Peritoneal Catheter Exit-Site Morphology and Pathology
Peritoneal Dialysis International, Vol. 16 (1996), Supplement 3
Printed in Canada All rights reserved.
RECOMMENDATIONS FOR EXIT CARE
Barbara F. Prowant and Zbylut J. Twardowski
Division of Nephrology, Department of Internal Medicine, Dalton Research Center,
University of Missouri, Harry S. Truman Veterans Administration Hospital, Dialysis Clinic, Inc.,Columbia, M issouri. U.S.A
Prevention of peritoneal dialysis (PD) catheter
infection begins with good surgical practice for
catheter implantation and includes appropriate preoperative
patient preparation and surgical technique as well as
postimplantation care (1,2). Because antibiotic penetration
into the coagulum is poor, antibiotics should be present in
sufficient concentration in the blood and tissue fluids before
the coagulum is formed. This can be achieved if systemic
antibiotics are given preoperatively. In an accompanying
manuscript we showed that early colonization of exits is
predominantly by Grampositive bacteria; however, some
exits were colonized by Gram-negative bacteria, and these
cases developed early infection (3). Therefore, systemic
coverage for both Gram-positive and Gram-negative
organisms seems desirable for prophylaxis. Topical
antibiotics may not be effective during the early
postimplantation period, because they can be washed away
by drainage from the exit.
The evening preceding surgery the patient should
shower using a long-Iasting disinfectant. The surgical
preparation of the integument should be similar to that used
for any major surgery. Perfect hemo stasis during surgery is
of utmost importance in order to avoid hematoma formation
along the catheter tunnel, because hematoma predisposes to
early infection.
The surgical incision and exit site should be covered
with several layers of absorbent gauze dressing. It is
important to immobilize the catheter as well as secure the
dressings. Semipermeable dressings applied directly to the
wound and occlusive dressings
KEY WORDS: Catheter exit site; exit-site care; exit -site
assessment; prevention of exit -site infection.
Correspondence to: B.F .Prowant, Division of
Nephrology , MA 436 Health Sciences Center, University
of Missouri, Columbia, Missouri 65212 U.S.A.
0896-8608/96 $300 + .00
Copyright © 1996 International Society for Peritoneal Dialysis
are inappropriate because they trap drainage around the exit,
and the drainage is an excellent medium for bacterial
growth.
EXIT CARE POST CATHETER
IMPLANTATION
The optimal care of PD catheter exit sites post catheter
implantation is not known. There is no consensus regarding
specific procedures or cleansing agents, and no controlled
studies have been done; therefore, this discussion will be
based on broad, general principles.
The goals of dressing change procedures and exit care
immediately post catheter implantation are as follows: (1) to
prevent colonization during the early healing period; (2) to
minimize multiplication of bacteria; and (3) to prevent
trauma to the exit and cuffs by immobilizing the catheter.
It is generally agreed that postoperative dressing changes
should be restricted to specially trained staff ( 4). Daily
dressing changes postimplantation are not necessary. There
are two reasons for less frequent dressing changes: first.
each dressing change may contaminate the exit with
bacter1a even though aseptic technique is used; second.
each dressing change requires manipulation of the catheter,
increasing the risk of catheter movement and subsequent
trauma. We do weekly dressing changes for the first few
weeks post catheter implantation if there is not excessive
drainage. Once the exit is colonized, by week 3 in the
majority of cases (3) more frequent dressing changes are
indicated.
Aseptic technique, including both masking and wearing
sterile gloves, should be used for postoperative dressing
changes. The skin surrounding the exit should be cleansed
with a nonirritating agent to remove debris and decrease the
number of bacteria, if present. Strong oxidants such as
povidone iodine and hydrogen peroxide are cytotoxic to
mammalian cells in bacteriocidal concentrations (5,6) and
are harmful to granulation tissue if allowed to enter the
sinus. If these are used, care should be taken to use only on
the intact skin surrounding the wound or granulation tissue
(7).
We use a nonionic surfactant agent, poloxamer 188
(Shur-Clens, Calgon Vestal Laboratories, St. Louis, MO),
that cleanses well, but is not harmful to the granulation
tissue and does not require rinsing (8,9). If the cleansing
agent, such as soap or povidone iodine, needs to be rinsed
off, sterile water or sterile normal saline should be used.
The exit should be gently patted dry.
The exit and visible sinus should be evaluated for
quality of healing at each dressing change throughout the 6-
week healing period. If healing does not progress, if there
are signs of deterioration or infection, the exit is probably
already colonized (3). A clinical culture of the exudate
should be taken, and the frequency of dressing changes
increased to at least every other day, because the major
rationale for infrequent dressing changes, avoidance of exit
colonization, no longer exists. Moreover, more frequent
cleansing of the exit will decrease the number of bacteria at
the exit.
We recommend that our patients do not shower or take
tub baths post catheter implantation to avoid colonization
with water-borne organisms and to prevent skin maceration.
The principles of postimplantation exit care are
summarized in Table 1.

