Reply to: Opinion on exit-site care recommendations

As Tsinari et al. ¹ correctly state, the 2023 International Society for Peritoneal Dialysis (ISPD) guideline recommendations for catheter-related infections ² need to cater for widely varying peritoneal dialysis (PD) programmes around the world taking into account local circumstances (e.g. climate, etc.) and resource settings, as well as the available evidence. The optimal frequency of exit-site care has not been tested by randomised controlled trials (RCTs), but there is observational evidence that exit-site care frequency less than twice weekly is associated with higher odds of catheter-related infection. ³ The ISPD guidelines on physical activity and exercise in PD ⁴ also recommend exit-site cleaning after water contamination or exercise. Hence, the 2023 ISPD catheter-related infection guidelines ² recommend ‘that the exit site be cleansed at least twice weekly and every time after a shower or vigorous exercise, including running, cycling, swimming and water sports’. The 2023 ISPD guidelines further recommend ‘daily topical application of antibiotic cream or ointment (mupirocin or gentamicin) to the exit site to prevent catheter-related infection’ based on demonstrated safety and efficacy of mupirocin and gentamicin in RCTs and meta-analyses. ² However, the Guideline Working Group also stated that the ‘certainty of this evidence is reduced by indirectness (highly variable approaches to administering the intervention including nasal vs. exit site application), risk of bias and inconsistency’ such that it ‘was not able to recommend the optimal site of topical application (nasal vs. exit site)’. The 2023 Guidelines therefore include the 2C recommendation, ‘We suggest that the comparative efficacies of topical mupirocin versus topical gentamicin or exit site versus nasal application of mupirocin for preventing catheter-related infection are uncertain’. Consequently, daily nasal application of mupirocin may also be a reasonable option for catheter-related infection prophylaxis and would not be incompatible with twice weekly exit-site cleaning. The ISPD Guidelines Working Group anticipate that the most common practice would be daily exit-site cleansing followed by topical exit-site application of antibiotic ointment or cream (mupirocin or gentamicin). Hopefully, currently planned RCTs like COSMO-PD ⁵ will help better inform future recommendations.