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Mupirocin Once Weekly Reduces the Incidence of Catheter Exit-Site Infection in Peritoneal Dialysis Patients

Editor: A study was carried out to determine the possible effectiveness of prophylactic application of mupirocin once weekly at the exit site of peritoneal dialysis catheters to reduce the incidence of exit-site infection (ESI). The study was carried out on 28 patients on continuous ambulatory peritoneal dialysis who had never been treated with mupirocin. Mean age of the patients was 54.93 ± 11.82 years. None of the patients were on steroid therapy. As per usual protocol, all the patients had been cleaning the exit site with liquid antibacterial solution once daily. This was continued and, in addition, during the prospective period of the study, patients, caregivers, and nurses were instructed to apply mupirocin ointment (Bactroban Ointment; SmithKline Beecham Pharmaceuticals, Philadelphia, Pennsylvania, USA) once weekly at the conclusion of routine exit-site care. Patients’ exit sites were monitored once every 2 weeks during the study period. Patients were given instruction to identify and report any evidence of ESI. Patients’ results were analyzed 12 months before (historical observation) and 12 months after (prospective observation) the introduction of mupirocin. During the 12 months preceding the application of mupirocin, 30 episodes of ESI were reported among the studied patients, compared to only 14 episodes after application of mupirocin, once weekly, during 12 months of prospective observation. The overall incidence of ESI was reduced from 1.07 episodes per dialysis-year to 0.48 episodes per year (p < 0.0001). The prevalence of gram-positive micro-organisms was 21 (70%) before mupirocin application, compared to 6 (42.9%) after mupirocin application. Staphylococcus aureus ESI was significantly reduced, from 15 episodes before, to 2 episodes after mupirocin application (p < 0.0441). There were 5 episodes of Staphylococcus epidermidis and other coagulase-negative staphylococcal ESI prior to mupirocin, but none after its use. Streptococcus agalactiae was isolated once after mupirocin introduction, with none isolated before its use. Diphtheroids were isolated in two cases after mupirocin introduction, compared to one case prior to its use. The number of ESIs caused by gram-negative micro-organisms was 8 (26.7% of the infections) before, compared to 8 (57.1% of the infections) after mupirocin application. Culture-negative ESI was observed once before and after mupirocin use. Peritonitis episodes were also reduced, from 17 episodes (0.6 episodes/year) before mupirocin application to 12 episodes (0.4 episodes/year) after. No bacterial resistance to mupirocin was reported in any organism isolated on culture. We also did not observe any deleterious effects on peritoneal dialysis catheters during the study period. Daily application of mupirocin at the catheter exit site has been shown to reduce episodes of ESI in peritoneal dialysis patients (1,2). However, deleterious effects of mupirocin on the dialysis catheter (3,4) and the emergence of mupirocin resistance are problems that might occur due to prolonged daily application of mupirocin (5). Our observations suggest that application of mupirocin ointment once weekly at the exit site of peritoneal dialysis catheters could be effective in reducing ESI, without deleterious effects or emergence of bacterial resistance. Further studies are required to confirm our observations.