CARE OF THE HEALED PERITONEAL CATHETER

EXIT SITE

The primary goal of chronic exit-site care is to prevent

exit-site infections. A secondary goal is to assess the exit
regularly and to identify problems early. Routine exit -site
care includes cleansing of the exit, assessment of the exit,
anchoring or immobilizing the catheter, and protecting the
exit, cuff, and catheter from trauma.
We believe there are several principles upon which exit
care protocols should be based (Table 2). The optimal
frequency of exit-site care has not been established;
however, frequent cleansing, daily or every other day, or a
minimum of twice weekly is essential to reduce resident
bacteria. Good and perfect exits have a better barrier
against micro-organisms and may not require the same
frequency of care as equivocal exits. It is generally believed
that infected exits require daily care. Finally, exit-site care
should be done when the exit becomes grossly dirty or wet.
Good hand-washing prior to exit care is critical to avoid
cross-contamination. Healthy catheter exit sites should be
washed with antibacterial soap (or a medical disinfectant)
to keep the exit clean and to dimin ish resident bacteria.
Liquid soap is recommended to
avoid the risk of cross-contamination from bar soap. The
choice of a soap or cleansing agent may need to be
individualized because of skin sensitivities or allergies.
Hydrogen peroxide is no longer routinely used (4),
presumably because it is cytotoxic. A clean wash cloth and
towel are recommended. The use of sterile gauze or cotton-
tipped applicators is not necessary.
Povidone iodine solutions contaminated with
Pseudamanas species have been implicated as the source of
both peritonitis and exit-site infection in continuous
ambulatory peritoneal dialysis patients (10-12). To avoid
contamination of liquid soaps and disinfectants, these
solutions should not be transferred from one container to
another .
It is important not to forcibly remove crusts or scabs
during cleansing. This may traumatize the exit, causing a
break in the skin, and thus increasing the risk of exit
infection. The exit should be rinsed and gently dried after
cleansing.
Because there are no data to document lower infection
rates with dressings, the use of dressings for chronic care is
based on anecdotal experience or patient preference.
Dressings are indicated for all
patients when the exit is infected or likely to become
grossly contaminated. Furthermore, dressings may help to
immobilize the catheter .
The goal of catheter immobilization is to reduce tension,
tugging, and twisting of the catheter, thus reducing trauma
to the exit and/or cuff and subsequent injury. A number of
devices for catheter immo bilization are available. The
effectiveness of these devices is under investigation.
Finally, it is imperative that both patients and staff
inspect and assess the exit site and tunnel prior to exit care.
Signs and symptoms of exit-site infection should be
included in the initial patient education content, and
patients should be encouraged to notify the PD unit staff
promptly when signs of exit-site deterioration develop.
Staffmembers should also evaluate the exit site at each
routine clinic visit. This assessment should include visual
inspection of the exit site and sinus using magnification and
good lighting, palpation of the tunnel, and especially the
cuff, for tenderness and induration, and gently squeezing
the external cuff in an effort to express exudate externally.
Exit characteristics can then be used to determine the
category of exit classification. Detailed documentation will
enable comparison and determination of improvement or
deterioration at subsequent visits. An exit attribute checklist
can be used both as a guide
for assessment and for documentation (Table 3).
PREVENTION OF PERITONEAL CATHETER EXIT
INFECTIONS
Efforts to reduce or to eliminate risk factors associated
with increased infection should also reduce the incidence of
exit infection. Improved nutrition, good control of glycemia
in diabetic patients, and systemic, prophylactic antibiotic
treatment inStaphylacaccus aureus nasal carriers may
reduce the overall incidence of exit infection.
The two key concepts of exit care in preventing
peritoneal catheter infections are avoiding trauma to the
exit and tunnel and avoiding gross contamination of the exit
(13).
The accompanying exit-site study found that trauma
preceded deterioration of all perfect exits and half the good
exit sites studied (14). In a broad sense trauma can be
anything that breaks the integrity of the skin at the exit site
or the epithelium or granulation tissue in the sinus. Trauma
would also include a pull on the catheter sufficient to
disrupt tissue ingrowth at the cuff. Table 4 outlines sources
of trauma.
An accidental hard pull on the catheter is the most
serious trauma, which may lead to partial or complete
separation of the cuff from the surrounding
tissue and chronic cuff infection (14). The exit can also be
traumatized by undue pressure, repeated or prolonged
pressure from tight clothing, belts, seatbelts, sleeping on the
abdomen, or leaning against the exit for a prolonged time
(15,16). Inappropriate exit care is another source of trauma.
Overly vigorous cleansing or scrubbing can cause trauma,
as can forcibly removing crusts or scabs. Allergy to the
cleansing agent or sensitivity to dressing or tape can also
result in skin breakdown. Anchoring the catheter too tautly
or in an unnatural position can cause constant pressure at
both the exIt and at the cuff. Finally, patients can cause
trauma when they scratch or pick at the exit.
Trauma should be reported to the dialysis unit if it causes
severe pain or bleeding, or if there is subsequent
deterioration of the exit-site appearance with redness,
exudate, persistent pain, or tenderness. Prophylactic
antibiotics should be prescribed for re ported trauma (17).
Recurrent or chronic infection may be either a result or
cause of cuff extrusion. When the cuffis not infected, but
extrudes because of pressure due to shape memory, the
extruding cuff causes irritation to the exit site, another form
of trauma.
Avoiding gross contamination of the exit site is the
second principle of preventing exit infections. Patients
should be instructed to wear dressings when the exit is
likely to become contaminated and to do exit-site care
whenever the exit becomes dirty or wet.
Submersion of the exit obviously increases the exposure
to water-borne organisms. There are no controlled studies
evaluating swimming as a risk factor for exit-site and tunnel
infections. There is general agreement, however, that
swimming in clean ocean waters and well-chlorinated
private pools is acceptable, but that swimming in
contaminated wa ters such as rivers, lakes, and public pools
is not (2). We believe that swimming poses less of a risk to
patients with good and perfect exit sites than to those with
equivocal and infected exits (18). It seems reasonable to
follow the recommendation of some units that patients
cover the exit site with a waterproof dressing or ostomy
appliance prior to swimming ( 19 ). There is universal
agreement that exit care should be done immediately after
swimming (2). Submersion in whirlpools and hot tubs must
be avoided.
Another source of potential exit contamination is the use
of over-the-counter preparations for exit care. The use of
substances such as coal tar, petroleum, vitamin E oil, and
cosmetic creams has been reported by our patients. Patients
should be instructed not to use any substance for exit care
without the approval of the PD staff.
Ways to prevent gross contamination of the exit are
summarized in Table 5.
PDI

