter exit site reduces exit-site infections and peritonitis in peritoneal dialysis patients. Perit Dial Int 2000; 20: 566-68. 13. Thodis E, Bhaskaran S, Pasadakis P, et al. Decrease in Staphylococcus aureus exit-site infections and peritonitis in CAPD patients by local application of mupirocin ointment at the catheter exit site. Perit Dial Int 1998; 18: 261-70. 14. Chu KH, Choy WY, Cheung CC, et al. A prospective study of the efficacy of local application of gentamicin versus mupirocin in the prevention of peritoneal dialysis catheter-related infections. Perit Dial Int 2008; 28: 505-08. 15. Danguilan RA, Evangelista LP, Abrenica MS, Rondilla SMS. Comparative study of mupirocin and sodium fucidate in the prophylaxis of exit-site infections in CAPD patients. Perit Dial Int 2003; 23: 591–605. 16. 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 exit site versus cyclic oral rifampin. Am J Kidney Dis.1996; 27: 695-700. 17. Bernardini J, Bender F, Florio T, et al. Randomized, double-blind trial of antibiotic exit site cream for prevention of exit site infection in peritoneal dialysis patients. J Am Soc Nephrol 2005; 16: 539-45. Peritonitis Treatment and Prophylaxis

(February 2014)

KHA-CARI Guidelines – Caring for Australasians with Renal Impairment ______________________________________________________________________________________

18. Sesso R, Parisio K, Dalboni A. Effect of sodium fusidate and ofloxacin on Staphylococcus aureus colonization and infection in patients on continuous ambulatory peritoneal dialysis. Clin Nephrol 1994; 41: 370-76. 19. Lim CTS, Wong KS, Foo MWY. The impact of topical mupirocin on peritoneal dialysis infection in Singapore General Hospital. Nephrol Dial Transplant 2005; 20: 2202–06. 20. Tse KC, Lui SL, Cheng VC. A cluster of rapidly growing mycobacterial peritoneal dialysis catheter exit-site infections. Am J Kidney Dis 2007; 50: e1-5. 21. Montenegro J, Saracho R, Aguirre R. Exit-site care with ciprofloxacin otologic solution prevents polyurethane catheter infection in peritoneal dialysis patients. Perit Dial Int 2000; 20: 209-14. 22. Woodrow G, Davies S. Peritoneal dialysis in CKD. UK Renal Association; 30 July 2010. www.renal.org/guidelines/modules/peritoneal-dialysis-in-ckd. 23. Johnson DW, MacGinley R, Kay TD, et al. A randomized controlled trial of topical exit site mupirocin application in patients with tunnelled, cuffed haemodialysis catheters. Nephrol Dial Transplant 2002; 17: 1802–07. 24. Piraino B, Bailie GR, Bernardini J, et al. Exit-site care. Peritoneal dialysis-related infections recommendations: 2005 update. Perit Dial Int 2005; 25: 107–31.

Peritonitis Treatment and Prophylaxis

(February 2014)

KHA-CARI Guidelines – Caring for Australasians with Renal Impairment ______________________________________________________________________________________

APPENDICES Table 1 – Characteristics of included studies Study ID (author, year) Sit et al 2007

N

Study Design

Setting

Participants

Intervention (experimental group)

Intervention (control group)

Follow up (months)

49

Randomised controlled clinical trial

Single centre Turkey

Intranasal mupirocin ointment twice daily for th 5 days every 4 week.

No prophylactic treatment.

6

Davey et al 1999 and Mupirocin Study Group 1996

267

Randomised controlled clinical trial

Multi-centre UK, France, Belgium

Intranasal mupirocin ointment twice daily for 5 days each month.

Placebo

18

Perez-Font et al 1992

24

Single centre Spain

95

Intranasal 2% mupirocin ointment 3 times a day for 7 days. Gentamicin ointment applied to exit site.

Intranasal 0.1% neomycin sulphate ointment 3 times a day for 7 days Mupirocin ointment applied to exit site

10

Chu 2008

Randomised controlled clinical trial Randomised controlled clinical trial

Danguilan et al 2003

100

Randomised controlled clinical trial

Single centre Singapore

Adult CAPD patients not previously treated or with a known allergy to intranasal mupirocin. Adult CAPD patients who were nasal carriers of S. aureus not treated with mupirocin or with a known allergy Adult CAPD patients with S aureus Adult PD patients without: active infection, exit site infection and peritonitis in previous 4weeks, known allergy to gentamicin or mupirocin. New adult CAPD patients without exit site infections.

Mupirocin ointment applied to exit site

Sodium fucidate ointment applied to exit site

45

Peritonitis Treatment and Prophylaxis

Single centre Hong Kong

(February 2014)

12

Comments

KHA-CARI Guidelines – Caring for Australasians with Renal Impairment ______________________________________________________________________________________ Bernardini et al 1996

82

Randomised controlled clinical trial

Single centre US

Bernardini et al 2004

133

Randomised controlled trial clinical trial

Multi-centre US

Sesso et al 1994

31

Randomised controlled trial clinical trial

Single centre Brazil

Peritonitis Treatment and Prophylaxis

Adult PD patients free of catheter infection or peritonitis and no antibiotic use 2 weeks prior. Adult PD patients with no known allergy to study ointments or Adult CAPD patients identified as S. aureus carriers who had not had peritonitis or exit site infection within one month prior or antimicrobial therapy78 hours prior.

(February 2014)

2% mupirocin ointment applied daily to the exit site

Oral 300 mg rifampin twice a day for 5 days every 3 months

12

Mupirocin ointment applied to exit site

Gentamicin applied to exit site

8

1. 200 mg of ofloxacin taken orally every 48 hours for 5 days every month.

