Effect of preventing Staphylococcus aureus carriage on rates of peritonealcatheter-related staphylococcal infections. Literature synthesis

Objective: To determine whether specific preventive measures reduce the rat e of peritoneal catheter-related infections and peritoneal catheter loss du e to Staphylococcus aureus. Design: Structured literature synthesis. Methods: Relevant studies were identified by MEDLINE search, from personal files, and from the reference lists of retrieved articles. We analyzed Engl ish-language studies on treatment targeted at S. aureus, with at least 10 s ubjects and at least 3 months of follow-up, and data on staphylococcal peri toneal dialysis catheter infections. We excluded noncontrolled studies. Two investigators abstracted data using a structured form. Results:We evaluated six studies with concurrent controls and eight studies with historical controls. In one randomized, placebo-controlled, blinded s tudy, periodic nasal mupirocin ointment reduced the rate of staphylococcal exit-site infection from 0.42 to 0.12 episodes/patient-year (p=0.006), but had no effect on the rates of staphylococcal tunnel infection, peritonitis, or catheter loss. In one randomized study without placebo control, periodi c oral rifampin reduced the rate of staphylococcal exit-site infection from 0.65 to 0.22 epi/pt-yr (p=0.011), but had no effect on the rate of staphyl ococcal peritonitis. In another nonblinded, randomized, controlled study, t he use of either rifampin or mupirocin was associated with low rates of sta phylococcal catheter infections and catheter loss. In one study with histor ical controls, the rate of staphylococcal exit-site infection and peritonit is was lower after oral rifampin prophylaxis. In seven other studies compar ing nasal or exit-site mupirocin to historical controls, the rate of staphy lococcal exit-site infection decreased from 0.17 to 0.05 epi/pt-yr, the rat e of staphylococcal peritonitis decreased from 0.18 to 0.06 epi/pt-yr, and the rate of catheter loss decreased from 0.09 to 0.05 epi/pt-yr during the mupirocin period. Conclusion: The literature provides strong evidence that staphylococcal car riage prophylaxis using either oral rifampin or mupirocin ointment in the n ares or exit site reduces significantly the rate of exit-site infection due to Staphylococcus aureus. Weaker evidence based on studies with historical controls suggests that rifampin or mupirocin prophylaxis also reduces the rate of staphylococcal peritonitis and peritoneal catheter loss. Studies wi th a stronger level of evidence are needed to verify this last point.