Journal of Hospital Infection (1991) 17, 69-72
to the Editor
Sir, Housewife We
of a pathogen
the control of wound infection caused by at the Tenckhoff catheter exit site in patients undergoing continuous ambulatory peritoneal dialysis (CAPD).’ This resulted in a substantial decrease in the rate of S. aweus peritonitis. This control comprised strict adherence to aseptic technique and clearance of staphylococcal carriage of the patient by the application of antiseptics but without the use of prophylactic antibiotics. The low rate of S. aweus peritonitis has been maintained by these procedures.* We report a case of unforeseen transmission of S. aweus from a wife to a husband on CAPD with consequent peritonitis and catheter loss. A 62-year-old man with end-stage renal failure had a Tenckhoff catheter inserted in November 1989. He was not a carrier of S. aweus in either nose or groin and anti-staphylococcal antisepsis to these sites was discontinued following discharge from hospital. The patient was disabled as a result of rheumatoid arthritis, and therefore his wife was trained to change the Tenckhoff exit site dressing aseptically. His wife was not screened for staphylococcal carriage. Four months after insertion of the catheter, the patient presented with an exit site which was erythematous and discharging pus, from which Staphylococcus aweus was’isolated. One week later, despite treatment with erythromycin, the patient developed peritonitis. A strain of S. aweus indistinguishable by antibiogram and phage type was isolated from the was treated with turbid dialysate effluent. Th e episode of peritonitis intraperitoneal ciprofloxacin to which the causative strain was sensitive (MIC 0.5 mg 1-l). Peritoneal dialysate at the end of treatment was clear and sterile. The infection recurred 9 days later and was then treated with intraperitoneal vancomycin. Five weeks later the patient developed a further episode of peritonitis with an indistinguishable strain, which also failed to be cleared by intraperitoneal vancomycin. The patient was admitted for removal and replacement of the Tenckhoff tube at a single procedure.3 The patient and his wife were screened for staphylococcal carriage before reinsertion of the tube. Staphylococcus aweus was not isolated from the nose or groin of the patient, but his wife harboured an indistinguishable strain in Staphylococcus
0 1991 The Hospital
to the Editor
her nose. Carriage in the wife was cleared by treatment with topical chlorhexidine and neomycin cream (‘Naseptin’, ICI, UK). The patient has been free from infective complications of CAPD since his Tenckhoff tube was replaced. It is probable that the patient acquired the infecting strain from his wife during the course of dressing the exit site wound. We have revised our recommendations for the care of exit site wounds following this case. Where the exit site wound is dressed regularly at home by a person other than the patient, that person is sampled for 5’. LZUY~US nasal carriage, and if positive receives ‘Naseptin’ to the anterior nares twice daily for 1 month. In most cases the attendant is a spouse or another member of the patient’s family, and in our experience these attendants are happy to comply with the screening procedure and eradication of staphylococcal carriage as necessary. We thank
Dr A. J. Wing
M. S. Dryden M. McCann I. Phillips
Department of Medical Microbiology and the Renal Unit, UMDS, St Thomas’ Hospital, London SE1 7EH References
1. Ludlam HA, Young AE, Berry AJ, Phillips I. The prevention of infection with Staphylococcus aureu~ in continuous ambulatory peritoneal dialysis. J Hosp Infect 1989; 14: 293-301. 2. Ludlam HA, Dryden MS, Wing AJ, Phillips I. The prevention of peritonitis in continuous ambulatory peritoneal dialysis. Lancet 1990; 1: 1161. 3. Ludlam HA, Young AE, Wing AJ. Removal and replacement of Tenckhoff catheter at single operation. Lancet 1989; 1: 1028.
We were interested to read the case report of Pseudomonas paucimobilis bacteraemia associated with haemodialysis by Calubiran et al. in a recent issue of the Journal.’ The authors did not specify the dialysis fluid used. In our own renal unit we isolated this organism from the residue in a 10 1 plastic container of liquid bicarbonate fluid concentrate Solution B2 (Macarthy Medical) which contains sodium chloride, bicarbonate and dextrose. Solution B is proportionately mixed with Solution A and water to form bicarbonate-based dialysis fluid for use instead of acetate-based fluid. The investigation was prompted by the chance observation of a pungent smell on first opening, and a haziness in the solution.