title: Pseudomonas exit-site infection: treatment outcomes with topical gentamicin in addition to systemic antibiotics.
abstract: BACKGROUND
  Although, Pseudomonas exit-site infection (ESI) is recognized as a major complication of peritoneal dialysis (PD) with high risk of catheter loss due to refractory/recurrent infection or peritonitis, there is remarkably little literature about treatment outcomes. International Society for Peritoneal Dialysis guidelines advise the use of one to two antibiotics; in addition, we change standard exit-site care by stopping prophylactic mupirocin and starting regular use of gentamicin 1% cream.
  
  
  METHODS
  Retrospective review of outcomes of Pseudomonas ESI from January 2012 to March 2015.
  
  
  RESULTS
  During the study period, a total of 135 patients were on PD with an overall incidence of any ESI of 0.36/patient-year. There were 14 patients with ESI episodes with Pseudomonas with a rate of 0.12/patient-year. In total, 13 of 14 patients with ESI episodes were treated with oral ciprofloxacin and/or intraperitoneal (IP) gentamicin or ceftazidime, plus topical gentamicin, with a success rate of 38% (5/13). One patient had gentamicin-resistant Pseudomonas species and was treated successfully with topical polymyxin/bacitracin cream. Median follow-up time in cured patients was 385 days (range 74-1107). Six patients had associated with Pseudomonas peritonitis, four during follow-up and two at initial presentation. Three patients had recurrent ESI with Pseudomonas, with one successfully re-treated with topical and IP gentamicin. In total, in only 50% of the patients was Pseudomonas ESI successfully treated. Five of the patients (36%) changed modality to permanent haemodialysis following catheter removal.
  
  
  CONCLUSIONS
  Eradication of Pseudomonas ESI remains difficult even with the addition of topical gentamicin to the exit site. There should be a low threshold for catheter replacement.
authors.affiliation: Clinic for Transplant Immunology and Nephrology , University Hospital Basel , Basel , Switzerland.
authors.forename: Felix
authors.initials: F
authors.lastname: Burkhalter
authors.affiliation: Imperial College Renal and Transplant Centre , Hammersmith Hospital , London , UK.
authors.forename: Michelle
authors.initials: M
authors.lastname: Clemenger
authors.affiliation: Imperial College Renal and Transplant Centre , Hammersmith Hospital , London , UK.
authors.forename: San San
authors.initials: SS
authors.lastname: Haddoub
authors.affiliation: Imperial College Renal and Transplant Centre , Hammersmith Hospital , London , UK.
authors.forename: Jacqueline
authors.initials: J
authors.lastname: McGrory
authors.affiliation: Imperial College Renal and Transplant Centre , Hammersmith Hospital , London , UK.
authors.forename: Nora
authors.initials: N
authors.lastname: Hisole
authors.affiliation: Imperial College Renal and Transplant Centre , Hammersmith Hospital , London , UK.
authors.forename: Edwina
authors.initials: E
authors.lastname: Brown
keywords: Pseudomonas aeruginosa; exit-site infections; peritoneal dialysis; topical gentamicin