Placebo tablets

7.8

2. Sodium fusidate ointment applied intranasally and to the exit site twice daily for 5 days every month.

KHA-CARI Guidelines – Caring for Australasians with Renal Impairment ______________________________________________________________________________________

Table 2 – Quality of randomised trials Loss to follow up (%)

Comments ‡

(outcome assessors)

Intentionto-treat analysis †

Unclear

Unclear

No

4%

(–)

Yes

Yes

Yes

No

1%

Unclear

Unclear

Unclear

No

8%

Study ID (author, year)

Method of allocation concealment *

Blinding (participants)

(investigators)

Sit et al 2007 Davey al 1999 and Mupirocin Study Group 1996 Perez-Font et al 1992

Flip of coin

No

Not stated Not stated

(Ø) (–)

Alternate (–) Chu 2000 allocation Unclear Unclear Unclear No 29% Danguilan et al (–) 2003 Not stated Unclear Unclear Unclear Yes Unclear Bernardini et al (–) 1996 Not stated No No No Yes 9% Bernardini et al (+) 2004 Central Yes Yes Yes Yes 2% Sesso et al (–) 1994 Not stated Unclear Unclear Unclear Unclear Unclear * Choose between: central; third party (e.g. pharmacy); sequentially labelled opaque sealed envelopes; alternation; not specified. † Choose between: yes; no; unclear. ‡ Quality score – “How successfully do you think the study minimised bias?” Choose between: very well (+); okay (Ø); poorly (–).

Peritonitis Treatment and Prophylaxis

(February 2014)

KHA-CARI Guidelines – Caring for Australasians with Renal Impairment ______________________________________________________________________________________

Table 3 – Results for dichotomous outcomes Study ID (author, year)

Outcomes

Sit et al 2007

Negative culture at end of study Peritonitis

Sit et al 2007

Chu et al 2008

S. aureus exit site infections Total exist site infections Eradication of S. aureus – first treatment Recolonisation after 3 months Total exit site infections

Chu et al 2008

Peritonitis

Danguilan et al 2003

ESI free at 6 months

Danguilan et al 2003

ESI free at 12 months

Danguilan et al 2003

Total exit site infections

Danguilan et al 2003

Peritonitis

Bernardini et al 1996 Bernardini et al 2004

One or more positive S. aureus cultures Total exit site infections

Bernardini et al 2004

Total peritonitis

Mupirocin Study Group 1996 Mupirocin Study Group 1996 Perez-Font et al 1992 Perez-Font et al 1992

Peritonitis Treatment and Prophylaxis

Intervention group (number of patients with events/ number of patients exposed)

Control group (number of patients with events/ number of patients not exposed)

Relative risk (RR) [95% CI]

Risk difference (RD) [95% CI]

13/23

1/24

13.57 (1.93, 95.53)

0.52 (0.31, 0.74)

1/23

1/24

1.04 (0.07,15.72)

0.00 (-0.11, 0.12)

14/134

44/133

0.32 (0.18, 0.55)

-0.23 (-0.32, -0.13)

33/134

53/133

0.62 (0.43, 0.89)

-0.15 (-0.26, -0.04)

12/12

4/10

2.35 (1.15, 4.82)

0.60 (0.29, 0.91)

5/12

3/4

0.56 (0.23, 1.33)

-0.33 (-0.84, 0.17)

15/43

9/38

1.47 (0.73, 2.97)

0.11 (-0.08, 0.31)

13/43

12/27

0.96 (0.50, 1.84)

-0.01 (-0.22, 0.19)

42/50

47/50

0.89 (0.78, 1.03)

-0.10 (-0.22, 0.02)

30/50

26/50

1.15 (0.81, 1.64)

0.08 (-0.11, 0.27)

10/50

11/50

0.91 (0.42, 1.95)

-0.02 (-0.18, 0.14)

6/50

1/50

6.00 (0.75, 48.05)

0.10 (0.00, 0.20)

24/41

23/41

1.04 (0.72, 1.52)

0.02 (-0.19, 0.24)

Mupirocin 29/66

Gentamicin 15/67

1.96 (1.16, 3.31)

0.22 (0.06, 0.37)

Mupirocin 28/66

Gentamicin 22/67

1.29 (0.83, 2.01)

0.10 (-0.07, 0.26)

(February 2014)

KHA-CARI Guidelines – Caring for Australasians with Renal Impairment Study ID (author, year)

Sesso et al 1994

______________________________________________________________________________________ Outcomes Intervention group Control group Relative risk (RR) Risk difference (RD) (number of patients (number of patients [95% CI] [95% CI] with events/ number with events/ number of patients exposed) of patients not exposed) Exit site infections Fusidate 6/9 Placebo 4/13 2.17 (0.85, 5.53) 0.36 (-0.04, 0.76) Exit site infections Exit site infections

Sesso et al 1994

Peritonitis Peritonitis Peritonitis

Peritonitis Treatment and Prophylaxis

Ofloxacin 2/9

Placebo 4/13

0.72 (0.17, 3.14)

-0.09 (-0.46, 0.28)

Fusidate 6/9

Ofloxacin 2/9

3.00 (0.81, 11.08)

0.44 (0.03, 0.45)

Fusidate 1/9

Placebo 6/13

0.24 (0.03, 1.67)

-0.35 (-0.69, -0.01)

Ofloxacin 5/9

Placebo 6/13

1.81 (0.66, 4.92)

0.25 (-0.16, 0.66)

Fusidate 1/9

Ofloxacin 5/9

6.00 (0.89, 40.31)

0.56 (0.19, 0.93)

(February 2014)

Suggest Documents