CARE OF THE INFECTED EXIT
Medical intervention for infected exits is presented in an
accompanying paper (17). Nursing care of the infected exit
site has three major components: assessment, appropriate
modifications in the exit-care regimen, and patient
education.
Upon diagnosis of an infection a culture is taken in order
to guide the choice of antibiotic therapy. Almost all exits
are colonized within a few weeks of catheter implantation;
however, the resident flora mayor may not be the
organism(s) responsible for ensuing infections. Therefore, it
is important to culture the exudate, rather than the skin
around the catheter. Holley and Moss found that tugging
gently downward on the catheter and squeezing the subcu-
taneous cuff successfully expressed drainage from the sinus
that was not otherwise seen (20). An accom
panying study confirmed that in acute infections, sometimes
external drainage is seen only after pressure on the sinus
(14). Theinfectingmicro-organism(s) may change over the
course of a chronic infection, so repeated cultures are
indicated if the infection does not respond promptly to
therapy (14,17).
Exuberant granulation tissue should be cauterized with
silver nitrate. This is done by gently touching the
granulation tissue with the tip of a silver nitrate stick. Care
should be taken not to touch healthy tissue. The granulation
tissue turns grayishwhite after cauterization (14). One
application may be sufficient for an acute infection; several
cauterizations, once or twice weekly, may be required for
chronic infections. We prefer that silver nitrate application is
done by either a physician or nurse, but not by patients and
partners.
Local antibiotics may be prescribed for an equivocal exit,
and systemic antibiotics should be prescribed for infected
exits (14,17). The patient or caregiver should be given clear
instructions regarding the prescription both orally and in
writing. As with any antibiotic therapy, it is important for
the patient to complete the entire course of therapy.
Increasing the frequency of exit-site care to once daily or
even twice daily is the most frequent recommendation for
care of infected exits (4). Changing the cleansing agent is
also common. Certainly, when an exit is equivocal or
infected, the exit-care procedure should be evaluated. If the
cleansing agent or method of securing the catheter or
dressings is causing irritation or skin breakdown, it should
be changed. Also, an infected exit usually has regression of
the epithelium in the sinus with the remainder of the visible
sinus covered with granulation tissue (14,18). As with a
healing exit, it is important that cytotoxic agents are not
allowed to enter the sinus. For patients who do not have
good vision and/or fine motor coordination or are not
meticulous about their technique, it is appropriate to change
to a milder cleansing agent.
Sterile dressings should be used for infected exits to
absorb drainage, to reduce exposure to microorganisms, and
to protect the exit from trauma. Effectively securing the
catheter will prevent trauma to the infected exit from
catheter movement. Patients and caregivers must receive
appropriate instruction regarding all changes in exit-care
procedures.
Large, irritating crusts may develop around infected
exits. As in routine care, crusts or scabs should never be
forcibly removed, but they can be gradually
softened with saline, soap and water, poloxamer, or exit
soaks. Soaks to the exit 2 -4 times daily may be prescribed
(4,17). Polic ies and procedures have to be developed and
patients must receive appropriate instructions for safely
applying compresses.
 Infected exits require continued monitoring. We prefer
to evaluate infected exits every 7 -10 days. This schedule
allows us to reassess the exit and to evaluate the
effectiveness of therapy as well as to recauterize exuberant
granulation tissue and to change therapy, if indicated. Table
6 summarizes principles of care for the infected exit.
9. Laufman H. Current use of skin and wound cleansers
11. Mileto G, Pellegrino E, Cardia P, Ferraò O, Consolo
12. Goetz A, Muder RR. Pseudomonas aeruginosa infections
13. Prowant B. Nursing interventions related to peritoneal catheter
ACKNOWLEDGMENT
Supported in part by Nep hrology Research Fund.
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