title: Staphylococcus aureus bacteremia and buttonhole cannulation: long-term safety and efficacy of mupirocin prophylaxis.
abstract: OBJECTIVE
  Buttonhole (constant-site) cannulation (BHC) continues to gain popularity with home and in-center dialysis programs worldwide. However, long-term safety data are lacking. This paper reports the authors' single-center experience with Staphylococcus aureus bacteremia (SAB) and the efficacy of topical mupirocin prophylaxis (MP).
  
  
  METHODS
  This study was a retrospective prepost comparison of SAB rates after establishing MP. Fifty-six consecutive patients on home nocturnal hemodialysis via arteriovenous fistulae, mean age 51.5 +/- 10.6 years, 38% women, and vintage 44.5 +/- 34.5 months were observed for a total of 93.4 (pre-MP) and 193.5 (post-MP) patient-years.
  
  
  RESULTS
  Ten episodes of SAB were observed, with metastatic complications in four cases, including pneumonia (n = 2), septic arthritis, and a fatal C3 epidural abscess. When analyzed by observation period, the odds ratio (OR) for SAB before versus after the introduction of MP was 6.4 [95% confidence interval (CI) = 1.3 to 32.3; P = 0.02]. Two SAB episodes occurred after the MP started. Both patients had discontinued the MP for 3 weeks (nonadherent) preceding infection; hence, no SAB episodes were observed on treatment. In an as-treated analysis, the OR for SAB in the absence of MP was 35.3 (95% CI = 2.0 to 626.7; P = 0.01).
  
  
  CONCLUSIONS
  BHC is associated with a significant risk of SAB with metastatic complications. In this prepost comparison of SAB rates, no infections were observed with MP. While awaiting more definitive studies, this simple intervention should be considered for patients using BHC.
authors.affiliation: Division of Nephrology, The University of Western Ontario, London, Ontario, Canada. gnesrallah@hrrh.on.ca
authors.forename: Gihad E
authors.initials: GE
authors.lastname: Nesrallah
authors.forename: Meaghan
authors.initials: M
authors.lastname: Cuerden
authors.forename: Joseph H S
authors.initials: JH
authors.lastname: Wong
authors.forename: Andreas
authors.initials: A
authors.lastname: Pierratos
mesh_terms: D000287:Administration, Topical; D000328:Adult; D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D019072:Antibiotic Prophylaxis; D001166:Arteriovenous Shunt, Surgical; D016470:Bacteremia / Q000517:prevention & control; D002406:Catheterization, Peripheral / Q000009:adverse effects* / Q000401:mortality; D005260:Female; D006437:Hemodialysis, Home; D006801:Humans; D008297:Male; D008875:Middle Aged; D016712:Mupirocin / Q000008:administration & dosage*; D016017:Odds Ratio; D009864:Ontario; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013203:Staphylococcal Infections / Q000382:microbiology / Q000401:mortality / Q000517:prevention & control*; D013211:Staphylococcus aureus / Q000302:isolation & purification*; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents; D016712:Mupirocin