Potential clinical value of catheters impregnated with antimicrobials for the prevention of infections associated with peritoneal dialysis

ABSTRACT

Introduction

Peritoneal dialysis (PD) is a widely used dialysis modality, which offers the advantage of being a home therapy but is associated with a risk of potentially serious infections, including exit site infection, catheter tunnel infection, and peritonitis that may result in morbidity, technique failure, and increased mortality. Catheters impregnated with antimicrobials hold promise as a novel technique to reduce PD associated infections.

Areas Covered

We describe PD modalities, catheters, technique, complications, and the microbiology of associated infections, as well as standard measures to reduce the risk of infection. A novel technique for the impregnation of silicone devices with antimicrobial agents has been used to produce antimicrobial impregnated ventricular shunt catheters with proven clinical efficacy that have now been adopted as the standard of care to reduce neurosurgical infections. Using the same technology, we have developed PD and urinary catheters impregnated with sparfloxacin, triclosan, and rifampicin. Safety and tolerability have been demonstrated in urinary catheters, and a similar study is planned in PD catheters.

Expert Opinion

Catheters impregnated with antimicrobials offer a simple technique to reduce PD associated infections and thereby enable more people to enjoy the advantages of PD. Clinical trials are needed to establish efficacy.

Lay summary

Peritoneal dialysis (PD) is a type of treatment for kidney failure. To perform PD, a silicone tube is placed in the abdomen and the other end exits through the skin. Fluid is run into the abdomen via the tube and then drained out again after 1–12 hours. This process is repeated multiple times per day. Toxins and other waste chemicals normally removed by the kidneys enter the fluid, while it is in the abdomen and are then removed from the body when the fluid is drained out. In this way, PD partially replaces kidney function. Sometimes bacteria get into the tube, and this can cause serious infections in the abdomen. At present, measures available to prevent PD tube infections include careful hygiene when handling the tube, application of antibiotic creams or ointments to the exit site or treatment with antibiotics at the time of medical procedures that may increase infection risk. Despite these measures, peritonitis (abdominal infection) is one of the most common causes of people having to stop PD and change to another form of dialysis that involves direct filtration of the blood (hemodialysis). Frequent use of antibiotics may also cause the bacteria that cause peritonitis to become resistant to antibiotics. There is, therefore, an urgent need to develop new ways to prevent PD tube infections. Tubes have been used in patients who have a particular type of brain surgery with antibiotics introduced into the material that the tube is made from, and in these patients, the risk of infection has been reduced by 60–80%. The same technology is also being tested for urine tubes that are placed in the bladder and tubes used for PD. These urine tubes and PD tubes need further testing to establish safety and effectiveness. Though our experience with them leads us to expect that they are safe, the authorities that control new drugs and devices require us to show this beyond doubt before they can be introduced into routine care.

KEYWORDS:

• Antimicrobials
• catheter
• impregnation
• peritonitis
• peritoneal dialysis

Article highlights

• Peritoneal dialysis is a widely used dialysis modality but is associated with a risk of potentially serious infections including exit site infection, catheter tunnel infection, and peritonitis

• Despite universal training of patients in the use of aseptic technique during fluid exchanges, Infections remain the most common and dangerous complication of peritoneal dialysis

• A novel technique for the impregnation of silicone devices with antimicrobial agents has been used to produce antimicrobial impregnated ventricular shunt catheters used in neurosurgery with proven clinical efficacy

• The same technology has been used to develop urinary and peritoneal dialysis catheters impregnated with sparfloxacin, triclosan, and rifampicin.

• Safety and tolerability have been demonstrated in urinary catheters, and a similar study is planned for peritoneal dialysis catheters.

Declaration of interest

Maarten W. Taal is the Principal Investigator, together with Roger Bayston on an ‘Innovation for Improvement’ (I4I) grant, funded by the National Institute for Health Research entitled: Clinical Evaluation, Development and Commercialisation of an Antimicrobial – Impregnated Catheter Against Peritonitis (The CAP Study). Roger Bayston has received speaker fees and consultancy fees from Integra LifeScience which are paid directly to their university, and they have no personal financial interest. Though they are named inventor of antimicrobial devices, they do not receive any royalties or other payments. They receive no other financial payments of any kind from Industry. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewers disclosure

Peer reviewers in this manuscript have no relevant financial relationships or otherwise to disclose.

Additional information

Funding

This paper was supported by NIHR Innovation for Improvement (NIHR202104).